The letter by Waite et al. highlights the need for sterile gowns in spinal anaesthesia [1]. Our local survey of 202 anaesthetists found that 178 (88%) would consider omitting a sterile gown if guidelines allowed. Currently, a number of anaesthetists reported that they do not use sterile gowns for elective and emergency obstetric spinal anaesthetics (20 (10%) and 63 (31%), respectively). The ‘rapid sequence spinal’ method described in 2010 promoting gown omission in emergencies, may explain this [2]. Guidelines from the USA, Canada and Germany do not mandate sterile gowns for spinal anaesthesia [3]. In a 2018 survey across 151 institutions in 13 countries, approximately 48% of respondents did not use sterile gowns routinely for epidural placement [4].

Barrier precautions for neuraxial procedures differ across specialities and our discussions with local colleagues support these findings. Notably, during the administration of intrathecal chemotherapy to immunosuppressed patients, haematologists do not typically wear sterile gowns.

A 2008 review suggested that infectious complications from spinal anaesthesia often arise from poor aseptic practices or contaminated equipment [5]. The importance of proper facemask use and oropharyngeal sources of common meningitis-causing organisms was stressed. This was supported by a 2018 review, which found that not using a mask was the most frequent risk factor in cases of septic meningitis, with Streptococcus salivarius being the most isolated organism [6].

Our survey showed 95% (192/202) face mask compliance in elective settings and 87% (176/202) in emergencies. Considering the infectious complications reported, perhaps it is also important to question whether assistants preparing spinal anaesthesia equipment should wear face masks. Our data indicated this is not common practice (12%, 24/202).

The infrequency of rare, but potentially devastating, infectious complications effectively precludes a randomised controlled trial, and there will likely never be definitive evidence to either support or reject sterile gown usage. Nonetheless, it is feasible to make a practical decision by weighing the practices of our international peers alongside the environmental impact of sterile gown usage. For instance, the carbon dioxide emissions produced yearly from sterile gown use for spinal procedures at one centre in Severn (UK) were 4000 kg of carbon dioxide equivalent (over 2500 spinal procedures annually) [3]. Reducing consumables from sterile gowns is an immediately actionable intervention to help deliver the more environmentally sustainable surgery outlined by Ledda et al. [7].

Our findings indicate many anaesthetists are forgoing sterile gowns, especially in emergency obstetric anaesthesia, mirroring results from NHS Tayside [1]. This suggests a general acceptance of changing practices among anaesthetists nationwide. If guidelines are revised, the importance of face mask use should be stressed and possibly extended to include assistants.

Waite 等人的这封信强调了脊髓麻醉中无菌衣的必要性 [1]。我们对 202 名麻醉师的当地调查发现，如果指南允许，178 名 （88%） 会考虑省略无菌衣。目前，一些麻醉师报告说，他们不使用无菌防护服进行择期和紧急产科脊髓麻醉剂 （分别为 20 名 （10%） 和 63 名 （31%））。2010 年描述的“快速序列脊髓”方法在紧急情况下促进脱衣，这可能解释了这一点 [2]。美国、加拿大和德国的指南并未强制要求脊髓麻醉使用无菌衣 [3]。在 2018 年对 13 个国家/地区的 151 家机构进行的调查中，大约 48% 的受访者没有常规使用无菌防护服进行硬膜外放置 [4]。

椎管内手术的屏障预防措施因专业而异，我们与当地同事的讨论支持这些发现。值得注意的是，在对免疫抑制患者进行鞘内化疗期间，血液科医生通常不穿无菌病衣。

2008 年的一项综述表明，脊髓麻醉的感染并发症通常由不良的无菌操作或设备污染引起 [5]。强调了正确使用口罩和常见脑膜炎致病微生物的口咽来源的重要性。2018 年的一项综述支持了这一点，该评价发现，在脓毒性脑膜炎病例中，不使用口罩是最常见的危险因素，其中唾液链球菌是最孤立的微生物 [6]。

我们的调查显示，在选择性环境中，95% （192/202） 的口罩合规性，在紧急情况下 87% （176/202） 的口罩合规性。考虑到报告的感染并发症，也许询问准备脊髓麻醉设备的助理是否应该戴口罩也很重要。我们的数据表明这不是常见的做法 （12%，24/202）。

罕见但具有潜在破坏性的感染并发症发生频率低，实际上排除了随机对照试验，并且可能永远不会有明确的证据支持或拒绝使用无菌防护服。尽管如此，通过权衡我们国际同行的做法以及使用无菌衣对环境的影响来做出实际决定是可行的。例如，在塞文（英国）的一个中心，使用无菌防护服进行脊柱手术每年产生的二氧化碳排放量为 4000 千克二氧化碳当量（每年超过 2500 例脊柱手术）[3]。减少无菌衣中的耗材是一种立即可操作的干预措施，有助于实现 Ledda 等人 [7] 概述的更环保的手术。

我们的研究结果表明，许多麻醉师正在放弃无菌衣，尤其是在紧急产科麻醉中，这与 NHS Tayside 的结果相吻合 [1]。这表明全国麻醉师普遍接受了不断变化的做法。如果修订指南，应强调使用口罩的重要性，并可能将其扩展到包括助手。