Effect of active warming during general anaesthesia on post-operative body temperature, shivering, thermal comfort, pain, nausea and vomiting in adult patients: a randomized clinical trials protocol


  • Özlem Şahin Akboğa Institute of Health Sciences, Department of Nursing, Marmara University, Turkey
  • Aysel Gürkan Faculty of Health Sciences, Department of Nursing, Marmara University, Turkey




General anesthesia, Hypothermia, Pain, Post-operative nausea and vomiting


Background: This study aims to investigate the effects of individual and combined use of intraoperative forced-air warming and warmed intravenous and irrigation fluids on post-operative body temperature, shivering, thermal comfort, pain, nausea and vomiting in adult patients receiving general anaesthesia.

Methods: This is a randomised controlled clinical trial. A 2x2 factorial design will used in the experiment. Eligible patients will be randomly assigned to one of four groups. We attempt to report this randomized controlled trial to comply with the spirit. The study population will consist of 120 adult patients receiving general anaesthesia at university hospitals in Turkey. After the induction of anaesthesia, the first group (n=30) will be warmed with only forced-air warming device, the second group (n=30) will receive only warmed intravenous and irrigation fluids, forced-air warming as well as warmed intravenous (IV) and irrigation fluids will be applied to the third group (n=30), the fourth group (n=30) will consist of the control group without any intervention. Blood and blood products to be applied intraoperatively to all groups will be heated to 37°C.

Conclusions: The primary outcome measures are post-operative body temperature, shivering, thermal comfort, pain, nausea and vomiting. The primary results will be subjected to a one-way analysis of variance for covariant such as amount of bleeding and volume of intraoperative fluids.

Trial registration: The trial has been registered in clinical trials: https://clinicaltrials.gov/. Registration number: NCT04907617).


Madrid E, Urrútia G, Roqué Figuls M, Pardo-Hernandez H, Campos JM, Paniagua P et al. Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults. Cochrane Database Systematic Rev. 2016:4:CD009016.

Torossian A, Bräuer A, Höcker J, Bein B, Wulf H, Horn EP. Clinical practice guideline: Preventing inadvertent perioperative hypothermia. Dtsch Arztebl Int. 2015;112:166-72.

Giuliano KK, Hendricks J. Inadvertent perioperative hypothermia: Current nursing knowledge. AORN J. 2017;105(5):453-63.

Bindu B, Bindra A, Rath G. Temperature management under general anesthesia: Compulsion or option. J Anaesthesiol Clin Pharmacol. 2017;33:306-16.

Anestezi T, Reanimasyon Derneği V, TARD. Anestezi uygulama klavuzları: İstenmeyen perioperatif hipoterminin önlenmesi rehberi. Turk J Anaesth Reanim. 2013;41:188-90.

Iden T, Höcker J. Prevention of Perioperative Hypothermia-Guidelines for Daily Clinical Practice. Anasthesiol Intensivmed Notfallmed Schmerzther. 2017;52:554-62.

Jeyadoss J, Thiruvenkatarajan V, Watts RW, Sullivan T, Van Wijk RM. Intraoperative hypothermia is associated with an increased intensive care unit length-of-stay in patients undergoing elective open abdominal aortic aneurysm surgery: A retrospective cohort study. Anaesth Intensive Care. 2013;41(6):759-64.

Lista F, Doherty CD, Backstein RM, Ahmad J. The impact of perioperative warming in an outpatient aesthetic surgery setting. Aesthet Surg J. 2012;32(5):613-20.

Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B et al. ASPAN's evidence-based clinical practice guideline for the promotion of perioperative normothermia: Second edition. J Perianesth Nurs. 2010;25(6):346-65.

Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety ıssues ıdentified by perioperative nurses. AORN J. 2013;97(4):402-18.

Association of periOperative Registered Nurses, (AORN). 2019. Available at: https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-tables. Accessed on 13 July 2021.

Su SF, Nieh HC. Efficacy of forced-air warming for preventing perioperative hypothermia and related complications in patients undergoing laparoscopic surgery: A randomized controlled trial. Int J Nurs Pract. 2018;24(5):e12660.

Aydın H, Şimşek T, Demiraran Y. Effects of ınadvertent perioperative hypothermia on metabolic and ınflammatory mediators. Turk J Anaesthesiol Reanim. 2019;47(6):448-55.

Riley C, Andrzejowski J. Inadvertent perioperative hypothermia. BJA Education. 2018;18(8): 227e233.

Campbell G, Alderson P, Smith AF, Wortting S. Warming of intravenous and irrigation fluids fr preventing inadvertent perioperative hypothermia. Cochrane Database Syst Rev. 2015;13(4):CD009891.

Choi JW, Kim DK, Lee SW, Park JB, Lee GH. Efficacy of intravenous fluid warming during goal-directed fluid therapy in patients undergoing laparoscopic colorectal surgery: A randomized controlled trial. J Int Med Res. 2016;44(3):605-12.

Kim YS, Lee JY, Yang SC, Song JH, Koh HS, Park WK. Comparative study of the influence of room-temperature and warmed fluid irrigation on body temperature in arthroscopic shoulder surgery. Arthroscopy: J Arthroscopic Related Sur. 2009;25(1):24-9.

Ayhan S, Ballı SS, Fırat AC, Kayhan Z. Spinal anestezi ile sezeyan ameliyatı uygulanan gebelerde hipotermi önlenebilir mi? J Anesthesia. 2018;26(4):238-44.

Benson EE, McMillan DE, Ong B. The effects of active warming on patient temperature and pain after total knee arthroplasty. Am J Nurs. 2012;112 (5):26-33.

Buggy DJ, Crossley AW. Thermoregulation, mild perioperative hypothermia and post-anaesthetic shivering. Br Journal Anaesth. 2000;84:615-28.

Lopez MB. Postanaesthetic shivering- from pathophysiology to prevention. Rom J Anaesthesia Intensive Care. 2018;25(1):73-81.

Sessler DI, Rubinstein EH, Moayeri A. Physiologic responses to mild perianesthetic hypothermia in humans. Anesthesiology. 1991;75:594-610.

Kim D. Postoperative Hypothermia. Acute Crit Care. 2019;34(1):79-80.

Mohammadi SS, Jabbarzadeh S, Movafegh A. Efficacy of granisetron on prevention of shivering, nausea and vomiting during cesarean delivery under spinal anesthesia: A randomized double-blinded clinical trial. J Obstetr Anaesthes Cri Care. 2015;5(1):22-6.

Nalivaiko E. Thermoregulation and nausea. Handb Clin Neurol. 2018;156:445-56.

De Boer HD, Detriche O, Forget P. Opioid-related side effects: Postoperative ileus, urinary retention, nausea and vomiting, and shivering. Best Pract Res Clin Anaesthesiol. 2017;31(4):499-504.

Sessler DI. Perioperative Thermoregulation and heat balance. Lancet. 2016;25,387 (10038):2655-64.

Su SF, Nieh HC. Efficacy of forced-air warming for preventing perioperative hypothermia and related complications in patients undergoing laparoscopic surgery: A randomized controlled trial. Int J Nurs Pract. 2018;24(5):e12660.

Fanelli A, Danelli G, Ghisi D, Ortu A, Moschini E, Fanelli G. The efficacy of a resistive heating under-patient blanket versus a forced-air warming system: A randomized controlled trial. Anesthesia Analgesia. 2009;108(1):199-201.

Duff J, Di Staso R, Cobbe KA, Draper N, Tan S, Halliday E et al. Preventing hypothermia in elective arthroscopic shoulder surgery patients: A protocol for a randomised controlled trial. BMC surgery. 2012;12(1):1-6.

Boutron I, Guittet L, Estellat C, Moher D, Hróbjartsson A, Ravaud P. Reporting methods of blinding in randomized trials assessing nonpharmacological treatments. PLoS Med. 2007;4(2):e61.

National Institute for Health and Clinical Excellence. NİCE. Inadvertent perioperative hypothermia overview, 2021. Available at: https://pathways.nice. org.uk/pathways/inadvertent-perioperative-hypothermia#path=view%3A/ pathways/inadvertent-perioperative-hypothermia/inadvertent-perioperative-hypothermia-overview.xml&content=view-node%3 Anodes-intraoperative-phase. Accessed on 13 July 2021.

Cobb B, Cho Y, Hilton G, Ting V, Carvalho B. Active warming utilizing combined IV fluid and forced-air warming decreases hypothermia and improves maternal comfort during cesarean delivery: A randomized control trial. Anesth Analg. 2016;122:1490-7.

Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, et al. Metabolic impact of shivering during therapeutic temperature modulation: The Bedside Shivering Assessment Scale. Stroke. 2008;39(12):3242-7.

Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T et al. Guidelines on the management of postoperative pain. J Pain. 2016;17(2):131-57.

Odejobi YO, Maneewat K, Chittithavorn V. Nurse-led post-thoracic surgery pain management programme: İts outcomes in a Nigerian Hospital. Int Nurs Rev. 2019;66(3);434-41.

Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg. 1970;49(6): 924-34.

Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth. 1995;7:89-91.

Bender M, Self B, Schroeder E, Giap B. Comparing new-technology passive warming versus traditional passive warming methods for optimizing perioperative body core temperature. AORN J. 2015;102(2):183.e1-8.