Operating Theatre Research Articles

MT35 The Economic and Capacity Impact of Time Saved in the Operating Theatre Performing Holmium Laser Enucleation of the Prostate with Moses™ Technology vs Standard Technology

Reducing operating theatre time can help hospitals to optimise operational efficiency and effectively allocate scarce resources. Holmium Laser Enucleation of the Prostate (HOLEP) is an established procedure for the treatment of symptoms secondary to Benign Prostatic Hyperplasia (BPH). It can be performed with Standard Technology (standard HOLEP) or MOSES™ Technology (MOLEP, Boston Scientific Corp). A recent meta-analysis demonstrated significantly reduced operative time with MOLEP vs. standard HOLEP. Our objective is to understand the potential economic impact of reducing theatre time with MOLEP vs. standard HOLEP and potential increases in operational capacity in hospitals in major European DRG-system countries, England, France, Germany and Italy.

Design and development of an electroanalytical enzymatic sensor using anodized laser induced graphene for the management of Hirschsprung Disease

Hirschsprung's disease (HD) is widely characterized by the absence of ganglion cells in the colon of infants and children resulting in a spectrum of diseases starting from constipation to intestinal obstruction. The disease can have a serious manifestation of Hirschsprung-associated enterocolitis which can lead to significant morbidity and even mortality. Presently the treatment includes surgical excision of the pathological segment of the colon. Identification of the segment requires histopathology and immunohistochemistry which is time-consuming and requires significant expertise of a pathologist. There is a gap in the management of the disease in the form of absence of suitable, sensitive, and efficient technologies to detect the pathological segment of the intestine, which could significantly reduce surgery duration in the operation theatre, as well as associated risks to patients. It, therefore, becomes a matter of extreme importance to develop a point-of-care platform for early and efficient identification of the occurrence of HD in neonates and older children during surgery. The present work reports on the development of an electrochemical enzymatic biosensor using anodized laser-induced graphene (aLIG) conjugated with acetylcholinesterase enzyme (AchE), for detection of HD as a function of acetylcholine – the key biomarker. The developed sensor was initially characterized using cyclic voltammetry (CV) and electrochemical impedance spectroscopy (EIS), while the sensor's analytical performance was assessed using CV. The sensor exhibited a limit of detection of 0.26 μM with a shelf life of 1 month, while remaining unperturbed in the presence of common interferants. The performance of the developed sensor was also examined in spiked serum samples and was observed to yield a high degree of linearity. • First report on the design and development of electroanalytical biosensor for detection/management of Hirschsprung disease. • Anodized laser induced graphene conjugated with acetylcholinesterase (aLIG/AchE) as a robust platform for detecting acetylcholine – the key biomarker. • High degree of linearity with enhanced limit of detection of acetylcholine in spiked serum. • Simple, cost-effective development of highly selective and stable sensor. • Exhibiting huge potential for deployment in intra-operative scenario for identifying pathological segment of the colon.

Controversies in the management of proximal deep vein thrombosis.

Controversies in the management of proximal deep vein thrombosis.

Effect of Modified Ultrafiltration (MUF) on Lactate Levels in Pediatric Patients Undergoing Cardiac Surgery

Objective: To determine the effect of MUF on pre and post MUF lactate levels.
 Study Design: Analytical Cross-sectional study.
 Place and Duration of Study: Pediatric Operation Theater at Armed Forces Institute of Cardiology/National Institute of Heart Disease, Rawalpindi Pakistan from Oct 2021 to Dec 2021.
 Methodology: It was descriptive cross-sectional study and non-probability consecutive sampling technique was used. Data was collected during Oct 2021 to Dec 2021, from Tertiary Care Hospital, Rawalpindi Pakistan. Current study was conducted in pediatric OT at Armed Forces Institute of Cardiology/National Institute of Heart Disease. MUF technique was applied to 115 pediatric patients during congenital cardiac surgeries. Pre and post MUF lactate levels were noted. Inferential statistics were applied with the help of test of significance (Paired T-Test), p value ≤ 0.05 was considered statistically significant at 95% Confidence Interval (CI) with margin of error 5%. Collected data was analyzed by IBM SPSS version 25.
 Result: Significant decrease in post MUF lactate level (p<0.05) was observed. This result revealed that MUF had significant effect on lactate levels. Out of 115 study participants, 46(40%) were female and 69(60%) were male patients having mean age 3.44±2.25 years, mean height 95.60±18.78cm, mean weight 15.06±5.18kg, mean body surface area 0.63±0.17 m2 CPB time 127.95±36.78 minutes and cross clamp time 92.60±40.49 minutes. Paired t-test was applied to check the mean difference between pre and post lactate levels and it revealed statistically significant findings (p-value < 0.05).
 Conclusion: Current result revealed that use of MUF caused decrease in lactate levels. MUF technique showed beneficial effects in maintaining normal physiology of the body. Current results encouraged the use of MUF technique in every cardiac surgery.

Frequency of Respiratory Complications in Post COVID-19 Patients After Coronary Artery Bypass Grafting

Objective: To determine the frequency of post-operative pulmonary complications after (coronary artery bypass grafting)CABG surgery and to compare the respiratory complications of post COVID and comparison group 
 Study Design: Analytical Cross- sectional study
 Study Place and Duration: Study was conducted in Adult Intensive Care Unit, Armed Forces Institute of Cardiology,Rawalpindi Pakistan, from Sep 2021 to Mar 2022.
 Methodology: 40 patients were selected, and divided into two groups using Non-Probability consecutive sampling. Group-A had history of COVID-19 infection and Group-B was a comparison group and had no history of COVID-19 infection. Patients presenting for elective On-Pump (coronary artery bypass grafting) CABG surgery and known history of COVID-19 were included in our study. Patients of age ranging 30 to 70 years irrespective of gender were included in the study. Any patient who had cardiopulmonary bypass time of more than 120 min, respiratory illness like asthma or Chronic Obstructive Pulmonary Disease (COPD), history of smoking, or requiring post-operative re-ventilation due to cardiac or neurological complication, were excluded from the study. After patients were received from Operation theatre, they were monitored for the respiratory complications and both groups were compared. 
 Results: A total of 40 patients were included in this study having mean age 57.9±7.62 years. Most of the patient population was male 31(77.5%) and only 09(22.5%) were female patients. Study population was equally divided into two groups i.e.20(50%) in comparison group and 20(50%) in post COVID-19 group. There was no significant difference in age (p=0.714), ventilation time (p=0.068), gender (p=1.000), and re-ventilation (p=0.451) of both groups. While Intensive Care Unit stay(p=<0.0001) and non-invasive ventilation (NIV) were found to be significant (p=0.007).

Frequency of Delirium Associated with Dexmedetomidine and Propofol in Post CABG Patients: A Comparative Study

Objective: To find out the frequency of delirium associated with peri-operative use of dexmetedomidine and propofol in post CABG patients.
 Study Design: Comparative Cross-sectional study.
 Place and Duration of Study: Adult Intensive Care unit, Department of Cardiac Anesthesiology and Intensive Care, Armed Force Institute of Cardiology, Rawalpindi Pakistan from Feb to Jun 2022.
 Methodology: All post CABG patients who have undergone elective surgery were included through non-probability consecutive sampling technique. All the delirious patients amongst them were subjected to a modified version of ICU-CAM to establish post-operative delirium (POD) caused by either dexmedetomidine or propofol. POD in both the category of patients was compared.
 Results: A total of 179 CABG patients were included in our study. 140(78.2%) of the patients were subjected to the use of dexmedetomidine throughout their surgery while 39(21.8%) of the patients were given propofol. After subjecting the patients to our exclusion criteria which aimed to eliminate the confounding causes of POD in post-CABG patients, only 30(16.8%) had delirium while 149(83.2%) didn’t develop delirium (p-value=0.003). Majority of the delirious patients were given dexmedetomidine (n=29; 20.77%) in the operation theatre while only a fraction (n=1; 2.58%) were given propofol. Average duration of ICU stay in our study population was 5 days. 15(8.4%) cases out of our total study population underwent reintubation and re-ventilation because of low cardiac output or respiratory distress.
 Conclusion: Dexmedetomidine could possibly be associated with POD in patients undergoing cardiac surgery. Propofol on the other hand is considerably safe in this regard and doesn’t cause POD.

Initial experiences of cataract & lens surgery in 1269 patients in outpatient clean rooms using a portable laminar air flow device.

In 2020, routine cataract surgery was halted in most countries due to the COVID-19 pandemic in order to reduce transmission. With a consequent lack of theatre space, we developed a safe cataract pathway in outpatient department clean rooms to minimize patient exposure and time spent in hospital using a sterile laminar air flow device. We describe our initial experiences of restarting elective cataract surgery in the UK outpatient setting, outside of the operating theatre environment. This was a prospective consecutive study of our clinical practice. A sterile air zone unit, the Toul Meditech Operio Mobile device, was used to create a sterile surgical site in three separate outpatient clean rooms from May 2020 to December 2021 in different geographical locations within Herefordshire, UK. Observations of the time spent in the department and a formal patient satisfaction survey were carried out for the initial 100 patients. All patients were followed up to assess development of post-operative complications. 1269 patients were included in the study. No patients sustained post-operative infection (n = 0/1269, 0%). For the initial 100 patients, the average time spent within the department was 74.3 min (unilateral cases, range 45-115 min) and 93.1 min (bilateral, 55-135 min). Patient satisfaction was high. Initial results demonstrate a safe, efficient and effective cataract surgery pathway with high patient satisfaction by converting outpatient clean rooms into ophthalmic operating theatres using the Toul Meditech Operio Mobile.

Minimizing patients total clinical condition deterioration in operating theatre departments

The operating theatre is the most crucial and costly department in a hospital due to its expensive resources and high patient admission rate. Efficiently allocating operating theatre resources to patients provides hospital management with better utilization and patient flow. In this paper, we tackle both tactical and operational planning over short-term to medium-term horizons. The main goal is to determine an allocation of blocks of time on each day to surgical specialties while also assigning each patient a day and an operating room for surgery. To create a balance between improving patients welfare and satisfying the expectations of hospital administrators, we propose six novel deterioration rates to evaluate patients total clinical condition deterioration. Each deterioration rate is defined as a function of the clinical priorities of patients, their waiting times, and their due dates. To optimize the objective functions, we present mixed integer programming (MIP) models and two dynamic programming based heuristics. Computational experiments have been conducted on a novel well-designed and carefully chosen benchmark dataset, which simulates realistic-sized instances. The results demonstrate the capability of the MIP models in finding excellent solutions (maximum average gap of 4.71% across all instances and objective functions), though, requiring large run-times. The heuristic algorithms provide a time-efficient alternative, where high quality solutions can be found in under a minute. We also analyse each objective function’s ability in generating high quality solutions from different perspectives such as patients waiting times, the number of scheduled patients, and operating rooms utilization rates. We provide managerial insights to the decision makers in cases where their intention is to meet KPIs and/or maintaining trade-offs between patients and administrators expectations, more fair assignments, or ensuring that the most urgent patients are taken care of first.

Impact of COVID-19 pandemic in management of Surgical patients during Nationwide COVID-19 Lockdown in a Military hospital

Introduction: The COVID-19 pandemic has had a major impact on healthcare in many countries. This study assessed the effect of a nationwide lockdown during the second wave of COVID-19 on surgical management for acute surgical conditions and the subsequent impact on postoperative mortality. Methods: This was a retrospective study, evaluating data from the hospital discharge database during the second wave of COVID -19 pandemic. All adult patients admitted through the emergency and outpatient department requiring surgical treatment between April 29 and June 29, 2021 were included in the study. The primary outcome was the change in number of hospital admissions for acute surgical conditions. Mortality was assessed among the patients with COVID-19 infected cases. Results: During the second wave of nationwide COVID-19 lockdown period, a total of 329 patients were provided surgical consultation either in emergency or outpatient basis. Among them, 227 cases required surgery. Out of this 122(53.74%) required minor surgeries and were performed in minor operation theatre in local anesthesia (LA) while 105(46.2%) underwent major surgical procedures. Of all the patients who underwent major surgical procedures 76(72.3%) were surgical emergencies, 15(14.2%) were GI and breast malignancies while 14(13.3 %) were elective cases. The mortality rate due to COVID-19 in surgical patients was 02(16.66 %) during the lockdown period. Conclusion: A decrease in hospital admissions for elective surgical cases with prioritization to emergency and malignant cases was observed during the lockdown period.

From virtual reality to first cataract surgery; trainee perspective from a developing country

Cataract surgery is one of the most performed procedure worldwide with a fascinating evolution in the use of technology [1]. EyeSi is a high-fidelity, task-oriented, virtual reality, intraocular surgery simulator widely adopted by residency programs across the developed world for skill development in cataract surgery, with proven effectiveness and decrease in complication rates [2]. We aim to provide a trainee’s reflective perspective on learning cataract surgery via virtual reality simulation and performing first real surgery from a low middle-income, developing country [3]. Simulation training as part of formal residency curriculum was documented, hence ethical approval was exempted. EyeSi course software (V3.0.6) was used for skill development as a self-learning tool, reinforced with real cataract surgery training, documented over a period of 8 months for a single participant. EyeSi provides a binocular microscopic viewing system, with hand-piece instruments and foot pedals of the same configuration as used in operating theatres. The software generates feedback reports for each task using microscopic calibrations inside the model eye. By the end of the 8-month period, simulation data showed a logged time of 45.7 hours, 74 intraocular lenses injected, 1,581 intraocular tasks completed and 772 capsulorhexis done with complications including 679mm2 of injured corneal area, 113 mm2 of injured lens area and 862 posterior capsule ruptures. In comparison, the real surgery logbook noted 30 intraocular lenses injected, 86 intraocular tasks and 31 capsulorhexis complete with a total of 1 complication and 1 complete cataract case performed. Subjective comparison reported increased confidence, lower stress levels, good preparation of left-hand skills, and passive learning of surgical theory and technicalities ( Comparison of virtual reality and real surgery experience Despite challenges of affordability and traditional surgical culture in a low middle-income country, simulation training provides safe learning alternatives to trainees which are effective and should be widely adopted. Although the learning curve is slightly longer, but skills acquired are replicable in operation theatre and significantly reduce the complication rate in the interest of patient safety. 1. Davis G. The Evolution of Cataract Surgery. Missouri Medicine. 2016;113(1):58. 2. Ahmed TM, Hussain B, Siddiqui MR. Can simulators be applied to improve cataract surgery training: a systematic review. BMJ Open Ophthalmology. 2020;5(1):e000488. 3. Aga Khan University. Simulation success story: Eye surgery.

Comparative efficacy of three different doses of intranasal dexmedetomidine for premedication in children

Preoperative emotional distress in children should be addressed properly for better anesthetic experience. The present study was a Prospective randomized double-blind study to evaluate comparative efficacy of three different doses of intranasal dexmedetomidine for premedication in children. Sixty children were then randomly allocated to one of the three groups of 20 each by a computer generated table. The drug was administered 45 minutes prior to induction of anesthesia intra-nasally. Following intra-nasal drug administration, anxiety was assessed at 0 minutes -baseline, 30 minutes, 45 minutes and at parental separation in the preoperative area just before shifting in operation theater using the mYPAS (modified Yale Preoperative Anxiety Scale). At induction, induction compliance was assessed using the induction compliance checklist and heamodynamic response to definitive airway was assessed.It was observed that intranasal dexmedetomidine in lower doses of 0.5 and 1µg/kg was effective in reducing anxiety from baseline values but was not sufficient for providing anxiolysis at the most stressful time - at parental separation and shifting to OR (Operating room). The dosage of 1.5µg/kg was found to be the most effective dose for allaying preoperative anxiety without any adverse effect. However, this dose was insufficient for optimizing induction as it is mainly anxiolytic and higher doses having additional sedative action may be required to make the child more compliant for induction of anesthesia.Based on our findings, we recommend that intranasal dexmedetomidine in the dose of 1.5µg/kg can be used for allaying preoperative anxiety, without any adverse events.• Question: To evaluate and compare the efficacy of three different doses of intranasal dexmedetomidine for premedication in children for preoperative anxiety using the mYPAS scale. • Findings: Dose of 1.5µg/kg can be used for allaying preoperative anxiety, without any adverse events. • Meaning: Optimum dose of intranasal dexmeditomedine which is efficient to allay preoperative anxiety in children.

Frequency and risk factors of musculoskeletal disorders in high risk occupation workers in Urban, Karachi

Objective: To determine the frequency and risk factors of musculoskeletal disorders in high-risk occupation workers in an urban setting. Method: The analytical cross-sectional study was conducted in Karachi from July to December 2020, and comprised office workers, operation theatre technicians and coolies. The presence of musculoskeletal disorders was assessed using the Nordic Musculoskeletal Questionnaire to determine factors associated with moderate to severe condition. Data was analysed using SPSS 20. Results: Of the 300 male subjects, 100(33.3%) each were office workers, operation theatre technicians and coolies. The overall mean age was 33.25±6.8 years (range: 18-50 years). The overall prevalence of musculoskeletal disorders was 179(59.7%). Besides, 117(65.4%) patients with musculoskeletal disorders had intermediate stage of the disease. The lower back and neck were the most common site of trouble involved in preceding 12 months 111(43.6%) each. Conclusion: Prevalence of musculoskeletal disorders was found to be a common problem affecting high-risk occupational workers. Key Words: High-risk occupations, Musculoskeletal disorders.

Fetomaternal outcomes of emergency obstetric hysterectomy in a tertiary care teaching hospital in eastern India: A prospective study

To evaluate frequency, indications, demographic characters and the fetomaternal outcomes of emergency obstetric hysterectomy in a tertiary care teaching hospital in Eastern India. Prospective, unicentric study. Records of all cases undergoing emergency obstetric hysterectomy in the emergency operation theatre of department of obstetrics and gynecology during the study period were analyzed as per required variables and data was processed to evaluate the results.: A total 22 obstetric hysterectomies were carried out during the study period, 7 (31.81%) cases following vaginal delivery and 15 (68.18%) cases during or following caesaren section. The incidence of obstetric hysterectomy was 0.63 per thousand deliveries. The mean age of the subjects was 26.81 ± 1.11 years. Placenta accreta spectrum was the most frequent indication for obstetric hysterectomy (36.36%). Hypotension requiring the use of vasopressors (77.27%) was the commonest complication faced by the subjects. Mortality rate amongst the subjects was 9.09%. Fetal outcomes were varied. 68.18% of the newborns were healthy. The mortality rate among the newborns was 9.09%.

The Effect of Laryngoscope Types on Hemodynamic Response and Intracranial Pressure by ONSD Measurement in Neurosurgery at Sanglah General Hospital: A Case Series

Object: Endotracheal intubation is the gold standard for ensuring a safe airway when applying general anesthesia. Endotracheal intubation can cause an increase in intracranial pressure (ICP). Ultrasound measurement of optic nerve sheath diameter (ONSD) is known as an accurate monitor of increased intracranial pressure. However, it is not known how the ICP fluctuations are caused by endotracheal intubation using various types of laryngoscopy. Therefore, the authors investigated the hemodynamic changes and intracranial pressure caused by the two types of laryngoscope used for endotracheal intubation in neurosurgical patients undergoing general anesthesia. Cases: The authors report 4 patients as a case series from the Central Operating Theatre (COT) of Sanglah General Hospital, Denpasar, Bali. We were performed optical nerve sheath diameter (ONSD) measurements on both eyeballs of those patients. All of the patients were performed general anaesthesia with endotracheal intubation. Correlation between ONSD and ICP measurements was determined, and changes were seen based on baseline data obtained from before intubation to 10 minutes after intubation. Sheath diameter more than 5.5 mm had a higher ICP value predicate than 15 mmHg with 100% sensitivity (95% CI, 100-100) and 100% specificity (95% CI, 100-100). Discussion: Our case series demonstrated a change in ICP in each patient endotracheal intubation with a McGrath video laryngoscope and a Macintosh laryngoscope, then the authors examined the optic nerve sheath by performing ultrasonography after induction before intubation (T0), 1 minute (T1), 3 minutes (T3), 5 minutes (T5) and 10 minutes after intubation (T10), which is known to increase ICP. In all patients ICP increased above normal values in baseline. There was a difference in diameter between the right and left eyes according to the location of each tumor. During tracheal manipulation, at first minute there was an increase in diameter in both eyes with ONSD increasing > 0,5 mm from the baseline value, and starting to decrease at 3, 5 minutes, and approaching or equal to the baseline value at 10 minutes. Conclusion: In neurosurgical patients undergoing general anesthesia with endotracheal intubation, laryngoscopy is unavoidable, the use of the type of laryngoscope should be carefully considered in order to select and use a better type of laryngoscope to prevent hemodynamic shock. Hemodynamic monitoring with patient monitors and ONSD ultrasonography is an accurate, simple, and rapid measure to detect ICP elevations and ICP changes in real time. Therefore, ONSD could be a useful tool for monitoring ICP, especially in conditions where invasive ICP monitoring is not available. Keywords: laryngoscope, hemodinamik, intracranial, ONSD, neurosurgery

Healthcare resource use and costs related to surgical infections of tibial fractures in a Spanish cohort

Surgical site infection constitutes a serious complication in the healing process of bone fractures and has been associated with increases in medical resource use and healthcare costs. This study evaluates the economic impact of surgical site infection in tibial fractures in a Spanish cohort. It is a retrospective, single-centre, comparative cohort study of patients with tibial fractures with longitudinal follow-up for up to 18 months post-surgery. Included patients (n = 325) were adults, with tibial fracture, either isolated or polyfracture, or polytrauma with an Injury Severity Score >15. Patients had been surgically treated within 30 days of the tibial fracture by external or internal fixation, or external followed by internal fixation. Most patients (84.9%) had an American Society of Anaesthesiology score of 1-2. 20% of the patients had one open tibial fracture, 12.3% had polytrauma, and 20% had multiple fractures. Most patients were treated with a nail (41.8%) or a plate (33.8%). 56 patients (17.2%) developed surgical site infection. Patients with infection had significantly higher hospital length of stay (34.9 vs 12.0 days; p<0.001; +191%), readmissions (1.21 vs 0.25; p<0.001; +380%) and mean operating theatre time (499 vs 219 min; p<0.001; +128%) than patients without infection. Mean length of stay in intensive care did not significantly increase with infection (2.8 vs 1.7 days; p = 0.25). Total in-hospital costs for patients with infection increased from €7,607 to €17,538 (p<0.001; +131%). Overall, infections were associated with significantly increased healthcare resource use and costs. Preventive strategies to avoid infections could lead to substantial cost savings.

Challenges of Anesthetic Monitoring in Low- and Middle-Income Countries: Availability of Equipment in Major Referral Hospitals in Kenya.

Anesthetic monitoring within standards defined by various professional anesthesia organizations has been shown to reduce perioperative mortality. Given the scarce resources for anesthesia and surgery in low- to middle-income countries, we sought to determine the availability of recommended monitoring devices in major referral hospitals in Kenya. We purposely selected the 16 major referral hospitals in Kenya. A cross-sectional survey was conducted in 103 operating theaters, 96 postanesthesia care unit (PACU) beds, and 16 areas where procedural sedation was routinely administered. A checklist questionnaire based on the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines of 2015 was used to determine the availability of basic and functional monitoring devices. We determined that only 1 of 16 (6.25%) hospitals had all the monitoring devices recommended by the AAGBI. Automated noninvasive blood pressure (NIBP) monitoring and pulse oximetry were present in all operating theaters. Continuous electrocardiography (ECG) was available in 102 of 103 (99%) operating theaters, skin temperature monitoring probes in 73 of 103 (70.9%), and capnography in 49 (47.6%). A nerve stimulator was accessible in 5 of 16 (31.25%) hospitals. There were functional patient monitors in all operating theaters (100%). One of the regional referral hospitals did not have a PACU. We encountered 9 of 96 (9.4%) PACU beds without any monitoring devices. Pulse oximetry was the most common device (84.4%) in the PACU beds equipped with monitoring. In 5 of 16 (31.25%) procedural sedation areas, pulse oximetry was the only monitoring device, whereas there were no devices in 2 of 16 (12.5%) areas. Portable multiparameter devices used for patient transport were present in 5 of 16 (31.25%) hospitals. The availability of recommended monitoring devices in major referral hospitals in Kenya is inadequate. Thus, there are challenges to anesthetic monitoring in these hospitals, and perioperative patient safety is jeopardized. We recommend the universal provision of basic monitoring devices and suggest the use of the data collected in this study to affect policy change and safe anesthesia practice in our country.

A survey on the availability, usage and perception of neuromuscular monitors in Europe.

Neuromuscular blocking agents (NMBAs) are routinely administered to patients in a multiplicity of anesthetic settings. Absence of postoperative residual neuromuscular block is widely considered an anesthetic patient safety mandate. Despite the increasing availability of a wider range of commercial quantitative neuromuscular monitors, the availability and use of neuromuscular monitoring devices is deemed to be suboptimal even in countries with above-average health system ratings. The present study aims to more precisely characterize the perceived availability, cost sensitivity and usability of neuromuscular monitoring devices within European anesthesia departments. A pre-registered internet-based survey assessing the availability, cost sensitivity and usability of neuromuscular monitoring devices was distributed as e-mail newsletter by the European Society of Anaesthesiology and Intensive Care (ESAIC) to all of its active full members. The survey was available online for a total of 120 days. Having targeted a total of 7472 ESAIC members, the survey was completed by a total of 692 anesthesiologists (9.3%) distributed across 37 different European countries. Quantitative monitors were reported to be proportionally more available than qualitative ones (87.6% vs. 62.6%, respectively), as well as in greater monitor-per-operating room ratios. Most anesthesiologists (60.5%) expressed moderate confidence in quantitative monitors, with artifactual recordings and inaccurate measurements being the most frequently encountered issues (25.9%). The commercial pricing of quantitative devices was considered more representative of a device's true value, when compared to qualitative instruments (average cost of €4.500 and €1.000 per device, respectively). The availability of quantitative NMM in European operating theaters has increased in comparison with that reported in previous decades, potentially indicating increasing monitoring rates. European anesthesiologists express moderate confidence in quantitative neuromuscular monitors, along with a sentiment of adequate pricing when compared to their qualitative counterparts. Trust in quantitative monitors is marked by caution and awareness for artifactual recordings, with a consequent expectation that developments focusing on accuracy, reliability and ergonomics of neuromuscular monitors be prioritized.

A Rare Occurrence of Bilateral Lefort III with a known case of Myocardial Infarction

Background: Patients with LeFort III fractures are at an elevated risk of needing emergency airway management because of midface instability and oropharyngeal airway obstruction. Lefort fracture includes fracture of the nasofrontal junction, bilateral area of the frontozygomatic suture, and probable fracture of the zygomatic arch. This fracture is also referred to as cranial facial disjunction. The Novel treatment for bilateral Lefort III is surgical management and medical management. It may be present in anyone who meets with an accident. Here we present the case of a 41-year adult man who came to the emergency department with complaints of head injury, absence of consciousness, nasal bleed drop by drop, swelling in the face, tooth avulsion, and prickling sensation over the lower right side of the face. The patient was kept in emergency ICU for observation and monitoring for one day, then referred to neurosurgery ICU where he was administered intravenous pan 40mg, Inj emset 2ml, Inj pause 1gm, Inj levopril 1gm, Inj ceftriaxone 1gm, Inj optineurin with 500ml ns, Tab zeredol 20 mg, Tab limce 500mg. The Patient was taken to the ophthalmology operation theater for suturing. Open reduction and internal fixation this surgical procedure is done on my patient. The patient's prognosis was good.

PREOPERATIVE FASTING AMOUNTING TO DEHYDRATION IN PEDIATRICS AGE GROUP- AN OBSERVATIONAL STUDY

Introduction: Pre-preoperative fasting, a universally practiced principle in elective cases helps to reduce the risk of pulmonary aspiration of gastric contents. Prolonged fasting for 8-10 hours has been practiced at various places to avoid complications like Mendelson's Syndrome and Aspiration Pneumonia. However, prolonged fasting may be an unpleasant experience causing distress, irritability, dehydration and hypoglycemia especially in pediatric patients. Studies have reported many children end up fasting for up to 12 or 15 hours inspite of recommended 6-4-2 guidelines, leading to side-effects like, hypoglycemia, metabolic acidosis, dehydration.In this study, we tried to acertain the dehydration status due to various reasons and also suggested a solution for the same. To assess the Aims dehydration status of pediatric patient based on clinical dehydration scale. (1) T Objectives: o asses the complaints of paient suggesting dehydration on well designed proforma.(2) To asses amount of dehydartion according to dryness of mucous membranes by using nger print impression This randomised trial was conducted on 100 NBM paediatric patients Materials And Methods: in age group of 0-14 yrs at Dr. D.Y.Patil Medical College ,Pune. Time at which the patient was wheeled into operation theater, duration of preoperative fasting was noted ,calculated, analyzed and compared. The tongue was assessed to nd the degree of hydration with help of nger impression from moist tongue on parchment paper and scoring was given as follows: Scoring:5- almost full nger impression,3- half nger impression and 1-No nger impression. The nger impression test was, No impression (score=1) in 40 patient Result: s, half nger impression (score=3) in 37 patients and almost full nger impression (score =5) in 23 patients. Fasting time for pe Conclusion: diatric patients in our study were typically far longer than current guidelines. This can be attributed to surgery timings of previous patients inside the theatre leading to prolonged fasting time.

Laparoscopic Management of a Juvenile Cystic Adenomyoma

<h3>Study Objective</h3> To demonstrate how to diagnose and surgically manage an adenomyotic cyst by a robotic assisted laparoscopic approach. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> Operating theatre. <h3>Patients or Participants</h3> A 17-year-old patient with acute pelvic pain in the setting of chronic dysmenorrhea associated with a 4 cm cystic lesion in the endometrium on MRI consistent with a juvenile cystic adenomyoma. After no improvement with hormonal management, the patient opted for laparoscopic exploration and removal. <h3>Interventions</h3> MRI imaging was used to identify the adenomyotic cyst. Upon laparoscopy, the surgical site was injected with vasopressin for hemostasis. Sharp and blunt dissection was used to minimize trauma and thermal injury to the surrounding myometrium. Chromopertubation was used verify no cavity entry after removal. Lastly, the myometrium was closed in multiple layers to prevent hematoma formation. <h3>Measurements and Main Results</h3> Successful outpatient procedure with improved pain post-operatively. <h3>Conclusion</h3> This video shows techniques to identify and perform a minimally invasive fertility preserving resection of a juvenile cystic adenomyoma.