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The normothermia challenge: Four steps toward tackling inadvertent perioperative hypothermia

By : Karin Ganlöv and Tina Unenge, October 13 2014Posted in: The Mölnlycke Health Care blog

One of the existing challenges in the surgical arena is ensuring that anaesthetized patients do not become hypothermic. It is a common but preventable problem. Multiple studies have shown conclusively that even mild perioperative hypothermia, which sets in at the onset of anaesthesia and contributes to a precipitous drop in core body temperature, can have severe consequences1, ranging from cardiovascular problems or morbidity2, bleeding3 and an increased risk of infection4,5 to longer recovery times, which has the add-on effect of creating longer, more expensive hospital stays3. It also contributes to the less tangible but very real issue of patient discomfort.

Perioperative hypothermia and its consequences are not the “hottest” issues when looking at the O.R. but ultimately the consequences can create a number of serious problems that, as a growing body of evidence illustrates, can at least in part be prevented with fairly straightforward and easy-to-implement solutions6. Evidence-based guidelines exist to direct patient warming7,8,9, including patient prewarming, into clinical practice – but, to this point, perioperative warming has not been perceived as essential. Perioperative patient care is complex on the whole, making patient warming and temperature management a consideration but not a priority.

The normothermia challenge poses a number of questions. How can the importance of maintaining normothermia be elevated? How can the challenge of IPH be tackled? A number of studies address different aspects of these questions. The possible consequences are well-documented, as illustrated by the references cited above.

The first piece of tackling the normothermia challenge is considering negative consequences and making these better known. Better patient outcomes is the first priority. Continuing to generate more evidence about both adverse consequences and especially about possible solutions – and sharing this information more widely in the medical community – will elevate the issue further.

A second part in tackling the normothermia challenge comes in the form of increased pressure felt by hospitals. Hospitals face the burden of having to increase efficiency on many fronts, that is, to reduce costs, reduce the length of hospital stays and reduce the number of adverse effects from hospital stays and surgical procedures. Using the aforementioned evidence coupled with studies illustrating the cost and efficiency benefits of adopting patient-warming methods into standard clinical practice will help hospitals alleviate these pressures. This is true in both the short and long run with challenges ranging from the immediate and more obvious outcomes, such as patient comfort and satisfaction10 and discharging patients sooner from recovery to longer-term possible savings in costs of having to readmit patients who have suffered as a result of IPH.

A third aspect of the normothermia challenge is emphasis on and the implementation of IPH guidelines. An example of one established piece of evidence is the recommendation for patient prewarming11,12. Evidence establishes, and guidelines codify, the importance of prewarming in ensuring that a patient never becomes hypothermic in the first place.

Fourthly, and finally, a big leap in turning the tide against IPH, is establishing practices and solutions that make it easier for anaesthesiologists to adopt perioperative temperature management as second nature. Luckily, the innovation landscape is changing to introduce new uses for existing and new technologies that can drastically alter surgical patient-care strategies and outcomes, sometimes without actually making drastic changes to clinical practices or the O.R. environment.


  1. Sessler DI. Complications and treatment of mild hypothermia. Anesthesiology 2001 Aug; 95(2):531-43.
  2. Frank S, Fleischer L, Breslow M, Higgins M, Olson K, Kelly S, Beattie C. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: A randomized trial. JAMA 1997; 227 (14): 1127-34.
  3. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 2008; 94: 108:71-7.
  4. Kurz A, Sessler D, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospitalization. N Engl J Med 1996; 334: 1209-16.
  5. Melling A, Ali B, Scott E, Leaper D. Effects of preoperative warming on the incidence of wound infection after clean surgery. The Lancet 2001 Sep 15; 358 (9285): 876-880.
  6. Raeder J, Geertsen K, Van de Velde M, Van Gerven E, Horn B, Torossian A. Reduced Hypothermia and Improved Patient Thermal Comfort by Perioperative Use of a Disposable Self-Warming Blanket- A randomized Multi-Center Trial. Poster session presented at: 67th Annual PostGraduate Assembly in Anesthesiology; 2013 Dec 13-17; New York, NY, USA.
  7. National Institute for Health and Care Excellence. Inadvertent perioperative hypothermia: The management of inadvertent perioperative hypothermia in adults [CG65] [Internet]. London: National Institute for Health and Care Excellence (GB); 2008. Available at:
  8. Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B, et al. ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia: second edition. J Perianesth Nurs. 2010;25(6):346-65.
  9. Torossian A, Bein B, Bräuer A, Greif R, Höcker J, Horn EP, et al. S3 Leitlinie Vermeidung von perioperativer Hypothermie. 2014. Available at:
  10. Wagner D, Byrne M, Kolcaba K. Effects of comfort warming on preoperative patients. AORN Journal 2006 Sep; 84 (3): 427-30, 432, 434-36, 438-448.
  11. Just B, Trévien V, Delva E, Lienhart A. Prevention of intraoperative hypothermia by preoperative skin-surface warming. Anesthesiology 1993; 79: 214-218.
  12. Horn EP, Bein B, Böhm R, Steinfath M, Sahili N, Höcker J. The effect of short time periods of preoperative warming in the prevention of perioperative hypothermia. Anaesthesia 2012 June; 67 (6): 612-7, doi: 10.1111/j.1365-2044.2012.07073.x.
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The surgical and wound care environment is always changing. The Mölnlycke Health Care blog addresses topics and trends in surgery and wound care. Among these topics are efficiency, health economy, infection control and patient safety. Read more about this blog and how to comment.

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