





No financial
disclosures
Neil Ramsay, Clinical
Anesthesia Fellow
SQAN
Dan Werry, Medical
Student
Nursing staff-...
Rational for promoting normothermia
in the perioperative period
2) Understand the reasons for hypothermia
3) Local experie...
Definition: as a temperature <36.0 C at
any point in the perioperative period.
 Mild hypothermia – 34-36o C is
associated...






Kurz NEJM 1996. Colorectal surgery N=200.
6% vs 19%. RR 0.31
Melling Lancet 2001. Clean general surgery.
N=421 S...
Leukocyte migration and oxidative killing
impaired
 Neutrophilphagocytosis
 Cytokine and antibody production
 Hypotherm...
Meta-analysis 24 RCT
 Normothermia was associated with a 22%
less risk of transfusion
 16% less blood loss
 Hypothermia...


Frank . JAMA 1997. High risk vascular,
abdominal & thoracic cases N=300.
1% vs 6%, RR 0.22



Level 1 evidence, grade ...


Increase in circulating catecholamines
› Cold induced HT, 3X fold in norepinephrine

Increase in systemic vasoconstrict...
Retrospective study 5050 OR cases
(cardiac and non-cardiac surgery)
 35% were hypothermic on arrival to ICU
 6% severely...


Surgical Care Improvement Project (SCIP) in
the US, initiated a pay for performance for
efforts to reduce surgical comp...









Patient temp measured and recorded
every 30 minutes.
Induction should not commence until
patient temp >36.
...
Guidelines





Core temperature <36O degree at end of
case is a ―failure‖
Similar statements as NICE guideline
Pre-war...
2001-2008

Hypothermia< 35.5
Sample size 86,000 cases

1.6%
2001-2008

Hypothermia <35.5

Sample size N=86,000

2011-2012

1.6%

Hypothermia <36.0
21%
Sample size N=870


Cold environment—what is your OR
temp?
› Suggested temperature 20-22O degree

› Frequent air exchanges

Exposed patient...






Two component
model
Core 2/3 of body
heat (trunk organs,
brain)
Peripheral 1/3—skin,
subcutaneous tissue
Vasodil...
5-60% of patients having GA
 33-50% of patients having epidurals &
spinals
 Thermal pain— cold sensation can be
worse th...








Gold standard Pulmonary Artery Catheter
Tympanic membrane probe-not typically used
Esophageal and oral –leve...


Increase heat
content in peripheral
compartment before
induction



Minimize
temperature
gradient between
core and per...
Bock, BJA 1998-- 30 minutes prior to major
laparotomy. Reduced transfusion, PACU
stays, increased PACU temperature N=40
 ...
Major non-cardiac procedures > 60
minutes were selected.
 Forced air warming of patients using Bair
Paws gowns.
 Pre and...
Temperature oC

36.80

Avg 68 min Pre-OR warming

36.75
36.70
36.65
36.60
Prewarming

PreOR
Lowest temperature –esophageal, NP
 Duration of anesthesia
 Duration of hypothermia
 Temperature in the last 30 minutes...
50

% Patients

40
30
20
10
0

T>36 C

T<36 C

Not Monitered
% Temp not charted

100
80
60
40
20
0
Spinal

GA

GA+ThEp
50

% patients

40

% OR time spent hypothermic

30
20
10
0
0%

<25%

25-50%

>50%
% Hypothermic in PACU

25
20
15
10
5
0
No pre-warming

Pre-warming
# patients

60

40

20

0
-1.6 -1.2 -0.8 -0.4 0.0 0.4 0.8 1.2 1.6

PACU temp - last OR temp ( oC)


63 nurse and 67 Anesthesiologist
interviews in the OR over a 7 week
period.



What has been done to reduce the
patien...
Patients reported to be at mod-severe risk

% Patients

80
60
40
20
0
Nurses

Anesthesiologists
NICE criteria for high risk of hypothermia:
3 or more of the following…
ASA grade II-IV
2. Pre-op temp < 36
3. Combined ge...
Patients reported to be at mod-severe risk

% Patients

80
60
40
20
0
Nurses Anesthesiologists

NICE
re
as
e

ro
om
Pr
te
m
ep
w
ar
m
be
B
ai
d
rH
W
ug
ar
ge
m
r
IV
Ex
flu
A
tr
id
ct
a
s
Fl
iv
e
an
Fl
ne
ui
ls
d
W
M
ar
on
m...
Mean OR temperature
= 19.9 +/- 0.1 0C
Forced Air Warming Gowns: Bair Paws
Do you think Bair Paws are useful?

Nurses = 63

depends

no

yes

Anesthesiologists = n=67
depends

no

yes
What do you mean, the gowns are not ―useful‖?

- Not necessary

- Can get soiled
- Hard to use
What do you mean, the gowns are sometimes ―useful‖?

- Only for high risk patients

- Patient Position
- Not as upper air ...
Do you feel comfortable converting
the gownto a blanket?

Nurses (n=63)

Anesthesiologists (n=67)

no
yes

no
yes
Why are you not comfortable converting the gowns
to blankets?

- Not user friendly
- Need more practice
What did we learn?
1.

Staff appropriately recognize the risk of
hypothermia but do not necessarily act on
the risk

2.

R...
Noisy
 Costly disposables
 ―blows bacteria‖ into surgical site—no
evidence
 Effects laminar airflow near surgical site—...


Warm Flannels—heat capacity is trivial
› cutaneous heat loss identical with warmed

and unwarmed blankets



Heated CO...
Should be assessed for risk:
 High risk if more than 2
ASA 2-5
Preoperative temp <36°C
Combined GA and regional
Intermedi...








Temperature should be monitored in most
pts undergoing GA >30 minutes, and in all
patients whose surgery > 60...
Patients temperature should be
monitored every 15 minutes
 Discharge criteria that patient
temperature is greater than or...
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
What’s Cool About Normothermia?
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What’s Cool About Normothermia?

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This presentation was delivered by Kelly Mayson, MD and Dan Werry, MSc (MD Candidate), at the BC Surgical Quality Action Network's 2013 annual meeting.

Learn how Vancouver General Hospital has tackled hypothermia. This presentation covers their early successes and explores the challenges of implementing interventions while considering OR culture.

Visit http://bcpsqc.ca/clinical-improvement/sqan/ to learn more about the event

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What’s Cool About Normothermia?

  1. 1.      No financial disclosures Neil Ramsay, Clinical Anesthesia Fellow SQAN Dan Werry, Medical Student Nursing staff-PCC, PACU, NSQIP nurse reviewers
  2. 2. Rational for promoting normothermia in the perioperative period 2) Understand the reasons for hypothermia 3) Local experience on the incidence of hypothermia in non-cardiac surgery 4) Review methods to maintain normothermia 5) Share our local QA project, and some of the culture of changing the status quo 1)
  3. 3. Definition: as a temperature <36.0 C at any point in the perioperative period.  Mild hypothermia – 34-36o C is associated with an increased risk of complications 
  4. 4.     Kurz NEJM 1996. Colorectal surgery N=200. 6% vs 19%. RR 0.31 Melling Lancet 2001. Clean general surgery. N=421 Systemic SSI 6% vs 14% RR 0.42, Local SSI 4% vs 14% RR 0.27 Wong Br J Surg 2007. Major abdominal cases N=103 13% vs 27% RR 0.48 Seamons Ann Surg 2012 Trauma laparotomies N=524 . Significant increase risk of SSI if temp < 35o C  Level 1 evidence, grade B recommendation
  5. 5. Leukocyte migration and oxidative killing impaired  Neutrophilphagocytosis  Cytokine and antibody production  Hypothermia-induced vasoconstriction reduces skin perfusion and hence decreased tissue oxygen tension 
  6. 6. Meta-analysis 24 RCT  Normothermia was associated with a 22% less risk of transfusion  16% less blood loss  Hypothermia impairs platelet function— release of thromoxane A2.  Impairs enzymes in the coagulation cascade  Decrease clot formation  Level 1 evidence. 
  7. 7.  Frank . JAMA 1997. High risk vascular, abdominal & thoracic cases N=300. 1% vs 6%, RR 0.22  Level 1 evidence, grade B recommendation
  8. 8.  Increase in circulating catecholamines › Cold induced HT, 3X fold in norepinephrine Increase in systemic vasoconstriction  Increase in cardiac demand 
  9. 9. Retrospective study 5050 OR cases (cardiac and non-cardiac surgery)  35% were hypothermic on arrival to ICU  6% severely hypothermic <35o C.  › In-hospital mortality 5.6% normothermic › 8.9% for all hypothermic patients › 14.7% for severely hypothermic patients › Karalapillai et al Anaesth 2009;64:968-972
  10. 10.  Surgical Care Improvement Project (SCIP) in the US, initiated a pay for performance for efforts to reduce surgical complications in July 2006 › 1st step with colorectal surgery 2006 › Oct 2009. SCIP Infection 10. ―At least one body temperature to be recorded within 30 minutes immediately before or in the 15 minutes immediately after anesthesia end time‖ for all patients regardless of age under going general or neuroaxial anesthesia one hour or longer.
  11. 11.       Patient temp measured and recorded every 30 minutes. Induction should not commence until patient temp >36. Intravenous fluids >500mls warmed with a fluid warming device. High risk patients warmed with forced air warming devices for anesthesia <30 minutes. All patients warmed with a forced air warmer for anesthesia >30 minutes. pre-warming—high risk patients
  12. 12. Guidelines    Core temperature <36O degree at end of case is a ―failure‖ Similar statements as NICE guideline Pre-warming should be initiated between 30 minutes to 2 hours prior to major surgery
  13. 13. 2001-2008 Hypothermia< 35.5 Sample size 86,000 cases 1.6%
  14. 14. 2001-2008 Hypothermia <35.5 Sample size N=86,000 2011-2012 1.6% Hypothermia <36.0 21% Sample size N=870
  15. 15.  Cold environment—what is your OR temp? › Suggested temperature 20-22O degree › Frequent air exchanges Exposed patient  Intraoperative fluids  › Actively warmed vs warmed solution  Anesthesia effect on Thermoregulation
  16. 16.     Two component model Core 2/3 of body heat (trunk organs, brain) Peripheral 1/3—skin, subcutaneous tissue Vasodilation results in a core-to-peripheral temperature gradient and redistribution of body
  17. 17. 5-60% of patients having GA  33-50% of patients having epidurals & spinals  Thermal pain— cold sensation can be worse than surgical pain & shivering aggravates pain  Increased oxygen consumption  › Vigorous shivering up to 600%, however 200% increase is all that can be sustained over long period  Increased catecholamine release
  18. 18.       Gold standard Pulmonary Artery Catheter Tympanic membrane probe-not typically used Esophageal and oral –level II-2 evidence, grade B recommendation Bladder temperature for regional procedures. Or axillary( in contact with artery, arm at side) IR tympanic thermometry—least reliable device—Grade D Temporal artery thermometer—inferior to oral. Scans skin temperature, detects the highest temperature, at 3 different points. ―inferior to all devices‖ ( A & A 2002)
  19. 19.  Increase heat content in peripheral compartment before induction  Minimize temperature gradient between core and peripheral temperature  Attenuate the impact of heat redistribution
  20. 20. Bock, BJA 1998-- 30 minutes prior to major laparotomy. Reduced transfusion, PACU stays, increased PACU temperature N=40  Melling, Lancet 2001—30 minutes FAW for clean procedures (breast, hernia, VV), SSI 5% vs 14% N=416  Horn, Anaesthesia 2012. FAW 10,20,30 min preop for OR lasting 30-90 minutes. N=200. PACU hypothermia 69% versus 13, 7 and 6%  › BJA 1998;80:159-163 Anaesth 2012;67:612 Lancet 2001;358:876-80
  21. 21. Major non-cardiac procedures > 60 minutes were selected.  Forced air warming of patients using Bair Paws gowns.  Pre and post temperatures were taken in PCC (oral temp)  Length of warming was tracked  Patients were allow to adjust temperature in preoperative care unit (PCC) 
  22. 22. Temperature oC 36.80 Avg 68 min Pre-OR warming 36.75 36.70 36.65 36.60 Prewarming PreOR
  23. 23. Lowest temperature –esophageal, NP  Duration of anesthesia  Duration of hypothermia  Temperature in the last 30 minutes of OR  Temperature on admission to PACU  Did the gown make it to PACU  PACU Length of Stay and complications  NSQIP 30 day outcomes 
  24. 24. 50 % Patients 40 30 20 10 0 T>36 C T<36 C Not Monitered
  25. 25. % Temp not charted 100 80 60 40 20 0 Spinal GA GA+ThEp
  26. 26. 50 % patients 40 % OR time spent hypothermic 30 20 10 0 0% <25% 25-50% >50%
  27. 27. % Hypothermic in PACU 25 20 15 10 5 0 No pre-warming Pre-warming
  28. 28. # patients 60 40 20 0 -1.6 -1.2 -0.8 -0.4 0.0 0.4 0.8 1.2 1.6 PACU temp - last OR temp ( oC)
  29. 29.  63 nurse and 67 Anesthesiologist interviews in the OR over a 7 week period.  What has been done to reduce the patient’s risk of developing hypothermia?  What do you think of the forced air warming gowns (―Bair Paws‖)?
  30. 30. Patients reported to be at mod-severe risk % Patients 80 60 40 20 0 Nurses Anesthesiologists
  31. 31. NICE criteria for high risk of hypothermia: 3 or more of the following… ASA grade II-IV 2. Pre-op temp < 36 3. Combined general and regional anesthesia 4. Intermediate – major surgery 5. Risk of cardiovascular complications 1.
  32. 32. Patients reported to be at mod-severe risk % Patients 80 60 40 20 0 Nurses Anesthesiologists NICE
  33. 33. re as e ro om Pr te m ep w ar m be B ai d rH W ug ar ge m r IV Ex flu A tr id ct a s Fl iv e an Fl ne ui ls d W M ar on m ito er rT em p? In c % Patients Anesthesiologists 100 Nurses 80 60 40 20 0
  34. 34. Mean OR temperature = 19.9 +/- 0.1 0C
  35. 35. Forced Air Warming Gowns: Bair Paws
  36. 36. Do you think Bair Paws are useful? Nurses = 63 depends no yes Anesthesiologists = n=67 depends no yes
  37. 37. What do you mean, the gowns are not ―useful‖? - Not necessary - Can get soiled - Hard to use
  38. 38. What do you mean, the gowns are sometimes ―useful‖? - Only for high risk patients - Patient Position - Not as upper air warmer
  39. 39. Do you feel comfortable converting the gownto a blanket? Nurses (n=63) Anesthesiologists (n=67) no yes no yes
  40. 40. Why are you not comfortable converting the gowns to blankets? - Not user friendly - Need more practice
  41. 41. What did we learn? 1. Staff appropriately recognize the risk of hypothermia but do not necessarily act on the risk 2. Risk reduction strategies rarely used include increasing OR temperature 3. The Bair Paw gowns had mixed reviews and so we may want to consider alternatives
  42. 42. Noisy  Costly disposables  ―blows bacteria‖ into surgical site—no evidence  Effects laminar airflow near surgical site— could this effect the ability to remove airborne contaminants?  Dasari et al Anaesth 2012;67:244-249 Belani et al Anesth Analg 2013;117:406-11
  43. 43.  Warm Flannels—heat capacity is trivial › cutaneous heat loss identical with warmed and unwarmed blankets  Heated CO2 for MIS procedures › Cochrane Systemic Review Jan 2011 › No effect on postoperative pain, or change in core temperature
  44. 44. Should be assessed for risk:  High risk if more than 2 ASA 2-5 Preoperative temp <36°C Combined GA and regional Intermediate to major surgery At risk for cardiovascular complications  Pre-warm patients 
  45. 45.      Temperature should be monitored in most pts undergoing GA >30 minutes, and in all patients whose surgery > 60 minutes Use esophageal and oral thermometry in anesthesized and awake patients , respectively Use IV fluid warmers for abdominal procedures > 1 hr duration. OR temperature. Ideally 22o C. But ideally at the start and end of case. Use FAW intraoperatively when procedures are expected to last > 30 minutes
  46. 46. Patients temperature should be monitored every 15 minutes  Discharge criteria that patient temperature is greater than or equal 36o C.  Actively warm patients with FAW whose temperature is less than 36o C 

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