Protocol-driven prevention of perioperative hypothermia in the pediatric neurosurgical population

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Perioperative hypothermia (PH) is a preventable, pathological, and iatrogenic state that has been shown to result in increased surgical blood loss, increased surgical site infections, increased hospital length of stay, and patient discomfort. Maintenance of normothermia is recommended by multiple surgical quality organizations; however, no group yet provides an ergonomic, evidence-based protocol to reduce PH for pediatric neurosurgery patients. The authors’ aim was to evaluate the efficacy of a PH prevention protocol in the pediatric neurosurgery population.


A prospective, nonrandomized study of 120 pediatric neurosurgery patients was performed. Thirty-eight patients received targeted warming interventions throughout their perioperative phases of care (warming group—WG). The remaining 82 patients received no extra warming care during their perioperative period (control group—CG). Patients were well matched for age, sex, and preparation time intraoperatively. Hypothermia was defined as < 36°C. The primary outcome of the study was maintenance of normothermia preoperatively, intraoperatively, and postoperatively.


WG patients were significantly warmer on arrival to the operating room (OR) and were 60% less likely to develop PH (p < 0.001). Preoperative forced air warmer use both reduced the risk of PH at time 0 intraoperatively and significantly reduced the risk of any PH intraoperatively (p < 0.001). All patients, regardless of group, experienced a drop in core temperature until a nadir occurred at 30 minutes intraoperatively for the WG and 45 minutes for the CG. At every time interval, from preoperatively to 120 minutes intraoperatively, CG patients were between 2 and 3 times more likely to experience PH (p < 0.001). All patients were warm on arrival to the postanesthesia care unit regardless of patient group.


Preoperative forced air warmer use significantly increases the average intraoperative time 0 temperature, helping to prevent a fall into PH at the intraoperative nadir. Intraoperatively, a strictly and consistently applied warming protocol made intraoperative hypothermia significantly less likely as well as less severe when it did occur. Implementation of a warming protocol necessitated only limited resources and an OR culture change, and was well tolerated by OR staff.

ABBREVIATIONS CG = control group; CMS = Centers for Medicare and Medicaid Services; FAW = forced air warmer; NPr = normothermia protocol; NSQIP = National Surgical Quality Improvement Project; OR = operating room; PACU = postanesthesia care unit; PH = perioperative hypothermia; RWL = radiant warming light; SCIP = Surgical Care Improvement Project; SSI = surgical site infection; WG = warming group.
Article Information

Contributor Notes

Correspondence Ian Mutchnick: Norton Children’s Hospital, Norton Neuroscience Institute, Louisville, KY. WHEN CITING Published online February 14, 2020; DOI: 10.3171/2019.12.PEDS1980.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
  • 1

    Beedle SEPhillips AWiggins SStruwe L: Preventing unplanned perioperative hypothermia in children. AORN J 105:1701832017

  • 2

    Benn JArnold GWei IRiley CAleva F: Using quality indicators in anaesthesia: feeding back data to improve care. Br J Anaesth 109:80912012

    • Search Google Scholar
    • Export Citation
  • 3

    Bernard H: Patient warming in surgery and the enhanced recovery. Br J Nurs 22:319320322–325 2013

  • 4

    Berríos-Torres SIUmscheid CABratzler DWLeas BStone ECKelz RR: Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 152:7847912017

    • Search Google Scholar
    • Export Citation
  • 5

    Bräuer A: Perioperative Temperature Management. New York: Cambridge University Press2017

  • 6

    Gasim GIMusa IRAbdien MTAdam I: Accuracy of tympanic temperature measurement using an infrared tympanic membrane thermometer. BMC Res Notes 6:1942013

    • Search Google Scholar
    • Export Citation
  • 7

    Giuliano KKHendricks J: Inadvertent perioperative hypothermia: current nursing knowledge. AORN J 105:4534632017

  • 8

    Gustafsson ILElmqvist CFrom-Attebring MJohansson IRask M: The nurse anesthetists’ adherence to Swedish national recommendations to maintain normothermia in patients during surgery. J Perianesth Nurs 32:4094182017

    • Search Google Scholar
    • Export Citation
  • 9

    Hannenberg AASessler DI: Improving perioperative temperature management. Anesth Analg 107:145414572008

  • 10

    Hart SRBordes BHart JCorsino DHarmon D: Unintended perioperative hypothermia. Ochsner J 11:2592702011

  • 11

    Hoda MRPopken G: Maintaining perioperative normothermia during laparoscopic and open urologic surgery. J Endourol 22:9319382008

  • 12

    Horosz BMalec-Milewska M: Niezamierzona śródoperacyjna hipotermia. Anestezjol Intens Ter 45:41472013

  • 13

    Kellam MDDieckmann LSAustin PN: Forced-air warming devices and the risk of surgical site infections. AORN J 98:3543692013

  • 14

    Kim PTaghon TFetzer MTobias JD: Perioperative hypothermia in the pediatric population: a quality improvement project. Am J Med Qual 28:4004062013

    • Search Google Scholar
    • Export Citation
  • 15

    Kurz ASessler DILenhardt R: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 334:120912151996

    • Search Google Scholar
    • Export Citation
  • 16

    Levin RFWright FPecoraro KKopec W: Maintaining perioperative normothermia: sustaining an evidence-based practice improvement project. AORN J 103:213.e1213.e132016

    • Search Google Scholar
    • Export Citation
  • 17

    McGovern PDAlbrecht MBelani KGNachtsheim CPartington PFCarluke I: Forced-air warming and ultra-clean ventilation do not mix: an investigation of theatre ventilation, patient warming and joint replacement infection in orthopaedics. J Bone Joint Surg Br 93:153715442011

    • Search Google Scholar
    • Export Citation
  • 18

    O’Donnell A: Anaesthesia: A Very Short Introduction. Oxford: Oxford University Press2012

  • 19

    Pearce BChristensen RVoepel-Lewis T: Perioperative hypothermia in the pediatric population: prevalence, risk factors and outcomes. J Anesth Clin Res 1:1022010

    • Search Google Scholar
    • Export Citation
  • 20

    Rajagopalan SMascha ENa JSessler DI: The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 108:71772008

    • Search Google Scholar
    • Export Citation
  • 21

    Ryan-Wenger NSims MPatton RWilliamson J: Selection of the most accurate thermometer devices for clinical practice: part 1: meta-analysis of the accuracy of non-core thermometer devices compared to core body temperature. Pediatr Nurs 44:1161332018

    • Search Google Scholar
    • Export Citation
  • 22

    Sessler DI: Mild perioperative hypothermia. N Engl J Med 336:173017371997

  • 23

    Sessler DI: Perioperative thermoregulation and heat balance. Lancet 387:265526642016

  • 24

    Sessler DI: Temperature monitoring: the consequences and prevention of mild perioperative hypothermia. S Afr J Anaesth Analg 20:25312014

    • Search Google Scholar
    • Export Citation
  • 25

    Sessler DI: The thermoregulation story. Anesthesiology 118:1811862013

  • 26

    Thompson DNPHartley JC: Shunt infections in Albright ALPollack IFAdelson PD (eds): Principles and Practice of Pediatric Neurosurgery ed 3. New York: Thieme2015

    • Search Google Scholar
    • Export Citation
  • 27

    Tillman MWehbe-Janek HHodges BSmythe WRPapaconstantinou HT: Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes? J Surg Res 184:1501562013

    • Search Google Scholar
    • Export Citation
  • 28

    Torossian ABräuer AHöcker JBein BWulf HHorn EP: S3-Leitlinie: Vermeidung von unbeabsichtigter perioperativer Hypothermie. Anasthesiol Intensivmed (Erlangen) 56:3083152015

    • Search Google Scholar
    • Export Citation
  • 29

    Wong PFKumar SBohra AWhetter DLeaper DJ: Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 94:4214262007

    • Search Google Scholar
    • Export Citation
  • 30

    Young VLWatson ME: Prevention of perioperative hypothermia in plastic surgery. Aesthet Surg J 26:5515712006



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