Necessity of mandatory postoperative intensive care unit management after clipping surgery for unruptured intracranial aneurysms.

OBJECTIVE: Many neurosurgeons routinely perform postoperative intensive care unit (ICU) management after clipping of unruptured intracranial aneurysms (UIAs). However, whether routine postoperative ICU care is necessary remains a clinical question. Therefore, we investigated which factors acted as risk factors that actually required ICU care after microsurgical clipping of unruptured aneurysms. METHODS: We included a total of 532 patients who underwent clipping surgery for UIA between January 2020 and December 2020. The patients were divided into two groups: those who really required ICU care (41 patients, 7.7%) and those who did not (491 patients, 92.3%). A backward stepwise logistic regression model was used to identify factors that were independently associated with ICU care requirement. RESULTS: The mean hospital stay duration and the operation time were significantly longer in the ICU requirement group than in the no ICU requirement group (9.9 ± 10.7 vs. 6.3 ± 3.7 days, p = 0.041), (259.9 ± 128.4 vs. 210.5 ± 46.1 min, p = 0.019). The transfusion rate was significantly higher (p = 0.024) in the ICU requirement group. Multivariable logistic regression analysis identified male sex (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.15-4.76; p = 0.0195), operation time (OR, 1.01; 95% CI, 1.00-1.01; p = 0.0022), and transfusion (OR, 2.35; 95% CI, 1.00-5.51; p = 0.0500) as independent risk factors for requiring ICU care after clipping. CONCLUSIONS: Postoperative ICU management may not be mandatory after clipping surgery for UIAs. Our results suggest that postoperative ICU management may be more required in the male sex, patients with longer operation times, and those who received a transfusion.

Cadaveric emergency cricothyrotomy training for non-surgeons using a bronchoscopy-enhanced curriculum.

BACKGROUND: Emergency cricothyrotomy training for non-surgeons is important as rare "cannot intubate or oxygenate events" may occur multiple times in a provider's career when surgical expertise is not immediately available. However, such training is highly variable and often infrequent, therefore, enhancing these experiences is important. RESEARCH QUESTION: Is bronchoscopy-enhanced cricothyrotomy training in cadavers feasible, and what are the potential benefits provided by this innovation for trainees? METHODS: This study was performed during implementation of a new program to train non-surgeon providers on cadaveric donors on our campus. Standard training with an instructional video and live coaching was enhanced by bronchoscopic visualization of the trachea allowing participants to review their technique after performing scalpel and Seldinger-technique procedures, and to review their colleagues' technique on live video. Feasibility was measured through assessing helpfulness for trainees, cost, setup time, quality of images, and operator needs. Footage from the bronchoscopy recordings was analyzed to assess puncture-to-tube time, safety errors, and evidence for a training effect within groups. Participants submitted pre- and post-session surveys assessing their levels of experience and gauging their confidence and anxiety with cricothyrotomies. RESULTS: The training program met feasibility criteria for low costs (<200 USD/donor), setup time (<30 minutes/donor), and operator needs (1/donor). Furthermore, all participants rated the cadaveric session as helpful. Participants demonstrated efficient technique, with a median puncture-to-tube time of 48.5 seconds. Bronchoscopy recordings from 24 analyzed videos revealed eight instances of sharp instruments puncturing the posterior tracheal wall (33% rate), and two instances of improper tube placement (8% rate). Sharp instruments reached potentially dangerous insertion depths beyond the midpoint of the anterior-posterior diameter of the trachea in 58.3% of videos. Bronchoscopic enhancement was rated as quite or extremely helpful for visualizing the trachea (83.3%) and to assess depth of instrumentation (91.7%). There was a significant average increase in confidence (64.4%, P<0.001) and average decrease in performance anxiety (-11.6%, P = 0.0328) after the session. A training effect was seem wherein the last trainee in each group had no posterior tracheal wall injuries. INTERPRETATION: Supplementing cadaveric emergent cricothyrotomy training programs with tracheal bronchoscopy is feasible, helpful to trainees, and meets prior documented times for efficient technique. Furthermore, it was successful in detecting technical errors that would have been missed in a standard training program. Bronchoscopic enhancement is a valuable addition to cricothyrotomy cadaveric training programs and may help avoid real-life complications.

Making knowledge clips with patients: What learning mechanisms are triggered in medical students?

OBJECTIVE: To prepare medical students for a rapidly changing healthcare landscape, where new means of communication emerge, innovative teaching methods are needed. We developed a project-based learning course in which medical students design audiovisual patient information in collaboration with patients and with students in Communication and Information Sciences (CIS). We studied what learning mechanisms are triggered in medical students by elements of a project-based-learning course. METHODS: In this qualitative study, twelve sixth year medical students that participated in the course were individually interviewed. Data were analyzed according to the principles of qualitative template analysis. RESULTS: We identified four learning mechanisms: Challenging assumptions about patients' information needs; Becoming aware of the origin of patients' information needs; Taking a patient's perspective; Analyzing language to adapt to patients' needs. These learning mechanisms were activated by making a knowledge clip, collaborating with patients, and collaborating with CIS students. CONCLUSION: Collaborating with patients helped students to recognize and understand patients' perspectives. Working on a tangible product in partnership with patients and CIS students, triggered students to apply their understanding in conveying information back to patients. PRACTICE IMPLICATION: Based on our findings we encourage educators to involve patients as collaborators in authentic assignments for students so they can apply what they learned from taking patients' perspectives.

Cuff inflation technique is better than Magill forceps technique to facilitate nasotracheal intubation guiding by GlideScope® video laryngoscope.

Video laryngoscopy is often selected to assist nasotracheal intubation in allowing better laryngeal visualization, although there is no comparative study evaluating the effectiveness between auxiliary techniques by using Magill forceps and inflated cuff in GlideScope video laryngoscopy for nasotracheal intubation. Fifty-one of 100 patients in a Magill forceps group and 47 of 100 patients in a cuff inflation group were included in the final analysis in this randomized, single-blind, parallel, clinical trial study. Induction agents were routinely administered according to body weight, while intubation time spent, attempts, and related side effects were recorded. Compared to the Magill forceps group, the cuff inflation technique shortened the total intubation time (70.0 ± 24.5 s vs. 87.0 ± 25.0 s, p = 0.001) and the time of advancing the nasotracheal tube from oropharyngeal space into the trachea (25.9 ± 16.4 s vs. 42.3 ± 21.2 s, p < 0.001). However, the number of intubation attempts was not significantly different between groups. During tube advancement, the tube was rotated to accommodate the glottis and trachea more frequently in the cuff inflation group (p = 0.009), but the blade of the laryngoscope shifted and was adjusted to the proper position more frequently in the Magill forceps group (p < 0.001). In the Magill forceps group, the tube cuff might be clipped incidentally and the intubator might shift their gaze away from the screen during intubation, although there was no significant difference in intubation-related side effects between groups. Unlike the conventional approach, nasotracheal intubation with the GlideScope® video laryngoscope using the auxiliary technique of cuff inflation could be more suited than using Magill forceps.

Bladed and bladeless conical trocars do not differ in terms of caused fascial defect size in a Porcine Model.

INTRODUCTION: Trocar insertion during laparoscopy may lead to complications such as bleeding, bowel puncture and fascial defects with subsequent trocar site hernias. It is under discussion whether there is a difference in the extent of the trauma and thus in the size of the fascia defect between blunt and sharp trocars. But the level of evidence is low. Hence, we performed a Porcine Model. METHODS: A total of five euthanized female pigs were operated on. The average weight of the animals was 37.85 (Standard deviation SD 1.68) kg. All pigs were aged 90 ± 5 days. In alternating order five different conical 12-mm trocars (3 × bladeless, 2 × bladed) on each side 4 cm lateral of the mammary ridge were placed. One surgeon performed the insertions after conducting a pneumoperitoneum with 12 mmHg using a Verres' needle. The trocars were removed after 60 min. Subsequently, photo imaging took place. Using the GSA Image Analyser (v3.9.6) the respective abdominal wall defect size was measured. RESULTS: The mean fascial defect size was 58.3 (SD 20.2) mm2. Bladed and bladeless trocars did not significant differ in terms of caused fascial defect size [bladed, 56.6 (SD 20) mm2 vs. bladeless, 59.5 (SD 20.6) mm2, p = 0.7]. Without significance the insertion of bladeless trocars led to the largest (Kii Fios™ First entry, APPLIEDMEDICAL©, 69.3 mm2) and smallest defect size (VersaOne™ (COVIDIEN©, 54.1 mm2). CONCLUSION: Bladed and bladeless conical 12-mm trocars do not differ in terms of caused fascial defect size in the Porcine Model at hand. The occurrence of a trocar site hernia might be largely independent from trocar design.

Characterisation of trocar associated gas leaks during laparoscopic surgery.

BACKGROUND: During laparoscopy, the abdominal cavity is insufflated with carbon dioxide (CO2) that could become contaminated with viruses and surgical smoke. Medical staff is potentially exposed when this gas leaks into the operating room through the instruments and past trocar valves. No detailed studies currently exist that have quantified these leakage pathways. Therefore, the goal of this study was to quantify the gas leakages through trocars and instruments, during minimally invasive procedures. METHODS: A model of the surgical environment was created, consisting of a rigid container with an interface for airtight clamping of laparoscopic equipment such as trocars and surgical instruments. The model was insufflated to 15 mm Hg using a pressure generator and a pneumotachograph measured the equipment gas leak. A protocol of several use cases was designed to simulate the motions and forces the surgeon exerts on the trocar during surgery. RESULTS: Twenty-three individual trocars and twenty-six laparoscopic instruments were measured for leakage under the different conditions of the protocol. Trocar leakages varied between 0 L/min and more than 30 L/min, the instruments revealed a range of leakages between 0 L/min and 5.5 L/min. The results showed that leakage performance varied widely between trocars and instruments and that the performance and location of the valves influenced trocar leakage. CONCLUSIONS: We propose trocar redesigns to overcome specific causes of gas leaks. Moreover, an international testing standard for CO2 leakage for all new trocars and instruments is needed so surgical teams can avoid this potential health hazard when selecting new equipment.

Efficacy of early clip-with-line method for colorectal endoscopic submucosal dissection.

BACKGROUND: Colorectal endoscopic submucosal dissection (ESD) remains demanding due to technical difficulties and high risk of perforation. Most of the reported traction methods are initiated after creating a mucosal flap, which is time consuming. To obtain a good visualization at the mucosal incision stage, we developed the early clip-with-line (ECL) method. This method was started immediately after injection of sodium hyaluronate solution into the submucosal layer. In this study, we evaluated the efficacy and the safety of the ECL method for colorectal ESD. METHODS: We retrospectively analyzed all cases of colorectal ESDs (41 cases in total) performed from January 2017 to February 2019 in our institution. From January 2017 to August 2018, 27 of these cases were performed using conventional (non-ECL) ESDs, while from September 2018 onwards, the remaining 14 cases were performed using the ECL method. Retrospective comparison between the ECL group and the non-ECL group was conducted in terms of clinical characteristics, treatment outcomes, and adverse events. RESULTS: There were no significant differences in clinical characteristics between two groups. Procedure time (median [range]) was significantly shorter in the ECL group than in the non-ECL group (66 [29-131] min vs 90 [30-410] min; P = 0.03). As for adverse events, no case of perforation occurred in the ECL group, whereas perforation was observed in 7.4% (2/27) cases in the non-ECL group (no significant difference). CONCLUSION: Early clip-with-line method for colorectal endoscopic submucosal dissection reduced procedure time.

Bronchopleural Fistula as a Complication in a COVID-19 Patient Managed With Endobronchial Valves.

Bronchopleural fistula (BPF) is associated with high morbidity if left untreated. Although rare, the frequency of BPF in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is becoming recognized in medical literature. We present a case of a 64-year-old male with BPF with persistent air leak due to SARS-CoV-2 pneumonia treated with Spiration Valve System endobronchial valve (EBV). An EBV was placed in the right middle lobe with successful cessation of air leak. In conclusion, the use of EBVs for BPF with persistent air leaks in SARS-CoV-2 patients who are poor surgical candidates is effective and safe.

Haemostatic devices in parotid surgery: a systematic review.

OBJECTIVE: The Harmonic Scalpel and Ligasure (Covidien) devices are commonly used in head and neck surgery. Parotidectomy is a complex and intricate surgery that requires careful dissection of the facial nerve. This study aimed to compare surgical outcomes in parotidectomy using these haemostatic devices with traditional scalpel and cautery. METHOD: A systematic review of the literature was performed with subsequent meta-analysis of seven studies that compared the use of haemostatic devices to traditional scalpel and cautery in parotidectomy. Outcome measures included: temporary facial paresis, operating time, intra-operative blood loss, post-operative drain output and length of hospital stay. RESULTS: A total of 7 studies representing 675 patients were identified: 372 patients were treated with haemostatic devices, and 303 patients were treated with scalpel and cautery. Statistically significant outcomes favouring the use of haemostatic devices included operating time, intra-operative blood loss and post-operative drain output. Outcome measures that did not favour either treatment included facial nerve paresis and length of hospital stay. CONCLUSION: Overall, haemostatic devices were found to reduce operating time, intra-operative blood loss and post-operative drain output.

Reducing Setup and Turnover Times in the OR With an Innovative Sterilization Container: Implications for the COVID-19 Era Military Medicine.

INTRODUCTION: The global 2019 coronavirus pandemic (COVID-19) is setting unprecedented demands on the nation and the military and surgical services. Surgical demands include a large backlog of surgical cases, strain on available resources, and the need for additional measures to prevent exposure. The purpose of this project was to evaluate the feasibility, duration, adverse events, and potential gains associated with using a Turbett Sterilization Pod (TSP) for total joint replacements. MATERIALS AND METHODS: A multidisciplinary team used the Plan-Do-Study-Act model to guide this project. A time-motion study was completed in the operating room (OR) to measure the average time required to set up surgical instrumentation for total joint replacement cases that required 12 or more instrument trays. We compared the amount of time it took to complete the setting up of instrumentation using the traditional method versus the TSP method. The traditional method consisted of unwrapping each surgical tray, checking for holes in the blue wrapper, and placing the tray on the back table. In the case of the TSP, the door of the pod was opened, and the instrument trays were transferred directly to the back table. We measured the time the staff took to perform the task using each of these methods. RESULTS: When compared to the traditional method, the use of the TSP resulted in improved turnover time, decreased room setup time, reduced environmental waste, and eliminated both the effect of damage to wrappers and the time previously spent wrapping surgical trays. CONCLUSION: The TSP minimizes the time needed by the staff to set up an OR suite for a total joint replacement, therefore permitting them to focus more on direct patient care. This time improvement suggests that all surgical specialties, including those requiring greater than 12 traditional instrument sets, may experience reduced turnover time between cases. The use of the TSP is one means to help rectify the OR backlog brought on by COVID-19.

Ephemeral history of the three-bladed tracheostomy dilator.

Tracheostomy remains a topical surgical procedure. The history of tracheostomy is marked by the development of various instruments, including the three-bladed tracheostomy dilator from the middle of the 19th century. The purpose of this historical note is to recall the use of this unusual instrument.

The Use of Acute Normovolemic Hemodilution in Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: The occurrence of coronavirus disease 2019 (COVID-19) has overwhelmed the blood supply chain worldwide and severely influenced clinical procedures with potential massive blood loss, such as clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH). Whether acute normovolemic hemodilution (ANH) is safe and effective in aneurysm clipping remains largely unknown. METHODS: Patients with aSAH who underwent clipping surgery within 72 hours from bleeding were included. The patients in the ANH group received 400 mL autologous blood collection, and the blood was returned as needed during surgery. The relationships between ANH and perioperative allogeneic blood transfusion, postoperative outcome, and complications were analyzed. RESULTS: Sixty-two patients with aSAH were included between December 2019 and June 2020 (20 in the ANH group and 42 in the non-ANH group). ANH did not reduce the need of perioperative blood transfusion (3 [15%] vs. 5 [11.9%]; P = 0.734). However, ANH significantly increased serum hemoglobin levels on postoperative day 1 (11.5 ± 2.5 g/dL vs. 10.3 ± 2.0 g/dL; P = 0.045) and day 3 (12.1 ± 2.0 g/dL vs. 10.7 ± 1.3 g/dL; P = 0.002). Multivariable analysis indicated that serum hemoglobin level on postoperative day 1 (odds ratio, 0.895; 95% confidence interval, 0.822-0.973; P = 0.010) was an independent risk factor for unfavorable outcome, and receiver operating characteristic curve analysis showed that it had a comparable predictive power to World Federation of Neurosurgical Societies grade (Z = 0.275; P > 0.05). CONCLUSIONS: ANH significantly increased postoperative hemoglobin levels, and it may hold the potential to improve patients' outcomes. Routine use of ANH should be considered in aneurysm clipping surgery.

Percutaneous tracheostomy for long-term ventilated COVID-19-patients: rationale and first clinical-safe for all-experience.

INTRODUCTION: COVID-19 infection has resulted in thousands of critically ill patients admitted to ICUs and treated with mechanical ventilation. Percutaneous tracheostomy is a well-known technique utilised as a strategy to wean critically ill patients from mechanical ventilation. Worldwide differences exist in terms of methods, operators, and settings, and questions remain regarding timing and indications. If tracheostomy is to be performed in COVID-19 patients, a safe environment is needed for optimal care. MATERIAL AND METHODS: We present a guidewire dilating forceps tracheostomy procedure in COVID-19 patients that was optimised including apnoea-moments, protective clothing, checklists, and clear protocols. We performed a retrospective analysis of the outcome after tracheostomy in COVID-19 patients between March 2020 and May 2020. RESULTS: The follow-up of the first 16 patients, median age 62 years, revealed a median intubation time until tracheostomy of 18 days and median cannulation time of 20 days. The overall perioperative complication rate and complication rate while cannulated was 19%, mainly superficial bleeding. None of the healthcare providers involved in performing the procedure developed any symptoms of the disease. CONCLUSIONS: This COVID-19-centred strategy based on flexibility, preparation, and cooperation between healthcare providers with different backgrounds facilitated percutaneous tracheostomy in COVID-19 patients without an increase in the overall complication rate or evidence of risk to healthcare providers. Our findings provide initial evidence that tracheostomy can be performed safely as a standard of care for COVID-19 patients requiring prolonged mechanical ventilation as was standard practice in ICU patients prior to the COVID-19 pandemic to promote ventilator weaning and patient recovery.

Fractured aluminum nasopharyngeal swab during drive-through testing for COVID-19: radiographic detection of a retained foreign body.

The ongoing coronavirus disease 2019 (COVID-19) pandemic has increased the need for safe and efficient testing as a key containment strategy. Drive-through testing with nasopharyngeal swab has been implemented in many places in the USA as it allows for expeditious testing of large numbers of patients, limits healthcare workers' risk of exposure, and minimizes the use of personal protective equipment. We present a case where the aluminum shaft of the nasopharyngeal swab fractured during specimen collection at a drive-through testing facility and was suspected to have remained in the asymptomatic patient. Initial evaluation with a series of radiographs covering the skull base, neck, chest, and abdomen did not reveal the swab. On further clinical evaluation, the swab was found endoscopically, lodged between the left inferior turbinate and nasal floor, and was removed by an otorhinolaryngologist. Using a phantom model, we aimed to delineate an imaging technique to better visualize the aluminum shaft of the nasopharyngeal swab on radiographs to help in identification. A technique using lower tube voltage (kVp) with tight collimation centered at the nasal bones area produced the best visualization of the aluminum shaft of the swab. Recognition that aluminum foreign bodies may be difficult to visualize radiographically and  optimization of radiograph acquisition technique may help guide clinical management in unusual cases. Further evaluation with computed tomography or endoscopy should be considered in suspected cases where radiographs are negative.

Laparoscopic or robotic intraoperative management to minimize aerosol dispersion: Adaptations to the context of the COVID-19 pandemic. / Manejo intraoperatório em cirurgia laparoscópica ou robótica para minimizar a dispersão de aerossóis: Adaptações ao contexto da pandemia por COVID-19.

The coronavirus infection, also known as SARS-COV2, has proven to be potentially fatal, representing a major global health problem. Its spread after its origin in the city of Wuhan, China has resulted in a pandemic with the collapse of the health system in several countries, some with enormous social impact and expressive number of deaths as seen in Italy and Spain. Extreme intra and extra-hospital measures have been implemented to decrease the transmission and dissemination of the COVID-19. Regarding the surgical practice, a huge number of procedures considered non-essential or elective were cancelled and postponed until the pandemic is resolved. However, urgent and oncological procedures have been carried out. In this publication, we highlight and teach adaptations to be made with commonly used materials in laparoscopy to help prevent the spread and contamination of the healthcare team assisting surgical patients.

A infecção pelo coronavírus determinante da doença COVID-19, também conhecida como SARS-COV2 foi classificada nos últimos meses como pandemia. Essa é potencialmente fatal, representando enorme problema de saúde mundial. A disseminação, após provável origem zoonótica na cidade de Wuhan, China, resultou em colapso do sistema de saúde de diversos países, alguns com enorme impacto social e número grande de mortes descritas na Itália e Espanha. Medidas extremas intra e extra-hospitalares têm sido implementadas a fim de conter a transmissão e disseminação da COVID-19. No âmbito cirúrgico, enorme quantidade de procedimentos considerados não essenciais ou eletivos foram prorrogados ou suspensos até resolução da pandemia. No entanto, cirurgias de urgência e oncológicas não permitem que o paciente espere. Nesta publicação, sugerimos e ensinamos adaptação a ser feita com materiais de uso corriqueiro em laparoscopias para evitar a contaminação ou a disseminação entre as equipes assistenciais e os pacientes.

Coronavirus disease 2019 communication: novel sign language system to aid surgical tracheostomy whilst wearing a respirator.

BACKGROUND: The coronavirus disease 2019 pandemic has necessitated rapid adaptations to all levels of clinical practice. Recently produced guidelines have suggested additional considerations for tracheostomy and advocated full personal protective equipment, including filtering facepiece code 3 masks. Air seal with filtering facepiece code 3 masks is often challenging, and full-face respirators and powered air-purifying respirators with hoods need to be employed. The infection prevention benefits of this equipment are accompanied by potential issues in communication. OBJECTIVE: In an attempt to minimise surgical error through miscommunication, the authors sought to introduce a simple sign language system that could be used as an adjunct during surgery. RESULTS: Following evaluation of pre-existing sign language platforms and consideration of multiple surgical factors, 14 bespoke hand signals were ultimately proposed. CONCLUSION: Whilst this novel sign language system aims to bridge the communicative gap created by additional personal protective equipment, further development and validation of the proposed tool might be beneficial.