ARTICLE IN PRESS

American Journal of Infection Control 000 (2020) 1−6

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major article

Impact of air-conditioner outlet layout on the upward airflow induced by

forced air warming in operating rooms
Kazuhiro Shirozu MD, PhD a,*, Hidekazu Setoguchi MD, PhD b, Kenzo Araki MD c, Taichi Ando MD d,
Ken Yamaura MD, PhD e
a
Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
b
Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
c
Department of Anesthesiology, Tagawa municipal hospital, Kyushu University Hospital, Fukuoka, Japan
d
Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
e
Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Key Words: A B S T R A C T
Forced air warming system
Cleanliness Background: Previously, we found that an upward air current in the head area, induced by forced air warm-
Particle counter
ing (FAW), was completely counteracted by downward laminar airflow. However, this study did not include
Surgical site infection
any consideration of the air-conditioner outlet layout (ACOL); hence, its impact remains unclear.
Anesthesia
Laminar airflow 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 sur-
gical 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.
© 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.

BACKGROUND
Actively warming patients during surgery, by methods such as
forced air warming (FAW), provides clear benefits.1,2 On the other
hand, FAW generates upward airflow in the head area, which poten-
tially causes contamination. We have previously reported that the
presence of downward laminar airflow (LAF) completely counteracts
this, which enables FAW to be used with negligible contamination.3
* Address correspondence to Kazuhiro Shirozu, MD, PhD, Lecturer, Department of
Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maida-
shi, Higashi-ku, Fukuoka 812-8582, Japan.
E-mail address: shiron@kuaccm.med.kyushu-u.ac.jp (K. Shirozu).
Conflicts of interest: None to report.Contribution: All authors helped review the
literature and write the manuscript, and approved the final version of the manuscript.
Funding: The authors received support from an educational research fund of the Oper-
ating Rooms in Kyushu University Hospital.
However, the previous study had the following limitations: (1) the
air-conditioner outlet in the operating room fully covered the operat-
ing bed, including the head area; (2) the FAW temperature was set at
38°C, so the results may not be applicable to relevant higher temper-
atures; and (3) the surgical lights were moved away from the operat-
ing field.
As compared to conductive fabric, Kumar et al. reported that an
FAW system set at 43°C significantly mobilized artificial bubbles that
were generated in head area, to move over the anesthesia drape, and
into the surgical field.4 However, this study did not mention the air-
conditioner outlet layout (ACOL) in the operating room, which has
recently been highlighted as an area of great importance in such
studies. In one study, fewer microbes were detected in the sterile
field of an operating room (OR) when a single large diffuser was
used, as compared to using a multi-diffuser array or 4-way throw dif-
fuser.5 In addition, Kumar et al. reported that an FAW set at a higher

https://doi.org/10.1016/j.ajic.2020.06.202
0196-6553/© 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
2 K. Shirozu et al. / American Journal of Infection Control 00 (2020) 1−6
temperature (43°C) disrupted the ventilation airflow over the surgi-
cal site.4 Refaie et al. found that surgical lights could further disturb
LAF.6 Given these previous studies, we hypothesized that surgical
field contamination was affected by the temperature setting of the
FAW, the OR ACOL, and the presence and location of any surgical
lights.
The specific purpose of this study was to examine the effects of
ACOL on the possibility of contamination into surgical field induced
by FAW, at the highest relevant temperature setting, 43°C, and in the
presence of a surgical light. We compared the FAW effects between
class 5 (352 < maximum particles (size 30.5 mm)/m3 < 3,520, former
classification class 100) and class 6 (3,520 < maximum particles (size
3 0.5 mm)/m3 < 35,200, former classification class 1,000) ORs with
different ACOLs (Table 1). The primary objective was to investigate
the effect of ACOL on the number or ratio of artificially generated par-
ticles that were shifted from the head area into the surgical field by
FAW. Additionally, we investigated how this particle movement was
affected by placing a cover above the under-warming blanket.
METHODS
Experimental operating room circumstance
This was a simulated study on manikins and not on human sub-
jects. The study was performed in 2 ORs at Kyushu University Hospi-
tal, Fukuoka, Japan, where all ORs are equipped with a unidirectional
vertical LAF system (Shinko Air Handling Unit; Shinko Industrial Co.
Ltd., Osaka, Japan). The ORs used in this study were designed as ISO
class 5 or 6, denoted as OR-5 or OR-6, respectively. The OR-5 used
had a height of 3 m, a floor space of 48.36 m2, and receives an air sup-
ply of 33,131 m3/h, resulting in 228 air changes per hour. This large
ventilation volume enables the OR-5 to achieve high levels of cleanli-
ness. However, the large ACOL in this room dose not fully cover the
operating table (Fig 1a and Table 1). In contrast, the OR-6 used had a
height of 3 m, a floor space of 34.22 m2, and receives an air supply of
10,102 m3/h, resulting in 98 air changes per hour. Here, the wide air-
conditioner outlet covers the entire operating table (Fig 1b and
Table 1). The air-conditioning outlet in each OR contains several pan-
els, which includes a final point-of-use high-efficiency particulate air
filter on each panel.
An upper-body manikin was placed in a supine position on the
operating table and covered with a surgical drape with an under-
warming blanket placed underneath it. Artificial particles were gen-
erated at the head area of the manikin by rubbing a typical surgical
towel 5 times, for a total of about 2 seconds. An anesthesia drape was
clipped to intravenous poles and raised 150 cm above the floor, and
the height of the operating bed was set as 100 cm above the floor. A
3M Bair Hugger (Model 750; 3M Company, Maplewood, MN) and
under-warming blanket (Model 585; 3M Company) comprised the
Table 1
Comparison of basic capability between OR-5 and OR-6
ISO classification Class 5 OR
Former classification Class 100
Cleanliness 352 < maximum particles
(size 3 0.5 mm)/m3 < 3,520
Height (m) 3 3
floor space (m2) 48.36
air supply (m3/h) 33,131
air change (per hour) 228
ACOL Non-fully covering
the operating table
ACOL, air-conditioner outlet layout.
FAW device, with the warming temperature set to 43°C. The air-con-
ditioning temperature in the OR was set to 25°C.
Particles shifting from the head area into the surgical field
Particles were counted in the surgical field based on general sur-
gery use assumptions, which included holding the head area in paral-
lel and using 2 particle counters (AeroTrak 9110, TSI Incorporated,
Shoreview, MN) at 30-second intervals for a total of 8 minutes. Suc-
tion sampling was performed at 1 cubic foot/min to measure the
quantity of dust particles with a grain size of at least 0.5 mm. A fabric
cover was used above the under-warming blanket to investigate the
prevention of the direct upward airflow caused by FAW, as well as
any subsequent affects.
Three-dimensional measurements of airflow direction and speed
The airflow caused by FAW or LAF, either in the presence or
absence of surgical lights above the operating table, were evaluated
by a 3-dimensional (3D) measurement of airflow direction and speed.
A 3D ultrasonic anemometer (WA-790; Sonic Corporation, Tokyo,
Japan) was used to measure the direction and speed of the airflow
within a total of 168 points with 300 mm intervals. These intervals
consist of 7 points on the x-axis, 6 points on the y-axis (with the head
located at point Y6), and 4 points on the z-axis. The axes and mea-
surement points are defined and denoted in Fig. 1c and d.
Cleanliness assessment
To investigate the OR cleanliness, a cleanliness recovery test was
performed in which dust was artificially generated in the surgical
field, with the air-conditioner turned off. The dust removal process
was then subsequently assessed after the air-conditioner was turned
on.7 Using a particle counter (KC-03A; RION Co., Ltd., Tokyo, Japan),
suction sampling was performed at 1 cubic foot/min to measure the
quantity of dust particles at least 0.5 mm in size. Either the air-condi-
tioner or FAW was turned on with an initial dust particle generation,
and changes in the dust particle quantity were measured at 1-minute
intervals until the particle concentration decreased below 10/cubic
foot. A total of 6 measurement points were taken at the centre and
edges of the operating table in the Y3 cross-section (Supplemental 1a
and b), at heights of 800 and 1,500 mm.
Statistical analysis
Further analysis was needed to review the number of particles
shifting from the head area into the surgical field under FAW, within
5 minutes of generation. Power analysis (a = 0.05, b = 0.20) indicated
that a subject sample size fewer than 3 per group was needed to
Class 6 OR
Class 1,000
3,520 < maximum particles
(size 3 0.5 mm)/m3< 35,200
34.22
10,102
98
Entirely covering the operating table
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K. Shirozu et al. / American Journal of Infection Control 00 (2020) 1−6 3

Fig 1. Experimental set-up and airflow measurement points. (a) Top view of the OR-5, with the patterned portion indicating the air-conditioner outlet. (b) Top view of the OR-6,
with the patterned portion indicating the air-conditioner outlet. (c) Top view illustrating the measurement points. The floor was marked with tape every 300 mm. There were 7
measuring points on the x-axis (X1-X7; X4 was the centre), and 6 measuring points on the y-axis (Y1-Y6). (d) The view from the foot of the operating bed. There were 4 measuring
points on the z-axis (800, 1100, 1400, and 2900 mm from the floor). All measuring points were 300 mm apart.

detect a significant difference between OR-5 and OR-6. The Data is
presented as median (IQR[range]) or mean § standard deviation.
Additionally, Tukey or Sidak’s multiple comparison post hoc test was
used in a 2-way analysis of variance (Fig 2, and Supplements 1 and
2). All statistical analyses were performed using Prism 6 software
(GraphPad Software, La Jolla, CA), with P < .05 considered to be statis-
tically significant.
RESULTS
Cleanliness in OR-5 and OR-6
Before the air-conditioner was activated, there was no significant
difference in the number of particles per cubic foot between OR-5
and OR-6, regardless of whether FAW was implemented or not (not
shown). The duration between activating the air-conditioner and
achieving a particle count below 10/ cubic foot was significantly
shorter in OR-5 (3.3 § 0.5 minute) than in OR-6 (6.3 § 1.6 minute)
without FAW (Supplement 1). The same finding was obtained when
FAW was used in OR-5 and OR-6 by achieving less than 10 particles/
cubic foot in 3.0 § 0.0 and 7.7 § 0.8 minutes, respectively. Notably,
there was also no significant difference in the times obtained (Sup-
plement 1).
Particle shifting in OR-5 and OR-6
As aforementioned, there was no significant difference in the ini-
tial number of generated particles in the head area in OR-5 and OR-6
either with or without FAW (Table 2). During the first 30 seconds
after particle generation under FAW working, 5,063 [2,449-9,523]
and 8 [3-16] particles/ cubic foot (P < .0001) shifted in OR-5 and OR-
6, respectively. Between 30-60 seconds, 4,140 [1,039-5,155] and 10
[2-14] particles/cubic foot (P < .0001) shifted in OR-5 and OR-6 under
FAW working, respectively (Fig 2a and Table 2). After a total of 5
minutes after particle generation, OR-5 and OR-6 exhibited 13,587
[4,341-15,913] and 106 [41-338] (P < .0001) shifted particles/ cubic
foot. In the first 30 seconds after particle generation without FAW
(Fig 2a), 54 [11-116] and 4 [2-6] particles/ cubic foot (P = .99) shifted
in OR-5 and OR-6, respectively. As a check, these results were con-
firmed to be quite similar to the shifting ratios, as defined by the par-
ticles found in the surgical field at each time point to those in the
head area at 30 seconds x 100 (Supplement 2a).
Particle shifting with FAW
Utilizing FAW in OR-5 increased the number of particles that
shifted during the first 30 seconds (5,063 [2,449-9,523] and 54 [11-
116] / cubic foot, P < .0001, with and without FAW, respectively) or
30-60 seconds (4,140 [1,039-5,155] and 50 [23-72]/cubic foot, P <
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4 K. Shirozu et al. / American Journal of Infection Control 00 (2020) 1−6

Fig 2. The number of particles shifting into surgical field. (a) A comparison of the number of particles shifting into surgical field from the head area between OR-5 and OR-6, with or
without FAW. Blue or brown represent the cases of the OR-5 or OR-6. Triangles or circles represent the cases of the with or without FAW. (b) The effect of covering the under-warm-
ing blanket on the number of particles shifting in OR-5. Red or purple represent the cases of the without or with FAW. (c) The view of covering above the warming-blanket. The
number of samples in each group was 10. Triangles or Circles indicate the median values. ****P < .0001.

.0001, with and without FAW, respectively) after particle generation,
as well as the total particles that shifted in 5 minutes (13,587 [4,341-
15,913] and 167 [75-349]/cubic foot, P < .0001, with and without
FAW, respectively) into surgical field (Fig 2a and Table 2). In using
FAW in OR-6, the number of particles shifted into the surgical field
did not significantly increase during 0-30, 30-60, or 60-90 seconds
and in 5 minutes after particle generation, which was 106 [41-338]
and 69 [52-99] / cubic foot, P = .47, with and without FAW, respec-
tively (Fig 2a and Table 2). These results are also similar to those for
the shifting ratio shown in Supplement 2a. Notably, there is no signif-
icant difference in the initial number of generated particles in the
head area with or without FAW in OR 5 or 6.
Particle shifting under FAW working with a covering above the under-
warming blanket
Generally, utilizing a physical cover above the under-warming
blanket did not affect in the number of particles in the 0-30, 30-60, or
60-90 seconds intervals after particle generation. It also did not affect
the total particles counted in the surgical field of OR-5 within the first
5 minutes (not shown). Furthermore, there was no significant differ-
ence in the initial number of particles generated in the head area in
OR-5, with or without the use of a covering (Fig 2b). These results
were also confirmed by the shifting ratio results (Supplement 2b).
3D airflow direction and speed in OR-5 or 6 under FAW working with
LAF without surgical light
From the feet side at Y3 cross section, LAF caused homogenous
downward airflow (»56 cm/s) around the operating table in OR-6,
but not in OR-5 (Fig 3).
3D airflow direction and speed in OR-5 or OR-6 under FAW working
with surgical light
From the right side at X4 cross section, FAW did not cause airflow
above the surgical drape or surgical field in OR-5 and OR-6. In head
area, upward airflow was detected both in OR-5 (»36 cm/s) and OR-6
(»39 cm/s) without LAF (Fig 4, upper and supplement 3). In OR-5,
upward airflow (»37 cm/s) in the head area remained under LAF. In

Table 2
Comparison of initial generated number in head area or shifting particle number into surgical field between OR-5 and OR-6

FAW Class 5 OR Class 6 OR

+ +

Initial generated number in head area 77,912 [44,926-92,766] 53,956 [43,818-95,696] 68,400 [23,396-10,1857] 86,823 [60,682-96,492]
Total number during 5 min in surgical field 13,587 [4,341-15,913] 167 [74.5-349] 106 [41-338] 69 [52-99]
During the first 30 s 5,063 [2,449-9,523] 54 [11-116] 8 [3-16] 4 [2-6]
Between 30-60 s 4,140 [1,039-5,155] 50 [23-72] 10 [2-14] 7 [0-12]
NOTE. Median (IQR[range]), number/cubic foot.
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K. Shirozu et al. / American Journal of Infection Control 00 (2020) 1−6
Fig 3. Airflow direction and speed at the Y3 cross section. Airflow direction and speed at the Y3 cross section in OR-5 (left) or OR-6 (right) under FAW working with LAF without sur-
gical lights. Airflow speeds are represented by the numeric values enclosed in the squares and by the length and colour of the arrows. The arrows in the figures indicated the mean
direction and speed for 10 s.
OR-6, upward airflow in the head area was completely counteracted
by LAF (downward airflow: »55 cm/s) (Fig 4, lower and supple-
ment 4).
DISCUSSION
To our knowledge, the ACOL effects on upward airflow induced by
FAW has not been previously investigated. Generally, in an OR with a
wide air-conditioner outlet that fully covers the operating bed, signif-
icantly fewer particles shifted into the surgical field from the head
area when compared with an OR with an air-conditioner outlet that
did not fully cover the operating bed, despite extremely high air
exchange times (Fig 2a and Table 1). Our results indicate that OR
cleanliness is determined primarily by the amount of ventilation air
and OR-5 is superior to OR-6 (Supplement 1). However, ACOL is more
important for preventing particle shifting that is induced by FAW. In
Fig 4. Airflow direction and speed at the X4 cross section. Airflow direction and speed
at the Y3 cross section with (upper) or without LAF (lower) caused by FAW with surgi-
cal lights. The red trapezoids represent surgical lights. Airflow speeds are represented
by the numeric values enclosed in the squares and by the length and colour of the
arrows.
5
fact, even when FAW was introduced, the number of particles shifting
did not increase when the air-conditioner outlet fully covered the
operating bed (Fig 2a).
Additionally, we hypothesized that upward airflow, induced by
FAW, could be prevented by covering the under-warming blanket,
which would inhibit direct flow. However, this had little actual effect
on the number of shifting particles (Fig 2b). Thus, indicating that
upward airflow around the head area might be due primarily to the
discharge of warmed air underneath the surgical drape, rather than
direct airflow from the small pores of the under-warming blanket. It
is also possible that covering the under-warming blanket was insuffi-
cient in this work because the fabric cover used had air permeability.
The investigation of airflow and speed (Fig. 3 and 4) clearly
revealed why the shifting particle shifting was so dramatically
affected by ACOL. Specifically, air-conditioner outlets that fully cov-
ered the operating table, such as that in OR-6, can generate a homo-
geneous downward airflow over a wide range that can counteract
the upward airflow in the head area caused by FAW. This effectively
prevents any particles from shifting into the surgical field. Contrarily,
if there is a defect in the outlet, as in OR-5, the downward airflow in
the surgical field becomes obscured, and subsequently it cannot pre-
vent particle shifting.
Previously, Belani et al. used artificially generated bubbles to ana-
lyse their movement from the head area into the surgical field. He
concluded that FAW caused surgical field contamination, while con-
ductive patient warming devices were safe for surgical use because
they do not impact the ventilation airflow.4 Additionally, by observ-
ing helium soap bubbles, McGovern et al. found that FAW caused
convectional air currents to develop between the surgeon’s body and
the operating table, which transported the floor-level air upward and
into the surgical site.8 These authors also recommended a conductive
warming device be used instead of FAW. Importantly, these reports
did not investigate the airflow around the operating bed or the ACOL,
and thus the results might be affected by ACOL. In recent study, we
showed that sanitation quality was kept under FAW working even in
non-LAF equipped OR. However, the upward FAW-induced airflow in
the head area was not counteracted.9 Although, the global guidelines
of the world health organization for SSI prevention indicate that the
use of LAF was not necessarily recommended for patients undergoing
total arthroplasty surgery, warranting further research on these
issues.
Notably, this study has certain limitations, including the lack of
uniformity in the number of generated particles. To address this, we
analysed the ratio of shifting particles, and the results were almost
identical to the results obtained based on the direct particle counting.
As a further limitation, we did not examine the effects of surgical
staff, surgical devices, or other factors that may influence OR airflow.
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6 K. Shirozu et al. / American Journal of Infection Control 00 (2020) 1−6
Additionally, we did not measure colony forming units or the direct
impact on SSIs. Further study is needed.
CONCLUSIONS
Overall, we conclude that the ACOL and the position relationship
between ACOL and operating bed, is an important factor in prevent-
ing particles from shifting into the surgical field. Additionally, FAW
can be used safely to warm the patient during the operation, without
causing surgical field contamination, in the case where the ACOL is
set directly and completely above the area experiencing upward air-
flow induced by FAW.
Acknowledgment
I would like to express our deepest appreciation to Mr. Tetsuya
Kai, who work in Kyushu Medical Hospital for his assistance in this
study.
SUPPLEMENTARY MATERIALS
Supplementary material associated with this article can be found
in the online version at https://doi.org/10.1016/j.ajic.2020.06.202.
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