Make Prewarming a Priority

Preventing inadvertent perioperative hypothermia, a complication that can cause a host of problems such as vasoconstriction, tissue hypoxia and an increased likelihood of acquiring an SSI, ultimately comes down to keeping your patients warm throughout the entire surgical journey — not just when they’re in the OR. Many facilities go to great lengths to keep patients warmed intraoperatively, which makes sense. That’s when patients’ core body temperatures tend to plummet.

Unfortunately, the practice of prewarming, or warming the patient preoperatively, still doesn’t get the emphasis it deserves. And that’s a mistake on several levels. Not only does prewarming decrease the chances of inadvertent hypothermia, it’s also a universal patient-pleaser.

At Advanced CardioVascular Solutions a heart and vascular center that in Oklahoma City, Okla., that aims to provide patient-first experiences for everyone who comes through its doors, prewarming means patients receive two warmed blankets as well as warmed gowns and socks, a unique take on traditional prewarming (warmed blankets only) that leads to plenty of positive patient comments. “When you hand a patient a warmed gown and you see them hugging the gown and thanking you, it’s a wonderful experience,” says Amanda Stanley, RN, BSN, CNOR, the center’s chief operating officer and chief nursing officer. Outside of the patient-centered warming measures that Advanced CardioVascular Solutions takes, staff also go to great lengths to make the pre-op bays as comfortable as possible temperature-wise. “We keep the thermostat in pre-op between 72 and 75 degrees,” says Ms. Stanley, adding that this is generally at least a few degrees warmer than their ORs.

When you hand a patient a warmed gown and you see them hugging the gown and thanking you, it’s a wonderful experience.
— Amanda Stanley, RN, BSN, CNOR

In addition to warmed blankets, gowns and socks, some patients at the facility undergo active warming measures during the preoperative phase. “It’s a clinical judgment,” says Ms. Stanley. “For instance, if the patient has an extremely low BMI, thin skin or has a low body temperature, we’ll take active warming measures in pre-op.” In addition, whenever patients are in pre-op for longer than an hour, they are also actively warmed.

Artesia (N.M.) General Hospital has a similar approach to prewarming its patients, many of whom undergo total joint surgeries and are released within the 23-hour period that is common with these procedures. Patients are generally admitted a few hours prior to surgery for education and prep, which includes treating the skin with CHG wipes and body hair clipping. All total joint patients are warmed preoperatively — most via warmed blankets —before they receive nerve blocks for intra- and post-operative pain control. 

However, there are occasions where active warming measures are administered preoperatively, says Randall Rentschler, RN, BA, CNOR, CSSM, TNS, perioperative service director at Artesia. “First we cover patients with warmed blankets, and if they’re obviously still cold after that we use active warming,” says Mr. Rentschler, who adds that his facility generally uses the 10-minute timeframe for active warming that is supported by the current literature.

While there are a multitude of benefits associated with prewarming patients, it’s important to remember keeping patients warm is something that must take place throughout the entire perioperative journey — from pre-op right through to the PACU. And while the bulk of facilities practice some form of intraoperative warming, there are challenges to maintaining normothermia in the OR as well. One prime example: The ambient temperature in the operating room. “Physician comfort can be an obstacle, because they are fully gowned and can become very warm while they work,” says Ms. Stanley. “Nurses and administrators are often combatting the ambient temperature of the room.”

Of course, because patient temperatures can drop to precipitous levels in an instant, temperature monitoring is critical to preventing hypothermia. Both Ms. Stanley and Mr. Rentschler have rigorous temperature monitoring practices in place from pre-op to the PACU, with an emphasis on the latter phase of the surgical journey. For instance, Ms. Stanley’s staff monitors patients’ temperatures every 15 minutes for the first hour after they arrive in the PACU, and every 30 minutes thereafter until they are eventually discharged. 

For facilities that have yet to implement a robust warming protocol but are considering doing more, Mr. Rentschler has some advice: “Just start,” he says. “Any warming measures you implement is better than not doing anything.”

This is true, of course, but ideally you should be keeping patients warm throughout the course of their surgical journey — as evidenced by the research. “There’s strong support in the literature that shows a normothermic patient has less pain and less chance of infection than a cold patient with even mild hypothermia,” adds Mr. Rentschler.

The most effective and appreciated way to prevent inadvertent hypothermia is through active warming. Ms. Stanley says that active warming is more soothing to the patient, although it does cost a bit more than warmed blankets. But that doesn’t mean you shouldn’t do it or avoid it due to the metrics. “You may end up discharging the patient sooner because of active warming,” she says. That, combined with a patient-satisfaction element, is a powerful incentive. OSM