Anaesthesia, 2007, 62, pages 605–608 doi:10.1111/j.1365-2044.2007.05021.

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APPARATUS
A randomised controlled trial of the electric heating pad vs
forced-air warming for preventing hypothermia during
laparotomy
K. K. Leung,1 A. Lai2 and A. Wu3
1 Resident, Department of Anaesthesia, United Christian Hospital, 2 Associate Consultant, 3 Consultant, Department
of Anaesthesia, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, People’s Republic of China

Summary
A randomised controlled trial was conducted to compare the efficacy of upper body forced-air
warming (Bair HuggerTM, Augustine Medical model 500 ⁄ OR, Prairie, MN) with that of an
electric heating pad (Operatherm 202, KanMed, Bromma, Sweden) for maintenance of intra-
operative body temperature in 60 patients undergoing laparotomy under general anaesthesia. The
nasopharyngeal temperature was recorded throughout the operative period. The mean (SD) final
temperatures were 36.2 (0.4) C with forced-air warming and 35.5 (1.0) C with electric heating
pad (p < 0.01). Upper body forced-air warming is more effective than the heating pad for
maintenance of body temperature during laparotomy.
. ......................................................................................................
Correspondence to: Dr Aaron Lai
E-mail: laikw2000@hotmail.com
Accepted: 5 January 2007

It is accepted practice to maintain body temperature electric heating pad. We hypothesised that the latter was
during surgery. The most commonly used method of as effective as forced-air warming for maintaining body
active warming is forced-air warming [1]. However, a temperature during laparotomy.
recent study showed that the Operatherm 202 electric
heating pad (KanMed, Bromma, Sweden) was as effective
Methods
as forced-air warming to maintain body temperature
during total knee replacement [2]. Unlike forced-air After approval by the hospital Ethics Committee, 60
warming, there is no consumable associated with use of patients were recruited. Inclusion criteria included age
the heating pad, so the latter is cheaper in long-term use. between 18 and 80 years, ASA physical status I–III and
For forced-air warming, the hose, the warming units and elective laparotomy. Exclusion criteria included preg-
even the brand new commercial blankets have been nancy, core temperature ‡ 37.5 C. Written informed
shown to be potential sources of nosocomial infection consent for the study was obtained from each patient.
[3–5]. The heating pad warming system, which comprises On the day of surgery, no premedication was given.
a control unit, an electric cable and a heating pad, has no Non-invasive blood pressure monitoring, electrocardio-
hidden space for bacterial colonisation and is theoretically graphy and pulse oximetry were applied. General anaes-
easier to clean. Hence, the risk of cross infection may be thesia was induced with an intravenous bolus of fentanyl
reduced. The heating pad has another theoretical advant- (1–2 lg.kg)1), propofol (2–2.5 mg.kg)1) and cisatracu-
age: it is placed beneath the patient. The surface area for rium (0.1 mg.kg)1). Tracheal intubation was performed
active warming is not limited during laparotomy as for when adequate neuromuscular blockade was achieved. A
forced-air warming [6]. We wished to determine whether nasopharyngeal temperature probe was inserted and its
the electric heating pad could be an alternative to forced- position secured. The first reading was recorded after
air warming during surgery. equilibration and body temperature recorded every 5 min
The aim of the current study was to compare upper until the end of anaesthesia. Anaesthesia was maintained
body forced-air warming and the Operatherm 202 with isoflurane (end-tidal concentration 0.5–1.0%) and

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Journal compilation  2007 The Association of Anaesthetists of Great Britain and Ireland 605
K. K. Leung et al. Æ Electric heating pad vs forced-air warming Anaesthesia, 2007, 62, pages 605–608
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nitrous oxide in 65–70% oxygen. Fresh gas flow was time of removal before emergence from general anaes-
kept at 1.5–2 l.min)1. Patients’ lungs were mechanically thesia), and surgery (from skin incision to last suture), the
ventilated to maintain an end-tidal concentration of volume of intravenous fluids given and the estimated
carbon dioxide between 4.6 and 5.3 kPa. Neuromuscular blood loss were recorded.
blockade was maintained with an intravenous bolus of Power analysis, assuming a clinically important differ-
cistracurium to achieve zero train-of-four. An intraven- ence of 0.3 C in final core temperature, suggested that
ous morphine bolus was given according to the haemo- 28 patients were required in each group (a = 0.05;
dynamic response to surgical stimulation. Blood loss was b = 0.2; SD = 0.4 C). Comparisons of normally distri-
replaced with crystalloid, colloid or packed red cells, buted data were made using the unpaired two-tailed
according to estimated blood loss. All intravenous fluids t-test. Comparisons of nominal data were made using the
were warmed to 37 C with an infusion warmer (BW Chi-squared test. Changes in nasopharyngeal temperature
485 l, Biegler GmBH, Mauerbach, Austria). At the last from control over time were compared with repeated
suture, inhalational anaesthetics were discontinued and measures ANOVA. A value for p < 0.05 was considered
the patients’ lungs were ventilated with 100% oxygen. statistically significant.
Residual neuromuscular blockade was reversed.
Patients were randomly allocated by drawing lots to
Results
receive active warming using upper body forced-air (Bair
HuggerTM, Augustine Medical model 500 ⁄ OR, Prairie, Patients’ characteristics and anaesthetic ⁄ surgical details
MN) or electric heating pad (Operatherm 202) systems. were similar in the two groups and are shown in Table 1.
For the forced-air group, the patients were positioned The final nasopharyngeal temperatures were 36.2 (0.4) C
supine with both arms extended. A cotton blanket was and 35.2 (1.0) C (p < 0.01) for the forced-air warming
folded once to make two layers in thickness, with the and heating pad groups, respectively (Table 2). Changes
forced-air warming blanket sandwiched between the two in nasopharyngeal temperatures over time are shown in
layers. It was then applied to cover the patient’s anterior Fig. 1. The repeated measures analysis confirmed that
chest and both arms. Warming was started after induction there was a significant difference in temperature change
of general anaesthesia and continued until the end of between the two groups (p < 0.01). Two patients in each
surgery. The forced-air warming unit temperature out- group experienced shivering in the postanaesthetic room.
put was set to 43 C. For the heating-pad group, the Fifteen patients in the forced-air warming group and 19
104 · 45 cm pad was placed on the operating table and a
pre-warmed gel pad was placed on top of it, as suggested Table 1 Characteristics and anaesthetic ⁄ surgical details of
by the manufacturer, covered in turn with a sheet. The patients warmed with either forced-air or heating-pad during
patient warming system was set to a temperature of 39 C laparotomy. Values are number (proportion) or mean (SD).
and warming started 10 min before patients were trans- There were no significant differences between two groups.
ferred to the operating table. The patient then lay on the
hospital bed sheet and a double-folded cotton blanket was Forced-air Heating-pad
(n = 30) (n = 30)
applied to cover the anterior chest and both arms, as for
the forced-air group. Warming was stopped at any time Sex; M : F 19 : 11 20 : 10
when the nasopharyngeal temperature was > 37 C. Age; year 66.1 (10.0) 64.1 (12.0)
The ambient temperature of the operating rooms and Body mass index; kg.m)2 22.5 (3.6) 23.1 (3.2)
First nasopharyngeal temperature; 36.4 (0.4) 36.5 (0.4)
of the postanaesthetic room was thermostatically adjusted C
to 20 ± 1 C by the engineering department of the Duration of anaesthesia; min 293 (113) 279 (150)
hospital. These temperatures were recorded every 5 min Duration of surgery; min 271 (113) 258 (148)
Time from anaesthesia ready to 8.9 (3.4) 7.2 (3.2)
by a thermometer positioned level with and not further skin incision; min
than 50 cm from the patient. A verbal analogue score Estimated blood loss; ml 617.1 (521.0) 509.6 (497.3)
(VAS) for thermal comfort (0 – extremely cold, 5 – Volume of intravenous fluids; ml
Crystalloid 3380 (1722.1) 2850 (1712.4)
thermally neutral, 10 – extremely hot) was obtained on Colloid 93.3 (254.5) 50 (159.2)
arrival in the postanaesthetic room. The presence of Packed red blood cells 100 (276.7) 50 (159.2)
shivering in the postanaesthetic room was recorded. All Types of surgery
Pancreatic surgery 5 (16.7%) 3 (10.0%)
patients were given a forced-air warming blanket in the Gastric surgery 10 (33.3%) 6 (20.0%)
postanaesthetic room if the core temperature was < 36 C Hepatobiliary 9 (30.0%) 10 (33.3%)
or shivering occurred. Colectomy 4 (13.3%) 9 (30.0%)
Abdominal aortic aneurysm 1 (3.3%) 2 (6.7%)
The duration of anaesthesia (from the time the Cystectomy 1 (3.3%) 0
nasopharyngeal temperature probe was inserted to the

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606 Journal compilation  2007 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2007, 62, pages 605–608
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Table 2 Final nasopharyngeal temperature and verbal analogue
score (VAS) for thermal discomfort in patients warmed with
either forced-air or heating-pad during laparotomy. Values are
mean (SD).
Final nasopharyngeal temperature; C*
Mean ambient temperature; C
VAS in postanaesthestic room; mm
*p < 0.01.
patients in the heating pad group had a final temperature
below 36 C. These patients received forced-air warming
in the postanaesthetic room as per protocol.
Discussion
The current study showed that forced-air warming was
more effective than the heating pad for maintaining body
temperature during laparotomy.
There was a rapid initial drop of nasopharyngeal
temperature of 0.45 (0.5) C in the forced-air group
and of 0.47 (0.5) C in the heating pad group within
the first 10 min. It corresponded to the time of skin
incision and exposure of internal body cavities to the
cold environment of the operating theatre. Subse-
quently, the mean temperature gradually dropped in the
forced-air group from 36.4 (0.4) C to 35.7 (0.4) C in
60 min and in the heating pad group from 36.5
Figure 1 Nasopharyngeal temperature
in patients warmed with either forced-
air or heating pad during laparotomy.
Values are mean (95% CI). Time 0
refers to the first nasopharyngeal tem-
perature after insertion and equilibration
of the temperature probe. Error
bars = 95% Cl.
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Journal compilation  2007 The Association of Anaesthetists of Great Britain and Ireland
K. K. Leung et al. Æ Electric heating pad vs forced-air warming
(0.4) C to 35.6 (0.5) C at 75 min into surgery. This
initial drop in body temperature was due to the core-
to-periphery heat redistribution and is known to be
difficult to treat [7].
Forced-air Heating-pad
The mean nasopharyngeal temperature increased
(n = 30) (n = 30) gradually after 60 min and approached the initial tem-
perature of 36.4 (0.4) C at 320 min in the forced-air
36.2 (0.4) 35.2 (1.0) warming group. However, in the heating pad group, the
22.1 (2.9) 21.1 (0.7)
5.05 (0.8) 4.96 (0.2)
mean temperature dropped from 36.5 (0.4) C to 35.6
(0.5) C at 75 min and then more slowly to 35.1 (0.7) C
at 275 min into surgery. It remained more than 1 C
below the initial temperature during the rest of the
surgery.
In a recent study [2], the heating pad was shown to be
as effective as the forced-air warming device for main-
taining body temperature during total knee replacement.
The discrepancy could be explained by the type of
surgery involved in the two studies. Heat loss is greater
during laparotomy than total knee replacement because
the large surface of the intestine was exposed to the
relatively cold environment of the operation theatre [8].
It has been shown that during open abdominal surgery
without active warming, body temperature could reach
below 36.0 C in 50–70% of patients and below 35.0 C
in up to one-third of patients [9]. This could explain the
greater drop of nasopharyngeal temperature in both
groups of patients in the current study compared with
those patients undergoing total knee replacement. It
could also account for the observation that the body
temperatures did not reach their nadir until about 60 min
Group
Forced-air warming Heating pad
37.0
36.5
Mean temperature
36.0
35.5
35.0
34.5
0 40 80 130 170 210 250 270 290 320 340 0 40 80 130 170 210 250 270 290 320 340
20 60 100 150 190 230 260 280 300 330 20 60 100 150 190 230 260 280 300 330
Time (min)
607
K. K. Leung et al. Æ Electric heating pad vs forced-air warming Anaesthesia, 2007, 62, pages 605–608
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into surgery in the current study compared with 30 min References

in the previous study. Other factors to be considered were 1 Sessler DI. Mild perioperative hypothermia. New England
the longer duration and the larger volume of fluid shift Journal of Medicine 1997; 336: 1703–7.
involved during laparotomy compared with total knee 2 Ng V, Lai A, Ho V. Comparison of forced-air warming and
replacement. electric heating pad for maintenance of body temperature
The theoretical advantage of the heating pad cannot during total knee replacement. Anaesthesia 2006; 61: 1100–
be translated into a clinical advantage. The relative surface 4.
area available for warming by the two devices was 3 Avidan MS, Jones N, Ing R, Khoosal M, Lundgren C,
apparently of less importance in the clinical situation. The Morrell DF. Convection warmers – not just hot air.
heating pad used was 104 cm long and 45 cm wide, Anaesthesia 1997; 52: 1073–6.
which should result in the entire back of the patient being 4 Sigg DC, Houlton AJ, Iaizzo PA. The potential for increased
risk of infection due to the reuse of convective air-warm-
warmed by the pad, whereas the upper body forced-air
ing ⁄ cooling coverlets. Acta Anaesthesiologica Scandinavica
warming blanket only covered the anterior chest and both 1999; 43: 173–6.
arms. The heat transfer by the heating pad may be limited 5 Baker N, King D, Smith EG. Infection control hazards of
by the poor perfusion in the dependent areas. In addition, intraoperative forced air warming. Journal of Hospital Infection
little heat is lost from the back of patients into the foam 2002; 51: 153–4.
insulation covering the operating tables in both groups. 6 Tuckey J. Forced-air warming blanket and surgical access.
There are limitations to our study. Firstly, there was no Anaesthesia 1999; 54: 97–8.
control group (no active warming) to compare with the 7 Hynson JM, Sessler DI. Intraoperative warming therapies: a
two warming strategies. However, we believe that active comparison of three devices. Journal of Clinical Anesthesia
warming was achieved in both groups as the core 1992; 4: 194–9.
temperatures, after the drop of 1–1.5 C during the first 8 Bock M, Muller J, Bach A, Bohrer H, Martin E, Motsch J.
Effects of preinduction and intraoperative warming during
hour of anaesthesia, would otherwise be expected to
major laparotomy. Bristish Journal of Anaesthesia 1998; 80:
decrease further for another 2–3 h [10]. Secondly, the 159–63.
output settings were higher in the forced-air group. 9 Frank SM, Higgins MS, Breslow MJ, et al. The cate-
However, the settings chosen were the maximum output cholamine, cortisol and hemodynamic responses to mild
of the respective equipment and as per the manufacturers’ perioperative hypothermia: a randomized clinical trial.
recommendation. The maximum energy output of the Anesthesiology 1995; 82: 83–93.
heating pad may also be limited to prevent the well- 10 Matsukawa T, Sessler DI, Sessler AM, et al. Heat flow
documented pressure ⁄ heat necrosis [11]. However, com- and distribution during induction of general anesthesia.
pared with the previous study [2], a number of surgical Anesthesiology 1995; 82: 662–73.
procedures were included in the current study. We 11 Crino MH, Nagel EL. Thermal burns caused by warming
believe that our results can be more reliably extrapolated blankets in the operating room. Anesthesiology 1968; 29:
149–51.
to other types of surgery in general.
In conclusion, upper body forced-air warming is more
effective than the heating pad for maintaining body
temperature intra-operatively.

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608 Journal compilation  2007 The Association of Anaesthetists of Great Britain and Ireland