Inadvertent perioperative hypothermia

1. Inadvertent perioperative hypothermia Implementing NICE guidance 2nd.edition August 2011 NICE clinical guideline 65

2. What this presentation covers Background Definitions Key priorities for implementation Costs and savings Discussion Related guidance Find out more

3. Background Surgical patients are at risk of developing hypothermia at any stage of the perioperative pathway. Inadvertent perioperative hypothermia is a common but preventable complication, which is associated with poor outcomes for patients.

4. Definitions • Preoperative - 1 hour before induction of anaesthesia • Intraoperative - the total anaesthesia time • Postoperative - 24 hours after entry into the recovery area in the theatre suite • Hypothermia - a patient core temperature of below 36.0°C. • Comfortably warm - the expected normal temperature range of adult patients • Temperature - used to denote core temperature

5. Advice for patients Patients (and their families and carers) should be informed before and on admission that: • staying warm before surgery will lower the risk of postoperative complications • the hospital environment may be colder than their own home • they should bring additional clothing to help them keep comfortably warm • they should tell staff if they feel cold at any time during their hospital stay.

6. Measuring patient temperature • When using any device to measure patient temperature, healthcare professionals should: • be aware of, and carry out, any adjustments that need to be made in order to obtain an estimate of core temperature from that recorded at the site of measurement • be aware of any such adjustments that are made automatically by the device used.

7. Preoperative phase • Each patient should be assessed for their risk of inadvertent perioperative hypothermia and potential adverse consequences before transfer to the theatre suite.

8. Patients at higher risk of perioperative hypothermia Some patients are at higher risk of inadvertent perioperative hypothermia; they should be managed accordingly if any two of the following apply: • ASA grade II to V • preoperative temperature below 36.0°C • undergoing combined general and regional • anaesthesia • undergoing major or intermediate surgery • at risk of cardiovascular complications.

9. Preoperative warming • If the patient’s temperature is below 36.0°C in the hour before they leave the ward or emergency department: • forced air warming should be started preoperatively on the ward or in the emergency department (unless there is a need to expedite surgery because of clinical urgency) • forced air warming should be maintained throughout the intraoperative phase.

10. Intraoperative phase • The patient’s temperature should be measured and documented before induction of anaesthesia and then every 30 minutes until the end of surgery. • Induction of anaesthesia should not begin unless the patient’s temperature is 36.0°C or above.

11. Intraoperative warming The following patients should be warmed intraoperatively from induction of anaesthesia using a forced air warming device: • those at higher risk of inadvertent perioperative hypothermia and who are having anaesthesia for less than 30 minutes • those who are having anaesthesia for longer than 30 minutes

12. Warming intravenous fluids Intravenous fluids (500 ml or more) and blood products should be warmed to 37°C using a fluid warming device.

13. Postoperative phase 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 36.0°C or above. • If the patient’s temperature is below 36.0°C, they should be actively warmed using forced air warming until they are discharged from the recovery room or until they are comfortably warm

14. Costs and savings per 100,000 population Costs correct at April 2008. Costs not updated for 2nd edition

15. Discussion Which key areas of local practice differ from the guideline? To ensure effective implementation: what equipment is needed? what are staff training needs? What will the impact be on the average length of patient stay if the guideline is implemented fully? How should Risk and Safety Managers be involved in the implementation of the guideline?

16. Related NICE guidance - NICE medical technology guidance – Inditherm Mattress • NICE medical technology guidance addresses ‘case for adoption’ for specific technologies • Recommendations are not intended to limit use of other relevant technologies • Inditherm patient warming mattress medical technology guidance published August 2011 • The inditherm patient warming mattress should be considered for use in patients undergoing operations carrying a risk of inadvertent hypothermia This medical technology guidance does not supersede NICE clinical guideline 65’s recommendations on pre- or peri-operative warming

17. NHS Evidence Visit NHS Evidence for the best available evidence on perioperative hypothermia Click here to go to the NHS Evidence website

18. Find out more • Visit www.nice.org.uk/guidance/CG65 for: • Other guideline formats • Costing report and template • Audit support • Implementation advice

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