795

C OPYRIGHT
2018 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Operating-Room Airflow Technology and
Infection Prevention
Mitchell C. Weiser, MD, MEng, and Calin S. Moucha, MD

Investigation performed at Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, and Icahn School of Medicine at Mount Sinai,
New York, NY

ä Operating-room (OR) heating, ventilation, and air-conditioning (HVAC) systems play an important role in the
reduction of airborne bacterial colony-forming units.

ä Laminar flow ventilation systems reduce OR bacterial counts, but their ability to lower surgical site infection (SSI)
rates in joint replacement procedures is controversial.

ä Airborne bacteria in the OR during surgery are primarily produced by the OR staff and circulate in the air on shed
skin particles (squames).

ä Airflow patterns in the OR are complex and may be affected by the layout and operational characteristics of the
HVAC system, door-opening events, heat generated by surgical equipment, forced-air warmers, and the movement
of equipment and personnel.

ä Forced-air warmers generate excess heat and convection currents within the OR but have not conclusively been
shown to increase SSI rates. They are considered safe for use by the Association of periOperative Registered
Nurses and remain the gold standard for maintaining perioperative patient normothermia.

Orthopaedic surgery represents >10% of all surgery performed
in the United States on a per annum basis1, with explosive
growth predicted in the need for total hip and knee arthroplasty
over the next 15 years2. Surgical site infections (SSIs) have been
identified as one of the most common causes of hospital-
acquired infection in a recent prospective multicenter survey3,
affecting 1% to 3% of surgeries4,5, with the annual economic
burden of periprosthetic infections in total joint arthroplasty
estimated to be >$1.6 billion by 20205. Accordingly, the reduction
of SSIs remains a primary focus of the Surgical Care Improve-
ment Project (SCIP)6.
The most common bacteria associated with SSIs are
gram-positive cocci7, which are often transmitted as part of the
patient’s or health-care team’s skin flora that become airborne
through the shedding of skin cells during the course of an
operation8-10, with the size of these skin cells on the order of
approximately 8 to 15 mm11,12. Unfiltered air in the operating
room (OR) is known to contain greater amounts of airborne
bacteria compared with filtered regimes13,14. Additionally, the
number of personnel in the OR greatly increases the airborne
bacterial counts, with a 34-fold increase in colony-forming
units (CFUs) when 5 people are in the OR compared with an
empty room15. Various designs of heating, ventilation, and air-
conditioning (HVAC) systems, particularly laminar flow sys-
tems, have demonstrated reductions in OR bacterial CFU
counts13,16,17; however, the overall impact on the reduction of
SSIs during total hip arthroplasty or total knee arthroplasty
remains controversial18-22. The prevention of SSIs is multifac-
torial, with preoperative optimization of patients, Staphylo-
coccus aureus decolonization, the use of perioperative antibiotic
prophylaxis, the use of adhesive drapes, surgical site antiseptic
skin preparations, and the implementation of appropriate

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest
forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial
relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/E716).

J Bone Joint Surg Am. 2018;100:795-804 d http://dx.doi.org/10.2106/JBJS.17.00852

 796
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
PREVENTION

may cause turbulent and unpredictable airflow patterns within

TABLE I Summary of ASHRAE Standard 170-2017*
an OR32-37.
1. Ceiling height between 9 and 12 ft (2.7 and 3.6 m)
OR HVAC Design
2. Nonaspirating diffuser ceiling air supply grid
Optimal OR HVAC designs allow for the comfort of the OR
3. Diffuser array face velocity of 25-35 feet per minute
staff while simultaneously protecting the sterile field and
4. 99.97% efficient HEPA filters upstream of or part of the ceiling reducing the airborne bacterial burden. The design specifica-
grid†
tions for modern OR ventilation systems vary by country and,
5. Ceiling grid size between 6 · 8 ft (1.8 · 2.4 m) and 8 · 8 ft (2.4 · in the United States, are in accordance with Standard 170-2017
2.4 m) centered over OR table
set forth by the American Society of Heating, Refrigerating and
6. Up to 30% of ceiling grid can be devoted to nonairflow delivery Air-Conditioning Engineers (ASHRAE)38 (Table I). Modern
(i.e., OR lights)
OR HVAC systems draw in fresh air from an outdoor air intake,
7. Ceiling grid must extend a minimum of 12 in (30 cm) beyond the passing it through a filter that removes particulates >10 mm in
OR table
size, subsequently conditioning the air for temperature and
8. At least 2 wall-mounted return grilles mounted at least 8 in humidity, and then passing the air through a high-efficiency
(20 cm) above the floor in either corner of the room
particulate air (HEPA) filter to capture 99.7% of particles
9. Twenty ACH with at least 4 ACH from outdoor air‡ >0.3 mm in size prior to delivering it to the OR38.
10. Room pressurized to 0.01-in wc (2.5 Pa) positive relative to ORs are normally kept under positive pressure, with a
adjacent spaces minimum pressure of 0.01-in water column (wc) (0.01-in wc =
11. Temperature 68-75F (20-24C) and relative humidity 2.5 Pa) with respect to adjacent spaces38. This prevents ingress
20%-60% of unfiltered air into the OR during door opening. Additionally,
the air in the OR is changed at least 20 times per hour, with 4 of
*Compiled from ANSI/ASHRAE/ASHE 38
standard 170-2017: Ven- those air changes consisting of fresh, filtered outside air38.
tilation of Health Care Facilities . †HEPA = high-efficiency par-
ticulate air. ‡ACH = air changes per hour. Increasing the number of air changes per hour (ACH) in the
OR has been correlated with substantial reductions in bacterial
CFUs13; however, experimental models have suggested that
surgical attire all playing a role in reducing the perioperative SSI there is little benefit to increasing ACH to >2029.
risk18,23-27. Nevertheless, the surgeon should develop an under- Although ASHRAE Standard 170-2017 is considered
standing of OR airflow to more fully participate in controlling the industry standard, this does not guarantee that the day-
environmental factors that may affect their surgical outcomes. to-day performance of a given OR HVAC system is meeting
the minimum standard39. Commercially available monitors
Understanding Airflow allow the surgeon and OR staff to monitor the performance
On a basic level, airflow patterns can be characterized as of the HVAC system in real time and can assist the surgeon
either a laminar, unidirectional flow or a turbulent, mixed flow.
Laminar flow is characterized by particles moving in parallel
streams with no mixing or swirling currents (eddies). In
contrast, turbulent flow results in less predictable motion of
particles, with the formation of eddy currents and mixing of
various streams. Air is also subjected to natural convection cur-
rents, in which the flow of particles is affected by the environ-
mental temperature causing warmer air to ascend and cooler
air to descend. In the context of the OR, the surgical personnel,
the patient, and the surgical equipment (lights, electrocautery,
etc.) all emit heat, resulting in thermal plumes. These thermal
plumes are pockets of warmer air that arise from the surface of
the thermal source, causing natural convection of the OR air,
leading to erratic airflow patterns28-31.
Airflow can also be controlled through pressure gra-
dients, with air preferentially flowing from areas of high
pressure to those with lower pressure. In the context of the
OR, this is accomplished by keeping the OR under higher
pressure than the surrounding spaces so that the air in the
OR flows out into the surrounding spaces when a door is
opened, avoiding unfiltered, contaminated air flowing into the
OR. The movement of personnel, the presence of equipment, Fig. 1
door-opening events, and the use of forced-air patient warmers OR pressure sensor and HVAC monitor.
 797
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
PREVENTION

Fig. 2-A Fig. 2-B

Fig. 2-C

Figs. 2-A, 2-B, and 2-C Ventilation systems. (Reproduced with permission of Dr. Jennifer Wagner of Prism EHS and Kevin Schreiber of SLD Technology

2018.) Fig. 2-A Air curtain ventilation system. The blue panels correspond to the laminar diffusers. The base of the ceiling-mounted lights has been
highlighted yellow to indicate the discontinuity of the coverage of the laminar flow system over the OR table. Fig. 2-B Multidiffuser array ventilation system.
The blue panels correspond to the laminar diffusers. The gaps in coverage of the laminar flow system over the OR table have been highlighted in yellow.
These include the base of the ceiling-mounted lights, as well as ceiling gaps between diffuser panels. Fig. 2-C Single large diffuser (SLD) array ventilation
system. What defines this setup as an SLD is that all of the laminar diffuser panels cover the ceiling over the OR table without interruption from ceiling-
mounted equipment or gaps between the panels.

and the OR staff in determining if the system is performing
optimally during surgery (Fig. 1). If these monitors are not
available, daily system checks of OR HVAC performance by
the hospital engineering department should be considered
to ensure the system is functioning as intended39.
Laminar Flow Compared with Conventional Ventilation
Laminar airflow (LAF) and the concept of a so-called ultraclean
room was first developed and implemented for the production
of atomic weaponry at Sandia Laboratory in New Mexico in the
early 1960s40. This ultraclean room substantially reduced air-
borne bacterial contamination, resulting in the rapid applica-
tion of laminar flow ventilation technology to an OR at Bataan
Memorial Hospital in Albuquerque40. Charnley and Eftekhar
subsequently adopted OR ultraclean air technology to reduce
infection rates following total hip arthroplasty13. They reported a
reduction from 80 to 90 airborne bacterial colonies per plate
per hour to 0 colonies per plate per hour when transitioning
from a nonfiltered ventilation system to a filtered laminar flow
system and noted that the infection rate decreased from 9% to
1.3%. This pioneering work led to the wider spread of the
installation of laminar flow ventilation units in orthopaedic
ORs17,21, with Whyte et al.41 defining ultraclean air in the OR as
having £10 CFU/m3.
LAF ventilation systems are either vertical, i.e., ceiling-
mounted with a downward, vertical flow over the OR table,
or horizontal, i.e., wall-mounted with a horizontal flow
across the OR table. Horizontal laminar flow systems are
 798
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
PREVENTION

Fig. 3-A Fig. 3-B

Figs. 3-A and 3-B Computational fluid dynamics (CFD) particle trace. (Republished, with permission of ASHRAE, from: Wagner JA, Schreiber KJ, Cohen R.
Improving operating room contamination control. ASHRAE J. 2014;56[2]:18-27. Copyright 2014; permission conveyed through Copyright Clearance
Center, Inc.) Fig. 3-A CFD particle trace shows chaotic dispersion of contaminants in a multidiffuser array system that meets ASHRAE Standard 170
guidelines. Fig. 3-B CFD particle trace at the same conditions shows efficient and settled movement of contaminants away from the surgical team in an SLD
system. The tracings in each image indicate particle movements in each regime, with darker, cooler colors indicating slower particle speeds, and lighter,
warmer colors indicating higher particle speeds.

very sensitive to the layout of the OR, particularly with re- ambient OR air. While laminar flow systems have traditionally
gard to the positioning of personnel during operative pro- been associated with a reduction in bacterial CFUs and infec-
cedures. Placement of staff between the horizontal laminar tion rates during joint arthroplasty13,17,45-48, several more
flow air inlets and the OR table has been associated with a recent studies have demonstrated the opposite effect19,20,49.
breakdown in laminar flow and increased rates of SSI during In addition, systematic reviews have failed to identify a clear
total knee arthroplasties, resulting in horizontal laminar superiority of LAF over conventional systems for the reduc-
flow falling out of favor in modern OR HVAC systems17,21,42. tion of SSIs18,22,50,51. Several explanations are possible for these
Traditional vertical LAF ventilation systems relied on vinyl
curtains or movable fiberglass panels to help direct the LAF
over the OR table40. Modern vertical LAF designs have
removed the need for panels or curtains to direct the laminar
flow with the introduction of exponential laminar flow
systems, which produce a flow of air similar in shape to the
end of a trumpet18. These designs can be classified under 3
categories: air curtain systems, multidiffuser arrays, or a single
large diffuser (Figs. 2-A, 2-B, and 2-C).
Air curtain systems have several small central diffuser
arrays centered over the OR table with a perimeter of slot
diffusers surrounding them in a rectangular configuration. The
air velocity of the central diffusers is set between 25 and 35 feet
per minute (FPM; 1 FPM = 0.005 m/s). The perimeter slot
diffusers have a much higher velocity of 85 to 100 FPM, thus
providing a curtain of clean air around the OR table, preventing
the ambient room air from entering the sterile field43. Multi-
diffuser arrays provide flexibility to allow for placement of
ceiling-mounted equipment such as booms or lights but are
associated with greater areas of air turbulence between arrays
compared with a single large diffuser because of gaps in cov-
erage of the ceiling space over the OR table44.
Fig. 4
Laminar Flow Ventilation and the Reduction of SSIs Schematic of dominant airflows in the OR. (Reproduced, with permission,
Conventional displacement (nonlaminar flow) ventilation sys- from: Bartley JM, Olmsted RN, Haas J. Current views of health care design
tems may have ceiling or wall-mounted inlets, and deliver and construction: practical implications for safer, cleaner environments.
turbulent air to the OR, resulting in mixing and dilution of Am J Infect Control. 2010 Jun;38[5][Suppl 1]:S1-12.)
 799
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
PREVENTION

TABLE II ISO Standards for Clean Rooms*

Maximal Acceptable Concentrations of Particles of the Sizes Listed Below (particles/m3)

ISO Class ‡0.1 mm ‡0.2 mm ‡0.3 mm ‡0.5 mm ‡1 mm ‡5 mm

ISO 1 10 2.37 1.02 0.35 0.083 0.0029

ISO 2 100 23.7 10.2 3.5 0.83 0.029
ISO 3 1,000 237 102 35 8.3 0.29
ISO 4 10,000 2,370 1,020 352 83 2.9
ISO 5 100,000 23,700 10,200 3,520 832 29.3
ISO 6 1 · 106 237,000 102,000 35,200 8,320 293
ISO 7 1· 107 2.37 · 106 1.02 · 106 352,000 83,200 2,930
ISO 8 1 · 108 2.37 · 107 1.02 · 107 3.52 · 106 832,000 29,300
ISO 9 1 · 109 2.37 · 108 1.02 · 108 3.52 · 107 8.32 · 106 293,000

*ISO (International Organization for Standardization) 1 represents the “cleanest” clean room, while ISO 9 is the “dirtiest” clean room. Orthopaedic
and transplant ORs are recommended to be ISO class 6, while general surgery may be ISO class 7, and minor ORs and endoscopy suites may be ISO
class 8. (
ISO. This material is reproduced from ISO 14644-1:2015 with permission of the American National Standards Institute [ANSI] on behalf of
the International Organization for Standardization. The complete standard can be purchased from ANSI at https://webstore.ansi.org. All rights
reserved.)

divergent conclusions. Some historical studies changed several
variables simultaneously or failed to control for the use of
antibiotic prophylaxis13,17,48. The velocity of the air delivered
from an LAF system may also be a contributing factor, as recent
airflow modeling studies have suggested that there is an opti-
mal air velocity in LAF systems, which is between 25 and 50
FPM, and that increasing air velocity beyond this point para-
doxically increases the number of particles that strike the
operative site28,29,52. This phenomenon may occur because air
in a laminar flow system beyond 50 FPM may no longer behave
predictably and is known to induce ambient room air to move
into the laminar flow43. Similarly, increasing the air velocity of
LAF systems may lead to “erosion” of squames from surgical
staff, leading to paradoxical increases in bacterial CFUs and
SSIs53. Furthermore, the surgical instrumentation may or may
not be located within the LAF field around the OR table, since
the current ASHRAE standard only requires the diffuser array
to extend 12 in (30 cm) beyond the OR table38. Higher bacterial
counts outside the LAF field54 can result in increased bacterial
deposition on the surgical instrumentation55. The use of ultra-
violet lighting has been shown to be a successful adjunct to56, and
even in lieu of, laminar flow57 in reducing bacterial counts and
possibly lowering SSI rates. However, reports of increased risk of
skin cancers and other medical problems from occupational
exposure have resulted in ultraviolet lighting falling out of
favor58, with the Centers for Disease Control and Prevention
(CDC) recommending against their use59.
Airflow Modeling
The use of computational fluid dynamics (CFD) has greatly
aided in the understanding and modeling of OR airflow and
has been used to compare the efficacy of different HVAC
designs28,29,37,43,44. CFD models the movement of particulates by
dividing the volume of the OR into thousands of small cubes,
using software to model the movement of particulates inside
each cube (Figs. 3-A and 3-B). This produces a computerized
simulation of predicted particulate movements under varying
conditions when subjected to different HVAC designs and OR
layouts, allowing for identification of optimal systems. Pio-
neering work using CFD modeling by Memarzadeh and
Manning demonstrated a low incidence of particles striking the
surgical field under various regimes of conventional and lam-
inar airflows, as the rising thermal plume from around the
surgical site due to the heat emitted from the patient and
overhead lighting provided a measure of protection29 (Fig. 4).
However, their work suggested that the optimal HVAC design
that minimizes the number of particles striking the surgical site
is one that delivers air over the OR table using unidirectional
vertical laminar flow at a low velocity of 25 to 35 FPM and
exhausts the air from the room using either low wall-mounted
exhaust grilles or a combination of low and high wall-mounted
exhaust grilles28,29. The exhaust grilles should be kept free from
obstruction by equipment or personnel to allow for optimal
functioning (Videos 1 and 2). In a recent study that built on the
work of Memarzadeh et al., Wagner et al. examined the effects
of varying ceiling air diffuser layouts using CFD and mock
surgical procedures, finding that a single large diffuser centered
over the OR table was the optimal design at clearing particles
away from the OR table and reducing bacterial counts com-
pared with either a multidiffuser array or an air curtain setup44.
The results of these CFD studies have been used to form the
basis of the current ASHRAE Standard 170-201738.
Assessing OR Air Quality
There are no consensus guidelines regarding OR air-quality
testing methodology, frequency of testing, or interpretation of
 800
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
the results60. Air-quality sampling methods have been bor-
rowed from industrial clean-room technology standards,
which utilize particle-counts as an indirect measure of micro-
biological cleanliness61, with particle counts serving as the
primary metric for classifying the cleanliness of clean rooms
(Table II). There is major debate on whether particle counts are
an appropriate surrogate for bacterial CFUs in the OR, or
whether direct measurements should be made regarding the
microbiological content of OR air12,62-65. Furthermore, micro-
biological air sampling methods are also controversial as there
is debate about whether the optimal method is passive, utilizing
settle plates, or active, utilizing air impactors to aspirate and
sample a set volume of air62,66,67. Settle plates are petri dishes that
collect bacteria that sediment out of the ambient air, expressing
the result as CFU/m2/hr, whereas air impactors collect a pre-
determined volume of air, exposing it to a collection medium
to capture airborne bacteria, and expressing the result as
CFU/m3. International standards governing the measurement
of biocontamination of clean rooms suggest that either tech-
nique is acceptable68. There is no internationally accepted
standard regarding acceptable levels of OR bacterial contami-
nation; however, many countries60 suggest a limit between 50
and 150 CFU/m3.
Other Factors That Affect OR Air Quality
Door Opening and OR Traffic
Recently, renewed attention has been devoted to raising awareness
and assessing the impact of increased OR traffic and door-opening
events during surgical procedures12,16,33,39,69-73. The presence of
multiple people inside the OR during surgery raises concern
for SSIs, as each individual person can shed up to 107 skin cells
per day74, and as many as 104 cells per minute while walking75.
Approximately 10% of all shed skin cells harbor viable bacteria76.
There is considerable variation in the density and variety of skin
microflora among individuals, with men being more likely to have
higher aerobic colonization rates than women. Additionally, some
individuals are naturally more predisposed than others to disperse
airborne bacteria, including S. aureus74, which has been tied to
an increased risk of SSI11,77. The correlation between the number
of personnel in an OR and bacterial CFU counts has long been
known and recently reconfirmed12,15. Furthermore, the use of
molecular typing techniques has shown that most of the air-
borne bacteria in the OR suite are produced by staff members
during the course of the surgical procedure10.
The association of OR door opening with the loss of pos-
itive pressure and increased bacterial CFUs is controversial15,33,39,72.
Mears et al. examined data regarding door-opening events in
191 hip and knee arthroplasties, finding that positive pressure
was transiently lost in 77 of the 191 cases during door open-
ing72. However, an experimental model of a mock OR and an
adjacent hallway, using carbon dioxide as a tracer gas, dem-
onstrated no air mixing between the positive-pressure OR and
the lower-pressure adjacent space during door opening if the
door was open for £15 seconds when positive pressure was at
the minimum ASHRAE guideline of 2.5 Pa (0.01-in wc)78. The
amount of time the door could be open without contamination
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
PREVENTION
from the adjacent space was found to be proportional to the
area the door occupied and the magnitude of the pressure
difference between the 2 spaces. Similar findings were observed
by Weiser et al. in a pressure and airflow study of empty ORs,
noting that positive pressure was not defeated when a single
door was open, even for up to 30 seconds, but that simulta-
neous opening of >1 door easily defeated OR positive pressure
and allowed ingress of contaminated air39. Lydon et al. used
CFD modeling to simulate alterations in OR airflow with door-
opening events in a laminar flow regime and found that posi-
tive pressure in the OR generally prevented contaminated air
flowing into the OR during door opening37. However, several of
their models simulating multiple door openings and loss of
positive pressure allowed contaminated air to flow in through
the open door and contaminate the operative site. They sug-
gested that this could be minimized by reducing door openings
and ensuring that the door was not in a direct line with the OR
table.
Forced-Air Warmers
Patient hypothermia is undesirable during the course of most
orthopaedic surgical procedures, and may result in increased
transfusion requirements, myocardial events, prolonged drug
metabolism, increased infection risk, prolonged hospital stay,
and inhibited postoperative recovery79-82. The use of forced-air
warming (FAW) devices to maintain patient normothermia
is widespread across many surgical specialties; however,
Fig. 5
Time-lapse photographs of forced-air warming showing upward mobiliza-
tion of neutrally buoyant detergent bubbles caused by hot air convection
currents. The red circle denotes particles being forced upward by con-
vection currents, while the red arrows highlight particles that have been
carried over the sterile barrier between the surgical field and the anes-
thesiologist as a result of these convection currents. (Reproduced, with
permission, from: Belani KG, Albrecht M, McGovern PD, Reed M, Nacht-
sheim C. Patient warming excess heat: the effects on orthopedic operating
room ventilation performance. Anesth Analg. 2013;117[2]:406-11.
https://journals.lww.com/anesthesia-analgesia/pages/default.aspx.)
 801
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
Fig. 6
Time-lapse photography of conductive fabric warming showing no notice-
able effect on ceiling-to-floor ventilation airflows. The red circle highlights
neutrally buoyant detergent bubbles being swept down and away from the
sterile field. (Reproduced, with permission, from: Belani KG, Albrecht M,
McGovern PD, Reed M, Nachtsheim C. Patient warming excess heat: the
effects on orthopedic operating room ventilation performance. Anesth
Analg. 2013;117[2]:406-11. https://journals.lww.com/anesthesia-an-
algesia/pages/default.aspx )
the practice has recently come under scrutiny for potentially
increasing SSI rates because of airflow disruption around the
surgical site during procedures utilizing orthopaedic implants36.
Several studies have demonstrated that the use of FAW devices
results in increased temperatures around the surgical site
causing air convection currents34,35,83. These unintended con-
vection currents may cause undesirable mixing of air from
under the OR table with the air over the surgical site, poten-
tially leading to increased particle counts in the vicinity of the
surgical site under simulated surgical conditions32,34-36; however,
these findings remain controversial79 (Fig. 5). Additionally,
FAW devices have been shown to harbor bacteria, including
staphylococcal species, within their internal surfaces and are
capable of emitting these bacteria in their expelled airstream,
despite the presence of internal air filters designed to prevent
this phenomenon84-86.
Conductive heat blankets, under-body inductive mat-
tresses, and reflective blankets are alternatives to FAW that are
equally effective at maintaining core body temperature87-90 and
do not utilize warm airflow to maintain patient normother-
mia32,34,83 (Fig. 6). In a retrospective cohort study, McGovern et al.
examined 1,437 patients undergoing total hip arthroplasty or
total knee arthroplasty, performed with either FAW (1,066 of
1,437 procedures) or conductive heat blankets (371 of 1,437
procedures), and correlated the type of intraoperative patient
warming with the risk of SSI within 60 days of surgery36. They
found that the rate of SSI was 3% (32) among 1,066 patients who
received FAW compared with 0.8% (3) of 371 patients who
received conductive heat blankets. Notably, they did not control
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
PREVENTION
for confounding factors such as patient comorbidities, obesity,
American Society of Anesthesiologists classification, different
antibiotic prophylaxis regimens, or postoperative transfusion
requirements. It should be noted that many of the studies
examining the impact of FAW on the surgical site are industry-
funded and subject to commercial bias32,36,79,83. In a recent ran-
domized control trial, Oguz et al. compared the bacterial counts
around the sterile field and instrument table using settle plates
during minor orthopaedic surgery performed on 80 patients
who were randomized to either FAW devices (40 patients) or
conductive heating blankets (40 patients)91. They found that
decreased operating time and the presence of laminar flow were
correlated with decreased bacterial counts, while the number of
people in the OR and type of patient warming device utilized
were not. Several subsequent reviews of the literature on this
topic have failed to definitively link the use of FAW devices to an
increase in SSI rates92-94, and the Association of periOperative
Registered Nurses still considers them to be safe for use in pre-
venting perioperative hypothermia92,95. Similar concerns about
FAW devices were raised at the International Consensus Meeting
on Surgical Site and Periprosthetic Joint Infection in 2013, but
the workgroup acknowledged that there is a lack of evidence
linking FAW devices to increased rates of SSI and periprosthetic
joint infection96 and they remain the gold standard for main-
taining perioperative patient normothermia76. A large-scale,
randomized, multicenter controlled trial examining the effect of
patient warming devices on the SSI rate and intraoperative
bacterial counts in patients undergoing hip or knee arthroplasty
would be most welcome to help resolve this controversy.
Overview
Understanding the basic principles regarding the requirements
of OR HVAC systems can allow the surgeon to develop a working
TABLE III Grades of Recommendation*
Recommendation Grade
Laminar flow ventilation reduces bacterial CFUs and A
particle counts in the OR when used correctly
Laminar flow ventilation reduces SSIs C
The number of people in the OR increases bacterial A
counts
Door-opening events affect the airflow pattern in the B
OR
Use of forced-air warming (FAW) devices affects the B
airflow pattern around the surgical site
Use of FAW devices increases risk of SSI C
97
*According to Wright , grade A indicates good evidence (Level-I studies
with consistent findings) for or against recommending intervention;
grade B, fair evidence (Level-II or III studies with consistent findings) for
or against recommending intervention; grade C, poor-quality evidence
(Level-IV or V studies with consistent findings) for or against recom-
mending intervention; and grade I, insufficient or conflicting evidence
not allowing a recommendation for or against intervention.
 802
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
relationship with the hospital engineering staff to promote
optimal functioning of the system during surgical procedures
and ultimately improve patient safety. Although LAF ventilation
systems have been shown to reduce airborne bacterial counts,
their impact on SSI rates is controversial. Airflow patterns within
the OR during a surgical procedure are complex and impacted
by multifactorial variables, such as the number of people in the
room, door-opening events, ambient air temperature, heat from
surgical lights and equipment, HVAC system setup and opera-
tional characteristics, and the use of FAW devices. While it is not
feasible to eliminate all bacterial contamination in the OR, the
surgeon and staff should work together as a team to understand
the factors that impact the microbiological qualities of OR air
and subsequently develop and promote practices that promote a
clean-air environment (Table III). The development of inter-
national consensus guidelines regarding the measurement of
biocontamination of ORs as well as defining the periodic testing
References
1. CDC/NCHS National Hospital Discharge Survey. Number of all-listed procedures
for discharges from short-stay hospitals, by procedure category and age: United
States, 2010. 2010. https://www.cdc.gov/nchs/data/nhds/4procedures/2010
pro4_numberprocedureage.pdf. Accessed 2017 March 20.
2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip
and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am.
2007 Apr;89(4):780-5.
3. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, Lynfield R,
Maloney M, McAllister-Hollod L, Nadle J, Ray SM, Thompson DL, Wilson LE, Fridkin SK;
Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use
Prevalence Survey Team. Multistate point-prevalence survey of health care-associated
infections. N Engl J Med. 2014 Mar 27;370(13):1198-208.
4. Abdul-Jabbar A, Takemoto S, Weber MH, Hu SS, Mummaneni PV, Deviren V,
Ames CP, Chou D, Weinstein PR, Burch S, Berven SH. Surgical site infection in spinal
surgery: description of surgical and patient-based risk factors for postoperative
infection using administrative claims data. Spine (Phila Pa 1976). 2012 Jul 1;37
(15):1340-5.
5. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of peri-
prosthetic joint infection in the United States. J Arthroplasty. 2012 Sep;27(8)
(Suppl):61-5.e1. Epub 2012 May 2.
6. Fry DE. Surgical site infections and the surgical care improvement project (SCIP):
evolution of national quality measures. Surg Infect (Larchmt). 2008 Dec;9(6):
579-84.
7. Berrı́os-Torres SI, Yi SH, Bratzler DW, Ma A, Mu Y, Zhu L, Jernigan JA. Activity of
commonly used antimicrobial prophylaxis regimens against pathogens causing
coronary artery bypass graft and arthroplasty surgical site infections in the United
States, 2006-2009. Infect Control Hosp Epidemiol. 2014 Mar;35(3):231-9. Epub
2014 Jan 29.
8. Ritter MA. Operating room environment. Clin Orthop Relat Res. 1999 Dec;(369):
103-9.
9. Whyte W, Hambraeus A, Laurell G, Hoborn J. The relative importance of the routes
and sources of wound contamination during general surgery. II. Airborne. J Hosp
Infect. 1992 Sep;22(1):41-54.
10. Edmiston CE Jr, Seabrook GR, Cambria RA, Brown KR, Lewis BD, Sommers JR,
Krepel CJ, Wilson PJ, Sinski S, Towne JB. Molecular epidemiology of microbial
contamination in the operating room environment: Is there a risk for infection?
Surgery. 2005 Oct;138(4):573-9, discussion :579–82.
11. Davies RR, Noble WC. Dispersal of bacteria on desquamated skin. Lancet.
1962 Dec 22;2(7269):1295-7.
12. Stocks GW, Self SD, Thompson B, Adame XA, O’Connor DP. Predicting bacterial
populations based on airborne particulates: a study performed in nonlaminar flow
operating rooms during joint arthroplasty surgery. Am J Infect Control. 2010 Apr;38
(3):199-204. Epub 2009 Nov 12.
13. Charnley J, Eftekhar N. Postoperative infection in total prosthetic replacement
arthroplasty of the hip-joint. With special reference to the bacterial content of the air
of the operating room. Br J Surg. 1969 Sep;56(9):641-9.
14. Hirsch T, Hubert H, Fischer S, Lahmer A, Lehnhardt M, Steinau HU,
Steinstraesser L, Seipp HM. Bacterial burden in the operating room: impact of airflow
systems. Am J Infect Control. 2012 Sep;40(7):e228-32. Epub 2012 Apr 26.
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
PREVENTION
and validation of OR HVAC systems would be welcome con-
tributions to the field. n
Mitchell C. Weiser, MD, MEng1
Calin S. Moucha, MD2
1Department of Orthopaedic Surgery, Montefiore Medical Center and
Albert Einstein College of Medicine, Bronx, New York
2Department of Orthopaedic Surgery, Icahn School of Medicine at Mount
Sinai, New York, NY
E-mail address for M.C. Weiser: mweiser@montefiore.org
E-mail address for C.S. Moucha: calin.moucha@mountsinai.org
ORCID iD for C.S. Moucha: 0000-0001-7666-8363
15. Ritter MA, Eitzen H, French ML, Hart JB. The operating room environment as
affected by people and the surgical face mask. Clin Orthop Relat Res. 1975 Sep;
(111):147-50.
16. Erichsen Andersson A, Petzold M, Bergh I, Karlsson J, Eriksson BI, Nilsson K.
Comparison between mixed and laminar airflow systems in operating rooms and the
influence of human factors: experiences from a Swedish orthopedic center. Am J
Infect Control. 2014 Jun;42(6):665-9. Epub 2014 Apr 6.
17. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Effect of
ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee
replacement: a randomised study. Br Med J (Clin Res Ed). 1982 Jul 3;285(6334):
10-4.
18. Evans RP. Current concepts for clean air and total joint arthroplasty: laminar
airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res. 2011
Apr;469(4):945-53.
19. Brandt C, Hott U, Sohr D, Daschner F, Gastmeier P, Rüden H. Operating room
ventilation with laminar airflow shows no protective effect on the surgical site
infection rate in orthopedic and abdominal surgery. Ann Surg. 2008 Nov;248(5):
695-700.
20. Hooper GJ, Rothwell AG, Frampton C, Wyatt MC. Does the use of laminar flow
and space suits reduce early deep infection after total hip and knee replacement?:
the ten-year results of the New Zealand Joint Registry. J Bone Joint Surg Br. 2011
Jan;93(1):85-90.
21. Salvati EA, Robinson RP, Zeno SM, Koslin BL, Brause BD, Wilson PD Jr. Infec-
tion rates after 3175 total hip and total knee replacements performed with and
without a horizontal unidirectional filtered air-flow system. J Bone Joint Surg Am.
1982 Apr;64(4):525-35.
22. Gastmeier P, Breier AC, Brandt C. Influence of laminar airflow on prosthetic joint
infections: a systematic review. J Hosp Infect. 2012 Jun;81(2):73-8. Epub 2012
May 9.
23. Bratzler DW, Houck PM; Surgical Infection Prevention Guideline Writers Work-
group. Antimicrobial prophylaxis for surgery: an advisory statement from the National
Surgical Infection Prevention Project. Am J Surg. 2005 Apr;189(4):395-404.
24. Evans RP; American Academy of Orthopaedic Surgeons Patient Safety Com-
mittee. Surgical site infection prevention and control: an emerging paradigm. J Bone
Joint Surg Am. 2009 Nov;91(Suppl 6):2-9.
25. Moucha CS, Clyburn T, Evans RP, Prokuski L. Modifiable risk factors for surgical
site infection. J Bone Joint Surg Am. 2011 Feb 16;93(4):398-404.
26. Salassa TE, Swiontkowski MF. Surgical attire and the operating room: role in
infection prevention. J Bone Joint Surg Am. 2014 Sep 3;96(17):1485-92.
27. Weiser MC, Moucha CS. The current state of screening and decolonization for
the prevention of Staphylococcus aureus surgical site infection after total hip and
knee arthroplasty. J Bone Joint Surg Am. 2015 Sep 2;97(17):1449-58.
28. Memarzadeh F, Jiang J. Effect of operation room geometry and ventilation
system parameter variations on the protection of the surgical site. In: Proceedings of
the American Society of Heating, Refrigerating and Air-Conditioning Engineers
(ASHRAE) IAQ (Indoor Air Quality) Conference 2004;; 2004 Mar 15-17. Tampa,
Florida; 2004.
29. Memarzadeh F, Manning AP. Comparison of operating room ventilation systems
in the protection of the surgical site. ASHRAE Transactions. 2002;108:3-15.
 803
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
30. Buchanan CR, Dunn-Rankin D. Transport of surgically produced aerosols in an
operating room. Am Ind Hyg Assoc J. 1998 Jun;59(6):393-402.
31. Sadrizadeh S, Tammelin A, Ekolind P, Holmberg S. Influence of staff number and
internal constellation on surgical site infection in an operating room. Particuology.
2014;13:42-51.
32. Belani KG, Albrecht M, McGovern PD, Reed M, Nachtsheim C. Patient warming
excess heat: the effects on orthopedic operating room ventilation performance.
Anesth Analg. 2013 Aug;117(2):406-11. Epub 2012 Jul 19.
33. Teter J, Guajardo I, Al-Rammah T, Rosson G, Perl TM, Manahan M. Assessment
of operating room airflow using air particle counts and direct observation of door
openings. Am J Infect Control. 2017 May 1;45(5):477-82. Epub 2017 Feb 13.
34. Legg AJ, Cannon T, Hamer AJ. Do forced air patient-warming devices disrupt
unidirectional downward airflow? J Bone Joint Surg Br. 2012 Feb;94(2):254-6.
35. Legg AJ, Hamer AJ. Forced-air patient warming blankets disrupt unidirectional
airflow. Bone Joint J. 2013 Mar;95-B(3):407-10.
36. McGovern PD, Albrecht M, Belani KG, Nachtsheim C, Partington PF, Carluke I,
Reed MR. Forced-air warming and ultra-clean ventilation do not mix: an investigation
of theatre ventilation, patient warming and joint replacement infection in orthopae-
dics. J Bone Joint Surg Br. 2011 Nov;93(11):1537-44.
37. Lydon GP, Ingham DB, Mourshed MM. Ultra clean ventilation system perfor-
mance relating to airborne infections in operating theatres using CFD modelling.
Build Simul. 2014;7(3):277-87.
38. ANSI/ASHRAE/ASHE standard 170-2017: Ventilation of Health Care Facilities.
Atlanta, Georgia: American Society of Heating, Refrigerating, and Air-Conditioning
Engineers;; 2017.
39. Weiser MC, Shemesh S, Chen DD, Bronson MJ, Moucha CS. The effect of door
opening on positive pressure and airflow in operating rooms. J Am Acad Orthop Surg.
2018 Mar 1;26(5):e105-13.
40. Turner RS. Laminar air flow. Its original surgical application and long-term
results. J Bone Joint Surg Am. 1974 Mar;56(2):430-5.
41. Whyte W, Lidwell OM, Lowbury EJ, Blowers R. Suggested bacteriological stan-
dards for air in ultraclean operating rooms. J Hosp Infect. 1983 Jun;4(2):133-9.
42. Sadrizadeh S, Holmberg S, Tammelin A. A numerical investigation of vertical
and horizontal laminar airflow ventilation in an operating room. Build Environ.
2014;82:517-25.
43. Cook G, Int-Hout D. Air motion control in the hospital operating room. ASHRAE J.
2009;51(3):30-6.
44. Wagner JA, Schreiber KJ, Cohen R. Improving operating room contamination
control. ASHRAE J. 2014;56(2):18-27.
45. Lidwell OM, Elson RA, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D.
Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter
study of 8,052 joint replacement operations. Acta Orthop Scand. 1987 Feb;58(1):
4-13.
46. Lidwell OM, Lowbury EJL, Whyte W, Blowers R, Stanley SJ, Lowe D. Airborne
contamination of wounds in joint replacement operations: the relationship to sepsis
rates. J Hosp Infect. 1983 Jun;4(2):111-31.
47. Ritter MA, Stringer EA. Laminar air-flow versus conventional air operating
systems: a seven-year patient follow-up. Clin Orthop Relat Res. 1980 Jul-Aug;
(150):177-80.
48. Fitzgerald RH Jr, Bechtol CO, Eftekhar N, Nelson JP. Reduction of deep sepsis
after total hip arthroplasty. Arch Surg. 1979 Jul;114(7):803-4.
49. Breier AC, Brandt C, Sohr D, Geffers C, Gastmeier P. Laminar airflow ceiling size:
no impact on infection rates following hip and knee prosthesis. Infect Control Hosp
Epidemiol. 2011 Nov;32(11):1097-102. Epub 2011 Sep 20.
50. McHugh SM, Hill AD, Humphreys H. Laminar airflow and the prevention of sur-
gical site infection. More harm than good? Surgeon. 2015 Feb;13(1):52-8. Epub
2014 Nov 7.
51. Bischoff P, Kubilay NZ, Allegranzi B, Egger M, Gastmeier P. Effect of laminar
airflow ventilation on surgical site infections: a systematic review and meta-analysis.
Lancet Infect Dis. 2017 May;17(5):553-61. Epub 2017 Feb 17.
52. Rui Z, Guangbei T, Jihong L. Study on biological contaminant control strategies
under different ventilation models in hospital operating room. Build Environ.
2008;43(5):793-803.
53. Lewis JR. Operating-room air-distribution effectiveness. ASHRAE Transactions.
1993;99(2):1191-9.
54. Hambraeus A, Bengtsson S, Laurell G. Bacterial contamination in a modern
operating suite. 1. Effect of ventilation on airborne bacteria and transfer of airborne
particles. J Hyg (Lond). 1977 Aug;79(1):121-32.
55. Diab-Elschahawi M, Berger J, Blacky A, Kimberger O, Oguz R, Kuelpmann R,
Kramer A, Assadian O. Impact of different-sized laminar air flow versus no laminar air
flow on bacterial counts in the operating room during orthopedic surgery. Am J Infect
Control. 2011 Sep;39(7):e25-9. Epub 2011 Apr 15.
56. Taylor GJ, Bannister GC, Leeming JP. Wound disinfection with ultraviolet radi-
ation. J Hosp Infect. 1995 Jun;30(2):85-93.
57. Ritter MA, Olberding EM, Malinzak RA. Ultraviolet lighting during orthopaedic
surgery and the rate of infection. J Bone Joint Surg Am. 2007 Sep;89(9):1935-40.
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
PREVENTION
58. Sylvain D, Tapp L, Department of Health and Human Services, Centers for
Disease Contral and Prevention, National Institute for Occupational Safety and
Health. UV-C exposure and health effects in surgical suite personnel; health hazard
evaluation report HETA 2007-0257-3082. 2009 May. https://www.cdc.
gov/niosh/hhe/reports/pdfs/2007-0257-3082.pdf. Accessed 2018 Mar 5.
59. Sehulster L, Chinn RY; CDC; HICPAC. Guidelines for environmental infection
control in health-care facilities. Recommendations of CDC and the Healthcare
Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep.
2003 Jun 6;52(RR-10):1-42.
60. Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp Infect.
2002 Jun;51(2):79-84.
61. International Organization of Standardization. ISO 14644–1:2015. Cleanrooms
and associated controlled environments—part 1: classification of air cleanliness by
particle concentration. 2015. https://www.iso.org/standard/53394.html. Ac-
cessed 2017 July 5.
62. Cristina ML, Spagnolo AM, Sartini M, Panatto D, Gasparini R, Orlando P, Ottria G,
Perdelli F. Can particulate air sampling predict microbial load in operating theatres for
arthroplasty? PLoS One. 2012;7(12):e52809. Epub 2012 Dec 21.
63. Landrin A, Bissery A, Kac G. Monitoring air sampling in operating theatres: can
particle counting replace microbiological sampling? J Hosp Infect. 2005 Sep;61(1):
27-9.
64. Wan GH, Chung FF, Tang CS. Long-term surveillance of air quality in medical
center operating rooms. Am J Infect Control. 2011 May;39(4):302-8. Epub 2011
Jan 22.
65. Birgand G, Toupet G, Rukly S, Antoniotti G, Deschamps MN, Lepelletier D,
Pornet C, Stern JB, Vandamme YM, van der Mee-Marquet N, Timsit JF, Lucet JC. Air
contamination for predicting wound contamination in clean surgery: A large multi-
center study. Am J Infect Control. 2015 May 1;43(5):516-21. Epub 2015 Mar 6.
66. Friberg B, Friberg S, Burman LG. Inconsistent correlation between aerobic
bacterial surface and air counts in operating rooms with ultra clean laminar air flows:
proposal of a new bacteriological standard for surface contamination. J Hosp Infect.
1999 Aug;42(4):287-93.
67. Napoli C, Tafuri S, Montenegro L, Cassano M, Notarnicola A, Lattarulo S,
Montagna MT, Moretti B. Air sampling methods to evaluate microbial contamination
in operating theatres: results of a comparative study in an orthopaedics department.
J Hosp Infect. 2012 Feb;80(2):128-32. Epub 2011 Dec 3.
68. International Organization for Standardization. ISO 14644-1:2015(en). Clean-
rooms and associated controlled environments — Part 1: Classification of air
cleanliness by particle concentration. https://www.iso.org/obp/ui/#iso:std:iso:
14644:-1:ed-2:v1:en. Accessed 2018 Feb 23.
69. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the
operating room: an explorative and descriptive study on air quality during orthopedic
trauma implant surgery. Am J Infect Control. 2012 Oct;40(8):750-5. Epub 2012
Jan 29.
70. Bédard M, Pelletier-Roy R, Angers-Goulet M, Leblanc PA, Pelet S. Traffic in the
operating room during joint replacement is a multidisciplinary problem. Can J Surg.
2015 Aug;58(4):232-6.
71. Lynch RJ, Englesbe MJ, Sturm L, Bitar A, Budhiraj K, Kolla S, Polyachenko Y,
Duck MG, Campbell DA Jr. Measurement of foot traffic in the operating room:
implications for infection control. Am J Med Qual. 2009 Jan-Feb;24(1):45-52.
72. Mears SC, Blanding R, Belkoff SM. Door opening affects operating room pres-
sure during joint arthroplasty. Orthopedics. 2015 Nov;38(11):e991-4.
73. Panahi P, Stroh M, Casper DS, Parvizi J, Austin MS. Operating room traffic is a
major concern during total joint arthroplasty. Clin Orthop Relat Res. 2012 Oct;
470(10):2690-4.
74. Noble WC. Dispersal of skin microorganisms. Br J Dermatol. 1975 Oct;93(4):
477-85.
75. Sciple GW, Riemensnider DK, Schleyer CA. Recovery of microorganisms shed by
humans into a sterilized environment. Appl Microbiol. 1967 Nov;15(6):1388-92.
76. Noble WC, Davies RR. Studies on the dispersal of staphylococci. J Clin Pathol.
1965 Jan;18:16-9.
77. Walter CW, Kundsin RB. The airborne component of wound contamination and
infection. Arch Surg. 1973 Oct;107(4):588-95.
78. Kee-Chiang C, Chin-Yuan Y, Chun-Wan C. The effect of the size of openings on
contaminant control between two adjacent spaces with differing air pressures. AIHA
J (Fairfax, Va). 2003 Nov-Dec;64(6):792-8.
79. Sessler DI, Olmsted RN, Kuelpmann R. Forced-air warming does not worsen air
quality in laminar flow operating rooms. Anesth Analg. 2011 Dec;113(6):1416-21.
Epub 2011 Sep 29.
80. Kurz A, Sessler DI, Lenhardt R; Study of Wound Infection and Temperature
Group. Perioperative normothermia to reduce the incidence of surgical-wound
infection and shorten hospitalization. N Engl J Med. 1996 May 9;334(19):1209-15.
81. Leijtens B, Koëter M, Kremers K, Koëter S. High incidence of postoperative
hypothermia in total knee and total hip arthroplasty: a prospective observational
study. J Arthroplasty. 2013 Jun;28(6):895-8. Epub 2013 Mar 20.
82. Berrı́os-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke
CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J,
 804
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O LU M E 100 -A N U M B E R 9 M AY 2, 2 018
d d
Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare
Infection Control Practices Advisory Committee. Centers for Disease Control and Pre-
vention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017
Aug 1;152(8):784-91.
83. Dasari KB, Albrecht M, Harper M. Effect of forced-air warming on the perfor-
mance of operating theatre laminar flow ventilation. Anaesthesia. 2012 Mar;67
(3):244-9.
84. Albrecht M, Gauthier RL, Belani K, Litchy M, Leaper D. Forced-air warming
blowers: An evaluation of filtration adequacy and airborne contamination emissions
in the operating room. Am J Infect Control. 2011 May;39(4):321-8. Epub 2010
Nov 20.
85. Reed M, Kimberger O, McGovern PD, Albrecht MC. Forced-air warming design:
evaluation of intake filtration, internal microbial buildup, and airborne-contamination
emissions. AANA J. 2013 Aug;81(4):275-80.
86. Albrecht M, Gauthier R, Leaper D. Forced-air warming: a source of airborne
contamination in the operating room? Orthop Rev (Pavia). 2009 Oct 10;1(2):e28.
87. Brandt S, Oguz R, Hüttner H, Waglechner G, Chiari A, Greif R, Kurz A, Kimberger O.
Resistive-polymer versus forced-air warming: comparable efficacy in orthopedic
patients. Anesth Analg. 2010 Mar 1;110(3):834-8. Epub 2009 Dec 30.
88. Kimberger O, Held C, Stadelmann K, Mayer N, Hunkeler C, Sessler DI, Kurz A.
Resistive polymer versus forced-air warming: comparable heat transfer and core
rewarming rates in volunteers. Anesth Analg. 2008 Nov;107(5):1621-6.
O P E R AT I N G -R O O M A I R F L O W T E C H N O L O G Y AND INFECTION
PREVENTION
89. Negishi C, Hasegawa K, Mukai S, Nakagawa F, Ozaki M, Sessler DI. Resistive-
heating and forced-air warming are comparably effective [table of contents.]. Anesth
Analg. 2003 Jun;96(6):1683-7.
90. Tjoakarfa C, David V, Ko A, Hau R. Reflective blankets are as effective as forced
air warmers in maintaining patient normothermia during hip and knee arthroplasty
surgery. J Arthroplasty. 2017 Feb;32(2):624-7. Epub 2016 Jul 21.
91. Oguz R, Diab-Elschahawi M, Berger J, Auer N, Chiari A, Assadian O, Kimberger O.
Airborne bacterial contamination during orthopedic surgery: A randomized controlled
pilot trial. J Clin Anesth. 2017 May;38:160-4. Epub 2017 Feb 20.
92. Kellam MD, Dieckmann LS, Austin PN. Forced-air warming devices and the risk
of surgical site infections. AORN J. 2013 Oct;98(4):354-66, quiz :367–9.
93. Sikka RS, Prielipp RC. Forced air warming devices in orthopaedics: a focused
review of the literature. J Bone Joint Surg Am. 2014 Dec 17;96(24):e200.
94. 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 Nov;88(3):132-40. Epub 2014 Aug 27.
95. Bashaw MA. Guideline implementation: preventing hypothermia. AORN J. 2016
Mar;103(3):305-10, quiz :311–3.
96. Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on
Periprosthetic Joint Infection. Bone Joint J. 2013 Nov;95-B(11):1450-2.
97. Wright JG. Revised grades of recommendation for summaries or reviews of
orthopaedic surgical studies. J Bone Joint Surg Am. 2006 May;88(5):1161-2.