MEDISAINS - VOL. 19 NO.

2 (2021) 29-34

Original Article

Heating pad vs. infusion warmer to prevent hypothermia in intraoperative

patients: which one is more effective?
I Gede Eka Arinjaya 1,2, I Gede Putu Darma Suyasa 2, I Made Rismawan 2, Agus Baratha
Suyasa 2
1
Central Surgical Department, Sanjiwani General Hospital of Gianyar Regency, Bali, Indonesia
2
Faculty of Health, Institute of Technology and Health Bali, Bali, Indonesia

ARTICLE INFORMATION AB S T R AC T

Background: The use of heating pads and infusion warmers on intraoperative

Received: July 22, 2021 patients has been proven to prevent hypothermia. However, the differences in
Revised: August 25, 2021 the effectiveness of the two methods have not been studied.
Available online: September 06, 2021 Purpose: This study aims to compare the effectiveness of a heating pad and
infusion warmer in preventing hypothermia (decreased body temperature and
the incidence of shivering) in intraoperative patients.
KEYWORDS
Methods: This research was a quasi-experimental design by a Posttest-Only
Hypothermia; Shivering; Heating; Intraoperative Design with Nonequivalent Groups. The populations in this study were surgical
Period patients with regional anesthesia, with a total sample of 64 respondents (32 re-
spondents in the heating pad group and 32 respondents in the infusion warmer
group) selected randomly. The incidence of hypothermia was perceived from
CORRESPONDENCE two indicators: a decrease in body temperature and the prevalence of shivering,
which was observed and recorded during the intraoperative period. The data
Phone: +62 813-3729-4276 were analyzed by discrimination tests (mean discrimination test and proportion
E-mail: anabe4338@yahoo.co.id discrimination test) to determine the difference in the effectiveness of the two
groups.

Results: The average decrease in body temperature during the intraoperative

period (0-40 minutes of operation) in the group given the infusion warmer was
greater than the group given the heating pad (p<0.001). The group given the
infusion warmer was 8.750 times more likely to experience shivering than the
group given the heating pad (p<0.001; OR=8.750).

Conclusion: Using a heating pad is better in preventing hypothermia in in-

traoperative patients than using an infusion warmer.

INTRODUCTION to 40%, pain in the surgical wound due to shiver, interfere

with the interpretation of the monitoring result of oxygen
The prevalence of intraoperative hypothermia around the saturation, blood pressure, pulse rate, and electrocardio-
world varies between 44.3%-78.6%.1–3 While in Indonesia, gram so that it slows down the transfer of patients from the
the prevalence of hypothermia in postoperative patients recovery room to the inpatient room. Prevention of hypo-
also varies, yet several studies have found a rate above thermia during surgery can be done by two methods,
80%.4,5 Studies also found that around 5%-65% of cases namely non-pharmacological and pharmacological.7,8
of hypothermia are experienced by patients undergoing
general anesthesia and about 30%-57% experienced by The pharmacological approach is prepared by administer-
patients undergoing subarachnoid block regional anesthe- ing opioids, α2-agonist, anticholinergic, central nervous
sia.6 system stimulants, corticosteroids that can prevent and
treat shivering symptoms due to hypothermia.9 The non-
Hypothermia can cause discomfort to the patient during pharmacological approach is recognized as the rewarming
surgery and also can cause metabolic rate to increase up
https://doi.org/10.30595/medisains.v19i2.11034
©(2021) by the Medisains Journal. Readers may use this article as long as the work is properly cited, the use is educational and not for
profit, and the work is not altered. More information is available at Attribution-NonCommercial 4.0 International.
 I GEDE EKA ARINJAYA / MEDISAINS - VOL. 19 NO. 2 (2021) 29-34

technique, which consists of 3 parts, namely external pas- group (32 respondents),16,17 with the inclusion criteria of
sive, external activities, and internal active.6 patients undergoing urological surgery, obstetrics and gy-
necology surgery, general surgery and orthopedic surgery,
The passive heating method can be conducted by provid- aged 17-60 years old, ideal body weight, regional anesthe-
ing a cotton cloth blanket that aims to reduce direct expo- sia type (subarachnoid block) and maximum operating
sure to cold air and inhibit releasing body heat. The inter- time of 2 hours. Patients who experienced hypothermia
nal active heating method can be done by giving warm in- (body temperature <35.5°C) or hyperthermia (body tem-
travenous fluids, warm oxygen, peritoneal lavage, stom- perature >37.5°C) preoperatively were excluded from the
ach, colon, and mediastinum using warm irrigation fluids. study.
External active heating can be done by providing a warm
Experimental Procedure
blanket or electric blanket that produces a warm tempera-
ture, a heating pad or mattress, a heating lamp, a warm The instrument used in the heating pad group is the RoHS
humidifier, and an increased room temperature.6,10,11 brand model/type Tk-HP2412, which uses electrical sen-
sor technology to prevent overheating. Respondents use
Research on the use of electric heating pads and intrave- this tool during surgical procedures on the back and shoul-
nous fluids warmed with an Infusion warmer to prevent in- ders. The temperature setting at level 2 is in the range of
traoperative hypothermia has been done previously. The 37°C-39°C (Figure 1A). On the other hand, in the infusion
results presented that both the use of an electric heating warmer group, the intervention was carried out by admin-
pad and the administration of warm intravenous fluids istering 500cc of ringer lactate fluid intravenously during
were equally effective in preventing hypothermia. Previous the surgical procedure. The liquid is warmed with an Infu-
studies have found that using an electric heating pad is as sion Warmer at 37°C (Figure 1B).
effective as using forced-air warming in maintaining the
stability of the patient's intraoperative body temperature.12 The Variable, Instrument, and Measurement
In another study, it was revealed that the administration of The variable observed in this study was the prevalence of
warm fluid therapy and a heating blanket had an effect on hypothermia, which was perceived from two indicators;
increasing body temperature and preventing shivering in body temperature and the occurrence of shivering. Re-
postoperative patients in the recovery room compared to spondents' body temperature was measured using a digi-
the administration of fluids at room temperature.13,14 tal thermometer at the beginning of the operation or 0
minutes and during the operating period (10 minutes, 20
Based on the results of several previous studies, no stud- minutes, 30, and 40 minutes). The occurrence of shivering
ies directly distinguish the effectiveness of the usage of was also observed during the surgical period and recorded
electric heating pads and infusion warmer on surgical pa- on the data collecting sheet.
tients. Therefore, it is necessary to research to analyze the
usage effectiveness of an electric heating pad using an in- Data Analysis
fusion warmer to prevent hypothermia in intraoperative. Two discrimination tests of dual means and proportions
The purpose of this study was to compare the effective- were employed to determine the difference between the
ness of heating pads and infusion warmers in preventing two intervention groups in this study. Data with numerical
hypothermia with indicators of decreased body tempera- scale were tested using the Independent t-test, while the
ture and the prevalence of shivering in intraoperative pa- categorical data were tested using the chi-square.
tients.
Ethical Consideration
METHOD This research has received research ethics permit from the
Research Ethics Committee of Institut Teknologi dan
Study Design Kesehatan (ITEKES) Bali registration number
This research was a quasi-experimental research by Post- 04.0105/KEPITEKES-BALI/II/2021.
test-Only Design with Nonequivalent Groups.15
RESULTS
Settings and Respondents
The study was conducted at the Sanjiwani Hospital Gian- Respondents in both groups in the study were female, with
yar, Bali, Indonesia, in March-May 2021. The population in an average age range of 35.3 years in the heating pad
this study were all patients who undertook surgery at the group and 38.1 years in the Infusion Warmer group. The
Central Surgical Installation of the Sanjiwani Hospital type of surgery in both groups was dominated by obstetric
Gianyar, Bali. The sample in this study amounted to 64 re- surgery with a length of surgery between 45-115 minutes
spondents who were randomly divided into the heating (Table 1).
pad group (32 respondents) and the infusion warmer

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Figure 1. Heating Pads and Infusion Warming Devices

The average body temperature of patients in the Infusion The results of the analysis of the prevalence of shivering
Warmer group appeared to tend to decrease with time of demonstrated that the percentage of shivering was more
surgery, that was 36.0 0C at the beginning of the surgery, experienced in the Infusion Warmer group than in the
decreased to 35.5 0C at 10 minutes of surgery time, then Heating pad group, namely 64.2% vs. 36.4%). The analy-
decreased to 34.9 0C, 34.4 0C, and 33.9 0C at 20 minutes, sis results displayed a significant difference in the propor-
30 minutes, and 40 minutes of surgery time. On the other tion of shivering between the heating pad group and the
hand, the Heating Pad group tended to be more stable. infusion warmer group (p<0.0001). Administrating an infu-
The analysis results indicated a significant difference in sion warmer to surgery patients was 8,750 times more
body temperature decrease between the Heating Pad likely to experience shivering than those using a heating
group and the Infusion Warmer group during the operating pad (Table 2).
period (Figure 2).

Table 1. Characteristics of Respondents

Characteristics Heating Pad (n=32) Infusion Warmer (n=32)
Sex
Male 13 (40.6%) 11 (34.4%)
Female 19 (59.4%) 21 (65.6%)
Age, Years (Mean±SD; (Min-Max)) 35.3±13.1 (18-60) 38.1±12.6 (19-60)
Surgery Duration, Minutes (Mean±SD; (Min-Max)) 83.90±20.11 (45-115) 73.28±20.42 (45-115)
Surgery Types
Urology 6 (18.8%) 7 (21.9%)
Obgyn 15 (46.9%) 18 (56.3%)
Orthopedics 4 (12.5%) 3 (9.4%)
General surgery 7 (21.9%) 4 (12.5%)

Table 2. Differences in The Prevalence of Shivering in The Heating Pad and Infusion Warmer Groups
Group Shivering occurrence p-value OR
No Yes
Heating pad (n=32) 14 (63.6%) 8 (36.4%)
0.0001 8.750
Infusion Warmer (n=32) 7 (16.7%) 35 (64.2%)
Total 21 (32.8%) 43 (67.2%)

perature.18,19 Whereas shivering is a compensatory re-

DISCUSSION sponse of the body to increase heat production in a hypo-
thermic state.20
Hypothermia in patients undergoing surgery occurs due to
a combination of anesthesia and the surgery itself. The in- This study found that using a heating pad (as an external
teraction of the two can cause regulating body temperature warmer) during surgery can significantly prevent hypother-
mia compared to using an infusion warmer (as an internal
to be disturbed and cause a decrease in core body tem-
warmer) with the indicators of body temperature and the
prevalence of shivering. The higher average decrease in

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Figure 2. Differences in Body Temperature Decline During Surgery Between The

Heating Pad Group and The Infusion Warmer Group

body temperature occurred using an infusion warmer of tested on hypothermic subjects with the result that there is
2.1°C (from the beginning of the surgery to 40 minutes of a significant increase in total heat in respondents who ex-
surgery), while the decrease in average body temperature perience hypothermia.24 Other studies have also found the
with the use of a heating pad was 0.8°C. The results of the use of electric heating pads in patients undergoing Lapa-
analysis of the prevalence of shivering also exhibited that rotomy surgery. The average temperature can be main-
the prevalence of shivering was more experienced in the tained at 35.5°C.25
infusion warmer group than the heating pad group, which
was 64.2% compared to 36.4%, p<0.0001. Administering warm fluids through an infusion warmer can
result in changes in temperature in the blood vessels that
Using a heating pad as an external heating method in this thermoreceptors can directly detect in the hypothalamus.
study was better than using an infusion warmer as an in- The hypothalamus directly monitors the heat level in the
ternal heating method in preventing loss of body heat dur- blood flowing to the brain. The hypothalamus then stimu-
ing surgery. The results of this study were different from lates the vasomotor center resulting in vasodilation of
previous studies, which found that administering warm blood vessels which causes increased blood flow. The
fluid therapy (internal heating method) was better in in- high speed of blood flow causes the surface of the body to
creasing the body temperature of post-spinal anesthesia become warm. Previous studies have also found that
patients than using blankets as external warmers.13,21 warm infusion can prevent hypothermia in surgical pa-
tients.14,26
The heating pad device used in this study is an electric coil
inserted into a waterproof pad and covered by cotton or The ineffectiveness of using an infusion warmer compared
flannel. The pad is connected to an electric wire which has to a heating pad in the study may be caused by the insuf-
a regulator unit to regulate the temperature. This heat pad ficient device providing heat to the infusion fluid or be-
is powered by 30 watts of electricity, equipped with a circuit cause the number of infusion drops given to the patient is
breaker fuse and an automatic heat indicator light, making not constant (too fast or too slow), so that it affects the
it safe and efficient. The temperature on the heat pad process of heating the infusion fluid. At the beginning of
reaches 42°C. In comparison, the infusion warmer device the completion of anesthesia and during surgery, the fluid
used in this study is the one commonly used in hospitals. needs of each respondent are different. In the first 5
This device is used to warm intravenous fluids or blood minutes post-anesthesia, the patient is given a more rapid
during transfusion procedures to reduce the cold temper- drip infusion to meet the blood vessels' fluid needs. The
ature of fluids or blood that enters the patient's body. rapid drip causes much cold fluid to enter the respondent.
Even though this device has been warmed up to 36-37°C,
The external heating method can transfer warm tempera- the heat generated cannot be maintained in the infusion
tures to the core body temperature to affect the increase fluid. The study results also explained that the effective-
in peripheral temperature.22 The warm temperature result- ness of the provided heating was inversely proportional to
ing from using a heating pad will be responded to through the increase in the drip rate; the faster the infusion fluid,
the stimulation of skin nerve points. This stimulus will be the lower the heating of the fluid.27
sent to the hypothalamus to maintain an average body
temperature.23 Electric heating pads have also been

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CONCLUSIONS AND RECOMMENDATION 2013;4(1):36-42.

doi:https://doi.org/10.22219/jk.v4i1.2379
11. Shaw CA, Steelman VM, Deberg J, et al.
The use of heating pads in intraoperative patients is better
Effectiveness of active and passive warming for the
in preventing hypothermia compared to infusion warmers. prevention of inadvertent hypothermia in patients
Standard operating procedures to prevent intraoperative receiving neuraxial anesthesia: A systematic
hypothermia need to pay attention to the findings of this review and meta-analysis of randomized controlled
study. trials. J Clin Anesth. 2018;(1):93-104.
doi:10.1016/j.jclinane.2017.01.005.
12. Ng V, Lai A, Ho V. Comparison of forced-air
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