Inadvertent Perioperative

Hypothermia: Current Nursing

Knowledge
KAREN K. GIULIANO, PhD, RN, FAAN; JANE HENDRICKS, BSN, RN, CNOR

ABSTRACT
Inadvertent perioperative hypothermia is estimated to affect 70% of surgical patients and is associated
with adverse clinical outcomes, lengthened hospital stays, and increased costs. To better understand
the current level of nursing knowledge on this subject since the release of the “Guideline for prevention
of unplanned patient hypothermia,” we conducted an e-mail survey of AORN members. The overall
response rate was 6.5% (N ¼ 324), and most responding nurses overestimated or underestimated
the lower and upper limits for normothermia. When asked about the most common complications
associated with hypothermia, respondents identified shivering (68.2%), surgical site infections (65.4%),
and cardiac events (61.7%); only 44.8% and 33.6% identified blood loss and pressure injuries, respec-
tively. These results indicate a need for ongoing interventions to increase awareness and promote
best practices to prevent and manage inadvertent perioperative hypothermia. AORN J 105 (May 2017)
453-463. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.03.003
Key words: inadvertent hypothermia, normothermia, perioperative hypothermia, hypothermia
prevention.

I nadvertent perioperative hypothermia continues to be a

clinical challenge when caring for patients undergoing a
surgical procedure. Up to 70% of surgical patients expe-
rience inadvertent hypothermia, generally defined as a core
body temperature lower than 36 C (96.8 F).1-5 Inadvertent
perioperative hypothermia increases the risk of medical com-
plications;1-6 results in higher hospital costs;3,7 prolongs post-
operative anesthesia care unit (PACU), intensive care unit,
and overall hospital lengths of stay;1,3,7 and decreases patient
satisfaction.3,7
SIGNIFICANCE TO NURSING
Although a strong body of research characterizes the causes of,
risk factors for, and interventions to prevent inadvertent
perioperative hypothermia, the literature lacks recent data
concerning nurses’ depth of knowledge regarding perioperative
hypothermia. Nurses play a primary role in caring for and
monitoring patients throughout the perioperative continuum;
therefore, a better understanding of nurses’ knowledge of
perioperative hypothermia is an important part of improving
patient outcomes. Results from a previous survey of attendees
at an annual perioperative nursing conference revealed signif-
icant knowledge gaps concerning the definitions of hypo-
thermia and normothermia, risk factors for hypothermia, and
strategies to prevent perioperative hypothermia.8
RESEARCH QUESTION
This study consisted of one research question: Has the level of
nursing knowledge on inadvertent perioperative hypothermia
improved since the development and dissemination of the
AORN practice guideline3 for the prevention and manage-
ment of perioperative hypothermia?

http://dx.doi.org/10.1016/j.aorn.2017.03.003
ª AORN, Inc, 2017
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GiulianodHendricks
PURPOSE
The purpose of this study was to assess the current level of
nurses’ knowledge regarding perioperative hypothermia and
compare it with the knowledge of nurses surveyed approxi-
mately 10 years ago,7,8 and after AORN developed and
disseminated their “Guideline for prevention of unplanned
patient hypothermia.”3-5
LITERATURE REVIEW
The American Society of PeriAnesthesia Nurses (ASPAN)
defines normothermia as a core temperature ranging from 36
C to 38 C (96.8 F to 100.4 F),4 which differs slightly from
the range of 36.5 C to 37.5 C (97.7 F to 99.5 F) estab-
lished by the National Institute for Health and Clinical
Excellence (NICE).5 AORN, ASPAN, and NICE define
hypothermia as a core temperature below 36.0 C (96.8 F).3-5
The definition from NICE further distinguishes mild
hypothermia as a core temperature ranging from 35.0 C to
35.9 C (95.0 F to 96.6 F), moderate hypothermia as 34.0
C to 34.9 C (93.2 F to 94.8 F), and severe hypothermia as a
core temperature of 33.9 C (93.0 F).5
Incidence
The typical core temperature heat loss post anesthesia induc-
tion is estimated at 1.0 C to 3.0 C (1.8 F to 5.4 F).9
Declines in temperature occur most rapidly during the first
hour of surgery, characterized by a loss of 1.0 C to 1.5 C
(1.8 F to 2.7 F).5,10 The reported incidence of hypothermia
in surgical patients during the perioperative period ranges from
50% to 90%,7 with 70% of patients estimated to be hypo-
thermic on admission to the PACU.1,2
Causes
Inadvertent hypothermia occurs in response to general or
regional anesthesia as a result of the loss of behavioral
responses to cold and impaired thermoregulatory heat-
preserving mechanisms.1,2,5,9-11 Some anesthetic agents
interfere with heat production because they cause vasodilation,
muscle relaxation, and disruption of the shivering response.2,9-11
Muscle relaxants interfere with the transmission of nerve
impulses that promote muscle activity, which decreases heat
generation.2,9-11 Volatile anesthetic gases used to maintain
anesthesia cause vasodilation, resulting in increased blood flow
to the skin and radiant heat loss into the environment.2,9-11
Risk Factors
Patient factors associated with an increased risk for perioper-
ative hypothermia include extremes in age, low body weight,
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May 2017, Vol. 105, No. 5
chronic or systemic health conditions, and poor nutritional
status.2-5,10 Neonates and patients older than 70 years of age
are particularly susceptible.2-5,10,12 Higher body mass indices
decrease the risk of hypothermia.1-5,10,12 Patients with dia-
betes, peripheral vascular disease, hypothyroidism and other
endocrine disorders, cardiac conditions, arthritis, paralysis,
hypoglycemia, intoxication, and head or spinal cord injuries
are at a greater risk for hypothermia.2-5,10,12 Surgical risk
factors include the following:
 low core temperature before surgery,
 preoperative fasting and fluid deprivation before anesthesia,
 administration of cool IV or irrigation fluids,
 exposure of large body surface areas,
 evaporative heat loss during skin preparation using volatile
solutions,
 large open cavity or abdominal surgery,
 longer duration of surgery and exposure to anesthesia,
 burn injuries, and
 extensive blood loss.1-3,5,9-12
Environmental factors can also increase patients’ risk for hy-
pothermia and include cool ambient temperatures and airflow
in the OR, minimal covering during surgery, and exposure to
cool temperatures or drafts during patient transport.2,3,9,12
Consequences
Patients affected by perioperative hypothermia experience
numerous physiological changes (Figure 1).13 Metabolic
changes combined with peripheral vasoconstriction, altered
tissue perfusion, and inhibition of enzymatic reactions of the
coagulation cascade place patients at an increased risk for
adverse effects that range from patient discomfort to increased
morbidity and mortality.1,6,9 Patients experiencing hypother-
mia are at an elevated risk for
 cardiac arrhythmias, ischemia, and arrest;
 impairments in immune function and increased risk of
infections;
 longer intensive care stays;
 prolonged overall hospital stays;
 increased intraoperative blood loss and blood transfusions;
and
 increased mortality.1,7,9,10,14,15
The risk of surgical site infection (SSI) increases because of
reduced skin oxygen tension, compromised immune status,
and subcutaneous vasoconstriction.1,6,9,15 A seminal study16
evaluated the association of hypothermia with the risk of
SSI and prolonged hospital stay resulting from delayed
healing. Researchers randomly assigned patients to routine
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Figure 1. Physiological changes caused by inadvertent perioperative hypothermia.
intraoperative thermal care (ie, the hypothermia group) or
perioperative warming (ie, the normothermia group). Nineteen
percent of patients in the hypothermia group experienced in-
fections, compared with only 6% of patients in the normo-
thermia group (P ¼ .009), with an adjusted odds ratio for
infection of 4.9 (95% confidence interval ¼ 1.7-14.5) for the
hypothermia group. The mean duration of hospital stay was
12.1 days for the normothermia group and 14.7 days for the
hypothermia group (P ¼ .001).16 Additional consequences of
perioperative hypothermia include increased risk of pressure
injuries, prolonged PACU stays, and lower levels of patient
satisfaction because of thermal discomfort.1,9
Management Strategies
Guidelines and recommended practices for the management of
perioperative hypothermia include regular patient monitoring
along with interventions to maintain or restore normo-
thermia.3-5 Recommended prevention strategies include
maintaining ambient room temperature at 24 C (75.2 F),
actively warming patients who are hypothermic, and providing
preoperative warming.3,17
In addition, there are several passive interventions to maintain
normothermia during surgery, including
 forced-air warming;
 circulating-water garments;
 energy transfer pads;
 warm IV and irrigation fluids;
 increasing the temperature of the OR;
 radiant heat or resistive heating;
 limiting skin exposure to low ambient temperatures; and
 passive warming with cotton blankets, surgical drapes, and
reflective composite drapes.5,9,17
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Inadvertent Perioperative Hypothermia
Patients who are normothermic in postoperative settings
benefit from passive measures, ambient room temperatures of
24 C (75.2 F), regular assessment of thermal comfort level,
and continuous monitoring for signs and symptoms of hy-
pothermia.10 Patients who are hypothermic on admission to
the PACU require active-warming interventions.17
NURSES’ KNOWLEDGE OF
PERIOPERATIVE HYPOTHERMIA
Information on nurses’ depth of knowledge about perioper-
ative hypothermia and the practices they employ to manage it
is limited despite the high incidence, serious consequences,
and availability of effective interventions to prevent and treat
this frequent surgical complication. A 2006 survey of all
nursing and medical staff members (N ¼ 140) employed at a
single trauma center in Australia assessed their depth of
knowledge and understanding concerning inadvertent hypo-
thermia and its effects on trauma patients. The survey con-
sisted of 14 questions, including items to assess the ability of
respondents to define normothermia and hypothermia,
identify consequences of hypothermia, identify sources of heat
loss in adults, list instruments to measure core body tem-
perature, identify the goal temperature to achieve when
rewarming hypothermic patients, and identify methods to
restore normothermia.8
Analysis of 96 completed surveys (69% overall response rate)
revealed that both nurses and physicians were unsure of the
definition of hypothermia. All respondents identified two or
more factors that contributed to hypothermia, with ambient
temperature among the most frequently cited causes. All
respondents were able to list at least one rewarming strategy,
and 95 respondents reported two additional warming
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interventions. Notably, few staff members identified mini-
mizing patient exposure, removing wet clothing or bandages,
or using dry linens as strategies for heat loss prevention or
rewarming. Barriers to monitoring patients’ temperatures
included noncompliance, anatomic injury, lack of patient
access, lack of available equipment, patient acuity, and human
factors. Recognition of the complications associated with
hypothermia was low.8
Hegarty et al7 conducted a survey using a volunteer conve-
nience sample of attendees at the 2007 National Annual
Conference of the Irish Anaesthetic and Recovery Nurses
Association regarding nurses’ knowledge of perioperative
hypothermia. Of the 198 conference participants, 130
(65.7%) completed a survey consisting of two demographic
questions and nine questions that assessed knowledge of the
definition of hypothermia, risk factors for hypothermia,
potential sources of heat loss, interventions to prevent hypo-
thermia, and adverse events associated with hypothermia.
Respondents completed a 22-item Likert scale survey to
evaluate the importance of specific risk factors in the devel-
opment of hypothermia. Nurses were also asked whether
patients’ temperatures were routinely monitored in their
clinical setting and to identify factors in their clinical setting
that interfered with their efforts to maintain normothermia.7
Most respondents indicated that normothermia was defined as
a core body temperature ranging from 36 C to 37 C (96.8 F
to 98.6 F), with 55 nurses (42.3%) reporting that patients’
temperatures were routinely monitored in their practice
setting. Fifty nurses (38.5%) identified factors that contrib-
uted to the occurrence of hypothermia, with room tempera-
ture noted most frequently, followed by surgeon preference for
room temperature, overexposure, lack of warming equipment,
and lack of air conditioning.7
In response to an open-ended question asking nurses to
identify three common factors contributing to the develop-
ment of hypothermia, nurses cited 74 factors, including
(in order of frequency)
 ambient temperature in the OR,
 body exposure,
 length of surgery,
 fluid and blood loss,
 anesthesia-induced bradycardia,
 patient age,
 infusion of cold fluids,
 prolonged exposure,
 shock, and
 fasting.7
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All nurses identified at least one method to prevent hypo-
thermia, with warming devices the most frequently mentioned
intervention, followed by use of a fluid or blood warmer,
control of the ambient temperature, covering patients with
blankets, regular temperature monitoring, and foil wrapping to
prevent heat loss.7
Nurses readily identified two or more complications associated
with perioperative hypothermia, including delayed recovery,
postoperative shivering, hypotension, increased postoperative
pain, and delayed incision healing. Based on the nurses’ re-
sponses to the 10-point Likert scale ranking of factors involved
in the development of hypothermia, the researchers reported
mean scores greater than 9 for the following categories:
 major surgery involving a large, uncovered area (9.9);
 neonates younger than one month (9.8);
 patients with third-degree burns (9.6);
 major surgery (9.5);
 pediatric surgery (9.4); and
 duration of surgery exceeding two hours (9.4).7
The researchers reported mean scores less than 8 for the
following categories:
 low body weight patients (7.9),
 level of spinal anesthesia (7.7),
 open pelvic or abdominal surgery (7.7),
 general anesthesia (7.4),
 OR temperature ranging from 18 C to 20 C (64.4 F to
68.0 F) (6.9),
 spinal or epidural anesthesia (6.8),
 OR temperature ranging from 20 C to 22 C (68.0 F to
71.6 F) (5.2),
 use of a tourniquet (5.2),
 normal preoperative body temperature (4.9), and
 minor surgical procedures (4.0).7
STUDY DESIGN, SETTING, AND SAMPLE
In 2015, we conducted an e-mail survey using a convenience
sample of AORN members selected from the AORN mem-
bership database. All nurses who were current, active members
with at least five years of experience in the care of surgical
patients in perioperative settings were eligible to complete the
survey. We obtained institutional review board approval
through Endicott College, Beverly, Massachusetts.
Methods
Eligible nurses received an e-mail message explaining the
purpose of the study, inviting them to participate, and
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May 2017, Vol. 105, No. 5
providing a link to the electronic survey using the Qualtrics
online survey platform (https://www.qualtrics.com). The invi-
tation also stated the approximate time required to complete
the survey and informed nurses that their participation was
voluntary and anonymous.
We distributed the one-time invitation and survey on March
26, 2015, with a deadline of April 3, 2015, for submission of
completed questionnaires. We did not send any follow-up
e-mails. To enhance the survey completion rate, nurses who
returned a completed survey on or before the submission
deadline were eligible to receive a $1,500 scholarship to attend
the 2016 AORN Surgical Conference & Expo and coauthor
the manuscript. Qualtrics has a feature that allows storage of
respondent e-mail addresses in a file separate from the survey
responses to ensure the two cannot be linked. We planned to
use a random number generator to select and notify the
winner by e-mail address. Unfortunately, an error between the
Qualtrics survey and the principal investigator’s computer
resulted in a loss of the separate e-mail address file, and
Qualtrics technical support was unable to rectify the error.
Thus, we invited an experienced perioperative nurse known to
the principal investigator to participate as the manuscript
coauthor and receive the scholarship to attend Expo.
Instrument
We constructed a questionnaire (Figure 2) based on the
instrument administered by Hegarty et al.7 A user could
complete the questionnaire in approximately 10 to 15
minutes. Demographic questions assessed years of practice as a
perioperative nurse, level of education, participation in post-
graduate training in perioperative nursing, primary work
setting, and clinical setting (Table 1). We also assessed nurses’
definitions of hypothermia and institutional practices
regarding hypothermia monitoring in perioperative settings.
We asked nurses to identify factors associated with anesthesia
or surgery that could result in hypothermia, sources of
potential loss of body heat in adult patients, clinical strategies
to prevent hypothermia, and complications potentially caused
by hypothermia, which matched the survey questions asked by
Hegarty et al.7
The final question asked respondents to rank 22 risk factors
for the development of intraoperative hypothermia. Hegarty
et al7 also assessed these risk factors after adapting research
performed by Macario and Dexter18 and asked respondents to
rate risk factors for the development of hypothermia.
Responses were indicated on a scale of 1 to 10, with a response
of 1 considered “not likely to be important” and a response of
10 considered “most likely to be important.” Hegarty et al7
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Inadvertent Perioperative Hypothermia
reported a Cronbach alpha of 0.876 for the 22-item scale.
The item-total correlation for items on this scale exceeded
0.3, which they interpreted as confirmation that all items
evaluated the same attribute of risk factors for perioperative
hypothermia.7
Based on the work of Macario and Dexter18 and Hegarty
et al,7 we developed the Risk of Inadvertent PeriOperative
Hypothermia (RIPOH), a 22-item individual question
(number 17 on the questionnaire) using a revised root ques-
tion and response choices to more clearly assess the concept of
risk. The root question reads, “At what point on a scale of 1 to
10 would you rate the following in the development of
hypothermia, with 10 being the highest risk?”7(p710) Total
reliability of the RIPOH yielded a Cronbach a of 0.943, with
a corresponding range of 0.939 to 0.943 for single-item
deletions. The mean item-total correlation was 0.646 (range,
0.361 to 0.785).
Statistical Analysis
We downloaded raw data from completed surveys from the
Qualtrics web site as a single comma-separated values file,
which was imported and analyzed using SPSS version 21.0.
We generated descriptive statistics for each question. We
calculated the median, mean, mode, and standard deviation
(SD) for all continuous variables and frequency counts and
determined percentages for categorical variables. The per-
centage of missing data was recorded for survey items with
categorical response options.
RESULTS
We distributed the survey to the most current e-mail addresses
of 5,000 AORN member nurses who met the study eligibility
criteria. Completed questionnaires were returned by 324 nurses,
for an overall response rate of 6.5%. The mean length of
experience as a perioperative nurse was 17.75 years (SD ¼
12.29 years), with more than 90% of respondents practicing
in intraoperative settings. More than 50% held at least a
bachelor degree. The most frequently reported work settings
were community hospitals and university teaching hospitals.
Characteristics of the clinical settings in which respondents
worked and their knowledge and practices regarding hypo-
thermia are summarized in Table 2. The mean number of
hospital beds was 315.69 (SD ¼ 380.63 beds) with a mean of
14.15 beds (SD ¼ 17.58 beds) in the OR.
A total of 274 respondents answered question 12 on the
frequency of routine temperature monitoring in the periop-
erative setting: 223 nurses (81.4%) answered “yes” to routine
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GiulianodHendricks
Figure 2. Perioperative nurse questionnaire regarding knowledge, recognition, and treatment of unintentional
perioperative hypothermia.
monitoring of patients, 44 nurses (16.1%) monitored tem-
perature based on patient assessment, and 7 nurses (2.6%) did
not use routine monitoring. The mean institutional cutoff
point for hypothermia was 35.13 C (SD ¼ 3.80 C [95.23 F;
SD ¼ 6.84 F]). When nurses were asked to state the lowest
and highest temperatures used to define normothermia, the
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May 2017, Vol. 105, No. 5
mean responses were 35.63 C (SD ¼ 3.41 C [96.13 F;
SD ¼ 6.14 F]) and 37.03 C (SD ¼ 3.87 [98.65 F;
SD ¼ 7.0 F]), respectively.
Responses to questions showed that surgical factors (question
13, N ¼ 273) were considered to have the greatest effect on
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Respondents rank ordered warming interventions from most

Table 1. Survey Respondent Demographics to least effective, with a score of 1 assigned to the most
(N ¼ 324)
effective and 5 indicating the least effective strategy
Characteristic Response (Figure 3).4-8 Respondents considered warming blankets to be
Years as perioperative nurse
the least effective method and forced-air warming devices the
 Mean (SD); median 17.75 (12.29); 16 most effective. We also queried nurses about the types of
Level of education, n (%) complications caused by inadvertent perioperative hypother-
 Associate degree 110 (34) mia (Figure 4). The potential answers included five common
 Bachelor degree 180 (55.6) complications associated with hypothermia (ie, increased
 Master degree 1 (0.3)
 Doctoral degree 28 (8.6) blood loss, SSIs, cardiac events, pressure injuries, shivering)
 Missing 5 (1.5) and three random complications not known to be associated
Participation in postgraduate courses in perioperative with hypothermia (ie, seizures, pneumothorax, renal failure).
nursing, n (%) The most frequently noted complications were shivering,
 Yes 63 (19.5) cardiac events, and SSIs. Most respondents recognized that
 No 256 (79.0)
 Missing response 5 (1.5) seizures, renal failure, and pneumothorax were not complica-
tions of hypothermia.
Primary work setting, n (%)
 Preoperative 18 (5.6)
 Intraoperative 299 (92.3) Rankings of risk factors for hypothermia on the RIPOH
 Postoperative 6 (1.9) revealed seven factors with ratings of 9 or higher, which
 Missing response 1 (0.3) included neonates less than one month of age (mean ¼ 9.88),
Clinical setting, n (%) patients with third-degree burns (mean ¼ 9.74), patients older
 Community hospital 182 (56.2)
than 70 years (mean ¼ 9.43), patients undergoing major sur-
 Academic teaching hospital 89 (27.5)
 Ambulatory surgical center 47 (14.5) gery with a large exposed area (mean ¼ 9.38) or cardiac surgery
 Missing response 6 (1.8) (mean ¼ 9.28), patients experiencing preoperative hypothermia
SD ¼ standard deviation. (mean ¼ 9.15), and patients undergoing pediatric surgery
(mean ¼ 9.05). Factors with rankings less than or equal to
seven were spinal anesthesia (mean ¼ 6.74), epidural anesthesia
patients’ risk for hypothermia, with 134 nurses (49%) indi- (mean ¼ 6.64), tourniquet use (mean ¼ 6.54), preoperative
cating this response. When asked about the best time to normothermia (mean ¼ 5.65), ambient temperature in the
intervene for patients experiencing hypothermia (question 14, OR ranging from 20 C to 22 C (68.0 F to 71.6 F)
N ¼ 270), 228 nurses (84.4%) indicated “at all times,” (mean ¼ 5.58), and minor procedures (mean ¼ 4.56). A
whereas 39 respondents (14.4%) felt preoperative intervention comparison of our results with those reported by Hegarty et al7
was optimal. is shown in Table 3.

Table 2. Respondent Demographics and Temperature Management Practices

Characteristic Mean (SD); N ¼ 324

Total beds in clinical setting 315.69 (380.63)
Total beds in OR 14.15 (17.58)
Temperatures indicative of hypothermia
 Institutional or work setting cutoff point 35.13 C (3.80 C) / 95.23 F (6.84 F)
 Lowest value used by nurse to define normothermia 35.63 C (3.41 C) / 96.13 F (6.14 F)
 Highest value used by nurse to define normothermia 37.03 C (3.87 C) / 98.65 F (6.97 F)
Frequency for monitoring temperature, n (%)a
 As required based on patient assessment 44 (16.1)
 At routine intervals 223 (81.4)
 Not at routine intervals 7 (2.6)
 Missing response 50 (18.2)
SD ¼ standard deviation.
a
n ¼ 274.

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GiulianodHendricks
Figure 3. Rank order of nurses’ ratings for effectiveness
of interventions to achieve optimal management of
hypothermia. Interventions are ranked on a 5-point
scale with 1 ¼ most effective and 5 ¼ least effective.
DISCUSSION
Successful efforts to prevent or effectively manage inadvertent
perioperative hypothermia require an awareness of the
clinical definitions for hypothermia and normothermia,
an understanding of the underlying causes of and risk factors
for hypothermia, recognition of potential adverse events
associated with hypothermia, and knowledge of strategies
to prevent or treat hypothermia. Our results are consistent
with those of earlier research,7,8 indicating a lack of awareness
of the evidence-based definitions for hypothermia and
Figure 4. Ratings of complications considered to be substantially associated with the onset of hypothermia.
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May 2017, Vol. 105, No. 5
normothermia.3-5 Although more than 90% of our survey
respondents practiced in intraoperative settings, there were
significant variations in the values that nurses reported for hy-
pothermia and the upper and lower values for normothermia.
AORN, ASPAN, and NICE define hypothermia as a core
temperature less than 36 C (96.8 F),3-5 which is consistent
with the mean value of 35.1 C (95.2 F) obtained in our
study. Our SD of 3.80 was large, however, suggesting that
many nurses overestimated or underestimated the core body
temperature indicative of hypothermia. Similarly, the mean
cutoff point for the lower limit of normothermia indicated by
our survey respondents was 35.6 C (96.1 F), which is less
than the lower limits recommended by ASPAN and NICE of
36 C (96.8 F)10 and 36.5 C (97.7 F),5 respectively. The
mean cutoff point for the upper limit of normothermia
reported by our survey respondents was 37 C (98.6 F),
which was lower than the upper limits of 38 C and 37.5 C
(100.4 F and 99.5 F) established by ASPAN and NICE,
respectively.4,5 In addition, the SDs for the upper and lower
values for core body temperatures for normothermia were
large, at 3.41 and 3.87. This finding suggests that most nurses
overestimated or underestimated both the lower and upper
cutoff points for normothermia.
Our finding that many nurses were unfamiliar with the
guideline-recommended values for hypothermia and normo-
thermia is particularly notable when we consider the mean
number of years of experience and level of educational
attainment of our survey respondents. Our respondents were
highly experienced and educated clinicians with an average of
more than 17 years of nursing experience. Almost two-thirds
held bachelor degrees or more-advanced nursing degrees.
Despite the experience and education of respondents, their
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1
Table 3. Rank Order Comparison of RIPOH and Hegarty et al Risk Factors

Risk Factor RIPOH Ranking, Mean (SD) Hegarty et al1 Ranking, Mean
Neonate <1 mo of age 9.88 (0.75) 9.4
Patient with third-degree burns 9.74 (0.69) 9.6
Patient older than 70 y 9.43 (0.99) 8.9
Major surgery with large uncovered area 9.38 (1.08) 9.9
Cardiac surgery 9.28 (1.26) 8.9
Patient hypothermic before surgery 9.15 (1.29) 8.6
Pediatric surgery 9.05 (1.37) 9.4
Open pelvic or abdominal surgery 8.99 (1.28) 7.7
Thin patient 8.67 (1.48) 7.9
Thoracotomy surgery 8.61 (1.57) 8.5
Surgery duration >2 hr 8.48 (1.70) 9.4
Major surgery 8.47 (1.47) 9.5
OR temperature <18 C (<64.4 F) 8.40 (1.75) 8.8
Blood loss >30 mL/kg 7.95 (1.89) 8.6
General anesthesia 7.62 (1.83) 7.4
   
OR temperature 18 C to 20 C (64.4 F to 68.0 F) 7.06 (2.16) 6.9
Degree of spinal anesthesia 6.74 (2.07) 7.7
Epidural anesthesia 6.64 (2.12) 6.8
Tourniquet use 6.54 (2.07) 5.2
Normothermia before surgery 5.65 (2.06) 4.9
   
OR temperature 20 C to 22 C (68.0 F to 71.6 F) 5.58 (2.51) 5.2
Small (ie, minor) procedure 4.56 (2.27) 4.0
RIPOH ¼ risk of inadvertent perioperative hypothermia; SD ¼ standard deviation.
Reference
1. Hegarty J, Walsh E, Burton A, Murphy S, O’Gorman F, McPolin G. Nurses’ knowledge of inadvertent hypothermia. AORN J. 2009;89(4):
701-704, 707-713.
Table adapted with permission from Hegarty et al.

awareness of the definitions of hypothermia and normo-
thermia was poor, suggesting the need for ongoing education
programs to reinforce recall of the critical values for core body
temperature in perioperative settings.
As Hegarty et al7 pointed out, evidence of knowledge gaps
about thermal regulation, normothermia, and hypothermia
among nurses providing perioperative care establishes the need
to promote awareness of and adherence to the current practice
guidelines issued by AORN, ASPAN, and NICE,3-5 combined
with educational initiatives to reinforce awareness of the
clinical significance of hypothermia, best practices to reduce
the risk of hypothermia, and effective interventions for man-
agement of hypothermic patients.
Nurses face numerous competing priorities in the periopera-
tive setting that may interfere with their ability to routinely
assess patients’ core temperatures, monitor for signs and
symptoms of hypothermia, and initiate interventions to
prevent or treat hypothermia. However, regular assessment
and the prevention or treatment of hypothermia can be
accomplished easily with resources that should be readily
accessible, such as blankets, forced-air warmers, and
thermometers.
Importantly, 212 (65.4%) of our survey respondents correctly
identified SSIs as a possible complication of inadvertent hy-
pothermia, with 112 (34.6%) failing to note this as a potential
outcome. This finding suggests that a sizable percentage of
nurses completing our survey were unaware of the relationship
between hypothermia and the risk of health careeassociated
infections, particularly SSIs. Regular patient monitoring
for inadvertent hypothermia combined with timely and
effective interventions to prevent or treat hypothermia have

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GiulianodHendricks
the potential to decrease rates of health careeassociated in-
fections, which is a key performance metric for health care
facilities.19 Educational interventions to address this knowl-
edge gap may significantly reduce infection rates among
surgical patients and improve institutional performance on
this quality measure.
Our respondents were knowledgeable about some of the
serious complications attributed to hypothermia, including
shivering (68.2%, n ¼ 221) and cardiac events (61.7%,
n ¼ 200). Blood loss and pressure injuries were correctly
identified as possible complications of hypothermia by only
145 (44.8%) and 109 (33.6%) respondents, respectively,
suggesting the need for education regarding the clinical
consequences of perioperative hypothermia.
Interventions to prevent or manage hypothermia were similar
when we compared our findings with those reported by
Hegarty et al.7 The earlier study identified forced-air warm-
ing devices, warming fluids, and control of the ambient
temperature as the most frequently used techniques to
manage hypothermia,7 and our survey yielded similar results.
For the most part, these interventions are consistent with
AORN, ASPAN, and NICE guidelines, although AORN and
NICE recommend the use of forced-air warming for the
prevention of hypothermia3,5 and ASPAN recommends this
strategy only for hypothermic patients.4 Additionally, NICE
recommends the use of warming fluids as a prophylactic
intervention;5 ASPAN states this intervention should be
limited to hypothermic patients;4 and AORN advocates for
the use of warming fluids only in situations in which large
volumes are transfused.3 Control of ambient temperature is
included in the recommendations by NICE and ASPAN;4,5
AORN states that raising the ambient room temperature
should be considered when active skin warming is not feasible
or in patients for whom active skin warming alone is not
sufficient.3
STUDY LIMITATIONS
Interpretation of our findings must take into consideration
several limitations. First, we selected a nonrandom sample of
AORN members. Second, most respondents were well
educated and possessed a significant number years of profes-
sional experience, which may or may not be representative of
practicing perioperative nurses in general. Finally, the small
sample size, missing data, and low response rate are additional
limitations of this study. A larger sample size with a higher
response rate might yield results that would be more repre-
sentative of the general population of nurses working in
perioperative settings.
462 j AORN Journal
May 2017, Vol. 105, No. 5
Our results are descriptive in nature. For this reason, they
cannot support any conclusions about causal relationships
regarding knowledge and behaviors associated with hypo-
thermia or associations between exposure to educational
interventions and awareness and practices related to the
assessment, monitoring, prevention, and management of
hypothermia.
RECOMMENDATIONS
Nurses require ongoing education, training, and evaluation of
training effectiveness to ensure that they are aware of the de-
tails of the leading guidelines regarding management of peri-
operative hypothermia, particularly when those guidelines are
modified and updated. An institutional commitment to edu-
cation regarding the causes, risk factors, consequences, and
strategies to prevent or manage hypothermia is essential for all
perioperative nurses. Such training should focus on changes in
guidelines as well as provision of information about best prac-
tices to ensure optimal management of patients who experience
inadvertent hypothermia before, during, and after surgery.
Future research should evaluate strategies to improve nurses’
knowledge of hypothermia and application of guideline-
recommended interventions to manage perioperative hypo-
thermia. We also concur with the research suggestion offered
by Hegarty et al7 to conduct observational studies that
monitor nurses’ activities to prevent and manage hypothermia.
We plan to conduct RIPOH-2 as a follow-up study and
further refine our questionnaire to yield a total hypothermia
knowledge score that will more precisely quantify nurses’
knowledge over time. Findings from RIPOH-2 and related
studies will inform the development of strategies to increase
the likelihood that patients remain normothermic during their
perioperative experience and reduce their risk of complications
associated with hypothermia.
CONCLUSION
Inadvertent perioperative hypothermia in surgical patients is a
preventable complication. The knowledge and skills of the
perioperative nurse can help prevent its occurrence and con-
sequences to patients. Nurses require ongoing education,
training, and competency evaluation to ensure that they are
aware of the leading guidelines regarding management of

perioperative hypothermia and institutional support for
education and training.
Acknowledgments: The authors thank Carole Alison Chrvala,
PhD, medical writer at Health Matters, Inc, Hillsborough, NC,
for assistance with creation of the initial draft of this article;
Michelle Trochsler, RN, BSN, student at Endicott College,
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May 2017, Vol. 105, No. 5
Beverly, MA, at the time of this study, for assistance with survey
development; and AORN, Inc, Denver, CO, for access to the
survey respondents.
Editor’s notes: Qualtrics is a registered trademark of Qualtrics,
LLC, Provo, UT. SPSS 21.0 is a registered trademark of IBM
Corporation, Armonk, NY. This study was funded by Sage
Products, Cary, IL.
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Karen K. Giuliano, PhD, RN, FAAN, is a nurse
scientist at Hallmark Health, Medford, MA, and director
of Clinical Outcomes at Sage Products, Cary, IL; she was
an adjunct nursing faculty member at Endicott College,
Beverly, MA, at the time this research was conducted. As
an employee of Sage Products, Cary, IL, Dr Giuliano has
declared an affiliation that could be perceived as posing
a potential conflict of interest in the publication of this
article.
Jane Hendricks, BSN, RN, CNOR, is a clinician level
III and head of Transplant Services at the University of
Virginia Health System, Charlottesville. Ms Hendricks has
no declared affiliation that could be perceived as posing
a potential conflict of interest in the publication of this
article.
AORN Journal j 463