Video cardiothoracic-surgery--the-patient-journey.mp4 Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides cardiothoracic-surgery--the-patient-journey.mp4 Overview Good day to everyone and on behalf of three am I would like to welcome you to the best practices for improving surgical outcomes in cardiothoracic surgery. The patient journey webinar. And I want to thank you for making time in your busy schedule to participate in this very important webinar. My name is V. C. New Ready. I'm the director of cardiac surgery at Tristar Medical Center in Nashville Tennessee and I'm partnering today with dr cassie Gabrielle and anesthesiology specialist, joining us from Vancouver Washington over the next hour or so. We will share strategies for reducing surgical site infections, complications and costs. We're also going to discuss best practices for setting up your patient for a successful discharge. Again, my name is V. C. New Ready and I'm a cardiac surgeon here in Nashville Tennessee and I want to talk about specifically surgical site infections, their impact their causes and some strategies to reduce their currents for cardiac surgery. Please make sure any products devices or therapies that we refer to in this presentation. Please refer to the F you for those devices By way of disclosure, I am a speaker for three a.m. So now let's talk about incisions for a moment. We know that certain surgical procedures have inherent to them complications that may occur. One of the most dreaded complications are surgical site infections. These complications sometimes will be related to the procedure itself, and that would be an example listed on the left side of this slide. For example, we know that hip and the arthur plasticine, those fractures that are open fractures that need reduction bypasses done in compromised areas such as vascular compromised limbs. With them. Pop bypasses. Certainly those procedures that require immuno suppression such as renal transplants, all the procedures and cardiac that involves turn autumn ease and other G. Y. N. Procedures are intrinsically higher risk for wound infections. Similarly, there are sometimes patient factors that can lead to increased rates of surgical site infections. These patient factors include those that are very obvious to us, such as obesity, poorly controlled diabetes radiation to the field. But there may be other ones that are less common, such as Yuri miA, patients with very poor nutrition, those with the city's, those with known cancers, certainly things like anemia and jaundice. Other systemic uh types of diseases can certainly affect the rates of wound infections. So I think it's very important for us as a framework to understand. There are procedures that are elevation in terms of risk, but they're also patient specific factors that raise the risk. Surgical site infections are a major concern. Vote to the health system to the patient as well as to the provider. There are about eight million people at risk for healthcare associated infections and post surgical complications lead to significant increases in costs. In fact, we know that surgical site infections make up nearly a quarter 21.8% of all health care associated infection, And that once an infection occurs, it increases the average length of stay nearly 10 days, 9.58 days, with an additional cost of approaching $40,000. Other common complications, including wounded Hisense, hematoma and Ciroma may also occur. And the other important thing that we should remember is that the consequences of these surgical site infections extend far beyond the time of discharge. And those consequences are not only important to the patient, but often their families into their caregivers. We know that CMS has emphasised the need to decrease the cost and to improve the care by identifying these hospital acquired conditions because reimbursement will be lacking for them. And there are three major areas that they have identified media sinusitis, which we mentioned following coronary bypass grafting, certain orthopedic procedures that involve this this size, and then those exercises that occur after bariatric surgery. There are also other surgical site complications to consider besides S. S. S. That really affect the well being of the patient and can prolong and make recovery much more difficult. A few of these that I want to mention other than a true full born infection or some aromas, which are as we know, a collection of lymph fluid or other fluid in the region of the incision of the wound, hematomas, collection of blood or some small vessel bleeding that can occur into the field. Just generalized oedema due to impaired lymphatic flow. The essence of the incision itself, which is a separation at the skin level and readmission due to any of the above these all also can be affect the well being and the recovery of the patient. In addition to the surgical site infection itself, Well now, let's segue into what are some strategies to reduce surgical site infections and surgical site complications. The ones we just mentioned, such as Ciroma and hematoma and others. What we do understand by some basic study of this is that up to 60% of surgical site infections may actually be preventable by very straight forward use of evidence-based guidelines. That's evidence based guidelines. The first thing they do is create a consistent approach for preparing patients for surgery and by aligning to these guidelines and adopting best practices. Both practitioners and health systems may develop effective strategies to reduce the zohar complications. Some of them are going to fall into the realm of what do we do before surgery. Those are the preoperative type strategies And then they're going to be strategies in the operating room and finally they're going to be some strategies that extend beyond the operating room into the post operative period. We're going to go through several of these. But as you can see in this pictograms, basic things such as temperature monitoring in normal hermia, nasal decolonization, patient bathing and skin preparation, temperature management, appropriate hand hygiene, surgical prep, anti microbial drapes, temperature management and perhaps additional management of the closed incision. They all have roles and we'll look into each of these in some more detail. Let's start with patient decolonization. What do we know about microbial colonization and the neary's? The human body turns out is quite the reservoir for a basic organism known as staphylococcus aureus, or staph aureus. in fact, 30% of patients or the population really carry staph aureus in their narratives. This doesn't represent an infection, but it's just basically that up to 30% of patients or carriers for this organism. 30, another 30% or just intermittent carriers. They may not chronically be colonized with staph aureus, but may intermittently become in contact and have it uh inhabiting their Neris. And then we know that about a 30% rate of just non carriers. These are patients who have never had it and don't have staff warriors that's able to be cultured from their Mary's. But 80% of staph aureus infections have been traced to patients who have provided the bacteria for their own infection because of the residents in their Neri's. So, this is one important fact for all of us to realize is that we may be the source of some of our own infections. So why should we be concerned about decolonization again, decolonization first to the fact that these organisms are not causing an infection at the time, but they're acting as a reservoir that once a surgical site is created by an incision that then they may act up and become an infection. The interior in areas we know are recognizing the anatomical niche for where staph aureus can live because it has its own unique physiology and ecosystem. Secondly, we know that Staff Warriors is the leading cause of surgical site infections in acute care facilities. So another very important reason to be vigilant about Staff Warriors and the neris. Let's look at some global clinical guidelines about nasal decolonization. Let's first look at what the guidelines state regarding decolonization and we can look at who created these guidelines. Many robust and august bodies such as the World Health Organization in our field, the Society of thoracic surgeons and the C. D. C. Have all played a role in this as well as the association of preoperative registered nurses who are very active group in the operating room arena reducing infections first in terms of bathing, all agree that preoperative bathing advises patients to shower bathe full body with an anti microbe approval or not. Anti microbial soap or an antiseptic agent at least the night before the operative day. This strategy alone can reduce infection and that preoperative bathing for the facility should be included as well for certain high risk procedures such as cardiothoracic orthopedic and neurosurgery. In terms of nasal decolonization, the majority of guidelines say that screening should be done a simple nasal swab and then a culturing of that can understand if that the patient is colonized. Some strategy should be used typically a treatment with an ointment or other compound. Um Pearson has been used in the past and in 2019 the C. D. C. Updated their guidance so uh move beyond just anointment based and look at other things. Other strategies such as those beyond the pre op area. But in general these are two very important strategies bathing and focused nasal decolonization that could have a very big role. The C. D. C. Also has some core strategies that they recommend for implementing source control for high risk patients during high risk uh procedures. And here they're updated guidelines about implementing source control. That means a high risk patients such as my patients that reside in the ICU. As well as non ICU patients should get some decolonization undertaken. CHD bathing nasal decolonization and also great care with regard to the strategy of what type of central line or intravenous access is being used nasal be causation with concern or nasal PVP and CHD wipes has indicated. But keep in mind that the CDC core strategies are strongly supported by broadly published evidence and that their recommendation is should be the foundation for prevention of hospital acquired bloodstream infections as well. In other acute care facilities. One protocol that may be implemented is one that includes both CHD bathing and nasal decolonization is really a good global effective strategy for the reduction of all of these S. S. E. S. And other related bloodstream infections. The greatest impact really occurs when you combine both bathing and nasal decolonization. As far as a comprehensive strategy that's practiced and when these two practices are brought together, we have seen market reductions in catheter related bloodstream infections for example as well as the potential to reduce surgical site infections. One appropriate strategy for skin and nasal antiseptic use is using the proven in iodine 5% solution. This is a buffered solution and the buffering is done to make sure that the iodine stays in its active form. This solution helps reduce the risk of sec when it's part of a comprehensive preoperative protocol. We have seen a 99.5% reduction of staph aureus and the Neris within an hour and we know that this is maintained. Uh this reduction of 99.5% is maintained for at least 12 hours. Following the treatment with the providence iodine solution. Now let's turn our attention to some clinical evidence. What is the clinical evidence underlying nasal providence aydin solution? And why is it a reasonable alternative, two person in a multifaceted approach. So in this analysis which was preventing surgical site infections, which is a randomized open label trial comparing the nasal ointment and nasal provident aydin solution. This was an investigator initiated trial. It was prospective and randomized controlled trial and it compared S. S. Eyes after arthur plastic or spine fusion. All patients also receive simultaneous 2% CHD cloths for skin decontamination. And the patient populations were randomized to receive either maybe sarin protocol or the skin and nasal protocol. So let's see what they found. If you look at those that had the three M. Skin and nasal formulation and look at the overall infection rates, there was a market reduction. But if you go down to the staph aureus portion of the panel, you can see that we basically were able to eliminate uh that organism from existing with that combination approach. And this is compared directly to Professor Anointment. Now let's take a little bit more deeper look at surgical skin preparation and what are some strategies here in terms of surgical site infection reduction. So what are the global clinical guidelines in this arena? Again, some of the same organizations we mentioned earlier, such as the World Health Organization, the C. D. C. And A. O. R. N. Have looked in this area and have looked at some strategy. And the consensus is really to use a dual active surgical skin prep with one of the actors being alcohol. Unless it's contra indicated, what are some of the things we should consider when choosing a surgical prep? Obviously, patient factors are going to be predominant, such as allergies or sensitivities. Those patients that have demonstrated sensitivities to certain compounds, we have to avoid the age of the patient, the type and condition of the skin. Some patients may have pre existing skin conditions such as eczema or even open wounds that we have to be very cautious of. And then the location and the type of procedure. Second look at. What are the active ingredients. Are these a quick solution or they have some sort of dual properties. And then finally, what is the size of the era being prepped? And are we going to be effectively uh to be able to prep that area? For example, in cardiothoracic surgery. My own especially we have to do an entire body prep because we're operating both sometimes in the groins as well as at the chest and in the lower extremities. It's very important to us. For example, the ability to maintain antimicrobial effectiveness. Cardiothoracic procedures tend to be quite lengthy and we need something effective for many hours rather than for 30 minutes to an hour. So the persistence of anti microbial activity is very important. Also, the use of an incision drape is going to be important in the compatibility of the skin prep with the incision. Great the ability to see and work with all skin tone types and also the viscosity. The drying time, its application safety and efficacy are also going to be important. So one of the options we have is dura prep Adora prep surgical solution has active iodine in it and it's combined with isopropyl alcohol, which meets the guidelines as we just outlined from A. R. N. And other societies that it has alcohol based properties. It combines two broad spectrum antimicrobial agents alcohol providing the effective immediate anti microbial activity and then the iodine compound providing the longer lasting antimicrobial protection that's needed for longer procedures. Let's take a look at some of the clinical evidence that underlines the skin prep. We know that surgeries using idea for an alcohol based surgical preps, including the dura prep that we just mentioned had significantly lower surgical site infection rates than those using just claure preps skin preparation. This uh, is a study that had 3000, 209 patients. Each agent was adopted as the preferred modality for a six month period and was studied and you can see at a very highly statistical fashion with a p value of 60.1 that the idea for based surgical preps had a markedly lower surgical site infection rate 4.8 vs 8.2% for the corporate based. Now, let's look at another technique and adjunctive strategy, which is the insights barrier, drape, how to utilize it and the techniques that may help reduce again surgical site infections. One of the things that I worry about an operating room is always cross contamination. The risk of contamination is always present because there are residual microbes that survive on the skin surface even after skin prep and a deeper skin layers and especially in hair follicles. And we'll talk again a little bit about the appropriate preparation when patients are quite hirsute or have a lot of body hair without additional protection, residual bacteria on the skin surface and from those hair follicles can be picked up by other items that touch the skin. So it's very important to somehow isolate those areas when you have gloves, instrument sponges and fluids being in contact with these other areas. As you see depicted here in this slide that can easily be transferred into the decision and they're markedly increase the risk of patient infection that time. This is where a barrier type approach may come into play. The three am I banned anti microbial insides drape is something I've used for many years and it's indicated for use as an incised rape with continuous anti microbial activity. It's really intended obviously only for external use. But I find that it's very effective in preventing that cross contamination because it really isolates that portion of the surgical field from the area that you're working. Let's look at some of the clinical evidence that supports and is foundational to the insides drape. So the iban to incise drape has been shown as a cost effective intervention that has been closely associated with significant lower incidences of surgical site infection. This study's objective was done to compare the efficacy and cost of an idea impregnated rape versus a standard rate that had been used previously in terms of how the study was done. It was a retrospective retrospective study That had prospectively collected data from 5100 cardiac surgical patients between January of 2008 and March of 2015 Of these patients. 1,016 were matched in terms of risk factors. So there were a matched group in terms of standard propensity matching one group of 808 patients received antiseptic and a standard incised rate. The other group of 808 patients received antiseptic. And the I've been incised rate. The overall cost for each group where the measure taking in consideration the cost of the drapes, antibiotic, any future needed back therapy, any wound revisions and those uh resources involved with extended hospital stay. What were the results the results showed as you can see by the two bar graphs at the surgical site infection rate was carefully measured and reviewed and the group that received the standard trait reported the surgical site infection rate of 6.5%. The group that had the eye band rate reported a site infection rate of 1.9%. This is a market and statistically significant reduction in those wound infection rates. I think the it's obvious to understand that it wasn't just the barrier component, but the type of barrier is very important. And then when we went further and looked at the cost analysis demonstrated that I've been impregnated drapes because of their market reduction compared to standard rates were associated with the savings of almost $1000 per patient. Finally, let's talk a little bit about post incision closure and management as an additional strategy to look at altering surgical site infections and surgical site complications Of the three improving a therapy system. Well, how does it work? It works by delivering a continuous negative pressure, approximately 125 mm of mercury negative pressure. That can be used continuously for up to seven days. There are a couple of things that occur when a Praveen A type system is utilized. First of all, there's increased um bolstering of the incision and reduction of sheer and stress forces of separating the incision. So you're basically holding the incision edges together better during that early important period of healing No two. Because of the negative therapy being applied from the surface, there's better circulation of fluids underneath the incision resulting in reduced to Dema and removes fluids that may be accumulating just underneath the skin and being able to evacuate furthermore. Very important in my, especially since the stern artemis is very close to the head, neck and mouth. This is an area that acts as a true barrier to the entry of external infectious sources. Whether it's from the marys as we talked about earlier in this presentation or simply from the mouth and the oral pharynx as people eat and speak uh and sneeze. These are this barrier component I think is very important as well. And as I mentioned due to the negative pressure therapy, there's a nice reduction in adama and you'll get to see that in a few pictures in a couple of minutes. So what's the indication statement? Well, this is the really important part of the message is that the previous system has been granted a de novo indication statement by the U. S. FDA. Really. The therapy and said therapy unit is utilized to manage the environment of a close surgical incision by removing fluids away from the surgical incision with the application of 125 millimeter negative continuous pressure therapy. And in this arena it has been shown and it's effective and has an indication for reduction of superficial surgical site infections. In both class one and class two words, let's look at what the therapy indication statement is. The eu indication statement is that the three improving the incision management system is intended to manage the environment of clothes, surgical incisions and surrounding and tax skin and patients at risk for developing postoperative complications such as infection by maintaining a closed environment with the application of a negative pressure wound therapy system to the incision and for uh the use indications in latin America. Similarly, it's intended to manage the environment of surgical incisions that continue to drain following future or stapled closures by maintaining that closed environment and removing exit dates and by the application of the negative pressure therapy. What does the system look like? These are the different types of the units you can see on the left side, there's the three improving a 125 therapy unit. There's the Praveen a plus and then there's the Praveen a plus. That's a 14 day In terms of the dressings, they range in size from a 13 centimeter to a 20 centimeter to the 35 centimeter strip, again with the interface with silver impregnated lining. And then there's also a fully customizable one that has various perforations in the dressing that allows you to cut it and customize it. There are a couple of other ones that are specifically designed for orthopedic usages and other areas of the body. So let's look at the clinical evidence that underlies the Praveen A therapy. So first of all, there's been a broad number of publications that have looked at this with various levels of uh Clinical evidence. We know that the level events can range from level one a. All the way to level five depending on the robust nature of the data being generated. And if you look at it by specialty such as vascular cardiothoracic. Both of those specialties have a large number of solid publications all related to surgical site infections and complications. Now in my fuel. Specifically when you look at post star anatomy wound infections, particularly those high risk patients such as obese patients. I think what you see here is that when you evaluate the Praveen A for those high BMI patients that is greater than 30 and you look all the way up to 90 days after medium stern. Ah To me, what you'll find is that the Praveen a group in these group of to 75 75 patients in the control group 75 in the province, a group And looking at a hypothetic economic model. You can see that the infection rate was nearly reduced by 3/4. It's 4% versus 16%. If you give an average cost of infection of 37,000, which we've mentioned in this, uh, webinar this morning earlier. And then you look at the cost of this infection per patient and the cost of the therapy at the total cost for patients in the control group of 6000 versus approximately $2000 in the Praveen a group. This is a market multi fold reduction just by the use of this therapy in this high risk population. Figueira was another study done recently. This is a multi center randomized controlled trial. Again, looking at the effectiveness of the previous system, uh, in mitigating surgical site complications in very high risk patients after revision, the arthur a plastic. And what they looked at here. The purpose was seeing what were the infection rates at 90 days. And it was perspective as multi center and it was randomized And you had fairly large numbers in each group. Approximately 242 patients. 147 the closed therapy group, 147 in the silver impregnated group. And then when you look at the results at 90 days for surgical site complications, 3.4% of the Praveen a group, 14% in the standard of care group and readmissions were lower as well as they let the stay if they were readmitted. So the only thing different that was not markedly different and statistically, although it was actually different was the 90 day re operation rate. What can we conclude from the Higuera study is if you look at the primary analysis at 90 days after adjusting for the revision type subjects treated with closed negative pressure therapy, or 78% less likely to experience those life limiting surgical site complications that we've talked about After 90 days compared with the standard of care And more importantly for the health care system. The readmission rates were significantly lower for those in the closed negative pressure therapy group when compared to standard of care, 3.4%, compared to nearly 10.2% in the standard of care group. And if they did have to get re admitted, there was a shorter length of stay, Which I think was very important to note as well. And that the 90 day re operation rate if something did occur uh such as a surgical site complication, it was lower in the Praveen a group. Now I want to wrap things up with a case presentation. As with any study, I want you to understand these are my own personal experiences. Individual results may vary depending on your patient population and your case complexity. So the first case studies a 67 year old female patient presented with this neon exertion and classic engineer with activity. Medical history included a previous close mastectomy. In the previous me, The patient's labs revealed elevated creatinine levels of 1.6 And sorry, at 1.6 mg for desk leader representing some chronic kidney disease, stage three and a normal hematocrit. The operation was a long operation. Do the complex coronary anatomy and the patient was on a presser leave a fed at the conclusion of the procedure, putting them in a higher risk group for eventual or possible when complications. The pictograph on the left shows a clean clothes surgical incision with as you can see a barrier draped in place. The next slide shows that the barrier drape has been removed and their three improve in a decision dressing has been applied And the final pictures shows the decision very well approximated on postoperative day 10, 1 of the things to take note of is the more advanced wound healing that has already occurred in this patient with some neo revascularization going on, showing a wound that's much further along in its healing pathway. Case study #2 is a 48 year old male that returned to the hospital for complex internal reconstruction after an aortic valve replacement two years prior that was done in another institution, Basically this patient at a complex medical history of ongoing smoking, a disrupted sternum with external fracture and a prosthetic heart valve in place. The patient was quite large, £260 with a body mass index of 36 due to some tattooing that can be very identifiable. We had to limit the amount of field that's visible for viewing. But basically this patient had a three improve in addressing. Applied at the conclusion of a very complex procedure. You can see here and fairly the two drains coming out and then once we remove the dressing, an excellent re approximation, a very nice cosmetic result, but also a very nice wound healing result in terms of how nicely everything has healed up in a very short period of time. Going to our third case study. This is a 64 year old male who also had dystonia with very minimal activity, really, life limiting shortness of breath had a medical history that includes includes very poorly controlled diabetes, which as we saw earlier in one of the sides is a direct risk factor for surgical site infection as well as poor nutrition. Again, putting him in the high risk group with a low preoperative albumin had lung disease with COPD and really appeared much older than the patient stated age. The labs were consistent with what we saw above in the previous bullet point, a low albumin level and elevated hemoglobin. A one C of eight showing the poorly controlled diabetes and elevated glucose is even on admission. This patient underwent an operation to revascularization, did very well. We again took down the barrier draped, put on the application of the three M dressing was applied for a total of five days. You can see the barrier effect because again, with the oral pharynx and the nose and the body habit is here very easily could have had things spilled on this wound or cross contaminated with the telemetry wires. We can see that the drains were no issue. The media style grains are in place and slightly uh medial and lateral. And then finally, when you see the dressing taken down on post day five, you can see how nicely re approximated it is and you can really make out there's less oedema in the region of the dressing compared just laterally. And you can see that the incision really likes any sort of Ciroma hematoma and certainly no infection. Final case study is in a very obese female that had to undergo an emergency procedure which again puts them in the high risk group at very poor tissue quality at very poorly controlled diabetes. Again, poor nutritional status with a low albumin had very large pendulous breasts that we're gonna put a lot of stress on the incision laterally. So this patient underwent bypass surgery and then add the Praveen a therapy for a little over 6.5 days. You can see on the next slide here the very large pendulous breast that would have been pulling at the incision. You can see the decision very nicely contours to this patient again, creating the barrier for the oral pharynx and the neris is not interfere with the central line had drains in fairly but really helped reduce that shear stress. Once the dressing was taken down again you saw very nicely healed incision, a little bit of residual from where the adhesive of the Praveen a device was but no disruption in the decision whatsoever. Despite this very large lateral force being applied to the patient in this brief video will be able to see a example of the application of the Praveen a closed incision negative pressure therapy system to a new lee closed sternal incision. As you can see the sternal incision was closed and the standard fashion. One important aspect does not to apply any sort of barrier like mental math, Accolate or any other. Silent over the incision because you really want the Praveen a device to be able to remove any exit date or fluid that may come up through the incision. The next important thing is as you saw we made use of the three M barrier drape that drape is then cut away just at the time before the application of the previous system. You can see here we chose the appropriate Trevena Pre made size. This is the 20 centim device. Some incisions are small enough to use the 13th centim device. As you can see the device does not interfere with the normal placement of drains or pacing wires. The drains were in place just in fairly and slightly laterally to their usual location. To allow plenty of room for the Praveen a device and its adhesive to take place. The pacing wire was then placed slightly in fairly and laterally. Next we can see that the device is then connected to the Praveen a pump. You can now see the foam starting to take the contour as the 125 millimeters of negative pressure therapy is being applied. The dressing very nicely and straight poorly becomes adherent and almost contours to the incision. It doesn't interfere with the central line that lies here in the jugular reason region doesn't interfere with the drainage tubes or with the pacing wire and takes on a very nice configuration. And now the patient is ready to be transported to the ICU. So the results in my own personal series has shown that all patients that I use this device on have multiple comorbidities, most often obesity, poorly controlled diabetes, poorly controlled hypertension that are undergoing cardiac surgery. Mean incision length is typically 16 centimeters, but I have incisions that ranged from 13 to 18 and therefore can be covered with the 13 centimeter 20 centimeter device that follow up ranging between one and three months. All of the decisions were intact. Had excellent re approximation of the skin and there was absolutely no Ciroma formation. There were also no cases external wounded medicines, wound infection or other surgical site complication that required additional procedures. So I think the real takeaways for the practitioner out their viewing this webinar, is that number one, going back to our early slides. Consider the procedure you're about to undertake. Is it a high risk or low risk procedure? Think about it. This is a unique procedure. Is this is kind of a usual simple procedure. Remember about the length of your procedure. Again, we saw some data showed lengthy procedures. We want persistent efficacy of any type of surgical site infection reduction strategy we're using versus a brief procedure. Then pause and look at your patient. Is this a high risk patient or a low risk patient? What types and numbers of comorbidities these patients have? Are they really healthy patients? And then make sure uss secondary factors such as M. R. S. A colony colonisation, that staph aureus or diabetes or other disease states. And then look at your alternatives. What do you want to do? And I think I would argue do something rather than the usual. And this is where all of the techniques we talked about by doing. Being proactive and using active strategies to reduce surgical site infections. You can really impact the patient. I think you can conclude that negative pressure incision management systems may be considered a very viable nonsurgical adjunct over clean clothes decisions, especially when you have these complex patients undergoing complex procedures. Well thank you for your attention for this webinar. At this point I'm going to turn over our webinar to Dr Gabrielle. She will be talking to you about hypothermia and strategies to manage this during the peri operative period. Thank you again. Thank you Doctor Ready very much. We really appreciate your information again. I'm cassie Gabriel. I'm a private practice anesthesiologist with Colombia anesthesia group in Vancouver Washington. And today I'm going to be focusing on preventing hypothermia which is a well known risk factor for surgical site infections. First of all some important information I am a paid speaker for three M. And the information I'm presenting today is based on my personal experience. I would like to mention that if you have any questions about safety information any indications for use please refer to labelling provided on the product. Visit the three and website or contact your area representative Disclosures again. I am a paid speaker for three a.m. Okay, first of all, let's just just talk a little bit about unintended hypothermia. Peri operative hypothermia is defined as a core temperature of less than 36°C or about 96.8°F Up to 90% of surgical patients will experience unintended hypothermia if we don't take steps to prevent that from happening. Inadvertent peri operative hypothermia is considered a frequent preventable complication of surgery and we have research suggesting that even mild hypothermia can result in significant negative outcomes. First, I'm going to talk a little bit about thermal regulation. Normal core temperature is approximately 37°C And it's tightly regulated to within about 2/10 of a degree. This is defined as the inner threshold range which is depicted here on the slide by the dotted circle. When temperature rises about the top of this inner threshold range, there's pre capillary vessel dilation of the extremities. And if the temperature rises even further, sweating happens when temperatures drop below this set range, arteriovenous vessel constriction occurs, which prevents further heat loss coming from the extremities. If temperature drops even further About it, 1°C lower shivering occurs. Thermal regulation is a tightly controlled home in a static mechanism because metabolic and enzymatic function are both very dependent on proper temperatures. There are both behavioral and autonomic mechanisms in place to achieve thermal regulation. Unfortunately, these mechanisms are significantly disrupted by anesthesia, both general and your axle. I just want to take another minute to talk about thermal regulation, particularly in the elderly population. The elderly comprise our fastest growing segment of the population, with a significant proportion of the disease. About one third of our surgical population fits into this category. And there are some characteristics that are common in the elderly that place them at even greater risk of unintended hypothermia. They have a lower basal metabolic rate and they produce less heat. They're both physically and medically frail. They have less subcutaneous fat and a higher burden of disease. Typically, they tend to have reduced intravascular volume and cardiovascular function, which can blunt this vase oh, active response. What this essentially does is creates a wider inner threshold range at baseline, with the vessel constriction response to cold occurring at a lower temperature and these last two the lower intravascular volume in the cardiovascular function, and this vessel constriction response are probably somewhat related. So here is a study that was done by kurtz at all, and it demonstrated that patients having general anesthesia in this case, they used isil flooring and nitrous. The threshold for thermo regulatory vessel constriction was significantly lower in elderly patients, approximately 1.2°C.. And this finding is consistent with the fact that elderly patients do have a lower threshold for thermo regulatory basil construction at baseline. So because our elderly patients are at higher risk and are such a large part of our practice, we need to be even more vigilant and preventing hypothermia in this fragile population because there is a huge cost associated with hypothermia in surgical patients, not just increased risk of surgical site infections. So now I want to talk a little bit more just explaining why hypothermia occurs. I've described a bit about it already and how the body works to keep the core temperature within the narrow range. And now I would like to move on to some information as to why anesthesia itself contributes to peri operative hypothermia. Both your axle and general anesthesia. Place your patients at risk for experiencing hypothermia. So we can indeed add hypothermia to the list of things you can blame on anesthesia. So of all the factors that contribute to an intended peri operative hypothermia. It's this induction period of anesthesia that plays the greatest role. About 81% of temperature job in our patients occurs within this first hour and it is directly related to anesthesia. The other 19% is related to environmental and other factors exposed body cavities cold ours, patience wearing thin gowns, longer surgeries if we're infusing a lot of fluids that are not warmed up. But I wanted to discuss a little bit about this redistribution temperature drop that occurs. So anesthetic induced faisel dilation results from inhibition of central thermal regulatory control. Blood from the core compartment will mix with cooler blood here in the periphery and this results in a drop in core body temperature. And we see this happen in both general and your axle anesthesia because they both cause significant basal dilation. And it exacerbates this effect, particularly if you have a patient who is having both general and inter axial. It does compound this effect. So just right here is a few of the things that can happen with peri operative hypothermia. It may seem very simple and it's not something that you really think about on a daily basis. However, it is a big deal to maintain or normal hermia in the peri operative period. A great deal of research has shown that even mild hypothermia below 36°C can result in significant negative outcomes for patients. The risk of complications including infections, cardiac issues, excessive bleeding that can lead the need for blood transfusions that wouldn't otherwise be needed. For example, even mild hypothermia can increase blood loss by 16% with the risk of trade and the risk of transfusion by 22%. So let's just discuss these a little bit further. So we have a core temperature less than 36°C and this can lead to shivering and thermal discomfort. So a patient who is shivering in the pack you is likely to get Demerol to treat this Demerol can lead to post op nausea, vomiting, which can lengthen the pack your length of stay. Also, patient satisfaction patients feel cold, they feel uncomfortable. They can get agitated and you know, we all feel like we want to snuggle up in a blanket when we're cold and they're shivering. The patient may not be cooperative with getting monitors placed or remaining still. And so we also get inadvertently nurse dissatisfaction. Um but shivering and thermal discomfort is a very real thing we're going to talk a little bit more about that. Also shivering causes an increase in Mario cardio auction demand. Which can lead to some cardiac disturbances. You can get a ski mia, rhythm disturbances, tactic art such as tachycardia. You get a catacomb release which can lead to ischemia and increased morbidity and mortality. Normal hypothermia has been shown in a study by frank at all to increase rates of morbid cardio events. Also increased postoperative ventricular tachycardia and this mismatch of myocardial oxygen demand and what's available can lead to ischemia unintended. Hypothermia also causes severe discomfort experienced by patients, especially when shivering. So shivering occurs has been shown to occur in 40-60% of unworn patients recovering from general anesthesia. And some patients have even expressed the feelings of thermal discomfort and shivering to be more significant than their post surgical pain. It's rare to see intense shivering in the pack. You in patients that have a normal thermic temperature. Here's another unintended consequence here. We can also see with temperatures less than 36°C,, prolonged and altered drug effects. Many of the anesthetic drugs that we use can prolong emergence from anesthesia. Some of these drugs include propofol vecuronium and neo stick. Mean, with delayed emergence, so you have more time in the R and you have more length, a longer pack, you stay and both of these um sacrifice both cost and efficiency. So here's a slide that's just demonstrating um that drug metabolism is indeed reduced by hypothermia neuromuscular blocking agents such as vecuronium, which is a non polarizing muscle relaxant, with a relatively short, predictable half life, The average duration of action and action in a warm patient is about 28 2 minutes. But research shows that when a patient's body temperature drops to 34 4.3 degrees Celsius, the average acting duration of vecuronium more than doubles at 62 minutes. And similarly, our traditional reversal agent for for vecuronium and other must relax and stigma is also affected by hypothermia. So this Study by Lenart at all indicated that hypothermic patients need an average of 90 minutes longer in the pack you than patients who were kept normal thermic. And they based their discharge. They based their findings on discharge criteria Which considered respiratory and hydrodynamic parameters, consciousness, nausea, activity level and a core temperature of greater than 36°C.. The study concluded that maintaining core enormous hermia is likely to decrease pack you time. A couple more of the negative outcomes that we're going to discuss. Our kogel apathy, which has been shown to increase the rate of transfusion, which can, as we know, increase morbidity and definitely increased cost. And then finally, as Dr Reddy has discussed, the increased rate of surgical site infections with wounded has since increased length of stay, risk of readmission. Again, increased morbidity and increased cost and decreased patient satisfaction as well. So in this study, by Schmidt at all, a group of 30 hypothermic patients, Eight units of allergenic packed red blood cells were required by seven of the patients to only one norma thermic patient. Out of a group of 30, we require just one unit of allergenic flood. The increase of surgical blood loss may be due to hypothermia, which can impair platelet function, reduce clotting and increased vibrant a license. Here's a very interesting study. This study by Kurtz at all showed that hypothermic colorectal surgical patients with core temperature's just 1.5 to 2°C below normal have been shown to be at greater risk for a culture positive wound infection as a as normal thermic patients, There was a 19% rate of infection as opposed to 1/6 rate of infection in normal thermic patients. In addition, maintenance of normal 30 Hermia led to shorten tots hospital length of stay. These findings may be a result of the fact that hypothermia increases the patient's susceptibility to peri operative wound infections by causing vessel constriction and impaired impaired immunity. So in addition to the potential harm to patients that can happen due to unintentional hypothermia, I've also alluded to the significant cost. The financial burden of healthcare is high and patients hospitals and third party payers all have a vested interest in keeping costs down. The importance of normal hermia has also been addressed in Iraq's protocols and we have a rest protocols that are designed to improve patient experience and outcomes while reducing the cost and the areas protocols that we have in place now and say that normal thermal should be maintained throughout the peri operative course and they should be measured accurately. And as I discussed previously, the redistribution temperature drop that occurs in anesthesia is definitely the most significant contributor to peri operative hypothermia. And I'm going to talk now about the best way that we the best techniques that we have in place to mitigate the effects of redistribution temperature drop. And one of these is through pre warming. So what is pre warming? Pre warming is the application of heat prior to anesthesia for the purposes of increasing the patients total body temperature. Pre warming is done before induction. Generally in the pre op area. It can lessen and help to prevent hypothermia before it occurs in the first place. So as we know, the core is comprised of the head and trunk and it's about 50% of the body surface area. The remaining 50 Are the limbs. And what these do for the body is they serve as a buffer zone and they help maintain the core temperature within that narrow range of about 2/10 of a degree as I mentioned previously. So temperatures in the periphery tend to be a bit cooler and they're particularly so when patients are exposed to ambient hospital temperatures, they're wearing very thin gowns, they typically don't have a lot of covers. And the goal with pre warming is to keep the entire patient warm. We're not aiming to warm up the core of the body. Were aiming to just have total body temperature be a little higher. So including those extremities were trying to keep the patient nice and warm because what we want to do is decrease that central to peripheral gradient so that when that redistribution of blood flow occurs, we don't have as much mixing a very cool blood back into the court to drop the temperature. And this is what we mean by banking heat. So this is just I think this is a really helpful graph and it does a great job depicting why it's so important to pre warm patients versus just warming in the O. R. Alone. So pre warming is a practical way to head off hypothermia before it starts. Once that redistribution temperature drop occurs as we can see here with the little pink dots, it's very difficult to fix or treat it. It just takes time and not all surgeries are very long. We want to occur that big drop from happening happening in the first place. Look how steep that slope is. It's much more effective to be proactive and try and prevent that from happening as much as you can buy pre warming and then you combine this with oh are warming. And what we're trying to do is kind of flatten this curve. So these are the family of products that we use that the institutions where I practice um they're forced air warming blankets and they blow more mayor on the patient either underneath them or on various placements in the operating room. And we also use the pre warming gowns at one of the institute institutions where I work. So this is a prospective randomized controlled trial by mailing it all. And it was published in the Lancet in 2001. They wanted to study the effects of preoperative warning warming on the instance of wound infection after clean surgeries. So they recruited 421 patients who were undergoing surgeries, clean surgeries, varicose veins, hernias, breast cancers. And these patients were randomly assigned to be there actively pre warmed for a minimum 30 minutes before surgery and with the addition of interOP warning or to receive no pre warming therapy and they received interOP warming only. So in order to compare subsequent rates of surgical site infections between the groups, active warming was provided either systemically using a bear hugger forced air warming system or locally to the operative site. And what they found that was that 14% of the un warmed group Developed surgical site infections within six weeks after surgery, Compared to only 5% in the actively warmed group. And what I mean by that is, patients who had both pre warming and or warming warren patients had significantly better wound scores than unformed patients and were prescribed significantly fewer antibiotics. The authors concluded the active pre warming before clean surgery appears to be beneficial in helping reduce the risk of surgical site infection with the added benefit of having no known side effects. This particular study is looking at the efficacy of a forced air warming blanket that fits under the body so full underbody. And these are some of my favorite ones to use. This study was done in cardio coronary artery bypass surgery, patients who had normal thermic cardiopulmonary bypass and they wanted to see if the full underbody would help with preventing postoperative hypothermia. So they had a control group who received standard thermal care management and then they had an intervention group where they placed a bear hugger underbody forced air warming system in addition to the standard thermal care. Mhm. And so routine heat conservation methods were applied. Both groups had draping, they used warming warmed fluids, they used normal thermic heart lung machine management, Absing at keeping the temperature at 36.5. And they tried to keep the peripheral to core temperature gradient in less than 3°.. And they measured the core temperatures using a bladder catheter. Now in the intervention group, the ones that had the underbody Bair hugger on the entire time, 90% of the patients did have a normal temperature at 36 degrees Celsius, whereas only 46.7% of the ones that did not have the underbody Bair hugger, Only 46% of them had normal for MIA. So the peripheral temperature was also significantly higher uh in the group that had the underbody forced air warming. And again, I really personally like using the underbody blankets in my practice and the patient gets to move over to a nice warm table and they like that and it stays on the entire time while the patients exposed and while prepping is happening before the surgery. So there's really no interruption in the warming of the patient. So some facts about forced air warming. Recently some makers of other warming. Mortalities have attempted to generate concerns that forced air warming increases bacterial contamination operating rooms. And I know we've all heard this before and so I just wanted to present some of the clinical evidence summarize it related to this issue. Numerous studies show forced air warming does not increase bacterial contamination of operating rooms wang at all. Found a decrease in bacterial count at the surgical site when forced air warming was used. And Olmstead at all found that forced air warming had no negative effects, negative effects on air quality in the operating room. In fact, in 2017, the F. D. A. Actually issued a letter indicating that it had thoroughly reviewed available data and it was unable to identify consistently reported association between the use of force, their thermal regulating systems and surgical site infections. So we know warming is important. But unless we record it it never happened and it needs to be done consistently and accurately to be of any use. So this slide summarizes just some of the guidelines and the entities um that have put out some information for us regarding temperature monitoring. So there's a general consensus that the same method and route should be used when feasible and it should be as continuously or frequently if the case is short. And our arrest protocols state that all surgical patients and especially infants, should have their core temperature monitored continuously throughout the peri operative journey. So we should re recording temperatures both before they have surgery, during the operating room and of course in the recovery room and after surgery all surgical patients should be warned until they have a core temperature that's within the normal range. So again, if our patients come to the pack you cold and we're spending a lot of time warming them, we can increase pack you stages from not alone. So this is what we call these the little dots. Uh This is the bear hugger temperature monitoring system that I use that one of my facilities. It's a zero Heat flux monitor and it creates his own of insulation, allowing the warmer temperature to rise to the skin surface where the core temperature can be measured non invasively. So here there are um are multiple third party studies that evaluate have evaluated the efficiency or the efficacy rather of this temperature monitoring system. So the one in the Journal of cardiothoracic and vascular anaesthesia compared to your heat flux to conventional methods which included a soft jail formulary artery, nasal and nasopharyngeal temperature monitoring. So they were able to find uh to determine that it is a reliable way to measure temperature and it's not invasive, which we all can appreciate. It's easy to use. So we have a lot of great evidence that supports the importance of preventing preoperative hypothermia. And we have the technology available to us to keep patients warm and to measure their temperatures accurately. So what does this look like out in the real world? So here's what we have at one of the facilities where I work, we have a best practice bundle and what this is is a group of evidence based strategies related to a disease process that when done together consistently result in better outcomes than when implemented individually. So what we're trying to do here, what this is Is aimed at doing is lowering the risk of a surgical site infection. And the five ah techniques that are included in this best practice bundle are glucose control, peri operative, normal ther mia skin prep techniques giving antibiotic prophylaxis and surgical wound dressings. We implemented all of these at the same time. So with regards to maintaining preoperative normal Hermia, which is we define as temperature core temperature of 36-37.5°C.. We pre warm our patients using a forced air gown. We use the bear paw gown, we use forced air warming throughout the peri operative period And we do this for all adults and pedes that are greater than 50 kg. If they're having a surgery that's greater than one hour. And what we do is we place the patients in the gowns and we asked them to warm start warming themselves 30-45 minutes prior to their procedure. And they're and they're kind of reminded before surgery could um a couple times to to use their gown. They're monitored and they have a continuous monitor going as well for their temperature. They use the little forehead dot um the anesthesia team members when they get to the O. R. Have been asked to start monitoring the temperature as soon as feasible prior to induction if they can. So what we're trying to do is record what their temperature was when they got into the O. R. And it's again pretty easy to do when we use uh zero heat flux uh monitor. We can just plug it right in and start recording. And the kind of the reasoning behind this is that we're hoping that it will make everybody aware when the anesthesiologist sees the the patient coming into the room and they see the temperature is either already cool or they're nice and toasty. But the monitors right there next to them and it kind of just increases awareness to keep an eye on it and if you see the temperatures start to come down, you can kind of take measures if you can to keep that from dropping further as much as possible. One of the things that we also do if possible is we have an additional helper with scrubbing. So if there's more than one area on the patient to be scrubbed or there is a large area, we have two people in tandem and that helps reduce the time that the patient is uncovered. So how do we measure our outcomes? So sometimes it's really hard to kind of discern what exactly is working and what's not working with this bundle um, specifically, but what we do is every time we have a surgical site infection case, it gets sent for review by a committee and they take a deep dive into the clinical course. They look at everything and they evaluate the execution of the best practice funnel. And the purpose of this is to look for opportunity to improve the system and not to punish anyone individual. Um, and on our experience, the two most common potential contributors to the development of surgical site infections are the things that come up over and over again are inadequate glycemic control and hypothermia. And so then we have to look at why is it these two things that we're having a hard time with? And basically I think it boils down to a lack of consistency and compliance. So then we have to look at how do we address these things? Well, first of all, we, I think education is really important. If people don't see the value in something or understand why it's helpful. Sometimes there's just not as much incentive for them to do that. Most of us that work in healthcare are scientifically minded. We really want to know if we're doing something, we're taking the time to do it. We want to know why and you know how to use it properly of course. Um and what we need to do is streamline and improve the process so that we can make execution easier and more palatable. So if the nurse is constantly spending time back and forth making sure all the patients have their warming gowns on. Uh if the anesthesiologists are having a just basically we just have to get buy in from the entire health care team so that we can make things easier for everybody and worthwhile and they can actually see the benefit. And I think it's really important when we're working on improved system improvements to get feedback from the team members, see what it is, it's um causing you know kind of a little bit of either pushback on doing things or you know just a system that's not quite right. So we have the evidence. We have all the necessary tools and our patients are depending on us to take excellent care of them. I hope this presentation has been helpful to you and that you can take some of this information back to your own practices and use it to keep your own patients warm comfortable and as free from complications as possible. I thank you for your time. Thank you Dr Gabriel, for the Excellent Talk and on behalf of three m, dr Gabriel and myself, I would like to thank you for participating in this educational activity. Please provide us your feedback in a short post survey. This helps us to understand your thoughts on the program, as well as the need for potential educational programs in the future. We want to thank you for your participation in your time and for your attention. Thank you again. Published Created by
