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Perioperative temperature control: Survey on current practices

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DOI: 10.1016/j.redar.2015.06.006

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Rev Esp Anestesiol Reanim. 2016;63(4):207---211

Revista Española de Anestesiología

y Reanimación
www.elsevier.es/redar

BRIEF REPORT

Perioperative temperature control: Survey on current

practices夽
N. Brogly ∗ , E. Alsina, I. de Celis, I. Huercio, A. Dominguez, F. Gilsanz

Servicio de Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain

Received 21 November 2014; accepted 3 June 2015

Available online 8 February 2016

KEYWORDS Abstract
Hypothermia; Introduction: Prevention of perioperative hypothermia decreases morbidity and mortality, as
Prevention; well as hospital costs. This study was conducted to evaluate the level of implementation of
Quality health care; protocols in 3 tertiary Spanish University Hospitals.
Assessment of Material and methods: A survey among anaesthesiologists assessed estimated importance and
professional practice; clinical practice in terms of prevention of perioperative hypothermia. Results were compared
Safety depending on their experience. p < 0.05 was considered significant.
Results: A total of 116 anaesthesiologists answered the survey, of whom 48 (41.3%) were resi-
dents, 32 (27.6%) were staff with less than 10 years of experience, and 36 (31.1%) staff with
10 years or more of experience, In a 0---10 importance scale, prevention of hypothermia was
scored 7.49 ± 1.79, with no difference between groups (p = 0.58). Younger staff were more con-
cerned of the end surgery temperature than other colleagues (p = 0.02). The most usual practice
was a combination warming the intravenous fluids and an electric blanket (55%). Only 20% of
the anaesthesiologists monitored temperature intra-operatively, even though 75% considered
it an important parameter. No unit had a written protocol for prevention of perioperative
hypothermia.
Discussion and conclusion: Despite the absence of prevention protocols, the anaesthesiologists
were aware of the importance maintaining a normal peri-operative temperature, but this aware-
ness is still not enough to influence their perioperative management to diagnose and prevent
hypothermia. A harmonisation of practice at local, regional and national level could improve
this practice in the future.
© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published
by Elsevier España, S.L.U. All rights reserved.

夽 Please cite this article as: Brogly N, Alsina E, de Celis I, Huercio I, Dominguez A, Gilsanz F. Control de la temperatura perioperatoria:
encuesta sobre las prácticas actuales. Rev Esp Anestesiol Reanim. 2016;63:207---211.
∗ Corresponding author.

E-mail address: nicolas0brogly@hotmail.com (N. Brogly).

2341-1929/© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights
reserved.
208 N. Brogly et al.

PALABRAS CLAVE Control de la temperatura perioperatoria: encuesta sobre las prácticas actuales
Hipotermia;
Prevención; Resumen
Calidad asistencial; Introducción: La prevención de la hipotermia perioperatoria disminuye la morbimortalidad y
Evaluación el coste hospitalario. Este estudio evaluó su nivel de aplicación en 3 hospitales universitarios
de prácticas españoles de tercer nivel.
profesionales; Material y métodos: Una encuesta entre anestesiólogos evaluó la importancia estimada y la
Seguridad práctica clínica en materias de prevención de la hipotermia perioperatoria. Los resultados se
compararon en función de la experiencia. Una p < 0,05 fue considerada significativa.
Resultados: Ciento dieciséis anestesiólogos contestaron a la encuesta, 48 (41,3%) residentes,
32 (27,6%) adjuntos de menos de 10 años de experiencia, y 36 (31,1%) adjuntos de 10 o más
años de experiencia. La prevención de la hipotermia fue evaluada con 7,49 ± 1,79 puntos en
una escala de importancia de 0 a 10, sin diferencias entre grupos (p = 0,58). Los adjuntos recién
graduados valoraban la temperatura al final de la intervención más que el resto de aneste-
siólogos (p = 0,02). El calentador de sueros, junto con una manta convectiva fue la medida de
prevención más habitual (47%). Solo un 20% de los encuestados monitorizaban la temperatura
intra-operatoria, aunque un 75% lo consideraban un parámetro importante. Ninguna unidad
disponía de un protocolo de prevención de hipotermia.
Discusión y conclusión: A pesar de no existir protocolos de prevención, los anestesiólogos son
conscientes de la importancia de la normotermia perioperatoria, pero aún no influye suficiente
en su manejo peri-operatorio para diagnosticar y prevenir la hipotermia. Una armonización a
nivel local, regional y nacional podría mejorar estas prácticas en el futuro.
© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado
por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction Materials and methods

Until recently in Spain, as in many other European countries,
perioperative temperature control was not considered an
important parameter.
A number of studies have been published since the end of
the last century showing the negative effects of inadvertent
perioperative hypothermia, defined as a core body temper-
ature below 36 ◦ C. Hypothermia in this context has been
associated with greater morbidity and mortality related
to increased incidence of surgical wound infection, car-
diovascular events (myocardial ischaemia, arrhythmia), a
higher rate of coagulation changes, increased blood loss,
longer hospital stays, hospital costs, and higher risk of
mortality.1---7
In the wake of a growing number of studies on hypother-
mia and the development of perioperative temperature
monitoring devices, various scientific societies and national
and international institutions have taken an interest in
perioperative hypothermia, and clinical guidelines on the
prevention and treatment of this condition have been
published.8---12 However, the extent to which clinicians in
Spain are aware of and follow hypothermia prevention and
monitoring strategies, and their understanding of the impact
of hypothermia on morbidity and mortality, has yet to be
determined.13,14
The aim of this study is to explore and evaluate, by means
of a questionnaire, the practices used by anaesthesiologists
from 3 Spanish tertiary teaching hospitals to detect and pre-
vent perioperative hypothermia.
Anaesthesiologists from 3 tertiary teaching hospitals com-
pleted the questionnaire during an interview with one of the
study evaluators. The questionnaire consisted of dichoto-
mous or multiple-choice questions aimed at evaluating the
strategies used to maintain normal temperature and the
perceived importance of perioperative hypothermia preven-
tion strategies.
The following parameters were evaluated: experience (in
years) of the anaesthesiologist (resident, specialist with less
than 10 years experience, and specialist with 10 or more
years of experience), existence of standardised protocols
for hypothermia management in different types of surgery,
measures usually used to monitor intra- and postoperative
temperature, and type of warming devices routinely used.
We also asked anaesthesiologists to list the types of surgery
and clinical situations in which these devices were most
important, and the ultimate aim of hypothermia prevention
strategies. They were also asked whether they considered
it important to measure body temperature before, during,
at the end and after surgery. The perceived importance
of hypothermia prevention was assessed on a scale of 0---
10 points (in ascending order of importance).
The parameters were analysed descriptively, qualita-
tive variables were compared using the chi-square test and
quantitative variables were analysed using the ANOVA test.
Quantitative variables were analysed both overall and by
levels of professional experience. Statistical significance
was set at p < 0.05.
Perioperative temperature control: Survey on current practices 209

60

50

40

30
55

20

10
16
10 9 10 7
4 3 2
0
Convective blanket

Conductive blanket

Fluid warmer

Radiator

Heated mattress

Cotton blanket

Convective blanket + fluid warmer

Conductive blanket + fluid warmer

+ radiator + heated mattress

Convective blanket + fluid warmer

+ fluid warmer
Conductive blanket + convective blanket

+ cotton blanket
Conductive blanket + fluid warmer

+ radiator
Conductive blanket + fluid warmer
Figure 1 Intraoperative hypothermia prevention measures.

Results prevent hypothermia (9.5%), improve oxygen saturation

(6.9%) and reduce the risk of infection (6.5%), with no sig-
A total of 116 anaesthesiologists were interviewed (38.6% nificant difference between groups (p = 0.27).
of the anaesthesiologists employed by the 3 study hospi- The anaesthesiologists considered prevention of periop-
tals): 41.3% were residents, 30.2% specialists with less than erative hypothermia to be important, rating it at 7.5 ±
10 years experience, and 28.5% specialists with over 10 years 1.8 points, with no significant difference between groups
experience. (p = 0.58). In addition, 28.4% of respondents stated that they
Hypothermia prevention protocols had not been imple- were concerned about preoperative temperature, with no
mented in any of the surgical departments in which they significant difference between groups (p = 0.20). In total 75%
worked, and only 20% of respondents routinely monitored of respondents considered it important to measure tem-
intraoperative body temperature, while 55% measured tem- perature during surgery, and 55.2% at the end of surgery.
perature in the postoperative period. The most commonly Specialists with less experience rated both these time points
used hypothermia prevention devices used were warming higher than other groups (p = 0.049 and p = 0.02, respec-
blankets (forced air convective systems or conductive warm- tively). Furthermore, 65.5% of specialists were concerned
ing blankets) together with fluid warming devices (56%), with postoperative body temperature, with no difference
although many different combinations of warming devices between groups (p = 0.27).
were used (Fig. 1).
When asked to evaluate the risk of hypothermia accord- Discussion
ing to type of surgery and patients status, 52% of residents
considered hypothermia prevention to be more important in
The response rate for this survey is similar to that reported
patients at the extremes of the body mass index (lower than
in other studies.13 However, our survey has a number of
15 kg/m2 or higher than 40 kg/m2 ), and 44% in prolonged
methodological limitations: temperature monitoring and use
interventions. Specialists with less experience considered
of hypothermia prevention devices may be overestimated
it to be more important in patients at the extremes of
(dilution effect) due to data being based on possibly exag-
age (31%) and in prolonged interventions (33%), while 90%
gerated statements made by anaesthesiologist in respect of
of experienced specialists considered it to be important in
real practice.
aggressive surgical procedures.
Current clinical practice related to perioperative tem-
Respondents considered hypothermia prevention strate-
perature management varies greatly. This could be due to
gies to be most useful in paediatric surgery (38%), cardiac
the wide range of surgical interventions included in the
surgery (21%), and general surgery (15.8%), with no differ-
field of anaesthesiology, and the absence of protocols in
ence between groups (p = 0.94) (Fig. 2).
responding hospitals. Nevertheless, the lack of protocols
The aims of active warming, according to respondents,
is not indicative of lack of interest: respondents rated
were: to prevent blood loss (40.5%), reduce tremor (16.4%),
the importance of hypothermia prevention strategies at
210 N. Brogly et al.

50

40

Number of patients
30

45
20

25
10
18

10
1 3 4 4 4
0
Neurosurgery

General surgery

Orthopaedics

Obstetrics and gynaecology

Burns and reconstructive surgery

Critical care

Urology

Maxillofacial surgery

Heart surgery

Thoracic surgery

Vascular surgery

Paediatric surgery

Non-surgical areas
Figure 2 Types of surgery in which patients benefit most from intraoperative hypothermia prevention measures.

7.5 on a scale of 10. Specialists with less experience showed 2. Hypothermia prevention should be discussed in profes-
greater interest in the problem of inadvertent perioperative sional forums to raise awareness of the problem and
hypothermia. educate anaesthesiologists.
Understanding of perioperative hypothermia has broad- 3. Measures should be adapted to each hospital setting.
ened since 2007, and anaesthesiologists are increasingly 4. Professional training tools must be developed and imple-
aware of the strategies available to prevent intraoper- mentation monitored.
ative hypothermia and the impact of this on high-risk 5. Effective, easily implemented monitoring and patient
interventions. These measures, however, have yet to be warming technologies should be developed and made
formalised into care protocols.13 Most respondents con- available to professionals.
tinue to inadequately monitor perioperative temperature:
the self-perceived rate of intraoperative monitoring has not These measures will be costly and time-consuming, but
changed since 2007, probably due to the inconvenience will ultimately substantially improve clinical practice and
of using current monitoring devices.11 This finding is sim- patient safety and lead to savings in the medium and long-
ilar to Castillo Monzón et al., who reported that 10% of term.16
respondents confirmed they monitored intraoperative tem- This survey has revealed a positive change in attitudes to
perature. According to the 2007 survey, active warming perioperative temperature control. Further progress will be
devices were used in 40% of surgical patients.13 The per- made when existing international guidelines are adapted to
centage of patients receiving active warming reported by the field of anaesthesiology and strict quality control meas-
Castillo Monzón et al. (70%) is far above the findings of our ures instigated by local committees. Quality control in the
survey, probably due to the wide range of activities of the evaluation of clinical practice is a new focus that should
anaesthesiologists interviewed, and the design of the study be implemented in the near future. In Spain, we must work
(self-perceived assessment). towards achieving the high standard of care set by national
Despite the recent publication of clinical guidelines, and international scientific societies and enshrined in the
the results of this survey of trends in the prevention of Declaration of Helsinki.17
inadvertent intraoperative hypothermia are disappointing.
International guidelines often carry too little weight to
effectively improve professional practice. Action on several
Conclusion
different levels is needed to improve care at the local level,
change entrenched attitudes and modify existing clinical Perioperative temperature control is an important but
practice15,16 : achievable goal. Monitoring and prevention strategies can
be easily and economically implemented and have proven
to be beneficial. Despite improved understanding, it is
1. Clinical guidelines need to be drawn up by Spanish sci- alarming to observe that international recommendations are
entific societies and local expert groups. consistently ignored. Variability in clinical practice can be
 Perioperative temperature control: Survey on current practices
overcome by introducing local protocols. This will improve
the quality of care and ensure that all hospitals across Spain
offer the same standard of care.
Conflict of interests
The authors declare they have no conflicts of interest.
References
1. Mahoney CB, Odom J. Maintaining intraoperative normoth-
ermia: a meta-analysis of outcomes with costs. AANA J.
1999;67:155---63.
2. Buggy DJ, Crossley AW. Thermoregulation, mild periopera-
tive hypothermia and postanaesthetic shivering. Br J Anaesth.
2000;84:615---28.
3. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to
reduce the incidence of surgical-wound infection and shorten
hospitalization Study of Wound Infection and Temperature
Group. N Engl J Med. 1996;334:1209---15.
4. Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypother-
mia increases blood loss and transfusion requirements during
total hip arthroplasty. Lancet. 1996;347:289---92.
5. Sessler DI. Perioperative heat balance. Anesthesiology.
2000;92:578---96.
6. Campos Suarez JM, Zaballos Bustingorri JM. Hipotermia
intraoperatoria no terapéutica: causas, complicaciones, pre-
vención y tratamiento (I parte). Rev Esp Anestesiol Reanim.
2003;50:135---44.
7. Zaballos Bustingorri JM, Campos Suarez JM. Hipotermia intra-
operatoria no terapéutica: prevención y tratamiento (parte II).
Rev Esp Anestesiol Reanim. 2003;50:197---208.
View publication stats
211
8. Inadvertent perioperative hypothermia: The management of
inadvertent perioperative hypothermia in adults: quick refer-
ence guide. London: National Institute for Health and Clinical
Excellence; 2008.
9. Forbes SS, Eskicioglu C, Nathens AB, Fenech DS, Laflamme C,
McLean RF, et al. Evidence-based guidelines for prevention
of perioperative hypothermia. J Am Coll Surg. 2009;209, 492-
503e1.
10. Hooper VD. Hypothermia: two tales of one temperature. J Peri-
anesth Nurs. 2010;25:139---40.
11. Mantenimiento de la normotermia. Guías de Práctica Clínica en
el SNS --- Ministerio de Sanidad, Política social e Igualdad. Guía
de práctica clínica para la seguridad del paciente quirúrgico;
2010. p. 124---40.
12. Torossian A, Brauer A, Hocker J, Bein B, Wulf H, Horn EP. Pre-
venting inadvertent perioperative hypothermia. Dtsch Arztebl
Int. 2015;112:166---72.
13. Torossian A. Survey on intraoperative temperature management
in Europe. Eur J Anaesthesiol. 2007;24:668---75.
14. Castillo Monzón CG, Candia Arana CA, Marroquín Valz HA,
Aguilar Rodríguez F, Benavides Mejía JJ, Álvarez Gómez JA.
Temperature management during the perioperative period and
frequency of inadvertent hypothermia in a general hospital. Rev
Col Anest. 2013;41:97---103.
15. Clarke CM, Persaud DD. Leading clinical handover improvement:
a change strategy to implement best practices in the acute care
setting. J Patient Saf. 2011;7:11---8.
16. Odwazny R, Hasler S, Abrams R, McNutt R. Organizational and
cultural changes for providing safe patient care. Qual Manage
Health Care. 2005;14:132---43.
17. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki
Declaration on patient safety in anaesthesiology. Eur J Anaes-
thesiol. 2010;27:592---7.