Join us for a unique opportunity to learn about strategies for reducing the risk of Surgical Site Infections, 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:
Describe the clinical and economic burden of surgical site complications and surgical site infections
Review the importance of pre-, intra-, and postoperative management strategies & best practices to reduce the risk of Surgical Site Infections (SSIs) in spine surgery
Describe guidelines and recommended practices that support the strategies to reduce the risk of SSIs
Explain unintended perioperative hypothermia, and illustrate why prewarming is beneficial in helping to prevent unintended perioperative hypothermia
Examine the role of closed incision negative pressure wound therapy (ciNPT) for Incision
Management in reducing the incidence of Surgical Site Infections, surgical site complications,
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
on behalf of three M. I'd like to welcome you to this webinar entitled surgical site infections, reduction strategies in spine surgery. From start to close peri operative considerations during this presentation. Will share best practices for setting up your patient for uh successful discharge and wound healing in some of these high risk case studies and will include some tips and pearls to applying advanced modalities in the treatment of the these challenging patients. Um During this presentation uh you'll you'll see some of my photos like the one on the right where I use the tape around the border of the Praveen addressing which is a three a.m. Phone tape. This is not intended but is my preference. This ensures a better seal as find patients usually lying primarily on their backs post operatively and need the added security that the dressing will stay securely in place. My name's Kyle Mueller and I'm a neurosurgeon at the department and the department of neurosurgery at Rhode Island Hospital and Brown University. Um I specialize in complex in a minimally invasive spine surgery and the treatment of spinal oncology and deformity. I'm partner today with Dr richard Pryor lip, professor of anesthesiology at the University of Minnesota and he'll be providing the anesthesiology perspective in reducing surgical site infections in spine surgery. Before we begin, I'd like to remind you to complete the post events survey following this activity. This helps us to understand your thoughts on the program as well as the needs for potential future programs. If you have any questions about the safety information, every indications for use for products discussed during this presentation. Please refer to labelling provided with the product or visit the three M. K. Ci website at www dot SLT dot com. For detailed instructions on use As a disclosure, I am a speaker consultant for three. a.m. So overall are learning objectives for today are to kind of review the clinical and economic burden of surgical site complications. Will review some pre interim postoperative management strategies. Go over some best practices and tips and tricks to help you reduce surgical site infections in these challenging patients. And we'll examine through case studies emerging a modality such as close decisional negative pressure therapy. Well, improvement is fundamental to impacting outcomes and this has been shown in the history of medicine with our morbidity and mortality tracking process that it is important for us to understand the end result of our actions to better improve the care we deliver to patients. And this has been become more to focused over the last several years as the health care system has transitioned to a value based care. And um much of this is related to the financial pressure surrounding health care spending um and looking at how we can be more cost effective in our our value of health care that we've delivered. And so it's been about decades since dr Porter's value of health care article. And there's nowhere that the value of quality of care that we deliver is more important than in spine surgery, spine surgery is widely prevalent and is very, very common. And um when we look at health care spending, there's certainly improvements that we can make in the care that we deliver in these patient populations. One of the challenges that we face because of this in spine surgery is because of the variability and pathology that we have. Spine surgeons treat. Uh there's pathology related to the most common being wear and tear arthritis, degenerative disease, to infection, malignancy and trauma. There's because of this wide variety. We are faced with a very challenging, a lot of challenges. And whenever we think about our goals of spine surgery there's different goals that we have. Sometimes we need to stabilize decompress the neural elements realign and correct some deformity or create a diagnosis by removing a tumor. And as with any goal of spine surgery, the end result of wound healing is a vital component. But today are our main issue that we're wanting to tackle is we want to reduce surgical site infections. And so these are infections that occur at the site of surgery and can occur in different spaces. And the C. D. C. Has done a good job about defining them that hospital systems use. And in essence they divide them into superficial infections which are typically limited to the superficial layer of the dermis and the skin above the fascia. And then we also see deep infections. These deep infections are the ones that are the more concerning ones because these often require a return to the operating room for debridement, long term I. V. Antibiotics and an extended hospital linked to stay. There's also organ space disease. And so these this classification can kind of at least help us better understand um defining surgical site infections. But the reality is is the the deeper ones are the ones that we're most concerned about and our our big causes. We want to understand the ideology of surgical site infections which is typically multi variable in terms of endogenous or exogenous sources. Gram positive bacteria such as staphylococcus is very common endogenous organism on the patient's skin and even after the skin, exogenous sources can be present. And they can come from numerous sources such as the surgical instruments we use, the implants, we place the operating room services personnel. So there's a variety of ways in which um uh pathologic organisms and things can be introduced to cause a surgical site infection. And when we look at overall surgical procedures, um there's a lot of surgical procedures performed in the US. and up to 5% result in a surgical site infection. And so this um speaks to the importance and need for a continued approach to equality. Improvement care in reducing this. And not only do we need to reduce this because of for our own patients benefits. But as I spoke to about the value, there is a financial implication to all these. Many of these complications can have serious consequences not only financially but to the patient. And the this is becoming an ever important thing. As we go go forward, the increased cost that surgical site infections add on to these procedures and in spine surgery, with them being very common. This is important for us to tackle. And when we look at uh spine surgery, one of the big things we want to look at is who is at risk. And this is a very good paper that breaks factors down to into different components such as patient related factors, surgical related factors. And you can see here there's a variety of factors um that elevate a patient's risk patients that are diabetic obese that have had pre operate e ation, um increasing surgical site invasiveness index. All these interventions can elevate a patient's risk for developing a surgical site infection. So in patient, if you have patients with this, these are the ones that you want to optimize their chance of wound healing. And these are important to know because surgical site and prevention is part of the preoperative planning. This is something that you need to address inpatient counseling as well. As also look at the tools that you are using pre intra and postoperative to reduce this risk. And this chart demonstrates here that there are a variety of factors, both patient technical surgeon and post operative that are important and can contribute to a surgical site infection. So all these are avenues that we have to understand to optimize these patients. Well, our current tools start in the O. R. Before the incision. Some of the things to consider are are the surgical prep and um there's no one prep that will meet all your prepping needs. But but certainly um some sort of surgical prep pre incision is of benefit. And the two big ones are the dura dura prep and Clara prep. And these help to reduce some of those endogenous organisms that are on the skin as an initial cleaning. And there's been studies that have shown that dura prep and Clara prep are roughly equal. So some form of skin prep is important in your management strategy in these high risk patients. But sometimes that's not enough just the prep. And so the other thing you want to consider is placing a antimicrobial drape, which uh many surgeons do use this um on such as the band drape. And so this uh a band drape can potentially also help you maintain that sterility that you've created and helped to clean. And these are just some studies showing that there is a reduction in utilizing infection rates when utilizing I have and drapes over standard or no drapes. And so when we think about our strategy for optimizing the patient's incision and that is high risk. We think about who, defining understanding who are these patients that are high risk. So understanding the factors such as you see listed here that elevate one's the risk of developing it. And then we think about what should we be doing in the operating room parry operatively during the surgery and post operatively. So this paper here nicely demonstrates some of the things that are out there that surgeons utilize to help minimize this risk. And what you'll see here is one of the emerging ones is the utilization of clothes, decisional negative pressure wound therapy dressing um as an emerging strategy for reducing the rate of surgical site infections and wound complications. But it's not the only thing. There's a variety of things that you as a surgeon should be should be doing. And this nicely shows that well negative pressure therapy has been around for a long time and um the studies that have been done at the basic science level have really shown that negative pressure wound therapy optimizes the conditions around the incision to better enhance the ability and chance of it healing and not breaking down. So. And and it's been utilized for a variety of years um in this regard. And recently it's been utilized in other surgical specialties, such as this large prospective multi center randomized trial. The promise study in which the negative pressure incision all negative pressure therapy was shown to reduce uh surgical site and um infections and complications after total knee arthur classy in the orthopedic population. And this study again showed that there was a 78% less likely uh chance of patients to experience a surgical site complication after nine days compared to the standard. There was also a reduction in readmission rates that were significantly lower for the negative pressure dressing. So then this is an article from the orthopedic literature, but there's also articles and cardiothoracic and other plastic surgery and other surgical specialties. And so as spine surgeons um that whose us to better study this and understand, can we apply um closing signal negative pressure dressing in our patients? Is there a benefit in whom should we be doing it? So when we look at the spine literature, um there's there's a variety of very small studies where people have looked at the use of an incision all um vax. Um This is a very small study that again demonstrated an improvement. And so There there's an emerging train. You can see these articles from 2019. Recently there's been an emerging trend to suggest that utilizing this in spine surgery patients would be beneficial. And this this um article here is um was a was a study that looked at utilizing negative pressure incision negative pressure therapy in in deformity patients. So again, better understanding doesn't have a role in spine surgery and with whom. And this patient population. It did show a 50% reduction in wounded his since as well as a 30% reduction in infections. This was another paper out of the world neurosurgery. Again demonstrating compared to a non negative pressure wound therapy dressing, which is typically a some sort of sterile inclusive dressing. There was a decrease in surgical site infection rates in lumbar fusions through both anterior or posterior approaches. So certainly there's some small studies out there that seemed to suggest that there is an impact of negative pressure therapy dressing in in reducing surgical site infection, complications in spine surgery as with other fields. And so my experience has been over three years now of utilizing negative pressure therapy, which began with this patient here that you can see on the right who's incision completely d hist after 30 days. And um this is this is a collaborative experience and learning with the plastic surgeons um at Georgetown, where I did my training. What I've noticed is that there was a overall there seemed to be a reduction in surgical site infection rates as similar to other people in the literature, specifically with patients with instrumentation and patients that were high risk deformity, malignancy. A lot of high risk factors. And um what I have found was what Trevino therapy allowed was it provided an optimization strategy of the incision, all environment during that immediate postoperative period when pain control and mobilization are things that the spine surgeon is doing. And overall, I I did see um anecdotally an impact on the health care quality uh and patient's quality of life um related to this, there was an initial learning curve. As I started out, I made my own uh incision back. So you can see here these photos where you just have the black foam applied. And so the application process was it was an evolution. Um As I said, that's my patients are typically postoperative lying on their back lot. And so sometimes patients are difficult to mobilize and the seal would break down so I would reinforce it with this three and foam tape. And what I noticed and saw um was that the negative pressure therapy in these high risk patients tended to optimize the incision healing. So that curve that we looked at for incision all strength now was modified so that it reflected more of the dotted line and above. And so what this allows us to do is in patients that are high risk whose scar strength curve is more flattened. It allows us more time for that scar strength to catch up even in the high risk patients. And so after initial pilot study, I undertook a more thorough, larger prospective trial. And um you can find this in the May issue of the Red Journal. And what what we found was in in our large heterogeneous population. There was an overall reduction in surgical site infection rates that was statistically significant when closed, institutional negative pressure dressing was used versus standard tell fatigue return dressing. Additionally, we saw that patients that underwent decompression alone procedures didn't really, they didn't have a statistically significant benefit, but there was a reduction. So potentially in some patients it may be beneficial, but the major reduction was in cases requiring instrumentation and those with that would fall into a high risk patient population. And I think that as spine surgeons, this is this is the population that we initially want to address. These are the ones that whenever we see, We do a lot of hard work. We want to help reduce that risk to the patient, to the health care system of having an infection. And there's, there's just so much variability in these high risk closure pathways as I talked about. And so what we're, what hope to do is in these in these high risk patients is take that variation away and to create some sort of standardized closure pathway. And then once we have that pathway, we can then seek to improve the variables of that pathway to better care for our patients. And still, currently this is sort of my high risk complex wound closure pathway that emerged out of out of utilizing um, Praveen a therapy is how can I incorporate this? And the first and foremost is I don't use uh this whenever a Dorado me is uh is incidentally or on purposely created um even if it's primarily repaired because the evidence lacking the impact of negative pressure at varying depths. But you can see um there's a combination of factual releases um that can be performed with plastic surgery. There's the utilization of surgical drains, futures and um a variety of their accessories from uh super factual iodine irrigation to maximize and powder. And um this is a variety of strategies that when combined can form a pathway to treat uh and help optimize your patient for reducing their risk of surgical site infection. Additionally after the Praveen A is off. Um One of the things is the healing doesn't stop there. And so one of things that I've started doing is I will have daily um dressing changes of Beta Dean cleanse over the incision, bacitracin, ointment and zero form. And I do this for typically 7 to 14 days after. So you get a total of three weeks of of close attention to the incision. And one thing that I feel is that if people just looked at the incision daily, you potentially may reduce your rate of infections, but sometimes patients will go off to rehab or at home. They don't have that. And so these are some strategies that you can utilize to to help that some pearls that I've mentioned related to placing a negative pressure dressing related to spine surgery is one is the foam tape border. Um Again not intended for use, but I found that in patients it helps augment that seal and patient population that's predominantly on their back, especially in obese patients or in patients with a lot of hair where that seal can be difficult to maintain. Um I drain my surgical drains are tunneled distance of minimum, greater than five cm from the incision, which I plan out pre operatively. And uh this allows you to remove the drains while not compromising the seal when you are placing a negative pressure dressing up Trevena in the cervical spine, the neck folds and the hair. Uh the lower aspect of the patient's head can be, can be challenging to maintain the seal. What I recommend is you take the drape the and cut it to make a border around the incision and then place the Praveen over that. This will effectively take the Praveen a um out of the neck fold space and you'll you'll find that you are, your seal will be better. I additionally augment that with phone tape as well as you saw in some of my initial ones I bridged um and oftentimes this was done the plastic surgeons Woodbridge for patient comfort. However anecdotally I found that um the patients really did not have any discomfort with a midline pro vina. And I noted also no major issues with the lily pad breaking off with midline. So I personally don't bridge. I don't think it's necessary. I think it adds time. Not a lot of time, but it adds time to your workflow. The other thing is you don't want to overstretch the tape that you place over that. That when you overstretch the tape and apply a negative pressure that can then apply even more stretched to the epidermal layer which can lead to remote blister formation which typically heals on its own. It's just cosmetically. Can can be a source of discomfort and anxiety for the patient. And so what what what I what I found with negative pressure is that it stabilizes the closure and prevents here in motion around the incision. It is a valuable adjunct in the incision. All management strategy and pathway. Especially for high risk patients that you should consider adopting into your workflow. It's not for every spine incision and I love this patient picture because this was a patient who um had a numerous comorbidities and was high risk and so but needed both the cervical and lumbar operation. Well the lumbar operation we utilize the minimally invasive techniques and was able to reduce the infection rate through that way. However the posterior cervical was more traditional. So I I um felt like I needed some extra optimization and and so I augmented his closure with a negative pressure dressing and the patient did well. So as a spy surgeon, the ones you should initially look to target are those with the high risk incisions, the long multilevel fusions, the patients with multiple risk factors. And what you'll find is there's a minimal change to your normal dressing routine. And um your your you'll notice a reduction in your own personal infection rates and um you'll be performing more cost effective and value based find surgery. So let's look at a couple of cases of how how you can use this. This first case is a 45 year old um male presented to the emergency room with debilitating back pain. He has uh he had some leg weakness and he has a multiple risk factors and he has a history of a. T. 78 Osteo disc. Itis. Um An epidural abscess that he had a drastic lemon ectomy performed at an outside institution several months prior. And what you'll notice is on the C. T. Shows worsening of the osteomyelitis resulting in a chaotic deformity and in the MRI you can see some of that abscess. And so uh this patient was taken to the O. R. And required a surgical stabilization and decompression. And so this was what I went and performed. And so now you're left with. How can I optimize this patient's wound healing because he has numerous risk factors. And so this is what I did interrupt. You'll see the skin and dressing closure. Uh He was closed with um the standard pathway that you saw. Um And on the skin there you have staples with interrupted to Oprah lean vertical mattress. Futures that are removed the staples and sutures removed in a sequential fashion over time. Um This was covered with a Praveen addressing. And you can see six weeks post op. The incision looks great, it's well heeled and the patient has continued to do well now several months after this This is another patient um a 56 year old female who presented with back androgenic qualification to the hospital. Um numerous patient related risk factors and additionally she had was very limited in her mobility because of her pain and classification. You can see here she has a lot of risk degenerative disease and lumbar stenosis. And um she has an elevated super fashionable distance. And so this patient um underwent a multi staged operation in which she uh Stage one came from the front with an L. Ford S. One uh anterior lumbar fusion. And then the stage two was A. L. 34 lateral followed by a L. Three to pelvis with a decompression and stabilization. Um I closed the postoperative, the posterior part with a privy to the anterior part was done with general surgery and vascular surgery. And there we did not close with Vienna just staples and standard dressing. And that's why I'll show you what happened. Um But this is a great utilization of a Praveen addressing. Is this patients coming in with limited mobility? You know, post operatively. She's going to be very difficult to mobilize and will likely require discharge to a rehab facility. These are the patients you want to look at. These are high risk. What can I do To optimize that? And so the pro-Vina acts as a very strong barrier for the full seven days. And during those seven days during 24 hours is optimizing the wound conditions for healing. And so This patient uh definitely benefited from that. And so here you can see seven days after the dressing was removed, followed by six weeks. You can see the incisions coming together and then subsequently at 10 weeks and now we're several months later she's well healed from her posterior incision and has had no issues. However, her anterior incision um began to break down um roughly around the same timeframe seven days after the drain was removed. And so this this is a very powerful case study to me in terms of showing you impatient with similar risk factors, how the use of a close inspection negative pressure dressing in this patient helped me to get the wound healed um while in the front it was not done. So where do we go from here? We'll research is always needed to continue to advance the field. And I think it's clear now that in spine surgery and in patients with high risk that the utilization of clothes incision, all negative pressure therapy will overall optimize and enhance the value and quality you care. It will lead to a reduction and surgical site infections and complications. I think going forward, we need to perform cost effective studies to figure out how much of a cost effectiveness is with these dressings. This will better allow us to target appropriate patients to use this. On spinal oncology is one area where this can be greatly utilized because wound complications in this population often requires a halt to their other chemotherapy radiation treat. I think patients with a high surgical site invasiveness index, um looking at this is good and at Brown, we are currently looking at all three of these. I think there should be some basic science work in terms of better understanding the impact of negative pressure therapy at various steps with that further knowledge, we can then explore if there's any potential role for it um in patients with Dorado Me, potentially if we if we um have a primarily repair. And so in conclusion, I hope through the various clinical studies that have shown the evidence and my own personal experience, I hope I've shown you how close institutional negative pressure therapy is a powerful adjunct to optimizing high risk surgical incisions. It's very adaptable to the surgeons current workflow and overall by reducing the surgical site infection and readmission rates in these high risk patient populations. We will ultimately improve the health care costs and value in spine surgery and because of its prevalence, it's incumbent upon us as fine surgeons to continue to do that and we should be the ones leading the charge. It's selective use will justify the upfront cost of this dressing because the overall long term impact will be an enhancement in the value. Um With that I think like to thank you for your attention and I'm pleased to pass the mic on to DR prelate. Who will be providing the anesthesiology perspective and reducing surgical site infections in spine surgery. Thank you very much. Thank you dr Mueller. I appreciate the introduction. And again we're going to be focusing on the same global subject matter of surgical site infections and spine surgery. But I'll be presenting a little different perspective from the anesthesia side of the ether screen just as before. There is important information here for you to review when considering use of any of these products or devices for their safe application to patient care. And we encourage you to utilize this information to optimise safe application in the way of disclosure. I am on the Speaker's Bureau for Merck Company Incorporated And a consultant and speaker for the 3M company. Yeah, I like to begin with this important concept slide of the invisible infection. Merry go round. This highlights the three critical components for surgical site infections and the origin of these infections as alluded to by Dr Mueller in the earlier presentation. These three critical components are the patients themselves, healthcare workers and particularly the hands of healthcare workers and of course the preoperative operating room and pack you environments in which we all work. This merry go round concept is important because it illustrates how these uh pathogenic organisms can easily find themselves migrating from location to location and do equally well waiting for the next vulnerable patient on which to initiate an infection. Indeed doctor mu knows price and infectious disease expert out of Milwaukee has determined and coined the term the hospital fecal patina to describe sometimes how the reality falls short of our aspirations. These two pictures illustrate a I. C. U. Bay following a prior patient discharge who was known to be infected with banco mason resistant enterococcus. Each of these stars represents locations where V. R. E. Was subsequently cultured despite a terminal environmental services cleaning specifically to focus on pathogenic bacterial cleaning requirements. Well, how can we deal with such a complex situation? Well, there's no magic bullet but we know that individual interventions and specific interventions when bundled together in uh constellations of care can prove to be very effective because there are limited time here. We're only going to be able to touch on a few select components of these bundles of care. So let's talk about smoking cessation. I think the information here can be very useful in your discussion and council of patients. This is information which highlights that a single cigarette which has been smoked will decrease tissue oxygenation From a mean of 65 mm of mercury down to 44 mm of Mercury, And that this reduction will last for 30-50 minutes for each cigarette. Thus, a pack a day smoker will suspend the majority of their time enduring tissue hypoxia. And as we know and illustrated here on the right hand graph, is that the concentration of tissue oxygenation is inversely correlated with the risk for wound complications and wound infection rates. A common question, which follows is how long do patients need to quit smoking in advance of surgery to confer maximum benefit. So, to summarize on the right hand side of the screen, you can see that there's sort of three increments of cessation intervals of one day, one month or two months, which will confer improved tissue oxygenation, improved wound healing and the maximum reduction in pulmonary complications, respectively. Now let's move on and talk about the patients themselves and the inevitable microbial burden which we all carry as part of our normal bacteriology flora. We're going to focus here on the nasal cavity and the skin. As you can see, there's ample evidence to maintain this sharp focus on patient decontamination prior to even the initial surgical incisions. Across here are multiple guidelines and recommendations from numerous organizations, all with the focus of infection control and optimization of peri operative healing and reduction in surgical site infection. These organizations are both the surgical and medical and include US british with the National Institute for Health and Care Excellence, our own C. D. C. And as well, the World Health Organization looking at these topics from a global perspective and as you look through these guidelines, you'll see broad support For the requirement of both skin and nasal preparation prior to surgery. And as you've heard earlier, the strong recommendation to utilize chlor hex 18 showers or wipes on the day before and the morning before surgery. And as well till you consider nasal decolonization as part of the routine care for our special or higher risk patients. Well, why is this required? It turns out that the human body is just a rich reservoir for staphylococcus aureus. And we know that as a consequence, the human population will have non carriers, But also a very large number of intermittent and even persistent carriers of staph aureus on a continual basis of a special alarm is the fact that these carriers will be 2-9 times more likely to develop a surgical site infection. So it is a modifiable factor that needs to be strongly considered in the preparation of patients before elective surgery. In addition, there special populations such as those on chronic renal dialysis who are even more frequent carriers and their rate of carrier of staff Maybe as high as 20 to 50%. Now there's a couple different strategies to try and control this. Uh staff like kokko state before surgery, There's a universal approach in which we would treat all patients before surgery and there's active investigations and evolving data to evaluate this strategy and I encourage you to stay tuned and look for additional information when considering invoking this sort of application. The other approaches. A targeted one where preoperative patients are actively screened with cultures for staph aureus and those who are obviously staph aureus positive or those who are at special risk will then be treated as we'll discuss below. one of the applications for treatment is the topical antibiotic using an ointment of applied to the nasal mucosa with the antibiotic comparison. This requires very active patient cooperation with the application of the ointment internationally twice a day for five days prior to the anticipated surgery. So it does require a significant motivated and cooperative patient for appropriate compliance. Alternatively, there's the 5% covid own iodine solution which can be applied immediately before surgery in the preoperative holding area. This Potvin own iodine solution will also reduce nasal bacteria and including staph aureus By over 99% within 60 minutes of its initial application. And it has very good durability With a reduction that's maintained for at least 12 hours. It has proven efficacy in reducing site infections in orthopedic prosthetic joint surgery and cardiac surgery and similar cardiovascular operations. Now, when looking to apply this sort of approach, there's the two potential interventions that we talked about on the previous slide, phillips and others actually did a randomized prospective controlled trial comparing surgical site infections after arthur plasticky or spine surgery In patients using uh either the mu pierson or the 5% of adonai iodine solution. It's important to note that all of these patients receive the recommended chlor exiting Klaus and then were randomized. Either the comparison or the three M skin and nasal iodine solution. As you can see here in the per protocol analysis, there was significant reductions in the overall infection rate as as well as the specific staph aureus infection rate. It appears then that we can conclude that preoperative decontamination with antiseptic protocol decreased the S. S. I. Rate by a approximately 7 70% and makes this a very valid alternative to Mcpherson, particularly in those populations which may be at risk of developing antibiotic resistance or in those in whom you might feel their compliance with. A five day regimen may not be complete If you're not familiar with this product. It's illustrated here in this small bottle of the solution with four applicators. It is a 5% covid own iodine solution, which actually comes as a fairly gelatinous material because of a film forming polymer, which has been added in order to improve its durability and persistence in the patient. It needs to be applied approximately one hour before surgical, but within those 60 minutes it varies significantly reduces the bacterial counts of staph aureus within the neris And will maintain that for a period of 12 hours, the gelatinous material improves the patient tolerance and minimizes the amount of dripping which may otherwise occur. It's a very buffered solution and importantly, the product is safe for virtually all our patients, including those pediatric population down to as young as two months of age. Likewise, the application is done by any appropriate provider within the preoperative holding area and takes a grand total of two minutes for application and uh appropriate administration to the patient. From start to finish, we're going to move on now and talk about the concept of temperature, homeless stasis and the avoidance of hypothermia. Yeah, it's become increasingly recognized. This is an important factor with uh intense outcome parameters for the consequences of unintended hypothermia. Patients who get cold will have increased blood loss and therefore are at increased risk for blood transfusions. We also know these patients will have increased shivering, an increase cardiac demand with the potential for ischemic events. And likewise, and the focus of our current subject matter, surgical and wound healing may be compromised with an increased risk for wound infections. Regardless, we know, these patients will all spend increased time in the pack you to restore normal therm. Eah. And indeed, they may also have an increased hospital length of stay. Importantly, there's also a decreased in patient comfort, decreased drug metabolism, metabolism, often associated with again a slower wake up and prolonged pack you time and the vessel constriction can again create problems with decreased oxygen tension in the very vulnerable new wound and healing incision. It's important and interesting to look back at the history of temperature, homeostasis and maintenance in the operating room, Which goes back about 25 years to this landmark study By Kurt's Sessler and others, which was published in the New England Journal of Medicine in 1996. This was the seminal work which looked at a randomized Controlled study in 200 colorectal patients, which had routine care, which at that time primarily meant coverage with cotton blankets or with forced air warming. At the end of the analysis, there was about a two C difference between those in the treatment group versus standardized care. They all otherwise had routine standard of care maintenance for antibiotics and anesthetic and surgical management. The observers were blinded to the outcomes, which were finalised with culture testing. The results were very dramatic and you can see here the important reductions from a 19% rate of infection in the hypothermic group to only 6% in the normal thermic group. And this difference and obviously the rate of infection led to an important 2.6 Day reduction in the hospital length of stay as well. Now over the intervening 2.5 decades, we've gone on an expanded patient warming to the preoperative area and the construct of preoperative warming has proven to be equally important as a component of surgical site infection care bundles. Very recently, Zang and others published this meta analysis in the international journal of surgery, we're looking at the high quality studies was able to show a 40% reduction in the group which had preoperative warming. Yeah, the study also recognized that there is a wide variation in how people apply pre operative warming, but if it appears there's certain caveats which are important to improving postoperative outcomes. And these include No preoperative warming. Be applied for at least 30 minutes that you continue active warming strategies within the O. R. Itself. And you use a combination of warming methods within that oh our environment and that you monitor and maintain core temperature across the whole continuum of peri operative care from preoperative area to the pack. You. Additionally, the construct of patient thermal comfort is increasingly recognized and an increasingly important quality outcome parameter or surgical care. That is we all know that it's uncomfortable and distressing for people to be cold and maintaining normal therm miA is again increasingly recognized as a factor that patients report as improving their comfort. Indeed, some patients have reported feelings of cold and thermal discomfort and particularly shivering, maybe as distressing to them or even more significant than post surgical pain. And we know that thermal comfort is rated higher inactivity warm patients. So how can you achieve these goals? Well, I think most people are going to be very familiar with the Constellation of products from the three Bair Hugger forced air warming system. These products are illustrated here along with their active warming component, which provides the warm air flow through these various perforated blankets, which are applied to the patient and disperses the warm air over the appropriate patients surfaces. There are a number of specialty blankets which are now available, which will provide a application for even small infants in the pediatric population all the way through special applications, including uh, blankets for spinal surgery and even sterile blankets for full access during complex operations such as cardiovascular surgery. Importantly, We recognize that as long as 50% of the patient's body surface area is covered with one of these forced air warming blankets. We are able to maintain appropriate core temperature for our patients using this forced air warming strategy and you can maintain temperature as illustrated here in the blue line above the 36.0 threshold, which is the cut off for hypothermia. Obviously, we need to apply a constellation of efforts in order to maintain normal therm eah and achieve our goal of 100% peri operative normal therm mia. And we need to build that pyramid with both preoperative warming strategies as well as inter operative forced air warming In order to achieve this important quality metric and patient comfort metric of 100% peri operative normal therm. Eah. In addition, we know that again, there's ample evidence and international and national guidelines, all of which are very supportive of utilizing these strategies of both pre pre warming as well as inter operative forced air warming in order to maintain normal therm E. A. For our patients. And has highlighted here, it reinforces that normal ther mia should be maintained for all our patients. And pre warming can be an important important addition to that strategy and to help improve its effectiveness. This illustrates the importance of pre warming to reduce the incidence of wound infections. In a study by melon and others In this prospective study, 421 patients were undergoing clean surgeries such as hernia or breast surgery And they were randomly assigned to be there actively pre warmed for a minute for a minimum of 30 minutes before surgery Or to receive no pre warming. 3rd pre warming therapy. Active warming was provided either systemically using the Bair hugger forced air warming system or locally to the operative site. As you can see here, the results were significant. 14% of the unworn group developed surgical site infections within six weeks after surgery compared to only 5% of the actively pre warmed group. A highly significant difference with a p value of 0001 warm patients had significantly better wound scores and were subscribed significantly fewer antibiotics. It should be evident that in order to target normal, normal ther mia, you need a good thermometer. Fortunately we have current technology which allows us to provide a consistent platform across the entire continuum of care from the preoperative holding area through the operating room and to the pack you in order to maintain a stable reference standard of how we're measuring core temperature. This involves technology utilizing utilizing zero heat flux technology, which actually is illustrated here, where you have two different sensors with an insulator and a heater, which forms a column of warm tissue to externalize the temperature between your core to the temperature sensor device itself sitting on the skin surface. It turns out the forehead is one area where core temperature can be readily accessed utilizing this type of technology, And we know that the 3M temperature monitoring system will have a high degree of precision when looking at measuring core temperature by a single skin sensor. If you're not familiar with this, the device is illustrated here and a patient before going into the operating room with a small adhesive disc placed on the forehead. And again, it's connected to a very small monitor which can be connected to a temperature monitoring system in the pre op area, to the operating room and then to the post op pack you utilizing the exact same technology across this entire spectrum. Thus you'll have a consistent platform and avoid the inevitable questions which arise when patients have an oral temperature taken in the pre op area. And then compared to Asafa deal or maybe axillary temperatures in the O. R. And then back to maybe a uh ear temperature uh measurement that will be taken in the pack you. So this device maintains a consistent platform across all domains. Let's move on and at least highlight again the requirement for consideration of hyperglycemia management during the before and during surgery, we know that hyperglycemia is an independent predictor of post surgical complications and that a hemoglobin, a one c of greater than 6.5% is an independent risk for wound complications. Indeed, it's important to also recognize that sustained or intermittent hyperglycemia defined as levels of 1:40 or above is common during the peri operative period. But the question still remains. Is is this simply a marker of sicker patients with already compromised and organ function? Or is the increased sugar levels actually the driver of the complications themselves? Well again, we need to stay tuned to future research to definitively answer that question. But clearly in the interval it's important to optimize preoperative and inter operative glucose during all of our surgery and particularly during complex spine surgery, of longer durations. And, lastly, as your anesthesiology colleague, I would be remiss if I didn't include at least one slide about drug. And this is an important drug because of your patient population where you are dealing with patients with pain oftentimes chronic pain that they have struggled with for prolonged periods of time. And as we know, many of these patients will have narcotics as part of their pain management strategy. Unfortunately, this often leads to some of your patients having an opioid use disorder and as a result, you're going to find some of your patients coming to surgery and being evaluated uh with preoperative buprenorphine as one of their medications. My recommendations to you is to be very vigilant about patients on buprenorphine and I recommend that you interact and get consultations with both the addiction specialists as well as the patient chronic pain patient advocates within your hospital setting. In summary, We discussed four important caveats to managing patients and minimizing the risk of surgical site infections with complex spine operations, smoking sensation, skin and nasal decontamination, normal therm miA and glucose management are all key pillars to managing your patients. I thank you for your attention and it's a pleasure to be here with the doctor Mueller in order to try and optimize the care of these complex by in surgical patients. Thank you. Well, thank you. Dr Prelate for providing the anesthesia perspective on this important subject matter and on behalf of three M. Dr pre lip and myself, I'd like to thank you for participating in this educational activity on this very timely subject matter. Again, I'd like to remind you to please provide us feedback in a short post survey. This again helps us understand your thoughts on the program as well as needs for potential future programmes. Thank you again for your attention.