Patent Publication Number: US-9889040-B2

Title: Warming device with provision for warming hands

Description:
RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 11/583,480, now U.S. Pat. No. 7,914,566, which claims priority to U.S. Provisional patent application 60/729,000, filed Oct. 20, 2005 and to U.S. Provisional patent application 60/835,602, filed Aug. 4, 2006. 
    
    
     This application contains subject matter related to the subject matter of the following patent applications, all commonly owned herewith and all incorporated by reference: 
     Patent Cooperation Treaty (PCT) Application No. PCT/US03/011128, filed Apr. 10, 2003, entitled “Patient Comfort Apparatus and System”, and published on Oct. 23, 2003 under Publication No. WO 2003/086500; 
     Patent Cooperation Treaty (PCT) Application No. PCT/US05/025355, filed Jul. 18, 2005, entitled “Perioperative Warming Device”, and published on Feb. 23, 2006 under Publication No. WO 2006/020170; 
     Patent Cooperation Treaty (PCT) Application No. PCT/US05/043968, filed Dec. 6, 2005, entitled “Warming Device with Varied Permeability”, and published on Jun. 15, 2006 under Publication No. WO 2006/062910; 
     Patent Cooperation Treaty (PCT) Application No. PCT/US05/044214, filed Dec. 6, 2005, entitled “Warming Device”, and published on Jun. 15, 2006 under Publication No. WO 2006/063027; 
     Patent Cooperation Treaty (PCT) Application No. PCT/US06/004644, filed Feb. 9, 2006, entitled “Warming Device for Perioperative Use”, and published on Aug. 17, 2006 under Publication No. WO 2006/086587; 
     U.S. patent application Ser. No. 10/411,865, filed Apr. 10, 2003, entitled “Patient Comfort Apparatus and System” and published on Oct. 16, 2003 under Publication No. US 2003/0195596 and issued on Feb. 21, 2006 under U.S. Pat. No. 7,001,416; 
     U.S. patent application Ser. No. 10/508,319, filed Sep. 20, 2004, entitled “Patient Comfort Apparatus and System” and published on Jun. 30, 2005 under Publication No. US 2005/0143796; 
     U.S. patent application Ser. No. 11/005,883, filed Dec. 7, 2004, entitled “Warming Device with Varied Permeability” and published on Jun. 8, 2006 under Publication No. US 2006/0122671, now U.S. Pat. No. 7,226,454; 
     U.S. patent application Ser. No. 11/006,491, filed Dec. 7, 2004, entitled “Warming Device” and published on Jun. 8, 2006 under Publication No. US 2006/0122672; 
     U.S. patent application Ser. No. 11/057,396, filed Feb. 11, 2005, entitled “Perioperative Warming Device”, and published on Aug. 17, 2006 under Publication No. US 2006/0184215, now U.S. Pat. No. 7,276,076; 
     U.S. patent application Ser. No. 11/057,403, filed Feb. 11, 2005, entitled “Warming Device for Perioperative Use”, and published on Aug. 17, 2006 under Publication No. US 2006/0184217; 
     U.S. patent application Ser. No. 11/057,404, filed Feb. 11, 2005, entitled “Clinical Garment for Comfort Warming and Prewarming”, and published on Aug. 17, 2006 under Publication No. US 2006/0184218; and, 
     U.S. patent application Ser. No. 11/363,136, filed Feb. 27, 2006, entitled “Forced Air Warming Unit” and published on Jul. 6, 2006 under Publication No. US2006/0147320. 
     This application also contains subject matter related to the subject matter of the following patent applications, all commonly owned herewith: 
     PCT Application No. US/2006/41028, filed Oct. 19, 2006, entitled “Multifunction Warming Device for Perioperative Use”, and published on Apr. 26, 2007 under Publication No. WO2007/047917; 
     PCT Application No. PCT/US2007/013073, filed Jun. 1, 2007, titled “Warming Device”, and published Jan. 31, 2008 under Publication No. WO 2008/013603; 
     PCT Application No. PCT/US2008/000141, filed Jan. 4, 2008, titled “Convective Warming Device with a Drape”, and published Jul. 31, 2008 under Publication No. WO 2008/091486; 
     U.S. patent application Ser. No. 10/895,672, filed Jul. 21, 2004, entitled “Perioperative Warming Device”, now abandoned, published on Jan. 20, 2005, under Publication No. US 2005/0015127; 
     U.S. patent application Ser. No. 11/057,397, filed Feb. 11, 2005, entitled “Thermal Blanket for Warming the Limbs”, and published on Aug. 17, 2006 under Publication No. US 2006/0184216, now U.S. Pat. No. 7,520,889; 
     U.S. patent application Ser. No. 11/492,425, filed Jul. 25, 2006, entitled “Warming Device”, and published on Nov. 16, 2006 under Publication No. US 2006/0259104; 
     U.S. patent application Ser. No. 11/583,432, filed Oct. 19, 2006, entitled “Multifunction Warming Device for Perioperative Use”, and published on Apr. 26, 2007 under Publication No. US/2007/0093882; 
     U.S. patent application Ser. No. 11/583,480, filed Oct. 19, 2006, titled “Multifunction Warming Device with Provision for Warming Hands”, and published on Apr. 26, 2007 under Publication No. US 2007/0093884; 
     U.S. patent application Ser. No. 11/583,481, filed Oct. 19, 2006, entitled “Multifunction Warming Device with an Upper Body Convective Apparatus”, and published on Apr. 26, 2007 under Publication No. US/2007/0093885; 
     U.S. patent application Ser. No. 11/656,777, filed Jan. 23, 2007, entitled “Convective Warming Device With a Drape”; 
     U.S. patent application Ser. No. 11/704,547, filed Feb. 9, 2007, entitled “A Forced Air Warming Unit”; 
     U.S. patent application Ser. No. 11/801,292, filed May 9, 2007, titled “Warming Device with Varied Permeability”, and published on Oct. 11, 2007 under Publication No. US 2007/023939; 
     U.S. patent application Ser. No. 11/899,872, filed Sep. 7, 2007, entitled “Perioperative Warming Method”; and published on Jan. 31, 2008 under Publication No. US 2008/0027522; 
     U.S. patent application Ser. No. 11/899,928, filed Sep. 7, 2007, entitled “Perioperative Warming Device” and published on Jan. 31, 2008 under Publication No. US 2008/0027521; 
     U.S. patent application Ser. No. 12/011,699, filed Jan. 1, 2008, titled “Warming Device” and published on Jun. 11, 2009 under Publication No. US 2009/0149931; 
     U.S. patent application Ser. No. 12/386,243, filed Apr. 15, 2009, titled “Warming Device with Provisions for Deploying Elements of an Upper Body Convective Apparatus and for Deploying the Lower Portion of the Warming Device” and published on Sep. 10, 2009 under Publication No. US 2009/0228083; and 
     U.S. patent application Ser. No. 12/653,825, filed Dec. 21, 2009, titled “Warming Device Constructions with a Poncho-Type Patient Gown”. 
     BACKGROUND 
     The field includes a warming device constituted of a clinical garment with at least one convective apparatus supported on an inside surface. 
     In this specification, use of the term “convective” to denote the transfer of heat from a device to a body refers to the device&#39;s principal mode of heat transfer, it being understood that heat may at the same time be transferred from the device to the body by conduction and radiation, although not to the degree of convection. 
     Convective devices that transfer heat to a human body are known. For example, there are devices that receive a stream of pressurized, warmed air, inflate in response to the pressurized air, distribute the warmed air within a pneumatic structure, and emit the warmed air onto a body to accomplish such objectives as increasing comfort, reducing shivering, and treating or preventing hypothermia. These devices are typically called “convective thermal blankets” or “covers”; for convenience, in this discussion and the following specification, they shall be called, simply, “thermal blankets.” Arizant Healthcare Inc., the assignee of this application, makes and sells such devices under the BAIR HUGGER® brand. One such device is the Model 522 Upper Body Blanket. 
     Thermal blankets have been specifically designed for particular deployments where therapeutic warming is indicated. Three representative thermal blankets known in the prior art are shown in  FIGS. 1A-1D . A “full body” thermal blanket  10  is shown in  FIG. 1A . The full body thermal blanket is adapted to lie upon a person and to extend longitudinally along the body of the person in order to cover substantially the person&#39;s entire body, from near the ankles or feet up to the neck. A “lower body” thermal blanket  12  is shown in  FIG. 1B . The lower body thermal blanket  12  is adapted to lie upon the person and to extend longitudinally along the body of a person in order to cover the person&#39;s lower body, from near the ankles or feet up to the waist or pelvis of the person. An “upper body” thermal blanket  15  is illustrated in  FIGS. 1C and 1D . The upper body thermal blanket  15  has a bow-tie shape that is adapted to lie upon and extend transversely across the upper body of a person in order to cover the person&#39;s chest and extended arms. A head drape  16  may be formed on or attached to the upper body thermal blanket  15  for draping over the head  17  of a person in order to retain warmed air expelled through the blanket  15  about the head to aid in therapeutic warming during surgery. When fed a stream of warmed pressurized air, each of the thermal blankets  10 ,  12 ,  15  inflates and distributes the air within itself. White the thermal blanket lies on the person, the warmed pressurized air flows through apertures or interstices in a permeable surface of the thermal blanket which faces the person. These thermal blankets may have one, two, or more inlet ports  18  through which an air hose  19  provides warmed pressurized air from a heater/blower unit (not shown in these drawings). 
     The construction of prior art thermal blankets is well understood. Examples of specific constructions are given in U.S. Pat. No. 5,620,482, U.S. Pat. No. 5,443,488, U.S. Pat. No. 5,360,439, and U.S. Pat. No. 5,304,213. See also U.S. Pat. No. 5,974,605. 
     A recent invention disclosed in the referenced Publication No. WO 2003/086500 adapts a clinical garment such as a robe or gown to receive a convective device in order to warm a person wearing the garment in a clinical setting for comfort and mobility of the person. Other adaptations of clinical garments for manifold use, including covering a patient after disrobing and warming the patient for comfort and therapeutic purposes, are described in the publications of other related patent applications identified above. 
     The term “perioperative” is defined in the PDR Medical Dictionary, Second Edition, (Medical Economics Company, 2000), as “around the time of operation.” The perioperative period is characterized by a sequence including the time preceding an operation when a patient is being prepared for surgery (“the preoperative period”), followed by the time spent in surgery (“the intraoperative period”), and by the time following an operation when the patient is closely monitored for complications while recovering from the effects of anesthesia (“the postoperative period”). 
     According to Mahoney et al. (Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. April 1999; 67,2:155-164.), therapeutic warming is employed during at least the intraoperative period in order to prevent or mitigate effects that result from hypothermia. In fact, it is increasingly manifest that maintenance of normothermia perioperatively enhances the prospects for a quick, successful recovery from surgery. For example, maintenance of perioperative normothermia appears to be a factor in decreasing the incidence of surgical wound infections in patients undergoing colorectal surgery, (Kurz A, Sessler D I, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. May 9, 1996; 334(19):1209-1215). Other studies suggest that maintenance of perioperative normothermia improves surgical outcomes at low cost, (Harper C M, McNicholas T, Gowrie-Mohan S. Maintaining perioperative normothermia. BMJ. Apr. 5 2003; 326(7392):721-722). The effectiveness of therapeutic warming depends upon delivery of enough heat to a patient&#39;s body to raise the patient&#39;s core body temperature to, or maintain it within, a narrow range, typically around 37° C. This range is called “normothermic” and a body with a core temperature in this range is at “normothermia.” Hypothermia occurs when the core body temperature falls below 36° C.; mild hypothermia occurs when core body temperature is in the range of 34° C. to 36° C. Therefore, “perioperative therapeutic warming” is warming therapy capable of being delivered during one or more of the perioperative periods for the prevention or treatment of hypothermia. 
     Therapeutic warming is contrasted with “comfort warming” which is intended to maintain or enhance a patient&#39;s sense of “thermal comfort”. Of course, therapeutic warming may also comfort a patient by alleviating shivering or a feeling of being cold, but this is a secondary or ancillary effect; and, comfort warming may have some therapeutic effect. However, even though thermal comfort is a subjective notion, environmental conditions that produce a sense of thermal comfort in a population of human beings are known and well tabulated. For example, Fanger (Thermal Comfort: Analysis and Applications of Environmental Engineering, Danish Technical press, Copenhagen, 1970) defines thermal comfort as “that condition of mind which expresses satisfaction with the thermal environment.” Even when a patient is normothermic, less than ideal environmental conditions can result in acute feelings of discomfort. Under normothermic conditions, thermal comfort is largely determined with reference to skin temperature, not core body temperature. Comfort warming is warming applied to a patient to alleviate the patient&#39;s sense of thermal discomfort. 
     Therapeutic warming may be indicated during any one or more of the perioperative periods. For example, for a short operation in a surgery with no warming equipment available, a person may be warmed preoperatively in a preparation area to raise mean body temperature to a level higher than normal in order to store enough thermal energy to maintain normothermia, without heating, intraoperatively. After surgery, it may be necessary to apply therapeutic warming in a recovery area to raise the core temperature to normothermia and maintain it there for a period of time while anesthesia wears off. Alternatively, for a long surgery in an arena with heating equipment available, a person may be warmed for comfort before surgery and warmed therapeutically during and after surgery. 
     Therapeutic warming is typically provided by convective devices such as the thermal blankets shown in  FIGS. 1A-1D . An example of use of a full body thermal blanket for therapeutic warming is found in U.S. Pat. No. 6,524,332, “System and Method for Warming a Person to Prevent or Treat Hypothermia”, commonly owned with this application. Comfort warming by convective means is described in the referenced Publication No. WO 2003/086500. 
     When delivered by convective devices, therapeutic warming is distinguished from comfort warming by intended effects and by the parameters of heat delivery that produce those effects. In this regard, a convective warming system typically includes a source of warmed pressurized air (also called a heater/blower unit, a forced-air warming unit, a heater unit, etc.), a convective device (which is, typically, inflatable), and a flexible conduit or air hose connecting the heater/blower unit with the convective device. Use of such a system for a particular type of warming requires delivery of warmed air through a convective device at parametric values that achieve a particular objective. For example, for comfort warming, the temperature at the hose end, prior to the air entering the convective device, may range from ambient to 42° C. (WO 2003/086500 at page 11, lines 24-26). The conditions by which a convective device such as a thermal blanket produces thermal comfort in normothermic individuals at steady state are significantly different from those necessary to treat hypothermia. Typically the conditions for thermal comfort are met in a system with a relatively low capacity heater/blower unit that delivers a stream of air at one combination of pressure and temperature, while those in a therapeutic warming system are achieved with a relatively high capacity heater/blower unit that delivers a stream of air at another combination of pressure and temperature. Alternatively, a single heater/blower unit may be provided with controls that enable it to adjust the combination of air pressure and temperature in order to vary its operation between support of comfort and therapeutic warming. 
     Patient comfort at any time is a major health care issue. For example, when awaiting surgery, with all covering shed save for a thin hospital gown, a patient can easily become demoralized, distressed and apprehensive. Often cold as well, a patient&#39;s discomfort can become acute as the preoperative period drags on. Any provisions to increase optimism, reduce tension, and enhance a patient&#39;s outlook contribute to the prospects for a successful outcome. Especially helpful in the preoperative period are measures that increase the patient&#39;s comfort. The provision of comfort warming by way of a convective thermal device mounted in a clinical garment as described in the applications disclosed above materially relieves patient distress whether looking forward to surgery or merely awaiting examination. However, while the patient may feel the comfortable flow of warmed air on the portion of his body within the clinical garment, the patient&#39;s hands and forearms are typically outside the garment where they may become cold and uncomfortable. 
     The problem of patient discomfort in the upper extremities, especially the hands and forearms, while the patient is warmed in other regions by means of a warming device constituted of a clinical garment with at least one convective apparatus supported on the inside surface of the garment is solved by provision of slits, openings, or apertures through the garment which enable the patient to insert the hands into the clinical garment for warming therein. 
     SUMMARY 
     A warming device includes a clinical garment with at least one convective apparatus supported on the inside of the garment. Slits are provided in the clinical garment which enables a patient to insert his or her hands inside the clinical garment to be warmed therein by operation of the convective apparatus. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIGS. 1A-1D  are illustrations of prior art full body, lower body, and upper body convective thermal blankets. 
         FIG. 2  is an illustration of a person wearing a warming device with hand slits. 
         FIG. 3A  is a perspective view of a clinical garment having an inside surface to support two convective apparatuses. 
         FIGS. 3B and 3C  are plan views of a first convective apparatus to provide therapeutic warming. 
         FIG. 3D  is a plan view of the first convective apparatus of  FIGS. 3B and 3C  overlapped by a second convective apparatus. 
         FIG. 3E  is a plan view showing the first convective apparatus in the overlapping relationship with the second convective apparatus, with the ends of the first convective apparatus unfolded. 
         FIG. 3F  is a rear elevation view of a multifunction warming device. 
         FIGS. 3G through 3I  are enlarged, partially schematic drawings showing an operation of an attachment mechanism embodied as double-sided tape. 
         FIGS. 4A-4C  illustrate preparation and deployment of a multifunction warming device to therapeutically warm the upper body of a patient. 
         FIG. 4D  illustrates deployment of the multifunction warming device to therapeutically warm the lower body of a patient. 
     
    
    
     SPECIFICATION 
     A warming device is constituted of a clinical garment and at least one convective apparatus supported on an inside surface of the garment. In this regard, a “clinical garment” is a garment that is typically used to temporarily clothe a patient in a clinical setting. Such garments include hospital gowns, robes, bibs and other equivalents. The clinical setting may be a medical or dental office or clinic, a hospital, or any facility or institution that provides medical or dental treatment to patients. A convective apparatus receives and distributes at least one stream of warmed pressurized air in a structure for being disposed on, adjacent, or next to the core and/or the limbs of a body. When pressurized with warmed air, a convective apparatus emits warmed air through one or more of its surfaces. 
     In one aspect, a warming device may be worn on a person where it receives a stream of warmed pressurized air, distributes the pressurized air within a convective apparatus, and emits the air through one or more surfaces of the convective apparatus to warm the person&#39;s body. 
     In another aspect, the warming device may be adapted for relieving patient discomfort in the upper extremities, especially the hands and forearms, while the patient is warmed in other regions by means of the warming device by provision of slits (or openings or apertures) through the clinical garment which enable the patient to insert the hands into the garment for warming therein. 
     In the warming device illustrated and discussed below, convective apparatuses are inflatable. That is, their structures, flaccid when not in use, tauten when receiving a stream of pressurized air. 
     In the description to follow and in the figures, an exemplary warming device is constituted of a clinical garment supporting two convective apparatuses, one with separately inflatable sections. However, neither the number of convective apparatuses nor the number of inflatable sections is a necessary element of the invention described herein. Instead, the principles to be set forth apply to a warming device constituted of a clinical garment with an inside surface supporting at least one convective apparatus. 
     Refer now to the figures, in which a person wearing a multifunction warming device  20  is illustrated in  FIG. 2 . The warming device  20  is constituted of a clinical garment  22  and at least one convective apparatus (not seen in this view) supported on an inside surface of the clinical garment  22 . A convective apparatus supported on the inside surface of the clinical garment  22  may be operated by receiving warmed, pressurized air from a heater/blower unit (not seen in this view) through an air hose with a nozzle that is received in an inlet port of the convective apparatus. One such air hose  24 , with a nozzle  26 , is shown in  FIG. 2 . One such inlet port is indicated by reference numeral  27  in  FIG. 2 . The inlet port  27  is accessed through a flap  28  in the clinical garment  22 . Other convective apparatus inlet ports may be accessed through other flaps in the clinical garment  22  such as flaps  29  and  30 . 
       FIGS. 3A-3D  illustrate the elements of a multifunction warming device; the assembled warming device  20  is itself illustrated in  FIG. 3F . The view in  FIGS. 3A and 3F  is from the rear of the clinical garment  22 , looking toward the inside surface of the garment, which faces the chest, or thorax of a patient and on which at least one convective apparatus is mounted.  FIGS. 3B through 3D  are plan views of uninflated convective apparatuses, looking toward the permeable surfaces through which air is expelled toward a patient when the blankets are inflated. As seen in  FIGS. 3A and 3F , the warming device  20  includes the clinical garment  22 . The clinical garment  22  includes an inside surface  43 , two slits  44  (also seen in  FIG. 2 ), two opposing lateral hems  45 , a lower hem  47 , and a longitudinal axis  49 . The clinical garment  22  has an upper portion  51  with two opposing sleeves  53  (also seen in  FIG. 2 ) and a scooped upper edge  54 , and a lower portion  55 . The flaps  28 ,  29 , and  30  that provide access to inlet ports through the front of the garment  22  are also visible in  FIG. 3A . The sleeves  53  may be long or short. Short sleeves are preferred if access must be had to a person&#39;s arms for instrumentation and/or IV delivery. Each sleeve  53  includes an elongate seam  56  (both seen closed in  FIG. 2 ). Each seam  56  may be held closed by means  57  including, for example, buttons, snaps, hook and loop material, tape, and/or straps, or any equivalent thereof. Such means can be operated to let a seam  56  be opened and to again close a seam, once opened. Cuffs  58  may be formed in the clinical garment  22  inside the sleeves  53 , near the ends of the sleeves  53 . The clinical garment  22  may open on a side. Preferably, the clinical garment  22  opens in the rear. The opening may be full, as illustrated in  FIG. 3A , or it may be a slit rising from the lower hem  47 . As per the example shown in  FIG. 3A , the opening may be closed by means  59  along the lateral hems  45  which releasably connect to keep the hems together. Such means may include, for example, buttons, snaps, hook and loop material, tape, and/or straps, or any equivalent thereof. In keeping with the example of  FIG. 3A , if straps are used to close the opening, the straps may be attached to the clinical garment  22 , or formed integrally therewith as a step in manufacturing the clinical garment  22 . For example only, two integrally-formed straps  59   s  for tying the opposing lateral hems  45  together in the upper portion  51  are seen in  FIG. 3A . Two additional straps may be attached to the outside surface of the clinical garment  22  with enough reach to be tied together around the outside of the clinical garment, near its middle. With enough overlap of the lateral hems  45 , the opening in the clinical garment  22  can be completely closed and secured, with the lateral hems overlapping to afford concealment of a patient&#39;s private parts. The clinical garment  22  may be constructed from non-woven or woven materials. Preferably, the clinical garment  22  is made from a non-woven blend of spunlace polyester and wood pulp. 
     In  FIG. 3B , a first convective apparatus  60  is shown fully opened for deployment to provide therapeutic warming. In  FIG. 3C , elements of the first convective apparatus  60  are shown folded. The view in both figures is toward a permeable surface of the convective apparatus  60  through which heated air is expelled when the blanket is inflated. As seen in these figures, the first convective apparatus  60  includes an inlet port  61 , two laterally-extending arms  62 , each transitioning to a respective end  63 , a permeable surface  64 , and a lower edge  65 . Each end  63  has a generally quadrilateral configuration with a periphery  63   p . Typically, the periphery  63   p  includes a seal with some width. In some aspects of the first convective apparatus  60 , ties  63   t  may be integrally formed or defined in the peripheries  63   p  by lines of weakness or perforations  63   w . One tie  63   t  is shown in dashed outline in  FIG. 3B  partially separated from the periphery  63   p  in which it is formed. Such ties may be used when the first convective apparatus  60  is deployed for use in securing the first convective apparatus  60 . As can be appreciated, from the separated tie  63   t , the arcuate shape near the end of the tie provides easy handling for tying to another tie, to a patient, or to equipment in the surgical area. See the assignee&#39;s U.S. Pat. No. 5,773,275 in this regard. Optionally, slits  63   s  may be formed in seals near the outer edges of the ends  63 . The slits  63   s  may be defined in the seals by lines of perforations. If provided, the slits  63   s  may be opened to be used as purchase holds for unfurling the ends  63  and/or for receiving the hands on the outstretched arms of a patient in order to anchor or secure the ends  63  such as when the first convective apparatus  60  is inflated and operated. 
     For stowing the first convective apparatus  60  prior to use, the opposing sides of the ends  63  may be folded toward each other as indicated by the arrows  68   a  in  FIG. 3B , and then folded as indicated by the arrow  68   b  in  FIG. 3C . The folds reduce each end  63  to a length that fits in a respective sleeve  53  of the clinical garment  22 . The folds are preferably made so as to be easily tucked between the clinical garment  22  and the first convective apparatus  60 . The ends of the folded configurations may be retained in the inside cuffs  58  in the sleeves of the clinical garment  22 . This allows the patient to insert an arm through the sleeve of the clinical garment  22  without catching the corresponding hand on the fold and inadvertently deploying the extended side. Preferably, the ends  63  are folded by a Z-fold, although a gatefold, accordion fold or any equivalent fold may be used. More generally, the ends  63  may be folded, rolled or gathered in any way that achieves the desired length reduction and neat compaction useful for stowing and retaining the ends  63  in the cuffs  58 , and unfolding them when the first convective apparatus is to be used for therapeutic warming. The first convective apparatus  60  has a line of weakness or perforation that extends transversely at  69  between each end  63  and a respective laterally-extending side  62 . 
     With further reference to  FIGS. 3B and 3C , in some aspects the first convective apparatus  60  may include an attachment mechanism, preferably in the form of double-sided tape  66 . Preferably, the double-sided tape  66  is attached on one side of the convective apparatus  60  to a sealed lower portion of the permeable surface  64  of the first convective apparatus  60 , along the lower edge  65 , centered between the ends  63 . Referring to  FIG. 3B , the surface  66   b  of the double-sided tape  66  that is visible is covered with a non-adhesive backing that can be stripped off to expose the adhesive with which both sides of the tape are covered. For convenience, the sealed lower portion of the permeable surface  64  where the attachment mechanism is mounted may be surrounded by a perforation  66   p  which allows either side of the attachment mechanism to be detached from the sealed lower portion and permit the attachment mechanism to pivot on its longitudinal edge. The perforation  66   p  also permits the attachment mechanism to be removed after use. 
     With reference to  FIGS. 3B and 3C , although one inlet port  61  is illustrated in the first convective apparatus  60 , one or more additional inlet ports may be provided for convenience. Unused inlet ports are sealed or closed by known means to prevent air escaping therethrough. Preferably the inlet port  61  is provided through the surface of the first convective apparatus  60  which is not visible in this figure; it may also be provided through an edge of the first convective apparatus  60 . The inlet port  61  may comprise a collar  61   a  of stiff material with an opening  61   b  to receive the nozzle of an air hose, or it may comprise a sleeve of material, or any other equivalent structure. When the first convective apparatus  60  is used for therapeutic warming, the ends of the sleeves are removed from the cuffs  58  and unfolded. Then, pressurized air flowing through an inlet port such as the inlet port  61  inflates the first convective apparatus  60 , from its central portion to its ends  63 . 
     A second convective apparatus  70  with separately inflatable sections is illustrated in  FIG. 3D . A “section” of the second convective apparatus  70  is a portion or division of the second convective apparatus  70  that may be inflated and operated separately from any other section of the second convective apparatus  70 . For example, the second convective apparatus  70  has a section  71  and a section  72 . The section  71  may be inflated and operated separately from the section  72 , and the section  72  may be inflated and operated separately from the section  71 . 
     In the second convective apparatus  70  shown in  FIG. 3D , the section  71  has an inlet port  74 , an upper edge  75 , an elongate central part  76 , and upper and lower transverse parts  77  and  78  that connect perpendicularly to the central part  76 . The ends of the upper and lower transverse parts  77  and  78  may be rounded, so that, in the plan view of  FIG. 3D , the section  71  has a “dog bone” shape. Alternatively, the section  71  may have the shape of a capital I, with upper and lower cross bars. Although one inlet port  74  is illustrated in the section  71 , one or more additional inlet ports may be provided for convenience. Unused inlet ports are sealed or closed by known means to prevent air escaping therethrough. Preferably the inlet port  74  is provided through the surface of the second convective apparatus  70  which is not visible in this figure. The inlet port  74  may comprise a collar  74   a  of stiff material with an opening  74   b  to receive the nozzle of an air hose, or it may comprise a sleeve of material, or any other equivalent structure. The space in the central part  76  is in fluid communication with the spaces in the transverse parts  77  and  78  so that pressurized air flowing through the inlet port  74  flows throughout the parts  76 - 78 , thereby inflating the first section  71 . The surface  79  of the section  71  which is visible in  FIG. 3D , including the surfaces of the parts  76 - 78 , is permeable, permitting pressurized air that is flowing into and inflating the section  71  to be expelled toward the interior of the clinical garment  22  (that is, toward a patient wearing the device  20 ). In some aspects of the first section  71 , the permeability of the surfaces of the parts  76 - 78  may vary in order to reduce or eliminate variances in temperature of air expelled through the permeable surface  79  of the section  71 . 
     As seen in  FIG. 3D , the second section  72  has a U-shaped outline with lower edge  82  and side edges  83  and  84 . The section  72  generally forms an outline that surrounds the first section  71  on three sides. Although one inlet port  85  is illustrated in the section  72 , one or more additional inlet ports may be provided for convenience. Unused inlet ports are sealed or closed by known means to prevent air escaping therethrough. Preferably the inlet port  85  is provided through the surface of the second convective apparatus  70  which is not visible in  FIG. 3F , although it may also be provided through an edge of the second convective apparatus  70 . The inlet port  85  may comprise a collar  85   a  of stiff material with an opening  85   b  to receive the nozzle of an air hose, or it may comprise a sleeve of material, or any other equivalent structure. Pressurized air flowing through the inlet port  85  inflates the section  72 . The surface  86  of the section  72  which is visible in  FIG. 3F  is permeable, permitting pressurized air that is flowing into and inflating the section  72  to be expelled toward the interior of the clinical garment  22  (that is, toward a patient wearing the device  20 ). 
     In some aspects of the second convective apparatus  70 , the upper edge  75  of the first section  71  is adjacent the upper edge  80  of the second convective apparatus in order to position the upper transverse part  77  approximately against and transverse to the upper chest, between the shoulders, of a patient wearing the clinical garment  22 . This advantageously locates the upper transverse part  77  for delivery of air for comfort warming the patient. 
     The dog-bone and U construction of the second convective apparatus  70  is not intended to be limiting; it is just one example of how the apparatus may be provided with separately-inflatable sections for comfort and therapeutic warming, and other possible two-section constructions are shown and described in the related applications that are listed above. 
     With reference to  FIG. 3D , in some aspects of the second convective apparatus the inlet port  74  of the first section  71  may have a smaller opening  74   b  than the opening  85   b  through the inlet port  85  of the second section  72 . In this case, the openings  61   b  of the first convective apparatus  60  and  85   b  of the second section  72  are preferably of equal size. Consequently, the inlet port  74  accepts an air hose nozzle with a smaller diameter than the air hose nozzle diameter accepted by the inlet ports  61  and  85 . The smaller nozzle diameter signifies a comfort warming air supply with an air hose having a smaller diameter than the air hose of a therapeutic warming air supply. Further, the smaller air hose may be coupled to a heater blower unit with a smaller capacity than that of the heater blower unit of a therapeutic warming air supply, which can be connected to either the first convective apparatus  60  or the second section  72  of the second convective apparatus  70 . The provision of an inlet port  74  dimensioned for a smaller-diameter hose enables the first section  71  to operate in response to a lower capacity heater/blower unit designed for comfort warming. The provision of inlet ports  61  and  85  dimensioned for a larger-diameter hose enables the first convective apparatus  60  and the second section  72  of the second convective apparatus  70  to operate in response to a higher capacity heater/blower unit designed for therapeutic warming. The first convective apparatus  60  is therefore constructed for therapeutic warming, and the second convective apparatus  70  has a first section  71  constructed for comfort warming and a second section  72  constructed for therapeutic warming. 
       FIG. 3D  illustrates a preferred relationship between the first and second convective apparatuses  60  and  70  as they are disposed, supported or constructed on the inside surface  43  of the clinical garment  22 . The blankets  60  and  70  are disposed such that the upper edge  80  of the second convective apparatus  70  overlaps the lower edge  65  of the first convective apparatus. The upper edge  80  may be retained in place by tacking, taping, or a light adhesive acting between the upper edge  80  and the first convective apparatus  60  and/or the inside surface  43  of the clinical garment. 
     Preferably, the overlapping upper edge  80  seen in  FIG. 3D  covers the double-sided tape  66 , but it may be folded back from the lower edge  65  to expose the double-sided tape  66  on the first convective apparatus  60 . An operation for deploying the double-sided tape for use is shown in  FIGS. 3G, 3H, and 3I . In  FIG. 3G , the double-sided tape  66  is adhered, on one side, to the first convective apparatus  60  centered along the lower edge  65 . Backing is still mounted to the surface  66   b  that faces the second convective apparatus  70 . The upper edge  80  of the second convective apparatus overlaps the lower edge  65  and the double-sided tape  66 . When being deployed for use, as seen in  FIG. 3H , the two short sections of the perforation  66   p  (best seen in  FIG. 3B ) are torn. This permits the portion of the first convective apparatus  60  to which the double-sided tape  66  is attached to pivot on its longitudinal edge so that the lower edge  65  with the double-sided tape  66  mounted therealong may be swung outwardly, away from the inside surface of the clinical garment (not shown), over the upper edge  80  of the second convective apparatus  70 . As seen in  FIG. 3I , the portion of the first convective apparatus  60  to which the double-sided tape  66  is mounted is swung back to lie on the outside of the upper edge  80 . In this position, the backing on the surface  66   b  may be stripped off and the tape  66  may be adhesively attached to the skin of a patient, thereby anchoring the warming device. As explained hereinabove with reference to  FIGS. 3B and 3C , the double-sided tape  66  may be removed after use by tearing along the long section of the perforation  66   p . Alternatively, the tape  66  may be stowed behind the upper edge  80  once the tape has been released from the patient, and the upper edge  80  may be adhered to the tape. 
     A head drape  87 , shown furled or folded in  FIGS. 3A-3D , preferably constituted of a sheet of clear plastic, may be attached to the inside surface  43  of the clinical garment  22 , near the scooped upper edge  54  (shown in  FIG. 3A ) or may be attached near the upper edge of the first convective apparatus  60  on the surface which faces the inside surface  43  (shown in  FIGS. 3B through 3D ). 
     In  FIG. 3E , the plan view shows the convective apparatuses  60  and  70  in the preferred relationship of  FIG. 3D , with the ends  63  of the first convective apparatus  60  unfolded, the double-sided tape  66  rotated, and the head drape  87  unfurled. 
       FIG. 3F  shows a multifunction warming device  20  for perioperative use assembled from the elements illustrated in  FIGS. 3A-3D . In the multifunction warming device  20 , the first and second convective apparatuses  60  and  70  are supported on the inside surface  43  of the clinical garment  22  with the relationship seen in  FIG. 3D . In  FIG. 3F , the view is toward the permeable surfaces of the convective apparatuses  60  and  70 . Together the first and second convective apparatuses  60  and  70  form a Tee-shaped figure, substantially centered on the longitudinal axis  49 , and with a thick base (the second convective apparatus  70 ) and an elongate top (the first convective apparatus  60 ) which is perpendicular to the base. 
     As illustrated in  FIG. 3F , the first convective apparatus  60  is an elongate convective apparatus disposed, supported, or constructed on the inside surface  43  of the clinical garment  22 , in the upper portion  51 , transverse to the longitudinal axis  49  and extending from sleeve  53  to sleeve  53 . Preferably, the first convective apparatus  60  is an upper body convective apparatus having the construction illustrated in  FIGS. 3B and 3C , with its ends  63  folded and retained in the inside cuffs  58 . An opening in the upper portion  51  of the clinical garment  22  (such as the flap  29  in  FIGS. 2 and 3A ) provides access by which an air hose can connect to the inlet port  61  of the first convective apparatus  60  in order to operate the convective apparatus  60  for therapeutic warming. Warmed, pressurized air flows into and inflates the first convective apparatus  60 , and exits through the permeable surface  64  toward a patient. The second convective apparatus  70  with separately inflatable sections for therapeutic and comfort warming is disposed, supported, or constructed on the inside surface  43 , in the lower portion  55 , and is disposed longitudinally to the clinical garment  22 , with the longitudinal axis  49  and extending from just above the lower edge  65  of the first convective apparatus  60  toward the lower hem  47 . Preferably, the second convective apparatus  70  has the construction illustrated in  FIG. 3D  with a dog-bone shaped section  71  to provide comfort warming, and a second, separately-inflatable section  72  that frames the dog-bone shaped section  71  to provide therapeutic warming. An opening in the lower portion  55  of the clinical garment  22  (such as the flap  28  in  FIGS. 2 and 3A ) provides access by which an air hose can connect to the inlet port  74  of the first section  71  of the second convective apparatus  70  to operate the first section for comfort warming. Warmed, pressurized air flows into and inflates the first section  71 , and exits through the permeable surface  79  of the first section  71 , toward a patient. An opening in the lower portion  55  of the clinical garment  22  (such as the flap  30  in  FIG. 2 ) provides access by which an air hose can connect to an inlet port  85  of the second section  72  of the second convective apparatus  70  to operate the second section for therapeutic warming. Warmed, pressurized air flows into and inflates the second section  72 , and exits through the permeable surface  86  of the second section  72 , toward a patient. 
     The first section  71  of the second convective apparatus  70  may be said to be “adapted” for comfort warming by virtue of an average or mean permeability in the surface  79  that is lower than the average or mean permeability in the surface  86  of the second section  72 . The lower average permeability of the surface  79  accommodates a lower air pressure entering the first section  71  from a relatively low capacity heater/blower unit, coupled by a smaller-diameter air hose to a smaller inlet port. Similarly, the second section  72  of the second convective apparatus  70  may be said to be “adapted” for therapeutic warming by virtue of an average or mean permeability in the surface  86  that is higher than the average or mean permeability in the surface  79  of the first section  71 . The higher average permeability of the surface  86  accommodates a higher air pressure entering the second section  72  from a relatively high capacity heater/blower unit, coupled by a larger-diameter air hose to a larger inlet port. 
     Each of the first and second convective apparatuses  60  and  70  may be formed by joining two sheets of material with a closed impermeable seam around their peripheries and, in the second convective apparatus, one or more additional closed impermeable seams to define the separate sections. One of the sheets is relatively impermeable and the other sheet is relatively more permeable to permit airflow therethrough. The sheets are further connected by discontinuous seals or stake points within the closed impermeable seams. The two sheets with which a convective apparatus is formed may be separate from the clinical garment  22 , in which case the convective apparatuses are permanently or releasably attached, fixed, or adhered to the inside surface  43  of the clinical garment  22 , with their permeable surfaces facing inwardly, toward a patient wearing the device  20 . An exemplary construction in this regard is illustrated in FIGS. 1A and 1D and FIGS. 3A-3C of PCT publication WO 2003/086500. Alternately, the convective apparatuses may be formed or constructed integrally with a clinical garment  22  made of relatively impermeable material by attaching relatively permeable sheets to portions of the inside surface of the clinical garment  22 . An exemplary construction in this regard is illustrated in FIGS. 1D and 1E and FIGS. 3D-3F of PCT publication WO 2003/086500. 
     According to the present best mode of construction of the multifunction warming device for perioperative use, the first and second convective apparatuses are formed or assembled separately from the clinical garment and then attached to its inside surface by sewing, gluing, heat sealing, or welding, or any combination of these. Each of the first and second convective apparatuses is formed by heat sealing two sheets of material together. The first convective apparatus is formed with a laminate sheet comprising a layer of nonwoven material on which a layer of polypropylene is extruded, and a polypropylene film. Apertures are formed through the laminate sheet and the polypropylene layer and polypropylene film are sealed around their peripheries. The polypropylene film is attached to the inside surface of the clinical garment and the nonwoven material faces the patient. The reason for locating the polypropylene film on the inside surface of the clinical garment is to reduce the bulk and stiffness of the first convective apparatus, thus making the warming device more comfortable to the patient. The sheets used for the second convective apparatus each comprise a layer of spunbond nonwoven material with a polypropylene extrusion coating on one side. This construction is used for both sides of the second convective apparatus. The extrusion-coated sides of the sheets are positioned facing the interior inflatable space of the second convective apparatus, away from the patient. The polypropylene extrusion makes the nonwoven material air impermeable. That way the air blown into the second convective apparatus can be dispersed to the patient by selectively perforating the patient side of the second convective apparatus, which forms the permeable surface of the second convective apparatus. The non-permeable side of the second convective apparatus that faces the inside surface of the clinical garment is nonwoven, and when the patient slides her or his hands into the slits  44 , they are in comfortable contact with a soft material. 
     When the multifunction warming device  20  is worn as shown in  FIG. 2  for comfort warming, a convective apparatus may be connected to a heater/bower unit via an air hose to receive a stream of warmed pressurized air. The convective apparatus inflates in response to the stream of air and emits air through its permeable surface. The multifunction warming device  20  retains warmed air within the clinical garment  22  for comfort warming preoperatively. Preferably, although not necessarily, the first section  71  of the second convective apparatus  70  is operated for comfort warming preoperatively. 
     When comfort warming is provided by operation of the first section  71 , the person being warmed may insert his or her hands through the slits  44  in the front of the clinical garment  22 , which open into space between the clinical garment  22  and the surface of the second convective apparatus  70  which faces the inside surface  43  of the clinical garment  22 . These slits  44  afford access to a space where the hands can be warmed for comfort and/or pre-warmed in preparation for and/or receipt of an IV needle. Alternatively, with reference to  FIGS. 3B and 3C , one end  63  of the first convective apparatus  60  may be unfurled or unfolded and extended through the sleeve  53  in which it is disposed to cover the arm and hand of the person wearing the warming device  20 . Then, the first convective apparatus  60  may be inflated by way of the inflation port under the flap  29  with a stream of warm air to pre-warm the arm and hand for receipt of an IV needle. 
       FIGS. 4A-4C  illustrate how the multifunction warming device  20  is adapted for therapeutic warming by using the first convective apparatus  60  in the same manner as an upper body thermal blanket. The view in these figures is toward the front of the clinical garment  22 , from a position above the patient, who is lying prone on an operating table (not shown), preferably one with cruciate support for the patient&#39;s arms. In  FIG. 4A , a patient is shown wearing a warming device  20  as preparation commences Ties  100  hold the clinical gown  22  closed. In  FIG. 4B , the ties  100  are untied, and the head drape  87  is unfurled, as are the ends  63  of the first convective apparatus  60 . A grasping target  88  (also seen in  FIGS. 3B-3D ), or a tab, not shown, may be provided on a free upper edge of the head drape  87  so that the drape may be grasped for deployment. The ends  63  are freed from the cuffs  58 , unfurled through the ends of the sleeves  53  and unfolded to be positioned over the hands and wrists of the patient. 
     Although not shown in the figures, lines of weakness (preferably, perforations) may be formed in each sleeve  53  to enable access to an end  63  folded and tucked into a cuff  58 . Refer to  FIGS. 3A and 3F . The perforations may be formed around the front half of a sleeve  53 , or they may be formed at or near the end of the sleeve. One pattern of perforations may be two opposing perforation lines formed on the outside and inside of the front side of the sleeve  53 , near its end, which enable a user to tear away the of the front half of the sleeve  53  and reach into the cuff to unfold the end  63 . Another pattern may be a single line of perforations formed just at the end of the sleeve  53  which permits a user to separate the two sides of the cuff  58  at the end of the sleeve  53 . In either case, once the end of the sleeve  53  is opened, the end  63  of the first convective apparatus  60  can be pulled through the now-opened end of the cuff  58 , through the end of the sleeve  53 . 
     In  FIG. 4C , the flap  29  has been folded back to expose the inlet port  61  of the first convective apparatus  60  and a heater/blower unit (not shown) may now be connected to the inlet port  61  via an air hose and nozzle (not shown). As explained above in connection with  FIGS. 3G, 3H, and 3I  the double-sided tape  66  is deployed for use. That is to say, the upper edge of the second convective apparatus  70  is pulled away from the double-sided tape  66  and the backing  66   b  is pulled off the tape&#39;s outer surface. As seen in  FIG. 4C , the ends  63  of the first convective apparatus  60  and head drape  87  are fully unfurled, the tape  66  is adhesively attached to the patient&#39;s body, and the lower portion of the clinical garment  22  is furled or folded at  22   f , together with the second convective apparatus  70 , over the first convective apparatus  60 , thereby removing the lower portion of the multifunction warming device  20  from the surgical site.  FIG. 4C  shows the first convective apparatus  60 , in the form of an upper body convective device, freed for deployment over and secured to the patient, and operated thereat to provide therapeutic warming during thoracic, abdominal, or pelvic surgery. In operation, the first convective apparatus  60  inflates in response to a stream of air from a heater/blower unit and emits air through its permeable surface toward the patient. The head drape  87  and unfurled ends  63  trap warm air around the patient&#39;s head and hands, which contributes to maintaining the core temperature at or near normothermia. 
     With reference to  FIG. 4C , after surgery, when the heater/blower unit is disconnected from the first convective apparatus  60 , the ends  63  may be removed along the perforations  69  seen in  FIGS. 3B, 4C, and 5E , or the first convective apparatus  60  may left intact to continue being used for warming in the postoperative period. The upper portion of the head drape  87  may be detached along the line of perforations  89  seen in  FIG. 4C , or the head drape may be left intact to continue being used for warming in the postoperative period. With reference to  FIG. 4C , the furled portion  22   f  of the clinical garment  22  may be unfurled or unfolded, together with the second convective apparatus  70 , from the center of the first convective apparatus  60  toward the patient&#39;s feet thereby reconfiguring the clinical gown  22  to be worn again by the patient. Alternatively, if the patient is to be warmed postoperatively while recovering from anesthesia, the unfurled clinical gown  22  can serve as a blanket or drape over the patient to trap warm air about the patient. 
       FIG. 4D  illustrates how the multifunction warming device  20  is adapted for therapeutic warming using the second convective apparatus  70  to warm the patient in the same manner as a lower body thermal blanket during surgery. The view is toward the front of the clinical garment  22 , from a position above the patient, who is lying prone on an operating table (not shown), preferably one with cruciate support for the patient&#39;s arms (also not shown). With reference to  FIG. 4D , the multifunction warming device  20  may be configured for therapeutic warming using the second section  72  of the second convective apparatus  70  by separating the sleeve seams  56  and pulling the sleeves  53  away from the patient&#39;s arms. The upper portion  51  of the clinical garment  22  is then pulled down from the patient&#39;s upper body and furled or folded at  22   ff , with the first convective apparatus  60 , over the lower portion  55 . As explained above in connection with  FIGS. 3G, 3H, and 3I  the double-sided tape  66  is deployed for use, the backing  66   b  is removed and the tape is adhesively attached to the patient&#39;s body. The flap  30  is folded back to expose the inlet port  85  of the second section  72  and a heater/blower unit (not shown) may be connected to the inlet port  85  via an air hose and nozzle (not shown). The second convective apparatus  70  is thus deployed and used in the same manner as a lower body thermal blanket during surgery on the patient&#39;s upper body, with the second section  72  providing therapeutic warming. While the patient is prone, the sides of the clinical gown  22  may be allowed to hang and act as a drape, trapping warmed air around the patient. After surgery, the upper portion  51  may be unfurled or unfolded, together with the first convective apparatus  60 , from the lower portion  55  toward the patient&#39;s upper body. The sleeves  53  may be pulled upwardly toward the patient&#39;s shoulders, and the seams  56  may be joined over the arms to reconfigure the clinical gown  22  to be worn by the patient. Alternatively, if the patient is to be warmed postoperatively while recovering from anesthesia, the unfurled clinical gown  22  can serve as a blanket or drape over the patient to trap warm air about the patient. 
     A multifunction warming device includes a clinical garment with at least one convective apparatus supported on the inside of the garment. Slits are provided in the clinical garment which enables a patient to insert his or her hands inside the clinical garment to be warmed therein by operation of the convective apparatus. 
     Although the invention has been described with reference to the presently preferred embodiment, it should be understood that various modifications can be made without departing from the spirit of the invention. Accordingly, the invention is limited only by the following claims.