R ES E A RC H

Inadvertent Perioperative Hypothermia

Risks and Postoperative Complications:
A Retrospective Study
J. Luke Akers, BSN, RN; Amanda C. Dupnick, BSN, RN; Elisa L. Hillman, BSN, RN;
Andrew G. Bauer, BSN, RN; Lauren M. Kinker, BSN, RN; Amy Hagedorn Wonder, PhD, RN

ABSTRACT
Inadvertent perioperative hypothermia is a widely known patient condition that is associated with postoperative
complications. This retrospective comparative study of 298 surgical patients was conducted at a single hospital
site in the midwestern United States. Our aims were to describe risk factors and outcomes associated with periop­
erative hypothermia. We compared the type and frequency of patient factors, clinical factors, and postoperative
complications during the inpatient stay of the sample patients to determine whether there were factors or compli­
cations associated with perioperative hypothermia. Significant factors associated with the occurrence of periop­
erative hypothermia included older age and type of surgery. Hypothermia in patients was associated with a higher
rate of postoperative complications when compared with normothermic patients. Nurses and perioperative leaders
should understand the risk factors and complications associated with perioperative hypothermia to collaboratively
develop and test evidence-­based initiatives, improve care, and promote optimal patient outcomes.

Key words: perioperative hypothermia, postoperative complications, temperature monitoring, normothermia.

M any patients experience hypothermia during

their surgical procedures. Perioperative hypo­
thermia has been documented in patients
during various procedures (eg, total hip arthroplasty, colo­
rectal surgeries) with incidence rates ranging from 17.0%
and demographic features of a sample of surgical patients.
Then we compared the type and frequency of these
patients’ postoperative complications during their inpa­
tient stays to determine whether the complications were
associated with perioperative hypothermia.
to 88.6% depending on the type of surgery.1-3

STATEMENT OF PURPOSE
We designed our study to support the goal of develop­
ing structures (eg, education, policies) for more effec­
tive perioperative processes (eg, nursing assessment,
interventions, documentation) and promoting optimal
outcomes for patients (eg, reduced incidence of periop­
erative hypothermia and its complications). Initially, we
described the factors associated with the occurrence of
perioperative hypothermia by reviewing specific clinical
SIGNIFICANCE TO NURSING
Nurses can help reduce the occurrence of perioperative
hypothermia by using a comprehensive approach that
begins during the preassessment for surgery and ends at
discharge. Nurses should be aware of demographic (eg,
age, sex) and surgery-­related factors (eg, type of surgery)
that place patients at a higher risk for inadvertent perioper­
ative hypothermia. After identifying at-­risk patients, nurs­
es can make informed decisions about the frequency and
method of temperature monitoring and determine which

http://doi.org/10.1002/aorn.12696
© AORN, Inc, 2019
AORN Journal  741  
Akers et al
interventions should be used to help these patients main­
tain normothermia (eg, warm blankets, warming devices).
LITERATURE REVIEW
Perioperative hypothermia commonly is defined as a body
temperature less than or equal to 36.0° C (≤96.8° F) during
the perioperative continuum of care.4-6 Multiple studies
describe negative outcomes associated with inadvertent
hypothermia, including surgical site infection, coagulation
dysfunction, increased intraoperative blood loss, sepsis, and
mortality.3,7-10 Although the seriousness of postoperative
complications varies, one research group found that mor­
tality increased fourfold in patients who had experienced
perioperative hypothermia.7 To help minimize the risk of
negative patient outcomes, perioperative nurses should
• be aware of factors associated with higher risk for
developing perioperative hypothermia,
• use intraoperative warming techniques to prevent
perioperative hypothermia,
• assist anesthesia professionals with intraoperative
patient temperature monitoring, and
• communicate the plan to minimize patient postop­
erative hypothermia to the postanesthesia care unit
(PACU) nurses to help reduce the risk of postoperative
complication resulting from hypothermia.11
Demographic Factors
Studies consistently show that patients 60 to 65 years of
age and older are at greater risk for perioperative hypo­
thermia.6,7 The higher incidence of perioperative hypother­
mia may be related to decreased thermoregulation in
older adults.12 Some studies have shown a ­significantly
higher ­incidence of perioperative hypothermia in female pa­
tients;3,13 others show a higher incidence in male patients.7
Studies consistently show that patients 60 to
65 years of age and older are at greater risk for
perioperative hypothermia.
Surgery-­Related Factors
A greater incidence of perioperative hypothermia is
associated with open and laparoscopic abdominal
742  AORN Journal 
June 2019, Vol. 109, No. 6
procedures,4,14 total knee arthroplasties,10 and total hip
arthroplasties.3,10. Research indicates other independent
predictors of perioperative hypothermia include severe ill­
ness upon admission to the hospital, neurologic disorders
(eg, Alzheimer disease), and anemia.7
STUDY DESIGN
We used Donabedian’s quality improvement frame­
work—which shows the importance of good organiza­
tional structures to improve processes and, ultimately,
outcomes—to structure this project.15 We conducted a
descriptive, retrospective, comparative study at a large
(≤500 beds) academic hospital in the midwestern Uni­
ted States. This hospital has received the American
Nurses Credentialing Center’s Magnet Recognition. We
obtained approval from hospital administrators at the
study site and an institutional review board associated
with the facility before collecting data via retrospective
chart review in the summer of 2017. We used a stratified
random sampling method to select 300 closed patient
charts. We conducted a power analysis using G*power
(version 3.1), which determined that we needed a sam­
ple size of at least 300 for the planned nonparametric
analyses. We included patients 18 years of age and older
who underwent a hysterectomy, laparoscopic cholecys­
tectomy, colectomy, hernia repair, total knee arthroplas­
ty, or total hip arthroplasty during a three-­month period
in 2017. We excluded two patients who did not meet
the age requirement and included the remaining 298
patients in our analyses.
METHODS
We developed a 20-­item data collection form using infor­
mation in the literature regarding factors that may be
associated with perioperative hypothermia and input from
leaders at the study site. We created the form in REDCap
(Research Electronic Data Capture), a secure, web-­based
application. We used the form to capture
• demographic factors (ie, age, sex),
• surgery-related factors (eg, type of surgery, length of
time in surgery, type of anesthesia), and
• postoperative complications (eg, required blood trans­
fusion, low hemoglobin, low hematocrit, surgical site
infection, sepsis, pneumonia, mortality) that occurred
during the inpatient stay.
June 2019, Vol. 109, No. 6
We used the study site’s criteria for low hemoglobin and
low hematocrit (ie, hemoglobin <12 g/deciliter, hemato­
crit <35%). We performed retrospective chart reviews
that spanned preoperative care to discharge, looking for
documentation of blood transfusions, diagnosis of postop­
erative complications (eg, surgical site infection, pneumo­
nia, sepsis), length of time in surgery (≤60 minutes or >60
minutes), type of anesthesia, and mortality. To promote
consistency in data collection, our research team outlined
and discussed the process and collected data together
on the first day (initially reviewing the same chart at the
same time and then reviewing various charts at the same
time). The lead researcher audited the collected data and
found an interrater reliability of 97% among the five team
members.
Data Analysis
We analyzed the data using SAS (Version 9.4) and used
descriptive statistics for demographic and surgery-­related
factors. We summarized the categorical variables by fre­
quency and percentage of patients who experienced
either hypothermia or normothermia, and summarized
the continuous variables by mean, standard deviation,
median, minimum, and maximum. We tested for differ­
ences in means and proportions between hypothermic
and normothermic groups using the Wilcoxon rank sum
test and Fisher exact test. We set significance at P < .05.
RESULTS
We reviewed and analyzed 298 closed patient records.
Patients were primarily female (n = 178, 59.7%) and white
(n = 286, 96.0%). The mean age of the patients was 59
years (standard deviation [SD] = 15.7, range  =  20 to 93
years). Surgical procedures included hysterectomy (n =
39), laparoscopic cholecystectomy (n = 58), colectomy (n =
24), hernia repair (n = 49), total knee arthroplasty (n = 93),
and total hip arthroplasty (n = 35).
We found seven instances in which patients had doc­
umented temperatures below 36° C (96.8° F). All
hypothermic temperatures initially were documented
by nursing staff members during the immediate post­
operative period in the PACU. The mean temperature
when hypothermia was first documented was 35.3° C
(SD = 0.8° C, range = 34.1° to 35.9° C), which is equiv­
alent to 95.5° F (SD = 1.4° F, range = 93.4° to 96.6°
F). Of the seven incidents of hypothermia, hypothermic
Inadvertent Perioperative Hypothermia
temperatures were recorded on one (n = 4), two (n = 1),
and three (n = 2) occasions in the PACU with results as
low as 32.8° C (91.0° F).
Demographic and Surgery-­Related Risk Factors
for Perioperative Hypothermia
The mean (M) age of patients with perioperative hypo­
thermia (Wilcoxon U statistic = 1,587; P = .02; M = 72.9
years, SD = 15.9) was significantly higher than those with
normothermia (M = 58.6 years, SD = 15.6). There were no
significant differences in sex, race, or ethnicity between
the hypothermic and normothermic groups (P > .05).
The type of surgery performed on the patients signifi­
cantly differed between the hypothermic and normother­
mic groups (Fisher exact test table probability <  .0001;
P  <  .004). Perioperative hypothermia was noted in
patients who underwent colectomy (n = 4), hysterectomy
(n = 1), laparoscopic cholecystectomy (n = 1), and hernia
repair (n = 1) procedures. None of the patients in our study
who underwent either total knee arthroplasty or total hip
arthroplasty experienced hypothermia.
Perioperative hypothermia was noted
in patients who underwent colectomy
(n = 4), hysterectomy (n = 1), laparoscopic
cholecystectomy (n = 1), and hernia repair
(n = 1) procedures.
The type of anesthesia did not significantly differ between
the hypothermic and normothermic groups. Although
multiple combinations of anesthesia (eg, general anesthe­
sia used in conjunction with spinal anesthesia) were noted
in the total sample, general anesthesia was used exclusive­
ly for most procedures (n = 294, 98.7%). All seven patients
who experienced perioperative hypothermia received
general anesthesia only.
Postoperative Complications Associated With
Perioperative Hypothermia
Our study showed that during the inpatient stay, a sig­
nificantly greater percentage of hypothermic patients
AORN Journal  743  
Akers et al
experienced complications than the normothermic pa­
tients. Of the complications our study identified, the
hypothermic patients experienced low hemoglobin and
low hematocrit the most, and several of the patients who
experienced these two complications required a blood
transfusion. Table  1 shows the occurrence and signifi­
cance of the association between the two study groups
and each complication.
DISCUSSION
Our results show that older adults (ie, more than 60 years
old) were at greater risk for perioperative hypothermia.
Our finding that older age is a risk factor for hypother­
mia is consistent with previous studies that have shown a
greater incidence of perioperative hypothermia in adults
60 to 65 years of age and older.6,7
The significant difference in types of surgical procedures
in the hypothermia and normothermia groups warrants
consideration when identifying patients at higher risk. Our
finding is consistent with other studies that have shown
greater risk for hypothermia with abdominal procedures
than other procedures.4,8 Nurses also should consider
how inadvertent hypothermia affects patients postoper­
atively. One study identified a correlation between the
improvement of a patient’s temperature during abdomi­
nal surgery and the length of stay in the intensive care
unit.16 The study showed that for patients with an intra­
operative temperature between 34.2°  C (93.5° F) and
36.9° C (98.4° F), each one-degree centigrade increase
in temperature resulted in 31% less time in the intensive
care unit.16
Table 1. Postoperative Complications and Their Significance in Patients With and Without Hypothermia (N = 298)
Postoperative Complications Hypothermic Patients (n = 7)
Required blood transfusion 4 (57.1%)
Low hemoglobin 7 (100%)
Low hematocrit 7 (100%)
Surgical site infection 0 (0.0%)
Sepsis 1 (14.3%)
Pneumonia 1 (14.3%)
Mortality 2 (28.6%)
a
 Table probability from Fisher exact tests.
744  AORN Journal 
June 2019, Vol. 109, No. 6
A growing body of evidence shows a positive correlation
between length of time in surgery while under anesthesia
and the risk for perioperative hypothermia.4,6,13 However,
our findings did not corroborate this evidence (P = .5997).
Other studies show that combining multiple types of anes­
thesia increases the risk for perioperative hypothermia,6,13
suggesting that this approach reduces the body’s natural
ability to regulate core body temperature.13 However, our
findings did not support this given that all seven patients
with hypothermia received general anesthesia only.
We compared the frequency of postoperative complica­
tions that occurred during the inpatient stays of the hypo­
thermic and normothermic study patients. The occurrence
of low hemoglobin and hematocrit during the postoperative
inpatient stay in all patients with hypothermia is a signifi­
cant concern. Although this was regarded as a complication,
previous research has shown that preoperative anemia is a
predictor for perioperative hypothermia.7 In our study, the
lack of preprocedure laboratory test results precluded our
ability to gauge whether patients’ hemoglobin and hemat­
ocrit test results were low before surgery (placing patients
at higher risk for hypothermia) or normal before surgery
and became low after the procedure. Similarly, our finding
regarding the frequency of blood transfusions in the hypo­
thermic group is consistent with prior findings that patients
who experience perioperative hypothermia tend to have
higher rates of coagulation complications and increased
bleeding during procedures.4 Our finding of an increased
incidence of sepsis in hypothermic patients was consistent
with earlier research.7 Our result that showed periopera­
tive hypothermia was associated with increased mortality
also was consistent with evidence in the literature.7
Normothermic Patients (n = 291) Fisher Test Statistica P
6 (2.1%) <0.0001 <.0001
162 (55.7%) 0.0179 .0205
158 (54.3%) 0.0151 .0183
2 (0.7%) 0.9535 .9999
1 (0.3%) 0.0460 .0465
2 (0.7%) 0.0676 .0691
3 (1.0%) 0.0045 .0046
June 2019, Vol. 109, No. 6 Inadvertent Perioperative Hypothermia

Key Takeaways
◆ Many patients experience inadvertent perioperative hypothermia, commonly defined as a body tempera-
ture less than or equal to 36.0° C (≤96.8° F). Negative outcomes associated with inadvertent hypothermia
include surgical site infection, coagulation dysfunction, increased intraoperative blood loss, sepsis, and
mortality.

◆ This retrospective comparative study of 298 surgical patients at a single hospital site in the midwest-
ern United States was conducted to describe risk factors and outcomes associated with perioperative
hypothermia.

◆ Study results showed that older adults (ie, more than 60 years old) were significantly more likely to experi-
ence hypothermia and that abdominal procedures posed a greater risk for hypothermia than other proce-
dures. In addition, perioperative hypothermia was significantly associated with postoperative anemia, sepsis,
and mortality.

◆ Nurses should be aware of demographic and surgery-related factors that place patients at a higher risk for
inadvertent perioperative hypothermia.

LIMITATIONS administration of acetaminophen-containing products

A larger national study of perioperative hypothermia risk
factors and associated complications is needed to increase
generalizability of results in other settings and popula­
tions. We randomly selected the study sample from closed
patient charts, which resulted in unequal group sizes.
We found great variability in the frequency of tempera­
ture assessed and documented in both intraoperative and
PACU settings. Therefore, additional patients may have
experienced hypothermia that was undetected or was
detected and treated but not documented.
or nonsteroidal anti-inflammatory drugs; and
• no data collected on the development of complications
after discharge.
RECOMMENDATIONS
Our results support the idea that perioperative nurses
need to be aware of the risk of perioperative hypother­
mia. Perioperative leaders and nurses should collabora­
tively develop policies and procedures that address

All temperatures at the study site were documented as
axillary. Evidence shows there are inaccuracies associat­
ed with axillary measures17,18 and the significantly larger
standard deviations compared with other methods of tem­
perature assessment.17 We found no preprocedure labo­
ratory results in the hypothermic patients’ charts, which
hindered our ability to identify when anemia had occurred
(ie, preoperatively, intraoperatively, postoperatively) and
specific factors associated with its occurrence (eg, antibi­
otic administration, hemodilution with crystalloid use). We
identified additional limitations associated with our meth­
ods, including
• no expert panel or pilot study to validate the data col­
lection form;
• no assessment of confounding variables, including
preoperative and intraoperative warming, comorbid­
ities, and preoperative and intraoperative antipyretic
• accurate identification of at-risk patients;
• frequency, method, and documentation of temperature
assessment; and
• perioperative warming methods that reflect applica­
ble guidelines from national organizations (eg, AORN,
American Society of PeriAnesthesia Nurses).
Future research could focus on describing other factors
that were not included in this study that may contrib­
ute to the incidence of perioperative hypothermia (eg,
comorbidities, preoperative and intraoperative antipyret­
ic administration of acetaminophen-­containing prod­­ucts
or nonsteroidal anti-­inflammatory drugs) and normo­
thermia (eg, use of specific medications, fluids, warming
devices). Future research also could focus on the con­
tribution of anemia to hypothermia and complications
of hypothermia and other possible contributing factors
(eg, antibiotic administration, crystalloid administration).

AORN Journal  745  
Akers et al
Researchers also should investigate the causes of post­
operative mortality in patients with hypothermia. Add­i­
tional research is needed to determine the best methods
to measure temperature in all phases of perioperative
patient care. Finally, future studies should track the
recovery of patients with perioperative hypothermia
after discharge.
CONCLUSION
This retrospective chart review sought to determine
factors that are associated with perioperative hypother­
mia and to investigate its complications. We found that
older patients were significantly more likely to experi­
ence hypothermia. Further, we found that postoperative
anemia, sepsis, and mortality were significantly associ­
ated with hypothermia. Nurses should be aware of this
condition and be diligent in preventing hypothermia
and monitoring temperature to prevent postoperative
complications.
Acknowledgments: The authors thank Indiana University
(IU) School of Nursing for supporting this research project
and the baccalaureate honors program. The authors also
thank the following individuals: Susan Ofner, MS, biostatis-
tician, Department of Biostatistics, IU School of Medicine,
Indianapolis, for her statistical support through all phases of
the project; and Ryan Cook, MPH, data manager II, Depart­­
ment of Biostatistics, IU School of Medicine, Indianapolis, for
creating an electronic form of the instrument for data col-
lection and training the research team on secure, web-­based
data entry.
Editor’s notes: ANCC Magnet Recognition is a registered
trademark of the American Nurses Credentialing Center,
Silver  Spring, MD. REDCap is a registered trademark of
Vanderbilt University, Nashville, TN. SAS is a registered
trademark of SAS Institute, Inc, Cary, NC.
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J. Luke Akers, BSN, RN, is a staff nurse on the
Cardiovascular Recovery Intensive Care Unit at Indiana
University Health, Bloomington. He was a student at
Indiana University School of Nursing, Bloomington, at the
time this article was written. Mr Akers has no declared affil-
iation that could be perceived as posing a potential conflict of
interest in the publication of this article.
Amanda C. Dupnick, BSN, RN, is a staff nurse at the
Emergency Medicine and Trauma Center at Riley Hospital
for Children, Indianapolis, IN. She was a student at Indiana
University School of Nursing, Bloomington, at the time this
article was written. Ms Dupnick has no declared affiliation
Inadvertent Perioperative Hypothermia
that could be perceived as posing a potential conflict of inter-
est in the publication of this article.
Elisa L. Hillman, BSN, RN, is a staff nurse on the
Cardiovascular Surgery Intensive Care Unit at the Cleve­
land Clinic, OH. She was a student at Indiana University
School of Nursing, Bloomington, at the time this article
was written. Ms Hillman has no declared affiliation that could
be perceived as posing a potential conflict of interest in the
publication of this article.
Andrew G. Bauer, BSN, RN, is a staff nurse on the
Progressive Care Unit at The Ohio State University
Wexner Medical Center, Columbus. He was a student at
Indiana University School of Nursing, Bloomington, at the
time this article was written. Mr Bauer has no declared affil-
iation that could be perceived as posing a potential conflict of
interest in the publication of this article.
Lauren M. Kinker, BSN, RN, is a staff nurse on the
Coronary Intensive Care Unit at the Cleveland Clinic
Heart and Vascular Institute, OH. She was a student at
Indiana University School of Nursing, Bloomington, at the
time this article was written. Ms Kinker has no declared
­affiliation that could be perceived as posing a potential con-
flict of interest in the publication of this article.
Amy Hagedorn Wonder, PhD, RN, is an associate
professor at the Indiana University School of Nursing,
Bloomington. Dr Hagedorn Wonder has no declared affilia-
tion that could be perceived as posing a potential conflict of
interest in the publication of this article.
AORN Journal  747