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7 Ways to Warm Your Patients Without Inflaming Your Staff
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How to adopt patient-warming technologies in your facility (without having to raise the thermostat).
Linda Chitwood, CRNA, MS
[email protected]
Ms. Chitwood ([email protected]) is a nurse anesthetist and freelance medical writer based in
Senatobia, Miss.
A 63-year-old woman comes to your outpatient facility for an abdominoplasty and liposuction of her
thighs and buttocks. During the five-hour procedure, she receives more than three liters of
intravenous fluids, and the surgeon injects three liters of fluid for the ultrasonic-assisted suction
lipectomy. When she reaches the post-anesthesia care unit, her temperature is 93°F, she is
hypertensive, and her shivering rattles the stretcher rails.
An ominous cardiac arrhythmia is unresponsive to standard therapies. You call her cardiologist. An
ambulance transfers the patient to a nearby hospital. During transport, she suffers a cardiac arrest
and the team is unable to resuscitate her.
Inconceivable? Not at all. As outpatient surgery centers now admit patients with extremes of age for
increasingly complex, lengthy and invasive procedures, the perils of hypothermia jut like an iceberg
from the sea. And these icebergs will sink your ship and its captain faster than the Titanic. Patienthypothermia-prevention device manufacturers know it (see “20 Ways to Warm a Patient” on page 50).
One warming-blanket manufacturer pledges to cover its product users for up to $500,000 if you’re
sued for malpractice associated with hypothermia when properly using one of its products.
It’s not just older or sicker patients who are at risk for hypothermia, though. All surgical patients are in
peril. Because it’s much easier to prevent hypothermia than to treat the effects of it, prevention should
be a priority. Yet even in the face of clear clinical evidence that warm is good and cold is bad, staff
who are sweltering under gowns, hoods and lights often complain about the heating blankets or other
technologies used to keep the patient warm. Warm ORs especially heat up complaints from surgeons
and staff. It’s understandable. Operating with sweat streaming down your back is an unpleasant
experience at best. Fortunately, there are ways to warm
your patients without inflaming your staff.
The fourth factor
A Simple Idea: Cover The
Patient's Head in Plastic
Defeating hypothermia requires an understanding of the
condition: the parameters that define it, the mechanisms of
heat loss in the surgical patient that cause it and the risks
associated with it.
Just as you cover your head
in the winter because the
majority of heat is lost
through the head, covering
the head of the surgical
patient can reduce heat loss, too. If your
patient is intubated (or has an LMA in
Every clinician has learned the ABCs of patient care: A for
airway, which must be open and patent. B for breathing, C place), the anesthetist can simply cover the
head with a clear plastic bag. I use the one
for circulation. But there is a fourth factor for patient survival: that the surgeon’s gown comes in. Cut it up
D, for degrees.
one side, cover the patient’s head and tuck
it under the blanket. Okay, it will initially
alarm the staff, but once they get used to
Generally, a patient is considered hypothermic when his
seeing it they’ll appreciate this free, safe
temperature is less than 95° F. To help prevent
and effective technique for patient
hypothermia, the Centers for Disease Control (CDC) and
warming.
major healthcare organizations recommend that operating
room temperature be set between 68°F and 73° F.
— Linda Chitwood, CRNA, MS
How to best assess hypothermia can be problematic. Axillary, skin and oral temperatures are
considered to be the least reliable. While rectal temps more closely reflect the patient’s core
temperature, most clinicians (and patients) prefer a tympanic temperature. No matter how it’s
measured, hypothermia increases the incidence of
surgical site infections, due to reduced perfusion of O2 in tissue;
cardiac arrhythmias and adverse myocardial events, which are resistant to treatment;
prolonged length of stay;
coagulopathy and impaired platelet function;
shivering, discomfort and lowered patient satisfaction;
impaired wound healing; and
altered metabolism of medications.
What's Surgeon Cooling Got To Do With Patient Warming?
For Terri Hurst, RN, keeping her surgeons cool is the key to keeping her patients warm.
“We looked at different things to maintain patient normothermia, because like everyone, we’re trying to keep
patients from getting cold. One of things we try to do is keep the OR temp between 68°F and 73°F, so we
needed a way to cool the surgeons and staff. Using medical air took too much out of our system, and it was
expensive,” says Ms. Hurst, the nurse manager of operating rooms at Ball Memorial Hospital in Muncie, Ind.
Her solution: Individual cooling vests for surgeons and staff. Three cooling vests are available for the OR
team:
• Glacier Tek offers a fabric vest packed with special cooling insert pockets. Loaded with gel-type inserts that
stay around 59°F to 60°F for between two and three hours, the Glaciertek vest weighs less than 5 pounds.
Each vest is about $150 and lets staff members move about freely, untethered to an electrical cooling unit.
• Cincinnati Sub Zero offers a vest connected by hoses to an electrical cooling unit. Cincinnati Sub Zero’s
Maxi-Therm Lite Vest, weighing about 2 pounds, circulates temperature controlled water through the vest to
cool the wearer. The cooling power never runs out because the wearer is connected to a central unit,
however, that connection limits the movement of the wearer. It also means another piece of electrical
equipment in an already-crowded OR.
• Texan Corporation offers a cooling vest that expels clean, dry, compressed medical air through hundreds of
tiny pressure drop points along the Pol-O.R. Bear tubing, which acts as a self-balancing distribution system.
Body cooling is achieved as perspiration evaporates. Lightweight air feed lines, connections and controls allow
freedom of movement without dragging or tugging at the user, says the company.
— Linda Chitwood, CRNA, MS
Cool Vests and Jackets
Glacier Tek, Inc.
(800) 482-0533
www.glaciertek.com
Maxi-Therm Lite Vest
Cincinnati Sub Zero
(800) 989-7373
www.cszmedical.com
Pol-O.R. Bear Personal
Air Conditioning System
Texan Corporation
(800) 255-6960
www.polorbear.net
As heat is lost in one of four ways, hypothermia must be battled on these fronts:
Conduction. Loss of heat to a solid, as when a patient loses warmth to a cold OR table.
Convection. Loss of heat through air or liquid, as when a patient is exposed to cool OR air or
cool IV fluids.
Evaporation. Loss of heat when fluid leaves the body and becomes a vapor, as when a body
cavity is open and internal tissue is exposed to cool OR temperatures.
Radiation. Loss of heat in the form of energy released from the body, a small factor in patient
hypothermia.
The war on hypothermia
There are myriad modes to defeat hypothermia. Some patient-warming techniques and tools are
complex and tedious but highly effective — albeit costly. Others are cheap and easy, a few simple
and succinct. Some are basic good sense that may be overlooked in a busy OR. Here are seven
ways to warm patients without inflaming your staff or scorching your bottom line.
1. Preheat the patient in the pre-operative area.
Applying an active warming technique in pre-op for just 30 minutes before surgery has been proven
to reduce the average temperature drop commonly seen during surgery. While this pre-warming
would most often be accomplished with a forced-air warming blanket, you can also begin warming
fluids, or use one of the newer technologies noted below. Heated cotton blankets from a blanket
warmer or patient warming gowns are superb patient-comfort measures, but they actually have little
heat-loss-prevention effect. To actively preheat the patient, use a warming device designed to reduce
or prevent hypothermia.
2. Warm the OR table before the patient settles onto it.
A warm table slows the rate of conductive heat loss, where the patient’s body heat is transferred to
the colder table and its cushion. A forced-air warmer’s hose set to high heat can be snuggled under
the table’s sheet to warm the table before the patient is transferred to it.
3. Cover the patient’s head and feet.
You cover your head in the winter, don’t you? It feels like winter in many ORs, so a head cover will
help keep the patient warm, because most heat is lost through the head. Covering the head with a foil
cap or clear plastic (if the patient is intubated) can significantly reduce heat loss. Socks help negate
heat loss too; two pairs layered on help prevent hypothermia.
4. Put a humid-moisture exchanger (HME) in the anesthesia circuit.
Reduce patient heat lost to the cool gases blown into the lungs during general anesthesia with these
small, inexpensive (a few dollars) devices. Moisture is retained and, as an added bonus, many HMEs
have a bacterial filter, too.
5. Cover up.
Limit the exposure of bare skin during prep, cleanup, and bandaging. If this seems obvious,
remember that personnel who aren’t cold in the OR and who are accustomed to exposed patients can
sometimes overlook just how chilly it is when bare skin is exposed to cold air. Evaporation of prep
solutions can expedite loss of heat too. When the surgery is completed, staff should wash, promptly
dry, and recover the patient as quickly as possible. Keep OR doors closed to reduce drafts that pull
heat (convective heat loss) from the patient.
6. Educate staff about the risks of litigation due to patient hypothermia.
Set up a simple in-service outlining the physiologic alterations that accompany hypothermia. Then
review the bad things that happen when good patients get cold: morbidity, mortality and lawsuits.
Many may be unaware of the risk of hypothermia or believe it insignificant because they haven’t seen
a hypothermia-related complication.
7. Try some of the new warming technologies.
If you’re only familiar with that large warming unit that rolls around on the floor and connects to a filmy
blanket, you’re out of the loop. Take a look at cutting edge hypothermia-prevention technology and
you’ll discover hope for finding a common ground between warm patients and cool staff.
Manufacturers produce compact forced-air heaters that clamp to IV poles or perch on the stretcher
rails. Newer forced-air warmers deliver the cozy air at a lower velocity to reduce turbulence, and
redesigned blankets have fewer tiny particles that can be puffed out into the surgical suite. Blankets
are available in more styles, materials and configurations to meet the needs of different specialties.
Some warmers have special HEPA filters to help reduce potential bacteria blown through the blankets
and into the OR.
Thermal warming pads (Kimberly-Clark) that adhere to the patient (used during cardiac bypass
surgeries) may be a viable alternative in longer ambulatory cases that can involve significant heat
loss, such as an abdominoplasty. A product expected to be available this summer (Dynatherm)
pending 510(k) approval only covers one hand or foot, leaving the rest of the patient available for
surgical care. Another advance comes with (Lexion Medical’s Insuflow) the warming, filtering and
hydrating of the gas insufflated into the abdomen for laparoscopic surgery, a major source of patient
cooling. Finally, if you still can’t keep your staff cool and your patients warm, try the cooling vests. It
may be the solution when the room should be warm but the staff has to be cool.
Maintaining normothermia
Advances in technology, coupled with simple common sense measures, mean most patients can be
normothermic upon arrival in the PACU. That means greater patient satisfaction, fewer complications
and lower risk of litigation.
Outpatient Surgery Magazine: Issue Date: July, 2004
20 Ways To Warm A Patient
Bair Hugger Large
Pediatric
Underbody
Blanket
Arizant Healthcare
(800) 733-7775
www.bairhugger.com
Enthermics Fluid
Warmer
Enthermics
Medical Systems
(800) 862-9276
www.enthermics.com
Belmont Buddy
EQ5000 Equator
Fluid Warmer
Convective Warmer
Belmont Instrument
Smiths Medical
Corp. (866) 663-0212
ASD, Inc.
www.belmontinstrument.com (800) 258-5361
www.smiths-medical.com
Blickman Double-Door
Warming Cabinet
Blickman Inc.
(800) 247-5070
www.blickman.com
Life-Air 1000
O.R. Solutions
Progressive
Irrigation Solution
Dynamics Medical,
Warmers
Inc.
O.R. Solutions
(269) 781-4241
(800) 343-6771
www.progressivedynamicsmedical.com
Mac Medical BlanketFluid Warmer
(877) 828-9975
www.macmedical.com
Soft-Air Convective
Warming Blankets
Adroit Medical
(800) 267-6077
www.adroitmedical.com
1200 Level 1 Fast Flow
MaxOne
Thermacare Upper Body
Fluid Warmer with Air
Automatic
Convective Warming
Detection
Medical Tech,
Quilt
Smiths Medical ASD, Inc.
Inc.
Gaymar Industries, Inc.
(800) 258-5361
(866) 4MAXONE
(800) 828-7341
www.smiths-medical.com
CSZ FilteredFlo
Warming Blankets
Cincinnati Sub Zero
(800) 989-7373
www.cszmedical.com
Insuflow
Lexion Medical
(877) 9-LEXION
www.lexion
medical.com
ChillBuster
Microtek
Medical
(800) 247-2841
www.mictrotekmed.com
Kimberly-Clark
Patient Warming
System
Kimberly-Clark
(800) KC-HELPS
www.kcpatientwarming.com
www.amtcorps.com
Mobile Heat
Advanced Surfaces
(800) 833-1822
www.surgicalpads.com
Olympic Warmettes
Blanket and Soluiton
Warmers
Olympic Medical
(800) 426-0353
www.olympicmedical.com
www.gaymar.com
Vitalheat*
Dynatherm Medical Inc.
(650) 777-4361
www.dynatherm
medical.com
* pending 510(k) approval
WarmTouch
Nellcor/Tyco Healthcare
(800) NELLCOR
www.nellcor.com
Ms. Chitwood ([email protected]) is a nurse anesthetist and freelance medical writer based in Senatobia, Miss.