Je-Bog Yoo, RN. & Ph D.
- Professor of Gyeonam National Univesity of Science and Technology
- Dept. of Nursing Science
- President of Korean association of Perianesthesia Nurses
1
Introduction
Backgrounds
 Approximately 50 – 90% of patients who has undergone
operations are known to experience hypothermia
 Hypothermia in operation causes various complications
-delayed recovery after operation
-delayed discharge from the recovery room, refer to ICU,
- extended hospitalization
-even additional administration of drugs or blood transfusion
→which can cause extra-charge
 In local anesthesia the patient’s body temperature compared to
the general anesthesia to overlook the risk of hypothermia
2
Backgrounds
• Geriatric Patient
→ can’t adjust body temperature
have a low compensation
Hypothemia
• In local anesthesia
→ don’t have much
recognition of the lowered
central body temperature
Total Knee
Replacement
Arthroplasty
Operating room temperature
(20℃ below)
→ Surgeon’s operating gown
(head gear wear)
•
•
Apply same heating protocol
→ no standardized guideline
To verify the effects of “ASPAN’s Evidence-based Clinical Practice Guidelines
for Promotion of Perioperative Normothermia
3
Purpose
 For the management of hypothermia of patients
Control group: received standard hypothermia management of the clinic
Experimental group: received the evidence-based clinical practice guideline
of ASPAN
1) To see the changes of body temperature
2) To see the changes of shivering of the subject
3) To see the changes of thermal discomforts of the subject
4
Research hypothesis
1)
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Experimental group keep higher temperature than control group
2)
3)
4)
Experimental group is smaller shivering than control group
Experimental group is lower discomfort on hypothermia than
control group
Experimental group will be shorter to get a normal temperature time
than control group
5
Study methods
Study design
 A randomized controlled trial designed
- independent variable : The evidence-based clinical practice guideline suggested by ASPAN
- dependent variable : The body temperature, shivering, thermal discomfort and thermal discomfort
Experimental group
Control group
Before operation
During operation
After operation
T1† X
T2† X
T3† X
T1†
T2†
T3†
X : ASPAN's EBP Guideline during operation period in patients
T1 : : the body temperature , shivering , thermal discomfort
T2 : : the body temperature, shivering
T3 : : the body temperature , shivering, thermal discomfort , thermal discomfort
† : measured in 30 min intervals
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Study subjects
G Power 3.0 : effect size .5, power of .80, p value of .05,
Patients in the age of 55~85
• For each group 33 subjects(drop-out rate 10% consider)
•
The inclusion criteria
(1) understood the purpose of this study and made written consent
(2) patients with class I and II in ASA clas
(3) Patients who received spinal anesthesia,
(4) Patients in normal temperature before operation
(5) Patients without known drug allergy, history of drug dependence, neurologic pathology, or
recent systemic or local infection.
(6) Patients in the age of 55~85
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Study endpoints
Body
• Measured by the tympanic thermometer which measures the deep temperature
temperature
• By adding heat to the tympanum and surrounding tissues by infrared
Shivering
Thermal
discomfort
• Collins tool (1996)
• 5 scores of scale; 0=no sign of shivering, 1=intermittent weak shivering of jaw and
neck, 2=strong shivering of chest, 3=intermittent or strong shivering of the whole
body, 4=persistent and strong shivering of the muscles of whole body
• Higher score means higher degrees of objective thermal discomfort due to shivering
• Thermal discomfort tool developed by Kim, Chung, and Park(2008)
• Total 5 scores of scale; 1=very warm, 2=warm, 3=normal(confortable), 4=cold,
5=very cold.
• Expression of feelings were recorded in 30-min intervals before, after the
operation
Time to
• The time to recover the body temperature over 36℃ since it was lowered than
achieve
36℃ while staying in the recovery room after operation calculated in minutes.
normothermia
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Data collection tool and procedures
(1) The effects the evidence-based clinical practice guideline suggested by ASPAN by the
(2) The approval from IRB of the hospital (No. 2011-10-053) was obtained prior to the study initiation.
(3) 33 pieces of paper the test group and another 33 pieces of paper the control group
in one pocket and randomly picked one in the order of arrival to the operation room
(4) Data were collected from 26Dec2011 until 31Mar2012.
(5) Operation schedules were checked prior to the day of operation
Visited the subject in the evening prior to the operation date
Obtained written consent upon explaining the objective and procedures of this study
Getting information about demographic information, disease, treatment-related
information from the subject after the consent.
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(6) Experimental group treatment
① Before operation
Under 36℃
Over 36℃
- Clothes, towel and blanket
- Bair hugger (43℃ apply)
- only blankets and socks were provided as passive
heating ( operation room temperature 20˜24℃)
② During operation
Under 36℃
Over 36℃
- surrounded by blanket (size of 100CM X 90 CM)
stored in the 50℃ incubator in the head and socks
in his/her feet saline heated by ANIMAC (Elltec,
Japan) set as 42℃
- heat pad(Cincinnati sub zero, Dermo temp) apply
- skin exposure was minimized
: operation room temperature 20˜24℃
- Thermal discomfort
: didn’t check during operation
③ After operation
Under 36℃
Over 36℃
- blanket and towel
- Bair hugger (43℃ apply)
- heated saline : ANIMAC (Elltec, Japan) set as 42℃
- passive (blanket, socks, towel,
operation room temperature 20˜24℃)
- Time to achieve normothermia
: the time to recover the body temperature over 36℃
since it was lowered than 36℃
(7) Control group treatment
Before operation
During operation
- 1˜2 blanket stored in the
incubator
- Blanket and heated pad
1~2
10
After operation
•
•
-
Under 36℃
heated blanket and towel
Bair hugger (43℃ apply)
Over 36℃
towel
heated blanket
Control and experimental group guidelines
Experimental group
Before operation
During operation
After operation
Location
Waiting room
Operating room
Postanesthesia care unit
Control
group
∙ apply towel
∙ measure the body temperature,
shivering, thermal discomfort in 30 min
intervals
∙ apply towel
∙ heated pad (Cincinnati sub zero)
∙ measure the body temperature,
shivering in 30 min intervals
Assess
ment
∙ Assess for risk factors for
perioperative hypothermia
∙ Measure tympanic temperature
∙ Measure shivering
∙ Measure thermal discomfort
∙ Assess for signs and symptoms of
hypothermia and/or cold extremities
∙ Document and communicate all risk
factor assessment findings to all
members (SBAR)
∙ Assess for risk factors for
perioperative hypothermia
∙ Measure tympanic temperature
∙ Measure shivering
∙ Assess for signs and symptoms of
hypothermia and/or cold extremities∙ ∙
Document and communicate all risk
factor assessment findings to all
members (SBAR)
Normal
tempera
ture
intervent
ion
∙ over 36℃
- passive heating
- Socks for sleep, heated blanket
- operating waiting room temperature
20 ~ 24℃
∙ over 36℃
- passive heating
- minimize skin exposure
- operation room temperature 20 ~
25℃
∙ under 36℃
- passive heating
- Socks for sleep, heated blanket
-operating waiting room temperature
20 ~ 24℃
- active heating
- Apply bair hugger
∙ under 36℃
- passive heating
- minimized skin exposure
-operation room temperature 20 ~
25℃
- active heating
- heated saline (ANIMAC)
- heated pad
(Cincinnati sub
11 zero)
Hypothe
rmia
Interven
tion
∙ measure body temperature
∙ under 36℃
- Bair hugger
∙ over 36℃
- apply heated blanket
- measure the body temperature,
shivering, thermal discomfort in 30 min
intervals
∙ Assess for risk factors for perioperative
hypothermia
∙ Measure tympanic temperature
∙ Measure shivering
∙ Measure thermal discomfort
∙ Assess for signs and symptoms of
hypothermia and/or cold extremities
∙ Document and communicate all risk
factor assessment findings to all
members (SBAR)
∙ over 36℃
- passive heating
- Socks for sleep, heated blanket
- PACU room temperature 20 ~ 24℃
∙ under 36℃
- passive heating
- Socks for sleep, heated blanket
- PACU room temperature 20 ~ 24℃
- active heating
- Bair hugger
- heated saline (ANIMAC)
- Apply heated towel around head
Data analysis method
 Data were analyzed by SAS Ver 9.2.
1) The general characteristics : in the real number, percentage, and standard deviation
2) The homogeneity test of demographic characteristics, disease-related characteristics and
dependent variables :
3) The change of the effect of intervention by time
- repeated measures ANOVA
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1) Homogeneity Test of General Characteristics between Experimental and Control Groups
Characteristics
Categories
Exp. (n=30)
Cont.(n=30)
Mean±SD or n(%)
(N=60 )
t or χ2(p)
Male
4 (13.3)
2 (6.7)
Female
26 (86.7)
28 (93.3)
Age (year)
70.8±5.2
70.9±5.1
-.08(.940)
Height (cm)
152.4±5.4
152.0±6.6
.26(.793)
Weight (kg)
66.9±9.4
65.8±8.4
.88(.092)
Gender
*Fisher’s exact test.
: No significant difference was observed between two groups of their homogeneity
*
연구 대상자의 일반적 특성의 동질성 검정 유의한 차이가 없었다
13
(.671)*
2) Homogeneity Test of Operation-related factors between Experimental and Control Groups (N=60 )
Factors
Categories
Exp. (n=30)
Cont.(n=30)
t or χ2(p)
Mean ± SD or n (%)
Operation time(min)
104.8±22.5
100.0±11.3
1.05(.302)
Anesthetic time(min)
145.4±23.9
138.0±15.1
1.44(.156)
30 (100)
30 (100)
Yes
30 (100)
30 (100.0)
No
0 (0)
0 (0.0)
Thoracic 1~T12
24 (80)
29 (96.7)
Lumbar 1
5 (16.7)
1 (3.3)
Sacrum 1
1 (3.3)
0 (0.0)
Past history of
Yes
19 (63.3)
12 (40)
operations
No
11 (36.7)
18 (60)
Type of anesthesia
Administration of
Sedative before
Anesthesia
Post of spinal
Anesthetic level
spinal
anesthesia
(.103)*
3.27(.071)
•Fisher's exact test
: No significant difference in the operation-related factors between two groups of their homogeneity
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3. 체온
Exp.
Con.
Pre-op.
Intra-op.
Post-op.
min.
Adm.
30min.
Adm.
30min. 60min.
90min. 120min.
Adm.
30min
60min.
dis.
Difference in body temperature between two groups (p= .002)
No change by time(p= .882)
No change by interaction between group and time (p= .173)
The temperature of the Experimental group was higher than the control group by 0.2-0.4˚C
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Pre operative period
Valuables
Admission
to waiting
Post 30
min
room
shivering
Intra operative period
Post operative period
Discharge
from
Admission
to operation
30min
60min
90min
120min
Adm
30min
60min
Recovery
F
p
group
0.16
.693
time
0.54
.860
0.27
.987
Sources
room
room
Exp.
0
0
0
0.1±0.3
0±0.2
0.1±0.3
0.1±0.3
0.1±0.3
0 ± 0.2
0
0
Cont.
0
0
0
0.1±0.3
0.1±0.3
0.1±0.3
0±0.2
0.1±0.3
0
0
0
(point)
group*
time
No difference in shivering between two groups during the whole course of the operation(p=.693)
No change by time (p=.860)
No interaction between groups and time (p=.987)
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point
point
Exp.
Exp.
Con.
Con.
Pre-op.
Post-op.
min
Adm.
min
30min
Adm.
30min
60min
ANOVA showed difference in thermal discomfort between two groups (p=.034)
The difference by time (p=.041)
No interaction between group and time (p=.438)
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Dis.
Experimental
Characteristics
( n=13)
Control
( n=17)
t
p
4.14
.010
Mean ± SD or n (%)
Time (minutes)
35.4 (±49.1)
68.3 (±58.2)
-The experimental group took 35.4minutes to achieve normothermia
while the control group took 68.3minutes.
-The experimental group recovered normothermia significantly faster than the control group( p=.010).
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Body temperature
•
Sessler(2000) demonstrated that active warming measures such as warmed IV fluid and warmed
gel pad must be initiated to maintain normothermia as the body temperature of a patient decreased
about 1~1.5℃ during first one hour after general anesthesia and keeps decreasing even after 2~3
hours.
Shivering
•
In this study the method of forced air convection warming after the admission to the
post-anesthetic care unit was applied equally to the patients of both groups whose
body temperature was better than 36 ℃.
•
The fact that no difference between both groups was found in terms of shivering and
little shivering occurred is thought to be owing to implementation of the effective patient
treatment from hospital rooms used in the study.
19
Thermal discomfort
•
With respect to thermal discomfort, significant difference was found between the
experimental group and the control group. Also change according to time elapsing took
place, but no interaction between the groups and time elapsing was found, the result of
which is assumed to be attributable to no measurement of thermal discomfort in the
intra-operative period.
Time to achieve normothermia
•
By remarkably reducing 32.9 minutes in terms of time to achieve normal body
temperature compared to the control group,
the systematic and individualized ASPAN’s guidelines were proven very effective by
this study.
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S Hospital
•
The patients of this study maintained relatively normal temperature regardless of
the groups. which is thought to be owing to effective management of body
temperature in the wards of the hospital.
.
Meaningfulness
•
The first application of ASPAN’s evidence-based clinical practice guidelines
by nurses in Korea for the preoperative, intraoperative and postoperative periods
was verified to be effective in managing hypothermia for elderly patients
undergoing TKRA.
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Temperature :
The difference between two groups was observed (p=.002),
No change by time (p=.882)
Interaction between group and time was observed (p=.173).
Body Temperature of the experimental group was higher than the control group.
Shivering :
There was no difference in shivering between two groups during the whole course of the
operation(p=.693), no change by time (p=.860), no interaction between groups and time(p=.987).
Hypothesis that less shivering would be observed in the experimental group than
the control group was not supported.
Thermal discomfort :
The difference between two groups was observed(p=.034),
By time were observed(p=.041), there was no interaction between group and time (p=.438)
Thermal discomfort of the experimental group was less than the control group.
Time to achieve normothermia
The difference between two groups was observed(p=.010)
Time to achieve normothemia was shorter in the experimental group than the control group.
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
As a result of this study, the ASPAN's EBP Guidelines were verified to have
features of being relatively more effective in maintaining the intraoperative
body temperature, lowering the thermal discomfort,
and more quickly arriving at the normal body temperature
from the hypothermic state than the conventional hypothermia management
method.

The present study was an experimental study with a randomized controlled
trial design which attempted to examine the effective and systematic
hypothermia management method through the assessment of body
temperature, shivering, thermal discomfort and time to achieve normal body
temperature by applying the ASPAN’ s evidence-based clinical practice
guidelines targeting patients who receive TKRA under spinal anesthesia.
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 Future researches should be incorporated in a diverse fashion,
by measuring the body temperature in 10 minute interval
to observe more clear tendency of change in the preoperative body
temperature and time to achieve normal body temperature.
 By conducting repetitive studies targeting patients in need of
at least one hour operation under local anesthesia
or under general anesthesia or targeting physically feeble children
or adults.
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
Age-related thermoregulatory differences during core colling in humans. Am J Physical Regulatory
Intergrative Comp Physiology, 279: 349-354, 2000.

Frank SM, Fieisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia redeuces the incidence
of morbid cardiac events: Arandomized clinical trial. JAMA, 277: 1127-1134. 1997.

Giuffre, M., Heidenreich. T., & Pruitt, L. (1994). Rewarming cardiac surgery patients: Radiant heat versus forced
warm air. Nursing Research, 43, 174-178.

Guyton(Ed). Texbook of Medical physiology(831-843) Philadelphia : Saunders.

Houdas Y. & Ring E.F.J. (1982) Human body temperature : Its measurement and regulation, PLENUM Press,
New york and London.
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Thank you for attention !
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