Systemic Warming as an Adjunct to Resuscitation in Peritonitis: A Pilot, Randomized Controlled Trial

The Effects of Local Warming on Surgical Site Infection

BACKGROUND

Surgical site infections (SSI) account for a major proportion of hospital-acquired infections. They are associated with longer hospital stay, readmissions, increased costs, mortality, and morbidity. Reducing SSI is a goal of the Surgical Care Improvement Project and identifying interventions that reduce SSI effectively is of interest. In a single-blinded randomized controlled trial (RCT) we evaluated the effect of localized warming applied to surgical incisions on SSI development and selected cellular (immune, endothelial) and tissue responses (oxygenation, collagen).

METHODS

After Institutional Review Board approval and consent, patients having open bariatric, colon, or gynecologic-oncologic related operations were enrolled and randomly assigned to local incision warming (6 post-operative treatments) or non-warming. A prototype surgical bandage was used for all patients. The study protocol included intra-operative warming to maintain core temperature ≥36°C and administration of 0.80 FIO2. Patients were followed for 6 wks for the primary outcome of SSI determined by U.S. Centers for Disease Control (CDC) criteria and ASEPSIS scores (additional treatment; presence of serous discharge, erythema, purulent exudate, and separation of the deep tissues; isolation of bacteria; and duration of inpatient stay). Tissue oxygen (PscO2) and samples for cellular analyses were obtained using subcutaneous polytetrafluoroethylene (ePTFE) tubes and oxygen micro-electrodes implanted adjacent to the incision. Cellular and tissue ePTFE samples were evaluated using flow cytometry, immunohistochemistry, and Sircol™ collagen assay (Biocolor Ltd., Carrickfergus, United Kingdom).

RESULTS

One hundred forty-six patients participated (n=73 per group). Study groups were similar on demographic parameters and for intra-operative management factors. The CDC defined rate of SSI was 18%; occurrence of SSI between groups did not differ (p=0.27). At 2 wks, warmed patients had better ASEPSIS scores (p=0.04) but this difference was not observed at 6 wks. There were no significant differences in immune, endothelial cell, or collagen responses between groups. On post-operative days one to two, warmed patients had greater PscO2 change scores with an average PscO2 increase of 9-10 mm Hg above baseline (p<0.04).

CONCLUSIONS

Post-operative local warming compared with non-warming followed in this study, which included intra-operative warming to maintain normothermia and FIO2 level of 0.80, did not reduce SSI and had no effect on immune, endothelial cell presence, or collagen synthesis. PscO2 increased significantly with warming, however, the increase was modest and less than expected or what has been observed in studies testing other interventions.

Forced-air warming: a source of airborne contamination in the operating room?

Forced-air-warming (FAW) is an effective and widely used means for maintaining surgical normothermia, but FAW also has the potential to generate and mobilize airborne contamination in the operating room.

We measured the emission of viable and non-viable forms of airborne contamination from an arbitrary selection of FAW blowers (n=25) in the operating room. A laser particle counter measured particulate concentrations of the air near the intake filter and in the distal hose airstream. Filtration efficiency was calculated as the reduction in particulate concentration in the distal hose airstream relative to that of the intake. Microbial colonization of the FAW blower's internal hose surfaces was assessed by culturing the microorganisms recovered through swabbing (n=17) and rinsing (n=9) techniques.

Particle counting revealed that 24% of FAW blowers were emitting significant levels of internally generated airborne contamination in the 0.5 to 5.0 µm size range, evidenced by a steep decrease in FAW blower filtration efficiency for particles 0.5 to 5.0 µm in size. The particle size-range-specific reduction in efficiency could not be explained by the filtration properties of the intake filter. Instead, the reduction was found to be caused by size-range-specific particle generation within the FAW blowers. Microorganisms were detected on the internal air path surfaces of 94% of FAW blowers.

The design of FAW blowers was found to be questionable for preventing the build-up of internal contamination and the emission of airborne contamination into the operating room. Although we did not evaluate the link between FAW and surgical site infection rates, a significant percentage of FAW blowers with positive microbial cultures were emitting internally generated airborne contamination within the size range of free floating bacteria and fungi (<4 µm) that could, conceivably, settle onto the surgical site.

Belani K, Nachtsheim C, Partington PF, Carluke I, Reed MR. Forced-air warming and ultra-clean ventilation do not mix

We investigated the capacity of patient warming devices to disrupt the ultra-clean airflow system. We compared the effects of two patient warming technologies, forced-air and conductive fabric, on operating theatre ventilation during simulated hip replacement and lumbar spinal procedures using a mannequin as a patient. Infection data were reviewed to determine whether joint infection rates were associated with the type of patient warming device that was used.

Neutral-buoyancy detergent bubbles were released adjacent to the mannequin’s head and at floor level to assess the movement of non-sterile air into the clean airflow over the surgical site. During simulated hip replacement, bubble counts over the surgical site were greater for forced-air than for conductive fabric warming when the anaesthesia/surgery drape was laid down (p = 0.010) and at half-height (p < 0.001). For lumbar surgery, forced-air warming generated convection currents that mobilised floor air into the surgical site area. Conductive fabric warming had no such effect.

A significant increase in deep joint infection, as demonstrated by an elevated infection odds ratio (3.8, p = 0.024), was identified during a period when forced-air warming was used compared to a period when conductive fabric warming was used. Air-free warming is, therefore, recommended over forced-air warming for orthopaedic procedures.

Forced-air warming blowers: An evaluation of filtration adequacy and airborne contamination emissions in the operating room

BACKGROUND

Forced-air warming (FAW) is widely used to prevent hypothermia during surgical procedures. The airflow from these blowers is often vented near the operative site and should be free of contaminants to minimize the risk of surgical site infection. Popular FAW blowers contain a 0.2-μm rated intake filter to reduce these risks. However, there is little evidence that the efficiency of the intake filter is adequate to prevent airborne contamination emissions or protect the internal air path from microbial contamination buildup.

METHODS

Five new intake filters were obtained directly from the manufacturer (Bair Hugger 505, model 200708D; Arizant Healthcare, Eden Prairie, MN), and 5 model 200708C filters currently in hospital use were removed from FAW devices. The retention efficiency of these filters was assessed using a monodisperse sodium chloride aerosol. In the same hospitals, internal air path surface swabs and hose outlet particle counts were performed on 52 forced-air warming devices (all with the model 200708C filter) to assess internal microbial buildup and airborne contamination emissions.

RESULTS

Intake filter retention efficiency at 0.2 μm was 93.8% for the 200708C filter and 61.3% at for the 200708D filter. The 200708D filter obtained directly from the manufacturer has a thinner filtration media than the 200708C filter in current hospital use, suggesting that the observed differences in retention efficiency were due to design changes. Fifty-eight percent of the FAW blowers evaluated were internally generating and emitting airborne contaminants, with microorganisms detected on the internal air path surfaces of 92.3% of these blowers. Isolates of Staphylococcus aureus, coagulase-negative Staphylococcus, and methicillin-resistant S aureus were detected in 13.5%, 3.9%, and 1.9% of FAW blowers, respectively.

CONCLUSION

The design of popular FAW devices using the 200708C filter was found to be inadequate for preventing the internal buildup and emission of microbial contaminants into the operating room. Substandard intake filtration allowed airborne contaminants (both viable and nonviable) to penetrate the intake filter and reversibly attach to the internal surfaces within the FAW blowers. The reintroduction of these contaminants into the FAW blower air stream was detected and could contribute to the risk of cross-infection. Given the deficiencies identified with the 200708C intake filter, the introduction of a new filter (model 200708D) with substantially lower retention efficiency is of concern.