1. Surgical Site Infections Claude Laflamme MD, FRCPC Medical Director Cardiovascular Anesthesia Assistant Professor University of Toronto Faculty, Safer Health Care Now Campaign December 4 th 2007

2. Surgical Site Infections Who cares?? We all do!! December 4 th 2007

4. The Anesthesiologist’s Role Anesthesiology 2006; 105:413-21 Hypothermia Hyperoxia Fluid Management Hyperglycemia Blood transfusion Antimicrobial Prophylaxis

6. Efficacy of Protocol Implementation on Incidence of Wound Infection in Colorectal Operations J Am Coll Surg Vol. 205, No. 3, September 2007

7. Presentation Outline Prophylactic Antibiotics Prevention of Hyperglycemia Maintain Normothermia Hair removal Optimize Oxygen Tension Sunnybrook’s Experience Next Steps

8. Blood Glucose Control Cardiac Surgical Patients

9. Poor Blood Glucose Control Low Cardiac Output Increased inotrope Malignant arrhythmias Prolonged mechanical ventilation Stroke, Encephalopathy Renal dysfunction Infectious outcome

10. Blood glucose control Immunosuppression Leucocytes GranulocytesMonocytesLymphocytes

12. Bode Protocol Endocrine Practice March/April 2004 (BG mg/dl – 60) X 0.02 = units of insulin/h ((BG mmol/L X 18) – 60) X 0.02= units/h Target 6.0–8.0mmol/L When BG is greater then target, increase multiplier by 0.01 When BG is less then target, decrease multiplier by 0.01

14. GROUP MEAN Blood Glucose Levels mmol/L

15. Surgical Site Infection Cardiac Surgery

16. Deep SSI in Cardiac Surgery

17. Normothermia

18. Complications of mild hypothermia Increases duration of hospitalization Increases intra-operative blood loss Increases adverse cardiac event Increases patient shivering in PACU Promotes metabolic acidosis Increases SSI rates

19. Complications and treatment of mild hypothermia Hypothermia Impairs neutrophils function Vasoconstriction Tissue hypoxia

20. Minimizing hypothermia Anesthetics profoundly inhibits central thermoregulation decreasing the vasoconstriction threshold by 2-4ºC The second major factor is the magnitude of the core-to-peripheral temperature gradient Minimizing the core-to-peripheral temperature gradient and preoperative vasodilatation, is the basis to reduce heat redistribution Degree of adiposity, concurrent medication

21. Hypothermia Redistribution: 1.6ºC, 1 Hr Linear decrease: 1.1ºC, 2-3Hrs Plateau: 34-34.5ºC

22. Normothermia for colorectal surgery A Kurz, NEJM 1996; 334:1209-15 200 patients, double-blind study Followed for 2 weeks 34.7±0.6 Celsius VS 36.6±0.5 Celsius SSI 18.8% VS 5.8% (p=0.009) Sutures were removed one day later (p=0.002) Hospital LOS prolonged by 2.6 days (p=0.01)

23. Cutaneous warming Passive insulation reduces heat loss by approximately 30% Active cutaneous heating: efficacy will be proportional to the skin surface warmed Circulating water, Forced air, Radiant warmers

24. Active cutaneous warming systems Forced-air systems Circulating-water mattresses Resistive heating systems (ICU,trauma) Carbon-fiber patient cover Circulating-water garments Water has a conductivity of heat 26 times higher than air Infrared radiation

25. Minimizing hypothermia Prewarming:Decreases core-to-peripheral temperature gradient Eventually provokes vasodilatation Pharmacologic vasodilatation

26. Laparatomy

27. Core temperature monitoring Pulmonary artery Nasopharynx Tympanic membrane Aural thermocouples probe Infrared thermometer Temporal Artery Distal Oesophagus Rectal temperature during neuraxial anesthesia

28. Surgical Site Infections Project (General Surgery) Compliance Performance Ratings