Ellen D. Dillavou, MD, FACS
Richard C. Prielipp, MD, MBA, FCCM
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 vascular 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 the prevention of 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
Hello. Good afternoon and good evening thank you for joining our program. I would like to welcome you to the surgical site infections, induction strategies in vascular surgery From start to close three operators consideration with without further delay. It's my pleasure to produce our keynote speaker. DR ALAN D. Level is an associate professor vascular surgery at Duke University Medical Center and the Chief of vascular surgery. A Duke Regional Hospital in Chapel Hill north Carolina dr ditches. Pilot is a professor of anesthesiology at the University of Minnesota Medical School. He is the executive section editor for patient safety for anesthesia and analgesia Donald through the lagoon. I will turn it over to you. Hello. I'm dr Ellen deliveroo from the division of vascular surgery at the Duke University Medical Center. Today I have the privilege of talking about incision, all management to decrease surgical site infection after vascular surgery. You may refer to the details of the slide but please keep in mind that it is important to adhere to the instructions for use or if us of any three M. Product. As the disclosure. I am a speaker for 12 or an associate. I'm a consultant and speaker for Casey I, which is now part of the three M. Company and I am a consultant and speaker for an geodynamic incorporated. So why should we be concerned about surgical site infections? There are estimated eight million people in the US. at risk for healthcare associated infections. Every year, post surgical site infections can lead to significant cost And our estimated almost 22 of all healthcare associated infections. These average length of stay of approaching 10 days and add an additional $38,000 plus normal hospital ST. In the era of covid 19 we may find that surgical site infection prevention more important than ever, patients may have more remote business making wound inspection more difficult and patients and hospitals may play a higher value on avoiding readmissions and increased traffic in and out of the hospital. At the Duke University, we had a problem with surgical site infection and therefore introduced our bundle care effort focused on implementing evidence based practices to improve outcomes. Because our institution was a misquote high outlier for FC. We developed and implemented a multidisciplinary team including surgical anesthesia, nursing and peri operative professionals to reduce surgical site infections through the use of a vascular preventive bundle, here is a breakdown of our reduction bundle. We have flipped it into preoperative operative and postoperative efforts in the preoperative era. Not only did we look at preoperative planning, such as control of glucose and hemoglobin levels, but we instituted cortex it in once, hair clipping, increase antibiotic prophylaxis and standardized prepping for every patient. When we were in the operating room, we limited oh our traffic tried to optimize the patients and use a dedicated closer tray before closing the wound. We also used intravenous therapies that will put on in the operating room and then continued into the postoperative phase, up to seven days for patients who receive Trevena. They had this dressing on and impact for seven days. If patients did not receive Trevena, they received gauze and an inclusive dressing usually together. Um That was removed at 48 hours. After that standard dressing was removed, we wiped the wound down with daily ch G. White. An important part of any operation is skin prep. one of the aspects of our chair Bundle that was addressed was that circulating nurses underwent education on proper skin prep. And then this became the standard of care. A circulating nurse or attending physicians were the only team members who are allowed to press and we defer to the surgeon on which craft was used. These decisions included patient allergies, age, skin conditions and the size of the area being pressed. We also used strategically a three Idol band dressing two, decrease the contamination of any prosthetic ground that may be going into the body. I personally use this whenever I am using prosthetic in an arm, a leg or growing. This is a graph that shows our surgical site infection trends as our vascular bundle was implemented. If you look upon the X-axis, you can see they're not in October of 2015. Our surgical site infection rate was 7.44%, which was a high outlier. And in this clip benchmarking database Shortly after this, we initiated the first changes of the bundle and we rolled out the entire bundle by April of 2016. After our entire bundle was rolled out, our infections fell to within an acceptable range and have thankfully remained there ever since. We use the Praveen a therapy portfolio in addressing our wound issues in a multitude of sight. The Praveen A therapy units are the Trevena 1 25 which is a seven day unit, the Praveen A Plus, which is also a seven day unit, and the new 14 day Praveen A Plus which can extend our therapy to twice this time. The dressings we used are shown on the right side of the screen, the corvina standard 13 cm or 20 cm. He elongated 35 cm. Or the customizable dressing, which is my choice when doing a vein bypass on a lower extremity. We believe that Trevena therapy provides surgical incision management by delivering continuous negative pressure, 100 negative 125 millimeters of mercury for up to seven days over the entire area underneath the dressing. This helps hold an incision together. It removes fluid and other infectious materials that could gather underneath the incision. It acts as a barrier to external sources that could contaminate the incision and it reduces oedema by extracting excess fluid. After we started using our peri operative preventative care bundles, we went back and looked at the results. We compared those patients who had conventional dressing who were 279 patients, to those who received Trevena, who were 225 patients. We started this comparison by looking at the demographics between the two groups, We found that there were more women in the negative pressure groups. We found that more of the negative pressure group were active or former smokers. And we did not find any differences in patients undergoing re operative surgery with a high BMI or who were on dialysis. What this shows us is that the patients who were receiving Trevena or higher risk. It is well proven in the literature that female sex and current smokers have a higher effective risk than other patients. We then looked at the inter operative characteristics between the conventional and negative pressure dressing. We found that patients who had negative pressure dressing were more likely to have several popular field bypasses, less likely to have endovascular surgery and more likely to have elongated operative times. We then looked at peri operative characteristics and found that in the incidence of surgical site infection, the negative pressure group, the Praveen a group Was significantly less likely to develop an infection. They were significantly less likely to develop any wound complication and also less likely to have 19 immortality. To be fair, we have not been able to pinpoint a reason for the decrease 90 day mortality and that this does not seem to be related to surgical site infections or return to operating room through a retrospective logistic regression. We then look back at the risk factors for surgical site infections. We found that female sex predicted a higher rate of infection. We found an endovascular aneurysm repair predicted a lower rate of infection. And we felt that use of a negative pressure wave therapy or Brovina, decrease significantly the chance of any infection. Looking at the literature, we are not the only institution to come up with these results, Kwan and all looked at a randomized clinical trial evaluating negative pressure therapy to decrease vascular groin incision complications. They had 100 and 19 high risk blowing incision and 59 of them receive Trevena, 60 of them received a standard dressing In their low risk group. All 21 of those patients receive the standard dressing. What they found was in the high risk group, which was defined as a bmi of greater than 30 or less than 18 patients who had a significant panis and abnormal skin lesions, suspicious for fungal infections, who were receiving a prosthetic graft, who are on immune suppression therapy, who had a hemoglobin a one c of greater than 8% steve patients were randomized to Praveen A for five days versus standard gauze dressings, bilateral incisions got one of each type of dressing and the lowest group with everybody else. And all of those patients received a guard reference. When they looked at their results, they found that any moon complication were decreased in the high risk group with Trevena versus standard gauze dressing. This was significant to less than Key .001. Any wound complications major was decreased with Trevena therapy and any infections were decreased with Trevena therapy. In the high risk groups, interestingly, the low risk groups, of course below both levels. But this is to be expected when Kwan look at re operation, they found that the Praveen a group had a significantly lower instance of re operation and a significantly lower risk of readmission for all of their high risk patients. In conclusion, they stated, the the application of negative pressure to close your incision appears to decrease the incidence of wound complications, particularly in patients at high risk for this common problem. The routine use of this device for all high risk growing incisions is recommended. Pleasure until looked at reduction of groin wound complications and vascular surgery Patients using a closed incision negative pressure therapy and did this. In a prospective randomized single institution study, they had negative pressure versus standard dressing and found that the risk of hematoma as well as the risk for any wound infection was significantly decreased with a Praveen addressing, they concluded that the use of a closed incision negative pressure therapy demonstrates a statistically significant reduction of postoperative wound complications in the groin on postoperative days 57 and 30 and in revision surgery until day 30 post operatively in patients after several vascular surgery. As we all know, this is our highest risk group and to have a tool that decreases all wound complications in this group is a very important abandoned. See aromas can be the bane of our existence, taking an otherwise uncomplicated operation and putting it at significant risk of infection. Seven prospective studies were included in a meta analysis, looking at Ciroma risks after negative pressure therapy. What they found was that patients treated with the treatment which was a negative pressure therapy dressing versus control standard gauze dressing were less likely or equivalent in all studies to have a aroma. This means that negative pressure therapy overall as you can see in the bottom square under total, decreases the risk of Ciroma in these fragile patients. The result of all of this research has been that Praveen therapy units have been granted a new indication statement in the U. S. By the FDA. The FDA declared that for Vienna and Praveen a Plus therapy units manage the environment, closed surgical incisions and remove fluid away from the surgical decision via the application of negative pressure. When these are used with legally marketed compatible dressings, they are intended to aid in reducing the incidence of Aroma and patients for high risk for post operative infections. They aid in reducing the incidence of superficial surgical site infection. Classes one and 2. The european Union has issued a statement stating that the Gravina in divisional management System is intended to manage the environment of closed surgical incisions and surrounding intact skin. In patients who are at risk for developing postoperative complications such as infection. By maintaining a closed environment via the application of negative pressure wound therapy to the incision, the Praveen incision dressing, skin interface layer with silver reduces microbial colonization in the fabric. So as a practicing surgeon, I say, what do we do with this data? I feel like my patient as pictured here is high risk. What are the possible activities that I could do to minimize the risk of infection in this obese diabetic woman who is undergoing reactive surgery for limb salvage? Well, I can double cover for gram positive organisms. I can optimize pre operatively her hemoglobin for her hemoglobin, A one C. And other metabolic factors. I can optimize the surgical environment, meaning normal temperature, normal glucose and decreasing blood loss. I can optimize the room by decreasing traffic and trying to use a separate closure trade. And I can optimize the wound dressing by the Trevena cross customizable dressing. And here you see the entire strip of the Praveen. Applause was applied to this death thing. The reason that there is a bandage on her foot is that we took off in the chronic toe And I have to confess that I was astounded when we took this dressing off post op day 7th and she had a beautiful incision with no wound healing problems whatsoever. So what did we do at Duke? The next step for this therapy was that we partnered with a data company named Sheila Health out of SAn Francisco to create a predictive model of vascular surgery, wound infection, Kettle health looked at over 72,000 vascular surgery patient records from the database and queried them to create a data bank to provide a deep learning predictive model for surgical site infection. We spend our data from 370 do patients into this model and group them at higher low risk and noted whether or not they have a ravine, addressing or standard care cause dressing. What we found was that our surgical infection rates In the high risk for Vienna group, with 6.8 in the high risk God's group, It was almost 21 in the lower risk Trevena and low risk Guys group the infection rate hovered Between the high 8 to high nine rates and was not significantly different. This gave us an overall infection rate of 12.4%,, resulting in an estimated $482,000 costs, With $88,000 being spent on the Trevena unit. We then said this data into the model and trying to predict if surgeons were perfect at predicting who is high risk and who is low risk, how would this have changed our results? So on the left side of your screen, you see the actual results that I went through just a moment ago. And if we had used the learning model, which is on the right side of the screen, we could have decreased Our overall infection rate to 6.8 overall in the high risk group and 8.8 overall in the low risk group. This would have taken our total infections from 46 down to 27 and and decrease our rate of infection from 12.4 down to 7.3%. What this shows us is by more accurate prediction of who is actually high risk for surgical site infections. We could decrease are effective rate and decrease our costs by about $150,000. This is a 27, I'm sorry, 26 cost reduction for patients, Almost $400 a piece. And this takes into consideration the cost of the provisioning unit. Based on this data, We are moving ahead with Tequila Health to institute a prospective infection assessment using Trevena as a tool in our high risk patients. In conclusion, efforts to reduce peri operative surgical site infection using peri operative care bundles appears to decrease wound complications in vascular surgery patients, a standardized skin prep and they're very a great thing are crucial. Gravina therapy appears to add an additional protective effect to reduce the incidents of physical site infection and overall wound complications. This was an independent predictor within the Duke bundled physical sight reduction package, predicting high risk patients may help to direct care choices and maximize cost efficiency in this high risk population. Deep learning models indicate that appropriate negative pressure weight therapy has the potential for true cost savings within our health care system. Thank you so much for your attention. It's now my pleasure to turn this over to dR pilot for the second half of our session on reduction of peri operative surgical site infections. Good evening. It's a pleasure to be with you here this evening to talk about surgical site infections from an anesthesia perspective. And I want to thank dr deliveroo for her excellent presentation and we're going to build off of that. My name is Richard Pryor lip. I'm a professor of anesthesiology at the University of Minnesota in Minneapolis. Yeah, similar to the earlier presentation, we want you to read through this important information and be sure to follow all manufacturer guidelines and package inserts as to critical information for appropriate use of the various products discussed during this evening's talk. Oh yeah. I want to disclose potential conflicts of interest as a member of the speakers bureau for Merck company Incorporated as well as a consultant for the three M company. I am also on the board of directors for the Anesthesia, patient safety Foundation and the executive section editor for patient safety in the journal Anesthesia and analgesia. I like to start with the take home message which is this invisible infection triangle. This conceptualize is the important interplay between the three constituent parts of surgical site infections which are patients health care workers and the pre op interrupt and postoperative environment in which we all work. The organisms which cause such infections. Happy to move about this merry go round of these three different hosts and we'll do this with equal facility. Our job is to interrupt this merry go round and prevent infections from moving from site to site across the infection triangle. How can we do that? Well, We need to be aware of the hospital fecal patina which is illustrated here. This is the work of Dr milano's price and infectious disease expert from the University of Wisconsin in Milwaukee. The red stars here illustrate in an ICU Bay where vancomycin resistant enterococcus was readily cultured immediately after terminal room cleaning from a prior patient having occupied the room with the V. R. E. Infection. As you can see illustrated here the environment of the hospital bed, furniture, surroundings as well as the monitors, pumps and various components are all potential sites of transmission of the resistant organisms from patient to patient using the environment as an intermediary host. Yeah. While there is no magic bullet, we know that there are care bundles and constellations of care which can be effective. You've already heard some of this information from Dr Dila phu in her earlier presentation. Our talk tonight will discuss four components of a more comprehensive care bundle and these include smoking sensation, skin and nasal decontamination, maintenance of normal therm eah and maintenance of normal glucose concentrations in the peri operative period. Yeah, we all know the consequences of smoking are bad. This is a important teaching moment for patients as they're very open to physician suggestions during the stress of preoperative and preoperative planning. One important teaching point can be to illustrate the patients that a single cigarette Will reduce their tissue oxygenation by about 1/3. as illustrated here, And that this reduction lasts for 30-50 minutes for each cigarette. Thus, a pack a day smoker will spend the majority of their time enduring tissue hypoxia. This becomes especially relevant to us as it's well recognized. There is a strong inverse correlation between tissue oxygenation and wound infections based on the wound oxygen tension. This is a slide illustrated And adopted from Archives of Surgery in 1997. Mhm. When discussing cessation of smoking, a common question arises as to how long do patients need to quit smoking in order to confer the maximum benefits. This is a complicated subject, and the answer often lies in looking at the target benefit, which is most desired to be achieved. We've already discussed the reduction in oxygen tension, which occurs on a hour to hour basis, But improved wound healing requires additional time, at least in excess of two weeks and probably in the time window of 3-4 weeks. As noted here in a comprehensive meta analysis from long and others in 2012. Oftentimes the improvement in respiratory function may be the priority target and in order to achieve those endpoints reliably, you can see that it will require in excess of four weeks And ideally up to eight weeks of smoke smoking cessation prior to surgery. So, on the right hand column, I've tried to summarize and simplify these relationships as follows, to improve oxygen transport and tissue oxygenation. Certainly no smoking on the day of surgery to improve wound healing. You want patients to have quit smoking for one month and to optimize their pulmonary function and reduce the risk of respiratory complications. Patients should have quit smoking for preferably eight weeks or two months prior to plan surgery. Moving on now, we know that all patients come with their own unique set of microbial microbiome, which is the natural organisms that exist in all patients. We're going to focus our attention on the skin and the nasal cavity. All our today's discussion, fortunately, we have clinical guidelines to help guide us in nasal decolonization procedures. As you can see here. We have important national international, such as the National Institute for Health and Care, Excellence of great Britain and global organizations such as the CDC's in all of whom are widely supportive of skin and nasal decontamination. For instance, the CDC Guidelines specify that nasal t colonization should be considered with new pierson or nasal overdone iodine five or above solution. In concert with chlorine exiting washing wipes or high risk surgical patients, iCU patients and non ICU patients with midline catheters. The human body is a reservoir for staff Laureates. Thus, it is not surprising to learn that in the elective surgical population, 15 to 30% will be nasal lee colonized with M. S. S. A. More alarmingly. 1-3 of these patients will be colonized with methicillin resistant staph warriors. Indeed, in the whole population there are both intermittent and persistent carriers of the staff organism. And if we look at certain populations such as dialysis patients, they are even more frequent carriers in the range, 20-50 will be colonist with staff warriors. Two strategies are under development to control this organism. In the surgery population, a universal approach treats all patients with therapy and data to support this process is in continuing evolution. Other strategy is a targeted approach where patients are usually screened and cultured for staph aureus and those patients who test positive or are at special risk are treated. There are two routine approaches with treatment for staph aureus patients and these include the nasal antibiotic new papyrus anointment Or a pulver Adonai iodine, five solution specific to the pulver adonai iodine. We have come to understand that staph aureus will be reduced by 99.5 within one hour after a single nasal application And that this reduction will persist for up to 12 hours. Indeed, utilization of this approach with pelvic bone iodine has proven efficacy in arthropod, plastic orthopedic surgery, complex spine and many types of cardiovascular surgery and other surgical components are steadily applying this technique as well. Here we see an important comparison study looking at the antibiotic comparison compared to Covid own iodine solution. This was a randomized open label trial of these two treatment options in Over 1700 orthopedic surgical patients. You can see on the per protocol analysis that there were important trends of reduction in the overall infection rate and even more importantly, a reduction in the deep staph aureus infection rate. The outcome parameters illustrated here. Yeah. For those of you who may not be familiar with the pulver tone iodine preparation, This is the three skin and nasal five solution. This comes as a small bottle with applicators and is done in the preoperative holding area prior to surgery. The solution is actually gelatinous because of a special polymer preparation which improves its patient tolerance since it's non dripping as well as its anti microbial persistence. This application is readily done by a nurse or nursing assistant requiring a total of two minutes in the preoperative holding area and the activity will be continued for 12 hours into the peri operative period Because of this prolonged action, one application is necessary. This is in contrast to the mu pierson antibiotic ointment where the patient requires five days of application using the ointment twice a day with insertion into each nostril importantly, the iodine solution has been shown to be safe across the near entire spectrum of our patient population, including Children to as young as two months of age. Let's move on now to temperature management. We know that hypothermia has important negative consequences to patient outcomes. This includes increased risk of blood loss and therefore blood transfusions, increased rates of cardiac and ischemic events with troponin leaks surgical wound infections and therefore increased hospital length of stay and patient increased times in the pack you for restoration of normal therm mia. In addition, patients may be shivering and more recent hypothermia studies have begun to quantify this as a or patient comfort quality metric index. This is an important new parameter which captures the patients understanding and acceptance of their temperature management and for those of us who live in Minnesota and similar environments were all keenly aware of the discomfort associated with hypothermia similar to the nasal decolonization. We have widespread global clinical guidelines which are supportive and recommend the conventional utilization of forced air warming in the inter operative and preoperative period. Here we see organizations that are associated with peri operative care of patients, Including again, CDC guidelines which have a category one, a recommendation for peri operative norma Therm. Eah, which should be maintained in all patients. Yeah, what was the origin of these guidelines? Well, it's sometimes interesting to go back into the historic record. And this study by Kurt Sessler and others From 25 years ago was the defining landmark study which brought peri operative warming into the operating room across the country and really around the world. This study looked at 200 colorectal patients which were randomized to routine thermal care 1996 often involved just covering patients with a blanket versus those who had forced air warming application. The effects were very profound. As you can see here in this blinded study, The infection rates were reduced from 19 Down to 6%. A statistically and clinically very profound and important difference. A correlation of that was obviously a parallel reduction in the length of hospital stay for those patients who were maintained normal thermic because of their better outcomes and reduction in surgical site infections. Yes, more recently, the focus on maintenance of normal therm miA has expanded into the preoperative period. Again, we have a meta analysis here that was done last year by Zhang and colleagues and is summarized here with the seven most robust studies that have looked at preoperative warming. You can see the results here Have shown a 40 reduction in the risk of surgical site infection associated with use of preoperative warming techniques. The results here are Consistent across these seven studies, but historically of all the studies, there are widespread variations due to older studies, inconsistent warming methods, variable warming methods and study bias. But in conclusion, I think we can recommend that these patients be pre warmed for a minimum of 30 minutes. And that warming techniques are continued from the preoperative arena into the operating room itself with a combination of heating methods, a very common and convenient modality by which we can maintain normal therm miA is a process using the three Bair hugger, normal therm E. A. System which is probably familiar to most people who live and work within the operating room environment. This relies on a warm air generator which is distributed through a blanket or gown, which the patient will wear. Depending on the specific model. These blankets can be placed underneath over or around the patients and there is a wide host of options which to customize this to make it most convenient for the patient as well as appropriate for their specific requirements of various surgeries. Importantly, it's been shown with the three M Bair hugger system that as long as 50% of the body surface area is available For coverage and warming. The patient can be maintained at a temperature of 36.0° and above, which is the threshold for the definition of hypothermia. Here, the forced air warming patients are illustrated in the blue line and control patients with the orange line showing a steady detriment over the two plus hours of the observation period. Similar to the initial study showing The positive impact of forced air warming in colorectal surgery patients from 1996. We see similar outcome studies here with preoperative warming on the incidence of wound infection after clean surgery. In a randomized control study Here Melon studied 421 patients receiving 30 minutes of pre warming versus no pre warming. Again, the outcome is illustrated here in this column graph with an important reduction between the unwarranted and warm patients. This threshold of 30 minutes of free warming appears consistently within the literature and is the most common convention, which is applied as far as a goal for your peri operative care bundle and patient care. Mhm. In order to maintain normal thermal throughout the peri operative period, you need a good thermometer. This seems self evident, but in fact this can be a very complex effort, as there can be marked inconsistencies in the way core temperature is attempted to be measures. Oftentimes this starts with a oral temperature in the preoperative area will be transitioned by anesthesia to a Asafa jail temperature during surgery and then in the pack you period because of patients sedation and drowsiness, they may try and use nurses there may try and use a oral canal or tim panic membrane temperature. This provides sort of inconsistency just because of the different modalities of measurement, fortunately there is an older technology which has been recently Re examined and made more convenient, which is called zero heat flux thermometers. This is really a mechanism by which a small heater and sensor is applied to the patient's forehead. As illustrated here in the left hand column and with this heating and sensing process, it essentially creates an ayso thermal zone where we can actually examine core temperature and measure that on a convenient skin forehead site. Three M Bair hugger temperature monitoring system has been utilized and at my institution we use this process in order to provide a consistent measuring platform from pre op to interrupt to the post operative period and the pack. You nurses are very fond of this consistency and convenience of having the modality applied throughout the continuum of care. Likewise, the accuracy and precision of this system is as good as any of the other mechanisms of trying to measure core temperature. And finally, we would be remiss not to talk about hyperglycemia and our surgical patient population. Indeed, we know that elevated glucose is an independent predictor of post surgical complications And that sustained or intermittent hyperglycemia defined as a glucose above 140 mg/s is common. In fact, this was noted to occur in 25 to 30% of non cardiac surgery patients, 35 of vascular surgery and at least 80 of cardiac surgical patients will manifest hyperglycemia interestingly, 20-30 of these patients with peri operative hyperglycemia do not carry a preoperative diagnosis of diabetes. The question has been and continues to be whether this hyperglycemia is just a marker of sicker patients in general with compromised and organ function and thus are prone to peri operative complications, or is the elevated sugar actually the driver of these complications? The final answer has not been resolved, but there's at least sufficient evidence that many clinicians feel it's appropriate to optimist peri operative glucose throughout the surgical procedure and that this may improve surgical outcomes. Okay, lastly, there is no particular agreed upon threshold value of a preoperative hyper glycemic patient that would necessitate postponing elective surgery. However, some opinion pieces have been published, which suggests blood glucose elevations above 250 mg per deca litre should be re evaluated and consideration giving to delaying or postponing elective operations to establish better glucose control. Right? Where this does have consequences, particularly in the vascular surgery population. Here in a study by long and others, is a retrospective review of over 1000 vascular surgery patients where over a third of these patients manifest hyperglycemia in the peri operative period, defined as at least one glucose Over 180 mg per decade later in the 1st 72 hours. And I want to draw your attention here to the Universe Harriet outcome analysis, particularly to the bottom line, which highlights the surgical site infections, which are more than doubled in those patients who manifest a glucose over $10 million or 180 mg per deca litre. That information we know there are several key components to improving patient outcomes and reducing surgical site infections, smoking sensation is a given and we now understand that different time windows or duration of that cessation will confer different benefits. But even one day of a cessation will improve oxygen tissue oxygenation. In addition, both skin and nasal decontamination has become a growing importance and of increasing application across the country with both targeted and universal application of commonly available therapeutic techniques. This becomes even more vital and sicker and chronic chronically ill patients. We have long understood that normal therm miA is critical and that where are convenient modalities for both pre and inter operative warming using forced air warming technology. In addition, accurate temperature monitoring is now readily done with new zero heat flux modalities and technology which can be applied across the spectrum of care. And, lastly, of course, glucose management with maintenance of fasting blood sugars uh at 8 to 10 million moller or 100 and 40 to 180 mg per deca litre should be targeted for all our peri operative patients. Yeah.