Table overhang; hypothermia; separating sponges, skin lacerations when scrubbing; wound classification; forced air warming - Clinical Issues

AORN Journal,  July, 2003  by Carol Peterson

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* extremes in age (ie, very young or very old);

* being female;

* length, type, and extent of procedure;

* preexisting conditions (eg, peripheral vascular disease, endocrine disorders);

* cold irrigation or IV fluids;

* general or regional anesthesia; and

* significant fluid shifts. (5)

AORN supports the American Society of PeriAnesthesia Nurses' hypothermia guidelines, which recommend the following passive and active interventions to maintain patients' normothermia.

* Limit skin exposure with warm blankets, socks, and head covering.

* Use circulating warm water mattresses.

* Increase ambient room temperature to between 68[degrees]F and 73[degrees]F (20[degrees]C to 23[degrees]C).

* Institute active warming interventions (ie, forced air warming blanket systems, IV warming systems, warm irrigation fluids, humidified and warmed anesthesia gases). The growing body of research regarding hypothermia demonstrates reduced incidence of postoperative surgical site infections when patient warming is begun in the preoperative holding area. In one study, 421 patients undergoing clean surgeries were divided into two groups. One group of patients received either local or systemic warming in the preoperative holding area. Warming was applied at least 30 minutes before surgery. The other group of patients did not receive warming. Nineteen wound infections occurred among the 139 patients who were not warmed, and only 13 wound infections occurred among the 277 patients who underwent warming procedures preoperatively. Although both systemic warming and local warming had a significant effect on reducing the rate of wound infections, slightly fewer wound infections were noted in patients who were warmed locally compared to those who were warmed systemically. (8)

Many institutions use warming devices intraoperatively and postoperatively, but they are seldom used preoperatively. The evidence in this study indicating that preoperative warming for at least 30 minutes before surgery reduces postoperative surgical site infections is compelling. Warming patients preoperatively helps prevent unplanned hypothermia and decreases the incidence of wound infections postoperatively.

Maintaining a patient's temperature is a key component of safe patient care. If a surgeon gets too hot during a surgical procedure, there is an alternative to lowering the room temperature that may be more effective. "Cool jackets" developed for race car drivers have been adapted for use in the OR. Other systems currently on the market are designed for OR personnel. Contact your purchasing department to find a manufacturer of these jackets.

Question: I have just moved to a different area of the country and started working in an inpatient OR. I am having trouble adjusting to how they count sponges before a procedure. They completely unfold each sponge down to a single layer during the initial count. They then must refold the sponges to use them. I have been a perioperative nurse for 18 years and never have encountered this practice. I always have separated sponges during the initial count, but I did not think this meant it was necessary to completely unfold each one. Have I been performing sponge counts incorrectly, or is this practice taking separating sponges to the extreme?