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PATIENT CARE


setting on forced-air warming devices should be set at maximum and then adjusted to maintain a patient temperature of at least 36.5˚C.


• All irrigation fluids used intraoperatively should be warmed in a thermostatically controlled cabinet to a temperature of 38˚C-40˚C.


Post-operative phase The post-operative phase is defined as the 24 hours after the patient has entered the recovery area of the theatre suite. The patient’s temperature should be measured and documented on admission to the recovery room and then every 15 minutes. Ward transfer should not be arranged unless the patient’s temperature is 36˚C or above. If the patient’s temperature is below 36˚C, they should be actively warmed using forced-air warming until they are discharged from the recovery room or until they are comfortably warm. Patients should also be kept


comfortably warm when back on the ward. Their temperature should be measured and documented on arrival and then as part of routine four-hourly observations. They should be provided with at least one cotton sheet plus two blankets, or a duvet. If the patient’s temperature falls below 36˚C while on the ward: • They should be warmed using forced- air warming until they are comfortably warm.


• Their temperature should be measured and documented at least every 30 minutes during warming.


Updated guidance Although the NICE guidance refers to forced-air warming in the guidance, it has since issued further guidance on alternative warming technology, in view of a growing body of evidence to support its effectiveness. In August 2011, NICE published guidance on the Inditherm patient warming mattress for the prevention of inadvertent hypothermia (NICE medical technology guidance 7).15 The clinical effectiveness of the


Inditherm mattress was examined in five studies, cited in the NICE guideline: one randomised controlled trial (RCT;Wong et al, 2007), two unpublished RCTs (Satheesan et al, conference abstract, 2006; Baxendale et al, 2000), one pilot RCT (Harper and Crook 2010) and one non-randomised comparative study (Engelen et al, 2007). Data from 14 summary reports of audits carried out in 10 UK hospitals were also assessed. NICE explained that the medical


technology guidance does not supersede the clinical guideline CG65 but addresses


60 THE CLINICAL SERVICES JOURNAL Ultimately, when making a decision on


which technology to use, the priorities must be to reduce patients’ distress, morbidity and mortality, as well as treatment costs and hospital stay. 


References 1 Frédéric Lapostolle et al. Risk factors for onset of hypothermia in trauma victims: The HypoTraum study. Critical Care 2012; 16: R142 doi: 10.1186/cc11449.


2 Ireland et al. Resuscitation 2011; 82(3): 300-6. Epub 2010 Nov 12.


Forced-air warming systems are available with a variety of blanket styles.


the case for adoption of the Inditherm patient warming mattress as an alternative to forced-air warming. It concluded that the effectiveness of the Inditherm system appears to be similar to that of forced-air warming, but it may also offer some practical advantages. The mattress can be left in place on an


operating table throughout a theatre operating list with low running costs, which may allow faster turnaround times for patients compared with the use of forced-air warming. In addition, it is a reusable device and no consumables are needed. This limits the need for disposal of consumables and any impact that might have on the environment. The guideline also points out that the Inditherm mattress is silent, has low energy consumption and specifically warms the patient without inadvertently warming the surgical team. Furthermore, NICE also claims that


the mattress could also offer cost savings. According to the guideline, the average annual cost saving associated with use of the Inditherm patient warming system is estimated to be £9,800 per theatre, assuming all eligible patients are warmed. This is based on the average annual cost of £1,300 for the Inditherm patient warming system and an average annual cost of forced-air warming of £11,100.


Conclusion In conclusion, the evidence shows that patient warming can improve outcomes and patient satisfaction. When specifying patient warming technologies, hospitals should be careful to investigate the track record of the technology being used; evaluate the available evidence (and its quality) supporting its efficacy, safety and cost-effectiveness; and be aware of the latest clinical guidance. Changing to a new method of


warming, like other changes to clinical practice, inevitably needs management and training, so it is important to ascertain whether the supplier can deliver the level of support that may be needed.


3 Blackburn E. Prevention of hypothermia during anaesthesia. Br J Theatre Nurs. 1994 Nov; 4(8): 9, 12-4.


4 Flores-Maldonado A et al. Mild perioperative hypothermia and the risk of wound infection, Arch Med Res 2001; 32(3): 227-231.


5 Bush HL et al. Hypothermia during elective abdominal aortic aneurysm repair. Journal of Vascular Surgery 1995; 21: 392-402.


6 Mahoney C, Odom J. Maintaining intraoperative normothermia. American Association of Nurse Anaesthetists Journal 1999; 67:155-64.


7 Kurz A et al. Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospitalisation. New England Journal of Medicine 1996; 334: 1209-15.


8 Benson et al. The Effects of ActiveWarming on Patient Temperature and Pain After Total Knee Arthroplasty. American Journal of Nursing, May 2012.


9 Sessler, Daniel I. MD: Mild Perioperative Hypothermia. New England Journal of Medicine June 1997; 336 (24): 1730-37.


10 Camus Y, Delva E, Just B et al. Leg warming minimizes core hypothermia during abdominal surgery. Anesthesia & Analgesia 1993; 77(5): 995-9. Cited at: http://www.preventhypothermia.org/ ph/typesofwarming/forcedair


11 Baker EA and Leaper DJ. Pressure-relieving properties of an intra-operative warming device. J.Wound Care 2003; 12(4): 156-60.


12 Belani KG, Albrecht M, McGovern PD, Reed M, Nachtsheim C. PatientWarming Excess Heat: The Effects on Orthopedic Operating Room Ventilation Performance. Anesth Analg. 19 July 2012.


13 Sessler DI, Olmsted RN, Kuelpmann R. Forced-AirWarming Does NotWorsen Air Quality in Laminar Flow Operating Rooms [Published online ahead of print September 29, 2011]. Anesth Analg. 2011 Sep 29; PMID 21965373.http://www.anesthesia- analgesia.org/content/early/2011/09/28/ ANE.0b013e318230b3cc.full.pdf.


14 NICE guidance, Perioperative hypothermia (inadvertent) (CG65), 2008. Accessed at: www.nice.org.uk/CG65


15 NICE medical technology guidance 7, Inditherm patient warming mattress for the prevention of inadvertent hypothermia, 2011. Accessed at: www.nice.org.uk/guidance/ MTG7


NOVEMBER 2012


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