Emergency Operating Procedures Research Articles

Microscopic inflammation in ileocecal specimen does not correspond to a higher anastomotic leakage rate after ileocecal resection in Crohn’s disease

BackgroundPatients with Crohn’s disease suffer from a higher rate of anastomotic leakages after ileocecal resection than patients without Crohn’s disease. Our hypothesis was that microscopic inflammation at the resection margins of ileocecal resections in Crohn’s disease increases the rate of anastomotic leakages.Patients and methodsIn a retrospective cohort study, 130 patients with Crohn’s disease that underwent ileocecal resection between 2015 and 2019, were analyzed. Anastomotic leakage was the primary outcome parameter. Inflammation at the resection margin was characterized as “inflammation at proximal resection margin”, “inflammation at distal resection margin” or “inflammation at both ends”.Results46 patients (35.4%) showed microscopic inflammation at the resection margins. 17 patients (13.1%) developed anastomotic leakage. No difference in the rate of anastomotic leakages was found for proximally affected resection margins (no anastomotic leakage vs. anastomotic leakage: 20.3 vs. 35.3%, p = 0.17), distally affected resection margins (2.7 vs. 5.9%, p = 0.47) or inflammation at both ends (9.7 vs. 11.8%, p = 0.80). No effect on the anastomotic leakage rate was found for preoperative hemoglobin concentration (no anastomotic leakage vs. anastomotic leakage: 12.3 vs. 13.5 g/dl, p = 0.26), perioperative immunosuppressive medication (62.8 vs. 52.9%, p = 0.30), BMI (21.8 vs. 22.4 m2/kg, p = 0.82), emergency operation (21.2 vs. 11.8%, p = 0.29), laparoscopic vs. open procedure (p = 0.58), diverting ileostomy (31.9 vs. 57.1%, p = 0.35) or the level of surgical training (staff surgeon: 80.5 vs. 76.5%, p = 0.45).ConclusionMicroscopic inflammation at the resection margins after ileocecal resection in Crohn’s disease is common. Histologically inflamed resection margins do not appear to affect the rate of anastomotic leakages. Our data suggest that there is no need for extensive resections or frozen section to achieve microscopically inflammation-free resection margins.

Spectrum of urological emergencies and surgical interventions in a single tertiary health center.

ObjectivesEmergency urologic conditions are relatively common, albeit rarely life threatening, there is often a need for prompt and expedient management in order to avert severe or permanent morbidities. This study aimed to evaluate the spectrum of Urologic emergencies and interventions offered in a tertiary hospital in Nigeria.Patients and methodsWe retrospectively reviewed the records of patients who were managed in our institution for emergency urologic conditions over a period of 6 years (2011–2017). The data extracted included; the demographic information, diagnosis and the treatment offered. The data obtained were analyzed using SPSS version 20. Data were displayed using mean +/− standard deviation and percentages.ResultsThe records of a total of 681 patients were retrieved and they span across almost all ages with age range or 2–90 years. Urinary retention was the commonest emergency seen, accounting for 51.7% of the patients. Testicular torsion was the next most common (10%), others are bilateral ureteric obstruction and priapism with 5.4% and 5.3% respectively. Suprapubic cystostomy (SPC) was the commonest operative procedure performed (37.6%). The age range for patients with urinary retention was 3–90 years, though the peak incidence was in the 7th decade (37.3%). Patients with testicular torsion were young adults between the ages of 11 and 44 years.ConclusionUrinary retention was the commonest urologic emergency followed by testicular torsion. Though urethral catheterization was successful in most patients urinary retention, making it the commonest procedure. SPC was the commonest emergency operative procedure performed. Other emergencies occurred sporadically.

Influence of Radiographic Soft Tissue Findings on Clinical Entrapment in Patients With Orbital Fractures.

Radiographic assessment of facial fractures with computed tomography (CT) scanning has become standard of care. As imaging resolution has improved, findings such as herniation of extraocular muscles (EOM) have become a means of diagnosing conditions like orbital entrapment. However, the sensitivity and specificity of these findings has not been well-studied. We sought to evaluate the value of radiographic findings such as fat herniation, EOM contour irregularity, and EOM herniation in predicting orbital entrapment after orbital fracture. Secondary endpoints include diplopia, abnormal EOM motility, and the need for surgical fixation. A single institution, retrospective review at a regional level 1 trauma center was conducted. Patients with orbital fractures were identified by International Classification of Disease (ICD) codes and CT reports were queried for the terms "herniation," "herniated," "entrapped," and "entrapment." Four hundred records were analyzed. Sixty-seven percent of radiology reports mentioned "entrapped" or "entrapment," while the incidence of clinical entrapment was 2.8%. The odds of entrapment, diplopia, and abnormal EOM motility were higher in those with EOM herniation; however, EOM herniation had a positive predictive value of 7.9% for clinical entrapment. Fat herniation alone and EOM contour irregularity had positive predictive values of 4.2% and 4.8%, respectively. While the odds of entrapment appear higher in patients with EOM herniation, this imaging finding is not predictive of clinical entrapment. Fat herniation and EOM contour irregularity did not have higher odds of entrapment, nor were they predictive. Diagnosis of orbital entrapment should be based primarily on physical exam, with CT as an adjunct only. The assumption that radiographic findings indicate orbital emergencies may result in unnecessary interfacility transfers, subspecialist consultations, and emergency operative procedures.

A study on otorhinolaryngology related emergency surgical procedures performed under general anaesthesia in a teaching hospital

<p class="abstract"><strong>Background:</strong> Most of the ear, nose and throat related disorders that present in emergency can be managed without anaesthesia. Some of them are potentially life threatening and critical requiring surgical interventions under general anaesthesia, too. Ear, nose, and throat related emergency conditions are in rise due to increased incidence of road traffic accidents, social violence and physical assault. This study was performed to find out common ear, nose, throat and head and neck related emergency conditions that required emergency surgical procedures under general anaesthesia for their treatment.</p><p class="abstract"><strong>Methods:</strong> One hundred and seventy-seven patients were enrolled in this prospective cross-sectional study. Patients who underwent emergency operative procedures under general anaesthesia were assessed to find out the common reasons of admission and the common procedures performed for their treatment. </p><p class="abstract"><strong>Results:</strong> Out of 177 patients enrolled in the study, 26.6% were children below the age of 10 years. About three fourths (74.6%) had presented with foreign body in the ear, nose, or throat, and about 77% of them requiring anaesthesia were foreign bodies of the esophagus. Next most common surgical procedures were performed for different traumatic injuries (23.7%). Rest 1.7% of patients required other procedures like tracheostomy, sphenopalatine artery cauterization and traumatic split lobule repair under general anaesthesia.</p><p class="abstract"><strong>Conclusions:</strong> Foreign bodies in the ear, nose and throat are the most common emergency conditions requiring emergency surgery under general anaesthesia followed by traumatic cut injuries in our institution. Prompt treatment of the emergency condition is required for the better patient outcome.</p>

Health care disparity exists among those undergoing emergent hernia repairs in New York State.

Socioeconomic factors predispose certain populations to an increased exposure to emergent operative procedures. The aim of this study is to evaluate the role socioeconomic factors play in emergent repairs of inguinal, ventral and umbilical hernias. The SPARCS database was used to identify all patients undergoing emergent ventral hernia repair (EVR), emergent inguinal hernia repair (EIR), and emergent umbilical hernia repair (EUR) between 2008 and 2015. Chi-square test with exact p values from Monte Carlo simulation determined marginal associations between repairs (elective vs. emergent), and patient characteristics and comorbidities. Multivariable logistic regression models were further utilized to examine socioeconomic disparity. 107,887 ventral hernias, 66,947 inguinal hernias, and 63,515 umbilical hernias (total 238,349) were noted. African Americans were most likely to undergo an EVR compared to Caucasians (OR 1.55, 95% CI: 1.48-1.61), Asians (OR 1.31, 95% CI: 1.15-1.5), and Hispanics (OR 1.3, 95% CI: 1.23-1.37). African Americans were most likely to undergo EIR compared to Caucasians (OR 2.2, 95% CI: 2.06-2.36), Asians (OR 1.74, 95% CI: 1.49-2.02), and Hispanics (OR 1.22, 95% CI: 1.12-1.34). African Americans were most likely to undergo EUR compared to whites (OR 1.29, 95% CI: 1.22-1.36), Asians (26.62%, OR 1.21, 95% CI: 1.01-1.46) and Hispanic (28.03%, OR 1.08, 95% CI: 1.01-1.16). Medicaid patients were also more likely to undergo EVR (OR 1.31, OR 1.73), EIR (OR 2.92, OR 4.55) and EUR (OR 1.63, OR 2.31) compared to Medicare and commercial insurance. Race is a contributing factor in who undergoes an emergent hernia repair in New York State. A significantly larger proportion of the African American population is undergoing hernia repair in the emergent setting. Socioeconomic status, as indicated by the significant number of Medicaid patients undergoing emergent hernia repairs, also plays a role.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

Dhruva simulator: core neutronics and thermal hydraulics modules

It is widely recognized that simulators play an essential and extremely important role in training programs for nuclear power plants (NPPs). The full-scope training simulators provide such in-depth training tools for reactor operators. A full-scope simulator has been developed for research reactor, Dhruva at BARC. The details about the development activities are covered in this paper. Safety analysis and operational experience consistently indicate that human error is one of the key contributors to the risk of a severe accident in a nuclear reactor. The use of full-scope simulator in the training of operators is an essential element to reduce human error. This paper presents the core neutronics and thermal hydraulics of model of Dhruva reactor incorporated in the Dhruva simulator. The core neutronics module is based on point kinetics model which estimates the reactor power depending on the core reactivity. The simulator can reproduce the different operational scenario, i.e., reactor operation under equilibrium and non-equilibrium condition, xenon transients, loss of regulation incidents, etc. The simulator will also be used to study the role of human reliability in safety of nuclear plants. The simulator was so designed that over and above training of the plant personnel, it will be used for safety studies in the area of reactor physics and thermal hydraulics. The interface was designed to support the interaction of the operators with the simulator through virtual panels supported by touch screens with high-fidelity graphic displays. Important Postulated Initiating Events (PIEs) like Loss of Offsite Power, Loss of Coolant Accident, Loss of Regulation Incident, etc. have been modeled. This information will provide an insight to verify and validate the plant Emergency Operating Procedures (EOPs). The simulator will also be used for development of human factor models as well as the design of future Visual Display Unit based control rooms. This will also enable the operators to align themselves from the traditional panel-based Human–Machine Interface to personal computers.

Development and validation of a numeric tool for partially degraded core quenching under low injection rates

Quenching of reactor core has been studied numerically with the help of several numeric tools reported in literature. These tools have been developed to simulate core quenching under design basis conditions. Hence, most of these tools make use of classical homogeneous equilibrium model of two phase flow which are reported to perform better under high pressure conditions with relatively small temperature gradients. System codes such as RELAP5 make use of two fluid model. Such system codes can simulate core quenching under design basis injection rates (1 g/s per unit length of single fuel pin) prescribed under Emergency Operating Procedures (EOPs). However, because of possibilities of flow path breakage under Severe Accident conditions, the injection rate reaching the core is expected to be lesser than the typical injection rate used for Severe Accident Management Guidelines (SAMG). A numeric tool ‘Program for Degraded Reactor Core Reflood’ (PDRCR) has been developed to simulate quenching of partially degraded reactor core under low injection flow rates. PDRCR has specific modules to tackle issues such as water packing, high temperature gradients in the fuel and simulation of parallel flow paths to account for flow re-distribution in partially ballooned fuel pin condition. This paper presents validation results for PDRCR. The predictions of PDRCR for SEFLEX and DRCRE test facilities and comparison with the experimental results are presented. The predictions of PDRCR are found to be better than RELAP5 for low injection flow conditions.

The National Burden of Orthopedic Injury: Cross-Sectional Estimates for Trauma System Planning and Optimization

BackgroundManagement of orthopedic injuries is a critical component of comprehensive trauma care. As patterns of injury incidence and recovery change in the face of emerging injury prevention efforts and technologies and an aging US population, assessment of the burden of orthopedic injury is essential to optimize trauma system planning. We sought to estimate the incidence of orthopedic injury requiring emergency orthopedic surgery in the United States. MethodsUsing nationally representative samples from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, we estimated the incidence of orthopedic injury, polytrauma with orthopedic injury, and emergency operative orthopedic procedures performed for the management of traumatic injury. We used multivariable logistic regression to identify patient, injury, and hospital characteristics associated with odds of emergency orthopedic surgery. ResultsA total of 7,214,915 patients were diagnosed with orthopedic injury in 2013-2014, resulting in 1,167,656 emergency orthopedic surgical procedures. Fall-related injuries accounted for 51% of health care encounters and 61% of emergency orthopedic surgical procedures. Odds of emergency orthopedic surgery were 2.04 times greater for patients with polytrauma, compared with isolated orthopedic injury (P < 0.001). ConclusionsThe total burden or orthopedic injury in the United States is substantial, and there is considerable heterogeneity in demand for care and practice patterns in the orthopedic trauma community. Population-based trauma system planning and tailored care delivery models would likely optimize initial treatment, recovery, and health outcomes for orthopedic trauma patients.

Understanding individualistic response patterns when assessing expert operators on nuclear power plant control tasks

We evaluated the performance of three highly practiced participants on three task types that comprised a simulated nuclear power plant control operation. Multiple subjective, physiological, and objective performance measures were collected on these three highly-practiced individuals. Results indicated ceiling effects in terms of performance accuracy, yet each individual adopted a unique response strategy across the respective sub-tasks. Their maximised accuracy was achieved at the expense of longer response times across differing sub-tasks. The measures which proved diagnostic and predictive of performance capacity were explored. The current conclusion presents us with an invidious problem in that performance and workload associations, insensitivities, and dissociations may be unique to each individual operator, and may well depend also upon the overall task in context. Such findings push our science away from seeking nomothetic assertions and toward individuated concerns. In consequence, the age of the idiographic may well be upon us. Practitioner summary: The importance and relevance of nuclear power control is self-evident. Concerns here have centred around the safety of the technology and its operators. Our work informs practitioners in this industry, and in Ergonomics in general, of the response of highly trained individuals in these safety-critical, operational domains. We show that even experts engage in personal and individual strategies, an observation critical to the assessment of this specific workplace, and potentially all others. Abbreviations: NPP: nuclear power plant; ROs: reactor operators; MCR: main control room; LOA: levels of automation; EOP: emergency operating procedure; OP: operating procedures; ISA: instantaneous self-assessment; DSSQ: Dundee stres state questionnaire

Comparative evaluation of augmented reality-based assistance for procedural tasks: a simulated control room study

ABSTRACT This research explores the design, implementation, and evaluation of a prototype augmented reality application that assists operators in performing procedural tasks in control room settings. Our prototype uses a tablet display to supplement an operator’s natural view of existing control panel elements with sequences of interactive visual and attention guiding cues. An experiment, conducted using a nuclear power plant simulator, examined university students completing both standard and emergency operating procedures. The augmented reality condition was compared against two other conditions – a paper-based procedure condition using paper manuals and a computer-based procedure condition using digital procedures presented on a desktop display. The results demonstrated that the augmented reality -based procedure system had benefits in terms of reduced mental workload in comparison to the other two conditions. Regarding task completion time, accuracy, and situation awareness, the augmented reality condition had no significant difference when compared against the computer-based procedure condition but performed better than the paper-based procedure condition. It was also found that the augmented reality condition resulted in fewer intra-team inquiry communication exchanges in comparison to both paper-based and computer-based conditions. The augmented reality condition, however, yielded poorer memory retention score when assessed against the other two conditions.

Study of bacteriological profile and sensitivity to various drugs in a case of wound dehiscence in tertiary care centre

Background: Surgical wound infection is a common post-operative complication causing significant post-operative morbidity and mortality, prolonged hospital stays and adds between 10-20% to hospital cost.Methods: This is a prospective study conducted in Department of General Surgery and Department of Microbiology, M.L.N. Medical College and Swaroop Rani Nehru Hospital, Allahabad. The study group comprised of all patients who underwent surgery during the period from October 2017 to September 2018 and were diagnosed with postoperative surgical site infection and wound dehiscence.Results: A total of 1640 patients were followed during one year of study. 540 (32.92%) patients were operated as emergency cases while 1100 (67.08%) were operated as elective cases.Conclusions: Wound dehiscence is a common surgical complication occurring in about 6.5% of surgical procedures. Emergency operative procedures are associated with higher incidence (16.67%) of wound dehiscence as compared to elective surgical procedures (1.67%). Male gender is more commonly associated with wound dehiscence especially in case of emergency surgical procedures with male to female ration of 1.67:1.Incidence of wound dehiscence increases with increasing age being maximum in older age group. Malnutrition is the most common risk factor present in surgical patients predisposing to wound dehiscence.

Prevalence of Surgical Site Infections in IPD Department of Surgery: A Hospital Based Study

Background: The most common causes of nosocomial infections are surgical site infections (SSIs). It is also reported that SSIs rate ranges from 2.5% to 41.9% worldwide and resulting in high morbidity and mortality. Methods: This study conducted in Department of Surgery, Ananta Institute of Medical Sciences and Research Centre, Rajsamand. Results: In this study, 410 cases were included, out of which 5.6% were infected post-surgery and 94.3% were non- infected. From the 5.6% cases 60.9% had mild infection and 30.4% had moderate infection and 8.7% had severe infection. Conclusions: In the present study, the infection rate was higher. This high infection rate was due to the contaminated and dirty procedures where some of the patients were first seen about 2 to 3 days after development of peritonitis. It has been noted that the infection rate was higher in the emergency operative procedures in comparison to the elective procedures.

Functional Information of System Components Influenced by Counteractions on Computer-Based Procedure

In an emergency condition of nuclear power plant, operators have to mitigate the accident in order to remove the decay heat and to prevent the release of radioactive material to the environment following the emergency operating procedures (EOPs). The action of operators on a component, for example, changing the parameter level of a component, which is described in a procedure step, will impact other components of the plant and the plant behavior. Nowadays, the advanced main control rooms have been equipped with the computer-based procedures (CBPs) which provide some features and benefits which are not available in paper-based procedures. However, most of CBPs do not provide information of the impact of the counteractions on each procedure step (components influenced and future plant behavior) although it is useful for operators to understand the purpose of the procedure steps before making decisions and taking the actions. This paper discusses the functional information and the method to generate the information using multilevel flow modeling (MFM) model of operator actions on some procedure steps of a simplified EOP of pressurized water reactor (PWR) plant, as an example.

New Procedural Path for F&B Operation and Its Risk Impact on a Nuclear Power Plant

Although a feed and bleed (F&B) operation is an important emergency task having a significant effect on the risk of a pressurized water reactor–type nuclear power plant, there is a high uncertainty regarding its modeling and analysis in a probabilistic safety assessment (PSA). This paper introduces a study on the design of an operational strategy for an F&B operation based on human reliability analysis (HRA) with plant-specific thermal-hydraulic (TH) and human performance time (PT) analyses. The emergency operating procedures (EOPs) of a reference plant were modified by adding a new procedural path for the F&B operation to reduce its effect on the plant’s risk. To support the modification of the procedure, an intensive TH analysis was conducted to evaluate the plant’s behavior in diverse accident conditions and to revise the success criteria for the HRA of the F&B operation. In addition, an empirical analysis of PT required to carry out the F&B operation was conducted based on plant-specific simulator records. The PSA model of the reference plant was revised by reflecting the modified EOPs and new success criteria for the HRA of the F&B operation, which showed that core damage frequency of the revised PSA was about 50% lower than that of the original PSA.

Computer-Based Human-Machine Interfaces for Emergency Operation

Emergency operating procedures (EOPs) are fundamental for coping with emergency and accident situations in nuclear power plants. Researchers at the Halden Reactor Project have developed a design concept including computer-based EOPs and other displays to support operators during emergency situations. The computer-based procedure system includes three displays: a symptom check display intended for monitoring EOP entrance criteria, a procedure selection and overview display, and a procedure performance display. A large-screen display provides shared information viewable for all operators in the control room. This paper describes the design, implementation, and initial testing of the displays in the Halden Man-Machine Laboratory. The original paper presented at the 10th International Topical Meeting on Nuclear Plant Instrumentation, Control and Human Machine Interface Technologies (NPIC&HMIT 2017) has been revised to include empirical results from a full-scope simulator study.

Preliminary Investigation of Time Remaining Display on the Computer-based Emergency Operating Procedure

One of the important thing in the mitigation of accidents in nuclear power plant accidents is time management. The accidents should be resolved as soon as possible in order to prevent the core melting and the release of radioactive material to the environment. In this case, operators should follow the emergency operating procedure related with the accident, in step by step order and in allowable time. Nowadays, the advanced main control rooms are equipped with computer-based procedures (CBPs) which is make it easier for operators to do their tasks of monitoring and controlling the reactor. However, most of the CBPs do not include the time remaining display feature which informs operators of time available for them to execute procedure steps and warns them if the they reach the time limit. Furthermore, the feature will increase the awareness of operators about their current situation in the procedure. This paper investigates this issue. The simplified of emergency operating procedure (EOP) of steam generator tube rupture (SGTR) accident of PWR plant is applied. In addition, the sequence of actions on each step of the procedure is modelled using multilevel flow modelling (MFM) and influenced propagation rule. The prediction of action time on each step is acquired based on similar case accidents and the Support Vector Regression. The derived time will be processed and then displayed on a CBP user interface.

Cesarean section in Murrah buffaloe

Cesarean section in buffaloes is an emergency operative procedure being performed principally for uncorrectable uterine torsions and for delivery of fetal monsters. Ten cases of uncorrectable uterine torsion and fetal abnormalities were reported at TVCC, IIVER, Rohtak. It was decided to perform cesarean section in all the cases. Buffaloes were restrained in left lateral recumbency with both forelimbs and hindlimbs tied separately. Cesarean sections were performed under local infiltration analgesia using 2% lignocaine HCl and sedation with triflupromazine. Uterus were sutured using absorbable suture material with chromic catgut no. 2 in all the cases. Before suturing, available antibiotic pessaries were placed in the uterus. Post-operatively fluid therapy (5 days), broad spectrum antibiotics (5 days), NSAIDS (3 days) along with multivitamin (3 days) were administered. All animals except one recovered uneventfully.

A pre-test analysis of ATLAS SBO with RCP seal leakage using MARS code

The accident in Fukushima Daiichi nuclear power plants shows the important of developing coping strategies for extended station blackout (SBO) scenarios of the nuclear power plants (NPPs). Many NPPs in United State of America are applying FLEX approach as main coping strategies for extended station blackout (SBO) scenarios. In FLEX strategies, outside water injection to reactor cooling system (RCS) and steam generators (SGs) is considered as an effective method to remove residual heat and maintain the inventory of the systems during the accident. This study presents a pretest calculation using MARS code for the Advanced Thermal-hydraulic Test Loop for Accident Simulation (ATLAS) SBO experiment with RCP seal leakage scenario. In the calculation, the turbinedriven auxiliary feed water pumps (TDAFPs) are firstly used after SBO initiation. Then, the outside cooling water injection method is used for long term cooling. In order to minimize operator actions and satisfy requirements of APR1400 emergency operation procedure (EOP), the SGs Atmospheric Dump Valve (ADV) opening ratio, auxiliary feed water (AFW) and outside cooling water injection flow rates were investigated to have suitable values. The analysis results would be useful for performing the experiment to verify the APR 1400 extended SBO optimum mitigation strategy using outside cooling water injection.

Traumatic Injuries Requiring Simultaneous Emergent Operative Procedures, Knife Wounds to the Top of the Skull and the Abdomen

The simultaneous commencement of operative interventions by two or more surgical teams in the multiply injured patient is gaining more acceptance.