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National Collaborating Centre for Nursing and Supportive Care (UK). The Management of Inadvertent Perioperative Hypothermia in Adults [Internet]. London: Royal College of Nursing (UK); 2008 Apr. (NICE Clinical Guidelines, No. 65.)

Cover of The Management of Inadvertent Perioperative Hypothermia in Adults

The Management of Inadvertent Perioperative Hypothermia in Adults [Internet].

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2PRINCIPLES OF PRACTICE

The principles outlined below describe the ideal context in which to implement the recommendations contained in this guideline.

These have been adapted from the NICE clinical practice guideline: Assessment and prevention of falls in older people (2004).

2.1. Person-centred care

  • People who are at risk of developing Inadvertent Perioperative Hypothermia (IPH) should be made aware of the guideline and its recommendations, and should be referred to the Understanding NICE Guidance version of the guideline.
  • All adult surgical patients should be involved in shared decision making about individualised care in preventing perioperative hypothermia.
  • Healthcare professionals are advised to respect and incorporate the knowledge and experience of people in shared decision making.
  • All adult surgical patients should be informed about the potential risks and/or associated complications of IPH.

2.2. Collaborative interdisciplinary approach to care

  • All members of the interdisciplinary healthcare team should be aware of the guidelines and all care should be documented in the patient’s healthcare records.
  • A collaborative, multi-disciplinary approach should be provided by appropriately trained professionals.
  • The roles of parents/carers and health professionals in implementing the guideline recommendations should be sensitively negotiated.

2.3. Organisational issues

  • There should be an integrated approach to the prevention and management of IPH across the three phases of the perioperative patient experience, these being the preoperative, intraoperative and postoperative phases.
  • Care should be delivered in a context of continuous quality improvement, where improvements to care following guideline implementation are the subject of regular feedback and audit.
  • The healthcare team should have received appropriate training and have demonstrated their competence in the prevention and management of IPH.
  • Commitment to and availability of education and training are required to ensure that all staff, regardless of their profession, are given the opportunity to update their knowledge, and are able to implement the guideline recommendations.
  • Adult surgical patients should be cared for by personnel who have undergone appropriate training and who know how to initiate and maintain appropriate prevention and management of IPH. Staffing levels and skill mix should reflect the needs of patients.

2.4. Background to the current guideline

In January 2006, The National Collaborating Centre for Nursing and Supportive Care (NCC-NSC) was commissioned by NICE to develop a clinical guideline on the ‘Management of perioperative hypothermia’ for use in Primary Care in England and Wales.

2.5. Clinical need for the guideline

Inadvertent perioperative hypothermia (IPH) is a preventable complication of perioperative procedures. The main aim of this guideline is to indicate the optimal clinical and cost-effective management of adult surgical patients in both preventing and managing IPH.

For the purpose of this guideline, the definition of hypothermia is a core temperature of less than 36.0°C. This definition applies regardless of the patient’s initial temperature. Inadvertent perioperative hypothermia is distinguished from therapeutic hypothermia, which is the deliberate induction of hypothermia. Inadvertent perioperative hypothermia is a recognised and common occurrence during surgery, with the adult surgical patient at risk of developing hypothermia at any stage of the perioperative pathway. In addressing this potential adverse event, the guideline considers the period from 1 hour prior to induction of anaesthesia (when the patient is prepared for surgery on the ward or in the emergency department, including possible use of premedication), the intraoperative time (measured as total anaesthetic time) and the postoperative period (24 hours after entry into the recovery room).

It is not unusual for a patient’s core temperature to drop to less than 35.0°C within the first 30 to 40 minutes of anaesthesia. If the perioperative team do not manage this risk throughout the perioperative patient pathway, as many as 70% of patients undergoing routine surgery may be hypothermic on admission to the recovery room. The reasons for hypothermia include the loss, under general or regional anaesthesia, of the behavioural response to cold and the impairment of thermoregulatory heat-preserving mechanisms; anaesthetic-induced peripheral vasodilation (with associated heat loss); patients getting cold while waiting for surgery; exposure of the body during surgery and environmental factors; fluid deprivation before anaesthesia (which varies from 2 to more than 12 hours) resulting in patients being dry and poorly perfused, impairing heat distribution, and; the use of unwarmed intravenous or irrigation solutions.

The degree of heat loss is also influenced by ambient temperature, airflow in the theatre and factors associated with skin preparation. Patients at high risk of perioperative hypothermia are generally those who are assessed by the perioperative team as having an ASA grade of greater than 2, and those patients who are at increased risk of a morbid cardiac event.

Typically these patients are around 50 years of age, with an ischaemic heart disease profile. Duration of anaesthesia has been identified as an IPH risk, and whether the patient is having medium to major surgery, which usually correlates to duration of anaesthesia, i.e. the larger the surgical procedure the longer the duration of anaesthetic time. The guideline includes a systematic review on the risk of developing IPH, the findings of which have informed both the economic modelling and recommendations.

Why prevent? Typically this question is answered by looking at the impact on both the patient and resources if an adverse outcome does present; in this guideline it is if the patient becomes hypothermic. Expressed as a consequence, if hypothermia does develop then patients can experience increased perioperative blood loss, longer post-anaesthetic recovery, postoperative shivering and thermal discomfort, morbid cardiac events including arrhythmia, altered drug metabolism, increased risk of wound infection, reduced patient satisfaction with the surgical experience and possibly a longer stay in hospital. This has been difficult to determine from the literature, mainly because many contemporary surgical procedures do not require the patient to have an overnight stay in hospital.

2.6. Management Issues

The aetiology of IPH is explained within the guideline. The focus of the GDG’s work has been to identify key information for patients and healthcare professionals that relate to each part of the perioperative pathway. This is summarised on the IPH algorithm, and identified as:

  • Maintaining patient thermal comfort preoperatively by encouraging the patient to wear their own warm clothing
  • Assessment of IPH risk by a member of the perioperative team
  • Maintaining ambient temperature in wards, emergency departments and theatre suites
  • Recording patient core temperature at regular intervals (i.e. immediately prior to leaving the ward or emergency department; every 30 minutes intraoperatively; every 15 minutes in the recovery area until a core temperature of 36.0°C is recorded, and then at hourly intervals until the patient reaches normothermia (36.5°C).
  • Only commencing induction of anaesthesia if the patient’s core temperature is above 36.0°C
  • Active warming of the patient using a combination of warmed fluids and warming devices.
Copyright © 2008, National Collaborating Centre for Nursing and Supportive Care.
Bookshelf ID: NBK53788

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