MAINTAINING NORMOTHERMIA
IN THE PERIOPERATIVE SETTING
WITH FOCUS ON POSTERIOR
SPINAL FUSIONS
BY BROOKE CLARK RN BSN CPN
ELAINE JOHNSON RN CNOR
DISCLAIMER
 WE HAVE NO CONFLICT OF INTEREST WITH
THE BAIR HUGGER/BAIR PAWS COMPANY
Brooke’s story
Elaine’s story
OBJECTIVES
THE LEARNER WILL BE ABLE TO:
 Describe scoliosis
 Define a posterior spinal fusion
 Define normothermia and appropriate interventions
for normothermia maintenance
WHAT IS SCOLIOSIS ?
Scoliosis is a condition that causes the
patient’s spine to curve to the side
 “S” or “C” shape
 Occurs in about 3% of all people
 Common between ages 10-20
 Most are idiopathic (unknown cause)
 Others: Cerebral Palsy, Muscular
Dystrophy and Spina Bifida
 Girls typically are more severe than
boys
 Severe scoliosis requires bracing or
surgery
What is a posterior spinal fusion?
This procedure reduces the curve of the spine using
metal rods, screws, hooks and bone graft.
Before and After
Greatest risk of infection
Risk Factors of Infection
 Length of Surgery, can take 6- 12 hours
 2015: CCMC average length = 6.5 hours

Range 4 - 11 hours
 2016: CCMC average length = 6.85 hours

Range 4 - 12 hours
 Any surgery over 4 hours increases your chance of infection by 10%
(Glotzbecker, et.al., year)
Risk Factors continued….
 Blood loss
 Hardware and bone graft are implanted
 Hypothermia
 Long incision
Dr. Mark Lee and Dr. Jeffrey
Thomson
 Our spinal fusion experts-
What is normothermia?
Temperature is
36 °C – 38 °C
or
96.8 °F – 100.4 °F
Effects of Hypothermia < 36 C
 Increase surgical site infection
 Increase in cardiac events = VT
 Increase in mortality in trauma patients
 Increase in blood loss due to inhibition of platelet activation
 Alteration in medication metabolism
 Increase in recovery time
 Prolonged hospital stay
 Decreased patient satisfaction
So why is the surgical patient at
risk for hypothermia?
Anesthesia-Induced
Thermoregulation Impairment
 Inhibits central nervous system control and
peripheral temperature conservation
mechanisms
 Lowers the threshold for vasoconstriction, which
normally protects the body from hypothermia
 Causes vasodilation
 Increases skin blood flow, skin temperature, and
surface heat loss
Hypothermic Pattern During
General Anesthesia
 1st Phase (1 hr. of anesthesia):
 Patient’s core temperature drops by 0.5°- 1.5 °C because
heat is redistributed from the body to the extremities
 2nd Phase (2-3 hr. of anesthesia):
 Temperature drops linearly because the amount of heat lost
is greater than that produced
 3rd Phase (3-5 hr. of anesthesia):
 aka the plateau phase
 Temperature remains constant because the amount of heat
lost is equal to that produced
Heat Loss Inherent to Surgery
and Surgical Environment
 Cold OR environment
 Administration of un-warmed IVF
 Loss of heat from the lungs when warm air in the lungs
is mixed with un-warmed inhaled gases
 Surgeries with inherently large heat loss index
 Open thoracic or abdominal procedures
 Visceral exposure results in the greatest heat loss since it
exposes the central compartment and the major vessels
 Gynecological surgeries
 Genitourinary procedures that use multiple liters of fluid for
irrigation
Patient-Specific Risk Factors
 Infancy or neonatal age
 Low body weight/thin: lack of tissue mass
 Obese or pregnant: relatively high body surface areas
 Burn patients
 Patients with some metabolic disorders
 Patients being chronically treated with antipsychotics or
antidepressants
Purpose
 To assess the Day Surgery, PACU, OR and PICU nursing
staff understanding of homeostasis and normothermia
before and after an educational intervention
 To assess understanding of the recommended frequency
of documentation and thermal interventions
 To determine if said educational intervention can
decrease the incidence of SSIs in spinal surgery patients
Aims
 Specific Aim 1: To collect data on the documentation of
temperature and thermal assessments in all phases of
care during a child's operative stay before and after an
educational intervention with the nursing staff of Day
Surgery, PACU, Periop and PICU.
 Outcome 1: The documentation of temperature and
thermal assessments in the medical record undergoing
spinal surgery before the education intervention will be
less than 70%. After the intervention, the documentation
of temperature and thermal assessments will be greater
than 98%.
 Specific Aim 2: To collect data before and after a thermal
management education for all phases of the operative
stay, on the of Day Surgery, PACU, Periop and PICU
nursing staffs’ comprehension of thermal management,
controlling for nursing characteristics of age, education,
and years of experience.
 Outcome 2: After the thermal educational interventions,
95% of nursing staff will correctly document temperature
and thermal assessment in the medical record of children
undergoing spinal surgery.
 Specific Aim 3: To collect and compare the data on the
rates of SSI in the three months following thermal
educational intervention and in the same three month
period in the previous year .
 Outcome 3: There will be a 30% decrease in the number
of SSIs in the three month period following the one
month educational intervention compared to the same
three month period in the previous year.
Timeline
Chart Review
from
04/09/2015
to 7/9/2015
Education
Intervention
3/1/2016 to
3/30/2016
Chart Review
from
03/31/2016
to 6/30/2016
Methods
 Pre/post survey
 Chart review
 Teaching
PowerPoint
Poster
Focused discussion
Pre/Post Survey
 Administer before and after educational intervention with
15 questions total including 5 outlining demographics
 Participant consent was included in the survey and was
given and implied completion of both pre/post survey
CHART REVIEW
We reviewed charts using an IRB approved data collection
form
All data was de-identified; electronically kept in a password
protected file and all paper records kept in a locked cabinet
All staff involved in reviewing charts were CITI trained
Chart Review
Chart Review
Target Population: Patients who underwent spinal fusion
surgery within specified time period
Inclusion Criteria
All posterior spinal fusion patients were included within the
previously mentioned dates due to sample size
Exclusion Criteria
None
Teaching
 PowerPoint
 Poster
 Focused discussions
Teaching
Staff members recruited through direct communication
 Ad hoc Day Surgery and PACU
 Use of dedicated OR in-service time
 Participants were given pre and post education
intervention surveys that included consent
 The intervention included use of PowerPoint,
freestanding poster, and focused discussion
Teaching
Staff Educational Intervention
Inclusion Criteria:
Day Surgery, PACU, OR and PICU nursing staff that
completed both pre/post survey
Exclusion Criteria:
Nursing staff on FMLA
Nursing staff unable to complete pre/post survey
Results
 Pre/post survey nursing
demographics
Results
Cost of gown: $10
Staff demonstrated a significant
increase (p > 0.0001) in
understanding the cost of
warming therapies
Pre-survey 56% were incorrect
Post-survey 100% correct
Results
 Cost of a posterior spinal fusion infection - $50,000
 Pre-survey 13% were incorrect, post-survey 100% were
correct
CHART REVIEWS 4/9/15-7/9/2015:
25 CHART REVIEWS
 3/31/16-6/30/2016:
14 CHART REVIEWS
 7/1/2016- 1/11/2017:
27 CHART REVIEWS
Perioperative
Temperatures
4/9/157/9/15
3/31/166/30/16
7/1/161/11/17
36.6
36.0
35.6
34.9
36.8
35.4
36.4
36.7
36.0
35.6
34.8
37.0
36.3
36.8
36.9
36.1
35.6
34.3
37.1
36.4
36.9
35.2
36.4
36.3
36.7
36.1
36.8
36.4
36.9
36.1
Results from chart review:
Average Preop
Lowest Preop
Average 1st OR
Lowest 1st OR
Average last OR
Lowest last OR
Average 1st
PACU/PICU
Lowest 1st
PACU/PICU
Average at 2hr
Lowest at 2hr
Results from chart reviews:
2015 Perioperative
Temperatures
2016 Perioperative
Temperatures
1
1
16
38
2
37
15
14
3
14
3
36
4
35
34
12
34
13
2
38
13
36
40
32
5
33
4
11
12
5
6
10
11
6
7
10
9
8
8
9
Pre-Op
1st OR
Last OR
1st PACU
Discharge/2° Post Op
7
Pre-Op
1st OR
Last OR
1st PACU
Discharge/2° Post Op
The Good
 There is an increase in collaboration between PACU and
the OR
 We received buy-in from our peers
 Our patients are consistently normothermic
 From 2015 we had one posterior spinal fusion infection
and in 2016 we have had no infections
 We are now pre-warming other patients
 Decrease linen costs and usage
 Staff is aware of location of equipment and cost
The Bad
The BAD
 Methods of taking temperature were all different
 Poor documentation of interventions used in
Preop/OR/PACU/PICU
 We also experienced an EPIC upgrade
 An abrupt change in location of post operative care:
Patients went to the PICU instead of PACU
 First OR temperature is usually recorded by anesthesia
personnel at time of positioning this did not improve after
education and interventions
 Novice to the IRB Process
THE UGLY
Where do we go from here?
Recommendations:
 We are pre warming other patients: children 10 years old and
older. Surgeries longer than 2 hours
 Pre warming is included in our new VP shunt and NUSS Bar
bundles
 Feedback from our peers includes using a Bair Hugger blanket
under the patient for use in the OR in that first hour prior to
incision-started 2/1/17.
 Initiation of taking the patient’s temperature just prior to transfer
to OR
 Teaching must be revisited to lead to real change and
implementation
Closing remarks
Questions?
References

Barnes, S. (2014). The drive to zero surgical site infections. AORN, 99 (5).

Diaz, V., & Newman, J. (2015). Surgical Site Infection and Prevention Guidelines: A Primer for
Certified Registered Nurse Anesthetists. AANA Journal 83 (1).

Edmiston, C., & Spencer, M. (2014). Going Forward: Preventing Surgical Site Infections in
2015. AORN, 100 (6).

Hooper, V., Chard, & R., Clifford, T., Fetzer, S., Fossum, S., Godden, B., Martinez, E., Noble,
K., O’Brien, D., Odom-Forren, J., Peterson, C., & Ross, J. (2010). ASPAN’s Evidence-Based
Clinical Practice Guideline for the Promotion of Perioperative Normothermia: Second Edition.
Journal of PeriAnesthesia Nurses 25, (6).

John, M., & Harper, M. (2014). Inadvertent peri-operative hypothermia: guidance and
protecting patients. British Journal of Healthcare Management 20 (5).

Centers for Disease Control

Spruce, L. (2014). Back to Basics: Preventing Surgical Site Infections. AORN, 99 (5).
References

Norman, B. (2010). An Ounce of Prevention: Best Practice Bundles

Med-Surg Matters, 19 (2): 8-9.

Pilcher, J. (2011). Creative Learning Ideas from Around the U.S.. Neonatal Network 30 (1).

Vitale, M., Riedel, M., Glotzbecker, M., Matsumoto, H., Roye, D. Akbarnia, B., Anderson,
R., Brockmeyer, D., Emans, J., Erickson, M., Flynn, J., Lenke, L., Lewis, S. Luhmann, S.,
McLeod, L., Newton, P., Nyquist, A., Richards, B., Shah, S., Skaggs, D., Smith, J.,
Sponseller, P., Sucato, D., Zeller, R. & Saiman, L. (2013). Building Consensus:
Development of a Best Practice Guideline (BPG) for Surgical Site Infection Prevention in
High-risk Pediatric Spine Surgery. Journal of Pediatric Orthopaedics 33(5), 471-478.

Ying, L., Glotzbecker, M., & Hedequist, D. (2012). Surgical site infection after pediatric
spinal deformity surgery. Curr Rev Musculoskeletal Med 5(2), 111-119.
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