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: vhooper@mcg.edu.not 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

Evid

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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.

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

Gu

Alt

hy

the

wi

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to

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loc

mi

ser

as

prinv

ex

Fo

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

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

(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

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

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-

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13:292-300.

NAME/AFFILIATION STRATEGIC WORK TEAM ROLE

Robin Chard, PhD, RN, CNOR

Association of periOperative Registered Nurses

Perioperative Nursing Specialist

rchard@aorn.org

AORN representative

Content Expert: Intraoperative warming

Theresa Clifford, MSN, RN, CPAN

Clinical Nurse Lead

Mercy Hospital

144 State Street,

Portland, Maine 04101

tclifford@aspan.org

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

sfetzer@cisunix.unh.edu

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

fossumsusan@hotmail.com

ASPAN Past President

Content Expert: Postoperative warming

Barbara Godden, MHS, RN, CPAN, CAPA

Clinical Nurse Coordinator - PACU

Sky Ridge Medical Center

Lone Tree, Colorado

bgodden@aspan.org

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

vhooper@mcg.edu; vhooper@knology.net

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

EMARTINEZ10@PARTNERS.ORG

ASA representative

Content Expert: Intraoperative warming

Kim A. Noble, PhD, RN, CPAN

Associate Professor

Widener School of Nursing, One University Place

Chester, Pennsylvania 10301

kimnoble@verizon.net

ASPAN EBP Committee Chair

Content Expert: Postoperative warming

(Continued)

Appendix: Strategic Work Team Members*

PROMOTION OF PERIOPERATIVE NORMOTHERMIA 361

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

dedeo@umich.edu

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

jodom29373@aol.com

Content Expert: Adverse events

Corey Peterson, MSN, CRNA

Instructor

Nurse Anesthesia Program

Medical College of Georgia

Augusta, GA

COPETERSON@mail.mcg.edu

AANA representative

Content Expert: Intraoperative warming

Jacqueline Ross, MSN, RN, CPAN

Patient Safety Analyst

The Doctors Company

Napa, California

jackieross@roadrunner.com

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

lwilson@aspan.org

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

Figure 1. Preadmission/preoperative recommendations.

PROMOTION OF PERIOPERATIVE NORMOTHERMIA 363

Figure 2. Intraoperative recommendations.

364 HOOPER ET AL

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