Intraoperative Phase Research Articles

Kinematic analysis and evaluation of a hybrid mechanism for computer assisted bone reduction surgery

Abstract. In severe fracture cases, a bone can be separated into two fragments and it is mandatory to reposition the bone fragments together. This type of surgery is called “bone reduction surgery”. Originally, the operation consisted in manipulating the bones fragments by hand in open surgery. The most advanced technique relies on robotic manipulators providing higher precision and stability. A new mechanical architecture is proposed based on a 3-RPS tripod parallel mechanism combined with a Double Triangular Planar parallel mechanism. Its kinematic and velocity models are calculated and the parasitic motion generated by the tripod mechanism is considered in the final result. The workspace it can generate is compared to the Stewart manipulator, which is a classical mechanism for the targeted application. The use of a robotic manipulator is due to be part of an entire surgical procedure involving a pre-operative simulation software dedicated to pre-planning reduction surgery, namely PhysiGuide. It is used to measure the kinematic associated with bone fragments manipulation and transfer it to the robot during the intra-operative phase. Simulations are then performed based on a real patient's fracture images showing the suitability of the present mechanism with bone reduction surgery.

Development and validation of a real-time mortality risk calculator before, during and after hepatectomy: an analysis of the ACS NSQIP database

BackgroundAlthough most conventional risk prediction models have been based on preoperative information, intra- and post-operative events may be more relevant to mortality after surgery. We sought to develop a mortality risk calculator based on real time characteristics associated with hepatectomy. MethodsPatients who underwent hepatectomy between 2014 and 2017 were identified in the ACS-NSQIP dataset. Three prediction models (pre-, intra-, post-operative) were developed and validated using perioperative data. ResultsAmong 14,720 patients, 197 (1.3%) experienced 30-day mortality. The predictive ability of the real-time mortality risk calculator was very good based on only preoperative factors (AUC; training cohort: 0.813, validation cohort: 0.731). Incorporating intra-operative variables into the model increased the AUC (training: 0.838, validation: 0.777), while the post-operative model achieved an AUC of 0.922 in the training and 0.885 in the validation cohorts, respectively. While patients with low preoperative risk had only very small fluctuations in the estimated 30-day mortality risk during the intraoperative (Δ0.4%) and postoperative (Δ0.6%) phases, patients who were already deemed high risk preoperatively had additional increased mortality risk based on factors that occurred in the intraoperative (Δ5.4%) and postoperative (Δ9.3%) periods. ConclusionA real-time mortality risk calculator may better help clinicians identify patients at risk of death at the different stages of the surgical episode.

Ischemic Cardiac Event

An estimated 92.1 million Americans have at least one type of cardiovascular disease (CAD).1 Even though death rates due to CAD have declined, at least 2200 Americans die each day of CAD. 2 In the U.S. at least 50 million operations occur every year and up to 4% are associated with adverse cardiac events. 3There are many identifiable risk factors for cardiac disease such as diabetes, hypertension, obesity, smoking, and high cholesterol. 1In addition, there are non-modifiable risks for cardiac disease; these include age, gender, family history, and homocysteine levels. 4 Hypotension and tachycardia are the most common causes of ischemic cardiac events in the intra-operative phase. The failure to detect myocardial injury early on may contribute to complications as long as 30 days post-operatively. Typically, ischemic findings on electrocardiography and elevated troponin measurements have been used as potential indicators of ischemia or myocardial injury after non-cardiac surgery in the peri-operative setting. In the treatment of ischemic cardiac events, intensified medical therapy (antiplatelet, beta-blocker, ACE inhibitor, or a statin) in patients who suffered from a troponin elevation in the postoperative period reduces the risk of having a major cardiac event within a year. This review contains 1 figure, 2 tables, and 74 references. Keywords: Myocardial Injury after Non Cardiac Surgery (MINS), Perioperative ischemia, Troponin assay, VISION study, Coronary artery disease

Ischemic Cardiac Event

An estimated 92.1 million Americans have at least one type of cardiovascular disease (CAD).1 Even though death rates due to CAD have declined, at least 2200 Americans die each day of CAD. 2 In the U.S. at least 50 million operations occur every year and up to 4% are associated with adverse cardiac events. 3There are many identifiable risk factors for cardiac disease such as diabetes, hypertension, obesity, smoking, and high cholesterol. 1In addition, there are non-modifiable risks for cardiac disease; these include age, gender, family history, and homocysteine levels. 4 Hypotension and tachycardia are the most common causes of ischemic cardiac events in the intra-operative phase. The failure to detect myocardial injury early on may contribute to complications as long as 30 days post-operatively. Typically, ischemic findings on electrocardiography and elevated troponin measurements have been used as potential indicators of ischemia or myocardial injury after non-cardiac surgery in the peri-operative setting. In the treatment of ischemic cardiac events, intensified medical therapy (antiplatelet, beta-blocker, ACE inhibitor, or a statin) in patients who suffered from a troponin elevation in the postoperative period reduces the risk of having a major cardiac event within a year. This review contains 1 figure, 2 tables, and 74 references. Keywords: Myocardial Injury after Non Cardiac Surgery (MINS), Perioperative ischemia, Troponin assay, VISION study, Coronary artery disease

Ischemic Cardiac Event

An estimated 92.1 million Americans have at least one type of cardiovascular disease (CAD).1 Even though death rates due to CAD have declined, at least 2200 Americans die each day of CAD. 2 In the U.S. at least 50 million operations occur every year and up to 4% are associated with adverse cardiac events. 3There are many identifiable risk factors for cardiac disease such as diabetes, hypertension, obesity, smoking, and high cholesterol. 1In addition, there are non-modifiable risks for cardiac disease; these include age, gender, family history, and homocysteine levels. 4 Hypotension and tachycardia are the most common causes of ischemic cardiac events in the intra-operative phase. The failure to detect myocardial injury early on may contribute to complications as long as 30 days post-operatively. Typically, ischemic findings on electrocardiography and elevated troponin measurements have been used as potential indicators of ischemia or myocardial injury after non-cardiac surgery in the peri-operative setting. In the treatment of ischemic cardiac events, intensified medical therapy (antiplatelet, beta-blocker, ACE inhibitor, or a statin) in patients who suffered from a troponin elevation in the postoperative period reduces the risk of having a major cardiac event within a year. This review contains 1 figure, 2 tables, and 74 references. Keywords: Myocardial Injury after Non Cardiac Surgery (MINS), Perioperative ischemia, Troponin assay, VISION study, Coronary artery disease

Opiate Intoxication Caused by Epidural Infusion of Morphine: A Case Report of a Near Fatal Medication Error

Epidural infusion of local anesthetics with opioids is widely used for pain control during the perioperative-and peripartum-periods. Selection of the opioid, appropriate dosing, and follow-up by the acute pain service are critical in providing safe postoperative epidural analgesia. A 71-year-old man was scheduled for a parastomal hernia repair with midline laparotomy. The parastomal hernia was a complication from a previously performed colectomy for ulcerative colitis. Preoperatively, the patient received a lower thoracic epidural catheter. The epidural infusate (0.2% ropivacaine with 0.5µg/mL sufentanil) was prepared and double-checked by holding area nurses. The fact that the right prescription medication label partially covered a morphine label went unnoticed. The intraoperative phase was characterized by stable parameters. Postoperatively, it was not possible to demonstrate an epidural nerve block. No pain was reported, and the patient could be transferred to the ward. The patient developed coma and delayed respiratory depression after discharge to the surgical ward, requiring intensive care unit admission and naloxone administration. Analysis of the syringe content revealed the presence of morphine (1mg/mL). Color-coded prefilled syringes combined with the use of an epidural specific syringe connector to prevent cross-connections should become standard practice. In addition, delayed respiratory depression should be considered after epidural administration of morphine.

Peri-operative temperature measurement. Guideline or fantasy?

Introduction Perioperative hypothermia is common but associated with adverse outcomes and is defined as patient core temperature below 36.0°C. During the first 30 to 40 minutes of anaesthesia, a patient's temperature can drop to below 35.0°C. National guidelines advise1: • Temperature to be measured and documented in the hour before patient leaves ward • If • Maintain active warming throughout intraoperative phase • Temperature should be 36.0°C before transfer from/to the ward Additionally it is suggested that: - Induction of anaesthesia should not begin unless temperature is 36.0°C - Intravenous fluids (500 ml or more)/blood products should be warmed to 37°C using a fluid warming device - Warm patients intraoperatively from induction of anaesthesia, using a forced-air warming device if they are undergoing anaesthesia for more than 30 minutes, or anaesthesia for less than 30 minutes but are at higher risk of inadvertent perioperative hypothermia. - The patient's temperature should be measured and documented before induction and every 30 minutes until the end of surgery - Temperature should be measured and documented on admission to the recovery room and then every 15 minutes. If the patient's temperature is Methods The electronic charts of 31 patients undergoing routine thoracic surgery of duration over 30 minutes in a dedicated cardiothoracic unit over a two-week period were reviewed. The use of peri-operative temperature measurement was examined. Results 41% of patients had a temperature measured on arrival in the operating department. At 30 minutes into the procedure only 29% had temperature recorded. In the PACU 11 (32%) of patients had temperature measured, and of these only 6 (19%) had an arrival temperate over 36.0oC. Subsequently 1/31 patient had temperature measured every 15 minutes and just 4/31 patients had temperature recorded every 30 minutes. However 42% of patients had temperature recorded at discharge from the PACU. Discussion These data show a small improvement when compared to a previous audit of a similar cohort of patients (38 patients undergoing elective thoracic surgery over 30 minute duration) as shown below: Temperature recorded 2018 2017 Arrival O R 41% 24% 30 min O R 29% 24% Arrival PACU 32% 24% Leave PACU 42% 5% However no single data point exceeded 50% despite efforts to educate operating department staff on the requirement to record temperature and the benefits of actively warming patients.

SecureSurgiNET: A framework for ensuring security in telesurgery

The notion of surgical robotics is actively being extended to enable telesurgery, where both the surgeon and patient are remotely located and connected via a public network, which leads to many security risks. Being a safety-critical application, it is highly important to make telesurgery robust and secure against active and passive attacks. In this article, we propose the first complete framework, called SecureSurgiNET, for ensuring security in telesurgery environments. SecureSurgiNET is primarily based on a set of well-established protocols to provide a fool-proof telesurgical robotic system. For increasing the efficiency of secured telesurgery environments, the idea of a telesurgical authority is introduced that ensures the integrity, identity management, authentication policy implementation, and postoperative data security. An analysis is provided describing the security and throughput of Advanced Encryption Standard during the intraoperative phase of SecureSurgiNET. Moreover, we have tabulated the possible attacks on SecureSurgiNET along with the devised defensive measures. Finally, we also present a time complexity analysis of the SecureSurgiNET through simulations.

Regional Anesthesia: An Overview

Advances in anesthesia techniques and guidance imaging have made regional anesthetics effective both for pain management and as a primary anesthesia modality for patients undergoing operative and other invasive procedures. Patients can receive regional anesthesia in most areas of the body, including the upper and lower extremities and torso. It is critical that perioperative nurses are familiar with regional anesthetic options and understand them well enough to support their patients in the preoperative, intraoperative, and postoperative phases of surgical care. They also should be familiar with the signs and symptoms of local anesthetic systemic toxicity and be prepared to help treat this condition as soon as indicated. Nurses play a pivotal role in ensuring patients are properly educated about regional anesthetics and remain safe throughout all phases of perioperative care.

Enhanced Recovery after Surgery in Breast Reconstruction: A Systematic Review

Enhanced Recovery after Surgery (ERAS) principles have received focused attention in breast reconstruction. Many protocols have been described in the literature for both autologous and alloplastic reconstruction. This systematic review serves to better characterize successful ERAS protocols described in the literature for potential ease of adoption at institutions desiring implementation. A systematic review of ERAS protocols for autologous and alloplastic breast reconstruction was conducted using Medline, the Cochrane Database, and Web of Science. Eleven cohort studies evaluating ERAS protocols for autologous (n = 8) and alloplastic (n = 3) breast reconstruction were included for review. The majority compared with a retrospective cohort of traditional perioperative care. All studies described the full spectrum of implemented ERAS protocols including preoperative, intraoperative, and postoperative phases of care. Most frequently reported significant outcomes were reduced length of stay and opioid use with ERAS implementation. No significant change in major complication or readmission rate was demonstrated. Based on this systematic review, several core elements that make up a successful perioperative enhanced recovery protocol for breast reconstruction have been identified. Elements include patient counseling and education, limited preoperative fasting, appropriate thromboprophylaxis and antibiotic prophylaxis dependent on reconstructive method, preoperative antiemetics, multimodal analgesia and use of local anesthetic, goal-directed intravenous fluid management, prompt removal of drains and catheters, early diet advancement, and encouragement of ambulation postoperatively. Implementation of ERAS protocols in both autologous and alloplastic breast reconstruction can positively enhance patient experience and improve outcomes by reducing length of stay and opioid use, without compromising successful reconstructive outcomes.

Dissecting Cardiac Surgery: A Video-based Recall Protocol to Elucidate Team Cognitive Processes in the Operating Room.

The aim of this study was to elucidate the cognitive processes involved in surgical procedures from the perspective of different team roles (surgeon, anesthesiologist, and perfusionist) and provide a comprehensive compilation of intraoperative cognitive processes. Nontechnical skills play a crucial role in surgical team performance and understanding the cognitive processes underlying the intraoperative phase of surgery is essential to improve patient safety in the operating room (OR). A mixed-methods approach encompassing semistructured interviews with 9 subject-matter experts. A cognitive task analysis was built upon a hierarchical segmentation of coronary artery bypass grafting procedures and a cued-recall protocol using video vignettes was used. A total of 137 unique surgical cognitive processes were identified, including 33 decision points, 23 critical communications, 43 pitfalls, and 38 strategies. Self-report cognitive workload varied substantially, depending on team role and surgical step. A web-based dashboard was developed, providing an integrated visualization of team cognitive processes in the OR that allows readers to intuitively interact with the study findings. This study advances the current body of knowledge by making explicit relevant cognitive processes involved during the intraoperative phase of cardiac surgery from the perspective of multiple OR team members. By displaying the research findings in an interactive dashboard, we provide trainees with new knowledge in an innovative fashion that could be used to enhance learning outcomes. In addition, the approach used in the present study can be used to deeply understand the cognitive factors underlying surgical adverse events and errors in the OR.

Laparoscopy versus laparotomy for surgical treatment of obese women with endometrial cancer: A cost-benefit comparative analysis.

The aim of the present study was to demonstrate the cost of obese patients affected by endometrial cancer undergoing open surgery compared with minimally invasive surgery. In the retrospective cohort study (Canadian Task Force classification II-2), the economic expenditure in pre-operative, intra-operative and post-operative phases of the selected patients was evaluated. Costs were analyzed for all blood tests, instrumental examinations, consultations, operating materials, drugs, gynecological examinations, hospital stay, intensive care hospitalization and management of operative complications. The average length of stay was longer for patients who underwent laparotomy, with an almost double median hospitalization cost in the open abdominal group compared with the laparoscopic group (€4,805.37 vs. €2,589.25; P<0.0001). Evaluation by another specialist (cardiologist, diabetologist, internist) was necessary in 30.9% of laparotomies vs. 10.4% of laparoscopies (P=0.003). A respiratory support was applied to 38 patients (28.8%), of whom 23 (41.8%) were in the open abdominal arm (P=0.011). Antibiotic and pain-relief therapies resulted in a significantly higher cost for the open abdominal than for the minimally-invasive approach (P=0.027). Considering all the pre-, intra- and post-operative course, the expenses for an obese patient operated by laparoscopy was €4,412.41 vs. €7,323.17 by open surgery, with an average saving of €2,911.03 in favor of minimally-invasive surgery. This study revealed that in obese patients with endometrial cancer, minimally invasive surgery is more advantageous both in terms of costs and post-operative complications. To conclude, laparoscopic surgery in obese patients allows an economic saving of ~60% less than open surgery.

Perioperative use of opioids: Current controversies and concerns.

In the midst of an epidemic of opioid abuse and overdose-related morbidity and mortality, the use of opioids remains the most common means of providing analgesia in the perioperative period. In this article, we review the risks and benefits of opioid use in preoperative, intraoperative and post-operative phases of care. Furthermore, we describe the role that surgeons and anaesthesiologists can play in reducing perioperative opioid use and mitigate their adverse effects, from both an individual and a population health perspective.

Improving the rate of surgical normothermia in gynecologic surgery

ObjectiveTo increase the rate of normothermia (core temperature ≥ 36 °C) in patients undergoing gynecologic surgery. MethodsThe rate of surgical normothermia was evaluated in a single institution. A two-phase quality improvement project was undertaken; Phase 1 included the use of intra-operative room temperature regulation and intra-operative patient warming and Phase 2 included pre-operative patient warming. Clinical characteristics, median temperatures, and rate of normothermia were abstracted for patients in each phase. Cohorts were compared using chi-square and t-tests. ResultsThe project was performed in two phases, each with a historic and intervention cohort. There were 503 patients in the historical cohort and 636 patients in the intervention cohort in phase 1; there were 291 patients in the historical cohort and 259 patients in the intervention cohort for Phase 2. Patient characteristics and anesthetic type and duration did not differ between cohorts.After intra-operative temperature regulation and patient warming in Phase 1, significantly more patients achieved normothermia (79% versus 68%, P < 0.0001). However operating room staff were more likely to rate the temperature as very hot in 40% of cases post-intervention, compared to only 2% historically.In Phase 2, after the intervention of pre-warming patients, there was no difference in achieving normothermia, 78% versus 83%, P = 0.09. Staff had no statistical difference in personal comfort with the temperature, however did feel efforts were very effective more frequently, 7.7% historic versus 32.7% post-intervention, P < 0.0001. ConclusionsQuality improvement methodology can be applied to pre- and intra-operative decision making to improve rates of surgical patient normothermia.

AORN Position Statement on Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure

<scp>AORN</scp> Position Statement on Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure

Updates on Evidence-Based Practices to Reduce Preoperative and Intraoperative Contamination of Implants in Spine Surgery: A Narrative Review.

The current communication seeks to provide an updated narrative review on latest methods of reducing implant contaminations used during spine surgery. Recent literature review has shown that both preoperative reprocessing and intraoperative handling of implants seem to contaminate implants. In brief, during preoperative phase, the implants undergo repeated bulk cleaning with dirty instruments from the OR, leading to residue buildup at the interfaces and possibly on the surfaces too. This, due to its concealed nature, remains unnoticed by the SPD (sterile processing department) or other hospital staff. Nevertheless, these can be avoided by using individually prepackaged presterilized implants. In the intraoperative phase, the implants (in the sterile field) are directly touched by the scrub tech with soiled (assisting the surgeon dispose the tissues from the instruments in use) gloves for loading onto an insertion device. It is then kept exposed on the working table (either separately or next to the used instruments as the pedicles hole are being prepared). Latest investigation has shown that by the time it is implanted in the patient, it can harbor up to 10e7 bacterial colony-forming units. The same implants were devoid of such colony-forming units, when sheathed by an impermeable sterile sheath around the sterile implant.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery.

Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Colorectal Surgery

The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery (ISCR), which is a national effort to disseminate best practices in perioperative care to more than 750 hospitals across multiple procedures in the next 5 years. The program will integrate evidence-based processes central to enhanced recovery and prevention of surgical site infection, venous thromboembolic events, catheter-associated urinary tract infections with socioadaptive interventions to improve surgical outcomes, patient experience, and perioperative safety culture. The objectives of this review are to evaluate the evidence supporting anesthesiology components of colorectal (CR) pathways and to develop an evidence-based CR protocol for implementation. Anesthesiology protocol components were identified through review of existing CR enhanced recovery pathways from several professional associations/societies and expert feedback. These guidelines/recommendations were supplemented by evidence made further literature searches. Anesthesiology protocol components were identified spanning the immediate preoperative, intraoperative, and postoperative phases of care. Components included carbohydrate loading, reduced fasting, multimodal preanesthesia medication, antibiotic prophylaxis, blood transfusion, intraoperative fluid management/goal-directed fluid therapy, normothermia, a standardized intraoperative anesthesia pathway, and standard postoperative multimodal analgesic regimens.

Quality Measures in Surgical Palliative Care: Adapting Existing Palliative Care Measures to Improve Care for Seriously Ill Surgical Patients.

Quality Measures in Surgical Palliative Care: Adapting Existing Palliative Care Measures to Improve Care for Seriously Ill Surgical Patients.

Flap warming improves intraoperative indocyanine green angiography (ICGA) assessment of perfusion. An experimental study

Indocyanine green angiography (ICGA) is slowly replacing conventional methods of evaluating perfusion during flap surgery. Microcirculatory changes during flap elevation create a marked state of hypoperfusion intraoperatively leading to ICGA underestimation of tissue viability and consequent resection of viable tissue. We propose a novel method of flap warming to induce maximum vasodilation before performing ICGA to increase accuracy in assessing perfusion. Submental flaps harvested on a single perforator were created in 8 pigs. ICG angiography was performed in the intraoperative phase (ICGA-C), after inducing maximum vasodilatation by warming the flap at 42 °C (ICGA-W) and at 24H postoperative (ICGA-24). By setting a fluorescence threshold of 33% as indicative of necrosis, the flap surface deemed viable by ICGA was measured for ICGAC, ICGAW and ICGA24. The results were then compared to the actual flap survival observed clinically at 7 days. The mean of ICG-C predicted flap survival (FS-C = 49.17%) is 12.97% lower than the mean of actual flap survival on postoperative day 7 (FS=62.14%). The mean difference between ICG-W and ICG-24 predicted flap survival (FS-W and FS-24) and actual flap survival in the postoperative day 7 (FS) is lower, 3.13% and 2.15%, respectively. Average perfusion recovery over 24 h was 10.83% (FS-24-FS-C). Conventional intraoperative ICGA underestimated perfusion in all cases. Warming the flap intraoperatively and achieving maximum vasodilation mitigates the effects of vasoconstriction and mimics the microcirculatory environment encountered at 24 h. Performing angiography after induced vasodilation improves ICGA assessment of flap perfusion.