Smith G
Curr Probl Surg. 1979 Jul;16(7):1-56. doi: 10.1016/s0011-3840(79)80002-7.
Using S. pyogenes as a tracer organism, an examination of the importance of air-borne infection of clean wounds in the modern, plenum-ventilated operating room has been made. It appears that, for most surgical procedures, additional ultra-clean air installations are not necessary. It has been shown that even if the air is sterile, the skin remains a possible source of infection. This is especially so as far as the patient's skin is concerned. It will remain so, since the skin cannot be sterilized. Indeed, until the ecology of the skin is better understood, rigorous efforts directed toward its disinfection may compromise its inherent defense mechanisms and its protective bacterial flora. It will be argued by some that operating rooms with ultraclean air should be afforded for certain specialized procedures in sugery; for example, those in which prosthetic materials are being implanted or in which the patient's immune mechanisms are depressed. Although not disagreeing with this, I wish to note that the only controlled trial on this aspect of surgery that exists to date shows no advantage for patients randomly apportioned to have hip arthroplasty, either in an isolator or in the same modern operating room but without the isolator. From this experience, I believe that any further trial of this nature, if it is to be controlled to a similar high level, will require very large numbers of patients to show even a marginal advantage for ultraclean air or isolator installations over the modern, plenum-ventilated and meticulously managed operating suite. The verdict on the need to install ultraclean air plant for operating rooms must, therefore, be couched in the third alternative that exists under Scots Law-- "not proved." I suggest the money could be better spent on devising methods to keep skin pathogens out of surgical wounds. Perhaps more urgently, there is a need to discover how to increase the defense mechanisms of the wound milieu to implanted harmful bacteria. There is also a pressing need to improve the ward environment with the aim of diminishing secondary infections of surgical wounds.
以化脓性链球菌作为示踪微生物，对现代全室通风手术室中清洁伤口空气传播感染的重要性进行了研究。结果显示，对于大多数外科手术而言，额外安装超净空气装置并无必要。研究表明，即便空气无菌，皮肤仍是可能的感染源。就患者皮肤而言尤其如此。由于皮肤无法进行灭菌处理，这种情况将持续存在。事实上，在对皮肤生态有更深入了解之前，针对其进行严格消毒的努力可能会损害其固有的防御机制及其保护性细菌菌群。有些人会认为，对于某些外科专科手术，应配备超净空气手术室；例如，那些植入假体材料或患者免疫机制低下的手术。虽然我并不反对这一点，但我想指出，迄今为止关于这方面手术的唯一对照试验表明，随机分配接受髋关节置换术的患者，无论是在隔离器中还是在没有隔离器的同一现代手术室中，都没有优势。基于这一经验，我认为任何进一步的此类性质的试验，如果要达到类似的高控制水平，将需要大量患者才能显示出超净空气或隔离器装置相对于现代全室通风且管理精细的手术室套件具有哪怕是微小的优势。因此，关于手术室是否需要安装超净空气设备的判定，必须依据苏格兰法律中的第三种选择——“未被证实”。我建议，这笔钱可以更好地用于设计防止皮肤病原体进入手术伤口的方法。或许更紧迫的是，需要探索如何增强伤口环境对植入有害细菌的防御机制。此外，迫切需要改善病房环境，以减少手术伤口的继发性感染。
