Preprocedure Warming Maintains

Normothermia Throughout the

Perioperative Period: A Quality
Improvement Project
Katie Hooven, BSN, RN, CAPA

Research supports the practice of preprocedure warming as a method to

prevent the development of unplanned perioperative hypothermia.
ASPAN defines hypothermia as a core temperature lower than 36 C.
The purpose of this quality improvement project was to explore the
idea that preprocedure warming maintains perioperative normother-
mia. Information was obtained through retrospective chart reviews
(n 5 148). Temperatures were compared for patients who received stan-
dard preprocedure care versus patients who were warmed with a warm-
ing gown for one hour preprocedure. Before the institution of warming,
about 50% of the patients received in the PACU were hypothermic. After
the warming was instituted, only 12% of patients were received in a hypo-
thermic state in the PACU. Concepts discussed in this paper include pre-
procedure warming, postprocedure hypothermia, and complications
associated with hypothermia.
Keywords: postoperative hypothermia, preprocedure warming, peri-
operative performance improvement.
Ó 2011 by American Society of PeriAnesthesia Nurses

HYPOTHERMIA is a very common problem in postoperative hypothermia. Careful monitoring

surgical patients, with numerous adverse effects
that have been well documented. Complications
include but are not limited to problems with co-
agulopathy, wound infection and healing, absorp-
tion of medicine, and pain.1-13 Research has
shown that preoperative warming is an effective
way to avoid or treat potential complications
that can arise from hypothermia.14 Patients should
be warmed throughout the perioperative period
by providing warm blankets and using various
warming devices to decrease the incidence of
of core temperature is also needed to validate
whether warming methods are effective.15 Evi-
dence supports the effectiveness of prewarming
in the prevention of postoperative hypothermia.16
Therefore, the purpose of this performance im-
provement project was to examine the effect of
preoperative warming on postoperative tempera-
ture in colorectal surgery patients.
Background

Katie Hooven, BSN, RN, CAPA, is an RN, St. Mary Medical
Center, Langhorne, PA.
The author reports no conflict of interest.
Address correspondence to Katie Hooven, St Mary Medical
Center, ASU, 1201 Newtown-Langhorne Rd, Langhorne, PA
19047; e-mail address: kjhooven@yahoo.com.
Ó 2011 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
doi:10.1016/j.jopan.2010.07.013
Body temperature is a regulation between heat
production and heat loss. The hypothalamus
is the most important temperature regulation cen-
ter of the body. Normal body temperature is 98.6 F.
A core body temperature less then 96.8 F is con-
sidered hypothermic. The body has thermoregula-
tory mechanisms, vasoconstriction and shivering,
that keep core body temperature at the most

Journal of PeriAnesthesia Nursing, Vol 26, No 1 (February), 2011: pp 9-14 9

10
desirable degree. Both of these mechanisms are in-
hibited during general anesthesia.12,17
Unplanned perioperative hypothermia (UPH) oc-
curs as a result of redistribution hypothermia, which
initially happens when the heat of the core
goes to the periphery of the body.18,19 The core
of a patient’s body is maintained at a temperature
of about 2 to 4 C warmer than the periphery.
This temperature difference is maintained by
thermoregulatory vasoconstriction throughout the
body. General anesthesia promotes vasodilatation
throughout the body and can lead to hypo-
thermia.20 Redistribution hypothermia can decrease
the core temperature by 1 to 1.5 C.21,22 Those most
susceptible to UPH include the elderly and/or female
patients. Other risk factors include the duration of
anesthesia, a history of diabetes, normal or low
body mass index, and the amount of body surface
or wound area that is uncovered.7,16 Preprocedure
active warming has been shown to reduce
the initial redistribution hypothermia during the
first few hours of anesthesia. When a patient is
warmed preoperatively, the body will store heat
in its periphery and will be able to maintain
a normothermic temperature longer than patients
who do not receive prewarming.23
UPH causes many problems for postoperative pa-
tients including altered medication metabolism
and protein metabolism; shivering, which increases
metabolic demands; altered tissue oxygenation and
perfusion; and impaired platelet function.24,25
Shivering increases oxygen demands by up to 500%
and induces discomfort, which also decreases tissue
perfusion, leading to the development of pressure
ulcers and infections.25
The consequences of hypothermia can affect a
patient directly after surgery and up to a few
weeks after. Hypothermic patients have an in-
crease in oxygen demand and energy expenditure,
which leads to an increase in the need for post-
operative mechanical ventilation.19,24 A meta-
analysis done by Mahoney and Odom21 indicates
that a 2 C drop in a patient’s temperature can in-
crease bleeding time by 100%. Patients who were
able to maintain normothermia had a decreased
length of stay in the postoperative intensive care
unit setting and were also able to be discharged
40% earlier than patients who became hypother-
mic. Hypothermic patients were also at a higher
KATIE HOOVEN
risk for infection and mortality.21 Additional re-
search showed an increase in hypothermia of per-
sons under 55 years of age who were unable to
compensate, and who therefore had an increased
mortality rate. A decrease in the production of in-
terleukin 2, which is a mediator in immune re-
sponse, also places the patients at a greater risk
for developing an infection. Hypothermia has
also been shown to increase blood pressure and
myocardial ischemia in patients with coronary ar-
tery disease. There is also an increase in the need
for transfusion of red blood cells, plasma, and
platelets, and also a reduced metabolism of drugs,
leading to an increased duration of action. Hypo-
thermic patients also have decreased repair of
damaged tissue and production of new tissue
when compared with patients who are normother-
mic, which places them at a greater risk for devel-
oping an infection.17,26
The application of heat as an intervention has been
used in the health care profession throughout all
different cultures for years. Heat can be delivered
to the body in many forms including conduction,
radiation, and convection. Nurses can warm a pa-
tient passively, which supports retention of heat
by providing insulation, and they can also warm
the patient actively, which increases the total
heat content of the body through an external
source. Passive warming is provided through
warm blankets, whereas active warming provides
a forced warm-air source or a blanket with electri-
cal heat.16 Research has shown that passive warm-
ing alone is not enough to prevent or treat
hypothermia, but active warming can maintain
normothermia in the surgical patient.14
Preoperative warming is an effective way to re-
duce the incidence of hypothermia that occurs in
the OR. Increasing the temperature of a patient’s
peripheries and therefore decreasing the tempera-
ture gradient from core to periphery will decrease
the likelihood of redistribution hypothermia.23
Even with all the research surrounding preproce-
dure warming, not all institutions use it as a stan-
dard of care.
Problem
In the surgical services department, registered
nurses (RNs) found a trend of patients who were
admitted to the PACU in a hypothermic state
PREPROCEDURE WARMING DURING THE PERIOPERATIVE PERIOD
(50%). As a quality improvement project, the
unit wanted to explore different options for main-
taining normothermia. The incidence of hypother-
mia was not seen in every patient, but overall, the
patients’ temperatures dropped by about 1 F
while in the OR. This was noted through a retro-
spective chart review.
Purpose
The purpose of the quality improvement project
was to determine whether the patients who received
preprocedure warming maintained normothermia
throughout the perioperative period. This was indi-
cated by a normothermic tympanic temperature
reading (96.8 -100.4 F) upon arrival to the PACU.
Current research shows a decrease in postoperative
complications when a patient stays normothermic
throughout the perioperative period.14
Methods
The quality improvement (QI) project was a com-
parison of temperature trends pre- and post-
practice change. The participating institution
implemented prewarming in March 2008 after
reviewing specific colorectal patients’ charts only
to find that most of the patients’ temperatures
dropped by about 1 F during their time in OR.
The measure of interest focused on the patients’
first recorded tympanic temperature when
they arrived in the PACU after a colorectal
procedure. The quality improvement project
took place over a two-year period from March
2007 to March 2009. During the first year, the
patients received the standard care, which did
not include prewarming. In March 2008, the RNs
on the unit were in-serviced on the use of the
new Bair Paws warming gown (Arizant, Inc, Eden
Prairie, MN) and prewarming was initiated. The
patients put on the gown in place of the regular
Table 1. Analysis of Variance for Temperatures of Warmed Versus Nonwarmed Patients
Controlling for Presurgical Temperature and Minutes in the OR
Prewarming
Postsurgical temp Yes
No
Mean preop to postop temperature Yes
change No
11
surgical gown and the active warming process
took place for one hour before the procedure.
Data analysis was conducted and compared for
each year.
Inclusion Criteria
The accessible population was patients having co-
lorectal surgeries. Surgeries included in the project
were hemicolectomy, laparoscopic colon resec-
tion, transverse colon resection, colon resection,
sigmoid colon resection, and ostomy.
Exclusion Criteria
Patients were excluded from the study if they had
an active infection that caused fever preopera-
tively. A fever was considered any temperature
above 100.4 F.27 This would also have given an in-
accurate representation of normothermia postop-
eratively. The highest temperature that was
included in the data collection preoperatively
was 99.1 F.
Measurements
The patient’s core body temperature was checked
using the Genius 2 infrared tympanic thermome-
ters (Covidien, Mansfield, MA). RNs checked the
patient’s temperature preoperatively before the
warming was initiated, and again postoperatively.
The nurses would place the thermometer in the
patient’s ear until they heard a beep and then re-
cord the digital reading in the patient’s chart.
The preprocedure warming blanket was the Bair
Paws patient gown, which was used in place of
a regular surgical gown. Before the project was ini-
tiated, the nurses involved were educated about
the importance of preoperative warming.

N Mean (SD) F P
77 97.56 (0.79) 1.67 .026
72 96.79 (1.18)
77 10.18 (0.99) 3.849 .052
72 20.92 (1.20)
12 KATIE HOOVEN

Table 2. Sample Demographics

No t test
Prewarming Prewarming Significance
N 149 77 72
Mean age (y) 64.87 62.90 P 5 .084
Mean weight (lb) 181.42 180.30 P 5 .918
Gender Male 36 37
Female 41 35
Average time in OR (min) 157.60 180.13 P 5 .048
Procedure Hemicolectomy 6 4
Open colon or sigmoid resection 28 14
Laparoscopic colon resection 40 48
Colostomy 3 5
Transverse colon resection 0 1
Presurgical temp ( F) 97.4 97.7 P 5 .008

Findings variables that had a significant difference. The non-

Data analysis was conducted using an analysis of
covariance. The distribution of the variables was ex-
amined including frequencies, means, and standard
deviations. The significance level was set at P , .05.
warmed patients were in the OR 32 minutes longer
on average then the warmed patients (P 5 .048)
The nonwarmed patients were 0.33 F warmer on
average when temperatures were taken prewarm-
ing (Table 2).

A total of 149 patients were included in the QI pro- Discussion

ject (warmed, n 5 77; nonwarmed, n 5 72). There
were 75 men and 73 women included in the anal-
ysis. The mean age was 63.9 6 13.4 years. Ages of
the patients ranged from 24 to 100 years. This was
a retrospective review of data and no patients were
identified. Data were collected over a two-year
period from March 2007 to March 2009. Twelve
patients were excluded from the analysis because
of preoperative fevers (Table 1).
Hypothermia presents a constant challenge for
nurses working in the perioperative setting, and
the prevention of hypothermia should be a stan-
dard of care in this environment.3 In this QI pro-
ject, it was found that using forced warm-air
blankets preoperatively decreased the incidence
of postoperative hypothermia in patients receiving
colorectal surgery (Table 3).

The patients who were prewarmed were very
similar to the patients who did not receive warm-
ing during the previous year. There were no signif-
icant differences in age, gender, weight, or the
number in each group. Intraoperative ambient
room temperatures were electronically controlled
at 68 to 72 F and remained the same throughout
the two-year period. The minutes in the OR
and the presurgical temperatures were the only
This QI project supports the idea that prewarmed
patients have a lower incidence of postoperative
hypothermia than patients who do not receive pre-
procedure warming. More research needs to be
done to focus on other types of surgical patients.
The positive results in this specific population of
colorectal patients in a specific institution gives
support for further projects on prewarming, and
a change in practice was implemented in the

Table 3. Percentage of Patients With Postoperative Hypothermia by Warming Group

Group Mean Temp ( F) Hypothermic* Percentage (N) Normothermic Percentage (N)
Preoperative warming 97.6 11.69 (9) 88.31 (68)
No warming 96.7 48.61 (35) 51.39 (37)
*Hypothermic 5 temperature less than 96.8 F.
PREPROCEDURE WARMING DURING THE PERIOPERATIVE PERIOD
Figure 1. Use of the Bair PawsÒ gown. This figure is available in color online at www.jopan.org.
surgical services area, which included prewarming
all of our colorectal surgery patients.
The implications concluded from the project are
not generalizable to every type of surgical patient.
These results can however support the existing
body of knowledge about the effect of preoperative
warming on a patient’s postoperative temperature.
This project served as a learning experience for the
author and as an educational opportunity for the
nurses involved. The project also initiated a change
in practice in the ambulatory surgical unit. From
this point, our unit may choose to examine some in-
traoperative warming interventions to keep the pa-
tients normothermic or expand the project to
incorporate all types of surgical patients.
Conclusions
Nurses play an important role in the care of patients
during the perioperative period, especially in
13
helping maintain their normothermia. Measures to
keep patients normothermic start with preventing
hypothermia. ASPAN’s clinical practice guidelines
support the idea that prewarming a patient is essen-
tial to prevent normothermia in the perioperative
setting.17 Figure 1 represents the use of the Bair
Paws gown in the preoperative setting.
There are many problems that hypothermia causes
for the postoperative patient. Knowing that these
problems can be avoided by keeping patients
normothermic is an important goal to strive for
as a perianesthesia nurse. This QI project found
that prewarming colorectal surgical patients
helped to decrease the amount of postoperative
hypothermia seen in the PACU.
Acknowledgments
The author would like to thank the surgical services RNs at
the participating hospital. A special thanks to Kathy Gray
14
Siracusa, PhD, MBA, RN, Research Coordinator, for her as-
sistance with the statistical analysis and guidance through
the process. Also, thanks to Pamela Ledger, MSN, RN,
References
1. Kurz A, Sessler DI, Lenhardt R. Perioperative normother-
mia to reduce the incidence of surgical-wound infection and
shorten hospitalization: Study of wound infection and tempera-
ture group. N Engl J Med. 1996;334:1029-1215.
2. Borms SF, Enmgelen SL, Himpe DG, et al. Bair Hugger
forced-air warming maintains normothermia more effectively
than Thermo-lite insulation. J Clin Anesth. 1994;6:303-307.
3. Murat I, Berniere J, Constant I. Evaluation of the efficacy of
a forced-air warmer (Bair Hugger) during spinal surgery in chil-
dren. J Clin Anesth. 1994;6:425-429.
4. Smith I, Newson CD, White PF. Use of forced air warming
during and after outpatient arthroscopic surgery. Anesth Analg.
1994;78:836-841.
5. Schmied H, Kyurz A, Sessler DI, et al. Mild intraoperative
hypothermia increases blood loss and allogeneic transfusion re-
quirements during total hip arthroplasty. Lancet. 1996;347:
289-292.
6. Rohrer M, Natale A. Effect of hypothermia on the coagula-
tion cascade. Crit Care Med. 1992;20:1402-1405.
7. Kurz A, Sessler DI, Christensen R, et al. Heat balance and
distribution during the core temperature plateau in anesthe-
tized humans. Anesthesiology. 1995;83:491-499.
8. Matsukawa T, Sessler DI, Sessler AM, et al. Heat flow and
distribution during induction of general anesthesia. Anesthesi-
ology. 1995;82:662-673.
9. Melling AC, Ali B, Scott EM, et al. Effects of preoperative
warming on the incidence of wound infection after clean
surgery: A randomized controlled trial. Lancet. 2001;358:
876-880.
10. Hohn L, Schweizer A, Kalangos A, et al. Benefits of intra-
operative skin surface warming in cardiac surgical patients. Br J
Anesth. 1998;80:318-323.
11. Horvath SM, Spurr GB, Hutt BK, et al. Metabolic cost of
shivering. J Appl Physiol. 1956;8:595-602.
12. Sessler DI, Rubinstein EH, Moayeri A. Physiological re-
sponses to mild perianesthetic hypothermia in humans. Anes-
thesiology. 1991;75:594-610.
13. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative
maintenance of normothermia reduces the incidence of morbid
KATIE HOOVEN
CPAN, CNA, Director of Surgical Services, for providing
me with the equipment, time, and support to perform
the QI project.
cardiac events. A randomized clinical trial. JAMA. 1997;277:
1127-1134.
14. Kumar S, Wong PF, Melling AC, et al. Effects of perioper-
ative hypothermia and warming in surgical practice. Int Wound
J. 2005;2:193-204.
15. Brendle TA. Surgical care improvement project and the
perioperative nurse’s role. AORN J. 2007;86:94-101.
16. Hooper VD, Chard R, Clifford T, et al. ASAPN’s evidence-
based clinical practice guideline for the promotion of perioper-
ative normothermia. J Perianesth Nurs. 2009;24:271-287.
17. Good KK, Verble JA, Secrest J, et al. Postoperative
hypothermia—The chilling consequences. AORN J. 2006;83:
1054-1060.
18. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of
mild perioperative hypothermia on blood loss and transfusion
requirement. Anesthesiology. 2008;108:71-77.
19. Hynson JM, Sessler DI. Intraoperative warming therapies:
A comparison of three devices. J Clin Anesth. 1992;4:194-199.
20. Sessler DI. Temperature monitoring and perioperative
thermoregulation. Anesthesiology. 2008;109:318-338.
21. Mahoney CB, Odom J. Maintaining intraoperative normo-
thermia: A meta-analysis of outcomes with costs. AANA. 1999;
67:155-164.
22. Sessler DI. Current concepts: Mild intraoperative hypo-
thermia. N Engl J Med. 1997;336:1730-1737.
23. Just B, Trevien V, Delva E, et al. Prevention of intraoper-
ative hypothermia by preoperative skin-surface warming. Anes-
thesiology. 1993;79:214-218.
24. Sessler DI. Complications and treatment of mild hypo-
thermia. Anesthesiology. 2001;2:531-543.
25. Scott EM, Leaper DJ, Clark M, et al. Effects of warming
therapy on pressure ulcers—A randomized trial. AORN J.
2001;73:921-938.
26. Scott EM, Buckland R. A systematic review of intraoper-
ative warming to prevent postoperative complications. AORN
J. 2006;83:1090-1113.
27. Bitner J, Hilde L, Hall K, et al. A team approach to the pre-
vention of unplanned postoperative hypothermia. AORN J.
2007;85:921-928.