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Effectiveness of cutaneous warming systems on temperature control: meta-analysis

Cristina Maria Galva o, Yuanyuan Liang & Alexander M. Clark
Accepted for publication 5 February 2010

Correspondence to C.M. Galva o: e-mail: crisgalv@eerp.usp.br Cristina Maria Galva o PhD RN Associate Professor College of Nursing, University of Sa o Paulo, Brazil Yuanyuan Liang PhD Assistant Professor School of Medicine, Epidemiology & Biostatistics, University of Texas Health Science Center, Austin, Texas, USA Alexander M Clark PhD RN Associate Professor Faculty of Nursing, University of Alberta, Canada

O C . M . , L I A N G Y . & C L A R K A . M . ( 2 0 1 0 ) Effectiveness of cutaneous GALVA warming systems on temperature control: meta-analysis. Journal of Advanced Nursing 66(6), 11961206. doi: 10.1111/j.1365-2648.2010.05312.x

Abstract
Title. Effectiveness of cutaneous warming systems on temperature control: metaanalysis. Aim. This paper is a report of a meta-analysis to identify the effectiveness of different types of cutaneous warming systems in temperature control for patients undergoing elective surgery. Background. Hypothermia is a common and serious complication of surgery. Different cutaneous warming systems are used to prevent hypothermia during surgery but there have been no previous meta-analyses of the effectiveness of different warming systems in controlling temperature. Data sources. We conducted a search of the CINAHL (2000 to April 2009), Medline (2000 to April 2009), Embase (2000 to April 2009) and the Cochrane Register of Controlled Trials (2000 to April 2009) databases for randomized controlled trials published in English, Spanish and Portuguese. The primary outcome measure of interest was core body temperature. Methods. A systematic review incorporating meta-analysis was carried out. Results. From 329 papers, 23 trials compared warming systems. Forced-air warming systems had a strong tendency towards superior temperature control over passive insulation via cotton blankets (mean difference: 029C; 95% condence interval: 002 to 059, three trials 292 patients) and radiant warming systems (mean difference: 016C; 95% condence interval: 001 to 033, three trials, 161 patients). However, circulating water garments tended to be more effective than forced-air warming systems (mean difference: 073C; 95% condence interval: 151 to 005, I2 = 97%; four trials, 198 patients). Pooled results approached statistical signicance and indicated clinically meaningful differences in temperature control. Conclusion. Current evidence suggests that circulating water garments offer better temperature control than forced-air warming systems, and both are more effective than passive warming devices. Keywords: circulating water garments, cutaneous warming systems, hypothermia, meta-analysis, nursing, surgery, temperature control

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Introduction
Hypothermia results when body temperature is below 36C (American Society of PeriAnesthesia Nurses 2001). This is a marked variation from normal functioning because body temperature normally only uctuates by 0204C around 37C. However, during surgery most patients undergoing anaesthesia become hypothermic because of the combined effects of alterations in thermoregulation physiology induced by the anaesthetic and exposure to a cooler environment in the operating room (Scott & Buckland 2006, Kurz 2008). The prevalence of inadvertent hypothermia during and after surgery is therefore high (Abelha et al. 2005, Polderman 2009). Avoiding hypothermia is important because it is associated with increased risks of adverse cardiac events, surgical site infection, intraoperative bleeding and blood transfusion (Scott & Buckland 2006, Kurz 2008). These complications not only endanger health, but also contribute to increased costs, because of the need for further care and longer stays in the recovery room. Clinical guidelines state that all healthcare providers are responsible for preventing hypothermia related to surgery (American Society of PeriAnesthesia Nurses 2001, Association of periOperative Registered Nurses 2009). Hypothermia is therefore an important complication that nurses should seek to minimize in their practice (Wagner 2006). This could include elements such as monitoring a patients core body temperature objectively during the preoperative, intraoperative and postoperative periods (Association of periOperative Registered Nurses 2009), but also includes initiating passive or active warming methods during the intraoperative period (Kurz 2008, Association of periOperative Registered Nurses 2009). Nurses are often involved in the selection of which intraoperative warming devices to use. Preventing hypothermia is therefore a consideration for nurses involved in purchasing decisions about heating methods. Passive warming techniques include cotton blankets (CB; warmed or unwarmed) and other covers such as surgical drapes that act to minimize heat loss from the body via increased insulation (Leslie & Sessler 2003). These passive techniques were the only source of warming used up until about 1990. These passive techniques have been superseded by active techniques using air, water or electricity to augment the heating process. In addition to reducing heat loss, active cutaneous warming techniques provide heat to patients skin via a range of means, including water or air-based systems (Kumar et al. 2005). The use of active cutaneous warming techniques is now widely recommended as being more effective for maintaining normothermic status during the intraoperative period (Kurz 2008, Association of periOper-

ative Registered Nurses 2009). However, research comparing the effectiveness of different cutaneous warming techniques in terms of temperature control and regulation has not been reviewed systematically (Galva o et al. 2009).

Different types of active warming systems

Forced-air warming systems (FWS) are systems in which heated air is circulated from the warming unit through a single-use blanket (Kabbara et al. 2002). Systems vary in terms of whether heat is provided to the upper or lower body, full body or surgical site only (Motamed et al. 2000, Ihn et al. 2008, Insler et al. 2008). Quieter convective warming systems (such as WarmAir Model 135, Cincinnati Sub Zero, Cincinnati, OH, USA) have also recently been developed (Wagner et al. 2008). Circulating water garments (CWG) are systems in which heated water circulates through hoses to a single-use blanket which is wrapped around different parts of the body, such as the trunk, upper or lower limbs (Taguchi & Kurz 2005, Kurz 2008). More recent circulating water systems deliver the heated water via adhesive energy transfer pads (ETP) lled with hydrophilic gel, which cover the patients dorsum, abdomen or thighs (Taguchi & Kurz 2005, Kurz 2008). The warm water and pulsating negative pressure system is a new method that involves the heating of a water-lled sleeve by hot air. This system combines heat and mild and steady negative pressure to increase cutaneous blood circulation and promote temperature increase (Rein et al. 2007). Carbon-bre resistive heating (CF) blankets are reusable blankets in which a low voltage electric current ows to the blanket and causes heat build-up in the carbon-bres which make up the blanket lling. The blanket can be used on different body parts. The blankets are made of resistant material and the surfaces can be washed or sterilized (Hofer et al. 2005). A new alternative method is the resistive carbonbre warming system; this provides heat by the positioning of the warming blanket underneath the patients body but on top of the operating table (Fanelli et al. 2009). Radiant warming (RW) systems are those in which heat is transferred through light to the patients face, hands or feet (Wong et al. 2004). There is no blanket involved in this system. Similarly, the circulating water mattress (CW) does not use a blanket to provide heat, but instead delivers heat underneath the patient through a heated mattress.

Effectiveness of different systems: research to date

Given the existing range of systems, it is important to identify the relative effectiveness of the techniques on
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temperature regulation. A previous systematic review using integrative methods (Galva o et al. 2009) compared trials of different warming systems. Combining the studies included in that review with very recent trials, four articles compared FWS to CB (Scott et al. 2001, Vanni et al. 2003, Fallis et al. 2006) or reexive blankets (Ng et al. 2003). Results favoured the FWS in three trials. In three trials, FWS were compared with RW systems (Lee et al. 2004, Wong et al. 2004, Torrie et al. 2005) and in two studies of these the rst system was more effective than the second (Lee et al. 2004, Torrie et al. 2005). In the same review, when comparing FWS to CWG or carbon-bre blanket warming systems, all three trials showed statistically signicant changes in temperature favouring CWG over forced-air systems (Janicki et al. 2001, 2002, Hofer et al. 2005). In two trials either forced-air systems to CW or carbon-bre blanket warming systems were examined (Matsuzaki et al. 2003, Negishi et al. 2003), but no differences were found between forced-air methods and carbonbre blankets, although both identied signicant improvements on forced-air and carbon-bre over CW. In two studies, the FWS with different disposable blankets was tested. Neither study showed statistically signicant differences in effectiveness (Motamed et al. 2000, Kabbara et al. 2002). Forced-air warming systems compared with various systems In recent literature, six trials were reported comparing various techniques of forced-air warming based on location of warming on the body (Ihn et al. 2008), combinations of active warming techniques (Insler et al. 2008), different strength of air ow (Wagner et al. 2008) and different heat application techniques (Grocott et al. 2004). Finally, comparisons have been made between FWS and systems involving carbon blankets being placed underneath patients during surgery (Fanelli et al. 2009) and pulsating negative pressure systems (Rein et al. 2007). FWS were only identied as having signicant effects in one trial (Ihn et al. 2008) compared with CW. Rein et al. (2007) identied favourable effects of warm water pulsating pressure over FWS; although this trial was small (n = 20), differences in temperature were clinically meaningful (07C). Similarly, Grocott et al. (2004) found FWS to be less effective than systems using ETP. Despite the potential of FWS, to date no study has been conducted to pool outcomes from previous trials to evaluate the inuence on temperature of competing systems. Therefore, we conducted a meta-analysis to support decisionmaking regarding choice of warming system in clinical practice.
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The review
Aim
The aim of the study was to identify the effectiveness of different types of cutaneous warming systems in temperature control during the intraoperative period for patients undergoing elective surgery.

Design
For the meta-analysis, the procedures of the Cochrane Collaboration were followed, including identication of a priori inclusion/exclusion criteria (Higgins & Green 2006). The review included the development of a structured clinical question linked to a comprehensive and detailed search of the literature using appropriate databases and a priori inclusion and exclusion criteria, systematic extraction and recording of study characteristics, methods, ndings and methodological quality and synthesis of comparable studies. Two independent reviewers were involved in each stage and cross-referenced their extractions and appraisals to ensure accuracy.

Search methods
A search of the following databases was conducted by two authors (AMC and CMG): CINAHL (2000 to April 2009), Medline (2000 to April 2009), EMBASE (2000 to April 2009) and the Cochrane Register of Controlled Trials (2000 to April 2009) using the search terms hypothermia or hypothermic and warming. In addition, to search for relevant studies, experts in the eld were consulted and reference lists of all study reports included were handchecked for additional studies. To be included, studies had to have a randomized controlled trial design, data collection during the intraoperative period, and be published in English, Spanish or Portuguese as full papers in journals from January 2000 to 14 April 2009. Populations had to consist of patients aged 18 years or older undergoing elective surgery. To prevent misattribution of effects, studies were excluded if prewarming interventions during the preoperative period or induced hypothermia had been used. Studies published prior to 2000 were excluded because of changes in technology and patient care and populations.

Search outcome
The initial search identied 329 possible studies. Screening of titles, abstracts and full papers against the inclusion criteria

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Potentially eligible studies identified (20002009) n = 329

Reasons for exclusion Not focused on reducing hypothermia with warming systems during Intraoperative period/not focused on cutaneous warming systems/ induced hypothermia = 179 Under 18 years of age/pediatric/elective surgical population Not a randomized controlled trial with usual care control group/ a randomized controlled trial with prewarming Not clinical trial Full paper was not in English, Portuguese or Spanish Repeated studies (duplicate reports) = 42 = 46 = 13 =5 = 21

Final cohort of studies n = 23

Figure 1 Study selection process.

resulted in the selection of 23 studies (see Figure 1). Only those in which temperatures (including standard deviations of temperatures) had been recorded could be included in pooling.

Quality appraisal
The methodological quality of the trials was assessed using the Jadad et al. (1996) Score, a standardized and validated method of trial quality assessment. Quality assessment was performed independently by two authors (AMC and CMG), with discrepancies resolved via discussion.

demographics (age and sex), type of surgery, the intervention and comparator groups, temperatures recorded at baseline, intraoperatively and at the end of the intraoperative period, and the statistical signicance/condence interval results of each trial. Incidence rates of hypothermia were not extracted because this was not recorded in the trials and could not therefore be synthesized. In instances in which a number of intraoperative temperatures were recorded (for example via a graph), the mean intraoperative temperature was calculated.

Synthesis
For the meta-analysis component, raw unstandardized mean differences of temperatures at the start of surgery/baseline, during surgery and at the end of surgery were extracted from papers giving these data. To calculate effect sizes, sample size and data on mean temperature and standard deviation of temperature were required. This method of pooling was
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Data abstraction
Data were extracted by CMG and AMC using a validated extraction form after gaining the authors consent (Ursi & Galva o 2006). These data included details of study sample,

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Table 1 Study details and comparison groups

Study n Type of surgery Method of anaesthesia

Forced-air warming systems compared with passive insulation Scott et al. (2001) I = 163 C = 161 Major surgery General or regional Ng et al. (2003) I = 100 C = 100 RB = 100 Unilateral total knee replacement Not stated Vanni et al. (2003) I = 10 C = 10 Abdominal surgery General Fallis et al. (2006) I = 32 C = 30 Caesarean section Epidural Butwick et al. (2007) I = 15 C = 15 Caesarean section Spinal Forced-air warming systems compared with radiant warming systems Wong et al. (2004) I = 21 C = 21 Laparoscopic cholecystectomy General Lee et al. (2004) I = 30 C = 29 Surgery more than two hours duration (non-cardiac surgical) General Torrie et al. (2005) I = 32 C = 28 Transurethral resection of the prostate Spinal Forced-air warming systems compared with circulating water garment to carbon-bre Janicki et al. (2001) I = 28 C = 25 Open abdominal surgery General Janicki et al. (2002) I = 12 C = 12 Orthotopic liver transplantation General Nesher et al. (2005) I = 45 C = 45 Off-pump coronary artery bypass General Hofer et al. (2005) I = 30 C = 30 CF = 30 Off-pump coronary artery bypass General Zangrillo et al. (2006) I = 16 C = 15 Off-pump coronary artery bypass General Forced-air warming systems compared with circulating water mattress compared with carbon-bre resistive heating blanket Matsuzaki et al. (2003) I = 8 C = 8 CF = 8 Laparoscopic cholecystectomy General Negishi et al. (2003) I = 8 C = 8 CF = 8 Open abdominal surgery General Epidural Forced-air warming system (surgical site) compared with forced-air warming system (upper body) compared with circulating water mattress Ihn et al. (2008) I = 30 C = 30 IA = 30 Total abdominal hysterectomy General Forced-air warming systems compared with energy transfer pads Grocott et al. (2004) I = 15 C = 14 Off-pump coronary artery bypass General Forced-air warming system compared with forced-air warming systems Motamed et al. (2000) I = 13 C = 13 Abdominal surgery General Kabbara et al. (2002) I = 44 C = 39 Major surgery (any type, >20 minutes) General Forced-air warming systems + circulating water mattress plus passive warming compared with circulating water mattress + passive warming Insler et al. (2008) I = 27 C = 29 Cardiopulmonary bypass General Forced-air warming system compared with resistive carbon-bre warming system Fanelli et al. (2009) I = 28 C = 28 Total hip replacement Spinal Forced-air warming system compared with warm water and pulsating negative pressure Rein et al. (2007) I = 10 C = 10 Laparotomy for gastric surgery General Forced-air warming system compared with convective warming (WarmAir) Wagner et al. (2008) I = 102 C = 94 Major abdominal and orthopaedic surgery General I, intervention group; C, control group; RB, reective blanket; CF, carbon-bre resistive heating group; IA, forced-air warming system (surgical site).

selected because the measure (mean temperature) is meaningful in hypothermia, well-recognized as valid, and was the most common form of measurement across the studies. As a result of the likelihood of diversity between the trials, settings and populations, a random effects model was used to synthesize the data.

Results
Description of trials
The 23 trials (Table 1) varied widely in terms of interventions (11 groups) and surgical populations. The method of anaesthesia was mostly general anaesthetic (n = 16 trials), general or regional (n = 2 trials), epidural (n = 1 trial), spinal (n = 3
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trials) or not indicated (n = 1 trial). Core temperature was recorded in a number of sites, mostly oesophageal (n = 9 trials) or tympanic (n = 8 trials) sites. Sample sizes in the trials were a mean of 76 patients (n = 1749 total) and ranged from 16 (Motamed et al. 2000) to 324 participants (Scott et al. 2001). Overall methodological quality was moderate (19 trials, Jadad Score = 3); four trials were of moderate to low quality (Jadad Score = 2) (Table 2). It was not possible to test for publication bias because the number of trials for which outcomes could be synthesized was too small.

Pooled comparisons
Based on comparisons of nal temperatures with baseline temperatures, there was a strong trend for FWS to show

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Table 2 Methodological quality of included studies

Described as randomized Method of randomization described and appropriate Description of withdrawals or dropouts

Study

Jadad Score

Allocation concealment

Results

Forced-air warming systems compared with passive insulation Scott et al. (2001) Yes Yes Ng et al. (2003) Yes Yes

Yes Yes

3 3

Adequate Adequate Adequate Adequate Adequate Adequate Adequate Adequate Unclear Adequate Adequate Adequate

++ CWG vs. FWS ++ CWG vs. FWS ++CWG vs. FWS ++ FWS vs. CF ++ CWG vs. FWS, CF Zangrillo et al. (2006) Yes Yes Yes 3 Adequate ++ CWG vs. FWS Forced-air warming systems compared with circulating water mattress compared with carbon-bre resistive heating blanket Matsuzaki et al. (2003) Yes Yes Yes 3 Adequate 0 FWS vs. CF ++ FWS, CF vs. CW Negishi et al. (2003) Yes Yes Yes 3 Adequate 0 FWS vs. CF ++ FWS, CF vs. CW Forced-air warming system (surgical site) compared with forced-air warming system (upper body) compared with circulating water mattress Ihn et al. (2008) Yes Yes Yes 3 Unclear ++FWS vs. FWSA ++ FWS, FWSA vs. CW Forced-air warming systems compared with energy transfer pads Grocott et al. (2004) Yes No Yes 2 Unclear ++ ETP vs. FWS Forced-air warming system compared with forced-air warming systems Motamed et al. (2000) Yes Yes Yes 3 Adequate 0 FWS vs. FWS Kabbara et al. (2002) Yes Yes Yes 3 Adequate 0 FWS vs. FWS Forced-air warming systems + circulating water mattress plus passive warming compared with circulating water mattress + passive warming Insler et al. (2008) Yes Yes Yes 3 Adequate 0 FWSU/CW/ST vs. CW/ST Forced-air warming system compared with resistive carbon-bre warming system Fanelli et al. (2009) Yes Yes No 2 Adequate 0 FWS vs. RTU Forced-air warming system compared with warm water and pulsating negative pressure Rein et al. (2007) Yes Yes No 2 Unclear ++ WWP vs. FWS Forced-air warming system compared with convective warming (WarmAir) Wagner et al. (2008) Yes Yes Yes 3 Adequate 0 FWS vs. WA ++, statistically signicant difference; +, non-statistically signicant trend; 0, no statistically signicant difference; FWS, forced-air warming system; CB, cotton blanket; RB, reective blanket; RA, radiant warming; CWG, circulating water garment; CF, carbon-bre resistive heating; CW, circulating water mattress; FWSA, forced-air warming system with a surgical access blanket; ETP, energy transfer pads; FWSU, full-access underbody forced-air warming system; ST, steri-drape cardiovascular sheet; RTU, resistive carbon-bre (under blanket); WWP, warm water and pulsating negative pressure; WA, WarmAir system.

Vanni et al. (2003) Yes Yes Yes 3 Fallis et al. (2006) Yes Yes Yes 3 Butwick et al. (2007) Yes Yes Yes 3 Forced-air warming systems compared with radiant warming systems Wong et al. (2004) Yes Yes Yes 3 Lee et al. (2004) Yes Yes Yes 3 Torrie et al. (2005) Yes Yes Yes 3 Forced-air warming systems compared with circulating water garment to carbon-bre Janicki et al. (2001) Yes No Yes 2 Janicki et al. (2002) Yes Yes Yes 3 Nesher et al. (2005) Yes Yes Yes 3 Hofer et al. (2005) Yes Yes Yes 3

++ FWS vs. CB ++ FWS vs. CB ++ FWS vs. RB ++ FWS vs. CB 0 FWS vs. CB 0 FWS vs. CB 0 FWS vs. RA ++ FWS vs. RA ++ FWS vs. RA

superior temperature control over passive insulation via CB [mean difference: 029C; 95% condence interval (CI): 002 to 059, I2 = 80%; three trials 292 patients] and RW systems (mean difference: 016C; 95% CI: 001 to 033, I2 = 19%; three trials, 161 patients) (Figures 2 and 3). Both

results bordered on statistical signicance but showed clinically important differences in temperatures that strongly favoured maintenance of temperature. Evidence of high statistical heterogeneity in trials comparing FWS to passive insulation is unlikely to be related to differences in
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Study or Subgroup Ng 2003 Fallis 2006 Butwick 2007

Mean

FWS CB Mean difference SD Total Weight IV, Random, 95% CI Year SD Total Mean 051 [035, 067] 2003 010 [011, 031] 2006 020 [019, 059] 2007 029 [002, 059]

Mean difference IV, Random, 95% CI

001 05765 100 052 05467 100 390% 07 04 32 08 04583 30 356% 1 04359 15 254% 08 06245 15

147 145 1000% Total (95% CI) Heterogeneity: Tau = 005; Chi = 984, df = 2 (P = 0007); I = 80% Test for overall effect: Z = 186 (P = 006)

1 05 0 05 1 Favours CB Favours FWS

Figure 2 Pooled data for forced-air warming systems vs. passive warming (nal and baseline temperatures).

Study or Subgroup Wong 2004 Lee 2004 Torrie 2005

Mean

FWS RW Mean difference SD Total Mean SD Total Weight IV, Random, 95% CI Year 21 01 04583 29 07 05568 32 052 04359 21 341% 30 276% 28 383% 000 [026, 026] 2004 030 [000, 060] 2004 021 [003, 045] 2005 016 [001, 033] 1

Mean difference IV, Random, 95% CI

01 04 04 06 031 05196

Total (95% CI) 82 79 1000% Heterogeneity: Tau = 000; Chi = 248, df = 2 (P = 029); I = 19% Test for overall effect: Z = 189 (P = 006)

05 Favours RW

05

Favours FWS

Figure 3 Pooled data for forced-air warming systems vs. radiant warming (nal and baseline temperatures).

Study or Subgroup Janicki 2001 Janicki 2002 Nesher 2005 Zangrillo 2006

FWS CWG SD Total Mean SD Total Mean 05 03606 25 04 07211 28 01 12 003 04 12 01 09 04359 45 06 06614 45 07 07211 15 05 06245 16

Mean difference Weight IV, Random, 95% CI Year 251% 010 [040, 020] 2001 255% 013 [036, 010] 2002 255% 150 [173, 127] 2005 238% 120 [168, 072] 2006

Mean difference IV, Random, 95% CI

97 1000% Total (95% CI) 101 Heterogeneity: Tau = 061; Chi = 8821, df = 3 (P < 000001); I = 97% Test for overall effect: Z = 183 (P = 007)

073 [151, 005] 0 2 1 1 2 Favours CWG Favours FWS

Figure 4 Pooled data for forced-air warming systems vs. circulating water garments only (nal and baseline temperatures).

Study or Subgroup Janicki 2001 Janicki 2002

CWG FWS Mean SD Total Weight SD Total Mean 01 06557 28 01 03606 25 435% 12 001 01732 0 04 12 565%

Mean difference IV, Random, 95% CI Year 020 [048, 008] 2001 001 [026, 024] 2002 009 [028, 009]

Mean difference IV, Random, 95% CI

Total (95% CI) 40 37 1000% Heterogeneity: Tau = 000; Chi = 099, df = 1 (P = 032); I = 0% Test for overall effect: Z = 098 (P = 033)

05 0 1 1 05 Favours CWG Favours FWS

Figure 5 Pooled data for forced-air warming systems vs. circulating water garments only (interim and baseline temperatures).

population, surgical procedures or temperature measurement because 2/3 trials included in this synthesis involved only female participants undergoing caesarean sections with temperature measurement undertaken in the oral cavity (Fallis et al. 2006, Butwick et al. 2007). Circulating water garments showed improved temperature control over FWS (mean difference: 073C; 95% CI: 151
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to 005, I2 = 97%; four trials, 198 patients) (Figure 4). In two trials temperatures were also recorded during surgery. A trend favouring CWG with no statistical hetereogeniety was evident using temperature recorded at the start of and during surgery, although the summative effect size on temperature was small (mean difference: 009C; 95% CI: 028 to 009, I2 = 0%; two trials, 77 patients) (Figure 5). There was

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FWS
Study or Subgroup Janicki 2001 Janicki 2002 Mean SD Total Mean 28 12 05 0755 003 04

CWG
04 03 009 01732 25 416% 12 584%

Mean difference
010 [020, 040] 2001 012 [037, 013] 2002 003 [024, 018]

Mean difference
IV, Random, 95% CI

SD Total Weight IV, Random, 95% CI Year

40 Total (95% CI) 37 1000% Heterogeneity: Tau = 000; Chi = 122, df = 1 (P = 027); I = 18% Test for overall effect: Z = 026 (P = 079)

1 05 0 05 Favours CWGFavours FWS

Figure 6 Pooled data for forced-air warming systems vs. circulating water garments only (interim and nal temperatures).

little evidence that temperature changes occurred in the period from the beginning to the end of surgery (mean difference: 003C; 95% CI: 024 to 018, I2 = 18%; two trials, 77 patients) (Figure 6).

Discussion
Based on components of this and a previous systematic review (Galva o et al. 2009), we conclude that while FWS offer superior insulation over passive systems, RW and CW, and are comparable with carbon-bre methods, strongest evidence exists to support the use of CWG. Conclusions based on trial comparisons were made based on indirect comparisons between the trials. While no trials examined CWG compared with passive insulation or to warming systems using radiant or CW, forced-air systems were all compared in trials with these methods and CWG were consistently superior in terms of temperature control to forced-air methods. The strengths of current evidence are the consistently moderate quality of the trials and the high degree of consistency of ndings in the groups. Sample size in the trials tended to vary, although this did not have an appreciable effect on outcomes. Our ability to synthesize outcomes was constrained by lack of data on incidence rates of hypothermia and lack of data (particularly standard deviation) for temperature. This reduced the number of trials for which outcomes could be pooled; both these factors should be measured in future studies. As with most meta-analyses, we focused on published data only and the possibility of publication bias could not be discounted because of the small number of trials identied. However, there was consistency between the ndings of this meta-analysis and a previous integrative review (Galva o et al. 2009). While ndings from the meta-analysis favouring CWG were very close to being statistically signicant, it is arguably more important that the condence intervals were relatively precise, the effect sizes were clinically signicant, and the ndings consistent (Borenstein et al. 2009). For example, the difference in temperature noted in

the CWG over FWS (073C) is important, given that only a 1C change from normothermic status indicates hypothermia. Moreover, ndings from the four trials from which ndings were synthesized were all in the same direction (Janicki et al. 2001, 2002, Nesher et al. 2005, Zangrillo et al. 2006). Notably, the more recent trials (Rein et al. 2007, Insler et al. 2008, Wagner et al. 2008, Fanelli et al. 2009) all concerned developing forced-air systems, whereas strongest evidence actually exists for CWG. This suggests that efforts would be best focused on further optimizing the effectiveness of CWG rather than FWS. One reason for this may be related to costs (Galva o et al. 2009); however, previous researchers have consistently failed to record costs related to purchasing and maintenance. Further research is needed to establish the costbenet ratio of the various warming techniques.

Implications for nursing

Maintaining a patient as normothermic in the operating room is important for nurses because it avoids hypothermia and its associated complications, and reduces costs associated with treatment of such adverse outcomes (Mahoney & Odom 1999, Kurz 2008, Association of periOperative Registered Nurses 2009). Nurses involved in decision-making about purchasing of systems should be aware that CWG offer the most effective means to avoid hypothermia. That said, FWS are more effective than methods other than CWG. The benets of all systems need to be considered in the light of initial and ongoing maintenance costs. Current data on costs remain scant and more research is needed to determine the total costs of competing systems. Those involved in purchasing warming systems should also consider whether particular types are supported by funding agencies. For example, CF systems are not supported by the Food and Drug Administration in the United States of America (Taguchi & Kurz 2005). The suitability of different methods for particular patient groups should also be considered. For example, although FWS are more effective than passive methods, RW and CW, they may be insufcient to maintain normothermic
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What is already known about this topic

Hypothermia is a common and serious complication of surgery of importance to nursing. Cutaneous warming systems are common and are used to prevent hypothermia during surgery by regulating and maintaining the patient temperature. Active warming systems appear to be more effective at maintaining patient temperature than passive warming systems.

should be considered in purchasing decisions for systems of different types, but there is currently insufcient knowledge to guide the costbenet element of decision-making.

Acknowledgements
Cristina Maria Galva o was supported by a scholarship from the Brazilian Council for Scientic and Technological Development. Alexander M Clark is supported by career investigator awards from Alberta Heritage Foundation for Medical Research and the Canadian Institutes for Health Research. University of Sa o Paulo supported the work via travel grants for the investigators.

What this paper adds

Circulating water garments are the most effective means of maintaining patient temperature and improve prevention of hypothermia. Forced-air warming systems are more effective than passive systems, more effective than radiant warming systems, and as effective as carbon-bre systems. More data are required on the relative purchasing and maintenance costs of warming systems.

Conict of interest
No conict of interest has been declared by the authors.

Author contributions
CMG, YL and AMC were responsible for the study conception and design; contributed to the data collection, analysis and interpretation and were responsible for the drafting, revising and approval of the manuscript. CMG and AMC obtained funding for the review.

Implications for practice and/or policy

Based on current evidence, circulating water garments offer best clinical performance in temperature regulation and should be the system used to prevent hypothermia. status in patients undergoing liver transplant or heart surgery, who are older or have multiple health problems (Kurz 2008).

References
Abelha F.J., Castro M.A., Neves A.M., Landeiro N.M. & Santos C.C. (2005) Hypothermia in a surgical intensive care unit. BMC Anesthesiology 5(7), 110. American Society of PeriAnesthesia Nurses (2001) Clinical Guideline for the prevention of unplanned perioperative hypothermia. Journal of PeriAnesthesia Nursing 16, 305314. Association of periOperative Registered Nurses (2009) Recommended practices for the prevention of unplanned perioperative hypothermia. In Perioperative Standards and Recommended Practices (Association of periOperative Registered Nurses, ed.), AORN, Denver, pp. 491504. Borenstein M., Hedges L.V., Higgins J.P.T. & Rothstein H.R. (2009) Introduction to Meta-Analysis. Wiley, Chichester, pp. 3450. Butwick A.J., Lipman S.S. & Carvalho B. (2007) Intraoperative forced-air-warming during cesarean delivery under spinal anesthesia does not prevent maternal hypothermia. Obstetric Anesthesiology 105, 14131419. Fallis W.M., Hamelin K., Symonds J. & Wang X. (2006) Maternal and newborn outcomes related to maternal warming during cesarean delivery. Journal of Obstetric, Gynecologic and Neonatal Nursing 35, 324331. Fanelli A., Danelli G., Ghisis D., Ortu A., Moschini E. & Fanelli G. (2009) The efficacy of resistive heating under-patient blanket versus a forced-air warming system: a randomized controlled trial. Anesthesia & Analgesia 108, 199201.

Conclusion
In the absence of data on the relative costs of the competing systems, CWG offer superior insulation to alternative systems, including various types of warming systems using forced-air, radiant and carbon-bre methods. Forced-air methods are more effective than passive insulation and systems using radiant and CW. There is potential for the effectiveness of forced-air systems to be improved via the use of surgical access blankets, but currently there is insufcient evidence to determine whether this will elevate effectiveness to that of CWG. There is an urgent need for rigorous data on the relative costs and benets of CWG and FWS. While CWG are likely to be more effective in reducing rates of hypothermia, it cannot be determined whether the cost-savings of reduced patient complications will outweigh the actual costs associated with the purchasing and maintaining the systems. Costs
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JAN: REVIEW PAPER Galva o C.M., Marck P.B., Sawada N.O. & Clark A.M. (2009) A systematic review of the effectiveness of cutaneous warming systems to prevent hypothermia. Journal of Clinical Nursing 18, 627 636. Grocott H.P., Mathew J.P., Carver E.H., Phillips-Bute B., Landolfo K.P. & Newman M.F. (2004) A randomized controlled trial of the Artic Sun temperature management sytem versus conventional methods for preventing hypothermia during off-pump cardiac surgery. Anesthesia & Analgesia 98, 298302. Higgins J.P.T. & Green S. (2006) Cochrane Handbook for Systematic Review of Interventions, Version 4.2.6. [Updated September 2006]. The Cochrane Collaboration, 2006. Retrieved from http:// www.cochrane.org/resources/handbook/index.htm on 5 February 2007.. Hofer C.K., Worn M., Tavakoli R., Sander L., Maloigne M., Klaghofer R. & Zollinger A. (2005) Influence of body core temperature on blood loss and transfusion requirements during offpump coronary artery bypass grafting: a comparison of 3 warming systems. The Journal of Thoracic and Cardiovascular Surgery 129, 838843. Ihn C.H., Joo J.D., Chung H.S., Choi J.W., Kim D.W., Jeon Y.S., Kim Y.S. & Choi W.Y. (2008) Comparison of three warming devices for the prevention of core hypothermia and pos-anesthesia shivering. The Journal of International Medical Research 36, 923 931. Insler S.R., Bakri M.H., Nageeb F., Mascha E., Mihaljevic T. & Sessler D.I. (2008) An evaluation of a full-acess underbody forcedair warming system during near-normothermic, on-pump cardiac surgery. Anesthesia & Analgesia 106, 746750. Jadad A.R., Moore R.A., Caroll D., Jenkinson C., Reynolds D.J.M., Gavaghan D.J. & McQuay H.J. (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Controlled Clinical Trials 17, 112. Janicki P.K., Higgins M.S., Janssen J., Johnson R.F. & Beattie C. (2001) Comparison of two different temperature maintenance strategies during open abdominal surgery. Anaesthesiology 95, 868874. Janicki P.K., Stoica C., Chapman W.C., Wright J.K., Walker G., Pai R., Walia A., Pretorius M. & Pinson C.W. (2002) Water warming garment versus forced-air system in prevention of intraoperative hypothermia during liver transplantation: a randomized controlled trial. BioMed Central Anaesthesiology 2, 15. Kabbara A., Goldlust S.A., Smith C.E., Hagen J.F. & Pinchak A.C. (2002) Randomized prospective comparison of forced-air warming using hospital blankets versus commercial blankets in surgical patients. Anaesthesiology 97, 338344. Kumar S., Wong P.F., Melling A.C. & Leaper D.J. (2005) Effects of perioperative hypothermia and warming in surgical practice. International Wound Journal 2, 193204. Kurz A. (2008) Thermal care in the perioperative period. Best Practice & Research Clinical Anaesthesiology 22, 3962. Lee L., Leslie K., Kayak E. & Myles P.S. (2004) Intraoperative patient warming using radiant warming or forced-air warming during long operations. Anaesthesia and Intensive Care 32, 358 361. Leslie K. & Sessler D.I. (2003) Perioperative hypothermia in the highrisk surgical patient. Best Practice & Research Clinical Anaesthesiology 17, 485498.

Effectiveness of cutaneous warming systems on temperature control Mahoney C.B. & Odom J. (1999) Maintaining intraoperative normothermia: a meta-analysis of outcomes with costs. American Association of Nurses Anesthetists Journal 67, 155164. Matsuzaki Y., Matsukawa T., Ohki K., Yamamoto Y., Nakamura M. & Oshibuchi T. (2003) Warming by resistive heating maintains perioperative normothermia as well as forced-air heating. British Journal of Anaesthesia 90, 689691. Motamed C., Labaille T., Le on O., Panzani J.P., Duvaldestin P.H. & Benhamou D. (2000) Core and thenar skin temperature variation during prolonged abdominal surgery: comparison of two sites of active forced-air warming. Acta Anaesthesiologica Scandinavica 44, 249254. Negishi C., Hasegawa K., Mukai S., Nakagawa F., Ozaki M. & Sessler D.I. (2003) Resistive-heating and forced-air warming are comparably effective. Anaesthesia & Analgesia 96, 16831687. Nesher N., Uretzky G., Insler S., Nataf P., Frolkis I., Pineaus E., Cantoni E., Bolotin G., Vardi M., Pevni D., Lev-Ran O., Sharony R. & Weinbroum A. (2005) Thermo-wrap technology preserves normothermia better than routine thermal care in patients undergoing off-pump coronary artery bypass and is associated with lower immune response and lesser myocardial damage. The Journal of Thoracic and Cardiovascular Surgery 129, 1371 1378. Ng S.F., Oo C.S., Loh K.H., Lim P.Y., Chan Y.H. & Ong B.C. (2003) A comparative study of three warming interventions to determine the most effective in maintaining perioperative normothermia. Anaesthesia & Analgesia 96, 171176. Polderman K.H. (2009) Mechanisms of action, physiological effects, and complications of hypothermia. Critical Care Medicine 37, S186S202. Rein E.B., Filtvedt M., Walloce L. & Raeder J.C. (2007) Hypothermia during laparotomy can be prevented by locally applied warm water and pulsating negative pressure. British Journal of Anesthesia 98, 331336. Scott E.M. & Buckland R. (2006) A systematic review of intraoperative warming to prevent postoperative complications. AORN Journal 83, 10901113. Scott E.M., Leaper D.J., Clark M. & Kelly P.J. (2001) Effects of warming therapy on pressure ulcers: a randomized trial. AORN Journal 73, 921938. Taguchi A. & Kurz A. (2005) Thermal management of the patient: where does the patient lose and/or gain temperature? Current Opinion in Anaesthesiology 18, 632639. Torrie J.J., Yip P. & Robinson E. (2005) Comparison of forced-air warming and radiant heating during transurethral prostatic resection under spinal anaesthesia. Anaesthesia and Intensive Care 33, 733738. Ursi E.S. & Galva o C.M. (2006) Perioperative prevention of skin injury: an integrative literature review. Latin American Journal of Nursing 14, 124131. Vanni S.M.D.A., Braz J.R.C., Mo dolo N.S.P., Amorim R.B. & Rodrigues G.R. (2003) Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anaesthesia and surgery. Journal of Clinical Anaesthesia 15, 119 125. Wagner V.D. (2006) Unplanned perioperative hypothermia and surgical complications: evidence for prevention. Perioperative Nursing Clinics 1, 267281.

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C.M. Galva o et al. Wagner K., Swanson E., Raymond C.J. & Smith C.E. (2008) Comparison of two convective warming systems during major abdominal and orthopedic surgery. Canadian Journal of Anesthesia 55, 358363. Wong A., Walker S. & Bradley M. (2004) Comparison of a radiant patient warming device with forced-air warming during laparoscopic cholecystectomy. Anaesthesia and Intensive Care 32, 9399. Zangrillo A., Pappalardo F., Talo G., Corno C., Landoni G., Scandroglio A.M., Rosica C. & Crescenzi C. (2006) Temperature management during off-pump coronary artery bypass graft surgery: a randomized clinical trial on the efficacy of a circulating water system versus a forced-air system. Journal of Cardiothoracic and Vascular Anesthesia 20, 788792.

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