Normothermia Guideline 12-10 JoPAN
Transcript of Normothermia Guideline 12-10 JoPAN
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ASPANs Evidence-Baso
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methods to integrate appropriate evidence; and
comprehensive and specific clinical coverage
based on current information.10,11 Guidelines are
ranking of practice recommendations.
Quality and Strength of Evidence andevidence for all ASPAN evidence-based clinical
practice guidelines. This tool ranks the strength
2010 by American Society of PeriAnesthesia Nurses1089-9472/$36.00
doi:10.1016/j.jopan.2010.10.006Address correspondence to e-mail address: [email protected] intended to serve as standards or absolute
requirements, but may be adopted, modified, or
rejected according to specific clinical needs andconstraints. Care based on evidence-based clinical
practice guidelines has been recognized by the
Agency for Healthcare Research and Quality
(AHRQ) and the Institute of Medicine (IOM) as
a key component in improving the quality, safety,
efficiency, and effectiveness of health care,1,12
and has been shown to positively impact clinical
Guideline Recommendations
Evidence-rating scales guide the clinician in evalu-ating the adequacy and sufficiency of research
and other types of evidence as they apply to a par-
ticular clinical problem. Criteria of interest include
the consistency of findings, type and quality of
studies, clinical relevance of findings, number of
sample characteristics similar to the situation in
which the findings will be applied, feasibility of
use in practice, and the risk versus benefit.23-25
Stetler and colleagues9,26 evidence rating scale
has been identified as the preferred instrument
for evaluation of the strength and quality of
Please see Appendix for author affiliations.Guideline for the PromNormothermia
Vallire D. Hooper, PhD, RN, CPAN,
Theresa Clifford, MSN, RN, CPAN, Susan Fe
Barbara Godden, MHS, RN, CPAN, C
Kim A. Noble, PhD, RN, CPAN, Denise OB
Jan Odom-Forren, PhD, RN, CPAN
Jacqueline Ross, MSN, RN, CPAN, Li
CLINICAL PRACTICE GUIDELINES are systemati-cally developed guidelines or statements designed
to assist the practitioner and/or patient in making
appropriate health care decisions in specific clinical
circumstances.1-3 Guideline development involves
a deliberate process of problem identification and
validation; exploration and retrieval of literature;rigorous review, critique, and synthesis of the
evidence; and design and recommendation of
a practice change.4-6 Guideline recommendations
are based on a body of evidence that can arise
from multiple sources including meta-analysis,
systematic reviews, randomized controlled trials
(RCTs), and expert opinion.7-9 Characteristics
common to quality clinical practice guidelinesinclude development by, or in conjunction
with, a professional organization; use of reliable346 Journal oed Clinical Practicetion of Perioperativeecond EditionN, Robin Chard, PhD, RN, CNOR,
, PhD, RN, Susan Fossum, BSN, RN, CPAN,
, Elizabeth A. Martinez, MD, MHS,
, MSN, RN, ACNS-BC, CPAN, CAPA, FAAN,
AN, Corey Peterson, MSN, CRNA,
Wilson, PhD, RN, CPAN, CAPA, BC
practice and patient outcomes across a wide
variety of specialties.8,13-22
ASPAN is committed to the promotion of the wel-
fare, health, well-being, and safety of patients,
and recognizes evidence-based practice (EBP) as
the critical link to improving nursing practiceand patient outcomes. To this end, ASPAN con-
vened an EBP Strategic Work Team in June 2004
to develop an organizational model for the devel-
opment, dissemination, and translation of evidence-
based clinical practice guidelines for all peri-
anesthesia practice settings. This model was
further refined by the team inOctober 2005 and in-
cludes specific guidelines for problem identifica-tion and prioritization, evaluation of evidence
quality and strength, and development and quality23,24f PeriAnesthesia Nursing, Vol 25, No 6 (December), 2010: pp 346-365
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fromof the evidence as levels ranging from a Level I,
which is a systematic statistical review of multiple
controlled studies (eg, meta-analysis), to a Level
VIII, which consists of consensus opinion ofrespected authorities, eg, a nationally known
guideline group. The quality of the evidence is
Table 1. Stetler
Level of Evidence Streng
Level I Systematic statistical review
Level II Systematic interpretive, tab
quantitative research
Level III Experimental studies; may
Level IV Quasi-experimental studies
interventional time serie
Level V Systematic interpretive, tab
qualitative research
Level VI Non-experimental studies,
qualitative research or sy
Level VII Systematically obtained, ve
Level VIII Consensus opinion of respe
*All such levels/sources of evidence must be of an acc
Notes.
1. Stetler, 2001b: Adapted from Utilization-focused inte
Rucki, S. Broughton, B. Corrigan, J. Fitzgerald, K. Giulian
11/4: 195-206.
2. Stetler, C. (2001). Evidence-based Practice and the U
Improve Care. DC: NOVA Foundation. (Only available
PROMOTION OF PERIOPERATIVE NORMOTHERMIAalso rated as A through D, with A reflecting the
highest quality study, and D representing findings
derived from a flawed study (see Table 1).
Supportive evidence for ASPAN evidence-based clin-
ical practice guideline recommendations is gatheredvia a structured, systematic search strategy. On the
basis of the type, amount, and quality of available
evidence obtained via a systematic search strategy,
assessment, intervention, and/or outcome recom-
mendations specific to the clinical problem of
interest are made. The recommendations are then
ranked to allow clinicians to make informed deci-
sions regarding incorporation of the guidelinesinto practice. Recommendations in these guidelines
are ranked using a modified version of the American
College of Cardiology/American Heart Association
(ACC/AHA) classifications (modified with permis-
sion of the ACC/AHA),27 which address the risk/
benefit ratio, and amount and quality of evidence
supporting the recommendation. Recommendation
classes are ranked from I to III, based on theclinical indication of the recommendation andconsideration of its risk versus benefit. These classes
are defined as follows27:
Class I: The benefit far outweighs the riskand the recommendation should be per-
formed or administered.
ence Hierarchy
f Individual External Evidence*
ultiple controlled studies (eg, meta-analysis)
integrative review of multiple studies, primarily of
lled randomized controlled trials (RCTs)
as non-randomized control group studies or
integrative review of multiple studies primarily of
as correlational, descriptive research, as well as
atically designed case studies
le quality or program evaluation data from the literature
authorities (eg, a nationally known guideline group)
le quality. Copyright Cheryl Stetler; 2001.
ve reviews in a nursing service, by C. Stetler, D. Morsi, S.
Havener, & E. Sheridan. Applied Nursing Research, 1998:
f Research: A Synopsis of Basic Concepts & Strategies to
the author.)
347 Class IIa: The benefit outweighs the risk andit is reasonable to perform or administer the
recommendation.
Class IIb: The benefit is equal to the risk andit is not unreasonable to perform or admin-
ister the recommendation.
Class III: The risk outweighs the benefit andthe recommendation should not be per-
formed or administered.
The above classes can be supported by 3 levels
of evidence (Level A-C) which are defined as
follows27:
Level A: Evidence frommultiple randomizedtrials or meta-analysis evaluating multiple
populations (3-5) with general consistency
of direction and magnitude of effect.
Level B: Evidence from single randomizedtrials or non-randomized studies evaluating
limited (2-3) populations.
Level C: Evidence from case studies, stan-dards of care, or expert opinion involvingvery limited (1-2) populations.
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tic
recommendations regarding the revision of the
1. Critique and synthesize the evidence regard-tain normothermia.
The prevention of unplanned perioperative hypo-
ing the promotion of perioperative normo-
thermia in the adult population to include:Clinical PracBackground
Content Expert: Jan Odom-Forren, PhD, RN,
CPAN, FAAN
Perioperative hypothermia, defined as a core tem-
perature below36 C, has adverse effects that rangefrom patient thermal discomfort to increased mor-
bidity and mortality.28,29 Even mild intraoperativehypothermia, a core temperature of 34 C to 36 C,has adverse consequences that are well docu-
mented. In a seminal study, Frank et al30 deter-
mined that hypothermic patients were three times
as likely to experience adverse myocardial out-
comes, and this is likely a conservative estimate.31
Hypothermia may directly impair neutrophil func-
tion or trigger subcutaneous vasoconstriction,which results in subsequent tissue hypoxia, causing
an increased incidence of surgical wound infec-
tion.29,32 Researchers have demonstrated that the
incidence of surgical site infection was increased
up to three fold after colon resection33 and signifi-
cantly increased in hypothermic patients undergo-
ing cholecystectomies.34 Interestingly, even when
patients with infectionswere excluded from the re-sults of one study, hypothermia increased the dura-
tionofhospitalizationby20%, likely due to impaired
healing of the wound.33 In a study of patients
undergoing hip arthroplasty, a reduction in temper-
ature of 1.6 C increased blood loss by 500 mL andincreased the need for allogeneic blood transfu-
sions.35 Preventing inadvertent perioperative
hypothermia significantly reduces blood loss andtransfusion requirements.28,36 Hypothermia also
causes prolonged and altered drug effects in many
drug classes, including muscle relaxants,37-39
volatile anesthetic agents,40 and intravenous
agents.38,41 Hypothermia has been linked to
pressure ulcer development42, increased length of
hospital stay for post-surgery patients33,43 and
delay of discharge from the PACU.44,45 Thermaldiscomfort has also been shown to decrease
patient satisfaction.46 There is clear evidence of
the consequences of hypothermia, thus providing
justification for evidence-based guidelines to main-
348thermia and promotion of normothermia remainsa national priority in the prevention of surgical siteASPAN Clinical Guideline for the Prevention of
Unplanned Perioperative Hypothermia, published
in 2001.49 The SWT included nationally recognized
academic and clinical practice experts from a wide
variety of geographic areas. Members included peri-
anesthesia nurses from all perianesthesia phases, an
anesthesiologist representing the American Society
ofAnesthesiologists (ASA), a nurse anesthetist repre-senting the American Association of Nurse Anesthe-
tists (AANA), a nurse representing the Association of
periOperative Registered Nurses (AORN), nurses
with expertise in clinical practice guideline develop-
ment, and representatives from the ASPANResearch
and EBP committees.
Consensus was defined by the group as 100%agreement regarding each guideline recommenda-
tion. While all guideline recommendations were
fully supported by all team members, the team
had agreed that if full agreement could not be
reached on a topic considered clinically important,
the majority and minority views would be pre-
sented in the guideline discussion.
Goals and Specific Aims
The SWT convened in October of 2008 in St. Louis,
MO, with the specific objective to improve healthoutcomes in adult surgical patients through the de-
velopment of a multi-disciplinary, multi-modal evi-
dence-based clinical practice guideline directing
the promotion of perioperative normothermia.
The specific aims of this conference were to:e Guidelineinfection, and has been designated as a quality mea-
sure by the Surgical Care Improvement Project(SCIP).47,48 Recognition of the continued adverse
impact of perioperative hypothermia on patient
safety and quality care prompted ASPAN to appoint
a Strategic Work Team (SWT) consisting of 11
multi-disciplinary, multi-specialty experts (Appendix)
charged with the systematic review and analysis of
published evidence and development of consensusHOOPER ET ALa. Identification and stratification of risk fac-
tors for perioperative hypothermia
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Gu
Alt
hy
the
wi
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as
prinv
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areideline Intent and Definitions
hough it is commonly agreed that perioperative
pothermia exists across all patient populations,
intent of this guideline is to provide clinicians
th an evidence-based, practical, bedside ap-
oach to the promotion of perioperative normo-rmia in the adult patient. The guidelines apply
both inpatient and outpatient settings and to
ocedures performed in the OR, aswell as in other
ations where sedation or anesthesia may be ad-
nistered. These guidelines are not intended to
ve as standards or absolute requirements, but
an evidence-based resource for anesthesia
oviders and perianesthesia/perioperative nursesolved in the care of adult patients at risk for, or
periencing perioperative hypothermia.
r the purposes of this guideline, the major terms
defined as follows:
Active Warming Measures: Active warm-ing measures include the application of
a forced air convection warming system,49
as well as circulating-water mattresses, resis-
tive heating blankets, radiant warmers,b. Identification of the clinical conse-
quences of perioperative hypothermia
c. Identification of preventative measures
for perioperative hypothermia
d. Identification of treatment recommenda-
tions for perioperative hypothermia
2. Develop multi-disciplinary, multi-modal,
evidence-based recommendations regardingthe promotion of perioperative normother-
mia in the adult population to include:
a. Temperature measurement
b. Preoperative assessment and manage-
ment
c. Intraoperative assessment and manage-
ment
d. Postoperative assessment and manage-ment
3. Identify areas of needed research to include:a. Gaps in the evidence regarding the pro-
motion of perioperative normothermia
b. Research priorities for the translation of
the source document (clinical practice
guideline) to practice
PROMOTION OF PERIOPERATIVE NORMOTHERMIAnegative-pressure warming systems,29 and
warmed humidified inspired oxygen. Assessment: A systematic and interactiveprocess of information gathering and analysis
for the purpose of identifying actual and
potential health problems and to evaluate
effectiveness of care.50
Clinical Practice Guidelines: Systemati-cally developed guidelines or statements
designed to assist the practitioner and/
or patient in making appropriate health
care decisions in specific clinical circum-stances.1-3
Core Temperature: The temperature of thecore thermal compartment, which is a well-
perfused compartment consisting of themajor organs of the trunk and head (not in-
cluding the skin and peripheral tissues).
This compartment maintains a relatively
stable temperature and provides the most
accurate indication of temperature during
periods of rapid temperature fluctuation.51
ExpectedOutcomes:Demonstrable changesin the patients status as a result of health
care intervention.50
Hypothermia: A core temperature less than36 C (96.8 F).49
ICU: Intensive care unit Normothermia: A core temperature range
of 36 C to 38 C (96.8 F to 100.4 F).49
Passive Thermal Care Measures: Passivethermal care measures include the applica-
tion of warmed cotton blankets, reflective
blankets, socks, and head covering, as well
as limiting skin exposure to lower ambient
room temperature.49
Perioperative: The time periods includingpreoperative, intraoperative, and postopera-
tive phases of surgical and anesthesia inter-
ventions.52
Phase I PACU: The nursing roles in thisphase focus on providing postanesthesia
nursing care during the immediate post-
anesthesia period, transitioning to a Phase
II level of care, the in-patient setting, or toan intensive care setting for continued care.
Basic life-sustaining needs are of the highest
priority. Constant vigilance is required dur-
ing this phase.53
Phase II PACU: The nursing roles in thisphase focus on the preparation for care in
349the home, extended observation, or an ex-
tended care environment.53
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Extremes of age (Class IIa, Level B)57,59,
Procedural duration (Class IIb, LevelC) Postoperative Shivering: Uncomfortablerhythmic muscle contractions.54
Prewarming: The warming of peripheraltissues or surface skin before induction of
anesthesia.55
Standard: Authoritative statements enunci-ated and promulgated by a profession by
which the quality of practice, service, or ed-
ucation can be judged. 50
Thermal Comfort: A patients perceptionthat they are neither too warm nor too cold.
Risk Factors for Perioperative Hypothermia
Content Experts: Vallire D. Hooper, PhD, RN,
CPAN, FAAN, Jacqueline Ross, MSN, RN, CPAN
The primary aim in risk factor identification in the
preoperative period is to determine the potential
risk of a patient developing hypothermia during
the perianesthesia/perioperative period. The con-
sensus group defined risk factors as an indepen-
dent predictor, not an associated factor of anuntoward event.56 Risk factors imply correlation
but not causation. A patient can have risk factors
and not develop perioperative hypothermia.
The content experts investigated the risk factors re-
lated to hypothermia during the perianesthesia/
perioperative experience. Medline and CINAHL da-
tabases were searched to locate published studieson risk factors for perioperative hypothermia in
the adult patient. The time frame searched was
January 1990 to September of 2008. Search terms
included hypothermia, perioperative complica-
tions, and risk factors. Twenty articles were re-
trieved and reviewed by the content experts.
Additional searches for non-indexed randomized
controlled trials using the reference lists of re-trieved articles were also conducted, with no
additional articles found. After review, it was deter-
mined that four of the articles did not pertain to
the question and theywere removed from the eval-
uation process, leaving 16 studies related to the
topic of interest. Although the range of surgical
procedures was varied, five studies involved ab-
dominal or colon procedures.46,57-60
In the investigation into risk factors, weight/body
350mass index (BMI)46,57,59,61-64 and age57,59,61-63,65
were the most common risk factors studied. Body surface/wound area uncovered (ClassIIb, Level C)
Anesthesia duration (Class IIb, Level C) History of diabetes with autonomic dysfunc-
tion (Class IIb/Level C)60
Temperature Measurement
Content Experts: Susan J. Fetzer, PhD, RN, Vallire
D. Hooper, PhD, RN, CPAN, FAAN
Although the measurement of core temperature
(eg, pulmonary artery, distal esophagus, nasophar-
ynx, tympanic membrane [via thermistor]) is the
best indicator of thermal status, core temperatures
are frequently not feasible andareunrealistic duringthe perianesthesia period. Skin temperature, easily
obtained during the perioperative period, is a func-
tion of external influences and thermoregulatory
function of the body. Clinically available near-
core measures (eg, oral, bladder, rectal, temporal61-63,65,70
Systolic blood pressure less than 140 mm Hg(Class IIa, Level B)58,66,69
Female gender (Class IIb, Level B)57,63 Level of spinal block (Class IIb, Level B)62
Risk Factors Supported by InsufficientEvidence (Class IIa or IIb, Level C)
BMI below normal (Class IIa, Level C)46,57,59,61-64
Normal BMI (Class IIb, Level C)61,63,67,68Ambient room temperature62,63,65,66 and duration
of surgical time61,63,67,68 were examined in four of
the studies. Studies also showed that patients
with a preoperative systolic blood pressure less
than 140 mm Hg were more likely to develophypothermia postoperatively.58,66,69 Gender was
investigated in two predictive models.57,63
Risk Factors Supported by Strong Evidence
There were no risk factors supported by strong
evidence.
Risk Factors Supported by Weak Evidence(Class IIa or IIb, Level B)
HOOPER ET ALartery, tympanic membrane [via infrared sensor],
axilla)must be relied on to evaluate thermal balance
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(Class IIb, Level B)across the perioperative period. Unfortunately,
each near-coremeasure has limitations in the ability
to reflect core temperature. Rectal measurements
are invasive and time-consuming, and positioning
for rectal temperature measurement in the peri-anesthesia period is difficult to impossible to
achieve. The difference between tympanic thermis-
tor and tympanic infrared measurements exceeds
1.5 C.71
The content experts conducted a comprehensive
and critical reviewof the research evaluating select
invasive and noninvasive temperature measure-ment methods used to evaluate core temperature.
Medline and CINAHL databases were searched
to locate published studies on temperature mea-
surement. The timeframe searched was January
1982 to September 2008. Search terms included
body temperaturemeasurement, core temperature
measurement, oral temperaturemeasurement, oral
body temperature, temperature measurement,temporal artery, temporal artery thermometer,
thermometer, tympanicmembrane, tympanic ther-
mometers, and chemical dot thermometry. Articles
were included if they were data-based, a clinical
study, included an adult population, and compared
a noninvasive core temperature measurement to
an invasive core measurement. Laboratory studies
and studies limited to the pediatric populationwere excluded. Thirty-seven articles were identi-
fied meeting the inclusion/exclusion criteria. The
references of these articleswere reviewed for other
research studies meeting the inclusion/exclusion
criteria.
The evidence revealed that it is generally accepted
that temperature inaccuracy between instrumentsshould not exceed 0.5 C.72 The majority of studiesseeking to validate the most appropriate measure-
ment device for clinical practice compare near-
core measures with some studies including a core
temperature for comparison. Infrared tympanic
membrane measurements have been compared
to axillary,73-75 oral,74,76,77 urinary bladder,75 and
temporal artery measures.74,76,78,79 Two studieshave specifically examined tympanic variability.80,81
Temporal artery measurements have been compared
to oral,74,76 and bladder.82 Four studies have tested
the ability of the chemical dot thermometer to
estimate an electronic oral temperature.83-86
PROMOTION OF PERIOPERATIVE NORMOTHERMIAOral, tympanic membrane and temporal artery
thermometers have been compared using theTemperatureMeasurementRecommendationsSupported by Conflicting Evidence
Oral chemical dot thermometers are accept-able near-core alternatives73,83-85 (Class I,
Level B)
Preadmission/Preoperative PatientAssessment and Management
Content Experts: Theresa Clifford, MSN, RN, CPAN,
Denise OBrien, MSN, RN, ACNS-BC, CPAN, CAPA,
FAAN
In an effort to reduce complications and costs asso-
ciated with perioperative hypothermia, it is imper-
ative to maintain normothermia throughout thecourse of the surgical continuum (Fig 1). It is diffi-
cult to treat hypothermia caused by heat redistri-ICU population, but only three studies sampled
perianesthesia patients.86-88
Overall the researchonperianesthesia temperature
measurement is weak due to a lack of controls, in-sufficient statistical analysis, and lackof replication.
TemperatureMeasurementRecommendationsSupported by Strong Evidence
Near-core measures of oral temperature bestapproximates core51,74 (Class I, Level B)
The same route of temperature measurementshould be used throughout the perianesthesia
period for comparison purposes86,87,89,90
(Class I, Level C)
Caution should be taken in interpreting ex-treme values (, 35 C, .39 C) from any sitewith near-core instruments72 (Class I, Level C)
TemperatureMeasurementRecommendationsSupported by Weak Evidence
Temporal artery measurements approximatecore temperature at normothermic tempera-
tures but not extremes outside of normother-
mia76,82,87,88,91,92 (Class IIb, Level C)
Infrared tympanic thermometry does not pro-vide accurate temperaturemeasurements dur-
ing the perianesthesia period51,72-74,76,87,93
351bution intra- or postoperatively because the
internal flow of heat is large and because heat
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intraoperatively than their non-prewarmed
counterparts.97-99,101 Prewarmed patients also
report
anxiety.1
operativ
and ne
len
co
in
ch
in
decre
PrReapplied to the skin requires a considerable amount
of time to reach the core compartment.94 An effec-
tive means of maintaining perioperative normo-
thermia is prevention through prewarming.95
Prewarming is defined as warming of peripheraltissues or surface skin before induction of anesthe-
sia.55 Prewarming reduces redistribution hypo-
thermia by two mechanisms, first by decreasing
the core-to-peripheral temperature gradient, and
secondly, by provoking vasodilation. The body
switches from the typical heat conservation
mode to heat dissipation.96 Without pre-warming,
a period of hypothermia is typical even ifactive warming is instituted after induction of
anesthesia.95
The content experts investigated preoperative
warming measures to define if specific patient pop-
ulations should be prewarmed, or if all patients
should be prewarmed. Medline and CINAHL data-
bases were searched to locate published studieson preoperative strategies for the prevention
of perioperative hypothermia. The time frame
searched was January 1982 through September of
2008. The search terms included preoperative
warming, perioperative hypothermia, forced air
warming, and active warming. Two-hundred
ninety-five articles and/or abstracts were retrieved
and reviewed by the content experts. Articleswere included for analysis if they were data-based,
included a sample of adults 18 years and older, and
specifically examined the effects of preoperative in-
terventions on intraoperative and/or postoperative
outcomes. Articleswere excluded if they referenced
only pediatric patients, laboring patients, or did not
use preoperative interventions to prevent inadver-
tent hypothermia. Fourteen studies were identifiedmeeting the inclusion/exclusion criteria. The refer-
ences of these articles were reviewed for any other
research studies that met the inclusion criteria.
Evidence reviewed included prewarming methods
and the minimal amount of time that a patient
should be prewarmed before anesthesia induc-
tion. The literature was relatively nonspecific re-lated to these issues. Researchers did demonstrate
that preoperative warming with forced air reduces,
but does not eliminate post-induction redistribution
hypothermia in all cases.97-100 In addition, patients
that are prewarmed with forced air will rewarm
352after the initial post-induction drop at a faster
rate intraoperatively. These prewarmed patientsanesthesia/surgical team106-108 (Class I,
Level A)
InterventionsB Implement passive thermal care mea-
sures109 (Class I, Level B)B Maintain ambient room temperature at or
above 24 C (75 F)110 (Class I, Level C)B Institute active warming for patients who
are hypothermic.111-116 (Class IIb, Level B)B Consider preoperative warming to reduce
the risk of intra/postoperative hypother-
mia97,98,103-105,117-119 (Class IIb, Level B)
- Evidence suggests prewarming for
a minimum of 30 minutes may reduce
the risk of subsequent hypother-mia103,105,119
Preadmission Testing/PreoperativeAdmission Expected Outcomesgth of stay,28,103 reduced total anesthesia
sts,103 decrease in ICU admissions,28 reduction
myocardial infarctions,28 reduced need for me-
anical ventilation,28 decreased time to extubation
mechanically ventilated patients,104 reduced inci-
nce of surgical site infection,105 and overall de-ased mortality.28
eadmission/Preoperativecommendations
AssessmentB Assess for risk factors for perioperative hy-
pothermia (see this guideline) (Class I,
Level C)B Measure patient temperature on admis-
sion (Class I, Level C)B Determine patients thermal comfort level
(Class I, Level C)B Assess for signs and symptoms of hypo-
thermia (eg, shivering, piloerection, and/
or cold extremities) (Class I, Level C)B Document and communicate all risk factor
assessment findings to all members of the Pagreater satisfaction and decreased02 Additional benefits associated with pre-e warming included decreased blood loss
ed for transfusions,28,103 shorter PACUwill also attain average higher temperatures
HOOPER ET ALtient will express thermal comfort
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were reviewed for any other research studies that
me
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but especially in patients who are at high risk oft the inclusion criteria.
e evidence reviewed indicated that when select-
an intraoperative intervention tobeused inaspe-c patient population, limitations associated with
e patient and the procedure of interest should be Nonemergent patients should be normother-mic prior to transfer to the OR/procedure
areaB Emergent patients should be warmed as
soon as clinically appropriate
Intraoperative Patient Assessment andManagement
Content Experts: Robin Chard, PhD, RN, CNOR,
Elizabeth A. Martinez, MD, MHS
Research indicates that patients are at risk for intra-
operative hypothermia largely due to an internal
core-to-peripheral redistribution of body heat.94
Furthermore, the greatest temperature decline
occurs during the first hour of surgery.94 To
detect and aid in the prevention of intraoperative
hypothermia, the content experts conducted a
systematic literature review to determine what in-
traoperative warming methods are supported by
the evidence and if there is a preferred single
or combination of interventions. The evidenceregarding intraoperative temperature monitoring
was also explored (Fig 2).
Medline and CINAHL databases were searched to
locate published studies on the specified topics.
The time frame searchedwas January 1982 through
September of 2008. Search terms included intrao-
perative warming, patient warming, forced-airwarming, warmed intravenous fluids and circulat-
ing water in addition to any identified warming
methods: circulating water mattress, circulating
water garments, Gel-pad, radiant heat, and resistive
warming. Randomized controlled trials that used
adult participants undergoing regional or general
anesthesia and used at least one method of intra-
operative warming as an intervention wereincluded. Pediatric studieswere excluded. Twenty-
five articles were identified meeting the inclusion/
exclusion criteria. The references of these articles
PROMOTION OF PERIOPERATIVE NORMOTHERMIAnsidered. For example, many of the studies may
t have been performed in the specific patienteither developing hypothermia or at increased
risk of suffering complications of hypothermia,
regardless of procedure length.
Intraoperative Recommendations
AssessmentB Identify patients risk factors for un-
planned perioperative hypothermia (See
this guideline)119 (Class I, Level C)B Frequent intraoperative temperature mon-
itoring should be considered in all cases(Class I, Level C)
B Assess for signs and symptoms of hypo-
thermia (Class IIb, Level C)B Determine patients thermal comfort level
(Class IIb, Level C)B Document and communicate all risk factor
assessment findings to all members of
the anesthesia/surgical team106-108 (ClassI, Level A)
InterventionsB All patients should receive the following:
Limit skin exposure to lower ambientenvironmental temperatures (Class I/
Level C)anesthetic time. It is the consensus of the commit-
tee that the implementation of methods to preventhypothermia should be considered for all patients,rming technique. Furthermore, theremay be lim-
tions to implementation of a specific warming
hnique, for example the limited area of skint canpotentially be covered by a forced airwarm-
device during a plastic surgery procedure in
ich large areasof skin (donor sites for skinormus-
flaps) are exposed for the surgical procedure.
ecific considerations in using the various warm-
methods are that all devices must be used ac-
rding to the manufacturers recommendations.rthermore, specific discussions should take
ce when there will be episodes of planned is-
emia (i.e. lower extremity revascularization)
d timing of warming. There is insufficient evi-
nce to support active warming for patients un-
rgoing procedures of less than 30 minutes ofon or procedure of interest, and there
different risks associated with a specific
353 Initiate passive warming measures(Class I/Level C).
-
clusion criteria. The references of these articles
354 HOOPER ET ALB There is evidence to suggest that alterna-
tive active warming measures may main-
tain normothermia when used alone or
in combination with forced air warming
(Class IIb/Level B). These warming mea-
sures include:
- Warmed IV fluids139,144-147 (Class IIa/
Level B)- Warmed irrigation fluids146,148 (Class
IIb/ Level B)
- Circulating water garments130,131,140
(Class IIb/Level B)
- Circulating water mattresses 126,135,136
(Class IIb/ Level B)
- Radiant heat133,141,142 (Class IIb/ Level
B)- Gel pad (Arctic Sun) surface warm-
ing128,149 (Class IIa/ Level B)
- Resistive heating133,141-143 (Class IIa/study evaluating the use of forced-air
warming devices compared its use ac-
cording to the manufacturers recom-
mendations versus placing the forced
air warming device between two
standard hospital blankets did not
report any thermal injuries,132 this
technique should never be used as it
falls outside of the parameters ofman-
ufacturer recommendations (Level C/
Class III).B Passive warming interventions in-
clude: cotton blankets, surgical dra-
pes, plastic sheeting and reflective
composites (space blankets).120
Maintain ambient room temperaturefrom 20-25 C based on AORN andarchitectural recommendations.121-124
(Class I/Level C)
B Patients undergoing a procedure with an
anticipated anesthesia time greater than
30 minutes (Class I/Level C) and/or who
are hypothermic preoperatively (Class I/
Level A), and/or patients at risk for hypo-
thermia (Class I/Level C) or at increased
risk for suffering its complications (Class
I/Level C) Forced air warming should be imple-mented61,103,104,118,125-143(Class I/Level A)
* Special Notation: Although oneLevel B)were reviewed for any other research studies that
met the inclusion criteria.
Evidence reviewed included studies evaluatingIntraoperative Expected Outcomes
The patient will be normothermic on dis-charge from the OR/procedure area
Postoperative Patient Management: PhaseI/II PACU
Content Experts: Susan Fossum, BSN, RN, CPAN,
Kim Noble, PhD, RN, CPAN
A majority of practitioners agree that temperature
management is one of the essential elements that
plays a role in a patients perception of well-being
and comfort during the perianesthesia/periopera-
tive period. Determination of the most effective
methods for postoperative rewarming should in-
clude consideration of overall patient comfort, im-prove patient outcomes, shorten PACU length of
stay, and generally decrease the cost of a hospital
stay for surgical patients.102
The content experts investigated postoperative
hypothermia patient management to determine
the most effective methods of maintaining patient
temperature, or rewarming the surgical patientduring the postoperative period. Medline and
CINAHL databases were searched to locate pub-
lished studies on postoperative temperature main-
tenance and rewarming strategies for the adult
surgical patient. The timeframe searched was Jan-
uary 1993 through September of 2008. The search
terms included postoperative hypothermia, post-
operative rewarming, postanesthesia care, andpostanesthesia warming. Forty-two articles and/
or abstracts were retrieved and reviewed by the
content experts. Articles were included for analy-
sis if they were data-based, included a sample of
adults eighteen years and older, and specifically ex-
amined various methods of postoperative temper-
ature management and/or rewarming and its effect
on patient outcomes. Articles were excluded ifthey referenced pediatric patients or rewarming
outside of the hospital environment. Nineteen arti-
cles were identified as meeting the inclusion/ex-passive thermal care measures (head covers,
-
reflectiv
warming
fluid-fille
rewarm
conclusair warm
care me
was eff
inconclu
circulati
rew
PhM Consider adjuvant measures:
139,144-
B Discharge teaching: Instruct the patient and
responsible adult of methods to maintain
PhasMana
Rese
In add
ciplin
for th
the SW
neede
the tr
of nee
tive n
Risk
PROMOTB Assess for signs and symptoms of hypo-
thermia (eg, shivering, piloerection, and/
or cold extremities) (Class I, Level C)
InterventionsB If the patient is normothermic, provide
thermal comfort measures:
- Implement passive thermal care mea-
sures109 (Class I, Level C)
- Maintain ambient room temperature
at or above 24 C (75 F)110 (Class I,Level C)
- Assess patient thermal comfort levelon admission, discharge, and more fre-
quently as indicated (Class I, Level C)
- Observe for signs and symptoms of
hypothermia (eg, shivering, piloerec-arming devices (Fig 3).114,116,150
ase I/II PACU Postoperative Patientanagement Recommendations
AssessmentB Identify the patients risk factors for peri-
operative hypothermia (see this guideline)
(Class I, Level C)B Document and communicate all risk factor
assessment findings to all members of the
health care team.106-108 (Class I, Level A)B Measure patient temperature on admis-
sion to the PACU (Class I, Level C)
- If normothermic, continue to measure
temperature at least hourly, at dis-
charge, and as indicated by patient
condition151 (Class I, Level C)
- If hypothermic, measure temperature
at a minimum of every 15 minutes un-til normothermia is achieved 151 (Class
I, Level C)B Determine patients thermal comfort level
(Class I, Level C)e blankets, and cotton blankets) and active
measures to include forced air warming,
d circulating blankets, negative pressure
ing, and humidified oxygen. The evidence
ively supports the effectiveness of forceding as compared with passive thermal
asures.111-116 Humidified inspired oxygen
ective in one study.62 The evidence is
sive on the effectiveness of fluid-filled
ng blankets112,140 and negative pressure
ION OF PERIOPERATIVE NORMOTHERMIAtion, and/or cold extremities) (Class I,
Level C)
Barch Indications
ition to developing evidence-based, multidis-
ary, multimodal clinical practice guidelines
e promotion of perioperative normothermia,
Twas also charged with identifying areas of
d research, as well as research priorities for
anslation of the guideline to practice. Areas
ded research in the promotion of periopera-
ormothermia are:
Factor Identificationnormothermia after discharge (eg, warm
liquids, blankets, socks, increased cloth-
ing, increased room temperature) (Class I,
Level C)
e I/II PACU Postoperative Patientgement Expected Outcomes
Patient achieves normothermia beforedischarge from the Phase I and/or Phase II
PACU
Patient verbalizes thermal comfort- Warmed intravenous fluids147 (Class IIb, Level B)
- Humidified warm oxygen62 (Class
IIb, Level C)
Assess temperature and thermal com-fort level every 15 minutes until normo-
thermia is achieved151 (Class I, Level C)or symptoms of hypothermia occur(Class I, Level C)
Implement active warming mea-sures as indicated (see below)
- Measure patient temperature prior to
discharge151 (Class I, Level C)B If the patient is hypothermic, in addition
to normothermic interventions, initiate
active warming measures: Apply forced-air warming system111-116
(Class I, Level A)- Reassess temperature if patients ther-
mal comfort level changes and/or signs
355Further study to characterize the risk factors
for perioperative hypothermia
-
BB What patients would benefit from preopera-
B
mal comfort to temperature?
setting?
rence
495-501.
3. Apfel CC, Greim CA, Haubitz I, et al. The discriminating
po
goi
sio
4
den
199
5
tion
200
6
evi
Nu
7
nur
and
8
vel
Jouwer of a risk score for postoperative vomiting in adults under-
ng various types of surgery [see comment]. Acta Anaesthe-
logica Scandinavica. 1998;42:502-509.
. Rosswurm MA, Larrabee JH. A model for change to evi-What is the impact of intraoperative warming
measures on patient outcomes across broad,heterogenous patient populations?
Refe
1. IOM. Clinical practice guidelines: Directions for a
new program. Washington, DC: National Academy Press;
1990.
2. Apfel CC, Greim CA, Haubitz I, et al. A risk score to predict
the probability of postoperative vomiting in adults [see
comment]. Acta Anaesthesiologica Scandinavica. 1998;42:tive warming?B What is the most effective single or combina-
tion of preoperative warming measures?B What is the minimal amount of time that
a patient should be prewarmed before his
or her procedure?B Is there a minimum core temperature that
should be obtained prior to transfer of the
patient to the operating/procedure area?
Intraoperative Patient Assessment andManagementWhat is the relationship between tempera-
ture and thermal comfort from a patients per-
spective?
Preadmission/Preoperative PatientAssessment and Managementce-based practice. Image: Journal of Nursing Scholarship.
9;31:317-322.
9
Nes
. Stetler CB. Updating the Stetler model of research utiliza-
to facilitate evidence-based practice. Nursing Outlook.
1;49:272-279.
. Titler MG, Kleiber C, Steelman VJ, et al. The Iowamodel of
dence-based practice to promote quality care. Critical Care
rsing Clinics of North America. 2001;13:497-509.
. Lia-Hoagberg B, Schaffer M, Strohschein S. Public health
sing practice guidelines: an evaluation of dissemination
use. Public Health Nursing. 1999;16:397-404.
. Miller M, Kearney N. Guidelines for clinical practice: de-
opment, dissemination and implementation. International
rnal of Nursing Studies. 2004;41:813-821.B What is the impact of the guideline on recom-
mended expected outcomes?
Public Review and Endorsements
This guideline was open for public review and
commentary prior to endorsement by the ASPANRepresentative Assembly on April 19, 2009.B What is the effect of passive thermal care
measures on postoperative temperature?
Translation of the Guideline to Practice:
B Is this guideline usable, easy to follow,and feasible to implement in the practicePostoperative Patient Assessment andManagement
B How frequently should temperature be mea-sured postoperatively?
B What is the relationship of self-reported ther-ative normothermia using consistent mea-
sures of temperature.
devices?B Research to develop a risk factor stratification
and prediction model for perioperative hypo-
thermia
Temperature Measurement
B What is the relationship between core tem-
perature measurement and near-core mea-
surements?B Replication of studies investigating perioper-
356B What is the best method, or combination of
methods, to maintain perioperative normo-
thermia across broad, heterogenous patient
populations?B What is the best warming method for certain
populations of patients such as major spineprocedures performed on specialty devices
and plastic surgery procedures in which large
areas are prepped as donor sites so as not to
be amenable to overlying forced-air warming
HOOPER ET AL. Stetler CB, Brunell M, Giuliano KK, Morsi D, Prince L,
well-Stokes V. Evidence-based practice and the role of
-
nursing leadership. Journal of Nursing Administration. 1998;
28:45-53.
10. Natsch S, van der Meer JWM. The role of clinical guide-
lines, policies and stewardship. Journal of Hospital Infection.
2003;53:172-176.
11. AGREE. AGREE: Appraisal of Guidelines, Research, &
Evaluation. http://www.agreecollaboration.org/. Accessed
February 6, 2009.
12. AHRQ. Directors Welcome. http://www.ahrq.gov/fund/
dirwelcome.htm. Accessed February 6, 2009.
13. Coopmans VC. Certified registered nurse anesthetist
performance and perceptions: Use of a handheld, computer-
ized, decision making aid during critical events in a high-
fidelity human simulation environment [Ph.D. 233 p.],
(Virginia Commonwealth University); 2005.
14. De Jonghe B, Bastuji-Garin S, Fangio P, et al. Sedation
algorithm in critically ill patients without acute brain injury.
Critical Care Medicine. 2005;33:120-127.
15. Di Blasio CJ, Rhee AC, Cho D, Scardino PT, Kattan MW.
Predicting clinical end points: treatment nomograms in pros-
tate cancer. Seminars in Oncology. 2003;30:567-586.
16. Fanning EL. Outcomes and cost effectiveness of treating
type 2 diabetes with a nurse case manager following treat-
ment algorithms versus primary care physicians [Ph.D. 163
p.], (The University of Texas Health Sciences Center at Houston
School of Public Health); 2002.
17. Hunt D, Haynes R, Hanna S, Smith K. Effects of computer-
based clinical decision support systems on physician perfor-
mance and patient outcomes: A systematic review. JAMA.
1998;280:1339-1346.
18. Morris AH. Treatment algorithms and protocolized care.
Current Opinion in Critical Care. 2003;9:236-240.
19. Patel VL, Arocha JF, Diermeier M, How J, Mottur-Pilson C.
Cognitive psychological studies of representation and use of
clinical practice guidelines. International Journal of Medical
Informatics. 2001;63:147-167.
20. Rushforth K. A randomised controlled trial of weaning
from mechanical ventilation in paediatric intensive care (PIC).
Methodological and practical issues. Intensive & Critical Care
Nursing. 2005;21:76-86.
21. Sveningson L. Commentary on application of an
algorithm for staging small-cell lung cancer can save one third
of the initial evaluation costs [original article by Richardson G
et al appears in ARCH INTERN MED 1993;153:329-36]. ONS
Nursing Scan in Oncology. 1993;2:21-22.
22. Titler MG, Everett LQ. Translating research into practice.
Critical Care Nursing Clinics of North America. 2001;13:
587-604.
23. Mamaril ME. Introduction of ASPANs Evidence-based
Practice Model. J Perianesth Nurs. 2005;20:236-238.
24. Mamaril ME, Ross J, Krenzischek D, et al. The ASPAN EBP
Conceptual Model: Framework for Perianesthesia Practice
and Research. J Perianesth Nurs. 2006;21:157-167.
25. Melnyk BM, Fineout-Overholt E. Evidence-based prac-
tice in nursing and healthcare. Philadelphia, PA: Lippincott,
Williams, & Wilkins; 2005.
26. Stetler CB. Personal communication; 2007.
27. ACC/AHA. Guidelines for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery. JACC. 1996;27:910948.
28. Mahoney CB, Odom J. Maintaining intraoperative normo-
PROMOTION OF PERIOPERATIVE NORMOTHERMIAthermia: a meta-analysis of outcomeswith costs. AANA Journal.
1999;67:155-164.29. Sessler DI. Complications and treatment of mild hypo-
thermia. Anesthesiology. 2001;95:531-543.
30. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative
maintenance of normothermia reduces the incidence of
morbid cardiac events. A randomized clinical trial. JAMA.
1997;277:1127-1134.
31. NICE. National Institute for Health and Clinical Evidence:
Clinical practice guideline: The management of inadvertent
perioperative hypothermia in adults. http://www.nice.org
.uk/nicemedia/pdf/CG65Guidance.pdf. Accessed February 10,
2009.
32. Beilin B, Shavit Y, Razumovsky J, Wolloch Y, Zeidel A,
Bessler H. Effects of mild perioperative hypothermia on cellular
immune responses. Anesthesiology. 1998;89:1133-1140.
33. Kurz A, Sessler DI, Lenhardt R. Perioperative normother-
mia to reduce the incidence of surgical-wound infection and
shorten hospitalization. Study of Wound Infection and Temper-
ature Group [see comment]. New England Journal of Medi-
cine. 1996;334:1209-1215.
34. Flores-Maldonado A, Medina-Escobedo CE, Rios-
Rodriguez HMG, et al. Mild perioperative hypothermia and
the risk of wound infection. Archives of Medical Research.
2001;32:227-231.
35. Schmied H, Kurz A, Sessler DI. Intraoperative hypother-
mia increases blood loss and allogeneic transfusion require-
ments during total hip arthroplasty. Lancet. 1996;373:289-292.
36. Rajagopalan S, Mascha E, Na J. The effects of mild perio-
perative hypothermia on blood loss and transfusion require-
ment. Anesthesiology. 2008;118:71-77.
37. Heier T, Caldwell J, Sessler DI. Mild intraoperative hypo-
thermia increases duration of action and spontaneous recovery
of vecuronium blockade during nitrous oxide-isoflurane anes-
thesia in humans. Anesthesiology. 1991;74:815-819.
38. Leslie K, Sessler DI, Bjorksten AR. Mild hypothermia alters
propofol pharmacokinetics and increases the duration of action
of atracurium. Anesthesia & Analgesia. 1995;80:1007-1014.
39. Smeulers NJ,WierdaMJ, van den Broek L. Effects of hypo-
thermic cardiopulmonary bypass on the pharmacodynamics
and pharmacokinetics of rocuronium. Journal of Cardiotho-
racic & Vascular Anesthesia. 1995;9:700-705.
40. Eger EL, Johnson BH.MAC of I-653 in rats, including a test
of the effect of body temperature and anesthetic duration.
Anesthesia & Analgesia. 1987;66:974-976.
41. Fritz HG, Bauer R, Walter B. Effects of hypothermia
(32C) on plasma concentration of fentanyl in piglets (abstract).Anesthesiology. 1999;91:A444.
42. Scott EM, Buckland R. A systematic review of intraoper-
ative warming to prevent postoperative complications. AORN
J. 2006;83:1090-1104, 1107-1013.
43. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative
maintenance of normothermia reduces the incidence of morbid
cardiac events. A randomized clinical trial [see comment].
JAMA. 1997;277:1127-1134.
44. Bissonnette B, Sessler DI. Mild hypothermia does not im-
pair postanesthetic recovery in infants and children. Anesthesia
& Analgesia. 1993;76:168-172.
45. Lenhardt R, Marker E, Goll V, et al. Mild intraoperative hy-
pothermia prolongs postanesthetic recovery. Anesthesiology.
1997;87:1318-1323.
46. Kurz A, Sessler DI, Narzt E, Lenhardt R, Lackner F. Mor-
357phometric influences on intraoperative core temperature
changes. Anesthesia & Analgesia. 1995;80:562-567.
-
47. Hooper VD. Adoption of the ASPAN Clinical Guideline
for the Prevention of Unplanned Perioperative Hypothermia:
A Data Collection Tool. J Perianesth Nurs. 2006;21:177-185.
48. SCIP. Quality Net: Surgical Care Improvement Project.
http://www.qualitynet.org/dcs/ContentServer?c=MQParents&
pagename=Medqic%2FContent%2FParentShellTemplate&cid=
1137346750659&parentName=TopicCat. Accessed February 8,
2009.
49. ASPAN. Clinical guideline for the prevention of un-
planned perioperative hypothermia. J Perianesth Nurs. 2001;
16:305-314.
50. Berman A, Snyder SJ, Kozier B, Erb G. Kozier & Erbs Fun-
damentals of Nursing: Concepts, Process, and Practice. 8th:
http://online.statref.com/Document/Document.aspx?fxId5189&docId51&offset5110&SessionId5E854ECISUMKJWNQO.Accessed February 9, 2009.
51. Hooper VD, Andrews JO. Accuracy of noninvasive core
temperature measurement in acutely ill adults: The state of the
science. Biological Research for Nursing. 2006;8:24-34.
52. AORN. Association of periOperative Registered Nurses.
www.aorn.org. Accessed February 9, 2009.
53. ASPAN. Standards of perianesthesia nursing practice:
2008-2010. Cherry Hill, NJ: ASPAN; 2008.
54. Eberhart LHJ, Doderlein F, Eisenhardt G, et al. Indepen-
dent risk factors for postoperative shivering. Anesthesia & An-
algesia. 2005;101:1849-1857.
55. Moayeri A, Hynson JM, Sessler DI, McGuire J. Preinduc-
tion skin surface warming prevents redistribution hypothermia
(abstract). Anesthesiology. 1991;75(A1):1004.
56. ASPAN. ASPANs Evidence-Based Clinical Practice Guide-
line for the Prevention and/or Management of PONV/PDNV.
J Perianesth Nurs. 2006;21:230-250.
57. Bush HL, Hydo LJ, Fischer E, Fantini GA, Silane MF,
Barie PS. Hypothermia during elective abdominal aortic aneu-
rysm repair: The high price of avoidable morbidity. Journal of
Vascular Surgery. 1995;21:392-402.
58. Kasai T, Hirose M, Matsukawa T, Takamata A, Yaegashi K,
Tanaka Y. Preoperative blood pressure and catecholamines
related to hypothermia during general anesthesia. Acta Anaes-
thesiologica Scandinavica. 2003;47:208-212.
59. Kasai T, Hirose M, Yaegashi K, Matsukawa T, Takamata A,
Tanaka Y. Preoperative risk factors of intraoperative hypother-
mia in major surgery under general anesthesia [see comment].
Anesthesia & Analgesia. 2002;95:1381-1383.
60. Kitamura A, Hoshino T, Kon T, Ogawa R. Patients with
diabetic neuropathy are at risk of a greater intraoperative reduc-
tion in core temperature. Anesthesiology. 2000;92:1311-1318.
61. Agrawal N, Sewell DA, Griswold ME, Frank SM,
Hessel TW, Eisele DW. Hypothermia during head and neck sur-
gery. Laryngoscope. 2003;113:1278-1282.
62. Frank SM, El-Rahmany HK, Cattaneo CG, Barnes RA. Pre-
dictors of hypothermia during spinal anesthesia. Anesthesiol-
ogy. 2000;93:1330-1334.
63. Kongsayreepong S, Chaibundit C, Chadpaibool J, et al.
Predictor of core hypothermia and the surgical intensive care
unit. Anesthesia & Analgesia. 2003;96:826-833.
64. Yamagage M, Kamada Y, Honma Y, Tsujiguchi N,
Namiki A. Predictive variables of hypothermia in the early
phase of general anesthesia. Anesthesia & Analgesia. 2000;
90:456-459.
35865. Frank SM, Beattie C, Christopherson R, Norris EJ, Rock P,
Parker S. Epidural versus general anesthesia, ambient operatingroom temperature, and patient age as predictors of inadvertent
hypothermia. Anesthesiology. 1992;77:252-257.
66. Kasai T, Hirose M, Matsukawa T, Takamata A, Kimura M,
Tanaka Y. Preoperative blood pressure and intraoperative hypo-
thermia during lower abdominal surgery. Acta Anaesthesiolog-
ica Scandinavica. 2001;45:1028-1031.
67. Matsukawa T, Sessler DI, Christopherson R, Ozaki M,
Shroeder M. Heat flow and distribution during regional anesthe-
sia. Anesthesiology. 1995;83:961-967.
68. Matsukawa T, Sessler DI, Sessler A, Schoder M. Heat flow
and distribution during general anesthesia. Anesthesiology.
1995;82:662-673.
69. Leslie K, Sessler DI. Reduction in shivering threshold
is proportional to spinal block height. Anesthesiology. 1996;
84:1327-1331.
70. Vaughan MS, Vaughan RW, Cork R. Postoperative hypo-
thermia in adults: Relationship of age, anesthesia, and shivering
to rewarming. Anesthesia & Analgesia. 1981;60:746-751.
71. Kelechi TJ, Michel Y,Wiseman J. Are infrared and thermis-
tor thermometers interchangeable for measuring localized skin
temperature? Journal ofNursingMeasurement. 2006;14:19-27.
72. Sessler DI. Temperature monitoring and peri operative
thermoregulation. Anesthesiology. 2008;109:318-338.
73. Farnell S, Maxwell L, Tan S. Temperature measurement:
Comparison of noninvasive methods used in adult critical
care. Journal of Clinical Nursing. 2005;14:632-639.
74. Lawson L, Bridges EJ, Ballou I. Accuracy and precision of
noninvasive core temperature measurement in adult intensive
care patients. American Journal of Critical Care. 2007;16:
485-496.
75. Moran JL, Peter JV, Solomon PJ, et al. Tympanic tempera-
ture measurements: are they reliable in the critically ill? A clin-
ical study of measures of agreement. Critical Care Medicine.
2007;35:155-164.
76. Frommelt T, Ott C, Hays V. Accuracy of different devices
to measure temperature. MEDSURG Nursing. 2008;17:171.
77. Giuliano KK, Scott SS, Elliot S, Giuliano AJ. Temperature
measurement in critically ill orally intubated adults: a compari-
son of pulmonary artery core, tympanic, and oral methods [see
comment]. Critical Care Medicine. 1999;27:2188-2193.
78. Fallis WM. Temperature measurements [comment]. An-
esthesia & Analgesia. 2003;96:1236, author reply 12361237.
79. Woodrow P, May V, Buras-Rees S, et al. Comparing no-
touch and tympanic thermometer temperature recordings.
British Journal of Nursing. 2006;15:1012-1016.
80. Erickson RS, Kirklin SK. Comparison of ear-based, blad-
der, oral and axillary methods for core temperature measure-
ment. Critical Care Medicine. 1993;21:1528-1534.
81. Gilbert M, Baron AJ, Counsell CM. Comparison of oral
and tympanic temperature in adult surgical patients. Applied
Nursing Research. 2002;15:42-47.
82. Kimberger O, CohenD, Illievich U, Lenhardt R. Temporal
artery versus bladder thermometry during perioperative and in-
tensive care unit monitoring. Anesthesia & Analgesia. 2007;
105:1042-1047.
83. Erickson RS, Meyer LT, Woo TM. Accuracy of chemical
dot thermometers in critically ill adults and young children.
Journal of Nursing Scholarship. 1996;28:23-28.
84. Fallis WM, Hamelin K, Symonds J, Wang X. Maternal and
newborn outcomes related to maternal warming during cesar-
HOOPER ET ALean delivery. JOGNN - Journal of Obstetric, Gynecologic, &
Neonatal Nursing. 2006;35:324-331.
-
85. Potter P, Schallom S, Davis S. Evaluation of chemical dot
thermometers for measuring body temperature of orally intu-
bated patients. American Journal of Critical Care. 2003;12:
403-407.
86. Washington GT, Matney JL. Comparison of temperature
measurement devices in post anesthesia patients. J Perianesth
Nurs. 2008;23:36-48.
87. Fetzer SJ, Lawrence A. Tympanic membrane versus tem-
poral artery temperatures of adult perianesthesia patients. J
Perianesth Nurs. 2008;23:230-236.
88. Harioka T, Matsukawa T, OzakiM. Deep-forehead temper-
ature correlates well with blood temperature. Canadian Jour-
nal of Anaesthesia. 2000;47:980-983.
89. Spitzer OP. Comparing tympanic temperatures in both
ears to oral temperature in the critically ill adult. Dimensions
of Critical Care Nursing. 2008;27:24-29.
90. Sund-Levander M, Grodzinsky E, Loyd D, Wahren LK. Er-
rors in body temperature assessment related to individual vari-
ation, measuring technique and equipment. International
Journal of Nursing Practice. 2004;10:216-223.
91. Carroll D, Finn C, Judge B, Gill S, Sawyer J. A comparison
of measurements from a temporal artery thermometer and
a pulmonary artery catheter thermistor. American Journal of
Critical Care. 2004;13:258.
92. Myny D, DeWaele J, Defloor T, Blot S, Colardyn F. Tempo-
ral scanner thermometry: A new method of core temperature
estimation in ICU patients. Scottish Medical Journal. 2005;50:
15-18.
93. DaanenHA. Infrared tympanic temperature and ear canal
morphology. Journal of Medical Engineering and Technology.
2006;30:224-234.
94. Sessler DI, Schroeder M, Merrifield B, Matsukawa T,
Cheng C. Optimal duration and temperature of prewarming.
Anesthesiology. 1995;82:674-681.
95. Leslie K, Sessler DI. Perioperative hypothermia in the
high-risk surgical patient. Best Practice & Research Clinical
Anaesthesiology. 2003;17:485-498.
96. Sessler DI. Complications and treatment of mild hypo-
thermia. Anesthesiology. 2001;95:531-543.
97. Hynson JM, Sessler DI, Moayeri A, McGuire J, Schroeder
M. The effects of preinduction warming on temperature and
blood pressure during propofol/nitrous oxide anesthesia. Anes-
thesiology. 1993;79:219-228, discussion 21A-22A.
98. Camus Y, Delva E, Sessler DI, Lienhart A. Pre-induction
skin-surface warming minimizes intraoperative core hypother-
mia. Journal of Clinical Anesthesia. 1995;7:384-388.
99. Kim JY, Shinn H, Oh YJ, Hong YW, Kwak HJ, Kwak YL.
The effect of skin surface warming during anesthesia prepara-
tion on preventing redistribution hypothermia in the early oper-
ative period of off-pump coronary artery bypass surgery.
European Journal of Cardio-Thoracic Surgery. 2006;29:
343-347.
100. Just B, Trevien V, Delva E, Lienhart A. Prevention of in-
traoperative hypothermia by preoperative skin-surface warm-
ing. Anesthesiology. 1993;79:214-218.
101. Vanni SM, Braz JR, Modolo NS, Amorim RB,
Rodrigues GR Jr. Preoperative combined with intraoperative
skin-surface warming avoids hypothermia caused by general
anesthesia and surgery. Journal of Clinical Anesthesia. 2003;
15:119-125.
PROMOTION OF PERIOPERATIVE NORMOTHERMIA102. Wagner D, ByrneM, Kolcaba K. Effects of comfort warm-
ing on preoperative patients. AORN Journal. 2006;84:427-448.103. Bock M, Muller J, Bach A, Bohrer H, Martin E, Motsch J.
Effects of preinduction and intraoperative warming during
major laparotomy. Br J Anaesth. 1998;80:159-163.
104. Vanni SM, Braz JR, Modolo NS, Amorim RB,
Rodrigues GR Jr. Preoperative combined with intraoperative
skin-surface warming avoids hypothermia caused by general
anesthesia and surgery. J Clin Anesth. 2003;15:119-125.
105. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preop-
erative warming on the incidence of wound infection after
clean surgery: A randomised controlled trial. Lancet. 2001;
358:876-880.
106. Aston J, Shi E, Bullot H, Galway R, Crisp J. Qualitative
evaluation of regular morning meetings aimed at improving
interdisciplinary communication and patient outcomes. Inter-
national Journal of Nursing Practice. 2005;11:206-213.
107. Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE.
The association between interdisciplinary collaboration and
patient outcomes in a medical intensive care unit. Heart &
Lung. 1992;21:18-24.
108. Baggs JG, Schmitt MH, Mushlin AI, et al. Association
between nurse-physician collaboration and patient outcomes
in three intensive care units [see comment]. Critical Care Med-
icine. 1999;27:1991-1998.
109. Sheng Y, Zavisca F, Schonlau E, Desmarattes R,
Herron E, Cork R. The effect of preoperative reflective
hats and jackets, and intraoperative reflective blankets on peri-
operative temperature. Internet Journal of Anesthesiology.
2003;6:8p.
110. AIA. American Institute of Architects: Guidelines for
design and construction of hospital and healthcare facilities.
Washington, DC: American Institute of Architects Press; 2001.
111. Brauer A, English MJ, Steinmetz N, Lorenz N, Perl T,
Weyland W. Efficacy of forced-air warming systems with full body
blankets. Canadian Journal of Anaesthesia. 2007;54:34-41.
112. Grossman S, Baustista C, Sullivan L. Using evidence-
based practice to develop a protocol for postoperative surgical
intensive care unit patients. Dimensions of Critical Care Nurs-
ing. 2002;21:206-214.
113. Sessler DI. Perianesthetic thermoregulation and heat
balance in humans. Faseb J. 1993;7:638-644.
114. Smith CE, Parand A, Pinchak AC, Hagen JF, Hancock DE.
The failure of negative pressure rewarming (Thermostat) to ac-
celerate recovery from mild hypothermia in postoperative sur-
gical patients. Anesthesia & Analgesia. 1999;89:1541-1545.
115. Stevens D, Johnson M, Langdon R. Comparison of two
warming interventions in surgical patients with mild and mod-
erate hypothermia. International Journal of Nursing Practice.
2000;6:268-275.
116. Taguchi A, Arkilic CF, Ahluwalia A, Sessler DI, Kurz A.
Negative pressure rewarming vs. forced air warming in hypo-
thermic postanesthetic volunteers. Anesth Analg. 2001;92:
261-266.
117. Fossum S, Hays J, Henson MM. A comparison study on
the effects on prewarming patients in the outpatient surgery
setting. J Perianesth Nurs. 2001;16:187-194.
118. Kim JY, Shinn H, Oh YJ, Hong YW, Kwak HJ, Kwak YL.
The effect of skin surface warming during anesthesia prepara-
tion on preventing redistribution hypothermia in the early
operative period of off-pump coronary artery bypass surgery.
Eur J Cardiothorac Surg. 2006;29:343-347.
359119. Sessler DI. Mild perioperative hypothermia. N Engl
J Med. 1997;336:1730-1737.
-
120. Kurz A. Thermal care in the perioperative period. Best
Pract Res Clin Anaesthesiol. 2008;22:39-62.
121. Anonymous. Recommended practices for the preven-
tion of unplanned perioperative hypothermia. AORN J.
2007;85:972988.
122. Morris RH. Influence of ambient temperature on
patient temperature during intraabdominal surgery. Ann Surg.
1971;173:230-233.
123. Morris RH, Wilkey BR. The effects of ambient tempera-
ture on patient temperature during surgery not involving body
cavities. Anesthesiology. 1970;32:102-107.
124. Wang CS, Chen CL, Huang CJ, et al. Effects of different
operating room temperatures on the body temperature
undergoing live liver donor hepatectomy. Transplant Proc.
2008;40:2463-2465.
125. Berti M, Casati A, Torri G, Aldegheri G, Lugani D,
Fanelli G. Active warming, not passive heat retention,
maintains normothermia during combined epidural-general
anesthesia for hip and knee arthroplasty. J Clin Anesth.
1997;9:482-486.
126. Elmore JR, Franklin DP, Youkey JR, Oren JW, Frey CM.
Normothermia is protective during infrarenal aortic surgery.
J Vasc Surg. 1998;28:984-992, discussion 992984.
127. Fleisher LA, Metzger SE, Lam J, Harris A. Perioperative
cost-finding analysis of the routine use of intraoperative
forced-air warming during general anesthesia. Anesthesiology.
1998;88:1357-1364.
128. Grocott HP, Mathew JP, Carver EH, Phillips-Bute B,
Landolfo KP, Newman MF. A randomized controlled trial of
the Arctic Sun Temperature Management System versus
conventional methods for preventing hypothermia during off-
pump cardiac surgery. Anesth Analg. 2004;98:298-302, table
of contents.
129. Hohn L, Schweizer A, Kalangos A, Morel DR,
Bednarkiewicz M, Licker M. Benefits of intraoperative skin sur-
face warming in cardiac surgical patients. Br J Anaesth. 1998;
80:318-323.
130. Janicki PK, Higgins MS, Janssen J, Johnson RF, Beattie C.
Comparison of two different temperature maintenance strate-
gies during open abdominal surgery: upper body forced-air
warming versus whole body water garment. Anesthesiology.
2001;95:868-874.
131. Janicki PK, Stoica C, Chapman WC, et al. Water warm-
ing garment versus forced air warming system in prevention
of intraoperative hypothermia during liver transplantation:
a randomized controlled trial [ISRCTN32154832]. BMC Anes-
thesiol. 2002;2:7.
132. Kabbara A, Goldlust SA, Smith CE, Hagen JF,
Pinchak AC. Randomized prospective comparison of forced
air warming using hospital blankets versus commercial blan-
kets in surgical patients. Anesthesiology. 2002;97:338-344.
133. Lee L, Leslie K, Kayak E, Myles PS. Intraoperative
patient warming using radiant warming or forced-air warming
during long operations. Anaesth Intensive Care. 2004;32:
358-361.
134. Lindwall R, Svensson H, Soderstrom S, Blomquist H.
Forced air warming and intraoperative hypothermia. Eur
J Surg. 1998;164:13-16.
135. Matsuzaki Y, Matsukawa T, Ohki K, Yamamoto Y,
Nakamura M, Oshibuchi T. Warming by resistive heating main-
360tains perioperative normothermia as well as forced air heating.
Br J Anaesth. 2003;90:689-691.136. Negishi C, Hasegawa K, Mukai S, Nakagawa F, Ozaki M,
Sessler DI. Resistive-heating and forced-air warming are compa-
rably effective. Anesth Analg. 2003;96:1683-1687, table of
contents.
137. Ng V, Lai A, Ho V. Comparison of forced-air warming and
electric heating pad for maintenance of body temperature dur-
ing total knee replacement. Anaesthesia. 2006;61:1100-1104.
138. Ng SF, Oo CS, Loh KH, Lim PY, Chan YH, Ong BC. A
comparative study of three warming interventions to determine
the most effective in maintaining perioperative normothermia.
Anesth Analg. 2003;96:171-176, table of contents.
139. Smith CE, Desai R, Glorioso V, Cooper A, Pinchak AC,
Hagen KF. Preventing hypothermia: convective and intravenous
fluid warming versus convective warming alone. J Clin Anesth.
1998;10:380-385.
140. Taguchi A, Ratnaraj J, Kabon B, et al. Effects of a circulat-
ing-water garment and forced-air warming on body heat content
and core temperature. Anesthesiology. 2004;100:1058-1064.
141. Torrie JJ, Yip P, Robinson E. Comparison of forced-air
warming and radiant heating during transurethral prostatic
resection under spinal anaesthesia. Anaesth Intensive Care.
2005;33:733-738.
142. Wong A, Walker S, Bradley M. Comparison of a radiant
patient warming device with forced air warming during laparo-
scopic cholecystectomy. Anaesth Intensive Care. 2004;32:
93-99.
143. Perl T, Flother L, WeylandW, Quintel M, Brauer A. Com-
parison of forced-air warming and resistive heating. Minerva
Anestesiol. 2008;74:687-690.
144. Camus Y, Delva E, Cohen S, Lienhart A. The effects of
warming intravenous fluids on intraoperative hypothermia
and postoperative shivering during prolonged abdominal
surgery. Acta Anaesthesiol Scand. 1996;40:779-782.
145. Hasankhani H, Mohammadi E, Moazzami F, Mokhtari M,
Naghgizadh MM. The effects of intravenous fluids temperature
on perioperative hemodynamic situation, post-operative shiver-
ing, and recovery in orthopaedic surgery. CanOper RoomNurs
J. 2007;25:20-24, 26-27.
146. Okeke LI. Effect of warm intravenous and irrigating
fluids on body temperature during transurethral resection of
the prostate gland. BMC Urol. 2007;7:15.
147. Smith CE, Gerdes E, Sweda S, et al. Warming intrave-
nous fluids reduces perioperative hypothermia in women
undergoing ambulatory gynecological surgery. Anesth Analg.
1998;87:37-41.
148. Mirza S, Panesar S, AuYong KJ, French J, Jones D,
Akmal S. The effects of irrigation fluid on core temperature in
endoscopic urological surgery. J Perioper Pract. 2007;17:
494-497, 499-503.
149. Stanley TO, Grocott HP, Phillips-Bute B, Mathew JP,
Landolfo KP, Newman MF. Preliminary evaluation of the
Arctic Sun temperature-controlling system during off-pump
coronary artery bypass surgery. Ann Thorac Surg. 2003;75:
1140-1144.
150. Grahn D, Brock-Utne JG, Watenpaugh DE, Heller HC.
Recovery from mild hypothermia can be accelerated by
mechanically distending blood vessels in the hand. Journal of
Applied Physiology. 1998;85:1643-1648.
151. Cory M, Fossum S, Donaldson K, Francis D, Davis J.
Constant temperature monitoring: A study of temperature pat-
HOOPER ET ALterns in the postanesthesia care unit. J Perianesth Nurs. 1998;
13:292-300.
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NAME/AFFILIATION STRATEGIC WORK TEAM ROLE
Robin Chard, PhD, RN, CNOR
Association of periOperative Registered Nurses
Perioperative Nursing Specialist
AORN representative
Content Expert: Intraoperative warming
Theresa Clifford, MSN, RN, CPAN
Clinical Nurse Lead
Mercy Hospital
144 State Street,
Portland, Maine 04101
ASPAN Immediate Past President
2010-2011
Content Expert: PAT/Day of surgery
Susan Fetzer, PhD, RN
Associate Professor
University of New Hampshire
Department of Nursing Educator
Durham, New Hampshire
Content Expert: Temperature
measurement
Susan Fossum, BSN, RN, CPAN
CN IV Clinical Educator (retired)
OR / PACU Same Day Surgery Center
UC Davis Medical Center
Sacramento, California
PACU Staff Nurse - Per Diem
Shriners Hospital for Children, Northern California
ASPAN Past President
Content Expert: Postoperative warming
Barbara Godden, MHS, RN, CPAN, CAPA
Clinical Nurse Coordinator - PACU
Sky Ridge Medical Center
Lone Tree, Colorado
ASPAN Director for Clinical Practice
Vallire D. Hooper, PhD, RN, CPAN, FAAN
Assistant Professor and Assistant Director of the PhD Program,
School of Nursing
Medical College of Georgia
Augusta, Georgia
EBP/Research Consultant: MCGHealth
Co-Editor, Journal of PeriAnesthesia Nursing
[email protected]; [email protected]
Project Director
Content Expert: Risk factors
Content Expert: Temperature
measurement
Elizabeth A. Martinez, MD, MHS
Massachusetts General Hospital
Department of Anesthesia, Critical Care, and Pain Medicine
Harvard University, 55 Fruit St., BRB 4-44
Boston, Massachusetts 02114
ASA representative
Content Expert: Intraoperative warming
Kim A. Noble, PhD, RN, CPAN
Associate Professor
Widener School of Nursing, One University Place
Chester, Pennsylvania 10301
ASPAN EBP Committee Chair
Content Expert: Postoperative warming
(Continued)
Appendix: Strategic Work Team Members*
PROMOTION OF PERIOPERATIVE NORMOTHERMIA 361
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Appendix. (Contd)
NAME/AFFILIATION STRATEGIC WORK TEAM ROLE
Denise OBrien, MSN, RN, ACNS-BC, CPAN, CAPA, FAAN
Clinical Nurse Specialist, Perianesthesia Care Areas
Department of Operating Rooms/PACU
University of Michigan Health System
Ann Arbor, Michigan
Content Expert: Preoperative warming
Jan Odom-Forren, PhD, RN, CPAN, FAAN
Assistant Professor, College of Nursing
University of Kentucky
Lexington, Kentucky
Co-Editor, Journal of PeriAnesthesia Nursing
Content Expert: Adverse events
Corey Peterson, MSN, CRNA
Instructor
Nurse Anesthesia Program
Medical College of Georgia
Augusta, GA
AANA representative
Content Expert: Intraoperative warming
Jacqueline Ross, MSN, RN, CPAN
Patient Safety Analyst
The Doctors Company
Napa, California
ASPAN Director for Research
Content Expert: Risk factors
Linda Wilson, PhD, RN, CPAN, CAPA, BC, CNE
Assistant Dean for Special Projects, Simulation and CNE Accreditation
Drexel University College of Nursing and Health Professions
Philadelphia, Pennsylvania
ASPAN National Office: Nurse Liaison for
Education,
Research and Clinical Practice
*The following members have disclosed the following relationships:
Denise OBrien, MSN, RN, ACNS-BC, CPAN, CAPA, FAAN: Research funded by Arizant Healthcare, Inc.
Acknowledgments
The authors would like to thank the American Society of PeriAnesthesia Nurses for their funding and support of this project; Linda-
Wilson, PhD, RN, CPAN, CAPA, BC, CNE, ASPAN Nurse Liaison for Education, Research, and Clinical Practice for her support of the
project; and the following CRNA students at the Medical College of Georgia School of Nursing who assisted with the literature search
and article retrieval for this project: Nicole Earhardt, MSN, CRNA, Demetria Goodwin, MSN, CRNA, DaDonna Marshall, MSN, CRNA,
Eugene Pikus, MSN, CRNA, and Tivoli Thomas, MSN, CRNA.
362 HOOPER ET AL
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Figure 1. Preadmission/preoperative recommendations.
PROMOTION OF PERIOPERATIVE NORMOTHERMIA 363
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Figure 2. Intraoperative recommendations.
364 HOOPER ET AL
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Figure 3. Phase I/II PACU postoperative patient management recommendations.
PROMOTION OF PERIOPERATIVE NORMOTHERMIA 365
ASPANs Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia: Second EditionQuality and Strength of Evidence and Guideline RecommendationsClinical Practice GuidelineBackgroundGoals and Specific AimsGuideline Intent and DefinitionsRisk Factors for Perioperative HypothermiaRisk Factors Supported by Strong EvidenceRisk Factors Supported by Weak Evidence (Class IIa or IIb, Level B)Risk Factors Supported by Insufficient Evidence (Class IIa or IIb, Level C)Temperature MeasurementTemperature Measurement Recommendations Supported by Strong EvidenceTemperature Measurement Recommendations Supported by Weak EvidenceTemperature Measurement Recommendations Supported by Conflicting EvidencePreadmission/Preoperative Patient Assessment and ManagementPreadmission/Preoperative RecommendationsPreadmission Testing/Preoperative Admission Expected OutcomesIntraoperative Patient Assessment and ManagementIntraoperative RecommendationsIntraoperative Expected OutcomesPostoperative Patient Management: Phase I/II PACUPhase I/II PACU Postoperative Patient Management RecommendationsPhase I/II PACU Postoperative Patient Management Expected OutcomesResearch IndicationsRisk Factor IdentificationTemperature MeasurementPreadmission/Preoperative Patient Assessment and ManagementIntraoperative Patient Assessment and ManagementPostoperative Patient Assessment and ManagementTranslation of the Guideline to Practice:Public Review and Endorsements
ReferencesStrategic Work Team MembersAcknowledgments