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Brock-Utne JG, Ward JT, Jaffe RA. Potential sources of operating room air contamination: a preliminary study. J Hosp Infect 2021; 113:59-64. [PMID: 33895163 DOI: 10.1016/j.jhin.2021.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Neptune® surgical suction system (NSSS) and the Bair Hugger® (BH) forced-air warmer both discharge filtered exhaust or heated air into the operating room (OR), often in close proximity to a surgical site. AIM To assess the effectiveness of this filtration, we examined the quantity and identity of microbial colonies emitted from their output ports compared with those obtained from circulating air entering the OR. METHODS Air samples were collected from each device using industry-standard sampling devices in which a measured volume of air is impacted on to a blood agar plate at a controlled flow rate. Twelve ORs were studied. Sample plates were incubated for one week per study protocol, then interpreted for colony counts and sent for species identification. FINDINGS The average colony count from the NSSS exhaust was not significantly different from that obtained from room air samples, however the average count from the BH output was significantly higher (P=0.0086) than room air. Genetic identification profiles revealed the presence of environmental or commensal organisms that differed depending on the source. High variability in colony counts from both devices suggests that certain NSSS and BH devices could be significant sources of OR air contamination. CONCLUSIONS Our study showed that the BH patient warming device could be a source of airborne microbial contamination in the OR and that individual BH and NSSS units exhibit a higher output of microbial cfu than would be expected compared with incoming room air. We make simple suggestions on ways to mitigate these risks.
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Affiliation(s)
- J G Brock-Utne
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - J T Ward
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - R A Jaffe
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Shirozu K, Setoguchi H, Araki K, Ando T, Yamaura K. Impact of air-conditioner outlet layout on the upward airflow induced by forced air warming in operating rooms. Am J Infect Control 2021; 49:44-49. [PMID: 32603852 DOI: 10.1016/j.ajic.2020.06.202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previously, we found that an upward air current in the head area, induced by forced air warming (FAW), was completely counteracted by downward laminar airflow. However, this study did not include any consideration of the air-conditioner outlet layout (ACOL); hence, its impact remains unclear. METHODS This study was performed in 2 operating rooms (ORs)-ISO classes 5 and 6, which are denoted as OR-5 and OR-6, respectively. Both ORs have distinct ACOLs. The cleanliness, or the number or ratio of shifting artificial particles was evaluated. RESULTS During the first 5 minutes after particles generation, significantly more particles shifted into the surgical field in OR-5 when compared to OR-6 (13,587 [4,341-15,913] and 106 [41-338] particles/cubic foot, P < .0001). Notably, FAW did not increase the number of shifting particles in OR-6. The laminar airflow system fully counteracted the upward airflow caused by FAW in OR-6, where the ACOL covered the operating bed. However, this did not occur in OR-5, where the ACOL did not fully cover the operating bed. CONCLUSIONS Regardless of cleanliness ability of OR, an ACOL that fully covers the operating bed can prevent upward airflow in the head area and reduce the number of artificial particles shifting into the surgical field, which are typically caused by FAW.
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3
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Cutler HS, Romero JA, Minor D, Huo MH. Sources of contamination in the operating room: A fluorescent particle powder study. Am J Infect Control 2020; 48:948-950. [PMID: 32046882 DOI: 10.1016/j.ajic.2019.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/28/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
Abstract
This study utilized fluorescent particle powder to investigate 2 potential sources of sterile field contamination in the operating room (OR): forced-air warming blankets and OR light manipulation. In part 1, sterile draping for knee replacement surgery was performed on a mannequin in a sterile OR, comparing field contamination with the forced-air warming on versus off during draping. In part 2, OR lights coated with fluorescent powder were manipulated over a sterile field. Proper operation of these devices may reduce the particle burden on the surgical field.
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Shirozu K, Takamori S, Setoguchi H, Yamaura K. Effects of forced air warming systems on the airflow and sanitation quality of operating rooms with non-laminar airflow systems. ACTA ACUST UNITED AC 2020; 21:100119. [PMID: 32838049 PMCID: PMC7261106 DOI: 10.1016/j.pcorm.2020.100119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/15/2020] [Accepted: 05/25/2020] [Indexed: 01/23/2023]
Abstract
Background : Previous studies have demonstrated that forced air warming (FAW) can be used safely in operating rooms with laminar airflow (LAF) ventilation systems. However, the effects of FAW on the airflow at surgical sites under non-LAF (nLAF) ventilation systems remain unclear, as nLAF systems generate outlet-to-inlet multidirectional airflows of the air conditioning system. Here, we evaluate the effects of FAW on the airflow and sanitation quality in surgical fields with nLAF ventilation systems. Methods : The airflow speed and direction were measured using a three-dimensional ultrasonic anemometer. Sanitation quality was evaluated by measuring the amount of dust particles after the activation of air conditioning. Results : FAW caused no meaningful airflow (> 10 cm/sec) and did not diminish the sanitation quality in the surgical field separated by the anesthesia screen. Above the head area, the upward FAW airflow was not counteracted by nLAF, which caused an upward airflow at the edges of the operating table, originating from outside of the operating table and the floor. Conclusions : Sanitation quality was kept under FAW working even in an nLAF-equipped OR. According to the inlet/outlet layouts of nLAF, the upward FAW-induced airflow in the head area was not counteracted, and the upward airflow from the floor induced by the air conditioner outlet could be detected.
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Affiliation(s)
- Kazuhiro Shirozu
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Shinnosuke Takamori
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | | | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Derilus D, Godoy-Vitorino F, Rosado H, Agosto E, Dominguez-Bello MG, Cavallin H. An in-depth survey of the microbial landscape of the walls of a neonatal operating room. PLoS One 2020; 15:e0230957. [PMID: 32243474 PMCID: PMC7122808 DOI: 10.1371/journal.pone.0230957] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 03/12/2020] [Indexed: 12/22/2022] Open
Abstract
Bacteria found in operating rooms (ORs) might be clinically relevant since they could pose a threat to patients. In addition, C-sections operations are performed in ORs that provide the first environment and bacterial exposure to the sterile newborns that are extracted directly from the uterus to the OR air. Considering that at least one third of neonates in the US are born via C-section delivery (and more than 50% of all deliveries in some countries), understanding the distribution of bacterial diversity in ORs is critical to better understanding the contribution of the OR microbiota to C-section- associated inflammatory diseases. Here, we mapped the bacteria contained in an OR after a procedure was performed; we sampled grids of 60x60 cm across walls and wall-adjacent floors and sequenced the V4 region of 16S rRNA gene from 260 samples. The results indicate that bacterial communities changed significantly (ANOSIM, p-value < 0.001) with wall height, with an associated reduction of alpha diversity (t-test, p-value <0.05). OR walls contained high proportions of Proteobacteria, Firmicutes, and Actinobacteria, with Proteobacteria and Bacteroidetes being the highest in floors and lowest in the highest wall sites. Members of Firmicutes, Deinococcus-thermus, and Actinobacteria increased with wall height. Source-track analysis estimate that human skin is the major source contributing to bacterial composition in the OR walls, with an increase of bacteria related to human feces in the lowest walls and airborne bacteria in the highest wall sites. The results show that bacterial exposure in ORs varies spatially, and evidence exposure of C-section born neonates to human bacteria that remain on the floors and walls, possibly accumulated from patients, health, and cleaning staff.
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Affiliation(s)
- Dieunel Derilus
- Department of Environmental Sciences, University of Puerto Rico, San Juan, Puerto Rico, United States of America
| | - Filipa Godoy-Vitorino
- Department of Microbiology and Medical Zoology, University of Puerto-Rico-School of Medicine, San Juan, Puerto Rico, United States of America
| | - Hebe Rosado
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Edgardo Agosto
- School of Architecture, University of Puerto Rico, San Juan, Puerto Rico, United States of America
| | - Maria Gloria Dominguez-Bello
- Department of Biochemistry and Microbiology, and of Anthropology, and the New Jersey Institute for Food Nutrition and Health, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Humberto Cavallin
- School of Architecture, University of Puerto Rico, San Juan, Puerto Rico, United States of America
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Uggen C. Editorial Commentary: Just Getting Warmed Up: Risks, Benefits, and Economics of Active Warming Devices. Arthroscopy 2020; 36:353-354. [PMID: 32014169 DOI: 10.1016/j.arthro.2019.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/13/2019] [Indexed: 02/02/2023]
Abstract
Efforts to maintain normothermia should be a part of every patient's perioperative care. Risks, benefits, and economic implications should be considered when deciding how to use active warming devices for orthopaedic surgery. The Centers for Medicare & Medicaid Services has implemented economic incentives and penalties driving hospitals to invest in active warming devices, including forced-air warmers and resistive heating devices. Even though forced-air warmers and resistive heating blankets are likely to statistically improve patient temperatures, they may not be worth the additional cost for shorter, less invasive, elective arthroscopic surgeries. In addition, recent research demonstrates minimal clinically significant differences between these 2 types of devices. Concern regarding possible increased risk of surgical-site contamination with forced-air warmers warrants further study but, again, is unlikely clinically relevant to arthroscopic cases, and proper staff training and warming equipment routine maintenance could minimize patient risk.
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7
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Bischof JC, Diller KR. From Nanowarming to Thermoregulation: New Multiscale Applications of Bioheat Transfer. Annu Rev Biomed Eng 2019; 20:301-327. [PMID: 29865870 DOI: 10.1146/annurev-bioeng-071516-044532] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This review explores bioheat transfer applications at multiple scales from nanoparticle (NP) heating to whole-body thermoregulation. For instance, iron oxide nanoparticles are being used for nanowarming, which uniformly and quickly rewarms 50-80-mL (≤5-cm-diameter) vitrified systems by coupling with radio-frequency (RF) fields where standard convective warming fails. A modification of this approach can also be used to successfully rewarm cryopreserved fish embryos (∼0.8 mm diameter) by heating previously injected gold nanoparticles with millisecond pulsed laser irradiation where standard convective warming fails. Finally, laser-induced heating of gold nanoparticles can improve the sensitivity of lateral flow assays (LFAs) so that they are competitive with laboratory tests such as the enzyme-linked immunosorbent assay. This approach addresses the main weakness of LFAs, which are otherwise the cheapest, easiest, and fastest to use point-of-care diagnostic tests in the world. Body core temperature manipulation has now become possible through selective thermal stimulation (STS) approaches. For instance, simple and safe heating of selected areas of the skin surface can open arteriovenous anastomosis flow in glabrous skin when it is not already established, thereby creating a convenient and effective pathway to induce heat flow between the body core and environment. This has led to new applications of STS to increase or decrease core temperatures in humans and animals to assist in surgery (perioperative warming), to aid ischemic stress recovery (cooling), and even to enhance the quality of sleep. Together, these multiscale applications of nanoparticle heating and thermoregulation point to dramatic opportunities for translation and impact in these prophylactic, preservative, diagnostic, and therapeutic applications of bioheat transfer.
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Affiliation(s)
- John C Bischof
- Department of Mechanical Engineering, University of Minnesota, Minneapolis, Minnesota 55455, USA;
| | - Kenneth R Diller
- Department of Biomedical Engineering, University of Texas, Austin, Texas 78712, USA;
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Liu S, Pan Y, Zhao Q, Feng W, Han H, Pan Z, Sun Q. The effectiveness of air-free warming systems on perioperative hypothermia in total hip and knee arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15630. [PMID: 31083262 PMCID: PMC6531108 DOI: 10.1097/md.0000000000015630] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Perioperative hypothermia is a common and serious complication during surgery. Different warming systems are used to prevent perioperative hypothermia. However, there have been no previous meta-analyses of the effectiveness of air-free warming systems on perioperative hypothermia in patients undergoing joint arthroplasty. METHODS We systematically searched PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases to collect randomized controlled trials (RCTs) from inception to August 2018. These RCTs compared the effects of air-free warming with forced-air (FA) warming system in patients undergoing joint arthroplasty. Postoperative temperature, core temperature during surgery, thermal comfort, blood loss and incidence of shivering and hypothermia were analyzed. RESULTS A total of 287 patients from 6 clinical studies were included in the analysis. In summary, there was no significant difference in the postoperative temperature (WMD -0.043, 95% CI -0.32 to 0.23, P = .758) between the air-free warming and FA warming groups. No statistical difference (WMD 0.058, 95% CI -0.10 to 0.22, P = .475) was found in core temperatures at 0 minutes during surgery between the air-free warming and FA warming groups. Furthermore, there was no statistical difference in thermal comfort, blood loss or incidence of shivering and hypothermia between the air-free warming and FA warming groups. CONCLUSIONS Air-free warming system was as effective as FA warming system in patients undergoing joint arthroplasty.
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Affiliation(s)
- Shuyan Liu
- Department of Ophthalmology, The Second Hospital of Jilin University, Changchun, China
- Department of Genetics, The University of Alabama at Birmingham, Birmingham, AL
| | - Yu Pan
- Department of Anesthesiology and Resuscitology, Okayama University, Okayama, Japan
| | - Qiancong Zhao
- Department of Genetics, The University of Alabama at Birmingham, Birmingham, AL
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Wendy Feng
- Department of Cell, Developmental and Integrative Biology, The University of Alabama at Birmingham, Birmingham, AL
| | - Hongyu Han
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, China
| | - Zhenxiang Pan
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, China
| | - Qianchuang Sun
- Department of Genetics, The University of Alabama at Birmingham, Birmingham, AL
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, China
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Aalirezaie A, Akkaya M, Barnes CL, Bengoa F, Bozkurt M, Cichos KH, Ghanem E, Darouiche RO, Dzerins A, Gursoy S, Illiger S, Karam JA, Klaber I, Komnos G, Lohmann C, Merida E, Mitt P, Nelson C, Paner N, Perez-Atanasio JM, Reed M, Sangster M, Schweitzer D, Simsek ME, Smith BM, Stocks G, Studers P, Talevski D, Teuber J, Travers C, Vince K, Wolf M, Yamada K, Vince K. General Assembly, Prevention, Operating Room Environment: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S105-S115. [PMID: 30348570 DOI: 10.1016/j.arth.2018.09.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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10
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Ackermann W, Fan Q, Parekh AJ, Stoicea N, Ryan J, Bergese SD. Forced-Air Warming and Resistive Heating Devices. Updated Perspectives on Safety and Surgical Site Infections. Front Surg 2018; 5:64. [PMID: 30519561 PMCID: PMC6258796 DOI: 10.3389/fsurg.2018.00064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 09/25/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction: Perioperative hypothermia is one of the most common phenomena seen among surgical patients, leading to numerous adverse outcomes such as intraoperative blood loss, cardiac events, coagulopathy, increased hospital stay and associated costs. Forced air warming (FAW) and resistive heating (RH) are the two most commonly used and widely studied devices to prevent perioperative hypothermia. The effect of FAW on operating room laminar flow and surgical site infection is unclear and we initiated an extensive literature search in order to get a scientific insight of this aspect. Material and Methods: The literature search was conducted using the Medline search engine, PubMed, Cochrane review, google scholar, and OSU library. Results: Out of 92 Articles considered initially for review we selected a total of 73 relevant references. Currently there is no robust evidence to support that FAW can increase SSIs. In addition, both of the two warming devices present safety problems. Conclusion: As unbiased independent reviewers, we advise clinicians to weigh the risks and benefits when using either one of these devices; no change in the current practice is necessary until further data emerges.
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Affiliation(s)
- Wiebke Ackermann
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Qianqian Fan
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States.,Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Akarsh J Parekh
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Nicoleta Stoicea
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - John Ryan
- Department of Orthopedics, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Sergio D Bergese
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, United States.,Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
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11
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Bischof JC, Diller KR. From Nanowarming to Thermoregulation: New Multiscale Applications of Bioheat Transfer. Annu Rev Biomed Eng 2018. [PMID: 29865870 DOI: 10.1146/annurev‐bioeng‐071516‐044532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This review explores bioheat transfer applications at multiple scales from nanoparticle (NP) heating to whole-body thermoregulation. For instance, iron oxide nanoparticles are being used for nanowarming, which uniformly and quickly rewarms 50-80-mL (≤5-cm-diameter) vitrified systems by coupling with radio-frequency (RF) fields where standard convective warming fails. A modification of this approach can also be used to successfully rewarm cryopreserved fish embryos (∼0.8 mm diameter) by heating previously injected gold nanoparticles with millisecond pulsed laser irradiation where standard convective warming fails. Finally, laser-induced heating of gold nanoparticles can improve the sensitivity of lateral flow assays (LFAs) so that they are competitive with laboratory tests such as the enzyme-linked immunosorbent assay. This approach addresses the main weakness of LFAs, which are otherwise the cheapest, easiest, and fastest to use point-of-care diagnostic tests in the world. Body core temperature manipulation has now become possible through selective thermal stimulation (STS) approaches. For instance, simple and safe heating of selected areas of the skin surface can open arteriovenous anastomosis flow in glabrous skin when it is not already established, thereby creating a convenient and effective pathway to induce heat flow between the body core and environment. This has led to new applications of STS to increase or decrease core temperatures in humans and animals to assist in surgery (perioperative warming), to aid ischemic stress recovery (cooling), and even to enhance the quality of sleep. Together, these multiscale applications of nanoparticle heating and thermoregulation point to dramatic opportunities for translation and impact in these prophylactic, preservative, diagnostic, and therapeutic applications of bioheat transfer.
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Affiliation(s)
- John C Bischof
- Department of Mechanical Engineering, University of Minnesota, Minneapolis, Minnesota 55455, USA;
| | - Kenneth R Diller
- Department of Biomedical Engineering, University of Texas, Austin, Texas 78712, USA;
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12
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Curtis GL, Faour M, George J, Klika AK, Barsoum WK, Higuera CA. High Efficiency Particulate Air Filters Do Not Affect Acute Infection Rates During Primary Total Joint Arthroplasty Using Forced Air Warmers. J Arthroplasty 2018; 33:1868-1871. [PMID: 29572038 DOI: 10.1016/j.arth.2018.01.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/09/2018] [Accepted: 01/25/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Studies have suggested that forced-air warmers (FAWs) increase contamination of the surgical site. In response, FAWs with high efficiency particulate air filters (FAW-HEPA) were introduced. This study compared infection rates following primary total joint arthroplasty (TJA) using FAW and FAW-HEPA. METHODS Primary TJA patients at a single healthcare system were retrospectively reviewed. A total of 5405 THA (n = 2419) and TKA (n = 2986) consecutive cases in 2013 and 2015 were identified. Patients in 2013 (n = 2792) had procedures using FAW, while FAW-HEPA was used in 2015 (n = 2613). The primary outcome was overall infection rate within 90-days. Sub-categorization of infections as periprosthetic joint infection (PJI) or surgical site infection (SSI) was also conducted. PJI was defined as reoperation with arthrotomy or meeting Musculoskeletal Infection Society (MSIS) criteria. SSI was defined as wound complications requiring antibiotics or irrigation/debridement. RESULTS The FAW and FAW-HEPA groups had similar rates of overall infection (1.65% [n = 46] vs 1.61% [n = 42], P > .99), SSI (1.18% [n = 33] vs 0.84% [n = 22], P = .27), and PJI (0.47% [n = 13] vs 0.77% [n = 20], P = .22). Regression models did not show FAW to be an independent risk factor for increased overall infection (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.65-1.57, P = .97), SSI (OR 1.47, 95% CI 0.83-2.58, P = .18), or PJI (OR 0.53, 95% CI 0.25-1.13, P = .09). CONCLUSION FAW were not correlated with a higher risk of overall infection, SSI, or PJI during TJA when compared to FAW-HEPA devices.
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Affiliation(s)
- Gannon L Curtis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Mhamad Faour
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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13
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Affiliation(s)
- Mitchell C Weiser
- Department of Orthopaedic Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Abstract
BACKGROUND Forced air warming systems are used to maintain body temperature during surgery. Benefits of forced air warming have been established, but the possibility that it may disturb the operating room environment and contribute to surgical site contamination is debated. The direction and speed of forced air warming airflow and the influence of laminar airflow in the operating room have not been reported. METHODS In one institutional operating room, we examined changes in airflow speed and direction from a lower-body forced air warming device with sterile drapes mimicking abdominal surgery or total knee arthroplasty, and effects of laminar airflow, using a three-dimensional ultrasonic anemometer. Airflow from forced air warming and effects of laminar airflow were visualized using special smoke and laser light. RESULTS Forced air warming caused upward airflow (39 cm/s) in the patient head area and a unidirectional convection flow (9 to 14 cm/s) along the ceiling from head to foot. No convection flows were observed around the sides of the operating table. Downward laminar airflow of approximately 40 cm/s counteracted the upward airflow caused by forced air warming and formed downward airflow at 36 to 45 cm/s. Downward airflows (34 to 56 cm/s) flowing diagonally away from the operating table were detected at operating table height in both sides. CONCLUSIONS Airflow caused by forced air warming is well counteracted by downward laminar airflow from the ceiling. Thus it would be less likely to cause surgical field contamination in the presence of sufficient laminar airflow.
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15
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Effectiveness of Early Warming With Self-Warming Blankets on Postoperative Hypothermia in Total Hip and Knee Arthroplasty. Orthop Nurs 2017; 36:356-360. [PMID: 28930905 DOI: 10.1097/nor.0000000000000383] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hypothermia is an important complication in joint arthroplasty. Commonly, forced air warming (FAW) devices are used intraoperatively to maintain body temperature in patients undergoing surgery. However, it is believed that these convective warming systems could increase the risk of deep surgical site infections due to disruption of unidirectional downward laminar airflow. Conductive warming devices have no noticeable effect on ventilation airflow. Nevertheless, the effectiveness of the self-warming (SW) blanket, a novel conductive warming device, on postoperative hypothermia in elective joint arthroplasty is unknown. PURPOSE The purpose of this study was to evaluate the effectiveness of early warming with SW blankets in the prevention of postoperative hypothermia in elective total hip (THA) and knee arthroplasty (TKA) compared with FAW devices. METHODS Patients who underwent elective THA or TKA between May and June 2014 were assigned in the FAW or SW group. A total of 105 patients were enrolled into the study. In the FAW group, the FAW devices were applied after disinfection of the surgical site. In the SW group, the SW blankets were already applied in the orthopaedic department. The duration of warming with SW blankets before anesthetic induction was documented. The body temperature was measured preoperatively upon arrival in the orthopaedic department and postoperatively upon arrival in the postanesthesia care unit. The patient's body temperature was measured at the tympanic membrane, and hypothermia was defined as a body temperature of less than 35.5°C. RESULTS The SW blankets were applied for a median of 86.8 minutes (78.8-94.8) before anesthetic induction. Postoperative hypothermia was observed in 15 (31.3%) and eight (14.0%) patients in the FAW group and the SW group, respectively (p = .029). The median postoperative body temperature was 35.59°C (35.44-35.74) and 35.95°C (35.83-36.06) in the FAW group and the SW group, respectively (p < .001). CONCLUSION Early warming with SW blankets was more effective than FAW devices in the prevention of postoperative hypothermia in elective THA and TKA.
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Augustine SD. Forced-Air Warming Discontinued: Periprosthetic Joint Infection Rates Drop. Orthop Rev (Pavia) 2017; 9:6998. [PMID: 28713524 PMCID: PMC5505092 DOI: 10.4081/or.2017.6998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/15/2017] [Indexed: 11/23/2022] Open
Abstract
Several studies have shown that the waste heat from forced-air warming (FAW) escapes near the floor and warms the contaminated air resident near the floor. The waste heat then forms into convection currents that rise up and contaminate the sterile field above the surgical table. It has been shown that a single airborne bacterium can cause a periprosthetic joint infection (PJI) following joint replacement surgery. We retrospectively compared PJI rates during a period of FAW to a period of air-free conductive fabric electric warming (CFW) at three hospitals. Surgical and antibiotic protocols were held constant. The pooled multicenter data showed a decreased PJI rate of 78% following the discontinuation of FAW and a switch to air-free CFW (n=2034; P=0.002). The 78% reduction in joint implant infections observed when FAW was discontinued suggests that there is a link between the waste FAW heat and PJIs.
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Shin H, Pei Z, Martinez KA, Rivera-Vinas JI, Mendez K, Cavallin H, Dominguez-Bello MG. The first microbial environment of infants born by C-section: the operating room microbes. MICROBIOME 2015; 3:59. [PMID: 26620712 PMCID: PMC4665759 DOI: 10.1186/s40168-015-0126-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 10/29/2015] [Indexed: 05/20/2023]
Abstract
BACKGROUND Newborns delivered by C-section acquire human skin microbes just after birth, but the sources remain unknown. We hypothesized that the operating room (OR) environment contains human skin bacteria that could be seeding C-section born infants. RESULTS To test this hypothesis, we sampled 11 sites in four operating rooms from three hospitals in two cities. Following a C-section procedure, we swabbed OR floors, walls, ventilation grids, armrests, and lamps. We sequenced the V4 region of the 16S rRNA gene of 44 samples using Illumina MiSeq platform. Sequences were analyzed using the QIIME pipeline. Only 68 % of the samples (30/44, >1000 sequences per site) yielded sufficient DNA reads to be analyzed. The bacterial content of OR dust corresponded to human skin bacteria, with dominance of Staphylococcus and Corynebacterium. Diversity of bacteria was the highest in the ventilation grids and walls but was also present on top of the surgery lamps. Beta diversity analyses showed OR dust bacterial content clustering first by city and then by hospital (t test using unweighted UniFrac distances, p < 0.05). CONCLUSIONS We conclude that the dust from ORs, collected right after a C-section procedure, contains deposits of human skin bacteria. The OR microbiota is the first environment for C-section newborns, and OR microbes might be seeding the microbiome in these babies. Further studies are required to identify how this OR microbiome exposure contributes to the seeding of the neonatal microbiome. The results might be relevant to infant health, if the current increase in risk of immune and metabolic diseases in industrialized societies is related to lack of natural exposure to the vaginal microbiome during labor and birth.
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Affiliation(s)
- Hakdong Shin
- Division of Translational Medicine, New York University School of Medicine, 550 1st Avenue, BCD 690, New York, NY, 10016, USA
| | - Zhiheng Pei
- Division of Translational Medicine, New York University School of Medicine, 550 1st Avenue, BCD 690, New York, NY, 10016, USA
- Department of Veterans Affairs New York Harbor Healthcare System, New York, NY, USA
| | - Keith A Martinez
- Division of Translational Medicine, New York University School of Medicine, 550 1st Avenue, BCD 690, New York, NY, 10016, USA
| | - Juana I Rivera-Vinas
- Hospital Universitario, Medical Science Campus, University of Puerto Rico, Puerto Rico, USA
| | - Keimari Mendez
- Hospital Universitario, Medical Science Campus, University of Puerto Rico, Puerto Rico, USA
| | | | - Maria G Dominguez-Bello
- Division of Translational Medicine, New York University School of Medicine, 550 1st Avenue, BCD 690, New York, NY, 10016, USA.
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Wood AM, Moss C, Keenan A, Reed MR, Leaper DJ. Infection control hazards associated with the use of forced-air warming in operating theatres. J Hosp Infect 2014; 88:132-40. [PMID: 25237035 DOI: 10.1016/j.jhin.2014.07.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 07/06/2014] [Indexed: 01/25/2023]
Abstract
A review is presented of the published experimental and clinical research into the infection control hazards of using forced air-warming (FAW) in operating theatres to prevent inadvertent hypothermia. This evidence has been reviewed with emphasis on the use of ultra-clean ventilation, any interaction it has with different types of patient warming (and FAW in particular), and any related increased risk of surgical site infection (SSI). We conclude that FAW does contaminate ultra-clean air ventilation; however, there appears to be no definite link to an increased risk of SSI based on current research. Nevertheless, whereas this remains unproven, we recommend that surgeons should at least consider alternative patient-warming systems in areas where contamination of the operative field may be critical. Although this is not a systematic review of acceptable randomized controlled clinical trials, which do not exist, it does identify that there is a need for definitive research in this field.
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Affiliation(s)
- A M Wood
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - C Moss
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - A Keenan
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M R Reed
- Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - D J Leaper
- Huddersfield University, Huddersfield, UK.
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Casha AR, Manché A, Camilleri L, Gauci M, Grima JN, Borg MA. A novel method of personnel cooling in an operating theatre environment. Interact Cardiovasc Thorac Surg 2014; 19:687-9. [PMID: 24994697 DOI: 10.1093/icvts/ivu201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
An optimized theatre environment, including personal temperature regulation, can help maintain concentration, extend work times and may improve surgical outcomes. However, devices, such as cooling vests, are bulky and may impair the surgeon's mobility. We describe the use of a low-cost, low-energy 'bladeless fan' as a personal cooling device. The safety profile of this device was investigated by testing air quality using 0.5- and 5-µm particle counts as well as airborne bacterial counts on an operating table simulating a wound in a thoracic operation in a busy theatre environment. Particle and bacterial counts were obtained with both an empty and full theatre, with and without the 'bladeless fan'. The use of the 'bladeless fan' within the operating theatre during the simulated operation led to a minor, not statistically significant, lowering of both the particle and bacterial counts. In conclusion, the 'bladeless fan' is a safe, effective, low-cost and low-energy consumption solution for personnel cooling in a theatre environment that maintains the clean room conditions of the operating theatre.
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Affiliation(s)
- Aaron R Casha
- Department of Cardiac Services, Mater Dei Hospital, Msida, Malta
| | - Alexander Manché
- Department of Cardiac Services, Mater Dei Hospital, Msida, Malta
| | - Liberato Camilleri
- Department of Statistics and Operations Research, Faculty of Science, University of Malta, Msida, Malta
| | - Marilyn Gauci
- Department of Anaesthesia, Mater Dei Hospital, Msida, Malta
| | - Joseph N Grima
- Metamaterials Unit, Faculty of Science, University of Malta, Msida, Malta
| | - Michael A Borg
- Department of Infection Control, Mater Dei Hospital, Msida, Malta Department of Pathology, Faculty of Medicine, University of Malta, Msida, Malta
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Kellam MD, Dieckmann LS, Austin PN. Forced-air warming devices and the risk of surgical site infections. AORN J 2014; 98:354-66; quiz 367-9. [PMID: 24075332 DOI: 10.1016/j.aorn.2013.08.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 08/05/2013] [Indexed: 11/25/2022]
Abstract
The potential that forced-air warming systems may increase the risk of surgical site infections (SSIs) by acting as a vector or causing unwanted airflow disturbances is a concern to health care providers. To investigate this potential, we examined the literature to determine whether forced-air warming devices increase the risk of SSIs in patients undergoing general, vascular, or orthopedic surgical procedures. We examined 192 evidence sources, 15 of which met our inclusion criteria. Most sources we found indirectly addressed the issue of forced-air warming and only three studies followed patients who were warmed intraoperatively with forced-air warming devices to determine whether there was an increased incidence of SSIs. All of the sources we examined contained methodological concerns, and the evidence did not conclusively suggest that the use of forced-air warming systems increases the risk of SSIs. Given the efficacy of these devices in preventing inadvertent perioperative hypothermia, practitioners should continue to use and clean forced-air warming systems according to the manufacturer's instructions until well-conducted, large-scale trials can further examine the issue.
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Affiliation(s)
- Scott Augustine
- Augustine Temperature Management LLC, Eden Prairie, Minnesota,
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Weissman C, Murray WB. In response. Anesth Analg 2014; 118:883-4. [PMID: 24651245 DOI: 10.1213/ane.0000000000000103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Charles Weissman
- Department of Anesthesiology, Hadassah-University Hospital, Kiryat Hadassah, Jerusalem Department of Anesthesiology, Pennsylvania State University College of Medicine, Hummelstown, Pennsylvania,
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Augustine S. Another perspective on forced-air warming and the risk of surgical site infection. AORN J 2014; 99:350-1. [DOI: 10.1016/j.aorn.2013.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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