Patient Perioperative Warming

Measure with very different weighting

What makes perioperative warming an SSI preventing aspect

"... the maintenance of normothermia has a significant benefit in reducing the risk of SSI when compared to non-warming standard care.”1

In this context, the WHO also mentions relevant benefits of warming strategies, such as a possible decrease in myocardial events, blood loss and transfusion requirements.1

In addition, it is reported that studies have shown a correlation between unplanned perioperative hypothermia and impaired wound healing, adverse cardiac events, altered drug metabolism and coagulopathies.1

Guidelines

Guidelines
GuidelineRecommendationCategory (if mentioned)
CDC2“Maintain perioperative normothermia.”Category IA; strong recommendation; high to moderate-quality evidence
“... To optimize tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement.”Category IA; strong recommendation; moderate-quality evidence
WHO1“The panel suggests the use of warming devices in the operating room and during the surgical procedure for patient body warming with the purpose of reducing SSI.”Conditional recommendation; moderate quality of evidence
NICE3,4“Maintain patient temperature in line with NICE's guideline on hypothermia: prevention and management in adults having surgery.”3-
“The patient's temperature should be measured and documented before induction of anaesthesia and then every 30 minutes until the end of surgery.”4-
“Standard critical incident reporting should be considered for any patient arriving at the theatre suite with a temperature below 36.0°C.4-
“Induction of anaesthesia should not begin unless the patient's temperature is 36.0°C or above (unless there is a need to expedite surgery because of clinical urgency, for example bleeding or critical limb ischaemia).”4-

“In the theatre suite:

  • the ambient temperature should be at least 21°C while the patient is exposed
  • once active warming is established, the ambient temperature may be reduced to allow better working conditions
  • using equipment to cool the surgical team should also be considered.”4
-
“The patient should be adequately covered throughout the intraoperative phase to conserve heat, and exposed only during surgical preparation.”4-
“Intravenous fluids (500 ml or more) and blood products should be warmed to 37°C using a fluid warming device.4-

“Warm patients intraoperatively from induction of anaesthesia, using a forced-air warming device, if they are:

  • having anaesthesia for more than 30 minutes or
  • having anaesthesia for less than 30 minutes and are at higher risk of inadvertent perioperative hypothermia.

Consider a resistive heating mattress or resistive heating blanket if a forced-air warming device is unsuitable.”4

-
“The temperature setting on forced-air warming devices should be set at maximum and then adjusted to maintain a patient temperature of at least 36.5°C.”4-
“All irrigation fluids used intraoperatively should be warmed in a thermostatically controlled cabinet to a temperature of 38°C to 40°C.4-
KRINKO5With the exception of therapeutically or protectively desired hypothermia, accidental hypothermia should be avoided, especially in colorectal surgery.-

HARTMANN:

Denise Leistenschneider, Senior Clinical Consultant
“Patient perioperative warming not only has a feel-good aspect, but obviously also contributes to SSI prevention.”

Some recommended instruction

Temperature

  • Keep patient’s temperature in the range of normothermia and avoid hypothermia2–5

  • Do not induce anaesthesia before patient’s temperature is 36.0°C or above.4

Control

  • Measure and document patient’s temperature before and during (every 30 minutes) anaesthesia/surgery.4

Warm fluids

  • Warm intravenous fluids (500 ml or more) and blood products to 37°C.4

  • Warm perioperative used irrigation fluids to 38°C–40°C.4

Warming devices

  • Use warming devices for patient body warming.4

Aspects influencing patient’s core temperature6

Patient-centred and external factors, e.g.

  • drugs

  • comorbidities

  • trauma

  • environmental temperature

  • type of anaesthesia

  • extent and duration of surgery

Relevance of patient’s core temperature6

Perioperative hypothermia has negative effects on, e.g.

  • coagulation

  • blood loss

  • transfusion requirements

  • metabolization of drugs

  • discharge from the post-anaesthesia care unit

  • surgical site infections

Click to see full list References
  1. WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.
  2. Berríos-Torres SI, et al. (2017) Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg; 152(8): 784–791.
  3. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020. www.nice.org.uk/guidance/ng125.
  4. NICE (2016) Hypothermia: prevention and management in adults having surgery. NICE guideline. Published: 23 April 2008. Last updated: 14 December 2016. https://www.nice.org.uk/guidance/cg65/resources/hypothermia-prevention-and-management-in-adults-having-surgery-pdf-975569636293.
  5. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
  6. Rauch S, et al. (2021) Perioperative Hypothermia – A Narrative Review. Int J Environ Res Public Health 18: 8749.

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