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The Role of Irrigation FluidWarming in HypothermiaPrevention

A Continuing Education Activity

Sponsored By

Grant Funds Provided By


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Welcome to

The Role of Irrigation Fluid

Warming in HypothermiaPrevention

(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time.

Steps for Successful Course Completion

To earn continuing education credit, the participant must complete the following steps:

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needs and objectives. At the end of the activity, you will be assessed on the

attainment of each objective.

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reect the objectives.3. Complete the Test Questions. Missed questions will offer the opportunity to re-

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OVERVIEWPreventing unplanned hypothermia for all surgical patients is an important component of

perioperative nursing care. However, the development of unintended hypothermia is a

common occurrence throughout all phases of a patients perioperative experience. Thecomplications associated with unintended perioperative hypothermia are signicant and

well documented in the literature. Furthermore, treatment of these consequences incursunnecessary costs for health care facilities. Therefore, it is critical that perioperative

nurses understand the importance of maintaining normothermia in all surgical patients.

Today, there are several strategies available to maintain normothermia in surgical patients;

intraoperative irrigation uid warming is one method that makes hypothermia preventionan achievable goal. This continuing education activity will provide a review of the denitionand phases of unintended perioperative hypothermia. Patient complications due to

unplanned hypothermia and the clinical and cost benets of maintaining normothermia, as

documented in the literature, will be discussed. Finally, the role of intraoperative irrigationuid warming as an effective method to prevent unintended hypothermia, including itsclinical benets, warming methods, and best practices, will be outlined.

OBJECTIVESUpon completion of this continuing nursing education activity, the participant should be

able to:

1. Dene hypothermia.2. Distinguish the phases of unplanned perioperative hypothermia.

3. Identify the common patient complications associated with unintended

perioperative hypothermia as documented in the literature.

4. Describe the clinical and economic benets of maintaining normothermiathroughout a patients surgical experience.

5. Discuss the role of intraoperative irrigation uid warming in hypothermia

prevention.

INTENDED AUDIENCEThis continuing education activity is intended for nurses and other health care personnel

who are interested in learning more about the role of intraoperative irrigation uid warmingin preventing unplanned perioperative hypothermia.

CREDIT/CREDIT INFORMATIONAST CreditThis continuing education activity is approved for 3.0 CE credits by the Association ofSurgical Technologists, Inc. for continuing education for the Certied Surgical Technologistand Certied Surgical First Assistant. This recognition does not imply that AST approves orendorses and product or products that are discussed or mentioned in enduring material.


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RELEASE AND EXPIRATION DATEThis continuing education activity was planned and provided in accordance with accreditation

criteria. This material was originally produced inApril 2013and can no longer be used afterApril 2015 without being updated; therefore, this continuing education activity expires in April2015.

DISCLAIMERAccredited status as a provider refers only to continuing nursing education activities and does

not imply endorsement of any products.

SUPPORTGrant funds for the development of this activity were provided by ECOLAB.

AUTHORS/PLANNING COMMITTEE/REVIEWERSJulia A. Kneedler, RN, MS, EdD Aurora, CODirector of EducationPedler Enterprises

Judith I. Pfster, RN, BSN, MBA Aurora, CO

Program Manager

Pedler Enterprises

Kathryn Major, RN, BSN Aurora, COProgram Manager

Pedler Enterprises

Rose Moss, RN, MN, CNOR Elizabeth, CONurse Consultant


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Disclosure includes relevant nancial relationships with commercial interests related tothe subject matter that may be presented in this educational activity. Relevant fnancial

relationshipsare those in any amount, occurring within the past 12 months that

create a conict of interest. A commercial interestis any entity producing, marketing,reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Planning Committee/Authors/Reviewers:

Julia A. Kneedler, RN, MS, EdD Co-owner of company that receives grant funds from commercial entities

Judith I. Pfster, RN, BSN, MBA

Co-owner of company that receives grant funds from commercial entities

Kathryn Major, RN, BSNNo conicts of interest

Rose Moss, RN, MN, CNOR No conicts of interest

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INTRODUCTIONMaintaining normal body temperature (ie, a core body temperature in the range of 36C

to 38C [96.8F to 100.4F]1) throughout all phases of a patients surgical experience isa critical aspect of care for the perioperative nurse. One of the expected outcomes forall patients undergoing surgical or invasive procedures is that they are at or returning

to normothermia at the conclusion of the immediate postoperative period.2However,unintended or unplanned perioperative hypothermia, dened as a core temperaturebelow 36C (96.8F), is one of the most common complications associated with surgicalintervention, with an incidence of up to 20%.3The untoward effects of unintendedhypothermia and the benets of maintaining normothermia are well documented inthe literature. Therefore, perioperative nurses should understand the importance of

maintaining normothermia in all surgical patients and implement effective measures to

prevent hypothermia and its associated adverse effects; intraoperative irrigation uid

warming is one measure that plays a key role in achieving this outcome.

UNINTENDED PERIOPERATIVE HYPOTHERMIA: HOW AND WHYIn order to appreciate the role of irrigation uid warming as a strategy to maintainnormothermia, the bodys thermal regulation system and characteristics of the operating

room (OR) environment that contributes to the development of hypothermia must be

reviewed.

Normal Thermal Regulation ProcessThermal regulation is the bodys physiological mechanism to balance heat production

with heat loss.4The hypothalamus regulates body temperature in the central nervous

system by acting as a thermostat in response to temperature changes; vasoconstriction

or vasodilatation occurs to either increase or decrease the bodys temperature.5Normal

thermoregulatory vasoconstriction maintains the core body temperature two to four

degrees warmer than the peripheral temperature of the body.6Under normal conditions,

human thermoregulatory systems maintain a constant body temperature within a few

tenths of a degree centigrade of the normal body temperature of approximately 37C(98.6F).7In the OR, however, a combination of altered thermoregulatory mechanismsand intrinsic and extrinsic factors typically causes a decrease in core temperature.

The Effects of Anesthesia on Thermal RegulationUnder anesthesia, the bodys normal thermoregulatory mechanisms, in particular

vasoconstriction and shivering, are inhibited; therefore, inadvertent hypothermia (ie,

a core body temperature below 36C [96.8F]) is a recognized side effect of generalanesthesia.8This alteration in thermal regulation allows unwarmed patients to become

hypothermic.9It is not unusual for a patients core temperature to fall below 35C(95F) during anesthesia.10While the mechanisms may differ, hypothermia also is anunintended side effect of regional anesthesia (ie, spinal or epidural) because these

techniques alter the perception of cold in a conscious patient, thus allowing hypothermia

to go undetected.11


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There are three phases of unplanned hypothermia, as outlined below12:

Redistribution phase. In this phase, a rapid shift of heat from the bodys core tothe periphery occurs, resulting in a core temperature drop of approximately 1.6C(2.7F) during the rst hour after induction of anesthesia.13

Linear decrease phase. The initial temperature drop that occurs in the redistributionphase is followed by a slow linear decrease phase during the second andsubsequent hours of anesthesia; in this phase, heat loss exceeds the bodys abilityto metabolically produce heat. It is in this phase that warming the patient can

effectively limit additional heat loss.

Thermal plateau phase. The patients core body temperature often plateaus afterapproximately three to ve hours of anesthesia. This phase is characterizedby a core body temperature that remains constant, even during longer surgical

procedures.14

Mechanisms of Heat Loss in the ORIn addition to the redistribution temperature drop outlined above, maintaining normothermia

can be a challenge in the perioperative environment because of several factors inherent to

this practice setting. These include the low ambient temperatures in the OR, skin exposurecaused by the surgical procedure and positioning requirements, exposure of internal organs,and the use of room temperature irrigation and intravenous (IV) uids.15

Patients lose heat to the environment through four mechanisms: radiation, convection,

conduction, and evaporation; of these, the largest contributors to heat loss are radiation and

convection.16,17Each of these mechanisms are explained in greater detail below.

Radiation. All surfaces that exist at a temperature above absolute zero radiate heat;this radiated heat is absorbed by the surrounding surfaces. Therefore, the patient

radiates heat into the surrounding environment. Radiation accounts for the majority

of heat loss during surgery.

Convection. Under normal conditions, a thin layer of stationary air next to the skinacts as an insulator and limits conductive heat loss to surrounding air molecules.

When air currents disrupt this layer of air, its insulating properties are signicantlydiminished and heat loss increases. This is referred to as convection, or the wind

chill factor. In non-OR hospital settings, the room air exchange rate is normallyfour times per hour; in a typical OR, the air exchange occurs 15 times per hour,which makes an OR feel subjectively colder. While surgical drapes act as thermalinsulators to minimize convective heat loss, convective heat loss is considered the

second most signicant source of heat loss in the OR. Conduction. Conduction is the transmission of heat from one object to another,

eg, the patients body to a cold surface such as the OR table. The rate of heat

transfer depends on the temperature difference between the two objects and the

heat conductivity of the material. Conduction plays a minor role in heat loss during

surgery because the patient is in direct contact with the foam insulating mattress on

the OR table.


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Evaporation. Evaporation is the change of a liquid into a gas. This occurs atthe surface of a liquid where molecules with the highest kinetic energy are ableto escape, thus lowering the kinetic energy and decreasing the temperature.Evaporative heat loss generally occurs when sterile skin preparation solutions areapplied, but may also occur from the operative wound.

PATIENT COMPLICATIONS OF UNINTENDED PERIOPERATIVEHYPOTHERMIAThe combination of anesthetic-induced impairment of thermoregulatory control and

exposure to the cool OR environment makes most surgical patients hypothermic.18Several signicant patient complications associated with unintended perioperativehypothermia are well-documented in the literature, as outlined below.

Blood Loss and Transfusion RequirementsAn early study conducted by Schmied, et al, demonstrated that mild hypothermia

increases blood loss.19Blood loss and transfusion requirements were evaluated in60 patients undergoing primary, unilateral total hip arthroplasties; the patients wererandomly assigned to a normothermia group (dened as a nal intraoperative coretemperature of 36.6C) or a mild hypothermia group (dened as 35.0C). Crystalloid,colloid, scavenged red cells, and allogeneic blood were administered according to a

strict protocol. The study found that both intraoperative and postoperative blood loss

were signicantly greater in the hypothermic patients: 2.2 L for the hypothermic patientsversus 1.7 L for the normothermic patients. Eight units of allogeneic packed red cellswere required in seven of the 30 hypothermic patients, whereas only one normothermicpatient required a unit of allogeneic blood. A reduction of just 1.6C in core hypothermia

temperature increased blood loss by 500 mL (30%) and signicantly increased the needfor allogeneic blood transfusion. Based on these results, the authors concluded thatmaintenance of intraoperative normothermia reduces blood loss and allogeneic blood

requirements in patients undergoing total hip arthroplasty. This is important since there is

a growing body of evidence indicating that blood transfusions may be more harmful thanpreviously believed.20

Rajagopalan, et al, also conducted a meta-analysis and systematic review to evaluate

the hypothesis that mild perioperative hypothermia increases surgical blood loss

and transfusion requirements.21The authors conducted a comprehensive search of

published randomized controlled trials that compared blood loss and/or transfusion

requirements in normothermic and mildly hypothermic (34C to 36C) surgical patients.

A total of 14 studies were included in the analysis of blood loss; 10 studies were

included in the analysis of transfusion requirements. The results demonstrated thateven mild hypothermia (


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Surgical SiteInfection and Wound HealingSurgical site infections (SSIs) and impaired wound infections are common and serious

complications of anesthesia and surgery.22Today, SSIs are important clinical concerns.

According to data from the Centers for Disease Control and Prevention (CDC), in 2002an estimated 14 million operative procedures were performed in the U.S. SSIs have

been identied as the second most common healthcare-associated infection (HAI), asthey account for 17% of all HAIs in hospitalized patients.23A similar rate was obtainedfrom hospitals reporting data for 2006-2008 (15,862 SSIs following 830,748 operativeprocedures) with an overall rate of nearly 2%. While advances have been made ininfection control practices, SSIs remain a substantial cause of morbidity and mortality

among hospitalized patients. In one study, among the approximately 100,000 HAIsreported in one year, SSIs were associated with deaths in over 8,000 cases.24

It is estimated that SSIs increase postoperative hospitalization by an average of four

days and result in an increased attributable cost of $8,00025to $25,00026for each patient.

Hypothermia may contribute to perioperative wound infections in two ways. First, cooler

temperatures may directly impair neutrophil function; second, hypothermia may also

trigger thermoregulatory vasoconstriction.27The subsequent reduction in cutaneous

blood ow results in subcutaneous tissue hypoxia and failure of humoral immune defensesystems to reach target areas to ght infection.

Vasoconstriction-induced tissue hypoxia may also impair wound healing.28Scar formationrequires hydroxylation of proline and lysine residues to allow cross-linking within andbetween collagen strands to provide tensile strength. The hydroxylases catalyzing thisreaction depend on oxygen; because hypothermic vasoconstriction reduces the oxygensupply to tissues, there is a decrease in collagen deposition.

An early study conducted by Kurz, et al, examined 200 patients undergoing colorectalsurgery. The patients were randomly assigned to routine intraoperative thermal care

(ie, the hypothermia group) or additional warming (ie, the normothermia group); the

patients anesthetic care was standardized.29

In a double-blind protocol, their woundswere evaluated daily until discharge from the hospital and subsequently in the clinic

after two weeks. Wounds containing culture-positive pus were considered infected. Themean nal intraoperative core temperature was 34.7C 0.6C in the hypothermiagroup and 36.6C 0.5C in the normothermia group. Surgical wound infections werefound in 18 of 96 (19%) patients in the hypothermia group, but in only six of 104 (6%)patients in the normothermia group. In addition, suture removal was delayed by one day

in the hypothermia patients and their duration of hospital stay was prolonged by 2.6 days

(approximately 20%). The authors concluded that hypothermia itself may delay healingand predispose patients to wound infections; maintaining normothermia intraoperativelyis likely to reduce the incidence of infectious complications in patients undergoingcolorectal resection and shorten their hospital stay.

Melling, et al, also demonstrated the benets of warming patients to reduce the incidenceof wound infection.30In this study, 421 patients having clean surgical procedures (eg,

breast, varicose vein, or hernia) were randomly assigned to either a non-warmed (the


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standard) group or one of two warmed groups (either local or systemic). Warming was

applied for at least 30 minutes prior to surgery. The results of this study showed 19wound infections in 139 non-warmed patients (14%) but only 13 in the 277 patientswho received warming (5%). There was no signicant difference in the developmentof hematomas or seromas postoperatively, but patients in the non-warmed group were

prescribed signicantly more postoperative antibiotics. The authors concluded thatwarming patients before clean surgery appears to aid the prevention of postoperative

wound infection.

More recently, Hedrick, et al, who previously reported a 26% incidence of SSI inpatients undergoing elective colorectal resection, examined the effect of implementinga multidisciplinary wound management protocol that addressed several riskfactors, including hypothermia, in reducing the incidence of SSI.31The protocol

included maintenance of intraoperative normothermia (>36C [96.8F]) on patientsundergoing elective colorectal resection; the results were compared to baseline prior

to implementation of the protocol. The results demonstrated that compliance with

normothermia increased from 64% to 71%; the incidence of SSI fell from 25.6% to15.9%. The authors concluded that, after implementation of a multidisciplinary wound-management protocol, the incidence of SSI improved 39%. These results demonstratethat compliance with a prospectively designed protocol for perioperative care can

effectively reduce operative morbidity in patients undergoing colorectal procedures.

Adverse Outcomes after Off-Pump Coronary Artery Bypass Graft SurgeryHannan, et al, performed a retrospective study of 2,294 patients who underwent off-pumpcoronary artery bypass grafting to determine predictors of hypothermia and hyperthermia,

and the impact of hypothermia and hyperthermia on postoperative outcomes for off-pump

coronary artery bypass grafting.32The patients were classied as moderately to severelyhypothermic (34.5C), mildly hypothermic (34.6C to 35.9C), or mildly hyperthermic(37.5C to 38.8C) after leaving the operating room. Signicant independent predictorsof these temperature states and the independent impact of each of these states on

in-hospital mortality and complications were identied. The results showed that a total of37.7% of patients were mildly hypothermic, 9.0% of patients were moderately to severelyhypothermic, and 5.6% of patients were mildly hyperthermic. Signicant independentpredictors for postoperative hypothermia included older age, female gender, lower body

surface area, congestive heart failure, higher ventricular function, non-Hispanic ethnicity,

single/double-vessel disease, low postoperative hematocrit, previous cardiac surgery,

race other than white or black, and organ transplant. The patients with moderate tosevere hypothermia and those with mild hyperthermia had signicantly higher risk-adjusted in-hospital mortality than patients with normothermia. The patients with either

mild or moderate to severe hypothermia had signicantly higher rates of respiratoryfailure and unplanned surgical procedures. Patients with mild hyperthermia had a

signicantly higher rate of respiratory failure than normothermic patients. The authorsconcluded that it is important to maintain normal postsurgical core temperatures in

patients who have undergone cardiac surgery to minimize or avoid complications and

death.


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Morbid Cardiac EventsAn early randomized controlled trial conducted by Frank, et al, examined the relationshipbetween body temperature and morbid cardiac events (dened as unstable angina/ischemia, cardiac arrest, or myocardial infarction) during the perioperative period.33Three

hundred patients who either had documented coronary artery disease or were at high

risk for coronary disease undergoing non-cardiac (ie, abdominal, thoracic, or vascular)procedures were assigned to the routine thermal care (ie, hypothermic) group or to the

additional supplemental warming care (ie, normothermic) group. The results showed

that the mean core temperature postoperatively was lower in the hypothermic group

(35.4C 0.1C) than in the normothermic group (36.7C 0.1C) and remained lowerduring the early postoperative period. Perioperative morbid cardiac events occurred less

frequently in the normothermic group than in the hypothermic group (1.4% versus 6.3%,respectively). Hypothermia was an independent predictor of morbid cardiac events, ie,

there was a 55% reduction in risk when normothermia was maintained. Postoperativeventricular tachycardia also occurred less frequently in the normothermic group than in

the hypothermic group (2.4% versus 7.9%, respectively). The authors concluded that inpatients with cardiac risk factors who are undergoing noncardiac surgery, maintainingperioperative normothermia is associated with a decrease in the incidence of morbid

cardiac events and ventricular tachycardia.

Prolonged Drug EffectsBy decreasing drug metabolism, even mild hypothermia can lead to delayed awakeningand a prolonged length of stay in the post-anesthesia care unit (PACU).34,35Hypothermia

alters the effects of several classes of drugs, including muscle relaxants, volatile agents,and intravenous anesthetic agents.36,37Both hepatic and renal blood ow are diminishedin patients with mild hypothermia, which in turn decreases metabolism and drug

excretion, respectively; this results in a decrease in plasma clearance and an increase indrug effects.38

COSTS OF TREATING UNINTENDED HYPOTHERMIAThe patient complications resulting from the development of unintended hypothermiacause unnecessary costs for health care facilities today.

A 1999 meta-analysis of 18 studies covering 1,575 patients identied that even mildlyhypothermic patients (ie, those whose core temperature had dropped 1.5C below

normothermia) could experience an increase in adverse outcomes that were associatedwith additional health care costs ranging from $2,500-$7,000 per patient (see Table 1).39


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Table 1 Cost Effectiveness Associated with Maintaining Normothermia (perpatient)40

OutcomeCost Savings

(low end)Cost Savings

(high end)

Red blood cells (units) $117.60 $229.43

Plasma (units) $71.50 $76.90

Platelets (units) $33.07 $38.07

Length of hospital stay (days) $1,534.00 $4,602.00

Time in Intensive Care Unit (hours) $104.75 $314.25

Wound infections $545.40 $1,696.80

Myocardial infarction $67.67 $90.23

Mechanical ventilation $16.05 $25.68

Total cost savings $2,495.11 $7,073.55

After mortality $2,412.57 $6,839.55

Prevention InitiativesThese additional costs of care associated with adverse patient events have signicanteconomic consequences as health care facilities face increasing pressure from various

initiatives to improve the quality and safety of patient care.

As of 2009, hospitals are no longer reimbursed by the Centers for Medicare andMedicaid Services (CMS) for additional costs of care associated with certain hospital-

acquired conditions, including some SSIs which CMS deems as preventable.41The

acute-care Inpatient Prospective Payment System nal rule, which updated Medicare

payments to hospitals for scal year 2009, provided additional incentives for health carefacilities to improve the quality of care provided to Medicare patients by the inclusionof payment provisions to reduce preventable medical errors. In particular, if certain

conditions are not present upon admission, but are acquired during the course of the

patients hospital stay, Medicare no longer pays the additional costs of the hospitalization

and care; in addition, the patient is not responsible for these costs and cannot be billed.

Many private insurers followed this payment policy. CMS issued a nal rule that updatedscal year 2012 payment policies and rates for hospitals on August 1, 2011, as part ofthe 2010 Affordable Care Act. This rule continues the payment approach that incentivizeshospitals to adopt practices that reduces errors and prevents patients from acquiring new

illnesses or injuries during a hospital stay.42

As noted above, SSIs are common healthcare-associated infections (HAIs) today

and represent one of the leading causes of postoperative morbidity and mortality and

additional unplanned costs of care. Therefore, the Surgical Care Improvement Project

(SCIP), sponsored by CMS in collaboration with a number of other national partners,


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continues to focus on measures to reduce SSIs.43The 2013 National Prevention Targetis 95% adherence to process measures that prevent SSI, eg, appropriate prophylacticantibiotic administration and discontinuation; postoperative serum glucose level for

cardiac surgery patients, and hair removal for surgery patients. Preventing HAIs and

SSIs also continues to be a focus of The Joint Commission.44Goal seven of the 2013

Joint Commission National Patient Safety Goals is to reduce the risk of HAIs and SSIsby compliance with current hand hygiene guidelines and implementing evidence-basedprevention practices.

THE ROLE OF INTRAOPERATIVE IRRIGATION FLUID WARMING INHYPOTHERMIA PREVENTION

As demonstrated in the clinical studies cited above, unplanned perioperative hypothermia

is now widely recognized as a preventable cause of many complications and adverse

reactions in surgical patients, which not only impact patient safety, but also imposesignicant nancial consequences.45Therefore, perioperative nurses should implementeffective strategies to prevent this avoidable surgical complication.46While there are

several modalities available today for maintaining normothermia in surgical patients, this

discussion will focus on the role of warmed irrigation uid in preventing hypothermia.

Professional Nursing GuidelinesTwo professional nursing organizations support the use of warmed irrigation solutions to

prevent unintended perioperative hypothermia. The Association of periOperative Registered Nurses (AORN) Recommended

Practices forthe Prevention of Unplanned Perioperative Hypothermia47state

that interventions should be implemented to prevent unplanned perioperative

hypothermia. These recommendations include the use of warmed irrigation uid(near 37C [98.6F]) inside the abdomen, pelvis, or thorax as an adjunct therapyto reduce heat loss. When using warmed irrigation uids, to prevent patient injury,the temperature of the solution should be measured with a thermometer at the

point of use and veried prior to instillation. The American Society of PeriAnesthesia Nurses (ASPAN)Evidence-Based

Clinical Practice Guideline for the Promotion of Perioperative Normothermia48

also cites there is evidence that warmed irrigation uids, when used alone or incombination with forced-air warming, may maintain normothermia.

Clinical Studies: Benets of Warmed Irrigation FluidsThe benets of using warmed irrigation uids in preventing hypothermia across multiple

surgical specialties are also well documented in clinical literature.

Recently, Jin, et al, conducted a systematic review of randomized controlled trials to

establish whether warmed irrigation uid temperature could reduce the drop in bodytemperature and the incidence of shivering and hypothermia in patients undergoing

endoscopic procedures; this review included 13 studies with 686 patients.49The resultsdemonstrated that the use of room temperature irrigation uid caused a greater drop in


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core body temperature in patients, compared to the use of warmed irrigation uid. Theoccurrence of shivering and hypothermia was also lower in the patients who received

warmed irrigation uid than those patients who received room temperature uid. Theinvestigators concluded that in endoscopic surgical procedures, irrigation uid should bewarmed in order to decrease the drop in core body temperature and reduce the risk of

perioperative shivering and hypothermia; furthermore, warming irrigating uid should beconsidered standard practice in all endoscopic surgeries.

Mirza, et al, conducted a prospective observational study of 100 patients undergoingvarious types of endoscopic urological procedures (eg, cystoscopies, transurethral

resection of the prostate [TURP], transurethral resection of a bladder tumor [TURBT]percutaneous nephrolithotomy [PCNL]) to determine the temperature differencebetween preoperative and postoperative core temperatures and also to establish if this

change was related to patient age, weight, type of anesthetic, type and duration of the

procedure, amount of irrigation uid used, and if warming the irrigation uid to 37Cmade a difference in the degree of core temperature change.50The highest degree of

temperature drop was seen in the patients in the PCNL group. There was a signicantrelationship between the duration of the procedure and the temperature drop and also

the amount of irrigation uid used. The mean temperature drop for patients who receivedirrigation uid at room temperature (43 patients) was 1.37C and 0.95C for thosepatients who received uids that were warmed to body temperature (57 patients). Thistemperature difference is statistically signicant. These authors concluded that there

is a decrease in temperature in patients undergoing most genitourinary endoscopicprocedures; the cause appears to be multifactorial in origin, relating signicantly toweight, amount of irrigation uid used, and the type and duration of the operation.Warming irrigation uid to body temperature appears to signicantly reduce the degree ofcore temperature drop and consequently has potential benets.

Kim, et al, evaluated the effect of irrigation uid temperature on body temperature andother variables in a prospective randomized study of 50 patients undergoing arthroscopicshoulder surgery who received irrigation uid either at room temperature or warmed to

37C to 39C.51Core body temperature was checked at regular intervals and additionalvariables, such as length of anesthesia and surgery, amount of irrigation uid andintravenous uid used, amount of bleeding, weight gain, and postoperative pain werecollected intraoperatively and postoperatively.The results demonstrated that the nalcore body temperature was 35.5C 0.3C in the room temperature uid group and36.2C 0.3C in the warmed uid group. The temperature drop was 0.86C 0.2Cin the room temperature uid group and 0.28C 0.2C in the warmed uid group.Hypothermia occurred in 91.3% of patients in the room temperature uid group; whereas

the incidence of hypothermia was only 17.4% in the warmed uid group. Of the variablesmeasured, the patients age and amount of irrigation uid used correlated with core bodytemperature in the room temperature uid group; no variables correlated with core bodytemperature in the warmed uid group. The authors concluded that hypothermia occurredmore often in shoulder arthroscopic surgery when room temperature uid is used forirrigation than with warmed uid irrigation. The patients age and amount of irrigationuid used correlate with core body temperature when using room temperature irrigation


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uid. The use of warm irrigation uid during arthroscopic shoulder surgery decreasesperioperative hypothermia, especially in elderly patients.

An earlier study conducted by Board and Srinivasan designed to investigate therelationship between irrigation uid temperature and core body temperature in patients

undergoing arthroscopic shoulder surgery demonstrated similar results.52

Twenty-four consecutive patients undergoing arthroscopic subacromial decompression were

assigned to receive irrigation uid at either room temperature (22C) or warmed to 36C.There were no statistically signicant differences between the two groups in any of thepreoperative parameters. Core temperature was monitored throughout the procedure; the

maximum drop in core temperature for each patient was calculated. The results showedthat the mean maximum drop in core temperature was 1.67C in the room temperatureuid group and 0.33C in the warmed uid group. Additionally, the drop in coretemperature in the room temperature uid group persisted throughout surgery and onlynormalized postoperatively; however, the drop in the warmed uid group was transient,with core body temperature stabilizing after 30 minutes in most cases. Two patients inthe room temperature uid group were noted to suffer from severe shivering during theimmediate postoperative period. The authors concluded that, since core temperature

may be affected by the temperature of the irrigation uid, all arthroscopic shouldersurgeries should be performed with irrigation uid warmed to 36C.

Procedures Which Benet Using Warm Fluid

Warm irrigation solutions may be benecial to patients in preventing hypothermia inmany surgical specialties, ie, not only in large, open abdominal procedures, but for labor

and delivery, ENT, neonatal, and neurosurgery procedures as well. The use of warmedirrigation uid has been shown to decrease the drop in core temperature in patientsundergoing laparoscopic surgery.53

Irrigation Fluid Warming: Methods and Best PracticesWhen using warmed irrigation solution, it is important that it is at the right temperature

at the time of use during the surgical procedure (see Figure 1) to minimize the risk forpatient injury.

Risks to patient safety can occur when irrigation uid is either colder (risk of low coretemperatures and hypothermia) or too hot (risk of patient burn, tissue damage).

Figure 1 Patient Risks Associated With Irrigation Fluid Temperature

Normothermia

Risk of Hypothermia Risk to Patient Safety


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There are three methods for warming irrigation uid. Each of these is described in greaterdetail below:

1. Saline bottles in a cabinet warmer,

2. Closed uid warming systems, and

3. Open basin active warming systems.

1. Saline bottles in a cabinet warmer (see Figure 2).Solution bottles for irrigationand blankets should be stored in separate warming cabinets. ECRI recommendsthat the temperature of solution warming cabinets should be limited to 110F(43.3C), as temperatures above this level unnecessarily increase the risk ofburns and pose a patient safety risk.54AORN recommends that the solution-warming cabinet temperatures should be limited to the specications provided

by the solution manufacturer; additionally, the cabinet temperature shouldbe routinely monitored and documented on a temperature log or on a record

provided by an electronic recording system, according to facility policy.55

Figure 2 Example Fluid Warming Cabinet

However, storing saline bottles in a warming cabinet is not really that simple.

Because irrigation uid is considered a medication and saline has a limitedlifespan once placed in the warmer, the solution bottles must be labeled and

rotated in the cabinet. Some of the specic guidelines are:

Limit storage of bottles from three to 30 days at elevated temperature,depending on the saline brand;

Label each bottle with an expiration date and discard after this date; and

Do not put bottles back into cabinet after they are already warmed.

The AORN Recommended Practices also state that uids kept in warmers shouldbe labeledwith the date they should be removed or the date on which they areplaced in the warmer; solutions should be rotated on a rst-in, rst-out basis.56


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The advantages of using saline warmed in cabinet warmers include:

The relatively low cost to maintain after capital purchase; and

That warm bottles of saline are readily available for use.

The disadvantages include:

The space and location concerns;

Staff time is required to label and rotate saline inventory and routinelymonitor cabinet temperatures; and

The need to pull a bottle out of the warming cabinet close to the time ofuse. Overall, this is not an efcient use of nursing resources. Other safetyconsiderations include:

Possible changes in saline composition (more hypertonic, ie, highersalt content) under extended heat, and

Cabinet warmers can melt the saline bottles under prolonged heat.

Microwaves or autoclaves cannotguarantee a known or safe uid temperatureand therefore, should not be used to warm irrigation solutions.57

Another concern with this method is that even bottles taken from a warmingcabinet cool down quickly over time. It takes approximately seven minutes for abottle of uid to cool down to room temperature after it has been taken from the

cabinet warmer. In addition, uids that are too hot can risk injury, and those thatare too cold can risk hypothermia. Therefore, there is a very short time window ofve to seven minutes during which the uid temperature is appropriate for use.

2. Closed irrigation uid warming systems (see Figure 3).This type of system

warms the uid as it is being delivered to the patient. Its advantages include:

The temperature of the uid can be set and validated;

Standard size IV bags can often be used;

The irrigation uid is under pressure; and The uid is warmed quickly.

Closed irrigation systems are typically used when using large volumes of solution,

and delivery of the uid must be under pressure to deliver precise volumes toa small surgical site, as with laparoscopic surgeries. Unlike open uid warmingsystems, the method of closed irrigation systems do not allow cleaning the

surgical site or tissues with sponges, or washing the surgical site using a basin,

graduate, or container lled with uid.


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Figure 3 Example of Closed Irrigation Fluid Warming System

Considerations for use include that this type of system is typically used for

procedures requiring large volumes of uid or laparoscopic procedures; single

patient use tubing sets are required; and regular maintenance and/or calibrationof equipment may be required.

3. Open irrigation uid warming system (see Figure 4).An open irrigation uidwarming system warms the uid in an open basin, similar in practice to an openbasin on a ring stand, only the warming system providesimmediate access towarm irrigation uid within the sterile eld at a visible and controlled temperature.

Figure 4 Example Open Irrigation Fluid Warming System

The advantages of this type of system include:

It eliminates the need for labelling and rotating saline bottle inventory, whichis more efcient use of nursing time and effort.


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The visible display conrms the temperature of the uid at the time ofdelivery of the uid to the patient. This eliminates the guesswork of nursesand surgeons trying to determine the right temperature of the uid withtheir hands.

The temperature setting can be adjusted and locked with an accuracy of

2F. Immediate access to continuously warmed irrigation uid, at a veriable

temperature, is superior to using uid warmed in a cabinet, as this practicereduces the risk of patient burns from hot solutions or the risk of inadvertenthypothermia from solutions that have cooled down.

An early study by Harioka, et al, showed that the use of a continuouslywarmed irrigation system could prevent a decrease in body

temperature in patients undergoing transurethral resection of bladder

and prostate tumors under spinal anesthesia.58

A case report of an accidental burn during routine knee arthroscopydue to use of hot irrigation uid suggested that the temperature of anywarmed arthroscopic irrigation uid should be checked before andduring its use, since a warming cabinet may have a wide range of

temperatures within it despite an external thermometer and possiblyan unreliable temperature setting mechanism.59

The perioperative nurse can control and document uid temperature in thesterile eld, which assures optimal temperature in order to:

Minimize the risk for injury due to hot uids;

Improve patient safety and outcomes (eg, reducing the risk for costlySSIs);

Comply with the AORN recommendations for temperature control andverication of uid temperature before installation; and

Achieve the goals of CMS, SCIP, and The Joint Commission inreducing SSIs.

Considerations for use include that the system needs to be started during room

set up and covered with sterile drapes, as seen in Figure 4.

The key advantages and considerations for use of the three uid warmingmethods are summarized in Table 2.


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Table 2 Summary of Fluid Warming Methods

Advantages Considerations

Method 1: Saline Bottles in Warming Cabinets

Readily available supply of warmed uids Relatively low cost to maintain

Limited lifespan of warmed saline bottles

Possible changes in saline composition

Warmed saline bottles cool down quicklyover time

Saline bottles can melt under prolonged

heat

Space and location concerns

Inefcient use of staff time in pulling bottlesat time of use, labeling and rotating saline

inventory, routinely monitoring cabinet

temperatures

Method 2: Closed Irrigation Fluid Warming Systems

Fluid temperature can be set and validated

Standard size IV bags can typically be used

Irrigation uid is under pressure Fluid is warmed quickly

Used for large volumes of solution, when

uid must be under pressure to deliverprecise volumes to a small surgical site (eg,

with laparoscopic surgeries)

Does not allow easy cleaning of the surgical

site with sponges, or irrigating the surgical

site using a basin, graduate, or container

lled with warm uid Single patient use tubing sets are required

Regular maintenance and/or calibration of

equipment may be required

Method 3: Open Irrigation Fluid Warming Systems

Fluid is warmed in an open basin, similar in practice to

an open basin on a ring stand

Provides immediate access to warm irrigation uidwithin the sterile eld at a visible and controlledtemperature

Eliminates the need for labelling and rotating saline

bottle inventory Visible display conrms the temperature of the uid at

the time of delivery to the patient

Temperature setting can be adjusted and locked withan accuracy of 2F

Reduces the risk of patient burns from hot solutions orthe risk of inadvertent hypothermia from solutions thathave cooled down

Nurses can control and document uid temperature inthe sterile eld, which assures optimal temperature in

order to: Minimize the risk for injury due to hot uids Improve patient safety and outcomes

Comply with the AORN recommendations for

temperature control and verication of uidtemperature before instillation

Achieve the goals of CMS, SCIP, and The Joint

Commission in reducing SSIs

System needs to be started during room set

up and covered with sterile drapes


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SUMMARYUnintended perioperative hypothermia is dened as a core temperature less than 36.0C(96.8F) and is a common consequence of anesthesia and surgical intervention. Theuntoward effects of unintended hypothermia and the benets of preventing even mildhypothermia are well documented in the literature. Therefore, maintaining normothermia

throughout a patients surgical experience is a critical aspect of perioperative nursingcare. There are a number of interventions available today that allow the prevention of

perioperative hypothermia to be an obtainable goal. The use of warmed irrigation uidsis one measure that can be implemented to decrease the incidence of unintended

perioperative hypothermia. Furthermore, immediate access to continuously warmed

irrigation uid is superior to using uid warmed in a cabinet, as this practice reduces therisk of patient burns from solutions that may be too hot or hypothermia from solutionsthat are too cool. Through an increased awareness of the role of irrigation uid warming

in maintaining normothermia, perioperative nurses can reduce the risk for the adverseoutcomes and additional costs of care associated with unintended perioperative

hypothermia, thereby promoting positive patient outcomes.


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GLOSSARYAmbient Temperature The temperature of the immediate environment;

in the OR, the temperature should be maintained

between 20C to 23C (68F to 73F).

Conduction The transmission of heat from one object to another,eg, the patients body to a cold surface such as the

OR table; the rate of heat transfer depends on the

temperature difference between the two objects and

the heat conductivity of the material.

Convection The loss of heat as cold air moves across the thinlayer of stationary air next to the skin; also referred

to as the wind chill factor.

Core Body Temperature The temperature of the thermal compartment of thebody, which contains the highly perfused tissues and

major organs, as compared to the temperature of

peripheral tissues.

Evaporation The change of a liquid into a gas. Evaporative heat

loss occurs when sterile skin preparation solutionsare applied, but may also occur from the operative

wound.

Healthcare-Associated An infection acquired by patients duringInfection (HAI) hospitalization, with conrmation of diagnosis

by clinical or laboratory evidence. The infective

agents may originate from endogenous or

exogenous sources. HAIs, which are alsoknown as nosocomial infections, may not becomeapparent until the patient has been discharged

from the hospital.

Hypothermia A core body temperature less than 36C (96.8F).

Mild Hypothermia A core body temperature between 34C to 36C

(93.2F to 96.8F).

Normothermia A core body temperature between 36C to 38C(96.8F to 100.4F).

Radiation The transfer of heat from the patients body to thecolder environment in the form of radiant energy.


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Redistribution Hypothermia A decrease in body temperature occurring as heatis exchanged from the bodys core compartmentto the peripheral tissues.

Surgical Site Infection (SSI) An infection occurring at the site of a surgical

incision. The infection may be supercial, deep, ormay extend to organs.

Unintended Perioperative An unexpected core temperature decrease toHypothermia less than 36C (96.8F) as a result of surgery.


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18. Reynolds L, Beckmann J, Kurz A. Perioperative complications of hypothermia. BestPract Res Clin Anaesthesiol. 2008;22(4): 645-657.

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30. Melling AC, Ali B, Scott EM et al. Effects of preoperative warming on the incidenceof wound infection after clean surgery: a randomised controlled trial. Lancet. 2001;358(9285): 876880.

31. Hedrick TL, Heckman JA, Smith RL, Sawyer RG, Friel CM, Foley EF. Efcacy ofprotocol implementation on incidence of wound infection in colorectal operations. J

Am Coll Surg. 2007; 205(3):432-438.

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33. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance ofnormothermia reduces the incidence of morbid cardiac events. A randomized

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36. Leslie K, Sessler DI, Bjorksten AR, Moayeri A. Mild hypothermia alters propofolpharmacokinetics and increases the duration of action of atracurium.Anesth Analg.1995;80(5):1007-1014.

37. Heier T, Caldwell JE, Sessler DI, Miller RD. Mild intraoperative hypothermia

increases duration of action and spontaneous recovery of vecuroniumblockade during nitrous oxideisourane anesthesia in humans.Anesthesiology.1991;74(5):815-819.


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46. Lynch S, Dixon J, Leary D. Reducing the risk of unplanned perioperativehypothermia.AORN J. 2010; 92(5): 553-562.

47. AORN. Recommended practices for the prevention of unplanned perioperativehypothermia. In: Perioperative Standards and Recommended Practices. Denver,

CO: AORN, Inc.; 2013: 375-386.48. Hooper VD, Chard R, Clifford T, et al. ASPANs evidence-based clinical practice

guideline for the promotion of perioperative normothermia. J Perianesth Nurs.

2009:24(5):271-287.

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51. Kim YS, Lee JY, Yang SC, Song JH, Hoh HS, Park WK. Comparative study of theinuence of room-temperature and warmed uid irrigation on body temperature inarthroscopic shoulder surgery.Arthroscopy. 2009;25(1):24-29.

52. Board TN, Srinivasas MS. The effect of irrigation uid temperature on core bodytemperature in arthroscopic shoulder surgery.Arch Orthop Trauma Surg. 2008;128:531533.

53. Moore SS, Green CR, Wang FL, Pandit SK, Hurd WW. The role of irrigation in thedevelopment of hypothermia during laparoscopic surgery.Am J Obstet Gynecol.

1997; 176(3):598-602.

54. ECRI Institute. Warming cabinets. https://www.ecri.org/Documents/RM/HRC_TOC/SurgAn23ES.pdf. Accessed January 10, 2013.

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56. AORN. Recommended practices for a safe environment of care. In: PerioperativeStandards and Recommended Practices. Denver, CO: AORN, Inc.; 2013: 217-242.

57. Fogg D. Clinical issues. Absorbable hemostatic agents; transporting sterileinstruments; alcohol-based hand rubs; microwave warming of uid.AORN J. 2004;

80(1): 122-128.58. Harioka T, Murakawa M, Noda J, Mori K. Effect of continuously warmed irrigating

solution during transurethral resection.Anaesth Intensive Care. 1988;16 (3):324-328.

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