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Industry: Email Alert RSS FeedIs postanesthesia care unit length of stay: increased in hypothermic patients?
AORN Journal, Feb, 2005 by Kiekkas Panagiotis, Poulopoulou Maria, Papahatzi Argiri, Souleles Panagiotis
Inadvertent hypothermia is one of the most common complications experienced by surgical patients who are transferred to the postanesthesia care unit (PACU). The physiological definition of hypothermia in humans is core temperature greater than one standard deviation below the mean value under resting conditions in a thermoneutral environment. (1) Core temperature is defined as the blood temperature of the central circulatory system (ie, heart, lungs, brainstem), which can be measured reliably at the pulmonary artery, esophagus, or tympanic membrane. (2) Although there is no consensus in the literature concerning hypothermia threshold, most researchers define it as a core temperature of less than 36[degrees]C (96.8[degrees] F). (3,4) Both mean body and core temperature are determined by the balance between heat production and loss.
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In the OR, a decrease in body temperature is the result of heat loss due to exposure to a low-temperature environment combined with disorder of normal thermoregulatory mechanisms caused by anesthesia induction. (1) General volatile or IV anesthetic medications and neuromuscular blocking agents cause vasodilation and lack of muscular tone that result in heat loss. Regional anesthesia also has the potential to cause hypothermia, by means of decreased shivering and vasoconstriction thresholds. (5)
LITERATURE REVIEW
Many risk factors have been found to contribute to postoperative hypothermia, including the following. (6-8)
* Age--Older adult patients often have an impaired ability to maintain normal body temperature.
* Gender--The relationship between gender and hypothermia is not clear. Women experience less perioperative heat loss than men because their bodies contain more fat, which acts as a protective layer. On the other hand, they have less muscle mass and higher surface-to-mass ratios, making them more susceptible to heat loss.
* Type of anesthesia--General anesthesia traditionally is believed to be associated with a greater intraoperative decrease in body temperature. Hypothermia occurs commonly during regional anesthesia, but temperature often is not measured in patients undergoing regional anesthesia.
* Other patient-related factors include a small percentage of body fat, an American Society of Anesthesiologists (ASA) physical status of 3 or 4 and preexisting diseases, especially endocrine diseases.
* Other surgery-related factors include duration of anesthesia, OR temperature, type of surgery (eg, open thoracic, abdominal cavities), and cold fluid infusion.
Medical and nursing staff members often are not aware that the reduction of core temperature during the first hour of anesthesia primarily comes as a result of redistribution (ie, an internal heat flow from the warmer core to the colder periphery due to inhibition of temperature regulation), (9) so the risk of hypothermia tends to be underestimated during surgical procedures of low severity and short duration. The temperature of patients who undergo minor procedures often is not monitored, or they are not provided with the necessary thermal care. Consequently, hypothermia may be experienced by as many as 90% of intraoperative or postoperative patients. (10)
COMPLICATIONS OF HYPOTHERMIA. inadvertent hypothermia is a major cause of perioperative morbidity. (11) Intraoperative blood loss, postoperative wound infection, and myocardial ischemia have been reported to be the most severe complications of hypothermia. Most frequent adverse outcomes of the immediate postoperative period are
* prolonged recovery tithe and PACU stay, (12)
* markedly impaired thermal comfort, (13) and
* postanesthetic shivering (ie, muscular tone increase that causes involuntary skeletal muscular activity), which can be seen in 40% to 67% of postoperative patients. (14)
PACU LENGTH OF STAY (LOS). Patient LOS is a parameter of primary importance for health care managers. In the PACU, a high nurse:patient ratio is considered necessary. The staffing cost for a two-hour PACU stay is roughly equivalent to the staffing cost for a 24-hour stay in a hospital ward. (15) Decreasing the time of patient stay in the PACU, therefore, may reduce costs by permitting a decrease in the number of nursing personnel. (16) Use of a simulation model has confirmed that a reduction in PACU LOS would have a significant economic impact. (17) There is further potential for labor cost savings with a shorter PACU stay because this can reduce staff member overtime. (18)
Length of PACU recovery should be considered in terms of both actual and appropriate LOS. (15) Actual LOS is defined as the time from the patient's admission to the PACU to the time that the patient leaves the PACU, as recorded by the PACU nurses. A number of patient-related and non-patient-related factors, which are difficult to quantify and control, affect actual LOS. These include length of surgery; need for transfusion or additional administration of medication (eg, for pain or nausea); wait time for radiographs, laboratory results, or physician release; staff member shift changes; lack of an available bed in the ward; and transport delays. (18,19) A 2003 study using computer simulation found that the unavailability of nursing personnel to patients discharging from the PACU resulted in an increase in patient LOS and PACU overload. (20) Even minor perioperative anesthesia-related incidents, events, and complications have been shown to prolong the need for patient observation and PACU use by 6% to 26%. (21)
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