1. Infection Prevention Division Essentials EDU Learning Program ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 3M Infection Prevention Solutions Learning Connection ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Prewarming: Maintaining Normothermia from the Start

2. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Disclosure Sponsored by 3M, Infection Prevention Division 3M Health Care is a provider approved by the California Board of Registered Nursing Registered nurse participants can receive up to 1.0 contact hour upon course completion Presented by Cherrilyn Baker, RN, BSN, MBA Clinical Specialist 3M Infection Prevention Division

3. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Course Objectives  Explain how the body’s thermoregulation system works  Define unintended perioperative hypothermia  Identify adverse patient outcomes associated with unintended perioperative hypothermia  Discuss the definition of prewarming and associated clinical studies  Explain why prewarming is beneficial in the prevention of unintended perioperative hypothermia  Identify industry initiatives and guidelines citing normothermia

4. Attest ™ Sterile U Network Presentation Title ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 THE THERMOREGULATION SYSTEM

5. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Normothermia  Normothermia: the body’s ideal thermal state  Normal core temperature: 1  Approximately 37.0°C (98.6°F)  Temperature gradient: 1  2-4°C between the core and periphery  Hypothalamus 1,2,3  Regulates core body temperature 37 o C periphery 2-4 o C cooler Hypothalamus 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737. 2. Guyton AC, Hall JE. Textbook of Medical Physiology. 10 th Ed. © 2000. 3. De Witte J, Sessler DI. Anesth. 2002;96(2):467-84.

6. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 The body’s normal response to temperature (°C) 3233 3435363738394041 0.2°C Interthreshold Range Vasoconstriction Shivering NST Vasodilation Sweating Thermoregulation: Under Normal Circumstances 1.Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737. 4. Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3 rd ed. New York: Churchill/Livingstone 1990. Adapted from: Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3 rd ed. New York: Churchill/Livingstone 1990.

7. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 3233 3435363738394041 4.0°C Interthreshold Range Vasoconstriction NST Vasodilation Sweating Hypothermia : < 36.0°C Anesthesia-impaired response to temperature (°C) 1.Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737. 4. Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3 rd ed. New York: Churchill/Livingstone 1990. Adapted from: Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3 rd ed. New York: Churchill/Livingstone 1990. Effects of Anesthesia Depressed Hypothalmus

8. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12  40-year-old (70kg) patient 5 5  Awake: 70 kilocalories heat/hour  Anesthetized: 42 kilocalories  80-year-old (70kg) patient 5 5  Awake: 60 kilocalories heat/hour  Anesthetized: 38 kilocalories 5 Adapted from: Morrison, International Anesthesiology Clinics, 1988 Effects of Anesthesia Metabolic Heat Production

9. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 cold environment  Anesthesia causes vasodilation, or an opening of arterial shunts, allowing the warm blood from the core to flow freely and mix with the colder periphery  As the blood circulates, it cools until returning back to the heart where it causes a drop in core temperature  This is known as heat redistribution 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737. Effects of Anesthesia Heat Redistribution

10. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Characteristic Patterns of General Anesthesia-Induced Hypothermia  Core temperature can drop 1.6°C in the first hour of general anesthesia 5, 6  81% of this temperature decrease is due to core-to- peripheral heat redistribution 6  Commonly known as redistribution temperature drop 5,6 Elapsed Time (h) 0 2 4 6 DECREASE CORE TEMP 1hr 0 -2 -3 Core Temp (C ° ) 5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596. 6. Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C. Heat Flow and Distribution During Induction of General Anesthesia. Anesth. 1995;82(3):662-673. Adapted from: Sessler DI, Anesth. 2000; 92(2): 578-96.

11. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Phases of Hypothermia Development Typical Pattern of Hypothermia during General Anesthesia Elapsed Time (h) 0 2 4 6 DECREASE CORE TEMP 1hr 0 -2 -3 Core Temp (C ° ) Phase I: Rapid decrease in core temperature primarily caused by redistribution of heat. Heat loss: 81% redistribution; 19% environmental Phase I: Rapid decrease in core temperature primarily caused by redistribution of heat. Heat loss: 81% redistribution; 19% environmental Phase II: Slower, linear decrease in temperature primarily caused by heat loss which exceeds the body’s ability to produce heat Phase III: Temperature plateaus once it has dropped beyond the widened interthreshold range and triggers the thermoregulatory response Adapted from: Sessler DI, Anesth. 2000; 92(2): 578-96. 5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596. 6. Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C. Heat Flow and Distribution During Induction of General Anesthesia. Anesth. 1995;82(3):662-673.

12. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Causes of Unintended Perioperative Hypothermia  Administration of anesthetic drugs leading to heat redistribution 1,5 General anesthesia Regional anesthesia  Exposed body cavities 1,5  Cold O.R. temperatures 1,5  Length of surgery 1,5  Infusion of cold fluids and blood 1,5 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737. 5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.

13. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Maintaining Patient Normothermia  The induction of anesthesia is the most significant contributor to unintended perioperative hypothermia in surgical patients 1,5  Reducing the impact of redistribution temperature drop through prewarming is an effective way to help maintain patient normothermia 1,5 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737. 5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.

14. Attest ™ Sterile U Network Presentation Title ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 MAINTAINING NORMOTHERMIA: OUTCOMES, ECONOMICS, & INITIATIVES

15. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Unintended Perioperative Hypothermia  Perioperative hypothermia is defined as any core temperature less than 36.0°C (96.8°F) 1,5,7  Unintended perioperative hypothermia is considered a frequent, preventable complication of surgery  Unless preventative measures are taken, unintended perioperative hypothermia occurs in 50% to 90% of surgical patients 7  Research shows that even mild hypothermia can result in significant negative outcomes 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737. 5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596. 7. Young V, Watson M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006;551-571.

16. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Adverse Effects of Unintended Perioperative Hypothermia  There are many documented adverse effects of unintended perioperative hypothermia including: 8  Wound infection  Myocardial ischemia and cardiac disturbances  Coagulopathy  Prolonged and altered drug effect  Increased mortality  Shivering and thermal discomfort  Delayed emergence from anesthesia 8. Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28.

17. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Benefits of Normothermia  Maintaining normothermia may yield positive results such as: 9  Reduction in the use of blood products  Shortened length of hospital stay  Decreased ICU time  Reduced rate of wound infection  Decreased likelihood of myocardial infarction  Lower mortality rates 9. Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. 1999;67(2):155-164.

18. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Meta-Analysis Results Meta-Analysis Results 9 Cost Savings Range Blood products$227 - $344 Hospital stay$1,534 - $4,602 ICU time$105 - $314 Wound infections$549 - $1,697 Myocardial infarction$68 - $90 Mechanical ventilation$16 - $26 MortalityUndefined Total Per Patient Savings$2,495 - $7,073 Adapted from: Mahoney, Odom, AANA Journal, 1999 9. Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. 1999;67(2):155-164.

19. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 HAI and SSI Statistics  Hospital infections, including SSIs, are prevalent and costly  The fourth largest killer in the U.S., claiming more lives than AIDS, breast cancer and traffic accidents combined 7 7  SSIs may result in yearly medical costs of $1 billion to $10 billion 8 8  Patients who acquire SSIs are shown to have: 12 Readmitted to the hospital Admitted to the ICU Two times more likely to die 10. Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA, Cardo DM. Estimating healthcare-associated infections in US hospitals, 2002. Public Health Rep. Mar 2007;122(2):160-6. 11. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2008. CDC. Available at http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf.http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf Accessed 5/1/2012. 12. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control Hospital Epidemiology, 1999;20:725–30.

20. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Surgical Wound Infections  Hypothermic patients are at a greater risk for SSI  Reduction in core temperature of 1.9°C has been shown to triple the incidence of SSIs after colon resection 13 13. Kurz A, Sessler DI, Lenhardt R. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. New Engl J Med. 1996;334:1209-1215. Days  Length of hospital stay increased for hypothermic patients with SSI 13 *Adapted from: Kurz et al., New Engl J Med, 1996

21. Attest ™ Sterile U Network Presentation Title ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 THE SCIENCE BEHIND PREWARMING

22. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12  Prewarming: the application heat prior to anesthesia for the purpose of increasing total body temperature  Prewarming = “banking heat”  Total body temperature = the average combined temperature of the periphery and core  Prewarming increases the temperature of the periphery, which limits the amount of heat lost from the core through redistribution What Is Prewarming?

23. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Warming Goals  Goal of perioperative warming  Maintain normal core temperature during pre-op, surgery, and post-op 1,5  Goal of prewarming  Prevent or reduce RTD during Phase I 1,5,14 Pre-op Temp O.R. Temp Post-op Temp = ≥36.0°C Elapsed Time (h) 0 2 4 6 DECREASE CORE TEMP 0 -2 -3 Core Temp (C ° ) 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737. 5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596. 14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of prewarming. Anesth. 1995;82(3): 674-681. Adapted from: Sessler DI, Anesth. 2000; 92(2): 578-96.

24. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Surgical Site Infection Rates  Melling et al. studied 421 patients receiving 30 minutes of prewarming vs. no prewarming 15  30 minutes of prewarming appears to assist in the prevention of SSIs 15 Adapted from: Melling AC et al. Lancet. 2001;358(9285):876-880. Infection Rates 15. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after a clean surgery: a randomized controlled trial. Lancet. 2001;358(9285):876-880.

25. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Prewarming and Patient Satisfaction  Prewarming can provide both clinical and comfort benefits  Recent studies have examined the effects of prewarming on patient comfort and satisfaction 17,18,19  Prewarming with a forced-air warming gown vs. warmed cotton blankets can positively affect patient comfort and satisfaction 17,18,19 Warmth can play a role in a positive patient experience 17. O’Brien D, Greenfield ML, Anderson J, Smith B, Morris M. Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical trial. J PeriAnesth Nurs. Apr 2010; 25(2):88-93. 18. Leeth D, Mamaril M, Oman K, Krumbach B. Normothermia and patient comfort: a comparative study in an outpatient surgery setting. J PeriAnesth Nurs. Jun 2010;25(3):146-151. 19. Wagner VD, Byrne MJ, Kolcaba KL. Effects of Comfort Warming on Preoperative Patients. AORN Journal. September 2006:84(3):427-448.

26. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Yilmaz M, Popwich D, Halverson A, Mullaghy E, McCarthy R. Anesth. 2008;109:A880 141 colorectal surgery patients Intraoperative warming vs. preoperative/intraoperative warming Normothermia in PACU patients is achieved more effectively by prewarming combined with intraoperative warming versus only using intraoperative warming 20 Prewarmed patients had a propensity toward fewer infections and spent less time in the hospital 20 Study FindingsStudy Details Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery 20. Yilmaz M, Popwich D, Halverson A, Mullaghy E, McCarthy R. Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880. Adapted from: Yilmaz M, et al. Anesth. 2008;109:A880.

27. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Preoperative Combined with Intraoperative Skin- Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR. J. Clinical Anesthesia. 2008;15:119-125. Prospective, randomized trial of 30 patients undergoing elective abdominal surgery Combining prewarming with forced-air warming before the induction of anesthesia followed by intraoperative warming with forced-air warming prevented patients from experiencing hypothermia in surgeries of at least two hours in length 24 Study FindingsStudy Details 24. Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR. Preoperative Combined with Intraoperative Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical Anesthesia. 2003;15:119-125.

28. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Adapted from: Vanni S., et al. J of Clinical Anesthesia. 2003; 15:119-125. Core Temp (C ° ) Time (min) 38 37 36 35 34 33 32 -75end0-60-45-30-15306090120 PreoperativeIntraoperative 36 Pre + Intraop. Warming Group Intraop. Warming Group Control Group (no warming) Prewarming vs. Intraoperative Warming 31 0 Intraop Warming Only: To “re-warm” following temperature afterdrop requires time and may require maximum operating temperature of warming device. Prewarming + Intraop Warming: Maintain the warmth already gained while the patient was prewarmed by monitoring temps and adjusting the warming unit in the OR accordingly. 24. Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR. Preoperative Combined with Intraoperative Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical Anesthesia. 2003;15:119-125.

29. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12  Prewarming can prevent or reduce RTD 14,22,25  Prewarming + intraoperative warming can help patients achieve a higher core temperature in PACU 20,21,24  Prewarming is beneficial in procedures of shorter duration 23  Prewarming can positively affect patient comfort and satisfaction 17,18,19 Prewarming Study Summary 14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of prewarming. Anesthesiology. 1995;82(3):674-681. 17. O’Brien D, Greenfield ML, et al. Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical trial. J Perianesth Nurs. Apr 2010; 25(2):88-93. 18. Leeth D, Mamril M, et al. Normothermia and patient comfort: a comparative study in an outpatient surgery setting. J Perianesth Nurs. Jun 2010;25(3):146-151. 19. Wagner VD, Byrne MJ, Kolcaba KL. Effects of Comfort Warming on Preoperative Patients. AORN Journal. September 2006:84(3):427-448. 20. Yilmaz M, et al. Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880. 21. Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of Prewarming on Post-Induction Core Temperature and the Incidence of Inadvertent Perioperative Hypothermia in Patients Undergoing General Anesthesia. Brit Journal of Anaesth. 2008;101(5):627-631. 22. Kiekkas P, Karga M. Prewarming: Preventing intraoperative hypothermia. BJPN. Vol 15 No 10. October 2005. 23. Camus Y, Delva E, Sessler DI, Lienhart A. Pre-Induction Skin-Surface Warming Minimizes Intraoperative Core Hypothermia. Journal of Clinical Anesthesia. 1995;7:384-388. 24. Vanni SM, et al. Preoperative Combined with Intraoperative Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical Anesthesia. 2003;15:119-125. 25. Glosten B, Hynson J, Sessler DI, McGuire J. Preanesthetic Skin-Surface Warming Reduces Redistribution Hypothermia Caused by Epidural Block. Anesth Analg. 1993;77:488-93.

30. Attest ™ Sterile U Network Presentation Title ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 PREWARMING CONSIDERATIONS

31. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Passive Warming  Cotton blankets are passive insulators – they do not provide active warming 27  Heat from a warmed cotton blanket is quickly lost to its surroundings 27  Patient heat loss is virtually identical with warmed and unwarmed cotton blankets 27  Passive warming is not an effective way to prevent unintended perioperative hypothermia 27. Sessler DI, Schroeder M. Heat Loss in Humans Covered with Cotton Hospital Blankets. Anesth Analg. 1993; No. 1: 73-77.

32. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12  Active warming is the active application of heat  Examples: forced-air warming blankets or gowns, or conductive warming blankets or pads  Studies demonstrate that prewarming can be achieved by utilizing active warming methods such as forced-air warming or conductive blankets 22,28-32 Active Warming 22. Kiekkas P, Karga M. Prewarming: preventing intraoperative hypothermia. Br J Perioper Nurs. 2005;15(10):444-445. 28. Brauer A, Waeschle RM, Waeschle RM, Heise D, Perl T, Hinz J, Quintel M, Bauer M. Preoperative prewarming as a routine measure. Anaesthetist. 2012;59(9):842-850. *Study only available in German. Summary based off internal English translation. 29. Kim JY, Shinn H, Oh YJ, Hong YW, Kwak HJ, Kwak YL. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery. Eur J Cardiothoracic Surg. 2006;29(3):343-7. 30. Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A. 31. Shinn HK, Kwak YL, Oh YJ, Kim SH, Kim JY, Lee MH. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol. 2006;48(6):S5-10. 32. Kurz A, Kurz M, Poeschl G, Faryniak B, Redl G, Hackl W. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95.

33. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Active Warming vs. Passive Warming  Preprocedure warming for one hour can decrease the amount of post-op hypothermia 33 Forced-air Warming Gown Cotton Gown 33. Hooven K. Preprocedure warming maintains normothermia throughout the perioperative period: a quality improvement project. J PeriAnesth Nurs. 2011;26(1):9-14. Adapted from: Hooven K. J PeriAnesth Nurs. 2011;26(1):9-14.

34. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Prewarming and Fluid Warming  It is not possible to warm patients with warmed I.V. fluids alone 35  Warmed I.V. fluids cannot transfer enough energy to prewarm surgical patients 35 vs.  1 L. of saline at 37°C only increases a 70kg patient’s mean body temperature by 0.03°C 36 35. Sessler DI. Consequences and treatment of perioperative hypothermia. Anesth Clin N Am. 1994;12(3):425-426. 36. Horowitz PE, Delagarza MA, Pulaski JJ, Smith RA. Flow rates and warming efficacy with Hotline and Ranger blood/fluid warmers. Anesth Analg. 2004;993(3):788-792.

35. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Getting Started 1.Conduct a temperature audit 2.Implement a consistent, accurate patient temperature monitoring process 3.Actively prewarm patients 4.Consistent maintenance of normothermia “ The hypothermia literature is in agreement that prewarming is the key to maintaining normothermia in most patients.” 7

36. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Monitor Patient Temperature  Monitor your patients’ intraoperative temperatures and adjust temperature settings in the O.R. accordingly  Avoid patient sweating; intraoperative warming should not be too aggressive  High, Medium, and Low Settings  Check PACU temperature  If patients are ≥36°C, they have achieved normothermia, and you have successfully met the SCIP-Inf-10 normothermia measure  If patients are uncomfortably warm, examine your O.R. protocol and practices

37. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Prewarming Considerations Remember: Only 30 minutes of prewarming with forced-air can “bank heat” in the periphery and prevent or reduce redistribution temperature drop 14 14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of prewarming. Anesth. 1995;82(3): 674-681.

38. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12  All surgical patients – regardless of age, weight or other factors – undergoing general anesthesia may be susceptible to RTD  Monitor patient temperature to maintain normothermia throughout the entire perioperative period by starting in pre-op  Prewarming can be achieved by utilizing active warming methods 22  Studies demonstrate that prewarming can be achieved by utilizing active warming methods such as forced-air warming or conductive blankets 22,28-32 Prewarming Considerations: Overview 22. Kiekkas P, Karga M. Prewarming: preventing intraoperative hypothermia. Br J Perioper Nurs. 2005;15(10):444-445. 28. Brauer A, Waeschle RM, et al. Preoperative prewarming as a routine measure. Anaesthetist. 2012;59(9):842-850. *Study only available in German. Summary based off internal English translation. 29. Kim JY, Shinn H, et al. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery. Eur J Cardiothoracic Surg. 2006;29(3):343-7. 30. Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A. 31. Shinn HK, Kwak YL, et al. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol. 2006;48(6):S5-10. 32. Kurz A, Kurz M, Poeschl G, et al. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95.

39. Attest ™ Sterile U Network Presentation Title ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 INDUSTRY INITIATIVES & GUIDELINES

40. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Normothermia: An Important Topic Patient Normothermia

41. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Best Practices for Preventing SSIs  C lipping  Remove hair appropriately  A ntibiotics  Use prophylactic antibiotics appropriately  T emperature  Maintain normothermia  S ugar  Maintain glucose control

42. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 CMS SCIP-Infection-10 Perioperative Temperature Management Measure  Active warming used intraoperatively – OR –  At least one temp ≥36.0°C within 30 minutes immediately before or 15 minutes immediately after anesthesia end time 37 Numerator Denominator  All patients undergoing surgical procedures under general or neuraxial anesthesia of 60 minutes or longer 37 37. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-12 (1Q12) through 06-30-12 (2Q12).

43. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 CMS SCIP-Infection-10 Perioperative Temperature Management Measure What this means for facilities: 1. Warming more patients – regardless of age 2. Warming more procedures* – regardless of complexity 3. Ensuring normothermia Normothermia is the goal 37. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-12 (1Q12) through 06-30-12 (2Q12). *Excludes patients with physician documentation of Intentional Hypothermia for the procedure performed

44. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Hospital Compare  Hospital Compare is an online tool for consumers offered by U.S. Department of Health & Human Services 38  Gives consumers a tool to assist in the selection of care based on a variety of metrics  Scores include: 38  Patient satisfaction  Patient safety  Mortality  Readmission Rates  SCIP Measures – including SCIP-Inf-10 for normothermia maintenance 38. U.S. Department of Health & Human Services. Hospital Compare: Process of Care Measures. Available at http://www.hospitalcompare.hhs.gov. Accessed February 17, 2012. http://www.hospitalcompare.hhs.gov

45. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)  The first national, standardized, publicly reported survey to measure patients' perspectives of their hospital experience 39  Discharged patients answer 27 questions on their recent hospital stay  Designed for acute care hospitals  Beginning 10/1/2012, HCAHPS scores will be one of 13 measures used by CMS to calculate payment from its new Hospital Value-Based Purchasing Program 39  Adherence to the 12 quality care measures will be weighted at 70% of the payment formula  The patient satisfaction surveys will account for the remaining 30%. 39. HCAHPS Fact Sheet. Centers for Medicare & Medicaid Services, Baltimore, MD. http://www.hcahpsonline.org. Accessed: March 15, 2012. http://www.hcahpsonline.org

46. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 AORN’s Recommended Practices for Unplanned Perioperative Hypothermia  Create a plan to reduce the risk of unintended perioperative hypothermia 40  Monitor core temperatures starting in pre-op and continuing throughout the perioperative process 40  15 minutes of prewarming prior to the start of anesthesia 40  Maintenance of normothermia during surgery 40  Utilize a warming modality such as: 40  Forced-air warming – Safe, proven, effective and commonly used  Circulating-water garments – Effective in adult and pediatric patients  Energy transfer pads – Effective in reducing hypothermia during off-pump cardiac surgery 40. AORN. Recommended Practices for the Prevention of Unplanned Perioperative Hypothermia. Standards, Recommended Practices, and Guidelines. Denver, Colorado: AORN, Inc. 2012.

47. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 ASPAN Recommendations on Normothermia  ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia 41  Specific recommendations for pre-op include: 41  Assessing every patient by monitoring temperatures, identifying risk factors and thermal comfort level of the patient  Utilizing active warming for patients with temperatures <36°C  Providing thermal comfort through passive measures  Consider prewarming – “Evidence suggests that prewarming for a minimum of 30 minutes may reduce the risk of subsequent hypothermia.” 1,15,41 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737. 15. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after a clean surgery: a randomized controlled trial. Lancet. 2001;358(9285):876-880. 41. Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B, Martinez E, Noble K, O’Brien D, Odom-Forren J, Peterson C, Ross J. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. J PeriAnesth Nurs. 2009:24(5):271-287.

48. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Association of Surgical Technologists (AST)  AST adopted the Guideline Statement for the Maintenance of Normothermia in the Perioperative Patient 42  Institute a perioperative process to oversee and manage a patient’s core body temperature 42  Monitoring patient temperatures is a team effort involving all perioperative personnel 42 42. Association of Surgical Technologists. Guideline Statement for the Maintenance of Normothermia in the Perioperative Patient. October 2005.

49. Attest ™ Sterile U Network Presentation Title ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 CONCLUSION

50. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Conclusion  Perioperative hypothermia is defined as any core temperature less than 36.0°C (96.8°F) 1,5,7  Research shows that even mild hypothermia can result in significant negative outcomes  All surgical patients – regardless of age, weight or other factors – undergoing general anesthesia may be susceptible to RTD  Prewarming can prevent or reduce RTD 1,5,14,20  Studies demonstrate that prewarming can be achieved by utilizing active warming methods such as forced-air warming or conductive blankets 22,28-32 1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737. 5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596. 7. Young V, Watson M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006;551-571. 14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of prewarming. Anesthesiology. 1995;82(3):674-681. 20. Yilmaz M, et al. Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880. 22. Kiekkas P, Karga M. Prewarming: Preventing intraoperative hypothermia. BJPN. Vol 15 No 10. October 2005. 28. Brauer A, Waeschle RM, et al. Preoperative prewarming as a routine measure. Anaesthetist. 2012;59(9):842-850. *Study only available in German. Summary based off internal English translation. 29. Kim JY, Shinn H, et al. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery. Eur J Cardiothoracic Surg. 2006;29(3):343-7. 30. Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A. 31. Shinn HK, Kwak YL, et al. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol. 2006;48(6):S5-10. 32. Kurz A, Kurz M, Poeschl G, et al. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95.

51. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 Course Objectives  Explain how the body’s thermoregulation system works  Define unintended perioperative hypothermia  Identify adverse patient outcomes associated with unintended perioperative hypothermia  Discuss the definition of prewarming and associated clinical studies  Explain why prewarming is beneficial in the prevention of unintended perioperative hypothermia  Identify industry initiatives and guidelines citing normothermia

52. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 References 1.Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737. 2.Guyton AC, Hall JE. Textbook of Medical Physiology. 10 th Ed. © 2000. 3.De Witte J, Sessler DI. Perioperative Shivering. Anesth. 2002;96(2):467-84. 4.Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3 rd ed. New York: Churchill/Livingstone 1990. 5.Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596. 6.Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C. Heat Flow and Distribution During Induction of General Anesthesia. Anesth. 1995;82(3):662- 673. 7.Young V, Watson M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006;551-571. 8.Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28. 9.Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. 1999;67(2):155-164. 10.Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA, Cardo DM. Estimating healthcare-associated infections in US hospitals, 2002. Public Health Rep. Mar 2007;122(2):160-6. 11.Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2008. CDC. Available at http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf. Accessed 5/1/2012. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf 12.Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control Hospital Epidemiology, 1999;20:725–30. 13.Kurz A, Sessler DI, et al. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. New Engl J Med. 1996;334:1209-1215. 14.Sessler DI, Schroeder M, Merrifield B, et al. Optimal duration and temperature of prewarming. Anesth. 1995;82(3): 674-681. 15.Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after a clean surgery: a randomized controlled trial. Lancet. 2001;358(9285):876-880. 16.Hogenmiller J, et al. Preventing Orthopedic Total Joint Replacement Surgical Site Infections through a Comprehensive Best Practice Bundle/Checklist. Hospital: Truman Medical Center, Kansas City, MO. APIC abstracts, June 2011. 17.O’Brien D, Greenfield ML, et al. Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical trial. J PeriAnesth Nurs. Apr 2010; 25(2):88-93. 18.Leeth D, Mamril M, et al. Normothermia and patient comfort: a comparative study in an outpatient surgery setting. J PeriAnesth Nurs. Jun 2010;25(3):146-151. 19.Wagner VD, Byrne MJ, Kolcaba KL. Effects of Comfort Warming on Preoperative Patients. AORN Journal. September 2006:84(3):427-448 20.Yilmaz M, et al. Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880. 21.Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of Prewarming on Post-Induction Core Temperature and the Incidence of Inadvertent Perioperative Hypothermia in Patients Undergoing General Anesthesia. Brit Journal of Anaesth. 2008;101(5):627-631.

53. ©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12 References 22.Kiekkas P, Karga M. Prewarming: Preventing intraoperative hypothermia. BJPN. Vol 15 No 10. October 2005. 23.Camus Y, Delva E, Sessler DI, Lienhart A. Pre-Inductive Skin-Surface Warming Minimizes Intraoperative Core Hypothermia. Journal of Clinical Anesthesia. 1995;7:384-388. 24.Vanni SM, et al. Preoperative Combined with Intraoperative Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical Anesthesia. 2003;15:119-125. 25.Glosten B, Hynson J, Sessler DI, McGuire J. Preanesthetic Skin-Surface Warming Reduces Redistribution Hypothermia Caused by Epidural Block. Anesth Analg. 1993;77:488-93. 26.Just B, et al. Prevention of Intraoperative Hypothermia by Preoperative Skin-Surface Warming. Anesth. 1993;79(2):214-218. 27.Sessler DI, Schroeder M. Heat Loss in Humans Covered with Cotton Hospital Blankets. Anesth Analg. 1993; No. 1: 73-77. 28.Brauer A, Waeschle RM, et al. Preoperative prewarming as a routine measure. Anaesthesist. 2012;59(9):842-850. *Study only available in German. Summary based off internal English translation. 29.Kim JY, Shinn H, et al. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery. Eur J Cardiothorac Surg. 2006;29(3):343-7. 30.Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A. 31.Shinn HK, Kwak YL, et al. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol. 2006;48(6):S5-10. 32.Kurz A, Kurz M, Poeschl G, et al. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95. 33.Hooven K. Preprocedure warming maintains normothermia throughout the perioperative period: a quality improvement project. J PeriAnesth Nurs. 2011;26(1):9-14. 34.Fossum S, Hays J, Henson MM. A Comparison Study on the Effects of Prewarming Patients in the Outpatient Surgery Setting. J PeriAnesth Nurs. 2002;16(3):187-194. 35.Sessler DI. Consequences and treatment of perioperative hypothermia. Anesth Clin N Am. 1994;12(3):425-426. 36.Horowitz PE, Delagarza MA, Pulaski JJ, Smith RA. Flow rates and warming efficacy with Hotline and Ranger blood/fluid warmers. Anesth Analg. 2004;993(3):788-792. 37.Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-12 (1Q12) through 06-30-12 (2Q12). 38.U.S. Department of Health & Human Services. Hospital Compare: Process of Care Measures. Available at http://www.hospitalcompare.hhs.gov. Accessed February 17, 2012. 39.HCAHPS Fact Sheet. Centers for Medicare & Medicaid Services, Baltimore, MD. http://www.hcahpsonline.org. Accessed: March 15, 2012.http://www.hcahpsonline.org 40.AORN. Recommended Practices for the Prevention of Unplanned Perioperative Hypothermia. Standards, Recommended Practices, and Guidelines. Denver, Colorado: AORN, Inc. 2012. 41.Hooper VD, et al. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. J PeriAnesth Nurs. 2009:24(5):271-287. 42.Association of Surgical Technologists. Guideline Statement for the Maintenance of Normothermia in the Perioperative Patient. October 2005.