If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
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E-letters: Electronic letters published:
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NICE and warm
- SENTHILKUMAR VIJAYAN (29 December 2008)
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Re:NICE and Warm
- Senthil N Jayaseelan (15 October 2008)
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Re: Perioperative Temperature Audit- Not so NICE and warm
- C Mark Harper (23 September 2008)
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Response to Pre-operative hypothermia eletter
- C Mark Harper (23 September 2008)
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Response to 'Perioperative hypothermia' eletter
- C Mark Harper (23 September 2008)
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NICE- Will it make a difference?
- Pumali Gunasekera (15 September 2008)
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Perioperative hypothermia
- Helen J Lawrence (11 September 2008)
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Pre-operative hypothermia
- Robert A McCahon (10 September 2008)
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Perioperative Temperature Audit- Not so NICE and warm
- Claire E Williams, Glyn Harrison (10 September 2008)
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Green Guideline
- Gordon B Drummond (2 September 2008)
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SENTHILKUMAR VIJAYAN, specialist registrar
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NICE and warm Dear Editor I read with interest the editorial by Harper and colleagues1 regarding the recent National Institute of Clinical Excellence guidelines on inadvertent perioperative hypothermia2. A recent prospective audit in our Avon Orthopaedic Centre showed poor compliance with most of the NICE recommendations. I found 40% of our patients had a preoperative tympanic temperature of less than 36 degree Celsius, which was already been shown to exist among the surgical population3. Active warming methods were used only in 48% of the cases which included forced air warming and fluid warmers. This is more relevant in the context of elective Orthopaedic surgery as previous studies have shown that aggressive intraoperative warming reduces blood loss during hip arthroplasty4. Notably temperature monitoring was done in 14% of the cases and was not of recommended frequency. In the more protocol driven domain of recovery room the temperature monitoring and documentation was not regular. 52% of our patients had temperature less than 36 degree Celsius in recovery room and even though all patients had their temperature monitored on arrival in the recovery room, regular monitoring was not done and there was no clear documentation of actions taken to warm them. I agree with Harper and colleagues that these shortcomings will incur additional costs like use of forced-air warmers, fluid warmers and additional thermometers. Given the impact which previous NICE guidelines had on the clinical community and encouraged hospitals to buy ultrasound machines, I strongly hope addressing these shortcomings will help us to deliver better health care for our patients. We look forward to re audit our practice to note the impact and practicality of NICE guidelines and to see how we fare compared with other similar units in the country. S. Vijayan Bristol, UK E mail: sirvsk@yahoo.co.uk References 1. Harper CM, Andrzejowski JC, Alexander R. NICE and warm. Br J Anaesth 2008; 101: 293-5 2. NICE. Perioperative hypothermia (inadvertent): the management of inadvertent perioperative hypothermia in adults. NICE Clinical Guideline 65. London: National Institute for Health and Clinical Excellence, 2008 3. Mitchell AM, Kennedy RR. Preoperative core temperature in elective surgical patients show and unexpected skewed distribution. Can J Anaesth 2001; 48: 850-3 4. Winkler M, Akca O, Birkenberg B, Hetz H. Aggressive warming reduces blood loss during hip arthroplasty. Anaesth Analg. 2000 Oct; 91(4): 978-84 Conflict of Interest:None declared |
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Senthil N Jayaseelan
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I read with interest the editorial by Dr.Harper and colleagues.There should be a lot of emphasis placed on educating our anaesthetic and surgical colleagues along with the nursing staff regarding the importance of this vital aspect of patient management.This concept is poorly appreciated among health care professionals.Even after the guidelines came out in april 2008, the message has not reached everyone fully.This important information should be made available to all the wards,theatres and recovery in a simplified form.Every anaesthetic trainee should be educated by the department to keep their patients "NICE and warm" in their lists.The anaesthetists should talk about these guidelines with their ODPs and the anaesthetic nurses regularly so that they inturn appreciate the need to keep the equipments ready for temperature monitoring and maintenance[I think a significant number of patients would need them].The FY1s and FY2s should receive a teaching presentation regarding this topic in their hospitals so that they appreciate its importance in the preoperative and post operative care in the ward-many patients are being reviewed by them in the ward for several reasons and it would be good if they understand the importance of maintaining normothermia in the pre/post surgical patients. Conflict of Interest:None declared |
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C Mark Harper, Consultant Anaesthetist BSUH
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We would like to thank Drs Williams and Harrison for their interest in our article. As we mentioned in the paper, all methods of temperature measurement have significant problems as the degree of accuracy seems to increase only with their degree of invasiveness. Tympanic temperatures are a particular problem in clinical practice. One of the author's (CMH) institutions swapped over from temporal artery thermometers to tympanic and found a sudden increase in the incidence of post-operative hypothermia. We then audited the incidence of IPH according to each form of measurement and found that the tympanic thermometer read on average 0.73 degC lower than the temporal artery, giving incidences of IPH of 9.1% for the latter and 60.3% for the latter. The temporal artery thermometer has been shown to be reasonably accurate in the clinical situation and has even been used to demonstrate improved outcomes in warmer patients. In fact this study suggests that outcomes are improved if patient's temperatures are kept above 36.5 degC (reference 16 in the original article). Conflict of Interest:Author of editorial |
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C Mark Harper, Consultant Anaesthetist BSUH
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We would like to reassure Dr McCahon that we have adequately considered the time constraints placed on operating suites. The fact of the matter is that the NICE review of the data indicates that complications and costs are reduced by ensuring that patients' core temperatures do not dip below 36.0 degC. There is no doubt that this will probably cause serious logistical problems for the correspondent's institution but there is also no doubt that its achievement will bring about significant benefits to his patients. We might also add that the authors themselves cannot take credit for the guideline as most of the hard work was carried out by the superb technical team at NICE and that we made up only about 20% of the guideline development group. Furthermore, the document is a guideline as to best practice and so anaesthetists are not obliged to follow it to the letter. However, as we point out, it is hoped that they will use it as a lever to benefit their patients. Conflict of Interest:Author of editorial |
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C Mark Harper, Consultant Anaesthetist BSUH
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We would like to thank Dr Lawrence for her interest in our article and congratulate her on her timely audit. We would like to make a couple of points. First is that it is important to know how the temperatures were taken. In another audit we found that the tympanic probes commonly used on the wards read on average 0.73 degC lower than the temporal artery. This will obviously have a profound effect on the incidence of Hypothermia. Second is that, just because it is cumbersome from a practical point of view to warm patients in the anaesthetic room, it doesn't detract from the fact that this is best practice. It is all too easy to get so hung up on throughput just to keep the managers happy by hitting their targets. But the evidence suggests that, as a consequence, we are putting our patients at risk of increased morbidity. Using warming mattresses is a way round this: Wong et al showed improved outcomes if patients were put onto these pre-anaesthetic and then transferred onto the operating table on them where forced-air warming was added; the control group received just forced-air warming in theatre. Furthermore, increased cost should not be a problem as if the blanket intended for theatre is not stuck down it can also be used in the anaesthetic room. Conflict of Interest:Author of editorial |
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Pumali Gunasekera, CT2 Anaesthetics Hull Royal Infirmary
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Dear Editor, I read the above editorial with interest particularly as I had conducted an audit on inadvertent peri –operative hypothermia at a teaching hospital in the South East of England 2 years ago. At that time we did not have any national guidelines on this topic. We used the guideline produced by the American Society of Perianaesthesia Nurses(ASPAN) (endorsed by the American Society of Anaesthetists) (1) and the RCOA recommendations (2), as our standards. We conducted a retrospective audit on 50 patients undergoing laparotomy. Of this sample 67% (30) had 1 or more risk factors (as defined by the RCOA document) for the development of hypothermia. 15% of patients were noted to be hypothermic pre-operatively. None of them had any intervention to correct this until commencement of surgery, when active warming was instituted. 60% of all patients had warming methods intraoperatively. 80% of patients with risk factors were warmed. Both passive & active warming measures were used e.g. Radiant hats, towels, blankets, Bair Huggers, warmed intravenous & irrigation fluids. Nasopharyngeal temperature measurements were done in 50% of patients which suggested that we were not measuring the temperature in all the patients we were warming. Our incidence of hypothermia in the immediate post-op period was 20%. All these patients had one or more risk factors. None of them were actively warmed in recovery. Worryingly 82% of patients did not have a temperature at discharge from recovery documented. From this we concluded that although our intraoperative temperature management was acceptable we needed to improve our pre & post operative management. It was suggested that all patients being actively warmed should have intra-op temperature monitoring. It was argued that active warming was hard to commence on wards due to lack of resources, however it could easily be started in the anaesthetic room and could be continued in recovery. The importance of documenting the temperature at discharge from recovery was highlighted. We also recognised the need for a streamlined national guideline to make it easier to identify patients at risk and suggested a local protocol based on the ASPAN document. The availability of a guideline meant that it would be easier to implement warming methods for non anaesthetists. With this in view we welcome the NICE guideline. As suggested in your editorial it will also give an incentive for trusts to allocate funding for much needed equipment in theatres, recovery and hopefully wards as well. 1.American Society of PeriAnaesthesia Nurses: Clinical Guideline for the prevention of unplanned peri-operative hypothermia 2. RCOA : Raising the Standard; Temperature management. Conflict of Interest:None declared |
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Helen J Lawrence, ST1 Anaesthetics
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I read with interest the editorial on the new NICE guidelines concerning the prevention of perioperative hypothermia as I have just completed the first stage of an audit of practice at my hospital, a small DGH. Data was collected for 113 adult patients undergoing surgery in a three week period in August. 55% were scheduled day case operations. Anaesthetists and anaesthetic nurses were largely unaware of the NICE guidelines, and they were encouraged to carry out their usual practice with regard to temperature measurement and control. 13% of patients had a documented core temperature < 36°C on the ward prior to surgery, 16% were hypothermic intraoperatively, and 16% were hypothermic in recovery. The total incidence of perioperative hypothermia was 34%, rather higher than that found in the editorial author's audit. Furthermore, over half (54%) of the patients who could be classed as higher risk for perioperative hypothermia were indeed hypothermic at some point. The guidelines recommend that a forced air warming device be used at induction for higher risk patients and for those having anaesthesia for more than 30 minutes. This practice was largely not seen in the audit, with only two patients (1.7%) being actively warmed in the anaesthetic room. This is not surprising, and I suspect not uncommon. When the anticipated time in the anaesthetic room is short it seems time-consuming and cumbersome to set up a forced air warming device before transfer into theatre. There are also significant cost implications of implementing this part of the guidelines. I imagine it will be difficult to persuade anaesthetists of the benefit of active warming at induction, particularly for day case surgery, and therefore this aspect of the guideline seems impractical as it stands. It may be more realistic to recommend forced air warming at induction if the time in the anaesthetic room is expected to be prolonged. Conflict of Interest:None declared |
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Robert A McCahon
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Editor - The recent editorial by Harper and colleagues highlights a simple and effective intervention that is known to reduce perioperative morbidity.[1] The authors view the NICE perioperative hypothermia guideline as a significant lever to secure the necessary funding to introduce perioperative warming for essentially all operations.[2] Complete implementation of the guideline may not prove so simple. I feel that the authors have not considered adequately the time constraints that the guideline may have placed upon hard pressed operating suites. A prospective audit at a large teaching hospital demonstrated that 32% of adult patients arriving in theatre reception for non-emergent surgery had a tympanic temperature < 36 degrees centigrade. Further examination of the data revealed that 50% of patients > 70 years old were hypothermic on arrival in theatre reception. As the guideline states, these patients should have been warmed to normothermia prior to induction of anaesthesia. This would undoubtedly cause theatre delays and an increase in on-the-day theatre cancellations due to list over-runs. The effective management of pre-operative hypothermia, especially in the elderly, poses a significant challenge in terms of time and money. In this age of targets and tight budgets, some of our patients may still be left out in the cold. 1. Harper CM, Andrzejowski JC, Alexander R. NICE and warm. Br J Anaes 2008; 101: 293 - 295 2. NICE. Perioperative hypothermia (inadvertent): the management of inadvertent perioperative hypothermia in adults. In: NICE Clinical Guideline 29 (2008) London: National Institute for Health and Clinical Excellence. Available from www.nice.org.uk/CG065 Conflict of Interest:None declared |
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Claire E Williams , Glyn Harrison
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We read with interest the editorial by Harper and colleagues (1) about the recently published National Institute of Clinical Excellence (NICE) guidelines on inadvertent perioperative hypothermia. (2) We had been prompted by these guidelines to conduct an audit into current practice at our District General Hospital. A retrospective case note analysis of 57 adult patients revealed poor compliance with the majority of the recommendations. For example 33% of our patients had a preoperative tympanic temperature of below 36.0°C, a distribution that has already been noted in a surgical population. (3) A systematic literature review in 2002 found that the range of tympanic temperature was 35.4– 37.8 °C. (4) Is then the NICE trigger of 36°C appropriate? Many of our patients are day of admission surgery and data was collected during a relatively warm week in March. We found a postoperative hypothermia rate of 40%, which is double that quoted by Harper and colleagues, but given the 33% preoperative hypothermia rate is this so bad?
Intraoperative warming is indicated for surgery of duration greater than 30 minutes; 39 (68%) of our patients, but in our audit warming was only given in 15 (38%) of those cases. Notably temperature monitoring was only used in 3 (8%) of these patients and was of a recommended frequency in only one case. We expected that the performance in the more protocol based domain of the post-anaesthetic care room (PACU) would be better. Indeed whilst nearly all patients (91%) had their temperature measured on admission, the treatment or documentation of hypothermia was minimal. No patient had regular temperature measurement, for 30 (53%) patients no temperature was documented upon return to the ward and 5 (19%) of those with a documented temperature were hypothermic.
We agree with Harper and colleagues these shortcomings will result in additional costs: that of forced air warmers, disposables, additional thermometers and longer stays for patients in the PACU. Given the influence of previous NICE guidelines in the purchasing of ultrasound machines and our current shortcomings we hope to improve care for our patients. Once the audit tool is available it would be interesting to compare our results with other units in the UK.
C. Williams*
G. Harrison
*Email: cw424@wbic.cam.ac.uk
(1) Harper CM, Andrzejowski JC, Alexander R. NICE and warm. British journal of anaesthesia 2008; 101: 293-5
(2) NICE. Perioperative hypothermia (inadvertent): the management of inadvertent perioperative hypothermia in adults. NICE Clinical Guideline 65. London: National Institute for Health and Clinical Excellence, 2008
(3) Mitchell AM, Kennedy RR. Preoperative core temperatures in elective surgical patients show an unexpected skewed distribution. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2001; 48: 850-3
(4) Sund-Levander M, Forsberg C, Wahren LK. Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review. Scandinavian journal of caring sciences 2002; 16: 122-8
Conflict of Interest:None declared |
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Gordon B Drummond
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As far as I know, the two intraoperative monitors that have been convincingly shown to really make a difference in reducing postoperative morbidity are the routine assessment of neuromuscular transmission (adequately done with two ECG electrodes and the occasional need to replace a battery): and temperature measurement. They are both inexpensive to practise. For about two years I measured nasopharyngeal temperature routinely during open gynaecological surgery. I have now stopped wasting money on disposable probes in routine cases because the core temperature in recovery is almost always over 36 degrees, without the need for adjusting active heat input. The cheap and cheerful way to do this is merely put the arms, legs, and head of the patient in polythene bags and use an airway filter that is also a heat and moisture exchanger, and a circle system with a low fresh gas flow. No need to put heat in: just stop it getting out! The only important routes of heat loss in most procedures are by convection and evaporation. The important route of cold gain is cold fluids, and I agree that the warming cabinet is the best low cost way to stop giving cold to the patient. Before colleagues jump to use expensive disposables or cumbersome re- useable devices that are difficult to keep clean, I suggest two 600 x 900 mm bags for the legs, two 600 x 600 mm bags for the arms, and one 600 x 600 mm bag for the head. Light gauge clear polythene in perfect. One can easily make small holes to obtain access without materially affecting efficiency. Do the experiment! I am sure most will find this works perfectly well. It's remarkable that many of the references in this editorial are ten years old: WHY should it take convincing published evidence so long - and a guideline - to be accepted? Perhaps anaesthetists leave the polythene bags on their journals! Conflict of Interest:None declared |
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