During this webinar, the multi-specialty panel will share strategies and best practices to increase efficiency in the OR and decrease readmissions.
By the end of this webinar, attendees will be able to:
Recognize the financial and clinical burden of Surgical Site Complications
Review strategies & best practices for setting up your patient for successful discharge
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
Hello On good afternoon, I would like to welcome you to the three and visual Symposium with the title Enhanced recovery include efficiency on decrease the Admissions strategist, Mr Practices on novelty closures for surgical planning without further delay. It is my pleasure to introduce our keynote speakers. Is an Johnson on also Felix Surgery physician assistant in Washington D. C All of us not grass. Our colorectal vascular on general surgery Physician assistant in Tallaght Access Anjali West A plastic and reconstructive surgery Finton assistant in the Ohio State University Columbus, Ohio Iran I'll turn it over to you. Good afternoon, everyone. Thank you for joining us. My name is Ivan Johnson. I am an orthopedic surgery p A in Washington D. C. And I will be speaking to the impact of surgical site infections this afternoon. There's a lot of important information on this slide. I just must inform you that this information presented today is based on my own opinion. So free Thio read the slide at your leisure. I must disclose that I'm also a pacemaker for Casey. I now part of three in Before we get into the presentation, I would like to review a few objectives, So we would like to understand why complications with incisions can lead to serious consequences. Discuss the impact of surgical site infections on hospital systems as well as your clinical practice. We will discuss how these surgical site infections can affect patient outcome. Review the factors that reduce those surgical site infections and introduce negative pressure. Moon therapy as a means thio, peri operative and postoperative wound care management. So why should we be concerned about surgical site infections? Data shows that there are approximately 8.2 million people at risk for surgeon site infections annually. And those surgical site infections are 21% of all healthcare associated infections, so these complications lead to serious consequences. Those include increased costs longer stay in the hospital and direct complications related to the patient's wound. So as the most common types of hospital acquired infections, exercise can occur up to 300,000 times per year. That's a huge number in any surgical speciality. We know that exercise our greatest enemy. Surgical site infections unassociated with substantial morbidity and mortality. Patients that have exerciser twice as likely to die 60% are more likely to admit it to the I C U and five times more likely to be re admitted to the hospital after discharge. Over the next few slides, I will review a few studies and numbers that directly discuss how exercise impact hospital systems. So let's take a look at a retrospective study by Shepherd analyzing the change in hospital profit at four Johns Hopkins Health Care System over three year period, there were on the 400,000 inpatient admission, 25,000 surgical procedures of interests and 600 exercise identified that resulted in the S I rate of 2.7 per 100 surgical procedures. The state of suggests that there was a net loss in profits between 4000 and 22,000 per surgical site infection. The economic burden is not exclusive to the United States. This study reviews the impact of surgical site infections across six European country as well as various specialties. What I would like for you to focus on the slide. It's the cost comparison between the uninfected patient versus the effective patients, 24,000 versus 6000. In the uninfected population, that's a cost increase of almost 300%. It costs increase of almost 300% would negatively affect anyone's budgets. Currently, hospital systems are financially emerging due to decrease in Versant rates as well as increased costs associated with S. S. I. This is more than enough proof that exercise or an issue we have conditions have responsibility to be more diligent about reducing them. And, in fact, 60% of them are preventable. We'll get more into this later. This highlights exercise associate it with these three surgical procedures, which is not currently reimbursed by Medicare or Medicaid. So let's briefly touch on how surgical patient risk are classified. Increased risks are associating with link this case contaminated or dirty cases in patients with multiple come abilities. There are several organizations that have developed guidelines and recommendations in an effort to reduce exercise and improve patient outcomes. Think about the surgical prep for your O R cases. The A O. R N publishes an annual guidelines based on data that leads to the standard of care for skin prep. For each of our surgical patients, how does this impact? This is providers. There has always been a standard to minimize risk associated with patient care. What has traditionally been more difficult to impact is what happens after the patients discharged from the hospital into the community. We essentially have less control over those environmental factors. In fact, surgical site infections recognized after discharge are directly associated with higher medical costs. Recognizing surgical site infections and the ambulatory setting results in increasing utilization of resource is some of these include more phone calls to the office, more outpatient visit there even e d. Admission as healthcare changing and currently trending towards more outpatient and same day procedures. There's less opportunity to identify potential exercise while in the hospital, say, and in fact, it is estimated that majority of exercise will be identified following discharge. In the orthopedic world, we have transitioned to same day discharge total knee replacements. Therefore, in divisional cares critical tow. Avoid the red hot knee that pictured on the right. If the red hot me on the previous Black presented to clinic, it would likely earned him additional lab work admission into the hospital antibiotic treatment, possibly pic line as well as future revision surgeries. We spent all the time discussing how exercise impact hospital systems and conditions. But let's not forget the patient. Consider how these patients may be impacted by their surgical site infections. Initiatives to reduce exercise Focus on improving pre op conditions to post op. Didn't care pre optimization of your patients. Keith. Let's sit here. Cem Modifiable risk factors or things that we can change or optimized. Participate on the flat out, like for you to focus on the high risk patients represented by the Deep Purple. These are patients that we know may have difficulty healing their rooms. It feel director attention to the bottom to bolt from the slides. Imagine the likelihood of one of those high risk patients developing infection using passive therapy so a science and medicine are constantly involving shells won't care. Negative pressure One therapy was initially introduced in the 19 eighties. It was initially meant thio assist with chronic sons. However, over time it was found that negative pressure one therapy was beneficial for all types of rooms. The benefits. Something negative. Pressure one therapy, including increased blood flow, bring relation, tissue and decreased bacteria in the wound environment led to the development of individual Luczak in 2006 as negative pressure wound therapy begin to gain popularity as a means of institutional management. The surgeon that I worked with was introduced to it in 2014 which is represented by the dash line that you see on your screen. We traditionally used a silver in that it hydro correlate dressing. However, we were unhappy with the number of room complications that we saw in our complex patients, which are represented by the red box. This led to the development of our own many study that took a retrospective look at passes, one therapy versus the use of negative pressure when therapy and total me after classy. What we found is a trend across the board and increasing mobility. Decreasing the hiss. It's an infection. After we introduced Negative Pressure Month, they're being to our practice. As a result, we begin to use it on everyone, and now it's been proven as an insurance policy for favorable outcomes. What you see her? The standard components of the preventive therapy portfolio, including seven day and 14 day units. Praveen A. Has been proven to be beneficial and delivering continuous negative pressure, helping to keep those decisions that just together remove any extra extra date or fluid acts as a barrier and reduce the Dema. So why do we care about physical site infections? Well, it's costly, it's preventable. And we would like to keep patients safe and happy. In the next section, Julie will discuss enhance recovery after surgery. Thanks, Yvonne. Good afternoon, everyone. My name is Julie West. I'm a physician assistant at the Ohio State University Wexner Medical Center. I work in plastic and reconstructive surgery, and I think the best part about my job is that plastic surgery covers all of the surgical subspecialties or many of them kind of head to toe. The practice that I work in is heavy, um, in reconstruction, specifically in nerve and nerve injuries and amputee care and reconstruction and limb salvage. And it is a super exciting. Um, today I'm going to be talking about enhanced recovery after surgery, um, pre and post op management strategy. And I think this goes really well following Iran's talk about surgical site infections. It is part of a comprehensive plan to improve patient care overall. And, um, hopefully you will learn something from this before we get started. I just wanted toe flash this important information slide. I'm gonna be talking about some products today throughout the course of my talks, and I just wanna make sure that anybody, um, that uses these either concerts, the rep or their product information. My disclosures are that I am a paid baker for Casey, which is now part of three M. As you can see, the map here, which was published in The New York Times about a year ago, is a map of the opioid problem in the United States. And I don't think it would be right to begin a lecture about surgical pain and optimizing recovery if I didn't mention the opioid crisis that our country is facing. I live in Central Ohio, and I've seen first hand the toll it takes on Ohioans and Americans, and I think it's hard Thio understand who is actually to blame. Is it prescribers? Is it pharmaceutical companies are the patients to blame? Um, the drug trade. Uh, the answer is, maybe that all, um, play a part. To some extent, Um, it was quoted that there are enough prescribed opioids in the United States every year to keep every man, woman and child in the country medicated around the clock for one month. A lot of opioids um in 2018 opioid overdoses killed 33,000 Americans, is on par with, um, car accident deaths. And, um, the opioid dependence problem, as you're all aware, is significant. One data from the U. S. U s National Institute on Drug Abuse indicates that, um, opioid misuse in the United States costs about $78.5 billion per year. Um, and the staff on the screen that you can see, um, show that up to 30% of patients that are prescribed opioids for chronic pain misuse um, it's a terrible problem. And, you know, this crisis in the United States has helped to kind of propel a movement that was started on a much smaller scale a couple decades ago by anesthesiologists and surgeons. Actually, in Europe help understand and optimize surgical pain. I'm going to transition, um, now from this opioid problem into enhanced recovery after anesthesia. So how do you define surgical pain? Um, if I could see you right now, I would ask you, um, but I'm just going to tell you what I think of when I think of surgical pain. I think of the words temporary, intense emotional associated with swelling need medication? Um, and I think that the list could go on and on. The International Society for the Study of Pain defines pain azi. You can see on your screen as unpleasant sensory and emotional experience associated with actual or potential tissue damage described in terms of such damage. It seems like a very technical term, for I had surgery and it hurts. Um, and I think we all have experience with that. No matter what your specialty is, I think it's how the pain is handled and how it's dealt with. That is the rial game changer and what I wanna emphasize today. So we're gonna lean into some things that we know. Um, inadequately manage. Surgical pain increases many things that we don't want. Increased increases patient morbidity, prolonged hospitalization delays, return toe activities of daily living, increased health care costs. And there's mounting evidence that inadequately treated surgical pain have profound effects on both the physiologic and psychological aspect. Um, for patients, for their families, um, the health care system and for society um, it is the surgical stress response is just, um so drastic sometimes, um, that really identifying whatever we can pre operatively and making a plan for it is really integral to the success of patients you know in the hospital and then going forward through post up and the longer term recovery moving to more of a positive note. Um, adequately treated surgical pain allows for all of the things we want to see. Early emulation, um, the reduced risk of developing chronic pain conditions or syndromes Um, return thio activities of daily living, getting patients out of the hospital and back to work. Um, a reduced hospital length of stay. And, um, I think it promotes psychological well being with patients with their family members, who oftentimes are again. It's that stress responses of surgery and pain and the fear of not knowing, um, if they see their family member comfortable, you know that they're able to better understand and care for them. So what is enhanced recovery after surgery or era protocols? Um, it's a peri operative process designed to implement best practices for all of the phases of peri operative care from that clinic visit until after surgery, when you're seeing the patient after discharge, it is a program that is designed to help people recovered from surgery faster. It focuses on decreasing the risk and intensity of common post operative issues in, um, it focuses on fluid management, pain management, nutrition management co. Morbid medical co. Morbidity management and activity management. Many, um, many different surgical subspecialties have different protocols. Kind of tailored to their, um needs, Um, but it is a multimodal, you know, multidisciplinary, peri operative care pathway. When I was putting this presentation together, I, um, thought it was important to kind of learn the history of enhanced recovery after surgery. And so I found the first article that was published in 1997. Um, by a professor, Henryk Kellett. I hope I'm pronouncing that right. Um, who does first described enhance recovery programs or, you know, quote fast track programs. And they were published first and colorectal surgery, vascular surgery, Karasik and urology. Um, kind of in all around the same time when they started coming out. And, you know, they focused on all of these areas. I'm going to kind of go through his first paper over the course of the next few slides because I think, um, it's really a good outline that many here s protocols follow today. Um uh, you know, follow those basic principles that he lined up. Um, you know, 20 or so years ago, the main principles that we're going to focus on are these phases preoperative intra operative and post operative care. This is a bit of a busy slide, and I'm not going to stay on it long. But this is from that first paper. The multimodal approach to control postoperative path of physiology and rehabilitation is a mouthful. Um, and this is again where they focus on if you look in the left column, the preoperative intra operative and post operative, um, category What? The effects on outcome and, you know, kind of treatment guidelines are we're going to go through them over the course of the next few slides. But, um, I wanted to show just how thorough and how well thought out I thought his article was I'm sure many of you do this already. I sure know that Ideo in general and then as part of, um, these protocols when we're when I'm able to put patients into kind of a pathway, um, pre operatively. You know, you're kind of assessing and optimizing their medical Kumar abilities identifying and improving their nutrition status. Um, sometimes not possible if it's not an elective surgery, but certainly if there's any sort of elective nature to it, um, you know, having these patients in the healthiest state possible going into surgery, um, is really important. Interpretive management is, um, usually a combined effort between anesthesia and the parameters that you said it your institution. But in general, you know, trying to think ahead of time, you know, is this patient of candidate for a nerve block? Is there a way to do the least invasive procedure possible? And then what are we going to do? Pre operatively, um, interpretive lee and then post operatively for pain control to make sure that they're optimized with, you know, the least amount of, um, opioids as possible. Um, keeping the patient warm and then reducing. Um, you know, any unnecessary blood products uses, um, the other kind of p principles post surgical. Um, management is the busiest slide here. And from a pain standpoint, um, using multimodal analgesia, thio control patients pain after surgery, um, is really key to the success of this, um, improving sleep in early activity. I know at our hospitals for um, are abdominal wall reconstruction, you know, pathway, We have a specific order and, like a note goes on the door like, do not interrupt the patient between the hours of, you know, 12 and five so that, you know, they don't get anybody coming in their room. They're hooked up to a monitor. They you know, the nurses will check them if they need to, but otherwise it's, you know, minimal interruptions to allow their sleep. Um and so I think there's little nuances to these, um, you know, protocols close operatively that are really interesting, but also really helpful to certain patient population. I'm going to spend some time on multi modal analgesia right now. And three overall aim of a man optimal multimodal technique is to improve pain relief while limiting opioid use and then reducing opioid related adverse events. It's pretty common tohave, um, you know, to treat pain through many different pathways. Um, in an m m a, um protocol local anesthesia. Whether that is, with anesthesia giving nerve blocks or whether it's at the end of the case. Um, the surgical team putting in local anesthesia on Ben, you know, intra operatively pre intra and post operatively dozing a combination of acetaminophen and said, um, potentially cox two inhibitors or narrow modulators hitting pain through different pathways. Um, with the idea being that it should help control it better, um, and give lower adverse effects. Giving Mawr giving more medications, um lowers the incidence of adverse effects and such patients up for success post operatively. I'm going to go through a couple of arrest protocol examples. They're being developed in the number of surgical subspecialties, as I've said before, and each one has its own nuances based on institution specialty, Um, and even sometimes provider specific. And the example that I'm going to show our some that we use in our institution. This is an example of our enhanced recovery after surgery for abdominal wall reconstruction or complex hernia. One of the surgeons in the group that I work with, um, spearheaded the development of this, and it is it was hard to fit on this slide because it is so incredibly thorough. Um, and you know, this is only kind of part of it that I could get on there, but you see how the details and the preoperative assessment and screening, um what happened? That pre op visit one week before surgery? How you identify and treat at risk patients? Um and so I think it's it's really well thought out to give patients the best outcome post op. And this is just a continuation of the same abdominal wall protocol. This just really emphasizes and highlights the thoroughness of this. This is the day of surgery, um, pre and Inter operative management. And I think this is a good segue into Olivia's, um, presentation on peri Operative and intra operative management. I'll say, just from this era, Um, section, um, that I think is a is the important thing for us to remember is that you know, the surgical plan and the execution of the actual procedure that the surgeon is coming up with that were maybe assisting with if we're in the O. R is super important. But I think with also equally as important is making sure when we can that the patients are optimized before surgery. They have a plan for pain control and activity, and it's well spot out after surgery. And so I feel like a lot of these care pathways Andi enhanced recovery pathways or something that you know as P A. We really can own and help, you know, institute in our practices. And so I think it's a really exciting, um, exciting time and surgery to be able thio, um, care for patients better. Good afternoon. My name is Olivia Snodgrass. I am a physician assistant from Tyler, Texas, or in the East Texas area. I work with a group of colorectal vascular and general surgeon in a private surgical setting. Just want to take a moment to thank Yvonne and Julie for their contributions and that really think they did an amazing job outlining their topics. Today, I have the privilege of speaking with you all about peri operative and inter operative management techniques, toe help improve patient outcomes and focusing on ways that 3 a.m. and K C I three m company come alongside us in an effort to improve patient outcomes and values. In full disclosure. I am a paid speaker for Casey, I now part of Syria, and I would like to say that this information is based on my own personal experience as surgical position assistance. Many of us are gonna be very familiar with most if not all of these peri operative and inter operative management pearls, but they are were touching on. We've got appropriate antimicrobial therapy prior to the surgical procedures so dozing within 60 minutes of the first cut, you've got the important concern. Obstacle skin preparation. Management of patient, specific co morbidity risk factors optimizing intravascular volume during the procedure. It's very important for my vascular patients facilitating normal ther mia in patients during the operative course, choosing appropriate surgical closure. Whether it's the primary secondary may be delayed and then optimizing surgical dressing choices. You'll see that I have started because some of these items not necessarily that they're more important. But these are the ones that I'm gonna highlight in ways that Casey I, ah three and company in three M could really help facilitate improvement in these arenas. So for surgical skin preparation, it all starts pre operatively with the cortex city and shower at least a day prior. You're gonna have different variations of this, but most show that day Prior is very important. You've got peri operative hair removal utilizing clippers versus a razor in the O. R. You're gonna wanna use optimal surgical crept such as cortex sitting and during alcohol based skin prep and our Practice, our Colorectal Incidence Recovery program called for a combination of both actually and then selecting appropriate drape. Everybody knows and loves the traditional blue drape. But in our practice we use three M. I a band antimicrobial drape quite a bit. It's designed with continuous, broad spectrum antimicrobial activity in the job that, he says, where it can't be washed away, and it's clinically been shown to help reduce the risk of room contamination and immobilized bacteria on the skin. This product is fantastic, so abdominal procedures It's absolutely phenomenal for growing cut down on. We use it for our carrot and dark quite a bit due to the amount of exposure we need on the Mac. Operating rooms could be chilly, especially for us, but even more so for the patients. So facilitating normal. Stir me on these patients that could be very important. You want to minimize exposure, making sure that they're tucked and covered where appropriate, administer temperature regulated fluid and then recognition is to use the temperature regulation device. 80% of hospitals used three and bear hugger temperature management systems. This is what we use in our oh are very familiar with it. It's not over 170 studies documenting the effectiveness of the technology and ensuring normal thermic temperature zones of 36 to 37.5 degrees Celsius. This is an area where I still surgical physician assistants who really have the opportunity to make a huge impact in patient care and patient outcomes is optimizing surgical dress. Things in the operative sweet really got three different wings. You've got your traditional surgical dressing, which you're going to consider standard of care, whatever that is for you, whether it's got they had some sort of silver and pregnant addressing, you've got closed incision, negative pressure therapy or Praveen A that was so well mentioned earlier in this presentation. And then you've got negative pressure wound therapy or negative pressure wound therapy with installation for wounds that we're gonna be left to heal by secondary intention or possibly delayed closure later on, and we're gonna pour into back their flow here in a moment back there. Flow therapy is really everything we know and love about traditional back therapy with your macro strain, micro strain removal, about to get a controlled environment with allowing you the ability to instill different solutions, allow the solution to dwell and then remove it. It has many benefits We've already discussed about installation of fluid, but what that fluid is can vary could be anywhere from normal sailing to a topical, antimicrobial or antiseptic solution. It allows you to dwell and then remove that infectious material away from the wound is a controlled and protected environment for fleshing and cleansing wounds, and you've got that protection from external contamination sources. There are many different dressings you can use with back there flow. But this is the Holy Grail, or what I call the Swiss cheese of dressing is a great option. Clinch twice for wounds that have thick, fibrous ex students love a very, very dirty wound. Got the contact layer, which is the one with the holes. And then you've got your cover layers to allow for different depths of the wounds. This is a great option for when you have a wound that needs immediate wound cleansing therapy, and it might not be able to go to the O. R Do thio our space time available, or they might just be too sick clinched choices, an ideal option for winds that have again that thick ex student. Very thick fibrous material. Wet climbing accident. Or you have infectious material in the wound that you would like to remove together. Back their flow and their flow clinch Toys stressing have been shown to decrease contamination due to repeated when cleansing increased and promote granule ation tissue formation. Decrease the amount of fibrous material and slough due to repeated negative pressure cycles and decreasing tissue trauma compared to pulsed lavage and other cleansing methods. There are several questions I'm asked on a pretty regular basis at a surrounding back their flow. And this is probably the number. One question that I received is Olivia. Where do I start with Back there? Flow. What are the recommendations for setting? This is what the general consensus and the international panel has outlined as faras factor for recommendations. Negative pressure setting at negative 1 25 Your negative pressure wound Therapy time at 2 to 3 hours Installation. Dwell time in about 10 minutes and you wanna think normal failing first. Mhm. The other question that I'm commonly asked is what wounds are best utilized or would be the best utilization of bacteria for therapy or negative pressure. Wind therapy with installation and I always like to talk about, Well, what wound? Shouldn't you use it on? So in our practice are impatient wounds that we would typically treat with negative pressure wound therapy before we had the beautiful of technology there. Now, therefore, Wounds to Gabriel study does a great job of outlining why wounds that air impatient with negative pressure win therapy should be considered for negative pressure wound therapy with installation in your back there a flood was a retrospective analysis of patients with extremities or trunk wounds who are impatient, looked at multiple different and points and showed some really significant results in regards to patient outcomes and hospital measures. Due to the Gabriel study and other bacteria close studies that have been completed, you can argue that bacteria flow therapy can help possibly decreased total length of stay for patients. Decreased stage to final surgical procedure. Decrease the number of O R visits total, therefore leading to a total reduction inpatient costs. Before I had the opportunity to present my cases, I do want to take just a moment to touch base on a new and exciting products from Casey I three and company, which is going to be the germ attack drapes. This is a hybrid drape for HVAC therapy that utilizes both acrylic and silicone that help increased feeling and reposition abilities. Upon initial placement of this product, you've got less time of dressing changes because of improved ease of use and less waste. Very kind of patient skin and minimizing discomfort supports wound healing. I personally use a lot of silicone border dressings in my wound care practice, and so this is a really exciting item coming down the pipeline. This another really exciting thing about Don't Attack Drape is that it's got significant ease of use. You've got a single clear release liner. There's no need to windowpane. No need to use skin prep products and less cutting all Equalling, less total time for application and improving the time that you can spend with the patient when applying germ attack draped. There are some differences compared to the drape that we use all the time or the one to blue. You wanna make sure while utilizing germ attacks are leaving at least a five centimeter border on all sides of the phone and the wound. You want to apply loosely over the wound, making sure that you're not to retching the product. And you also want to make sure over curved areas, that you're cutting slits and overlapping the product so that you can fold it smooth and obtain an optimal. And now I'm so thankful to be able to present some of my cases that I've done in collaboration with my supervising physicians. And again, these are all based on my clinical experience in my practice in Tyler, Texas. This is a six year old female who initially presented to our clinic for limb salvage she had. It's really significant wound on her forefoot. She had multiple medical core abilities with super sick and also needed pretty aggressive wound care. While she was impatient, she was found to really not have any vascular issues. She had in line flow with no obvious cyanotic, reclusive lesions in her medical work up her impact. PPH was significantly elevated and therefore it was found that in addition to her wound care, she also required a sub total parathyroid ectomy that was performed while she was in patient due to secondary hyper parathyroid of them. Well, she stayed with us. We utilize bacteria so therapy for nine days with frequency of changed three times a week. And we did utilize the Holy Grail or the back there flow clinched choice dressing after bedside debridement. You could see on day one what the room looked like prior to her first dressing change and utilization of cliched. Twice before it was applied on day three. You could see this was after her first dressing. Change about toe have her second. You can see that there is significantly decreased slept and fibrous material, and you can see that beautiful, beefy red granule ations issues starting to peek through on day nine. This is what she looked like at hospital discharge. She had a beautiful looking wound. The clock is almost completely gone. She's got a majority of the wounds covered with beefy red granule ation tissue, and she was able to go home for wound care. She lived started in two hours from our clinic, so we actually outsourced her wound, care to an outlying wound care center where she went on to hell with collagen and a secondary dressing. Her installation solution during her therapy was normal. Saline her so kind with 10 minutes back, therapy time was four hours and her soak frequency with six times days. This case is near and dear to my heart. This was our very first experience with back. Their clothes are negative pressure wind therapy with installation at our hospital. This was a 60 year old female who was well known to our practice. She smoked and had a alphabet soup of medical co morbidity is, and she had a colon cancer that had been previously respected. Later, many years the patients on colleges found a large abdominal mass on pet CT required an exploratory laparotomy with pelvic mass excision and post op Day 16. The patient presented to our office with copious parliament foul smelling drainage from the abdominal abdominal surgical side. Of course, it was a Friday. The patient was identified to need I V antibiotics and aggressive wound care. She was admitted she had a bedside i m D of the abdominal surgical wound. She was given appropriate antibiotics and then she had bacteria flow therapy with barrack low cleansed dressing. And this is actually chest utilized for the 72 hours that she was admitted on the left is what the patient look like immediately after bedside i India that abdominal surgical wound to be noted or fashion was in clock and on the right is what you look like. On day 3 to 72 hours after that initial back barrack where was placed, her installation solution was taken, quarter spiked. She had so kind of 10 minutes back therapy kind of four hours and a stoke frequency of six times daily. She eventually went on to hell. She did fantastic. She had outpatient vaccine was transitioned thio collagen with a secondary went back. Therapy was no longer indicated. My last and final case is a gentleman that we recently saw for a dialysis groin wound. Complication after a B graft placement. He was a 67 year old obese gentleman who's been on hemodialysis for over 20 years or almost got 20 years. He's been a patient in our practice for over 15 years. In the course of his time with us, we have exhausted every upper extremity dialysis access and he was gonna be limited Teoh a C i A B G graphs, which is why one was placed or permanent catheter based dialysis, which was also located in the groin he underwent left by a B. G. He did great at his post op number, 14 days visit, though the patient was found to have Adidas surgical wound that he stated started draining the day prior, he was admitted from the clinic directly to the inpatient setting because the really needed some antibiotics and wound care, and that fearful of therapy was erected for this patient, also utilizing back there for clinch. Twice he had his dressings changed. Three times a week is recommended and, you know, for him there was no a B graft exposure at the base of this wound. It would really was thought that they could to try to heal it and minimizes risk of infection and complications. We could salvage the A V graft versus exciting It is. This was his last dialysis option. This is what the patient work laws on day one, when he was initially admitted, you could see had six cyber, uh, slimy drainage really thick. Excuse. This is what the patient look like after just one dressing change, you can see things were really starting to improve less fibrous accident. Let's stick drainage. You could start to see some beefy red granule ation coming through. This is Day eight on hospital discharge. Things have really continued to improve for this patient, and he was going home on traditional back negative pressure therapy while he was impatient. Is installation solution was normal? Sailing at 20 ccs. Soak time at three minutes back therapy time. Two hours and so frequency was 12 times daily. In the end, the patient went on to completely heal this wound in the gloin. He, like I said, went home on negative pressure wound therapy. When his wound was restaurant five millimeters in depth. I transitioned him off of back onto a college and products with silicone bordered foam, and he continued to close. That graph is now completely utilized for dialysis without complication. Spanish want to take a moment to thank my fellow presenters figure amazing contributions, interest ability to be here speaking with you all today. If you have any questions, I'm excited to answer them offended with presentations and our question and answer section. Now we will discuss some orthopedic case studies thes case studies air based on my own individual clinical experience and research. This first case study is a 54 year old. No significant medical history. Includes C B A. Obesity. Hypertension in tobacco use. Presented with a multi ligament injury due to motor vehicle accidents, this light demonstrates the media in the incision. Prior thio prevent a placement in the operating room. The patient was discharged. Two sub acute rehab. His Savina Vac was removed seven days after surgery by room care nurse at the facility, and he presented for follow up in our clinic four weeks later. This is how the incision looked at that time. The next case I will present. It's what they 75 year old male multiple commodities, including diabetes. 12. Morbid obesity he sustain in mid shaft humerus fracture secondary to motor vehicle accidents. We use preventive back on his upper extra. Me, I'll give you a couple of seconds. Thio Review The X rays. As you can imagine, this gentleman had a pretty large incision following fixation and pictured. Here is the incision before and after placement of preventive act. We actually use the customizable um, dressing on this patient case. Study number 3 40 year old male. Significant past medical history includes HIV tobacco use and ivy drug abuse. He underwent a right clavicle resection secondary to infection, and we place the smaller prevented back on for wound therapy. Postoperative demonstrated on the slide. It's the improvement in wound healing after one week in two weeks of Praveen a wound back therapy. I'll take this time to introduce him to the patina restore, and it's the next generation incision and soft tissue management and post office care. We're currently using it in our practices. Well, it has an extended therapy time of 14 days. However, dressing change is required a seven days. What makes the restore special is the effect that it has on reducing oedema. It includes an envelope too enclosed the soft tissue to increase lymphatic flow to allow the clearance of fluid similar to the traditional pra veena. The restore comes with a variety of dressing, including the author form Bella form and actual form. So I have a couple additional case studies using the Praveen to restore author form here. I just want you to focus on the application of the unit and how it's place on this right knee. Arthur. Classy. This is the patient on post op datum of 14. As you can see, she had minimal swelling to her knee with use of the author form. And interestingly enough, we actually used the traditional Praveen a on the contra lateral side. And the patient commented that she noticed the decrease in swelling. Um, with the author form for our last orthopedic case, this patient underwent a revision that was complicated by an introvert fracture. As you can see, we successfully used both the author form and the traditional preventive back in the patient. So to follow, Julie will present her cases with use of Trevena. And I will be available for questions after the presentation. Thank you. Okay, well, I'm going to present some case studies, um, of the use of Trevena, Um, and restore, um, Bella and a little bit of vera flow in plastic surgery practice that I work with. As I said before, I think the really neat thing about the, um, surgical subspecialty that I work in is that I get to operate on places from head to toe. Um, and as you can see here, you know, we have ah, variety of types of elective and non elective and in different procedures that were able to use these products on to optimize patients. The first case I'm gonna present is a 41 year old man who came to us after he had lost about £270. Um, the interesting thing about this gentleman was that he had a history of lap band surgery but then had it removed and actually ended up losing more weight about £175 through diet and lifestyle after having his lap band removed. But he was a younger gentleman and, um, was just getting these frequent rashes and fungal infections. Um and really just felt like he had done such a good, um, thing for himself that living with this excess skin and all of the, um, you know, things he had to do to kind of fit in close was just not worth it. So we took him to the operating room, and he was gonna undergo particular ectomy and flirted lee abdominal classy. For those of you that aren't familiar, particular to me is the removal of, um, skin and, um, soft tissue. Um, exclude above the muscle from the belly button down. Um, when you add on the Flor de Lee abdominal Classy, um, you can see in the picture on the left where there's a vertical component to it. And then again, you know, post operatively when that Praveen a is on, um, the vertical component. You know, you kind of address that excess tissue, um, that he had when he was standing up above his belly button. Um, sometimes insurance companies will cover that if again, the documentation is there and the skin folds or enough that patients are getting rashes. But sometimes patients will elect to pay for that just because, you know, they're the particular me gets approved and they're undergoing such a radical change, it would kind of be a unfortunate if they still had a lot of excess tissue. Um, in the vertical dimension. These are pictures of him, um, pre operatively, um, immediately post up and then on post op day one. What's his Trevena in place? So the patient stayed overnight and was discharged on post up day one with his corvina, and he went home, did well returned to our office on Post Update seven and you could see in the center picture immediately after Praveen A was removed, he did have a little bit of a red tape reaction. And then I'm grooving along the incision, which is to be expected. Um, he went home after that and came back the following week, and you could see the progression of that picture on the left. He's feeling well, everything looks great. The biggest difference for us when we started using Praveen in these cases was at that T junction, which is where the two incisions meet down at the bottom. Um, since using Trevena, we've had much less, um, breakdown there. Um, it's, you know, the highest risk, because it's the least vascular rised. Um, just because all of those corners there have been elevated during the skin reflection. And so we've really noticed that the Praveen A has helped tremendously in terms of that breakdown which helps the patient so much because they don't have to deal with a wound. The next case we're gonna talk about is, uh, this lovely 55 year old female who presented to clinic eight months after a Contra sarcoma excision with a pretty complex reconstruction on she. After this procedure, she'd really been rendered, um largely immobile just by the nature of the reception. She was living in a nursing facility and getting some therapy ing trying to kind of manage and her new normal. And she came in because she had some drainage from her incision line and also had developed a pressure sore below it there. It's kind of hard to see in this picture. Um, but when we saw the amount of drainage from her incision line and knowing that she had hardware in there, um, she was admitted from clinic to the hospital, Um, and taken to the O. R, I think the following morning. So when she went to the O. R. The next day, we have opened everything up in a assess. Everything and the Allah graft, as you can see in the top picture there that was placed at her initial reconstruction, was pretty prominent. And it had actually rubbed almost like an internal pressure sore from the inside. Orthopedic surgery came in and felt that they could remove this without losing the stability, because her free fibula flap in the hardware were well heeled. Um, so we made the decision thio to breed after the hardware was removed and replaced the back there. A flow on there and selling bacon core strength bacon solution with the parameters. You can see her pre and post agreement tissue cultures from this kind of grew up the kitchen sink. So infectious disease was consulted and made antibiotics recommendations on G. She was taken back kind of per our, um, protocol until her post agreement cultures were negative. At which point, um, her hardware was reassessed by or so and then she was closed in a Praveen a was placed. These are the pictures of her post operatively, Um, uh, immediately post up eight weeks and 16 weeks post up she completely healed, completed a course of antibiotics and is doing much better. Um, now, almost a couple of years out from certain moving on to the next generation of incision management, the next couple of cases, we're going to focus on the Praveen a restore Bella form dressing. So I have tow thank Dr Ellen Gabriel for letting me use this case. This is a patient at her 10 week post op follow up who had the Bella Farm place immediately after her breast cancer reconstruction with tissue expander placement and she didn't have any trouble healing and was able to be expanded rather rapidly. Um, this is her a 10 weeks, um and you can see she already has a fair amount of expansion. She had no wound healing issues, and her, um, nipple areola complexes and incisions field while after surgery. So another way that we've been using the Bella Form dressings is in amputee care. And I think it's a really unique application of the dressing. And so I wanted to present a couple of cases. The addition of the larger phone on the Bella form dressing gave us a great idea. We do a lot of nerve work and amputee care enclosures in our practice. And so we had this patient come in who had was about a year out from his initial amputation, and he's a super active, high functioning gentleman who had a significant, um, residual limb atrophy. And his prosthetic fit became difficult. And so when he came in for his some provisions, we were trying to figure out how to optimize his post operative care so that he could get back to work and hopefully getting back into his prosthetic. You know, a little bit sooner. Um, and he had had such significant swelling. We thought, like the bigger foam on the dressing, um, put on his residual limb would kind of envelope it and reduce the soft tissue oedema. And that's exactly what it did. You can see in the photos of placing it intra operatively. This is a little bit better pictures of it. Um, intra operatively. You can see that you're getting that only the incision, but that immediate soft tissue that we had raised up a manipulated during surgery as part of the revision. All of that was underneath that foam and in that, and this is a picture of the patient post operatively, and you can see he has really well controlled oedema. Um, and interestingly, this specific patient, um, who was the first patient that we used? Um, the Bella foreman. He was He had had a traditional Praveen of the year prior. And, you know, he made a comment just, you know, himself. Just noting that he thought it was, um, more comfortable. Um, and that, you know, he noticed a oedema reduction upon removal. Um, so anecdotal. Certainly. But we've used it in a number of amputees now and had some really good success with, um, kind of including that entire soft tissue envelope. Or as much as we can, um, in that I think there's promise in using the ballot form in many different locations. So I just wanted to thank you all for listening to our presentation today. We're gonna I invite you to the live question and answer session now, where Yvonne, Olivia and I will be available to answer any and all questions. Thank you.
