We asked 220 Outpatient Surgery Magazine readers to review 7 common surgical scenarios and then tell us which interventions they'd use to keep the patient warm before, during and after surgery. See if you can pick the best interventions to avoid hypothermia in your patients. The answers are circled in red. The percentages after each answer indicate how the survey respondents would have intervened.

1. Mr. Jones, 75, is scheduled for an open cholecystectomy. Based on evidence, what are 3 ways to maintain Mr. Jones' body temperature?
a. Pre-warm in the pre-operative hold area with forced-air warming. 89.0%
b. Cover with cotton blankets 47.2%
c. Keep the operating room temperature at or above 70 ?F 57.3%
d. Use warmed IV fluids 84.9%

Combining methods to prevent perioperative hypothermia remains the best approach, especially for surgeries involving open cavities. Open abdominal surgical approaches facilitate the loss of body heat quickly. In order to prevent heat loss overall, research shares that pre-operative warming is a great first measure to minimize heat loss once the patient arrives in the operating room. Be sure to use a forced-air warming device to pre-warm at least 30 minutes prior to the patient's entering the operating room. Next, studies show that operating rooms kept at or above 70 ?F keep heat loss to a minimum. Notably, the most heat lost in the operating room is during the first hour from the time the patient enters the room. Yet, many operating rooms remain well below 70 ?F. Understandably, surgical teams get warm while working. However, after the first hour in the room, body heat loss stabilizes. At the end of the first hour, lowering the ambient temperature has little effect on body heat loss overall, so decreasing the temperature to cool the surgical team is fine. Finally, adding warmed IV fluids remains another means of avoiding hypothermia in the surgical patient. In this case, you might also consider warmed irrigants with the open abdominal approach.

2. Your patients are scheduled for cataract surgery today. How will you maintain the body temperature? Select 3.
a. Place a cotton blanket on the patient pre-operatively. 43.8%
b. Check the patients' temperatures pre-operatively and use forced-air warming prior to entering the operating room if indicated. 75.6%
c. Give warm IV fluids. 56.2%
d. Keep the patient covered before, during and after surgery to maintain body temperature. 96.3%

Each of the measures listed will help minimize or avoid hypothermia in the surgical patient. However, minimizing heat loss pre-operatively using forced-air warming offers the best means to avoid hypothermia. While a cataract surgery may be quick and simple and time spent in the OR is short, the elderly, like infants and children, lose heat quickly. The aging process decreases the shivering response as well as thermoregulatory functions. So be sure to check the patient's temperature in the pre-operative hold area. If the patient is cold, or the temperature is low, begin forced-air warming. Additionally, the comfort associated with the warming device offers high-level satisfaction for these folks. Warm IV fluids may not be practical given the short duration of the surgery, but assist in minimizing body temperature loss. This intervention may be advantageous during longer eye surgeries.

3. You are working in a busy outpatient surgery center where the primary surgical procedures involve endoscopy cases. What's the best way to keep your patients warm?
a. Place a cotton blanket on the patient pre-operatively. 4.7%
b. Offer forced-air warming pre-operatively. 19.5%
c. No intervention is necessary, as patients undergoing endoscopies do not lose body heat. 0%
d. Keep the patient covered before, during and after surgery to maintain body temperature. 75.3%

Keeping patients covered before, during and after surgery represents the best approach to avoiding hypothermia. Additionally, patients enjoy the comfort of feeling warm overall. As with all surgical patients, checking the pre-operative temperature offers the opportunity to obtain a baseline assessment and then determine if forced-air warming might be useful prior to endoscopy. All patients are at risk for developing hypothermia. Factors associated with hypothermia are numerous. In this case, intravenous medications used during sedation for endoscopies foster heat loss. Sedatives and opioids are known to promote heat loss by altering the vasoconstriction threshold.

4. Mr. Adams, 60, is scheduled for a rotator cuff repair. What is the best way to keep your patient warm?
a. Place a cotton blanket on the patient pre-operatively. 8.8%
b. Offer forced-air warming pre-operatively. 29.5%
c. Check the patient's temperature pre-operatively and use forced-air warming prior to entering the operating room if indicated. 57.1%
d. Cover the patient upon entry into the post-anesthesia care unit. 4.6%

Avoiding unintentional hypothermia remains a goal for all surgical patients. Placing a cotton blanket on the patient pre-operatively helps keep the patient warm. However, it is best to determine the patient's body temperature first, and then decide which intervention is best. If the patient complains of being cold and/or the temperature is low, evidence supports the use of forced-air warming for at least 30 minutes prior to entering the operating room. Keeping the patient warm following surgery is essential as well. However, the best single answer for this patient is to advance the use of evidence for practice and warm the patient pre-operatively. As patients age, the thermoregulatory center function decreases. They are also prone to shivering, which increases oxygen consumption significantly. This may contribute to cardiac complications including myocardial infarction.

5. You're working in a busy pediatric surgery center. Today's children scheduled for surgery range in age from 4 to 7 years. Most will undergo ear, nose and throat surgery. Which 2 methods work best to maintain body temperature in the operating room?
a. Pre-warm in the pre-operative hold area with forced-air warming. 40.8%
b. Use forced-air warming intraoperatively. 70.2%
c. Keep the operating room temperature at or above 70 ?F. 56.9%
d. Use warmed IV fluids. 38.1%

Keeping children and babies warm represents additional challenges for the perioperative team. Due to the child's larger body surface area, heat is lost quickly. Special care to ensure the operating room is warm prior to the child's entry is even more important. While 70 ?F is best for adults, you might consider raising the temperature for children, especially during that first critical hour of heat loss. While the ENT cases described in the question do not foster a large amount of heat loss, children remain at risk for developing hypothermia while undergoing general anesthesia. Intraoperative forced-air warming is perfect for this case. The majority of the child's body is easily covered with the forced-air warming blanket, leaving only the head open to the environment. Ideally, pre-warming is advocated, but awake children less than school age probably would not cooperate with this wonderful warming measure!

6. Mrs. Smith is having an open hysterectomy. What are the 2 best ways to maintain normal body temperature?
a. Place a cotton blanket on the patient pre-operatively. 18.3%
b. Check Mrs. Smith's temperature pre-operatively and use forced-air warming prior to entering the operating room. 79.4%
c. No intervention is necessary as Mrs. Smith's temperature is 98.6 ?F. 1.8%
d. Keep the patient covered before, during and after surgery to maintain body temperature. 94.0%

In the case of the open lower abdominal surgery, keeping the patient warm before, during and after surgery offers the best deterrent to inadvertent hypothermia. Today's standard of care emphasizes checking the patient's temperature upon admission. The American Society of PeriAnesthesia Nurses' Normothermia Clinical Guideline recommends that if the patient's initial temperature is low or if the patient expresses they are cold or shivering, to begin active warming while waiting to enter the operating room. Studies show that active pre-warming minimizes temperature loss in the operating room and may prevent hypothermia. If active warming equipment is unavailable, be sure to keep the patient covered with layers of cotton blankets. Upon entering the operating room, make sure the thermostat is set at 70 ?F or greater at least for the first critical hour. In addition, keep the patient's upper body and extremities covered throughout surgery. Use forced-air warming if available. Warmed, humidified oxygen is useful when general anesthesia is used, as well as warmed IV fluids. Monitoring the patient's temperature throughout the surgery and in PACU provides an additional measure to keep the patient warm. Be sure to check the Clinical Guideline (tinyurl.com/79nxfs2).

7. Mr. Smith is scheduled for hand surgery lasting about 2 hours. What's the best way to keep your patient warm during surgery?
a. Use forced-air warming for 30 minutes before entering the operating room. 11.7%
b. Keep the operating room temperature at or above 70 ?F; use forced-air warming pre-operatively; keep the patient covered before, during and after surgery. 80.8%
c. Use heated, humidified oxygen. 3.3%
d. Use forced-air warming for 15 minutes before entering the operating room. 4.2%

The combination approach to minimizing the occurrence of perioperative hypothermia is well established. Keeping the patient warm before, during and after surgery fosters normal thermal balance. Maintaining near-normal body temperature before, during and after surgery minimizes the occurrence of untoward physiological effects commonly associated with hypothermia that affect all body systems. In this case, you offer the patient the best advantage of maintaining body heat by entering a warm operating room and keeping the patient covered from start to finish. Using forced-air warming is the gold standard for avoiding hypothermia before, during and after surgery. While using forced-air warming is an excellent measure pre-operatively, you should first check the patient's temperature.