Review Question - QID 5547

A 30-year-old female involved in a severe motor-vehicle collision that requires prolonged extrication. She arrives at a referral trauma center almost 10 hours after her initial injury. She receives tetanus and intravenous antibiotics upon arrival. The patient has an open tibial fracture with significant periosteal stripping and a closed head injury that requires intracranial pressure monitoring. She is cleared for operative intervention by the neurosurgery and trauma surgery services the following morning. She undergoes a thorough debridement, placement of an antibiotic bead pouch, and external fixator placement approximately 18 hours after her injury. She is definitively treated 4 days after her injury with a repeat debridement, gracilis flap and intramedullary nail. Which of the following factors places the patient at increased risk of infection?