CONTINUING EDUCATION
Preventing Unplanned
Perioperative Hypothermia in
Children 2.2
www.aornjournal.org/content/cme
SUSAN E. BEEDLE, MSN, RN, CPN; AMY PHILLIPS, MSN, APRN-CNS, CCRN;
SHIRLEY WIGGINS, PhD, RN; LEEZA STRUWE, PhD, MSN, RN
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Purpose/Goal
To provide the learner with knowledge of best practices related
to hypothermia in the pediatric surgical population.
Objectives
1. Describe the risk factors, adverse outcomes, and incidence
of unplanned perioperative hypothermia.
2. Compare unplanned perioperative hypothermia in the
adult surgical population with that in the pediatric surgical
population.
3. Discuss the methods and results of this study, which
measures the incidence of unplanned hypothermia in a pediatric surgical population after the implementation of a
clinical practice guideline.
Approvals
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check with your
state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures
Susan E. Beedle, MSN, RN, CPN; Amy Phillips, MSN,
APRN-CNS, CCRN; Shirley Wiggins, PhD, RN; and Leeza
Struwe, PhD, MSN, RN, have no declared affiliations that
could be perceived as posing potential conflicts of interest in
the publication of this article.
The behavioral objectives for this program were created by
Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Van Anderson and Ms Bakewell
have no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as CE for RNs. This recognition
does not imply that AORN or the American Nurses Credentialing
Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2016.12.002
ª AORN, Inc, 2017
170 j AORN Journal
www.aornjournal.org
Preventing Unplanned
Perioperative Hypothermia in
Children 2.2
www.aornjournal.org/content/cme
SUSAN E. BEEDLE, MSN, RN, CPN; AMY PHILLIPS, MSN, APRN-CNS, CCRN;
SHIRLEY WIGGINS, PhD, RN; LEEZA STRUWE, PhD, MSN, RN
ABSTRACT
Unplanned perioperative hypothermia is a common surgical risk. Unplanned hypothermia is defined as
a body temperature below 36 C (96.8 F) during any phase of the perioperative period. Perioperative
nurses at a Midwestern tertiary pediatric hospital developed an evidence-based clinical practice
guideline (CPG) designed to maintain normothermia for the pediatric surgical population. This CPG
outlined standard thermoregulation nursing interventions and required the consistent use of a
temporal artery thermometer. A test of this CPG before full implementation established a baseline
incidence of unplanned hypothermia at 16.3% (n ¼ 80). The purpose of this study was to measure the
rate of perioperative hypothermia in children after implementing the evidence-based CPG. The study
results demonstrated that the CPG, guiding research-based nursing practice, consistently prevented
unplanned hypothermia. The incidence rate of unplanned perioperative hypothermia after CPG
implementation was 1.84% (n ¼ 1,196). AORN J 105 (February 2017) 170-183. ª AORN, Inc, 2017.
http://dx.doi.org/10.1016/j.aorn.2016.12.002
Key words: unplanned hypothermia, pediatric, thermoregulation, perianesthesia nursing, clinical
practice guideline.
T
he quality of care and safety of children undergoing surgery are ever-present concerns in the
perioperative clinical area. Unplanned hypothermia can contribute to surgical complications including surgical
site infections, increased need for oxygen, altered pharmacokinetics of medications, impaired coagulation, and cardiac
arrhythmias.1-3 Perioperative nurses at a Midwestern tertiary
pediatric hospital noticed an increase in unplanned hypothermia in children and initiated a quality improvement (QI)
project to address this concern. Using an evidence-based
practice approach, our team concluded that consistent
nursing care and interventions were needed to prevent unplanned hypothermia for all children undergoing surgery. The
QI team’s synthesis of the evidence and analysis of the
literature, including the American Society of PeriAnesthesia
Nurses’ and AORN’s guidelines for the prevention of unplanned hypothermia,4,5 resulted in a pediatric clinical practice
guideline (CPG) focused on maintaining perioperative
normothermia.
We concluded our QI project with a month-long test of our
CPG. This test was conducted after a basic introduction of the
CPG to staff members in addition to the request that they use
either temporal or tympanic temperature measurement
consistently for each child. The results of the test of our CPG
established a baseline rate of 16.3% (n ¼ 80) of children
who developed unplanned perioperative hypothermia when
temperatures were measured by a consistent method.
http://dx.doi.org/10.1016/j.aorn.2016.12.002
ª AORN, Inc, 2017
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AORN Journal j 171
Beedle et al
When nurses measured temperatures using a combination of
methods (ie, a mix of tympanic, temporal, or axillary measurement for the same child), the incidence of unplanned
hypothermia was 26% (n ¼ 255). Although these rates are
below the reported 50% to 90% incidence rate in the adult
population, they are still high enough to place this vulnerable
pediatric population at risk.6,7 During the test, we also
determined that temporal artery thermometry resulted in less
variation in temperature ranges than tympanic measurement.
We concluded that data obtained from this test were insufficient to make the generalization that thermoregulatory
management was sufficient at our institution and that additional research was indicated. Full implementation of the CPG
ensued, including formalized nursing education regarding the
CPG and consistent use of temporal artery thermometers. The
elements of the CPG include
assessment of temporal artery temperature,
use of a consistent device for temperature measurement,
eight specific time points for perioperative temperature
documentation,
assessment of the subjective thermal comfort level of the
child,
nursing interventions that included consistent application of
warming measures to maintain the child’s thermal comfort
level and temperature, and
ambient intraoperative room temperature from 21.1 C to
23.9 C (70 F to 75 F).
STATEMENT OF PURPOSE
The purpose of this study was to measure the rate of perioperative hypothermia in the pediatric surgical population at our
facility after implementation of a CPG that included consistent temporal artery temperature measurements.
RESEARCH QUESTIONS
This research sought to answer these questions:
What is the incidence of perioperative hypothermia in the
pediatric surgical population after full implementation of the
perioperative nursing CPG on thermoregulation?
What are the characteristics of the pediatric surgical population identified as normothermic and hypothermic during
the implementation of the CPG?
STATEMENT OF SIGNIFICANCE TO
NURSING
Maintaining normothermia has been shown to reduce the risk
of surgery-related infections in the adult population.8-10 Clinical
practice guidelines have been widely used to reduce variation
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in nursing practice and promote evidence-based care.11
Perioperative normothermia is a desired clinical outcome
that assesses thermoregulatory management during surgery.12
Through implementing an evidence-based CPG, we hoped to
achieve a low incidence rate of unplanned perioperative hypothermia in children at our facility. Our results contribute to
narrowing the knowledge gap related to establishing standards
of nursing care for children. In addition, this standard of care
empowers nurses to define professional practice through the
process of critically appraising the evidence, integrating research
findings into patient care, and affecting clinical outcomes.
LITERATURE REVIEW
Unplanned perioperative hypothermia has been identified
as one cause of adverse outcomes in adult surgical patients.1-3,6,7,13 These adverse outcomes result in prolonged
hospitalization, an increased need for transfusion, an increased
risk of surgical site infection, increased health care costs, and
increased mortality.1,2,9,10,13 Reports of adverse outcomes in
adult patients cite a 4-fold increase in mortality and doubled
rates of complications resulting in sepsis, myocardial infarction,
stroke, and death.2 Reports of pediatric outcomes resulting
from perioperative hypothermia are limited. In the neonate and
infant population, hypothermia contributes to the development
of cardiac arrhythmias, hypoglycemia, increased oxygen
demand, metabolic acidosis, tissue hypoxia, and ischemia.14,15
Infants and children are considered to have a greater risk of
developing unplanned hypothermia because of differences in
body size, their limited stores of subcutaneous fat, and a less
effective regulatory capacity.14,16 Studies have identified
additional risk factors that contribute to the incidence of unplanned hypothermia in children: cool ambient room temperatures, prolonged length of surgery, increased surface
exposure to cold, positioning (eg, prone), type of anesthesia
used, extremes in age, substantial blood loss, high transfusion
rates, and lower preoperative temperature.14,17,18 Researchers
have identified numerous factors that may contribute to
inconsistent patient warming practices, which in turn
contribute to unplanned perioperative hypothermia; these
factors include inconsistent temperature monitoring (ie, the
use of different types of thermometers at varying sites) and a
lack of understanding of unplanned hypothermia causes and
outcomes.18,19 Unplanned perioperative hypothermia is widely
reported as a patient safety concern, and the related adverse
outcomes are no longer considered routine or unavoidable.19
Incidence
Research on incidence of unplanned hypothermia in the
pediatric surgical population is limited. The risk of occurrence
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February 2017, Vol. 105, No. 2
of hypothermia in the pediatric surgical population has been
reported as even higher than in the adult population.14,15
Current published estimates of pediatric perioperative hypothermia range from 4.2% to 60%.15 The risk of unplanned
perioperative hypothermia coupled with the significance of
possible adverse outcomes make this issue worthy of careful
evaluation and corrective intervention.
Temperature Monitoring
Methods of temperature measurement in the pediatric
perioperative environment and evidence supporting a specific
instrument or method are varied. In a pediatric QI study
evaluating the cause of unplanned perioperative hypothermia,
Kim et al15 reported that axillary temperature reflects core
temperature when the thermometer is accurately placed over
the axillary artery. Several research studies about children
undergoing general anesthesia concluded that axillary, temporal artery, tympanic, and rectal methods more closely
aligned with oral and esophageal core temperature measurements.15,20-22 Jay et al23 established that core temperature
assessment during anesthesia is essential in monitoring
children, but that some traditional core methods such as rectal
or nasopharyngeal measurement may lead to negative outcomes (eg, epistaxis, infection) as a result of traumatic tissue
injury. Holzhauer et al24 concluded that temporal artery
measurement provided the best method in a study focused on
atraumatic care for children, but that rectal methodology was
more accurate. Carr et al25 found the temporal artery method
to be more sensitive to temperature changes and enhanced
comfort for children. Sahin et al22 found no significant difference between temporal artery and nasopharyngeal temperatures and concluded that ideal temperature monitoring
should reflect the core temperature while providing safety,
efficiency, and comfort. Children pose unique challenges when
determining appropriate temperature assessment methods
related to ability to communicate temperature comfort levels,
tolerance of invasive methods, and accuracy.
Clinical Practice Guidelines
Preventing perioperative hypothermia is a standard clinical
practice supported by AORN, the American Society of
PeriAnesthesia Nurses, and the National Institute for Health
and Care Excellence.4,9,26,27 In 2013, perioperative hypothermia was ranked among the top 10 patient safety issues by
AORN members.27 Reducing the incidence of perioperative
hypothermia provides patients with the best quality of care,
improves patient outcomes, and reduces health care costs.
Clinical practice guidelines assist nurses in making appropriate
health care decisions in specific clinical circumstances.4
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Perioperative Hypothermia in Children
Clinical practice guidelines can be developed to fit a specific
population,28 and they help translate research and evidence
into practice, providing a foundation to reduce variation in
assessment, intervention, and evaluation and to promote
evidence-based health care.11 Establishing the incidence of
hypothermia in children and the implementation of a pediatricspecific CPG will formulate a foundation of knowledge on
prevention of unplanned hypothermia adverse outcomes.
OPERATIONAL DEFINITIONS
For the purposes of this study, we define hypothermia as a body
temperature less than 36 C (96.8 F). We define normothermia as body temperature greater than 36 C (96.8 F) and
less than 38 C (100.4 F). An open procedure is a surgical
procedure under anesthesia in which skin preparation was
completed and an incision made, creating an opening to
deeper tissue or a body cavity. A closed procedure is a surgical
procedure under anesthesia in which no incision was made
and a body cavity was not opened (eg, diagnostic radiology,
endoscopic procedures).
STUDY DESIGN
We used a quantitative descriptive research design to explore
whether implementing a pediatric perioperative thermoregulation CPG that included a consistent method of temperature
assessment would reduce the incidence of hypothermia.
Setting and Population
The setting for this study was the surgical services department
in a 146-bed freestanding regional pediatric hospital in the
midwestern United States; more than 11,000 surgical
procedures are performed each year at this facility. The mix of
pediatric surgical procedures ranges from simple outpatient
procedures (eg, bilateral myringotomy with tubes) to complex
high-acuity procedures (eg, congenital heart disease repairs,
craniotomies, spinal revisions). Surgical patients are admitted to
the outpatient preoperative unit and progress through surgery
to phase I recovery in the postanesthesia care unit (PACU).
Patients then move to phase II recovery in the outpatient unit
and are either discharged to home the same day or admitted to
the hospital for additional care.
Protection of Human Rights
This research study was reviewed and approved by the
organization’s pediatric institutional review board. All nurses
who enrolled participants completed formal training on the
protection of human subjects.
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Table 1. Participant Criteria
Inclusion Criteria
Exclusion Criteria
Surgical patients in the preoperative outpatient
area who progress to the phase I postanesthesia care
unit immediately postoperatively
31 days or older
Younger than 10 years
Females who have not reached menarche
American Society of Anesthesiologists physical
classification score of I-III
Surgical procedure lasting 30 minutes or longer
Patients who will not go to the postanesthesia care unit immediately
postoperatively
Surgical procedure with purposeful intraoperative cooling planned
Central nervous system impairment that may affect
thermoregulation
Active infectious process at the time of surgery, which would place
the child at risk for temperature outside normal limits (eg, fever,
sepsis)
Children who are state wards
Children whose parents or legal guardians are non-English and
non-Spanish speaking
Sample-Size Calculation
The study sample size was based on a 16.3% rate of perioperative unplanned hypothermia found during the initial test of
the evidence-based CPG developed as part of a QI project.
We calculated a desired sample size of 2,200 participants to
estimate the incidence rate 1.5% with 95% confidence.
Sampling Technique
We determined the population for this descriptive study using
inclusion and exclusion criteria (Table 1). Children older than
9 years 11 months were excluded from this study, as were
female patients who had reached menarche to ensure the
temperature measurements were not caused by other physiologic changes related to menarche. The parents of a child who
met all criteria were invited to allow their child to participate on
a voluntary basis. Each day the principal investigator (ie, the OR
clinical education specialist) or one of five perioperative charge
nurses reviewed the surgery schedule to identify children who
were eligible for participation according to the defined criteria.
Eligible children and their family members were approached by
the principal investigator or charge nurse during the preoperative period. The investigator or charge nurse described the
study and allowed time for parent and child questions. If the
investigator or charge nurse obtained informed consent from
the parents, the CPG was implemented.
The investigator or charge nurse assigned a temporal artery
thermometer to each child; the thermometer traveled with the
child through all phases of perioperative care. Nurses measured
temperatures with the assigned thermometer and documented
the results in the electronic medical record at the beginning
and end of each phase of perioperative care (ie, preoperative,
intraoperative, PACU phase I, phase II), for a total of eight
documentation points. Children who were found to have a
body temperature less than or equal to 36 C (96.8 F)
received nurse-initiated warming interventions as outlined by
the CPG (eg, forced-air warming, warm blankets, portable
warm infant mattress). Although the CPG was implemented
for all children regardless of study enrollment, thermometer
assignment and specific research temperature recordings were
required for research participants only.
Thermometers: Reliability and Validity
Nurses used Exergen TemporalScanner temporal artery
thermometers throughout the study. Personnel at Exergen
verify these instruments against test equipment calibrated with
the National Institute of Standards and Technology. The
hospital’s clinical engineers completed quality control tests of
the thermometers based on manufacturer’s guidelines before
initiation of the study and on an annual basis according to
hospital policy.
Procedure
RESULTS
Our team of approximately 100 perioperative RNs (OR,
preoperative, phase I and II recovery) successfully completed
prestudy education before participant accrual. The education
involved attending a lecture, completing a self-directed
learning module and exam, and performing a return demonstration to validate knowledge of the CPG, study guidelines,
effect and physiology of perioperative unplanned hypothermia,
and correct temporal artery thermometer use.
After enrolling 1,504 participants, we found an incidence of
unplanned hypothermia of less than 10%. Our statistician
performed a repeat power analysis and determined that
participant accrual was sufficient to meet our goal of
measuring incidence with 95% confidence. After data review
and cleaning, 1,394 children met all inclusion criteria, and
1,190 of these participants had complete data for every
temperature measurement point. We analyzed data on sample
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Perioperative Hypothermia in Children
Table 2. Sample Characteristics
Characteristic
All Participants (N ¼ 1,394)
n
Percent
Age, y
Length of Surgery, min
Participants With Hypothermia (n ¼ 22)
Mean (SD)
Range
4.0 (2.5)
74.4 (48.9)
n
Percent
Mean (SD)
Range
0.08-9.92
4.6 (2.7)
0.25-9.58
30-441
71.3 (41.1)
32-195
Sex
Male
847
60.8
10
45.5
Female
547
39.2
12
54.5
Craniofacial
18
1.3
1
4.5
Dental
74
5.3
1
4.5
Diagnostic
57
4.1
0
0
Endo-/bronchoscopic
108
7.7
1
4.5
Otorhinolaryngologic
432
6
27.3
Surgical Procedure
31
Ophthalmologic
35
2.5
2
9.1
General surgical
116
8.3
3
13.6
Hernia
226
16.2
2
9.1
14
1
0
0
8.5
Neurosurgical
Orthopedic
119
6
27.3
Urologic
195
14
0
0
Open
717
51.4
9
40.9
Closed
677
48.6
13
59.1
Surgical Complexity
SD ¼ standard deviation.
characteristics using measures of central tendency and dispersion. We used descriptive statistics to describe the major study
variable of perioperative hypothermia. We set the significance
level at P .05.
The characteristics of the total sample are presented in
Table 2. The characteristics we examined included age and sex
of the children. We characterized data by surgical procedure
length (ie, minutes from the time anesthesia started to the time
the child left the OR), type of procedure, and surgical
complexity (ie, classified as open or closed procedure).
Using only data from participants who had complete data sets
(n ¼ 1,190), the incidence of perioperative hypothermia was
1.34%, with a 95% confidence interval of 0.68% to 2.0%.
Using data from all cases for which hypothermia status could
be determined (ie, cases with complete data plus six cases with
partial data sets in which hypothermia was determined), the
incidence was 1.84% (n ¼ 1,196), with a 95% confidence
interval of 1.06% to 2.62%.
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Figure 1 shows mean temperatures by age group for each
point at which nurses documented temperature data during
the perioperative phase of care. Figures 2 and 3 show distribution of children by age in the normothermic and hypothermic perioperative samples. The differences in
temperature between the male and female patients with hypothermia and their counterparts with normothermia are
evident, but there is no statistical difference between male
and female patients in the hypothermia group at any of the
temperature documentation points (Figure 4). The differences in temperature were significantly different between the
normothermic children and the male patients with hypothermia at the intraoperative end (P ¼ .05) and PACU start
(P ¼ .048), whereas the differences between the children
with normothermia and female patients with hypothermia
were significantly different at all time points (P < .05) except
the PACU end and phase II start times. The body temperatures of all children in the perioperative population (N ¼
1,394) ranged from a low of 35 C (95 F) to a high of 40 C
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Beedle et al
Figure 1. Mean perioperative temperatures by age group in years (N ¼ 1,394). PACU ¼ postanesthesia care unit.
(104 F). Temperatures in the population with hypothermia
(n ¼ 22) ranged from a low of 35 C (95 F) to a high of
37.8 C (100 F) (Figure 5).
Research related to the incidence, risk factors, and outcomes of
unplanned perioperative hypothermia in children is limited. In
a QI project performed by Kim et al,15 there was a reduction
in the incidence of unplanned perioperative hypothermia in
children (neonate to 18 years) from 8.9% to 4.2% with the
introduction of a bundle of standard temperature management
guidelines. In our initial QI project, 16.3% of the children
(n ¼ 80) whose temperatures were consistently taken as either
temporal artery or tympanic developed unplanned perioperative hypothermia. In comparison, when temperatures were
taken using a combination of devices (tympanic, temporal
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In evaluating sex, surgical procedure type, and surgical complexity,
only the type of surgical procedure was significant, with a small
effect size (P ¼ .021). The size of the hypothermic group
was small, so the chi-square test was unreliable for evaluating
surgical procedures in this sample (Table 3). The sample size of
the population with hypothermia was not sufficient for us to
make conclusions about which surgical procedures create higher
risk of unplanned hypothermia.
DISCUSSION
Figure 2. Number of children with normothermia by age group (n ¼ 1,372).
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Perioperative Hypothermia in Children
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Figure 3. Number of children with hypothermia by age group (n ¼ 22).
artery, or axillary) for the same child, there was a 26%
(n ¼ 255) incidence of unplanned perioperative hypothermia.
Our QI project demonstrated a lower variation between
temperatures taken on a single child with the temporal artery
thermometer compared with those taken via a tympanic
thermometer (ie, temporal artery average temperature difference was 0.8 C 1.27 C [1.44 F 2.29 F] and the
tympanic average temperature difference was 1.33 C 2.35
C [2.40 F 4.23 F]). This research demonstrated that
implementing a CPG reduced the incidence of unplanned
perioperative hypothermia to 1.84% (N ¼ 1,394).
Active surveillance and steps to prevent hypothermia are
warranted for all pediatric age groups. The neonatal and infant
population are at increased risk for unplanned perioperative
hypothermia.16 The contributing factors for neonatal and
infant unplanned hypothermia risk include a reduced
weight-to-surface area ratio (ie, larger body-surface area) and
physiologic temperature regulation differences.14 Neonates are
unable to maintain core body temperatures, even in warmer
surgical environments.16 Kim et al15 completed a QI study in
a surgical population of children (N ¼ 1,785) who were between birth and 18 years of age. The unplanned perioperative
hypothermic temperature ranges were from 35.5 C (95.9 F)
to 35.99 C (96.78 F), and the highest incidence of hypothermia occurred in children in the 12- to 18-year age
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In this study, having a low body temperature at the beginning
of the perioperative experience was an indicator of risk
for developing hypothermia. The children with hypothermia
(n ¼ 22) in this study had significantly lower temperatures than
those of the children with normothermia (n ¼ 1,372) at all
perioperative temperature documentation points. Children in
the hypothermic group began the perioperative experience at a
lower temperature range than the that of normothermic group,
and this lower trend continued through all phases of care. Low
body temperature before anesthesia induction has been identified as a risk factor for developing perioperative hypothermia.16
Figure 4. Mean perioperative temperatures of male and female patients with hypothermia compared with those of
children with normothermia (N ¼ 1,394). PACU ¼ postanesthesia care unit.
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Figure 5. Normothermic (n ¼ 1,372) and hypothermic (n ¼ 22) temperature ranges by age group.
group.15 In our study, the mean age of the population with
hypothermia (n ¼ 22) was 4.6 years, and children of all age
groups up to 10 years old were represented, except children in
the eight- to nine-year age group.
Temperature trends in our hospital’s pediatric population with
hypothermia helped us establish the importance of assessing
the temperature at the designated documentation time points
outlined in the CPG. Two of the lowest temperature assessment points included the end of the intraoperative period and
the start of the PACU period. Galante14 described three phases
of thermoregulatory response during general anesthesia, which
include a rapid decrease in core body temperature (1 2 C
[1.8 3.6 F]) that occurs in a relatively short period of time
during the first phase of surgery.14 To capture this thermoregulatory response, only children whose surgical experience
was greater than or equal to 30 minutes were included in our
study. Children in the unplanned hypothermia population
(n ¼ 22) had a mean surgery time of 71.3 minutes; however,
the population of normothermic children (n ¼ 1,372) had a
mean time in surgery of 74.4 minutes. Both groups reflected
this thermoregulatory response during general anesthesia.
Table 3. Sex, Surgical Procedure Type, and Surgical
Complexity
Variable
Sex
Chi-Square df P Value Cramer’s Va
Value
2.205
1
.138
.040
Surgical procedure
21.042
10
.021
.123
Surgical complexity
0.984
1
.321
.027
a
Cramer’s V is a measure of the strength of association between
two nominal variables that factors out sample size.
178 j AORN Journal
Limitations of the Study
The ages of the children in this research study ranged from 1
month through 9 years 11 months; therefore, this sample
population does not provide information about older schoolage children and adolescents (10 through 18 years of age).
The time in surgery for the entire population of children
(N ¼ 1,394) ranged from 30 to 441 minutes, establishing a
large variation. In addition, the actual time of each temperature
measure was not collected. As a result, exploring temperature
variation related to the time in each of the assigned perioperative temperature assessment points was not possible. Six of the
22 reported cases of hypothermia had partially complete data
sets. Lastly, we established our baseline incidence of hypothermia during an early test of our CPG. This baseline was not
established with the rigor of our research study and, therefore,
we were not able to draw a firm comparison.
Recommendations for Clinical Practice
The clinical implications of this research study include the
importance of consistent CPG implementation to create the
highest quality nursing care for the perioperative pediatric
population. The findings from this research study demonstrate
that the application of evidence-based guidelines and nursing
innovation improved quality patient outcomes in pediatric
surgical care.
The research results identified that children who experience
mild hypothermia before anesthesia induction were unable to
maintain normothermia throughout the intraoperative period
without added warming interventions. Nurses should continue
to assess subjective reports of thermal comfort in combination
with measurement of body temperature to gain a more complete understanding of when to apply early warming measures.
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February 2017, Vol. 105, No. 2
The two time periods with the lowest recorded temperatures
for children in this study were the end of the intraoperative
time and the beginning of the PACU transition. This finding
establishes the continued importance of assessing temperatures
as the child transitions to the PACU and during all follow-up
assessments as congruent with the thermoregulatory response
from general anesthesia.15
Perioperative nurses should continue the practice of temperature assessment and management in children of all ages. The
literature has established unique physiologic risk factors for
perioperative hypothermia for infants and neonates, which
have enhanced the nursing focus on assessment and intervention for this age group.14,16 The findings of this study
suggest that unplanned perioperative hypothermia can occur
in all ages and that careful nursing assessment and intervention
should continue across the entire pediatric age continuum.
Recommendations for Nursing Education
The success of any change in nursing practice and improvement in patient care hinges on ongoing nursing education.
This research illustrates the important role that nursing
education plays in implementation and sustainability of an
evidence-based CPG to prevent unplanned hypothermia. This
education must provide nurses with the pathophysiologic
background of unplanned hypothermia, associated risks,
measures for prevention and treatment, and outcome results to
reinforce the maintenance of practice.
Recommendations for Future Research
Additional research is needed to establish more information
about the outcomes for infants and children who experience
unplanned perioperative hypothermia. The literature, describing
the postoperative outcomes for adults who experience
unplanned perioperative hypothermia, documents serious illness
and morbidity.9,29,30 Establishing a greater understanding of the
risk factors and postoperative outcomes for pediatric unplanned
perioperative hypothermia is necessary for quality nursing care.
Results of this study prompt additional inquiry into the timing
of temperature assessment and warming intervention, the
optimal length of time for warming, and the effect of the
specific types of warming methods on pediatric surgical outcomes. Additional research to examine variables such as body
mass index, blood pressure, nutritional status, length of hospital
stay, postoperative illness indicators (eg, surgical site infection),
discharge status, and readmission status in children who experience unplanned perioperative hypothermia is needed to assist
in building knowledge of the outcomes resulting from
unplanned hypothermia in the pediatric population.
www.aornjournal.org
Perioperative Hypothermia in Children
CONCLUSION
This research study demonstrated that implementing an
evidence-based CPG that includes using consistent tools to
monitor temperature resulted in a low incidence of unplanned
perioperative hypothermia in this pediatric surgical department. Continuing research may promote development of
evidence-based CPGs that establish effective, high-quality
nursing care, including assessment and warming methods,
for the pediatric surgical population.
Editor’s note: Exergen TemporalScanner is a trademark of the
Exergen Corporation, Watertown, MA.
References
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methods for optimizing perioperative body core temperature.
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2. Billeter AT, Hohmann SF, Druen D, Cannon R, Polk HC Jr.
Unintentional perioperative hypothermia is associated with severe
complications and high mortality in elective operations. Surgery.
2014;156(5):1245-1252.
3. Witt L, Dennhardt N, Eich C, et al. Prevention of intraoperative
hypothermia in neonates and infants: results of a prospective multicenter observational study with a new forced-air warming system with
increased warm air flow. Paediatr Anaesth. 2013;23(6):469-474.
4. Hooper VD, Chard R, Clifford T, et al; ASPAN. ASPAN’s evidencebased clinical practice guideline for the promotion of perioperative
normothermia: second edition. J Perianesth Nurs. 2010;25(6):
346-365.
5. Guideline for prevention of unplanned patient hypothermia. In:
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6. Burns SM, Wojnakowski M, Piotrowski K, Caraffa G. Unintentional
hypothermia: implications for perianesthesia nurses. J Perianesth
Nurs. 2009;24(3):167-176.
7. Lynch S, Dixon J, Leary D. Reducing the risk of unplanned perioperative hypothermia. AORN J. 2010;92(5):553-565.
8. Tveit C, Belew J, Noble C. Prewarming in a pediatric hospital:
process improvement through interprofessional collaboration.
J Perianesth Nurs. 2015;30(1):33-38.
9. Burger L, Fitzpatrick J. Prevention of inadvertent perioperative
hypothermia. Br J Nurs. 2009;18(18):1114-1119.
10. Cobbe KA, Di Staso R, Duff J, Walker K, Draper N. Preventing
inadvertent hypothermia: comparing two protocols for preoperative
forced-air warming. J Perianesth Nurs. 2012;27(1):18-24.
11. Clarke HF, Bradley C, Whytock S, Handfield S, van der Wal R,
Gundry S. Pressure ulcers: implementation of evidence-based
nursing practice. J Adv Nurs. 2005;49(6):578-590.
12. Hegarty J, Walsh E, Burton A, Murphy S, O’Gorman F, McPolin G.
Nurses’ knowledge of inadvertent hypothermia. AORN J. 2009;
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13. Paulikas CA. Prevention of unplanned perioperative hypothermia.
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14. Galante D. Intraoperative hypothermia. Relation between general and
regional anesthesia, upper- and lower-body warming: what strategies
in pediatric anesthesia? Paediatr Anaesth. 2007;17(9):821-823.
15. Kim P, Taghon T, Fetzer M, Tobias JD. Perioperative hypothermia
in the pediatric population: a quality improvement project. Am
J Med Qual. 2013;28(5):400-406.
16. Tander B, Baris S, Karakaya D, Ariturk E, Rizalar R, Bernay F.
Risk factors influencing inadvertent hypothermia in infants and
neonates during anesthesia. Paediatr Anaesth. 2005;15(7):
574-579.
17. G€orges M, Ansermino JM, Whyte SD. A retrospective audit to
examine the effectiveness of preoperative warming on hypothermia
in spine deformity surgery patients. Paediatr Anaesth. 2013;
23(11):1054-1061.
18. Pearce B, Christensen R, Voepel-Lewis T. Perioperative hypothermia in the pediatric population: prevalence, risk factors and
outcomes. J Anesth Clin Res. 2010;1(1):102. doi:10.4172/2155
-6148.1000102.
19. Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN J. 2010;92(5):567-571.
20. Drake-Brockman TF, Hegarty M, Chambers NA, von UngernSternberg BS. Monitoring temperature in children undergoing
anaesthesia: a comparison of methods. Anaesth Intensive Care.
2014;42(3):315-320.
21. Eyelade OR, Orimadegun AE, Akinyemi OA, Tongo OO,
Akinyinka OO. Esophageal, tympanic, rectal, and skin temperatures in children undergoing surgery with general anesthesia.
J Perianesth Nurs. 2011;26(3):151-159.
22. Sahin SH, Duran R, Sut N, Colak A, Acunas B, Aksu B.
Comparison of temporal artery, nasopharyngeal, and axillary
temperature measurement during anesthesia in children. J Clin
Anesth. 2012;24(8):647-651.
23. Jay O, Molgat-Seon Y, Chou S, Murto K. Skin temperature over the
carotid artery provides an accurate noninvasive estimation of core
temperature in infants and young children during general anesthesia. Paediatr Anaesth. 2013;23(12):1109-1116.
24. Holzhauer JK, Reith V, Sawin KJ, Yen K. Evaluation of temporal
artery thermometry in children 3-36 months old. J Spec Pediatr
Nurs. 2009;14(4):239-244.
25. Carr EA, Wilmoth ML, Eliades AB, et al. Comparison of temporal
artery to rectal measurements in children up to 24 months.
J Pediatr Nurs. 2011;26(3):179-185.
26. Hooper VD. Revisiting the ASPAN evidence-based clinical practice
guideline for the promotion of perioperative normothermia.
J Perianesth Nurs. 2010;25(6):343-345.
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February 2017, Vol. 105, No. 2
27. Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified by perioperative nurses. AORN J. 2013;97(4):402-418.
28. Foote JM, Brady LH, Burke AL, et al. Development of an evidencebased clinical practice guideline on linear growth measurement of
children. J Pediatr Nurs. 2011;26(4):312-324.
29. Forbes SS, Eskicioglu C, Nathens AB, et al. Evidence-based
guidelines for the prevention of perioperative hypothermia. J Am
Coll Surg. 2009;209(4):492-503.e1.
30. Macario A, Dexter F. What are the most important risk factors for a
patient’s developing intraoperative hypothermia? Anesth Analg.
2002;94(1):215-220.
Susan E. Beedle, MSN, RN, CPN, is the clinical
education specialist of Surgical Services at Children’s
Hospital and Medical Center, Omaha, NE. Ms Beedle
has no declared affiliation that could be perceived as
posing a potential conflict of interest in the publication of this article.
Amy Phillips, MSN, APRN-CNS, CCRN, is a clinical
nurse specialist in Nursing Education and Research at
Children’s Hospital and Medical Center, Omaha, NE.
Ms Phillips has no declared affiliation that could be
perceived as posing a potential conflict of interest in
the publication of this article.
Shirley Wiggins, PhD, RN, is a clinical research
nurse at Children’s Hospital and Medical Center,
Omaha, NE, and an associate professor of Nursing at
the College of Nursing at the University of Nebraska
Medical Center, Lincoln, NE. Dr Wiggins has no
declared affiliation that could be perceived as posing
a potential conflict of interest in the publication of
this article.
Leeza Struwe, PhD, MSN, RN, is an assistant
professor at the Niedfelt Nursing Research Center
in the College of Nursing at the University of
Nebraska Medical Center, Lincoln, NE. Dr Struwe has
no declared affiliation that could be perceived as
posing a potential conflict of interest in the publication
of this article.
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EXAMINATION
Continuing Education:
Preventing Unplanned
Perioperative Hypothermia in
Children 2.2
www.aornjournal.org/content/cme
PURPOSE/GOAL
To provide the learner with knowledge of best practices related to hypothermia in the pediatric
surgical population.
OBJECTIVES
1.
2.
3.
Describe the risk factors, adverse outcomes, and incidence of unplanned perioperative hypothermia.
Compare unplanned perioperative hypothermia in the adult surgical population with that in the pediatric
surgical population.
Discuss the methods and results of this study, which measures the incidence of unplanned hypothermia in a
pediatric surgical population after the implementation of a clinical practice guideline.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aornjournal.org/content/cme.
QUESTIONS
1. Unplanned hypothermia can contribute to surgical complications including
1. impaired coagulation.
2. increased need for oxygen.
3. surgical site infections.
4. cardiac arrhythmias.
5. bradypnea.
a. 4 and 5
b. 1, 2, and 3
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
2. This study measured the incidence of hypothermia in
children after the implementation of a clinical practice
guideline. The clinical practice guideline included
1. assessment of temporal artery temperature.
2. use of a consistent device for temperature measurement.
3. eight specific time points for perioperative temperature
documentation.
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4. assessment of the subjective thermal comfort level of
the child.
5. nursing interventions, including consistent application
of warming measures.
6. ambient intraoperative room temperature from
21.1 C to 23.9 C (70 F to 75 F).
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
3. In the neonate and infant population, hypothermia contributes to the development of
1. hypoglycemia.
2. cardiac arrhythmias.
3. metabolic acidosis.
4. tissue hypoxia.
5. increased oxygen demand.
a. 1 and 3
b. 2, 3, and 4
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
AORN Journal j 181
Beedle et al
4. Children and infants are considered to be at greater risk of
developing unplanned hypothermia than adults because of
differences in body size, limited stores of subcutaneous fat,
and less effective regulatory capacity.
a. true
b. false
5. Risk factors that contribute to the incidence of perioperative hypothermia in children include
1. prolonged length of surgery.
2. increased surface exposure to cold.
3. cool ambient room temperatures.
4. high transfusion rates.
5. use of anticoagulants.
6. substantial blood loss.
a. 1, 3, and 5
b. 2, 4, and 6
c. 1, 2, 3, 4, and 6 d. 1, 2, 3, 4, 5, and 6
6. Current estimates of the incidence of perioperative
hypothermia in children range from _____ to _____.
a. 10%, 80%
b. 4.2%, 60%
c. 8.5%, 70%
d. 5.2%, 65%
7. In this study, hypothermia is defined as a body temperature less than
182 j AORN Journal
February 2017, Vol. 105, No. 2
a. 36 C (96.8 F).
c. 35 C (95 F).
b. 37 C (98.6 F).
d. 36.5 C (97.7 F).
8. Inclusion criteria for participants in this study included
1. children younger than 10 years.
2. children 31 days or older.
3. children undergoing a surgical procedure lasting
30 minutes or longer.
4. female patients who have not reached menarche.
5. children with central nervous system impairment.
a. 4 and 5
b. 1, 2, 3, and 4
c. 1, 2, 4, and 5
d. 1, 2, 3, 4, and 5
9. Using data from all cases for which hypothermia status
could be determined (n ¼ 1,196), the incidence of perioperative hypothermia found in this study was
a. 16.3%.
b. 3.48%.
c. 11.8%.
d. 1.84%.
10. The two time periods with the lowest recorded temperatures for children in this study were the end of intraoperative time and beginning of the postanesthesia care
unit transition.
a. true
b. false
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LEARNER EVALUATION
Continuing Education:
Preventing Unplanned
Perioperative Hypothermia in
Children 2.2
www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing education
credit, you must complete the online Examination and
Learner Evaluation at http://www.aornjournal.org/content/cme.
Rate the items as described below.
6.
Will you be able to use the information from this article
in your work setting?
1.
Yes
2.
No
7.
Will you change your practice as a result of reading this
article? (If yes, answer question #7A. If no, answer
question #7B.)
7A.
How will you change your practice? (Select all that
apply.)
1. I will provide education to my team regarding why
change is needed.
2. I will work with management to change/implement
a policy and procedure.
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
change.
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice.
5. Other: __________________________________
7B.
If you will not change your practice as a result of
reading this article, why? (Select all that apply.)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others about the
purpose of the needed change.
3. I do not have management support to make a
change.
4. Other: __________________________________
8.
Our accrediting body requires that we verify the time
you needed to complete the 2.2 continuing education
contact hour (132-minute) program: _____________
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Describe the risk factors, adverse outcomes, and incidence of unplanned perioperative hypothermia.
Low
1.
2.
3.
4.
5.
High
2.
Compare unplanned perioperative hypothermia in the
adult surgical population with that in the pediatric surgical population.
Low
1.
2.
3.
4.
5.
High
3.
Discuss the methods and results of this study, which
measures the incidence of unplanned hypothermia in a
pediatric surgical population after the implementation of
a clinical practice guideline.
Low
1.
2.
3.
4.
5.
High
CONTENT
4.
5.
To what extent did this article increase your knowledge
of the subject matter?
Low
1.
2.
3.
4.
5.
High
To what extent were your individual objectives met?
Low
1.
2.
3.
4.
5.
High
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AORN Journal j 183