Tag Archives: surgical prep

Jun 28, 2018

3M Science at APIC 2018

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3M Science at APIC 2018The biggest infection prevention conference of the year, the 45th APIC Annual Conference, was held last week right in 3M’s backyard of Minneapolis, Minnesota. We were excited to be part of the movement to advance the infection prevention efforts of facilities across the country and to help clinicians move toward reducing rates of preventable infections.

Breakfast Symposium: Reducing the Risks of CLABSI and SSI

On Friday morning, 160 APIC attendees gathered for a symposium on “Reducing the Risks of CLABSI and SSI: What Is the Evidence?” Mark Rupp, M.D., professor and chief of the division of Infectious Diseases and director of Infection Control & Epidemiology at the University of Nebraska Medical Center, shared his expertise on evidence-based measures to prevent CLABSI/CRBSI. Peggy Prinz Luebbert, MS, CLS, CIC, CHSP, CSPDT, addressed interventions in preparing patients for surgery that help reduce the risk of SSI.

IP Survey: Human Factors and the Future of Infection Prevention

3M also highlighted the results from a survey of clinicians and infection preventionists (IPs), “Human Factors and the Future of Infection Prevention,” which uncovered the key challenges they face in their fight to reduce infections in their facilities.

The survey uncovered barriers that impact successful infection prevention, including a lack of adopting new technology and processes (51%), lack of senior leadership support (51%) and poor protocol compliance (50%). However, many IPs (45%) agree that their facility could prevent more infections with more high-quality data and tools. One-third of clinicians believe infections can be avoided entirely when providing care to patients.

We want to continue this conversation and find more ways to support clinicians in their fight against healthcare associated infections. Please join us July 11 for the first in a series of webinars to discuss the IP survey results.

Both the symposium and survey results emphasized the importance of preventing infections using a three-pronged approach: developing highly trained and committed people, incorporating industry standards and implementing evidence-based technology and we were excited to showcase some of our newest offerings that help clinicians in the fight to zero infections.

If you didn’t make it to the 3M booth at APIC 2018, here are some of the new product highlights:

3M™ Tegaderm™ Antimicrobial IV Advanced Securement Dressing

To better combat bloodstream infections, specifically peripheral line associated bloodstream infections (PLABSI), we introduced a new dressing to expand the 3M antimicrobial product offerings. The new dressing integrates 2% chlorhexidine gluconate (CHG) throughout the adhesive to suppress skin flora regrowth on prepped skin for up to 7 days, which can offer another line of defense against contamination. It also provides site visibility, catheter securement and is designed for consistent application. A non-bordered version of the dressing called Tegaderm Antimicrobial Transparent Dressing will also be available.

3M™ Skin and Nasal Antiseptic

Studies show that  approximately 30 percent of the population are colonized with Staphylococcus aureus (S. aureus), the leading cause of surgical site infections (SSIs). And, more than 80 percent of surgical site infections from S. aureus come from the patient’s own nasal flora. To combat this issue, 3M’s Skin and Nasal Antiseptic provides clinicians a simple, one-time application that reduces nasal bacteria, including S. aureus and MRSA, by 99.5 percent in just one hour and maintains this reduction for at least 12 hours. 3M’s nasal antiseptic is the only one supported by more than ten investigator-initiated clinical studies showing a reduction to the risk of SSIs.

3M™ Single-Patient Stethoscope

Leading healthcare organizations recommend using a single-patient stethoscope in isolation care settings, but the single-use stethoscopes on the market often fall short in terms of durability, sound quality and comfort. The new 3M stethoscope helps reduce the risk of cross-contamination  in isolation environments by providing clinicians a high-quality, disposable stethoscope that combines excellent sound quality and comfort to help eliminate the need to use personal stethoscopes.

3M™ Bair Hugger™ Temperature Monitoring System

Core body temperature is a vital indicator of health or illness of the acute care patient. For surgical patients, a small drop in core body temperature drop can result in unintended hypothermia (a temperature below 36.0°C), which can contribute to a number ofpreventable surgical complications. The 3M Bair Hugger™ Temperature Monitoring System is a non-invasive, consistent and easy-to-use system that accurately and continuously measures the patient’s core body temperature throughout the entire perioperative journey,  helpingclinicians proactively own the normothermic temperature zone and improve patient outcomes.

3M™ Attest™ Super Rapid Biological Indicator (BI) System for Steam and 3M™ Attest™ Auto-reader 490 and 490H units

Sterile processing professionals work to clean, disinfect, and sterilize all of the instruments that allow the perioperative staff to enter surgery prepared with the tools of their trade. 3M offers sterilization assurance solutions and expertise so the sterile processing department and your OR staff know surgical instruments are safe for patient use. Our new Attest™ Dual Auto-reader technology allows facilities to incubate both steam and Hydrogen peroxide BIs in the same auto-reader with fast 24-minute results – and is available via a free software upgrade to qualified hardware. Simplify, standardize and streamline Sterile Processing Department workflows with 3M innovation and expertise.

Jun 1, 2016

It’s Time for APIC 2016!

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It’s Time for APIC 2016!

It’s Time for APIC 2016! And it’s time to get inspired – the APIC 43rd Annual Conference is almost here! From June 11-13, the infection prevention community – some 5,000 strong – will gather in beautiful, historic Charlotte, North Carolina to share and take in the latest breakthroughs and best practices from around the world. This three-day event is filled with opportunities to listen, learn and recharge with some of the industry’s most innovative thought leaders on infection prevention and control. We’ll be there, and we wanted you to know about some of the highlights:

What to see at APIC 2016 Conference

Disinfection and Sterilization: The Good, the Bad, and the Ugly

Start this conference right with this plenary session featuring Dr. William Rutala, a professor in the Division of Infectious Diseases at the University of North Carolina School of Medicine. Dr. Rutala presents a “good” classification scheme, improved data, and new technologies; the “bad” noncompliance, with guidelines for reprocessing medical/ surgical devices; and the “ugly” endoscope reprocessing and infection risks that may expose patients. Don’t miss it!

Integrating Infection Prevention Control Programs into the Ambulatory Care Setting: An Evolving Model 

Get a quick dose of ambulatory care expertise in this 30-minute session with Faith Skeete of NYU Medical Center and Natalie Fucito of NYU Langone.

Duodenoscopy

Hear the latest on a procedure that presents formidable challenges in infection control, presented by Maroya Walters of the Centers for Disease Control and Prevention.

International Infection Prevention and Control (IPC) in Resource-Limited Settings

Here is a rare chance to attend a workshop on a globally vital topic, hosted by experts from the Liberian and Kenyan Ministries of Health as well as the Infection Control Africa Network and the US CDC.

Best Practices for High-Level Disinfection and Reprocessing Programs at Large Academic Health Institutions

Take the Emerging Science, Research, and Application track – this Concurrent Education session features the very latest information from experts from the Medical Center, Medical School and Health Department at the University of Minnesota.

Infection Prevention and Surveillance in Primary Care 

Explore the latest with officials from Thomas Jefferson University, Jefferson College of Nursing and the Hospital of the University of Pennsylvania.

What to see in 3M Medical booth 1503

This year we are focusing on two topics that we get a considerable amount of questions on:

Endoscope reprocessing

Cleaning endoscopes is critical because residual organic material can inactivate disinfectants, allowing potentially deadly bacteria to remain on the surfaces. Facilities that achieve the highest standard of care proactively monitor manual cleaning protocols for flexible endoscopes. Read how routine endoscope cleaning monitoring can contribute to a higher standard of care.

Reducing the risk of surgical site infections

Patient safety is a primary concern for the perioperative team. A lot of attention is focused on skin preps and ways to reduce the patient’s bacterial load. One method is to use a nasal antiseptic before surgery. Before the conference, read a summary of clinical evidence about the efficacy of nasal antiseptics.

These are just a few examples of what’s inspiring us at this year’s APIC conference. We look forward to seeing you!

Feb 25, 2016

Nosocomial Infection: Reduce the Risk of a Surgical Site Infection

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Nosocomial-Infections-Reduce-the-Risk-of-a-Surgical-Site-Infection

Ways to help reduce the risk of a nosocomial infection during surgery

Prevention of nosocomial infections is critical. These infections are more commonly known as healthcare-associated infections (HAIs).

Healthcare facilities and operating rooms are fast moving places with many things to keep track of. But, there are four principles that can help reduce the risk of spreading a HAI during surgery to always keep top of mind:

  1. Diligent hand hygiene. Hand hygiene should be practiced by everyone in a healthcare facility. Patients, visitors, and healthcare professionals should understand and practice the World Health Organization (WHO) Five Moments for Hand Hygiene. The perioperative team uses more specific guidelines from the Association of perioperative Registered Nurses (AORN). The periop team should know and remind each other when to practice hand antisepsis.
  2. Reduce Bacteria on the Patient. Bacteria from the skin are the leading cause of surgical site infections. Microorganisms such as Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus (MRSA) are serious threats that can cost a hospital as much as $60,000.1 The skin cannot be sterilized, but by using a surgical skin prep and an incise drape, a sterile operating field can be created. Evidence now suggests bacteria from the patient’s own nares can contribute to surgical site infections (SSIs). Clinical evidence demonstrates that using a nasal antiseptic helps reduce the risk of SSI when part of a comprehensive preoperative protocol.
  3. Maintain normothermia. Operating rooms are typically cold and patients are often exposed. Maintenance of normothermia is important to help reduce the risk of SSIs.2-5 Even a 1.6°C decrease in body temperature can produce inadvertent perioperative hypothermia.6-7 Forced-air warming is a technology that has been proven safe and effective for over 25 years. Maintaining normothermia is one of the easiest, least expensive, and most effective benefits you can offer to patients.
  4. Mitigate cross-contamination. In a clinical study, 77% of reusable ECG leadwires were found to be contaminated with antibiotic-resistant nosocomial pathogens even after being cleaned.8 This is one reason to use disposable leadwires. Disposable leadwires can also remain with the patient even while they are being transported.

Prevention and reduction of HAIs are a priority for the U.S. Department of Health and Human Services (HHS).

For more information on the HHS plan, visit the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. There is no one way to stop HAIs, prevention relies on people. By practicing proper protocols and looking out for the patient, we can all work together to improve infection rates.

1 Anderson DJ, Kaye KS, Chen LF, et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS ONE. 2009; 4(12): doi: 10.1371/journal.pone.0008305
2Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med. 1996;334:1209-15.
3 Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: A randomized controlled trial. Lancet. 2001;358:876-880.
4 Barie PS. Surgical site infections: epidemiology and prevention. Surg Infect. 2002;3:S9-S21.
5 Seamon, M.J., et. al. The effects of intraoperative hypothermia on surgical site infection: An analysis of 524 trauma laparotomies. Ann of Surg. 2012;255(4)
6 Sessler DI. Current concepts: mild perioperative hypothermia. N Engl J Med. 1997; 336:1730-1737.
7 Barie PS. Surgical site infections: Epidemiology and prevention. Surg Infect. 2002; 3: S-9 – S-21.
8 Jancin, Bruce. Antibiotic-resistant pathogens found on 77% of ECG lead wires. Cardiology News. 2004;2(3):14.
Jan 19, 2016

Surgical Skin Prep – Perioperative Patient Care Fundamentals

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When I think of the role of a circulating nurse in the Operating Room I’m struck by both the complexity of the work and the privilege of providing care for patients at a time when they are most vulnerable…when the patient cannot be their own advocate due to the effects of anesthesia. It is at this moment when the nurse becomes the eyes, ears, and voice for the patient. The nurse is entrusted to know how to care for the patient, to understand, guide and deliver this care with competence throughout the patient’s perioperative journey.  Care needs to be specific to and focused only on the patient being cared for.

One patient … one unique perioperative journey.

So how do you, as a circulating nurse, make certain you deliver the care each patient needs? How is it made unique to the patient?  Let me use surgical skin prep to illustrate. We know the surgical skin prep is a critical step in reducing the risk of a surgical site infection for patients undergoing surgery. Because all commonly used patient skin preps meet the FDA criteria for immediate microbial kill and persistent antimicrobial activity, it’s important to look at other factors that may affect performance when choosing a prep for each surgical patient. The circulating nurse is responsible for knowing the fundamentals of selecting and appropriately applying the surgical skin prep. Manufacturers provide instruction for use which include application method, contraindications and warnings for their surgical skin prep products. This is the best resource for learning about the surgical skin prep products used in your facility. Here are 7 basic considerations to personalize the prep selection for your patient:

1. Does your patient have allergies and sensitivities?

  • Check for patient allergies or sensitivities to the ingredients contained in the surgical skin preparation products used in your institution

2. Is your patient less than two months of age?

  • Certain skin preps are not recommended for patients under two months of age due to the risk of excessive skin irritation or absorption of the active ingredient.

3. What is the surgical procedure site?

  • If it is near the eyes: alcohol-based preps would  not be appropriate nor would chlorhexidine gluconate (CHG) products due to the risk of corneal damage
  • If it is near the ears: alcohol-based preps would not be appropriate nor would CHG products due to the risk of ototoxicity /potential deafness
  • If prep includes mucous membranes: no alcohol-based products should be used. CHG products should be used with caution
  • If the skin is not intact: alcohol-based preps should not be used.
  • If the site includes a lumbar puncture or contact with the meninges:  CHG preps would not be appropriate due to the risk of neurotoxicity

4. What challenges will your surgical site face? Does the procedure involve large amounts of fluids (e.g. blood and/or saline)? If so, select a prep that is resistant to being washed off when challenged with irrigation solution, blood or sponges that come in contact with the prepped skin.  You want a prep that will continue to work throughout the procedure into the post procedure phase. 5. Does the procedure involve the use of an incise drape?  Select a prep that enhances drape adhesion so that once you create that sterile field with an incise drape there is a reduced incidence of drape lift. 6. Does the procedure involve prepping a large surface area or include prepping an area of high microbial counts (e.g. groin, toes, axilla, fingernails, skin folds, etc.)?

  • When using a single use applicator it is important to select the appropriate size for the location you are prepping. Single use applicators specify the coverage area on the package insert. More than one applicator may be required. Using a single use applicator to cover an area greater then specified area can impact the efficacy of the prep.
  • Conversely, using a larger volume of prep than is needed for a small area increases the potential for pooling of solution which poses a risk for skin irritation and fire if the pooled solution or solution-soaked materials are not removed after the prep is complete.

7. Are you using a prep that contains alcohol? If so, to reduce the risk of fire, you should adhere to the specified dry times. The minimum dry time for a prep containing alcohol is 3 minutes on hairless skin and up to an hour in hair.  Following dry time ensures prep efficacy, patient safety and minimizes skin irritation. When you know the answers to these questions and have selected the appropriate prep for your patient and their procedure, the next step will be to apply the prep. To provide your patient with quality care, it is important to understand and follow the Instructions for Use (IFU) specific to the chosen prep. Here are 4 factors to consider: The application method for a surgical skin prep is critical for the prep to achieve its efficacy. Instructions for use (IFU) are based on the product application used during testing to meet the FDA efficacy requirements. Even if the skin antiseptic active ingredients are the same between manufacturers, the application methods utilized for their clinical studies and the resultant efficacy findings may vary based on product formulation and applicator design. Application methods range from being painted on, scrubbed on, or applied in gentle back- and- forth stokes. Application can vary in terms of contact time. For example; solutions that combine alcohol and another active ingredient (e.g. iodine povacrylex or CHG) kill bacteria more quickly and therefore generally have shorter application times than those that do not contain alcohol. Application time may vary dependent upon intended use. For example, prior to surgery, prior to inserting a vascular catheter or prior to performing an injection. If the application times are different, the different times and indications must be identified on the product label or in the IFU. Application time may vary depending on the site being prepped. For example, the prep times for a CHG/alcohol antiseptic are different depending on the prep site. If you are prepping a dry site (e.g. back, abdomen, leg) your application time will be 30 seconds. If the site you’re prepping is considered a moist site (e.g. axilla, groin) the antiseptic needs to be applied to the skin for 2 minutes. As you can see, even one of the most seemingly routine tasks in preparing your patient for surgery is anything but routine. The ability of the circulating nurse to customize the care for each patient is critical to keeping the patient safe throughout the perioperative journey. Be that advocate: be their eyes, their ears, their voice! Download the Skin Prep Decision Guide.

Nov 23, 2015

The Chain of Infection: A Patient Journey

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The Chain of Infection

Passing Thru the Gauntlet of Healthcare Associated Infections

Meet Mary J, an incoming patient. She’s been referred to your hospital because of its reputation as a state-of-the art facility and one that has minimized healthcare-associated infections – HAIs. Mary’s OB/GYN insisted that yours is the best hospital for her to have her surgery. What began as a persistent pain in her pelvic region has been diagnosed as ovarian cancer and a complete hysterectomy has been ordered. The life of this otherwise healthy, 46 year old mother and elementary school teacher has taken a dramatic turn. She must put her care in someone else’s hands, something she’s unaccustomed to doing. With her family and her students relying on her, the last thing Mary needs is to come through the procedure successfully but encounter an HAI. HAIs can be harbored in virtually any place Mary will be transiting.  According to a recent HAI prevalence survey1 administered by the CDC, 1 in 25 hospital patients in the US have experienced at least one HAI. Read how ready this facility is to mitigate and minimize the occurrence of HAIs in its commitment to patient safety.

Arrival – Let the Battle Begin

Hands, the most common source of pathogen transmission, are a critical battleground in the fight to reduce healthcare-associated infections so naturally they are at the center of the challenge. One challenge is that in order for any product to be effective, it would also need to be gentle enough to promote repeated and frequent use. In any hospital, an effective antiseptic hand solution should also be latex glove and Chlorhexidine Gluconate compatible. It should also be dye and fragrance-free and available in versatile and convenient point-of-care locations to promote compliance. Because your hospital has initiated a comprehensive hand hygiene policy using awareness training, products and tools that are effective against infection yet gentle on skin, Mary’s admission will be less of a risk. Your hospital has also incorporated appropriate environmental cleaning programs with detailed instructions to ensure consistent cleaning based on industry standards and best practices. Because of this, Mary’s chance to contract HAIs as she passes through the hallways and contacts various equipment is reduced. The OR has been cleaned and disinfected using a variety of cleaning products and tools including chemical management systems that mix disinfectants and other products in exacting quantities. Additionally, the Infection Preventionist and Environmental Services Manager routinely review a hygiene-management-system sampling plan to validate the cleaning process and address problem areas. In all areas where Mary will pass, particular attention is paid to disinfecting high-touch surfaces. Cleanliness is verified using a hygiene management and testing system that provides real-time results. The analysis confirms that environmental cleanliness is at or above the goal benchmark for frequently touched surfaces – where the risk of cross contamination tends to be the highest. In addition to physical testing, data-driven assessment tools also help provide facilities managers with the ability to track the cost of HAIs to their facilities and justify investments in infection prevention programs.

Pre-op – Even up Your Nose?

As Mary is prepped for her procedure, she is impressed and reassured to see that all personnel who come in contact with her sanitize their hands using an instant hand antiseptic. They are obviously well trained and sanitize their hands without a second thought. She changes into a forced-air warming gown which will keep her warm as she waits prior to surgery, as well as maintain a comfortable body temperature throughout her procedure. Her nurse administers the hospital pre-surgical cleansing policy, which includes nasal antiseptic applied to her intranasal cavity and even an oral rinse – no opportunity for an HAI is left to chance. Mary’s nurse explains that this routine will help minimize the bacteria in her nasal and oral passages, bacteria that could easily spread to her surgical wounds or her airway while she is on the breathing machine. Her skin is prepared for surgery using specially developed 2% chlorhexidine gluconate rinse-free cloths that address multidrug resistant organisms on the skin and are another layer of defense against surgical site infections. Mary is then transported into the operating room. Other members of the surgical team begin to arrive into the OR. The surgical assistant puts on a high fluid-resistant surgical mask, disinfects her hands with an antiseptic hand prep and then gowns up. All surgical tools are effectively monitored using chemical and biological indicators. These indicators serve as release criteria in the Central Sterile Supply Dept. (CSSD). CSSD places chemical indicators into each set before sterilization and then are checked prior to use in the OR to verify sterilization conditions have been met. This last step is adopted by the World Health Organization, Safe Surgeries Check List to indicate that sterilization conditions exist inside the set (http://apps.who.int/iris/bitstream/10665/44186/2/9789241598590_eng_Checklist.pdf)

The indicators show a “pass”, which means they have met the parameters for sterilization and the instruments are ready. Just before she goes under anesthesia, as part of the patient monitoring process, pre-wired monitoring electrodes are placed on Mary and connected to her monitors. These electrodes use a gentle, conductive adhesive that is repositionable and won’t tear delicate tissues when removed. Mary’s IV  is inserted and secured using a transparent dressing so her IV can be monitored without removing the dressing and exposing the IV site to additional bacteria. Your hospital realizes the importance and cost saving benefits to using dressings that provide superior wear time, gentle removal, and excellent moisture management in the battle against HAIs.

In the OR Zone

While Mary’s forced-air warming gown is keeping her warm before surgery, another warming product will be used during her procedure – a full access underbody blanket. (Recent studies found that underbody blankets delivered significantly warmer patients than resistive warming devices or standard warming therapy).2-5 Maintaining normothermia helps reduce the risk of infections as well as the hospital length of stay. Warmed blood and fluids are also beneficial in an effort to maintain normothermia and they will be administered using a leading blood and fluid warming device. Once Mary is anesthetized, her skin previously clipped of hair, done in periop, is prepared for surgery using an iodine povacrylex and isopropyl alcohol surgical solution, which keeps bacteria counts below baseline for at least 48 hours. During this time, the rest of the surgical team disinfects their hands with an antiseptic hand prep. Mary is then draped using a surgical drape that has an antimicrobial incise film to create a sterile surface. This front-line barrier provides a sterile surface all the way to the wound edge, and provides continuous broad-spectrum antimicrobial activity to further reduce the risk of SSIs and HAIs. Before making any incision, the team conducts a “time out” to make sure they are doing the right operation on the right patient, have all of the appropriate instrumentation present and confirm that the correct pre-surgical protocols have been followed. The team also makes introductions and states the roles they have in the surgery, all part of your hospital’s head- to-toe patient safety attitude. Satisfied that all of the proper procedures have been followed, her gynecologic oncologist initiates the operation. After successfully removing her uterus, fallopian tubes, omentum and ovaries, fluid and tissue samples are collected and sent for testing. Mary’s skin incision is then closed using a disposable skin stapler. Closing the incision this way maintains wound edge apposition, allowing for appropriate edema to occur and facilitate proper healing. The final touch is dressing the incision. Your hospital stocks an all-in-one dressing that is highly conformable; one that flexes with movement and swelling and provides a better exchange of moisture vapor and oxygen to reduce skin maceration. The post-surgical dressing of choice protects the wound while absorbing drainage, all of which promotes healing and greater comfort. At last, Mary is transferred to the recovery room and then the ICU.

Post op Success and New Horizons

As the staff ushers Mary though recovery, a new set of pre-wired monitoring electrodes are placed on her and connected to the patient monitor. Oral care is started with an oral rinse (Chlorhexidine Gluconate 0.12%). This process is done every four hours while Mary is in the Post Anesthesia Recover Unit, or PACU. Because the staff at your hospital had the right processes and products in place, from the surgical prep station to the sterilization room to the OR and onto the ICU, they helped reduce the risk of Mary walking away with a healthcare-associated infection. Why subject patients to needless risk of a HAI when risk can be mitigated?

References:

  1. CDC, Healthcare-associated Infections (HAIs), HAI Prevalence Survey, 2011, http://www.cdc.gov/HAI/surveillance/
  2. Tominaga A., Koitabashi T., et al. Efficacy of an underbody forced-air warming blanket for the prevention of intraoperative hypothermia. Anesth. 2007;107:A91.
  3. Insler SR., et al. An evaluation of a full-access underbody forced-air warming system during near-normothermic, on-pump cardiac surgery. Anesth Analg. 2008. 106(3):746-750.
  4. Teodorczyk JE., et al. Effectiveness of an underbody forced-air blanket in preventing postoperative hypothermia after coronary artery bypass graft surgery with normothermic cardiopulmonary bypass.  Critical Care. 2009. 13(1):P71.
  5. Engelen S, et al. A Comparison of under-body forced-air and resistive heating during hypothermic bypass. ASA Abstract. 2010. A075.
  6. World Health Organization, Health care-associated infections FACT SHEET, http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf