Join us for a unique opportunity to learn about strategies for reducing Hospital-Acquired Infection (HAIs), complications, and cost. During this one-hour program, gain best practices for setting up your patient for successful discharge and view case studies with tips and pearls to applying advanced modalities of treatment in challenging clinical scenarios.
By the end of this webinar, attendees will be able to:
Recognize the financial and clinical burden of Surgical Site Infections (SSIs)
Review strategies & best practices to reduce the risk of Surgical Site Infections (SSIs)
Describe guidelines and recommended practices that support the strategies to reduce the risk of SSIs
Examine the role of closed incision negative pressure wound therapy (ciNPT) for Incision and Surrounding Soft Tissue Management to help reduce hospital readmissions & post - op follow-up appointments
Demonstrate ciNPT efficacy via case & outcome reviews; share best practices & technique tips to manage the surgical site and enhance post-operative recovery
huh? Oh, hello. Thank you for attending the decreasing risk off Hospital acquired infections to optimize surgical outcome strategies from start to home within our It's my pleasure to introduce our keynote speakers. Dr. John Cooper on associate professor of orthopedic surgery from New York. Kathleen Koch, whose on infection prevention consultant with more than 20 years of experience in the field off infection prevention from Massachusetts on Dr Michelle Melo on associate professor of orthopedic surgery from Canada. Dr. Cooper, I'll turn it over to you. Well, thank you to everybody for your attention during this webinar Um, I wanted to start by talking about the clinical and the financial burden of surgical site infections, which, both of which are really big. Um, and I think that it's important that we're paying attention to them. So before I start, there is some important information to cover. Some of the products that we're going to show have clear indications for use, and if you have not used these before, if this is your first time, using them is always important to understand the specific indications contraindications and instructions for use what you're supplied in the packaging. It's also important to note that I have an ongoing consulting relationship with three m and K C I Onda have for a number of years, and I will be both in this first talking another one later discussing some of the products made by, um, by them. So surgical site infections. Um, that's the topic of tonight. And unfortunately, as healthcare providers, we all have to deal with these probably a lot more than we'd like. I think we'd all like if a patient never had toe face this fear. But this is one of the more common, um, complications of surgery and one of the more feared complications of surgery. So anything we could do to make a mark on this to make a decrease in its incidents, I think will be helpful for patients. These are, unfortunately, the most common type of hospital acquired infection. Um, in the United States, they account for over 20% of the healthcare acquired infections. That happens when a patient comes in from outside into the healthcare institution and in terms of ah, raw number somewhere between 163 100,000 times per year. The financial burden of these is also quite substantial. With the average s, I cost to be greater than $25,000. And if this S s I progresses to a deep surgical site infection in my world of orthopedic implants and and Arthur Plasticky, that burden can easily exceed $90,000. If it does involve the implant, it needs additional surgery to change that. And overall, when you add these numbers together, the SS I cost to our health care system in the United States, um is estimated to be somewhere between 3.5 and $10 billion annually. This also has an impact on the health care landscape, not only in our country, but obviously across the world. And this is a systematic review of healthcare acquired infections and surgical site infections and in some European countries, and they found quite similar findings that even in different kinds of health care, economic landscapes, uh, S s eyes remain in extremely costly complications. Um, one which there's a big financial incentive to avoid. And thus, um, it's important to have a really rigorous, uh, infection control and prevention strategy to minimize the risk of S s eyes to our patients, especially the ones that are thought of as potentially preventable. And so not surprisingly, when we're talking about things that are often thought of is, you know, potentially preventable or at least preventable at the same frequency. Um, things that cost a lot of money on D, things that are undesirable for patients with real ramifications, both short and long term. Um, it's It's not a big leap toe to be where we are now, where these are being built into some of the quality control measures that we're seeing and being held accountable for where, um, you know, insurance plans CMS are asking us as institutions, as hospitals, as healthcare providers to be accountable for these surgical site infections. Um, and it's become a real objective criteria for many institutions nationwide and certainly in some of the paper prefer formance initiatives that we have, particularly in my World, is in hip and Knee Arthur plastic. Now, this is an interesting study published in JAMA a few years ago, and this looks at that question of the economics of surgical site infections from the hospital perspective. And there was there was once a thought that, um from the hospital perspective that if you happen to have a complication? Of course it was. You know that terrible for patients, it's something that was very undesirable. But in dealing with that complication and caring for the patient with an additional level of care with a readmission with additional trips to the operating room, a t least that additional care was compensated. And, um, you know, that certainly changed. AST time has passed. Aziz prevention measures have been built into our quality control systems and our payment systems. But this is a study from from Johns Hopkins that looks retrospectively at the change in hospital profit due to surgical site infections. And they looked at data over a three year period. You know, really large numbers 25,000 surgical procedures. And they identified over 600 surgical site infections. Um, for a pretty common, you know, 2 to 3% rate and what they found when they looked at their actual dollar, um, their dollar spent. They found that when they had a surgical site infection in a patient, they were losing money, and they on the net. Loss in profits ranged between 4000 and $22,000 per surgical site infection so these were not additional income Sources for hospitals on before obviously looked at negatively not only from a clinical quality of care perspective but also from a financial perspective, really, things that there's a real incentive thio try to avoid. The conclusion from this paper was that hospitals have a real financial incentive to reduce surgical site infections. Um, and in order to do so, that they should expect increase in spending and cost in order to enact some infection control measures. But when they do that, they can expect also, um, increase in revenue when were able to successfully reduced thes surgical site infections. And this clearly opens the door for us. As health care providers. Thio come to our hospital leadership with with evidence based ideas with protocols or interventions that have been shown to be cost effective at reducing the rate of SSE. And I think there's a very good case to be made that it makes sense to spend a little bit morning Ah, little bit more up front if we are actually able to save on the back end with prevention in my world of hip in the Arthur plasticky para prosthetic joint infection It is our most feared complication, and this happens statistically somewhere between one and 4% of the time. In our primary cases, it depends a lot on patient co morbidity is and and kind of what patients bring with them to the table. Um, the overall burden of this, despite all of our advances in our surgical techniques and prosthetics, unfortunately continues to climb. It gets higher year over year, and not surprisingly, the cost to treat these infections gets higher year over year as well. Surgical site infections. I'm sorry, uh, surgical site complications, which are things that we see commonly have been shown again and again to predisposed to para prosthetic joint infection. And these air, unfortunately common after the surgeries that we do, and I believe that they're under reported in our literature. The reason why is that the vast majority of these do get better with time, even though some clearly predisposed to a deep infection. But when a patient gets a superficial surgical site complication, um, it is a risk factor for deep infection, and these were happening a lot more frequently than I think. We talk about the literature that does talk about them puts the rate of surgical site complications somewhere between five and 14% after primary hip and knee replacement. This is one of the studies that does that. This is a study that we published from our institution about four years ago, where we looked at in our hands the rate of surgical site complications like the one you see here after primary total hip replacement. And we found that in our patient population of 650 consecutive primary hips, we had an 11.5% wound complication rates, and of those about 10% or about 2% overall, needed to go back to the operating room for re operation. Most of these weren't infectious complications. They were non infectious complications but ended up needing additional procedures or the majority of additional care to get that incision to heal. And not surprisingly, risk factors were things that we'd expect, like obesity, diabetes and previous open surgery in that area. The cost of surgical site complications in this patient population is also something that's a real concern. There's a substantial economic burden to treat these kinds of things, um, at our American Academy, Orthopedic surgeons in March, at our virtual meeting, we presented data suggesting that patients who had this superficial surgical site complication not a deep infection, not not even a superficial surgical site infection. But these patients had about a $4000 increase in there. Post operative spend during a 90 day global post operative period because of things like increased nursing care, increased wound care, prolonged hospital stays, prolonged rehab stays, Um, any additional medications that we might have provided to these patients there. Also soft costs in these patients, which aren't necessarily quite, is measurable. But when you think about patients dealing with the surgical site complication or a surgical site infection, they are often delayed in resuming their life, getting back to work, getting back to their families. Clearly, there's a dissatisfaction that comes along with this going through this negative experience of dealing with this kind of a complication. Um, and this also creates a lot of increase, um, resource need on our teams, uh, to deal with the increased patient phone calls, the increase schedule of appointments when we could be seeing other patients who, um in scheduling in for surgery and really just the personal distress of having to deal with this and having to worry about this, you know, both during during office time and also, you know, it spills over into the evening and night times as well. When we're thinking about these things on our minds, mhm, he's also lead to an increase in readmissions. This is a good study from journal Bone in the Journal of Bone and Joint Surgery, published from the Rothman Clinic. Looking at all the reasons that patients were re admitted after, um, in an unplanned readmission after primary, elective hip or knee replacement, and you see some of the things that you'd expect, like, uh, in my blood clot G. I distress, um uh, para prosthetic fracture. But 50% of these unplanned readmissions are attributable to the surgical site itself things like, um, surgical site infection and the non infectious things like wound drainage hematoma that might bring a patient back through the ER. So to conclude the summary of the burden of surgical site infections, there's this clinical burden where patients are suffering increased morbidity. There is a slight increase in mortality in patients who get a surgical site infection. Clearly, their quality of adjusted life years of being affected and there these soft costs, where they're less satisfied where they're having a longer time resuming a normal life. In addition, there's some real economic downsides to this, whether the actual hard costs of treating the SSC, you have these opportunity costs that you're losing when you're having to spend time treating these unplanned or unexpected post operative complications. They clearly increased readmissions after surgery. They affect our pay for performance measures and also our quality data, which were increasingly relying on for for our financial reimbursement in this country. So with that, I'd like to conclude, and I'd like to turn it over to Kathleen to talk about some of the pre interrupt and postoperative strategies toe help, reduce or target the rate of surgical site infections. Thank you, Dr Cooper. Surgical site Infection prevention is a subject that's near and dear to my heart. As a former O. R nurse as an infection prevention ist, I have focused on these throughout my career, so today I will be presenting strategies and best practices to reduce the risk of surgical site infections. As you can see, I don't have any particular disclosures other than the fact that I am and consultant and a speaker for three M. So let's begin with talking about the human microbiome. And the point of this is to point out that the human body is made up of trillions of cells. And yet we also as part of that, have trillions of microbial cells that are housed, housed in the nose and the mouth. And they're found in the gut, in the groin and all over our skin, and they have very good functions on the problem with that is when that is all disrupted through illness or something like a surgery. Those microbial organisms can end up in places sterile body cavities, for example, and be very disruptive and cause harm, such as a surgical site infection. And we like to talk about a surgical site infection, uh, by the risk equation. And how can we think about this? And where will our opportunities and the strategies be developed related to this? So the risk of the surgical site infection is really the dose of bacteria times the virulence of that bacteria over the resistance of the host, which is actually the patient, and we try to control what we can. And that means we can control the dose of bacteria that occurs intra operatively and cause a surgical site infections. We cannot control the virulence of the bacteria because we have no idea what that actually would be. And then we can try and control the resistance of the host and optimize that patient for their surgical procedure. And so we'll walk through these throughout this presentation. I'm going to talk about this all within the context of surgical bundles. The Institute of Health Care Improvement defines a bundle as a structured way of improving the process of care and patient outcomes. And so these air typically small, straightforward sets of evidence based practices that, when implemented and perform collectively and reliably, they're proven to improve patient outcomes. And so simply put, if we provide the same care for every patient every time, we're going to go very far in preventing surgical site infections and improving patient outcomes. Overall, Now, the surgical site strategy, implementation by the whack, um, all approach means that we're putting a lot of things in place that never get hardwire. We do not fix the problems and then they're bound to come back again and again. And so it truly does feel like we're just whacking those moles over and over again because we haven't had a consistent and reliable approach. And that's what the bundles bring to us. So you'll see that I've given you an example of a coal and surgical bundle, and there are many components to this. Uh, there's pre op interrupt and some post op components on board. You could see there's lots of them to choose from, and most people choose several. So again, successful bundle implementation means that you take, ah, couple from maybe pre op and a couple from interrupt and really work on those and hardwire them on once you're successful in that regard than you might take a few more on and you yourself might actually be using some components of this colon surgical bundle in your organizations. Um, I'm going to talk about several of them as we go through these s S I strategies for prevention, and I'm going to start with using those in the context of the resistance of the host that we were talking about related to. How could we control on reduce the risk of surgical site infections. So you can see there are some things such as age that we can't control about the host or the patient. But perhaps we could optimize their blood glucose if they're diabetics. We can certainly try to, uh, control their core body temperature, hemoglobin saturation, the colonization of microorganisms, which I spoke to a little bit earlier. And if we're successful, we might be able to even control the length of stay. No. So we'll start with Phase one, where prevention actually starts at home and to get us started. We want to have patient education to prevent surgical site infections so that we can partner with our patients for success. Um, this increases patient knowledge, but we need to do it in a setting that provides a way for them to really be opening, tow, listening and learning that would then in turn increase their compliance with whatever it is that we want them to try to achieve. And so it's important that patient education not be done the day before surgery or the day of surgery, but really weeks out where they can really be open to listening and learning. The second part of a colon bundle is administering Orel antibiotics and also providing a mechanical prep and these air very important aspect of gut health management so that we can manage the endogenous sources of intra operative wound contamination. And so that's a very important preoperative step as well. A c H g Showering Now CSG showering is something that many of you are aware of them probably have implemented across many different surgical site. Uh, excuse me across many surgical procedures in your institutions, and the whole point of C H G showering or bathing is decreasing microbial counts on the skin and whether it's showering or a bath or wipes. The point is, uh, cleansing the skin to remove dirt and debris and then leaving a microbial layer behind that has a cumulative effect. Eso that if you do it the night before surgery and the day of surgery, it's more likely to reduce that bio burden overall. By the time they get to the operating room, there is a lot of clinical evidence for C H G bathing again. This is to manage the patient's own endogenous floor that can cause surgical site infections. Um, it CHD bathing is known to reduce the skin floor and, like I say, have a cumulative effect. And therefore, uh, it's a very low risk and low cost intervention that's proven effective in reducing bacteria on the skin, which is a risk factor of surgical site infections and something that we try to manage both pre op and inter operatively. The second phase is really what are we going to do in the pre upholding area. To reduce surgical site infections and patient decolonization is an important initiative to initiate in the pre upholding area, and we'll start with de colonizing the nose. So why implement an intervention to de colonize the Neri's? The first reason is because staph aureus is the leading cause of surgical site infections, and that's been since the dawn of time. Staph aureus is an important organism for us. Toe always manage and has always been sort of the bane of our existence. As infection prevention ist um, One of the reasons for that is that approximately 30% of the population are colonized with staff for is in their narratives, Andi. It's also likely that they're colonizing their eggs, ill a and their groins as well. 80% of staph aureus infections are caused by the patient's own nasal floor. This is an example of an endogenous colonization where this comes from the patient themselves. And this is a really interesting, uh, fact that we began to understand when it was first published in the New England Journal of Medicine that over 84% of the staph aureus strains that were isolated from patient narratives were identical to those isolated from the surgical site when those patients went on to have infections. And so this is really important link between the narratives and the patient's surgical site infection demonstrated that it is endogenous 80% of the time. So what are the options for nasal decolonization? Well, when this paper was first published, the only thing that was really available was comparison. And comparison does work really well. It took a while to figure out that the standard dozing would be five days and twice a day for those five days, and so there were some variability issues related to compliance with the patients. In addition, antibiotic resistance has been reported because comparison is an antibiotic. Unlike provolone iodine, which is an antiseptic, and there is a 5% Proton iodine formula that is made specifically for international application that's now available and a better option because it does reduce their ability of compliance pre operatively. So this is because you could just do a one and done in the pre upholding area on you know that the patients compliant because you're observing either them doing it themselves or you're doing that for them. And because it's an antiseptic, there's no risk of an emerging resistance, Okay. In addition, the CDC has published last year in 2020 19 Strategies to Prevent Hospital Associated Staff or his Bloodstream infections, which has even strengthened even further the use of C H G bathing and inter nasal decolonization, either through my comparison or an antiseptic approach. And they've done that for people that have midline catheters. And they have now come out as well and said from surgical site infection prevention strategy that patients undergoing high risk surgeries, uh, should be de colonized both nasal e and on their bodies with a CHT bathing program. And they go further to say, uh to have this just prior to surgery. And so when you're de colonizing the narratives, you should be thinking about de colonizing the skin as well with pre op wipes. Now the reason for this is similar to the narrative issue with comparison, and that you're hoping that the patient actually did take their showers and that they did that correctly, um, when they were at home. But because you can't always count on compliance, and you really aren't sure whether there skin has been fully de colonized and optimized as much as possible, um, it's important to try and integrate pre op wipes into your preoperative holding area. Programas. Well, it it reduces variability related to that patient compliance. And it's very consistent way to ensure that that skin is prepped prior to surgery. And again, this C H G wipe is an expensive way to really optimize that patient skin, uh, to reduce that micro, uh, micro bio burden. But something you need to think about is which do you de colonize first, the nose or the skin? And it's important to know that you have to stop the source of potential staph aureus colonization first before you remove it from the skin. So if the nose is the source of staph aureus, if you d colonize the nose first, where that active source of contamination comes from. Then you can then cleanse the body, knowing that that continued contamination will not be occurring. So if you need to remember, a simple nose before toes is how we like to think about it, so that we can remember to always do the narratives first and then do the patient's body. After you've done the patient's body, you can put them in fresh clothing, a patient gown, of course, and fresh linen so that they will be as optimized as possible before they go to the surgical um o r. The next thing I want to talk about related to the pre upholding area is maintaining normal therm, AEA and normal therm. EO is regulated by the hypothalamus and the temperature Grady in between the core and the periphery can be as much as 2 to 4 C, so it is significant to recognize that there's not just one body temperature, but there's the core. And then there's the periphery. And so the strategy of pre warming is really the application of heat prior to anesthesia for the purpose of increasing total body temperature prior to induction and the total body temperature is the average temperature of the periphery and the core and pre pretty warming, then is really banking heat. Anticipating that there will be lost inter operatively. So pre warming increases the temperature of the periphery, which limits the amount of heat loss from the core through redistribution during the anesthetic process. Measuring the core temperature is the only accurate way to monitor this impact. Oh, so what are the causes of unintended peri operative hypothermia? And there are many of them and we'll go through several of them. Administration of anesthetic drugs leading to heat distribution is really, um, um, important consideration, and that happens both in general and regional anesthesia. In addition, exposed body cavities called O our temperatures and the length of surgery itself can also cause hypothermia and the infusion of cold fluids and blood. The adverse effects of unintended peri operative hypothermia include wound infection, myocardial ischemia and cardiac disturbances, arrhythmias, Koegel apathy, these prolonged and altered drug effects, increased mortality has been shown in the literature shivering and thermal discomfort, post operatively and delayed emergence from anesthesia can all be postoperative pack. You sort of issues that you would have to manage if you're patient, comes out to you cold. The third phase of SS I prevention strategies is, um, uh, intra operative opportunities and intra operative Lee. One of the main focuses is on controlling the dose of bacteria that can cause wounds and contamination. So all of these things that you see listed here are things that the operative team does to focus on reducing bio burden on the patient's skin and in that surgical wound and at that sterile field during that surgical procedure process variability can negatively impact the success of all these prevention strategies so that if you are not hardwired in doing these successfully, um, then you are going to end up with that wack a mole type situation. So it's important to understand wound contamination In general, for example, wound contamination occurs when bio burden is introduced into the wound, and it's a realist ation that sterile fields are not sterile fields. There is bio burden all over between the patient's own endogenous source and then the O. R team, and the environments exogenous sources of potential wound contamination. And so the question is really how contaminated are those sterile fields? By the end of the case. So inter operative surgical site infection prevention strategies include in this particular bundle antibiotic prophylaxis, hair removal, surgical propping and draping an aseptic technique. Antibiotic prophylaxis is sort of old news, isn't it? Or is it because the purpose of antibiotic prophylaxis is to actually help kill any bacteria that's introduced into the body through the surgical procedure? That sterile field concept that I just referred Thio and the standard of care has been around for a very long time. But we used to have to report this as a skip measure if you recall, and now we don't have to, and that's been for years now. But the question is, Are you measuring it anyway? Do you know that if your practice has drifted, are you still compliant? And it really behooves you to validate that what you think you're doing is actually occurring on DSO? It's important to understand whether you are compliant with antibiotic prophylaxis because it's a very, very important surgical site infection prevention strategy. Hair removal is something else, that sort of old news. You would like to think it's not occurring anymore, but we know that we do remove more than is necessary at times, but mostly we only use clippers, which is good news. But the bad news is some people think that they should reuse disposable clippers as a cost saving device or program, I should say, and I want to caution that that's Ah, not according to manufacturer's number one and number two. That can be a nen FEC shin prevention issue all in and of itself. The third thing to remember is that although you're only supposed to remove any hair, if you have Teoh right just before the procedure, many people interpreted. That is literally just before the procedure. And so it was done frequently in the presence of a sterile field right in the operating room. But it should not be done in the presence of a sterile field, because imagine the amount of skin cells and bile burden that's introduced into this operating room, and then, potentially into that, patients wound when you remove hair in the operating room in the presence of an open, sterile field. So we need to try and do this work outside of the O. R. Immediately before that procedure in the pre upholding area, whenever possible, peri operative skin and triceps is has always been an important part of SSE reduction. And there's a lot of literature now that has gained consensus that using a dual active prep containing alcohol unless contra indicated, is the optimal prep to use for, ah, patients. Skin antiseptic is we know that Chlor up Claure Prep and Dura Prep are better than better. Dying alone, uh, in achieving optimal skin. Antiseptic sis. Okay. In addition, there's evolving support for the use of anti microbial insides drapes. And here are examples of many organizations that have come out with position paper stating that if you're going to use adhesive drapes, that, um, using a niota for impregnated anti microbial and size straight can be beneficial. And the reason for that is because the anti microbial properties of that drape can reduce the opportunity for regrowth of the remaining bacteria that is on the patient's skin. When we do the surgical prep, we do not sterilize the skin. It only reduces by several logs the amount of bacteria that is on the skin and during the surgical procedure. Over time, this bacteria can regrow, and so that iota form and anti microbial inside straight allows that to prevent regrowth. In addition, it provides a sterile surface to start from when you begin your surgical procedure. Aseptic technique is an incredibly important part of preventing surgical site infections and that the entire concept was developed simply to reduce the risk of wound contamination. And everyone that works in the operating room is very aware of all the principles surrounding preventing wound contamination. Clean dirty technique as part of the colon bundle is one way to also reduce that wound contamination because there's a potential for cross contamination when the bile burden from the NASA Moses is present during closure. So we've tried to reduce that bio burden by giving the patient oral antibiotics and also having them do a mechanical prep. But during the anastomosis, there could still be contamination that can occur. So many people use clean that it clean and dirty technique as part of that Colin bundle, and it looks like this. Usually people change gloves. All the scrub personnel change gloves prior to closure, and many programs will include changing gowns at the same time, draping with clean towels at the incision site. When they're dry, Then that helps to prevent the wicking from very moist, bloody and contaminated towels that may be under the drapes, um, that were present during the anastomosis and then dedicating moon closure instrument trays or sequestering instruments at the beginning of the procedure in order to have clean non contaminated instruments with which to close that incision with. And this has, uh, the effect of limiting three potential for cross contamination during the closure. So in conclusion, I'd like to just review that controlling process variability factors can reduce the bacterial load by utilizing surgical bundles to standardize your care. Reducing the bio burned pre operatively with decolonization strategies are important, and that includes the narratives as well as the skin. Managing hypothermia through all peri operative phases is important to also manage surgical site infection prevention initiatives and controlling intra operative wound contamination. Uh, through clean and dirty technique from a colon bundle perspective is important and then protecting the incision post op to give that incision the ability to seal. And then he'll. And with that I thank you for your time and I'll turn it over to Dr Cooper and Dr Mollo. Thanks very much to a Kathleen ev for talk. Um, I will talk about incision management and strategies for preventing surgical site infection. My name is Michelle Melo, or orthopedic surgeon, working in Montreal, Quebec, Canada. These are my disclosures. So when we look at these, uh, two images, both cases might look different Not only because one is a hip case on the left and the other one is une case on the right, but also because of the timing. A presentation of the drench one is that three week post up and the other one that three day post up. But in fact, they are similar because both refer to the essence of preventing surgical site infection. So today my role is to discuss the important topic of surgical incision management in General Onda more specifically in orthopedic surgery. So why surgical incision management is important. It is important because, and this is the main take home message. It is important because careful handling of the soft tissue and wound healing is crucial to the success or failure of a surgical procedure to prevent potential serious complications such as infection. Infection is definitely the most feared complications in surgery on, especially in orthopedic surgery, because it could be devastating. So, uh, today I'd like to share my approach to surgical incision management in what I call my top 10 rules. My rule number one, we have to be aware and to avoid Thea, the any potential surgical site complications involving the soft tissues, such as leaking one breakdown and the Croesus, which, when the cure is never good because they all thes complications are directly related to the risk of developing in infection. My rule number two very important to identify the patients at risk not only in regard to local factors or skin conditions such as a previous incisions and the vascular charity, but also in regard to systemic factors and some specific medical conditions. It it is important here thio, uh, pre operatively optimize any modifiable and medical risk factors. Otherwise there is, ah, danger of complications. And as an example in these two clinical cases, there are problems and you could looking at the images, you could see the complications of soft tissue, and in these cases we are undoubtedly in trouble. My rule number three ah, we have to use a skin prep agent containing alcohol. And in the current literature, there's ah, lack of evidence to support the use of one solution over the over another one. But there's an overall consensus that skin preparation solution should contain alcohol. And this was voted and approved by a super majority of delegates at the second International Consensus Meeting that was hold in Philadelphia in 2018. My rule number four use an antimicrobial in size drape. There is evidence that I, a dying in created incised rates, results in a reduction in bacterial colonization and contamination. And this statement also was approved by a super majority of delegates at the international Consensus. The meeting, my rule number five No, the blood supply Anatomy of the skin. Hanna s the Moses of vessels. Important too. Understand that Anesta Moses of vessels is just superficial, too deep fascia. And that's why stuff tissue dissection should be made underneath the deep fascia to protect skin vesicular charity, as it is shown here in the picture, here is an example in orthopedic surgery about skin blood supply of the knee. Most of the blood supply comes from the medial side, and then the lateral side of an incision is always most vulnerable, so we need to keep that in mind in our search called preparation and exposure. My rule number six. Use a standard incision and approach. Uh, an example for the knee. Azan example. For the knee, it will be a midline in medial per patellar are throttle me because it is versatile, extensible and secure. And there is There are some specific considerations in knee surgery. Um, when multiple incisions are involved. First, when there's, ah, two parallel incision, Um, we have to use the most lateral incision to have a medial robusta medial flap. Using a medial incision will increase the chance off skin edge, and it crosses because of the majority of blood supply coming from the medial side as we just a Z I just mentioned, and that will put some skin area at risk for necrosis. If across incisions are needed, there must be at more than a 60 degree. Otherwise, there is a high risk of getting in trouble as it is shown on the right side with potential and suffering of skin. The skin area. If this rule is not respected, this it could become more complicated, which, with a need for some soft tissue coverage as shown isn't in this example with the medial gas dropped flap and when we have to do so, definitely the leg could potentially be in job. Joe Perry. And finally, trans verse scars should be crossed perpendicular with no risk. My rule number seven make sure to obtain a tight water. Ah, watertight closure and almost has is to prevent bleeding and potential leaking. Um, of the wound Ah ah, I ah ah Still use ah capsule er closure using traditional interrupted suitor and I always check for repair with the full flexion of the articulation to make sure that we have watertight closure. My rule number eight No, the utility of transatlantic acid. Um, this can help reduce the rate of Peru prosthetic joint infection after primary total joint Martha plast e. And this protected effect is likely interlinked to reduction in blood loss and lower need for a Logie nick blood transfusion. My rule number nine do an appropriate one Irrigation. The rational is that lavage with Billu iodine solution before closure shown. I've has shown to decrease the rate of post operative infection and orthopedic, but also in other surgical specialities. And that solution is safe and expensive simple to use and really available. And it has a broad straight from backed Arar's saddle activities that includes Marseille. And there's a strong evidence to support this recommendation. And finally, my rule number 10. Choose the appropriate dressing to provide protective environment for healing. And, yeah, then we have to ask ourselves what is an ideal dressing? Well, I will definitely look for these characteristics. Yeah, when choosing the appropriate dressing, Uh, there's, Ah, this should be a good absorption capacity. Ability to visualize surgical site through the dressing eso transparency, waterproof and also having the ability to shower with addressing good control of moisture for wound healing. Good protective barrier for infection dressing has to be confirmable comfort comfortable and allow for early range of motion and rehabilitation. Also as to be easy to apply and to remove without trauma to the wound. Uh, hopefully it It could be left in place until staple removal up to 10 days without addressing changes required a proven performance and also patient insurgent satisfaction of the dressing. And then, ah, my, the ideal dressing for me is this one. The acrylic dressing. I've been using it for the last 10 10 years with the great satisfaction. And keep in mind that this type of dressing is, uh, ideal for, ah, standard cases and patients which are are not at high risk of potential one complications. Here are some cases to case of studies Thio illustrate how to use that dressing first. Uh, here is a case of 65 year old female and that ah, that I took care of for a left primary total Northrop last e for osteoarthritis. And, uh, this is, ah, skin closure that was made with a particular future glue and stare strips. And this is the way to apply the dressing, which is, uh, quite easy. You got to make sure to remove air and to obtain a dry skin to select the correct size of the dressing. And then you just need to smooth the border down as you gently peel off the outer paper. And, uh, once everything is done, you can see how it holds perfectly to the skin on, and it allows full range of motion with the great endurance case. Example. Number two. This is a case of the 70 year old female with a left primary total. New York capacity. And this case is to illustrate what it looks like in the post operative period. At that three days, uh, on the right, and at 10 days post up, you can see Theodore version of the exit date on, and there is no addition to the one with non traumatic removal of the dressing. And the wound is a completely dry. I thank you very much for your attention. And now we'll leave you back with Dr Cooper. Thank you. So thank you very much, Doctor Melo. Very good talk. I wanted to transition into some strategies for incision management and managing the soft tissue envelope after surgery, specifically focusing in a bit on hip and knee surgery, which is my world. So I'll start by introducing closed incision, negative pressure therapy and despite us using this a lot more commonly in recent years, this is not new technology. This is not a new concept. We were using this kind of thing. This kind of therapy in the 19 nineties, in the field of orthopedic trauma and the first known publication of Close decision negative pressure therapy was in 2000 and six from an orthopedic trauma study where they introduced in the literature three idea of these decisional vax to provide a clean and dry wound environment. Uh, in the early postoperative period, these were intended to be applied to high risk incisions in the operating room in areas that traditionally saw high rates of incision complications. And this is an example of what these decisional vax might have looked like. This is one of my patients from a number of years ago, and Praveen a. Takes the concept of this closed incision negative pressure therapy. And it was designed to deliver this to a closed surgical incision in a very consistent way and in a manner that was designed a Knop Tim ized based on a number of laboratory bench top in animal studies to provide this in the most consistent way. The basic Praveen. A set up includes both they surgical dressing, which comes in a number of different shapes or sizes, as you see here on the screen, Um, from 13 centimeter to 20 centimeter to 35 centimeter pre made peel and place dressings to a 90 centimeter customizable dressing, um, that you cut the link a zealous some some various, um, restored designs that were designed to address and challenging areas. There's also a source of negative pressure for these dressings, which were the pumps that you see on the left side of the slide. Um, both a seven day therapy unit, uh, Praveen, a plus seven day unit and a new in 2019 14 day therapy unit as well. Now the Praveen, a incision management system, provides incision management, but by delivering a continuous negative 1 25 millimeter of mercury level of pressure for up to seven days, um, it's designed to help hold the incision. I just together, um, removing any fluids or infectious materials from that incision. And it also acts as a barrier between the external environment or any external infectious sources and the surgical site itself. This is an example of the Praveen, a Arthur former store dressing applied to a patients need following primary knee replacement surgery. And you can see how the way this dressing was applied allows for motion of the knee from being fully straight to being bent back to almost 120 degrees in the operating room. So I wanted to focus on some click some key clinical studies of results that have been seen with Trevena dressings, and these range over a number of different surgical subspecialties. Um, and certainly we don't have the time to get into all of these. But there's There's really an abundance of literature in 2020 that that discusses this technology in a range of different applications. So I'm going to start with this study from orthopedic trauma. And this this actually is not a Praveen a study. It's an incision all back study. It was done before Praveen A was on the market. This is a randomized controlled trial of about 250 patients, um, who were recruited from one of three different Level one trauma centers. They were recruited with one of three high energy lower extremity fracture injuries, either cockiness, fracture, appeal on fracture or a tibial plateau fracture. And when they were indicated for surgery, they were randomized, either getting a dry dressing or an incision all back. And what the investigators found was that when the dry dressing was applied, which was their standard of care at the time, they had a 19% rate of infections. But when they use an incision all back in this study. Their protocol was two or three days of incision. All that treatment, that rate of surgical site infection dropped by about 50%. Similarly, they looked at the rate of wounded hastens after surgery, and they found that when they used the dry dressing, they had a 16% rate of Wendy Essence. But when they used negative pressure dressing the incision Novak, that rate again dropped by half, down to just over 8%. And these were both statistically significant. So going back to what we were talking about earlier in terms of cost effectiveness, this was not part of the original standard randomized controlled trial. But this was a post talk analysis of, um, the potential economic impact of negative pressure therapy and they this kind of pretty straightforward economic analysis. I think it's important to do what we're thinking about adapting, adopting new technology into our practices. But this analysis makes a number of assumptions number one. It assumes, most importantly, that the data in this randomized control trial is true, that if you take this high risk patient population and you use a negative pressure dressing that you're able to reduce the rate of post operative surgical site infection by about 50%. The second assumption is that it's expensive to treat one of these postoperative surgical site infections, and I don't think that so much of an assumption as it is something that we you know, I showed a lot of data on how costly these could get, both to the patient, the insurance provider and also to the hospital. Um, in this economic analysis, they used this number $64,000 which comes from the Thompson cost data. Eso using riel real numbers and the third assumption it makes is that it's more expensive to use, um, this negative pressure technology compared to gauze, which I think none of us would argue with. But when you make those three assumptions and ask the question if you use the negative pressure, more expensive negative pressure dressings upfront what you're able to reduce the risk of infection by about 50% and therefore save spending that additional cost to treat half of the infections. Would you end up spending more money on dressings, or would you end up saving money? And what this found was that using the assumptions that I just talked about. They would have saved about $7000 for every single patient in the study had they used a negative pressure dressing up front instead of random izing. I wanted to move into the field of vascular surgery next. And this is a recent randomized controlled trial from Philadelphia published by Kwon in the journal Vascular Surgery. And here they conducted a randomized controlled trial on vascular growing incisions. Opened our decisions. Um, 120 incisions closed primarily after elective surgery. Um, half were randomized, super veena. Half were randomized to cause and they looked at one complication. Rates like to stay three operation readmission and hospital costs using riel real dollars. What they found was that when they looked at their major wound complication rate using Trevena was able to reduce that risk by about two thirds from 25% down to 8% which was highly, statistically significant. They also found that the cost to care for these patients reduced substantially with Trevena by about $6000 per patient. Um, looking at the entire episode of care compared to gauze dressings. And a lot of this was that reduced risk of major complications. Even if they spent a bit more on dressings upfront, they were able to save money. Overall, this is a study from the field of cardiothoracic surgery. The growing study, published in 2013. Looking at Patients Undergoing Medium Stir Anatomy. This is a particularly high risk incision, because these patients are often obese, often have co morbidity is like smoking diabetes. And this is a particularly high risk incision because there's tension, and there's also decreased perfusion to this area as well. In this perspective study, they recruited 150 patients. 75 got Trevena, 75. Got a dry dressing, and they look they're wound infection rate. Within the 1st 90 days, you can see that with Trevena they were able to reduce their wound complication rate from 16% down to 4%. I'm sorry. This is a wound infection rate, which was statistically significant, and when they looked at the wound infection rate specifically with grand positive skin flora, meaning the kinds of infections that might likely toe happen. As a surgical site complication itself, that rate decreased from 13% down to 1.3% which was highly, statistically significant, a similar kind of economic analysis is, as we talked about with the standard study here, using the same kinds of assumptions, slightly different numbers. They would have saved about $7000 for every single patient in the study had they used the PRA Veena instead of gauze in the field of Hip and the Arthur Plasticky. This is a study that I published in 2016, which was the first comparative study looking at outcomes after hip or knee replacement. And this was a retrospective study of 140 of my patients that I had revised their hip or knee replacement. The purpose of this study was to compare my standard of care, which was a nic lucid hydro fiber, anti microbial dressing with pregnant of a silver to prevent him. And I began using the Praveen A for my higher risk revision cases in 2014. And this study compared this smaller group of high risk patients, starting from 2014 to 2015 to my larger revision population that I was using my aqua sells. For one thing that's important to point out is that because of the study bias in how these groups were selected. Um, the group that got a Trevena was actually a slightly higher risk group than the group that was treated with Aqua Cell. Because when I was choosing Trevena, I was choosing it for that patient that I was more worried about. And that came through in the data high risk kind of operation was more likely to get a pra Veena compared thio compared to those who got aqua cell. Now. Despite that study bias, I found that my wound complication rate dropped significantly from 27% down to 7% in favor of Trevena. My surgical site infection rate dropped from 18% down to 3% when I used to Praveen A instead of an aqua cell. When you have this data from different surgical subspecialties, I think meta analysis, uh, literature can really help toe Thio tie a lot of this together. And this is one that was published last year in the plastic and Reconstructive Surgery Journal by a group where they looked at, looked at this question from a number of different ways. They looked at randomized controlled trials, and they found that when they pulled the data across a range of different surgical specialties. They found that the overall odds ratio oven infection was about 2.6 times higher. Um, when the standard of care was used compared to negative pressure dressings with Trevena, they also looked at observation all trials. So not not prospective randomized trials, but you know, more retrospective comparative trials or cohort trials. And they found similarly, that the standard of care was associated with about a threefold higher risk of risk of infection. Compared to the Trevena dressings. This groups the trials a few different ways, looking at randomized controlled trials, looking at observational trials and then looking at sort of specialty specific trials that colorectal trials, obstetrics trials, lower extremity trials on Do you can see the number of studies in each of those groups. And you can see this the surgical site infection odds ratio, Um, almost all of which were significance in favor of Pra Veena compared to the standard of care. Because of this data, the international consensus on orthopedic infection came out with a statement a couple of years ago specifically talking about incision. All negative pressure therapy are these decisional vax, and they stated with a consensus panel of experts over 800 people that with a moderate level of evidence that it's a reasonable option for improved wound healing and decreasing the infection rate in AH higher risk group of patients who are at risk for such complications. And they agreed to this within 85% consensus, which was a super majority or strong consensus. The FDA, um, also made a statement about this through their de Novo process, which is a pathway to classify novel medical devices. And in 2019, um, they came out based on ah, lot of the evidence that I've talked about with a new indication statement specifically for Praveen as negative pressure therapy delivery device not for negative pressure as a general treatment, but specifically for Praveen A as a product, um, that this device was ableto aide in reducing the incidence of Ciroma, but also in patients who are at high risk for post operative infections that a Praveen A was able to aid in reducing the incidence of superficial surgical site infection. And I think this was a big deal because this is the first post operative dressing that has a non label indication statement from the FDA toe help prevent superficial surgical site infections. And the CEO Mark Indication statement for outside of the United States for more of the global market is that in patients who are at risk for developing postoperative complications such as infection, there is a non label indication for using Trevena for this patient population. So to conclude the published clinical evidence today does show that the close decision negative pressure therapy, um, can be quite helpful at reducing the risk of surgical site complications in high risk patients in high risk kinds of incisions on discovers not only orthopedic surgery, but also ah, quite a wide range of surgical subspecialties. Um, with that share these themes of high risk patients or high risk kinds of surgeries or procedures, and that the use of closed incision negative pressure therapy in these patient populations can certainly result in a riel cost savings. So I have a few case studies that I wanted to go through, um, about kinds of cases where I tend to find these helpful. Um, this first case is a 52 year old gentleman who's on chronic chronic anti coagulation. He'd had a left knee replacement done at an outside hospital in New York City in 2016, unfortunately, got an MRSA infection, and he had five failed attempts to treat that infection surgically over about a 12 month period. And, after failing for the fifth time, was referred to me with his knee open draining and still infected. You can see he had revision components in place, uh, still with calcium sulfate, antibiotic beads from his most recent surgical procedure. I took him to the operating room within a few days, took out the revision components and gave him a static antibiotic cement spacer. I treated him for his infection. Um, with consultation with an infectious disease expert. We used i v antibiotics kept him protected weight bearing. But to manage his incision, I used per Veena plus one of these customizable dressings, which you can see on the right that I applied directly over his clothes. Decision. Um, you can see his incision at two weeks. You can see his incision at four weeks, and you can see his incision at eight weeks And how it had healed after having this, uh, this negative pressure therapy device on in the early postoperative period At 10 weeks when I took him back to the operating room. You can see his incision is nicely healed. I was able to put a revision hinge knee component into him. At that time, we did a, um, rotational muscle flap using the medial gas truck and covered that with a split skin graft. I put a Praveen a directly on top of the muscle flap and skin graft you can see here he is at six days when that came off. Here he is six weeks later and then at 10 weeks healed and doing really well. And this patient is fortunately still still doing well, four years out from his surgery, this is the second case I wanted to talk about. This is a 70 year old lady, B m I of 38. She was sent to me with left hip arthritis and I did a primary elective left total hip replacement. Um, she was part of a randomized controlled trial that we're doing at my institution as the lead site of a multi center site. And we're comparing Praveen A to an anti microbial dressing she was randomized at after closure while still in the operating room to the anti microbial arm, and she got the antimicrobial dressing for seven days. This is her at her 16 day postoperative mark with a pretty healthy incision other than a little bit of Perry Incision. Larry Thema Here she is a week later with increasing parents, digital era thema and concern for a superficial surgical site infection. Here she is a week later with a DigiScents, both approximately and distantly, and she eventually healed without a return to the operating room, simply with local wounds care. During this time, she had very little to no hip pain, was functioning really well, but ended up dealing with this complication. For almost nine weeks, until our decision was finally able to heal. I wanted to compare that to this patient. Ah, similar kind of high risk patient, obese 79 in the same randomized controlled trial. But she was randomized to the ravine, a arm at at closure. I use this for seven days on her, and this is her incision at 15 days. When she came back, you could see nicely healed. She was going to come back for her six week visit, which is part of the study protocol, but she felt so good that she didn't want to come back to the office. So she texted a photo of her incision, tow us at six weeks, and you can see how nicely that sealed in. The last case I wanted to show was another high risk patient, 74 year old lady with a past medical history significant from morbid obesity lymphedema, She has, AH, strong history of peripheral peripheral vascular disease, recurrent blood clots. So she's on high dose anti coagulation as well as a few other co morbidity ease. She was treated with a right knee replacement in 2000 and five, well before I met her, which dislocated in 2013 when it dislocated. Unfortunately, she ruptured her papa teal vessel, and she needed emergent vascular surgery for a bypass. And since that point, she's been very limited functionally, she never underwent knee revision for the instability that she'd been dealing with. I met her in 2018 when she dislocated her knee for the second time, so ah, full five years later, she was fortunate this point not to rupture her Papa Teal bypass graft. We performed a closed reduction of her in the emergency room. You can see here. Harney is dislocated. Posterior lee. I want to draw particular attention to the amount of lymphedema and distal swelling and venous Stasis changes you see on her lower extremity. So really not a great candidate on high dose anti coagulation with these co morbidity is for surgery, but she needed it for her instability. So I took it to the operating room, uh, revised. Her need to this rotating hinge did not use a tourniquet. Um, put her back on her on her full strength. Xarelto immediately post operatively and use this Praveen A to manager and stealth manager Incision. This is an incision at seven days. So in a really high risk patient where I'd expect a pretty significant risk of the late incision healing or incision, all complications. Here she is. Beautifully. Hell, that seven days, Um and she's now two years out from surgery. Still doing really well without complications. So with that, I'd like to conclude the program. Thank you very much for your attention, thanks to Kathleen. And thanks to Dr Melo for their their talks is well, and we hope that you got something out of this tonight. Thank you.
