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Prevention of hypothermia in newborn submitted to surgical procedures: an integrative review

Prevención de la hipotermia en recién nacido procedimientos quirúrgicos: revisión integrative

ABSTRACT

Objective:

to discuss in the scientific literature the strategies used to prevent hypothermia in newborns undergoing surgical procedures.

Methods

this is an integrative literature review, with structured search in April and May 2020 in 08 databases, using the descriptors: Hypothermia; Surgical Procedures, Operative; Infant, Newborn; Protocols. Four primary studies were selected and analyzed using three instruments to assess the methodological quality of the Joanna Briggs Institute and content analysis.

Results:

Among the strategies used, the following stand out: room temperature control; establishment of humidification and quality of air conditioning cleanliness; use of a heated incubator or cradle; use of thermal mattress; use of caps and blanket; heated fluids; temperature monitoring and abdominal organ coverage.

Conclusion

good hypothermia prevention strategies were identified, despite the small number of publications on this topic; thus, it points out the need for research with strong evidence.

Descriptors:
Infant, Newborn; Hypothermia; Surgical Procedures, Operative; Disease Prevention; Neonatal Nursing

RESUMEN

Objetivo:

discutir, en la literatura científica, las estrategias utilizadas para prevenir la hipotermia en recién nacidos sometidos a procedimientos quirúrgicos.

Métodos:

revisión integrativa de la literatura, con búsqueda estructurada en abril y mayo de 2020 en 08 bases de datos, utilizando los descriptores: Hypothermia; Surgical Procedures, Operative; Infant, Newborn; Protocols. Se seleccionaron y analizaron cuatro estudios primarios utilizando tres instrumentos para evaluar la calidad metodológica del Instituto Joanna Briggs y el análisis de contenido.

Resultados:

entre las estrategias empleadas destacan: control de la temperatura ambiente; establecimiento de humidificación y calidad de aire acondicionado limpio; uso de una incubadora o cuna con calefacción; uso de colchón térmico; uso de gorros y mantas; fluidos calentados; monitoreo de temperatura; cobertura de órganos abdominales.

Conclusión:

se identificaron buenas estrategias de prevención de la hipotermia, a pesar del escaso número de publicaciones sobre este tema; por lo tanto, señala la necesidad de realizar investigaciones con evidencia sólida.

Descriptores:
Recién Nacido; Hipotermia; Procedimientos Quirúrgicos Operativos; Prevención de Enfermedades; Enfermería Neonatal

RESUMO

Objetivo:

discutir, na literatura científica, as estratégias utilizadas para prevenção de hipotermia em recém-nascido submetido a procedimentos cirúrgicos.

Métodos:

revisão integrativa de literatura, com busca estruturada em abril e maio de 2020 em 08 bases de dados, utilizando os descritores: Hypothermia; Surgical Procedures, Operative; Infant, Newborn; Protocols. Foram selecionados e analisados 04 estudos primários por meio de três instrumentos para avaliação da qualidade metodológica da Joanna Briggs Institute e da análise de conteúdo.

Resultados:

dentre as estratégias utilizadas destaca-se: controle da temperatura ambiente; estabelecimento de umidificação e qualidade de limpeza do ar condicionado; utilização de incubadora ou berço aquecido; uso de colchão térmico; uso de toucas e cobertor; fluidos aquecidos; monitoramento da temperatura; cobertura de órgãos abdominais.

Conclusão:

identificaram-se boas estratégias de prevenção de hipotermia, apesar de haver um número reduzido de publicações nesta temática; dessa forma, aponta-se a necessidade de pesquisas com evidências fortes.

Descritores:
Recém-Nascido; Hipotermia; Procedimento Cirúrgico; Prevenção; Enfermagem Neonatal.

INTRODUCTION

Inadvertent hypothermia in a surgical procedure is a problem for patients worldwide and is associated with harmful side effects(11 Munday J, Delaforce A, Forbes G, Keogh S. Barriers and enablers to the implementation of perioperative hypothermia prevention practices from the perspectives of the multidisciplinary team: a qualitative study using the Theoretical Domains Framework. J Multidiscip Healthc. 2019;12:395-417. https://doi.org/10.2147/JMDH.S209687
https://doi.org/10.2147/JMDH.S209687...
). In newborns (NBs), hypothermia is characterized by a reduction in body temperature reaching values below 36.5ºC(22 World Health Organization-WHO. Thermal protection of the newborn: a practical guide. In: Maternal and Newborn Health/Safe Motherhood Unit (WHO/RHT/MSM/97.2). Geneva: World Health Organization; 1997.). This is the result of an internal redistribution of body heat from the nucleus to the periphery, followed by heat loss greater than metabolic production(33 Sessler DI. Perioperative thermoregulation and heat balance. Lancet. 2016;25;387(10038):2655-64. https://doi.org/10.1016/S0140-6736(15)00981-2
https://doi.org/10.1016/S0140-6736(15)00...
).

In NBs, thermal control is in the maturation and adaptation phase, therefore, to maintain normothermia it is necessary to have a balance between the production and the elimination of heat(44 Albuquerque RS, Mariani Neto C, Bersusa AAS, Dias VM, Silva MIM. Newborns' temperature submitted to radiant heat and to the Top Maternal device at birth. Rev Latino-Am Enfermagem. 2016;24:e2741. https://doi.org/10.1590/1518-8345.0305.2741
https://doi.org/10.1590/1518-8345.0305.2...
). Ineffective thermoregulation is one of the main complications that affect NB, since hypothermia predisposes to metabolic disorders, respiratory distress, enterocolithenecrotizing and intracranial hemorrhage(55 Sousa DS, Sousa Jr AS, Santos ADR, Melo EV, Lima SO, Almeida-Santos MA, et al. Morbidade em recém-nascidos prematuros de extremo baixo peso em unidade de terapia intensiva neonatal. Rev Bras Saúde Matern Infant. 2017;17(1):139-47. https://doi.org/10.1590/1806-93042017000100008
https://doi.org/10.1590/1806-93042017000...
-66 Almeida MF, Guinsburg R, Sancho GA, Rosa IR, Lamy ZC, Martinez FE, et al. Hypothermia and early neonatal mortality in preterm infants. J Pediatr. 2014;164(2):271-5. https://doi.org/10.1016/j.jpeds.2013.09.049
https://doi.org/10.1016/j.jpeds.2013.09....
). The thermoregulatory mechanism is, therefore, considered a critical function for the survival of NBs(55 Sousa DS, Sousa Jr AS, Santos ADR, Melo EV, Lima SO, Almeida-Santos MA, et al. Morbidade em recém-nascidos prematuros de extremo baixo peso em unidade de terapia intensiva neonatal. Rev Bras Saúde Matern Infant. 2017;17(1):139-47. https://doi.org/10.1590/1806-93042017000100008
https://doi.org/10.1590/1806-93042017000...
-66 Almeida MF, Guinsburg R, Sancho GA, Rosa IR, Lamy ZC, Martinez FE, et al. Hypothermia and early neonatal mortality in preterm infants. J Pediatr. 2014;164(2):271-5. https://doi.org/10.1016/j.jpeds.2013.09.049
https://doi.org/10.1016/j.jpeds.2013.09....
).

Providing an environment that favors NB normothermia is a strong predictor of reduced morbidity and mortality at all gestational ages, being considered an indicator of quality of care(77 Perlman JM, Wyllie J, Kattwinkel J, Wyckoff MH, Aziz K, Guinsburg R, et al. Neonatal Resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2015;132(Suppl 1):S204-41. https://doi.org/10.1542/peds.2015-3373D
https://doi.org/10.1542/peds.2015-3373D...
), meeting the principles that guide patient safety strategies, which are defined as the absence of avoidable damage and the reduction of unnecessary risks associated with health care to an acceptable minimum, in order to reduce the occurrence of adverse events (AEs). AEs are characterized by incidents that result in unintentional damage to patient(88 World Health Organization (WHO). Patient safety: about us[Internet]. c2009-2018 [cited 2021 Mar 06]. Geneva: WHO; Available from: http:// www.who.int/patientsafety/about/en/
http:// www.who.int/patientsafety/about/...
-99 Wegner W, Silva MUM, Peres MA, Bandeira LE, Frantz E, Botene DZA, et al. Patient safety in the care of hospitalised children: evidence for paediatric nursing. Rev Gaúcha Enferm. 2017;38(1):e68020. https://doi.org/10.1590/1983- 1447.2017.01.68020
https://doi.org/10.1590/1983- 1447.2017....
), thus hypothermia in surgical NB is considered as an AE.

Accidental hypothermia is a frequent occurrence during neonatal surgery, which indicates the importance of developing evidence-based warming strategies for prevention(1010 Don Paul JM, Perkins EJ, Pereira-Fantini PM, Suka A, Farrell O, Gunn JK, et al. Surgery and magnetic resonance imaging increase the risk of hypothermia in infants. J Paediatr Child Health. 2018;54(4):426-31. https://doi.org/10.1111/jpc.13824
https://doi.org/10.1111/jpc.13824...
). NBs that present hypothermia in the intra and/or postoperative period will have a greater number of AEs when compared to normothermic ones(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
). In Canadian hospitals, it was found that there is a greater proportion of AE in surgical NBs when compared to clinical NBs(1212 Matlow AG, Baker GR, Flintoft V, Cochrane D, Coffey M, Cohen E, et al. Adverse events among children in Canadian hospitals: the Canadian Pediatric Adverse Events Study. CMAJ. 2012;184(13):E709-18. https://doi.org/10.1503/cmaj.112153
https://doi.org/10.1503/cmaj.112153...
).

A study reveals that AEs in relation to hypothermia in surgical patients constitutes a health problem and its incidence varies between 26% and 90%, with half of these events being preventable(1313 Bindu B, Bindra A, Rath G. Temperature management under general anesthesia: compulsion or option. J Anaesthesiol Clin Pharmacol. 2017;33(3):306-16. https://doi.org/10.4103/joacp.JOACP_334_16
https://doi.org/10.4103/joacp.JOACP_334_...
). Even though surgical treatment aims to save lives, security breaches and uncontrolled risks during surgical care can cause irreparable damage to patients(1414 Corona ARPD, Peniche ACG. A cultura de segurança do paciente na adesão ao protocolo da cirurgia segura. Rev SOBECC. 2015;20(3):179-85. https://doi.org/10.5327/Z1414-4425201500030009
https://doi.org/10.5327/Z1414-4425201500...
). Thus, it is necessary to have an accurate view of health professionals and, in particular, the nursing team, for prevention of hypothermia in surgical NBs(1515 Martins LA, Silveira SPX, Avila IMFT, Moraes JAS, Santos DSS, Whitaker COM, et al . Thermoregulation protocol implementation for newborns in surgical procedures. Rev Gaúcha Enferm. 2019;40(spe):e20180218. https://doi.org/10.1590/1983-1447.2019.20180218
https://doi.org/10.1590/1983-1447.2019.2...
).

In this sense, the need for studies that aim to: identify the procedures that predispose to perioperative hypothermia is highlighted; determine the relative value of quality improvement interventions; characterize the morbidity and mortality associated with perioperative hypothermia in neonatal patients(1616 Engorn BM, Kahntroff SL, Frank KM, Singh S, Harvey HA, Barkulis CT, et al. Perioperative hypothermia in neonatal intensive care unit patients: effectiveness of a thermoregulation intervention and associated risk factors. Paediatr Anaesth. 2017;27(2):196-204. https://doi.org/10.1111/pan.13047
https://doi.org/10.1111/pan.13047...
); seek new methods and care strategies for surgical NB, ensuring quality care, safe and free from risks and damage(1515 Martins LA, Silveira SPX, Avila IMFT, Moraes JAS, Santos DSS, Whitaker COM, et al . Thermoregulation protocol implementation for newborns in surgical procedures. Rev Gaúcha Enferm. 2019;40(spe):e20180218. https://doi.org/10.1590/1983-1447.2019.20180218
https://doi.org/10.1590/1983-1447.2019.2...
). There is still a high incidence of inadvertent hypothermia in the perioperative period(11 Munday J, Delaforce A, Forbes G, Keogh S. Barriers and enablers to the implementation of perioperative hypothermia prevention practices from the perspectives of the multidisciplinary team: a qualitative study using the Theoretical Domains Framework. J Multidiscip Healthc. 2019;12:395-417. https://doi.org/10.2147/JMDH.S209687
https://doi.org/10.2147/JMDH.S209687...
).

Given the above, the need for an integrative literature review emerged as a way to synthesize the national and international scientific evidence in this context of care for surgical NBs.

OBJECTIVE

To discuss in the scientific literature the strategies used to prevent hypothermia in newborns undergoing surgical procedures.

METHOD

Ethical aspects

The study respected national and international ethical principles, maintaining the ideas of the authors of the publications used in the development of this study.

Research design

This is an integrative literature review, a method that allows the broad analysis of a given subject, with deep knowledge about the proposed theme, allowing discussions about methods, results and conclusions from selected studies as well as reflections on conducting future studies(1717 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método e pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64. https://doi.org/10.1590/S0104-07072008000400018
https://doi.org/10.1590/S0104-0707200800...
).

The construction of this research was structured in five stages, according to the proposal of Whittemore and Knafl(1818 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-53. https://doi.org/10.1111/j.1365-2648.2005.03621.x
https://doi.org/10.1111/j.1365-2648.2005...
): elaboration of the research question and/or identification of objectives; literature search; data evaluation; analysis of studies; presentation of the integrative review results.

The Cumulative Index to Nursing & Allied Health Literature (CINAHL) and the National Library of Medicine (PubMed) databases were consulted. No systematic bibliographic research on the prevention of hypothermia in NBs submitted to surgical procedures was found, coupled with the absence of protocols and systematic review reports registered in the Joanna Briggs Institute (JBI) collections in the Prospective Register of Systematic Review (PROSPERO) and Cochrane Library.

Research question development

The question that guided the research was: what are the strategies used to prevent hypothermia in NBs submitted to surgical procedures? Its elaboration was based on the PICO strategy (Population; Intervention; Comparison; Outcomes)(1919 Santos CMC, Pimenta CAM, Nobre MRC. A estratégia PICO para a construção da pergunta de pesquisa e busca de evidências. Rev Latino-Am Enfermagem. 2007;15(3):508-11. https://doi.org/10.1590/S0104-11692007000300023
https://doi.org/10.1590/S0104-1169200700...
), being P- NB, submitted to surgical procedures, I - strategies used to prevent hypothermia, C - not applicable and O - prevention of hypothermia.

Literature search

Search for primary studies was carried out in April and May 2020 in the Scientific Electronic library online (SCIELO), Latin American and Caribbean Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE), National Library of Medicine (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase) and Web of Science databases. Google Scholar was also used, using the advanced search method. The descriptors were delimited according to the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS), being used: Hypothermia; Surgical Procedures, Operative; Infant, Newborn; Protocols. In the search strategy implemented for the crossing, the Boolean operator "AND" was used to associate the descriptors, as shown in Table 1.

Table 1
References found at the respective crossings (n=201), 2021

Original articles published in full and addressing the topics on strategies for prevention of hypothermia in surgical NB, methods of thermal control in surgical procedure, thermal control of the surgical environment for NB, technologies used in the prevention of hypothermia in surgical NB were included. There was no language restriction and initial investigation time limiting the final time to 2020, since there were no changes in the basic principles of thermal control over the years; however, new technological resources were added in order to qualify the care, thus enabling a breadth in the investigative process.

Gray literature (thesis, dissertation, monographs, books, protocols, manuals, among other non-indexed documents) and documents that did not answer the research question were excluded. After selecting the articles, they were submitted to the Mendeley bibliographic management tool, in order to exclude duplicate articles (n=14).

Data assessment

The investigation and selection of articles was carried out by 02 independent researchers, with the sequence of use of descriptors and crosses in each database being standardized. Then, results obtained and consensus among researchers were compared, so that each article was examined by title, abstract and full text, according to the inclusion and exclusion criteria established.

After selecting the articles, the researchers performed a critical assessment of methodological quality using three JBI instruments: JBI Critical Appraisal Checklist for Cohort Studies, JBI Critical Appraisal Checklist for Case Control Studies and JBI Critical Appraisal Checklist for Case Series(2020 Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Chapter 7: systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Manual for Evidence Synthesis. The Joanna Briggs Institute, 2020. https://doi.org/10.46658/JBIMES-20-08
https://doi.org/10.46658/JBIMES-20-08...
). The first assesses the methodological quality of cohort studies, the second, case-control, and the third, case series.

In these instruments, each question must be answered through four options: yes (Y), no (N), unclear (U) and not applicable (NA). The calculation of percentage of risk of bias and methodological quality is performed by the amount of "Y" selected in the checklist. Questions where the answers are "NA" are not included in the final calculation. The answers "N" and "U" do not score in the calculation. Studies with scores of up to 49% are considered to be at high risk of bias and low methodological quality; between 50% and 70%, the risk and methodological quality are moderate; above 70%, the risk of bias is low and the methodological quality is high.

The articles' level of evidence was assessed according to the classification model proposed by JBI(2121 Lizarondo L, Stern C, Carrier J, Godfrey C, Rieger K, Salmond S, et al. Chapter 8: Mixed methods systematic reviews. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Manual for Evidence Synthesis. The Joanna Briggs Institute, 2020. https://doi.org/10.46658/JBIMES-20-09
https://doi.org/10.46658/JBIMES-20-09...
). Considering that both cohort studies, as well as the case-control study have high methodological quality and low risk of bias, the evidence found is level III according to the JBI classification, being included in this review.

Data analysis

Critical analysis of the studies was based on content analysis(2222 Miles MB, Huberman M. Drawing valid meaning from qualitative data: toward a shared craft. Educational researcher, 1984.), in order to present the scientific evidence about the best practices used for prevention of hypothermia in NBs submitted to surgical procedures. The articles were read in a dynamic and cyclical back and forth process that allowed for data reduction, data presentation and verification of conclusions, thus enabling the visualization of four categories of analysis for the presentation of results(2222 Miles MB, Huberman M. Drawing valid meaning from qualitative data: toward a shared craft. Educational researcher, 1984.).

To present the studies included in the integrative review, the flowchart proposed by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes)(2323 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. Int J Surg. 2010;8(5):336-41. https://doi.org/10.1136/bmj.b2535
https://doi.org/10.1136/bmj.b2535...
) was used, as shown in Figure 1, as well as charts containing information on study characteristics, strategies, outcomes and recommendations.

Figure 1
Informative flowchart of integrative review phases anchored in PRISMA, 2021

RESULTS

After searching in database and according to established selection criteria, this integrative review included four articles(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
), which are presented in Chart 1. These were distributed in PubMed (2; 50%), followed by Embase (1; 25%) and MEDLINE (1; 25%) databases, published in the last 50 years, totaling as a sample 268 NBs submitted to surgical procedures.

Chart 1
Characteristics of articles, 2021
Chart 2
Assessment of methodological quality of articles through three Joanna Briggs Institute (JBI) instruments, 2021

The studies used methodologies with quantitative approaches, and the language of all articles was English, and the publications in medicine(2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
) and nursing(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
).

In assessing the articles' methodological quality, the scores ranged from 50% to 100% and all had the same level of evidence according to JBI.

The strategies, outcome and recommendations for hypothermia reduction presented in the selected articles are described in Chart 3. The main strategy in the prevention of hypothermia in surgical NB presented in the studies was thermal environment control in which surgery is performed(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
).

Chart 3
Strategies, outcome and recommendations of articles for reducing hypothermia, 2021

Other strategies for prevention of hypothermia in surgical procedures are also identified, namely: use of thermal mattress, chemical or heated blankets(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
-2525 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
); caps, overalls, and blankets(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
-2525 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
); use of a previously heated incubator or heated cradle(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
); infusion of heated fluids(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
); monitoring of body temperature in the axillary, nasopharyngeal, esophageal or rectal regions(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
); perioperative temperature measurement routines(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
); coverage of abdominal organs with wet and heated surgical compresses(2525 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
); establishment of relative air humidification(2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
,2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
); air conditioning cleaning quality(2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
) and heat lamps(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
).

The strategies used to prevent hypothermia in surgical NB are varied and can be categorized into: environment care(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
); NB care related to temperature monitoring and the use of technological equipment(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
); NB care related to preparing for surgery(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
,2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
); care related to the use of solutions, liquids, fluids and blood products(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
-2525 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
). It appears that hypothermia is a real and unresolved AE in the studies(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
)) analyzed. Thus, it points to the need for professionals involved in the care of surgical NB to rethink their practices and develop effective care protocols that stratify these data and develop actions that meet the clinical, environmental, structural and care demands in the prevention of hypothermia in surgical NB.

DISCUSSION

There is a shortage of literature that evaluates neonatal thermal care strategies(1010 Don Paul JM, Perkins EJ, Pereira-Fantini PM, Suka A, Farrell O, Gunn JK, et al. Surgery and magnetic resonance imaging increase the risk of hypothermia in infants. J Paediatr Child Health. 2018;54(4):426-31. https://doi.org/10.1111/jpc.13824
https://doi.org/10.1111/jpc.13824...
). This review also reveals that there is a reduced number of publications aimed at preventing hypothermia in NB undergoing a surgical procedure. The findings are concentrated in European and Asian countries and point to the need for research on this theme with strong evidence, outlined by methods of randomized clinical trials and cohort studies, since authors point out that the prevention of hypothermia is a critical determinant of neonatal morbidity and mortality(2727 Joseph RA, Derstine S, Killian M. Ideal site for skin temperature probe placement on infants in the NICU. Adv Neonatal Care. 2017;17(2):114-22. https://doi.org/10.1097/ANC.0000000000000369
https://doi.org/10.1097/ANC.000000000000...
).

Implementing practices based on scientific evidence results in a significant reduction of hypothermia in neonates and become a standard of care(2828 Yip WY, Quek BH, Fong MCW, Thilagamangai L, Ong SSG, Lim BL, et al. A quality improvement project to reduce hypothermia in preterm infants on admission to the neonatal intensive care unit. Int J Qual Health Care. 2017;29(7):922-8. https://doi.org/10.1093/intqhc/mzx131
https://doi.org/10.1093/intqhc/mzx131...
). This evidence is essential to support changes in care practices with NBs, allowing autonomy for multidisciplinary teams, supporting clinical practice, qualifying care safely and enabling innovation in the thermal control of NBs(2929 Lourenção DC, Tronchin DM. Patient safety in the surgical environment: translation and cross-cultural adaptation of validated instrument. Acta Paul Enferm. 2016;29(1):1-8. https://doi.org/10.1590/1982-0194201600002
https://doi.org/10.1590/1982-01942016000...
).

Establishing a neutral thermal environment is essential for prevention of hypothermia in the NBs that will undergo surgery, since it provides a reduced metabolic expenditure of heat loss, a minimum consumption of calories and oxygen, thus allowing temperature stability with the loss of heat equal to production(3030 Pinheiro JMB. Preventing hypothermia in preterm newborns: simple principles for a complicated task. J Pediatr. 2018;94(4):337-9. https://doi.org/10.1016/j.jped.2017.10.003
https://doi.org/10.1016/j.jped.2017.10.0...
).

Care with room temperature control was identified as the main concern in publications focused on the theme of neonatal thermal care(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
). Two articles(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
) compared the performance of a surgical procedure in different environments (Operating Room (OR) and Neonatal Intensive Care Unit (NICU)) and evaluated where there was a higher incidence of hypothermia in the NBs; another(2525 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
) analyzes the OR temperature and correlates it with small and large surgeries and, finally, investigates(2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
) the necessary strategies to provide the ideal surgical environment for maintaining normothermia in NBs. It is stipulated as thermal parameters of a neonatal operating room: room temperature with a variation of 22.7ºC to 28ºC(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,1515 Martins LA, Silveira SPX, Avila IMFT, Moraes JAS, Santos DSS, Whitaker COM, et al . Thermoregulation protocol implementation for newborns in surgical procedures. Rev Gaúcha Enferm. 2019;40(spe):e20180218. https://doi.org/10.1590/1983-1447.2019.20180218
https://doi.org/10.1590/1983-1447.2019.2...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
,3131 Trevisanuto D, Testoni D, Almeida MFB. Maintaining normothermia: why and how?. Semin Fetal Neonatal Med. 2018;23(5):333-9. https://doi.org/10.1016/j.siny.2018.03.009
https://doi.org/10.1016/j.siny.2018.03.0...
-3232 Meng-Meng T, Xue-Jun X, Xiao-Hong B. Clinical effects of warmed humidified carbon dioxide insufflation in infants undergoing major laparoscopic surgery. Medicine (Baltimore). 2019;98(27):e16151. https://doi.org/10.1097/MD.0000000000016151
https://doi.org/10.1097/MD.0000000000016...
), air humidity control between 32% and 62%(2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
,3232 Meng-Meng T, Xue-Jun X, Xiao-Hong B. Clinical effects of warmed humidified carbon dioxide insufflation in infants undergoing major laparoscopic surgery. Medicine (Baltimore). 2019;98(27):e16151. https://doi.org/10.1097/MD.0000000000016151
https://doi.org/10.1097/MD.0000000000016...
) and quality of air cleaning, based on the International Standardization Organization (ISO) 14644-1 with numerical classes(2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
).

Studies(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
) that compared surgical procedures in NICUs and OR identified that, in OR, the number of NBs that presented episodes of hypothermia was higher. The research(2525 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
) that analyzes the temperature management of the OR in small and large sized procedures found that NBs that undergo major surgery cannot maintain thermal stability as well as NBs that undergo minor surgery size in very cold rooms. In view of this evidence, the researchers point out the need to use exogenous sources of heat as well as other actions to provide normothermia for surgical NB. Another article(2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
) points out strategies and parameters for prevention of hypothermia in NB undergoing surgical procedures.

Scientific evidence also points to the use of equipment and accessories to provide an adequate environment and reduce NB heat losses, such as an incubator, heated cradle, thermal, chemical mattresses and heated blanket(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,1515 Martins LA, Silveira SPX, Avila IMFT, Moraes JAS, Santos DSS, Whitaker COM, et al . Thermoregulation protocol implementation for newborns in surgical procedures. Rev Gaúcha Enferm. 2019;40(spe):e20180218. https://doi.org/10.1590/1983-1447.2019.20180218
https://doi.org/10.1590/1983-1447.2019.2...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...

25 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar Z, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatr Anaesth. 2005;15(7):574-9. https://doi.org/10.1111/j.1460-9592.2005.01504.x
https://doi.org/10.1111/j.1460-9592.2005...
-2626 He ZR, Lin TI, Ko PJ, Tey SL, Yeh ML, Wu HY, et al. The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: a 10-year experience. Medicine (Baltimore). 2018;97(36):e12257. https://doi.org/10.1097/MD.0000000000012257
https://doi.org/10.1097/MD.0000000000012...
,3131 Trevisanuto D, Testoni D, Almeida MFB. Maintaining normothermia: why and how?. Semin Fetal Neonatal Med. 2018;23(5):333-9. https://doi.org/10.1016/j.siny.2018.03.009
https://doi.org/10.1016/j.siny.2018.03.0...
).

NB care related to temperature monitoring and the use of technological equipment such as the cradle with radiant heat and the heated and humidified incubators provide a neutral thermal environment for NBs. Thus, this equipment monitors NBs' temperature via a skin sensor, which needs to be positioned in the axillary or abdominal region so that more accurate and safe monitoring occurs, since these equipment use feedback mechanisms to determine the production of heat and maintain normothermia(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,1515 Martins LA, Silveira SPX, Avila IMFT, Moraes JAS, Santos DSS, Whitaker COM, et al . Thermoregulation protocol implementation for newborns in surgical procedures. Rev Gaúcha Enferm. 2019;40(spe):e20180218. https://doi.org/10.1590/1983-1447.2019.20180218
https://doi.org/10.1590/1983-1447.2019.2...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
,2727 Joseph RA, Derstine S, Killian M. Ideal site for skin temperature probe placement on infants in the NICU. Adv Neonatal Care. 2017;17(2):114-22. https://doi.org/10.1097/ANC.0000000000000369
https://doi.org/10.1097/ANC.000000000000...
).

Thermal mattress is another resource that has been widely used in the prevention of NB hypothermia, with an adjustment temperature between 37ºC and 42ºC(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
,1515 Martins LA, Silveira SPX, Avila IMFT, Moraes JAS, Santos DSS, Whitaker COM, et al . Thermoregulation protocol implementation for newborns in surgical procedures. Rev Gaúcha Enferm. 2019;40(spe):e20180218. https://doi.org/10.1590/1983-1447.2019.20180218
https://doi.org/10.1590/1983-1447.2019.2...
,2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
,2727 Joseph RA, Derstine S, Killian M. Ideal site for skin temperature probe placement on infants in the NICU. Adv Neonatal Care. 2017;17(2):114-22. https://doi.org/10.1097/ANC.0000000000000369
https://doi.org/10.1097/ANC.000000000000...
). This has shown satisfactory results and should be used during all operative procedures, regardless of the duration of the procedure(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
). In the situation where the body temperature reaches a value above 37ºC, it is recommended that temperature is reduced or the blanket is turned off to neutralize the NB temperature(2424 Tsingoglou S, Wilkinson AW. Heat loss during neonatal operations. Arch Dis Child. 1971;46:452. https://doi.org/10.1136/adc.46.248.452
https://doi.org/10.1136/adc.46.248.452...
).

Thermal blanket is an effective method to correct hypothermia, since it allows the central temperature to rise by about 0.75ºC in approximately one hour, being programmed with a temperature between 38º and 40ºC; if used previously for 30 minutes to the procedure, this temperature recovery can drop to 30 minutes(3333 Bernardis RCG, Silva MP, Gozzani JL, Pagnocca ML, Mathias LAST. Uso da manta térmica na prevenção da hipotermia intraoperatória. Rev Assoc Med Bras. 2009;55(4):421-6. https://doi.org/10.1590/S0104-42302009000400017
https://doi.org/10.1590/S0104-4230200900...
).

In Chinese hospitals, other strategies have been shown to be effective, namely: heated and humidified CO2 insufflation (35°C temperature and 95% relative humidity) in laparoscopic surgeries(3232 Meng-Meng T, Xue-Jun X, Xiao-Hong B. Clinical effects of warmed humidified carbon dioxide insufflation in infants undergoing major laparoscopic surgery. Medicine (Baltimore). 2019;98(27):e16151. https://doi.org/10.1097/MD.0000000000016151
https://doi.org/10.1097/MD.0000000000016...
); rewarming of children with postoperative hypothermia with the combination of an electric blanket and a forced air heating system(3434 Liu X, Shi Y, Ren C, Li X, Zhang Z. Effect of an electric blanket plus a forced-air warming system for children with postoperative hypothermia: a randomized controlled trial. Medicine (Baltimore). 2017;96(26):e7389. https://doi.org/10.1097/MD.0000000000007389
https://doi.org/10.1097/MD.0000000000007...
). These resources were associated with positive postoperative results, including less tremors and hypothermia, faster recovery of bowel movements and shorter hospital stay(3232 Meng-Meng T, Xue-Jun X, Xiao-Hong B. Clinical effects of warmed humidified carbon dioxide insufflation in infants undergoing major laparoscopic surgery. Medicine (Baltimore). 2019;98(27):e16151. https://doi.org/10.1097/MD.0000000000016151
https://doi.org/10.1097/MD.0000000000016...
).

A Brazilian study(1515 Martins LA, Silveira SPX, Avila IMFT, Moraes JAS, Santos DSS, Whitaker COM, et al . Thermoregulation protocol implementation for newborns in surgical procedures. Rev Gaúcha Enferm. 2019;40(spe):e20180218. https://doi.org/10.1590/1983-1447.2019.20180218
https://doi.org/10.1590/1983-1447.2019.2...
) points out actions used for thermal control similar to those identified in this review: i) keep NB involved in previously heated sweaters, when removing it from the incubator or heated cradle for transportation; ii) start the surgical procedure only when NBs present a normothermic state; iii) insert an esophageal thermometer before the surgical procedure for monitoring intraoperative temperature; iv) use a thermal blanket during major surgical procedures; v) monitor the temperature of NBs in the NICU after returning from the postoperative period, with a digital thermometer; vi) monitor the temperature of NBs at 15-minute intervals in situations that present a hyper or hypothermia chart; vii) administer solutions and blood products at an appropriate temperature. It should be noted that the fluids must be heated in thermoregulated greenhouses at an average temperature of 40º. Thus, when administered, infusions maintain a temperature between 37ºC and 38ºC(3535 Pereira NHC, Rocha AM, Mattia AL. Infusão venosa aquecida relacionada à prevenção das complicações da hipotermia intraoperatória. Rev SOBECC. 2014;19(2):74-8. https://doi.org/10.4322/sobecc.2014.013
https://doi.org/10.4322/sobecc.2014.013...
).

Regarding NB care related to the preparation for surgery and fluids, European research(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
)) recommends that, to prevent hypothermia in surgical NB, the orientation is: wearing a cap before and during surgery; transport must take place in a transport incubator preheated with the use of a chemical heating mattress; NICU heaters must be used intraoperatively within the OR parameters; intravenous fluids must be preheated; postoperatively, NBs must return to a preheated cradle or incubator(1111 Morehouse D, Williams L, Lloyd C, McCoy DS, Miller Walters E, Guzzetta CE, et al. Perioperative Hypothermia in NICU Infants. Adv Neonatal Care. 2014;14(3):154-64. https://doi.org/10.1097/ANC.0000000000000045
https://doi.org/10.1097/ANC.000000000000...
).

Another study(3636 Schroeck H, Lyden AK, Benedict WL, Ramachandran SK. Time trends and predictors of abnormal postoperative body temperature in infants transported to the intensive care unit. Anesthesiol Res Pract. 2016;2016:7318137. https://doi.org/10.1155/2016/7318137
https://doi.org/10.1155/2016/7318137...
) confirms the importance of using the thermal blanket and transport incubator in the transfer of NB between UTN and OR, since the use of these resources reduces neonatal hypothermia in the intraoperative period and presents significant improvements in obtaining postoperative normothermia in seriously ill neonates.

Among the surgical stages, the immediate preoperative period presents the highest risk of hypothermia, as NBs undergo clinical procedures and interventions, such as anesthetic induction, orotracheal intubation, venous access and soundings, which are usually performed with the exposed neonate and without an additional heat source. These actions predispose to heat loss and to reach the stabilization of body temperature it can take around 45 minutes(1010 Don Paul JM, Perkins EJ, Pereira-Fantini PM, Suka A, Farrell O, Gunn JK, et al. Surgery and magnetic resonance imaging increase the risk of hypothermia in infants. J Paediatr Child Health. 2018;54(4):426-31. https://doi.org/10.1111/jpc.13824
https://doi.org/10.1111/jpc.13824...
,3030 Pinheiro JMB. Preventing hypothermia in preterm newborns: simple principles for a complicated task. J Pediatr. 2018;94(4):337-9. https://doi.org/10.1016/j.jped.2017.10.003
https://doi.org/10.1016/j.jped.2017.10.0...
). It is noteworthy that, in these situations, the intervention of health professionals, especially nurses, is necessary, adjusting the heated incubator/cradle parameters and implementing actions to reduce heat losses, such as the use of thermal bags and mattresses(3030 Pinheiro JMB. Preventing hypothermia in preterm newborns: simple principles for a complicated task. J Pediatr. 2018;94(4):337-9. https://doi.org/10.1016/j.jped.2017.10.003
https://doi.org/10.1016/j.jped.2017.10.0...
).

In NB, homeothermic control is imperfect, since it has the ability to overheat and cool quickly and has an inability to conserve heat when exposed to thermal stress(3737 Pimenta PCO, Alves VH. Interhospital transport of the high-risk newborn: a challenge for the nursing staff. Cogitare Enferm. 2016;21(esp):01-09. https://doi.org/10.5380/ce.v21i5.45047
https://doi.org/10.5380/ce.v21i5.45047...
). To achieve improved thermal control, in surgical NB, it is necessary to apply basic thermodynamic principles - reducing heat loss and providing a combination of radiant and conductive heat. Thus, thermal control of neonates must be individualized, continuously monitored with a skin temperature probe throughout hospitalization and associated with continuous monitoring of data on quality of care improvements(3838 Caldas JP, Millen FC, Camargo JF, Castro PA, Camilo AL, Marba ST. Effectiveness of a measure program to prevent admission hypothermia in very low-birth weight preterm infants. J Pediatr. 2018;94:368-73. https://doi.org/10.1016/j.jped.2017.06.016
https://doi.org/10.1016/j.jped.2017.06.0...
).

Nursing care is necessary and essential for the recovery of NB, which is dependent on fundamental care for the promotion of a thermal environment capable of ensuring its survival, as well as adequate growth and development. Thus, health professionals, and especially nursing, need to be aware of the thermoregulation mechanisms to help NBs achieve thermal neutrality(3737 Pimenta PCO, Alves VH. Interhospital transport of the high-risk newborn: a challenge for the nursing staff. Cogitare Enferm. 2016;21(esp):01-09. https://doi.org/10.5380/ce.v21i5.45047
https://doi.org/10.5380/ce.v21i5.45047...
).

It is noteworthy that, in order to achieve high levels of thermoregulatory performance, the service team needs to engage in quality improvement (QI) intervention in partnership with other units, given that NICUs that participate in collaborative QI achieved better results in thermoregulation of those whose efforts are exclusively local(3030 Pinheiro JMB. Preventing hypothermia in preterm newborns: simple principles for a complicated task. J Pediatr. 2018;94(4):337-9. https://doi.org/10.1016/j.jped.2017.10.003
https://doi.org/10.1016/j.jped.2017.10.0...
).

A study shows that during the surgical approach there is a significant number of AEs, which are, in most cases, caused by the lack of a safe practice by health professionals working in the sector, in which the existing safety measures are not used properly(1414 Corona ARPD, Peniche ACG. A cultura de segurança do paciente na adesão ao protocolo da cirurgia segura. Rev SOBECC. 2015;20(3):179-85. https://doi.org/10.5327/Z1414-4425201500030009
https://doi.org/10.5327/Z1414-4425201500...
). This fact is related to the non-compliance with the guidelines recommended by WHO for safe surgery, representing a risk for surgical patients(3939 Almeida RE, Rodrigues MS. Implementation of the surgical safety checklist for pediatric operations: compliance assessment. Rev Gaúcha Enferm. 2019;40(esp):e20180270. https://doi.org/10.1590/1983-1447.2019.20180270
https://doi.org/10.1590/1983-1447.2019.2...
).

This research identified actions to prevent hypothermia, which favors reduction of AE in the perioperative period. However, it became evident that there are weaknesses in the implementation of new care technologies, which justifies the need for professionals to rethink their care process, with actions that eradicate the occurrence of neonatal hypothermia(4040 Espindola S, Nascimento KC, Knihs NS, Alvarez AG, Sebold LF, Paim SMS. Intraoperative patient safety during liver transplantation: integrative review. Acta Paul Enferm. 2020;33:e-APE20180187. https://doi.org/10.37689/acta-ape/2020ar0187
https://doi.org/10.37689/acta-ape/2020ar...
), as well as launching strategies to improve the prevention of perioperative hypothermia so that it is evaluated in the context of feasibility, effectiveness, safety, acceptability, cost and teamwork(11 Munday J, Delaforce A, Forbes G, Keogh S. Barriers and enablers to the implementation of perioperative hypothermia prevention practices from the perspectives of the multidisciplinary team: a qualitative study using the Theoretical Domains Framework. J Multidiscip Healthc. 2019;12:395-417. https://doi.org/10.2147/JMDH.S209687
https://doi.org/10.2147/JMDH.S209687...
), to safeguard the OR ideal conditions, taking care of a person, taking care of their individuality and vulnerability before, during and after surgery(4141 Penaforte H, Sá C, Seara L, Costa MJ, Mendes A. Normotermia no perioperatório: perspetiva do enfermeiro. Rev Investig Inov Saúde. 2019;2(1):7-17. https://doi.org/10.37914/riis.v2i1.43
https://doi.org/10.37914/riis.v2i1.43...
).

Hypothermia in surgical patients is an AE of high incidence and constitutes a public health problem(1313 Bindu B, Bindra A, Rath G. Temperature management under general anesthesia: compulsion or option. J Anaesthesiol Clin Pharmacol. 2017;33(3):306-16. https://doi.org/10.4103/joacp.JOACP_334_16
https://doi.org/10.4103/joacp.JOACP_334_...
). This research identified actions to prevent hypothermia, which favors the reduction of AE in the perioperative period; however, it was evident that there are weaknesses in the implementation of new care technologies, which justifies the need for professionals to rethink their care process, with actions that eradicate the occurrence of neonatal hypothermia.

NB surgical safety depends on actions that aim to prevent the occurrence of preventable AE and when it is not possible to minimize its consequences. Attention to NB hypothermia, during the pre, intra and postoperative period, is of fundamental importance and becomes the focus of nursing care, as it favors the reduction of neonatal morbidity and mortality secondary to hypothermia triggered by the surgical approach.

Study limitations

This study, because it is an integrative review, has limitations for using secondary data, since the information has already been previously constructed and for having presented a small number of articles. It is also noteworthy that research was restricted to level III of evidence, according to assessment instrument; however, studies have brought good strategies for prevention of hypothermia in NB submitted to surgical procedures. Furthermore, the limited number of studies related to the theme makes it impossible to include more up-to-date references, both in the study's foundation and in the discussion of the study.

Contributions to nursing and health

This integrative review brings contributions to the health area, especially for neonatal nursing, since: i) identifies strategies for improving clinical and care practices in care for surgical NB; ii) describes actions to prevent hypothermia, which favors the reduction of AEs in the perioperative period; iii) contributes to the strengthening of international patient safety policies; iv) indicates care strategies that can favor the reduction of neonatal morbidity and mortality; v) points out the need to build an assistance protocol for prevention of hypothermia in surgical NB.

FINAL CONSIDERATIONS

The evidence in the scientific bases reveals that the main strategies used for prevention of hypothermia in surgical NBs were: room temperature control; establishment of relative air humidity and evaluation of quality of air conditioning cleanliness; use of heated and humidified incubator or heated cradle for hospitalization; operative procedure and transport; use of thermal, chemical mattress or heated blankets in surgical procedures; use of caps, underwear and blanket for heating in the perioperative period; use and infusion of fluids that must be previously heated; monitoring of body temperature in the axillary, nasopharyngeal, esophageal or rectal regions; perioperative temperature measurement routines; coverage of abdominal organs with wet and heated surgical compresses in the intraoperative period; use of environmental heating equipment.

Analyzing the findings of this study, it is recommended to develop further research on this topic, with strong evidence, outlined by methods of randomized clinical trials and cohort studies. Along with this, there is a need for professional training for the use of new technologies and new studies that can investigate the factors that predispose NB to perioperative hypothermia, prevention of AEs in the intraoperative period related to thermoregulation and elaboration of protocols based on scientific evidence that aligns the basic principles of thermal control to the new technological resources for prevention of hypothermia to NBs submitted to surgical procedure, among other themes that favor safe practice. In the studies analyzed, episodes of hypothermia were still identified in the surgical NB with the strategies used.

ACKNOWLEDGMENT

We would like to thank Universidade Federal da Bahia.

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Publication Dates

  • Publication in this collection
    06 Sept 2021
  • Date of issue
    2022

History

  • Received
    14 Sept 2020
  • Accepted
    27 Apr 2021
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