perioperative normothermia – a lesson in how attention to detail matters

17
Perioperative Normothermia – a lesson in how attention to detail matters Addison K. May, MD, FACS, FCCM Professor of Surgery and Anesthesiology Division of Trauma and Surgical Critical Care

Upload: dinesh

Post on 25-Jan-2016

34 views

Category:

Documents


2 download

DESCRIPTION

Perioperative Normothermia – a lesson in how attention to detail matters. Addison K. May, MD, FACS, FCCM Professor of Surgery and Anesthesiology Division of Trauma and Surgical Critical Care. Objectives:. identify complications associated with perioperative hypothermia - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: Perioperative Normothermia – a lesson in how attention to detail matters

Perioperative Normothermia – a lesson in how attention to detail matters

Addison K. May, MD, FACS, FCCMProfessor of Surgery and Anesthesiology

Division of Trauma and Surgical Critical Care

Page 2: Perioperative Normothermia – a lesson in how attention to detail matters

Objectives:

1. identify complications associated with perioperative hypothermia

2. identify measures associated with intraoperative normothermia

3. review standardized processes introduced for the trauma/EGS services to maintain normothermia

Page 3: Perioperative Normothermia – a lesson in how attention to detail matters

What is normothermia?

• Definition: a condition of normal body temperature– 37°C (36.5–37.5°C) or 98.6°F (98–100°F) core temperature

– Peripheral tissues may fall significantly below and before core temperature falls

• Mild hypothermia: 32–35°C or 90–95°F– shivering– hypertension– tachycardia– tachypnea – vasoconstriction

– cold diuresis– mental confusion– hyperglycemia– hepatic dysfunction

Page 4: Perioperative Normothermia – a lesson in how attention to detail matters

• The World Health Organization standard: maintain patient core temperature > 36°C throughout the perioperative period

• Perioperative hypothermia:– Increases susceptibility to infections

• Decreased perfusion, decreased antibiotic penetration, altered phagocytic function

– Increases blood loss• Temperature induced coagulopathy, altered platelet function

– Decreases wound healing– Increases cardiac morbidity

• Vasoconstriction, shivering, cardiac dysthymias

• Randomized studies demonstrate improved outcome with normothermia

Why should we maintain normothermia?

Page 5: Perioperative Normothermia – a lesson in how attention to detail matters

What factors contribute to perioperative hypothermia?

• anesthetic-induced impairment of thermoregulation

• altered distribution of body heat

• exposure– body surface– body cavities

• application of fluids to body surface

• low ambient room temperatures

• delivery of and exposure to hypothermic fluids

Page 6: Perioperative Normothermia – a lesson in how attention to detail matters

Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization

• 200 patients

• elective colorectal surgery

• Interventions started at induction

• hypothermia vs normothermiaNormothermia– Target temps: 36.5 ° C– Fluids via warmer activated– Forced air @ 40°C

Hypothermia– Target temps: 34.5 ° C– Fluids via warmer in-activated– Forced air @ ambient temperature

Kurz A - N Engl J Med 1996; 334:1209-1215

Page 7: Perioperative Normothermia – a lesson in how attention to detail matters

Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalizationKurz A - N Engl J Med 1996; 334:1209-1215

Postoperative Findings in the Two Study Groups Multivariate Analysis of Risk Factors for Surgical-Wound Infection

• Active warming resulted in significant– reduction of infections, hospital length of stay– improved wound healing and resolution of ileus

Page 8: Perioperative Normothermia – a lesson in how attention to detail matters

Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomized controlled trial

• 421 patients

• clean (breast, varicose vein, or hernia) surgery

• Intervention prior to OR

Melling AC . Lancet 2001; 358:876-880

• Warming vs standardWarmingSystemic warming: forced air 30 min prior to ORLocal warming: radiant heat dressingStandardNo intervention

The effects of warming therapies compared with standard treatment

Page 9: Perioperative Normothermia – a lesson in how attention to detail matters

Randomized clinical trial of perioperative systemic warming in major elective abdominal surgeryWong PF. Br J Surg 2007; 94:421-426

• 103 patients

• All patients with– Forced air @ 40°C intra-op– Warmed fluids

• Treatment group– Warming pad beneath– 40°C - 2 hrs before and

throughout OR

• Control group– Warming pad beneath– Turned off

Core temp adm: treatment 36.5 control 36.5 Core temp at start: treatment 36.4 control 36.0 Core temp at study end: treatment 36.3 control 36.2

Page 10: Perioperative Normothermia – a lesson in how attention to detail matters

Randomized clinical trial of perioperative systemic warming in major elective abdominal surgeryWong PF. Br J Surg 2007; 94:421-426

• Addition of warming blanket before and through surgery improved outcomes

• Treatment group

fewer complications: 32 vs 54% (p=0.027)

less blood loss: 200 vs 400 ml (p=0.011)

Page 11: Perioperative Normothermia – a lesson in how attention to detail matters

How is VUMCs performance for normothermia?

Trauma/EGS cases for August 2008

• 240 of 255 cases with temp values

All cases:

– 55% of cases - lowest temp < 360C

– 20% never get above 360C

Elective cases:

– 59% of elective cases - lowest temp < 360C

– 41% of elective cases - 1st temp < 36°C

Colorectal cases for August 2008• 111 of 131 cases with temp values

– 41% of colorectal cases 1st temp < 360C

– 52% of cases have either the first or last temp recorded < 360C

Page 12: Perioperative Normothermia – a lesson in how attention to detail matters

Trauma/EGS normothermia initiative

Purpose/description:

• To improve maintenance of normothermia for the Trauma/EGS patient population

• Target goals:– > 90% patients with first and post-op temperature > 36°C.– > 80% patients with minimum temperature > 36°C

Page 13: Perioperative Normothermia – a lesson in how attention to detail matters

Trauma/EGS Perioperative Process

Pre-operative:• Bear Paws:

– All elective cases should have Bear Paws placed on the patient in holding room and forced warm air turned on to maintain temperature greater than 36.5°C at all times

Intra-operative:• Ambient room temperature:

– non-trauma cases: Room temperature should be set to 24°C (75°F)– Room temperature to be recorded in VPIMS– Adjust room temperature during case if core temp > 36.5°C

• Peri-induction and intra-operative management:– Bear Paws (if elective) / Bear Hugger applied, forced air @ 40°C prior to induction & prep– Upper & lower forced air warming devices should be applied as allowed by the case– Intraoperative fluids and irrigation should be warmed to 37°C

Post-operative management:• Patients immediately covered with either warm blankets and/or forced air device depending

on pt core temperature at completion of case

Page 14: Perioperative Normothermia – a lesson in how attention to detail matters

Trauma/EGS: % patients with temperature value < 36°CPe

rcen

tage

of p

atien

ts w

ith h

ypot

herm

ia

VPIMS reported data: Min temp = lowest recorded intra-op temp, first temp = 1st after induction

Page 15: Perioperative Normothermia – a lesson in how attention to detail matters

Colorectal: % patients with temperature value < 36°CPe

rcen

tage

of p

atien

ts w

ith h

ypot

herm

ia

VPIMS reported data: first temp = 1st after induction

Page 16: Perioperative Normothermia – a lesson in how attention to detail matters

My take home points:

• Strict attention to normothermia improves patient outcomes

• Attention to detail throughout the perioperative period required to achieve high level compliance with normothermia

• Ability to measure and monitor compliance is important in achieving our goals

• To maintain normothermia in the majority of patients, likely need

– Pre-op active warming to maintain > 36.5°C

– Intra-op maintenance of ambient temp, active warming, and warm fluids

Page 17: Perioperative Normothermia – a lesson in how attention to detail matters