Don't Put Off Patient Warming

Anesthesia

By: Connie Garrett

Published: 7/23/2019

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Efforts to prevent hypothermia work best when they begin in pre-op.


WARM AIR Pre-warming prevents the significant temperature drop that can occur during anesthesia induction.   |  Pamela Bevelhymer, RN, BSN, CNOR

Think of patient warming like saving for retirement — the sooner you begin, the more effective it is. Applying active warming measures in pre-op builds up a bank of thermal heat in patients so they're better able to withstand the chilling effects of donning a thin gown and laying in a cool OR while being subjected to the vasodilation properties of general anesthesia. During induction, thermal energy shifts from the body's core to its periphery, putting patients at increased risk of hypothermia-related complications. Hypothermic patients are more likely to suffer cardiac arrhythmias, ischemia and arrest. Their immune systems are impaired, putting them at increased risk of post-op infection. They're less likely to be satisfied with the care they receive and might not be ready for timely discharges.

There's no question active warming should be an important part of your efforts to ensure core body temperatures don't dip below 36 ?C before, during or after surgery, and it should begin as soon as patients shed their street clothes.

Warming in action

In our busy hospital, patients start their surgical journey in pre-op bays, where nurses place IVs, check vital signs and perform clinical assessments. Patients are then moved to a surgical holding area adjacent to the ORs until it's time for surgery. Previously, we wrapped patients in warmed cotton blankets in the pre-op area and only began active warming measures in the holding area.

The decision to initiate active warming in pre-op and continue applying the methods straight through to PACU actually began as a lean strategy aimed at reducing the significant laundry expense our hospital incurred from washing cotton patient gowns and the countless cotton blankets we used to warm patients throughout their stay. (Quick tip: If you're unaware of the number of blankets your staff goes through to keep patients warm and comfortable, hang a dated spreadsheet next to your blanket warming cabinet and ask staff to make a tick mark every time they grab a blanket. The number of blankets they use might be eye-opening.)

We replaced cotton gowns and blankets with disposable forced-air warming gowns, which patients slip on in pre-op and wear straight through to discharge. That option works best for us, but there are several effective active warming methods from which to choose, including forced-air warming coverlets, conductive blankets and mattresses placed over and under patients, reflective thermal blankets that trap the patient's own body heat and warm circulating water mattresses.

Smaller warming units are mounted on walls next to patient beds in the pre-op and holding areas. These smaller units deliver enough heated air to pre-warm patients, who can adjust the air flow to their comfort, and keep floors clear of tripping hazards in the busy, high-traffic areas.

We note the many clinical benefits of maintaining normothermia on laminated scripts that are attached to each wall-mounted unit (see "Post This Patient Warming Cheat Sheet"). The scripts ensure every staff member who comes in contact with patients, even those who don't regularly care for them in pre- and post-op areas, understand the clinical importance of patient warming and maintaining normothermia. That's where the script comes in handy. Any provider, no matter how well-versed they are with our patient warming protocols can refer to the script when interacting with patients.

HOT TAKE Connecting patients to active warming devices during each stop along the perioperative pathway helps to maintain normothermia.   |  Pamela Bevelhymer, RN, BSN, CNOR

When providers touch on the script's talking points, patients reach a new understanding of warming's benefits — including its link to lower risks of surgical site infections — and are more accepting of being warmed, even when they feel comfortable.

In the OR, patients' gowns are connected to a larger floor-based forced-air warming device, which delivers higher flows of hot air needed to maintain normothermia in patients exposed to the cool ambient OR air and chilling effects of inhalational anesthesia. After surgery, patients are reconnected to wall-mounted warming units in PACU, so we can maintain normothermia until discharge. (A normothermic temperature reading is one of the standardized criteria we use to determine discharge readiness.)

We also use warmed IV fluids, which have been shown to contribute to maintaining normothermia in surgical patients. A quick note here: Make sure warmed IV fluids are placed in a dedicated warming cabinet approved for keeping fluid warm — IV bags cannot be safely stored in blanket warming device — with a digital read out of the temperature at which the bags are warmed.

Our surgical team keeps irrigation fluids in a warming basin designed for that sole purpose in the OR. The basin keeps the fluids warm and displays a digital read out of the fluid's temperature. After open abdominal procedures, surgeons irrigate the wound cavity with the warmed irrigation solution before closing to avoid using fluids that are cooler than the patient's core body temperature.

EDUCATIONAL OPPORTUNITY
Post This Patient Warming Cheat Sheet
TALKING POINTS Connie Garrett, MSN, RN, CNL, CNOR, shows off the scripted notes her staff uses to inform patients about the importance of patient warming.   |  James A. Haley Veterans Hospital

Patients appreciate how active warming makes them feel, but are often unaware of the importance of maintaining normothermia. To ensure patients understand why our staff is constantly working to keep them warm, we laminated small tags that outline patient warming's clinical benefits and hung the tags on each warming unit in our facility. The tags note that active warming:

  • increases circulation;
  • promotes wound healing;
  • decreases risk of surgical site infection;
  • decreases risk of intraoperative bleeding;
  • decreases shivering, which impacts oxygenation;
  • decreases cardiac irritability; and
  • promotes smoother and faster emergence from anesthesia.

Staff members, even those who aren't fully up to speed on the importance of preventing hypothermia, can always refer to a standardized script when connecting patients to warming devices.

— Connie Garrett, MSN, RN, CNL, CNOR

Taking the temperature

We currently use ear probe monitors and digital oral thermometers to take patients' temperatures throughout the perioperative process, but we're looking forward to trialing a new non-invasive temperature monitoring system, which involves placing a disposable sensor on the patient's forehead. The sensor, which travels with the patient from pre-op to PACU, connects to small control units at various stops along the surgical pathway. The control units, which we've mounted next to EKG machines at each point of care, display easy-to-see digital temperature readings. When nurses routinely check EKG monitors, they can quickly glance at the patient's core temperature reading to decide if active warming methods are effectively maintaining normothermia.

COMFORT ZO\NE
Pamela Bevelhymer, RN, BSN, CNOR
COMFORT ZONE Patients appreciate how active warming makes them feel, but are often unaware of its clinical importance.

Having quick and easy access to continuous temperature readings would prove invaluable when talking with patients who feel warm and want us to turn down the heat. With a quick check of the control panel's digital display, our nurses could tell if stopping active warming would be appropriate. Nurses wouldn't have to disturb resting patients to take their temperature, instead determining with a quick glance at the digital display if the reading is within an acceptable range. The non-invasive forehead sensor also eliminates the need for using esophageal or rectal catheters to take the temperature of sedated patients in the OR.

The new monitoring system can automatically document temperature readings in some electronic health record platforms. That would take some of the recordkeeping burden off of our staff and help us meet requirements of the Surgical Care Improvement Project, which mandate the recording of a normothermic temperature reading within 30 minutes before or 15 minutes after anesthesia end time.

Efforts are heating up

Are our pre-warming efforts working? Anecdotally, they are. We don't yet have hard data to back up what we're observing on a daily basis — that temperatures are more often in the normothermic range and patients are more satisfied with their care — but our hopeful addition of the forehead monitoring system will let us more easily capture and track patients' temperature readings during every phase of their care, so we'll know for certain that we're doing all we can to keep them warm, safe and satisfied. OSM

Taking the temperature

We currently use ear probe monitors and digital oral thermometers to take patients' temperatures throughout the perioperative process, but we're looking forward to trialing a new non-invasive temperature monitoring system, which involves placing a disposable sensor on the patient's forehead. The sensor, which travels with the patient from pre-op to PACU, connects to small control units at various stops along the surgical pathway. The control units, which we've mounted next to EKG machines at each point of care, display easy-to-see digital temperature readings. When nurses routinely check EKG monitors, they can quickly glance at the patient's core temperature reading to decide if active warming methods are effectively maintaining normothermia.

COMFORT ZONE Patients appreciate how active warming makes them feel, but are often unaware of its clinical importance.

Having quick and easy access to continuous temperature readings would prove invaluable when talking with patients who feel warm and want us to turn down the heat. With a quick check of the control panel's digital display, our nurses could tell if stopping active warming would be appropriate. Nurses wouldn't have to disturb resting patients to take their temperature, instead determining with a quick glance at the digital display if the reading is within an acceptable range. The non-invasive forehead sensor also eliminates the need for using esophageal or rectal catheters to take the temperature of sedated patients in the OR.

The new monitoring system can automatically document temperature readings in some electronic health record platforms. That would take some of the recordkeeping burden off of our staff and help us meet requirements of the Surgical Care Improvement Project, which mandate the recording of a normothermic temperature reading within 30 minutes before or 15 minutes after anesthesia end time.

Efforts are heating up

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