Patient Repositioning Research Articles

809 Culture Change in the Burn Unit: A Comprehensive Pressure Injury Reduction Strategy

Abstract Introduction In our regional burn center, which treats approximately 800 patients annually, the prevention of pressure injuries continues to challenge the burn team. The nursing team, in particular, was demoralized by a steady prevalence rate despite utilizing evidence based practice. A comprehensive pressure injury reduction plan was developed to provide new strategies to prevent pressure injuries and to provide real time data about the effectiveness of nursing interventions. Methods A team of physicians, nurses, nutritionists, pharmacists, physical and occupational therapists developed a plan to encourage all members of the team to become active participants in pressure injury prevention. The first method was the introduction of a weekly pressure injury survey for all burn patients. This survey ensures any emerging pressure injury is recorded and appropriate interventions taken. Secondly, a new pressure mapping device was installed in all ICU beds in the burn center. The pressure mapping device provides data to nurses during patient repositioning. This important data demonstrated to nurses, in real time, if their offloading was effective. Lastly, a weekly pressure injury analysis provided root cause analysis of any pressure injuries discovered in weekly surveys. As a result, nurses were provided real time feedback about the effectiveness of prevention techniques. Results Reporting of pressure injuries increased over 50% in the first year of the program. In addition, since the inception of the weekly prevalence surveys, the burn center has not not had a pressure injury progress past a stage two. The overall prevalence of pressure injuries has dropped each quarter, Conclusions Providing nurses with real time feedback in the form of real time full body pressure mapping, weekly prevalence and pressure injury analysis allows nurses to quickly change prevention techniques to better offload patients. While pressure injury rates have decreased, nurse involvement in pressure injury prevention has increased. Applicability of Research to Practice Pressure injuries continue to pose a significant challenge to burn patients. Given the continuing emergence of pressure injuries, nurses in our burn center were left demoralized and dissatisfied with their evidence based practice. Providing nurses with real time data to support the effectiveness of their prevention techniques has dramatically changed the culture in our burn center. Nurses are now able to view real time data about their practice through pressure mapping, weekly surveys and pressure injury cause analysis. As a result, nurses are more engaged in the important work of pressure injury prevention.

Anterior lumbar interbody fusion in a lateral decubitus position: technique and outcomes in obese patients.

Multilevel lumbar interbody fusion (LIF) surgery in obese patients is problematic, with positioning and anaesthetic risks during posterior approaches, vascular and visceral complications during anterior approaches, and lack of access to L5/S1 during lateral approaches. Modified anterior LIF (ALIF) via an anterolateral retroperitoneal approach in the lateral decubitus position permits access to L3/4, L4/5, and L5/S1 levels without patient repositioning. This study reports our initial experience with this lateral ALIF in obese patients and describes modifications of existing lateral and anterior techniques. We retrospectively analysed a prospectively maintained registry including the first 30 consecutive patients who underwent lateral ALIF. In all patients, supine ALIF was relatively contraindicated because of obesity or previous abdominal surgery. All patients had a body mass index (BMI) ≥30 kg/m2. Fusion was assessed by high-definition computed tomography. Patient-reported outcomes included visual analogue scale pain scores, Oswestry Disability Index (ODI), and 36-Item Short-Form Survey (SF-36) physical and mental component scores (PCS and MCS). All patients underwent ≥2 years follow-up. At last follow-up (mean, 35.0 months) mean back pain improved 64%, leg pain improved 67%, ODI improved 54%, and PCS and MCS both improved 37% (P<0.05 versus preoperative for all). Mean BMI was unchanged postoperatively (P=0.83). Complications occurred in 7 (23%) patients: dysesthesia [2], retroperitoneal hematoma [2], radiculopathy [1], and subsidence [2]. Solid interbody fusion occurred in 19 (63%) patients at 12 months postoperatively and in 26 (87%) patients at 24 months. Lateral ALIF enables L5/S1 anterior fusion in obese patients and permits multilevel fusion using a single position. Satisfactory clinical outcomes and complication rates are achieved despite unchanged BMI and 87% radiological fusion rates. Lateral ALIF appears to be a reasonable alternative to posterior, lateral, and supine-position anterior approaches for L3/4, L4/5, and L5/S1 interbody fusions.

Inferior Maxillary Repositioning Remains Stable 1 Year After Surgery but Entails a High Risk of Osteosynthesis Failure

Inferior maxillary repositioning has continued to be among the most unstable orthognathic procedures. The overall purpose of the present study was to measure skeletal stability after inferior maxillary repositioning. We implemented a retrospective cohort study. The study cohort was derived from all orthognathic patients who had undergone treatment from January 2011 to December 2013 in Odense University Hospital. The inclusion criteria were orthognathic surgery with inferior maxillary repositioning in patients without maxillary segmentation or cleft lip/palate. The exclusion criteria were nonattendance at follow-up visits or requiring reoperation before the 1-year follow-up point. The primary predictor variable was the time from the 1-week follow-up examinationto the 1-year follow-up examination. The primary outcome variable was maxillary skeletal movement. The other variables of interest were age, gender, preoperative occlusal relationship, maxillary movement obtained, and surgery type (mono- or bimaxillary procedure). Skeletal stability was measured at the centroid, anterior, and posterior nasal spines using the semiautomatic measurement technique. Skeletal stability was clinically defined as less than 2mm of movement in any direction. The positive directions for the 3 axes were right, anterior, and superior. The data were analyzed using mixed model linear regression analysis and 1-sample t tests. A total of 17 patients were included in the present study (mean age, 28years; female gender, 35%; bimaxillary surgery, 59%). Inferior maxillary repositioning was stable with less than 0.3mm mean skeletal movement in any direction. Only 1 patient had experienced a relapse of more than 1mm in the posterior direction; no movement exceeded 2mm. However, 3 patients were excluded from the present analysis, because they had required reoperation during the first year after surgery for osteosynthesis failure. Inferior maxillary repositioning was stable during the first year after surgery; however, the complication rate was high (15%). Thus, this procedure might still benefit from the use of more rigid patient-specific printed plates to increase postoperative stability.

Hemşirelik Girişimleri İkincil Beyin Hasarına Neden Olabilir mi?

As a result of increase in intracranial pressure, decrease in cerebral perfusion pressure, hypotension and decrease in cerebral blood flow secondary brain insult may occur. The main focus of treatment and nursing care in neurosurgical patients is to prevent intracranial pressure increase. But some nursing interventions can also cause secondary brain damage. Routine nursing interventions such as endotracheal suction, oral care, body bath, rotationing and repositioning of patients and clusteringof nursing interventions may cause secondary brain insult by increasing cerebral metabolism rate, decreasing cerebral perfusion pressure and affecting cerebral blood flow. This systematic review aims to provide guidance to nurses about the prevention of secondary brain insult by reviewing the nursing interventions that may cause secondary brain insult in neurosurgical patients in the light of current literature

Kinesthetic Imagery and Visual Observation Improve Lumbar Repositioning in Patients with Low Back Pain

Kinesthetic Imagery and Visual Observation Improve Lumbar Repositioning in Patients with Low Back Pain

SMART (SiMulAtion and ReconsTruction) PET: an efficient PET simulation-reconstruction tool

BackgroundPositron-emission tomography (PET) simulators are frequently used for development and performance evaluation of segmentation methods or quantitative uptake metrics. To date, most PET simulation tools are based on Monte Carlo simulations, which are computationally demanding. Other analytical simulation tools lack the implementation of time of flight (TOF) or resolution modelling (RM). In this study, a fast and easy-to-use PET simulation-reconstruction package, SiMulAtion and ReconsTruction (SMART)-PET, is developed and validated, which includes both TOF and RM. SMART-PET, its documentation and instructions to calibrate the tool to a specific PET/CT system are available on Zenodo.SMART-PET allows the fast generation of 3D PET images. As input, it requires one image representing the activity distribution and one representing the corresponding CT image/attenuation map. It allows the user to adjust different parameters, such as reconstruction settings (TOF/RM), noise level or scan duration. Furthermore, a random spatial shift can be included, representing patient repositioning. To evaluate the tool, simulated images were compared with real scan data of the NEMA NU 2 image quality phantom. The scan was acquired as a 60-min list-mode scan and reconstructed with and without TOF and/or RM. For every reconstruction setting, ten statistically equivalent images, representing 30, 60, 120 and 300 s scan duration, were generated. Simulated and real-scan data were compared regarding coefficient of variation in the phantom background and activity recovery coefficients (RCs) of the spheres. Furthermore, standard deviation images of each of the ten statistically equivalent images were compared.ResultsSMART-PET produces images comparable to actual phantom data. The image characteristics of simulated and real PET images varied in similar ways as function of reconstruction protocols and noise levels. The change in image noise with variation of simulated TOF settings followed the theoretically expected behaviour. RC as function of sphere size agreed within 0.3–11% between simulated and actual phantom data.ConclusionsSMART-PET allows for rapid and easy simulation of PET data. The user can change various acquisition and reconstruction settings (including RM and TOF) and noise levels. The images obtained show similar image characteristics as those seen in actual phantom data.

317 Patient Engagement through Advanced Pressure Visualization as a Component of Pressure Injury Prevention

Hospital acquired pressure ulcers represent one of the most frequent health care problems in clinical practice. Burn patients specifically pose a greater challenge due to loss of skin integrity, post-op positioning requirements and high levels of moisture. As an adjunct to unit based standard of care, a new technology was initiated to identify if pressure visualization will encourage patient engagement in repositioning as a component of pressure injury prevention. The purpose of this project is to evaluate the impact of a new advanced pressure visualization (APV) system on patient engagement through visual feedback where body areas are exposed to pressure. The definition of engagement for this purpose is from Gruman, et al, as “actions individuals must take to obtain the greatest benefit from the health care services available to them.” Patients in the Burn Center with intact cognitive awareness and the ability to see and respond to a color screen at the foot of the bed were included. An APV was installed on all beds, which included a pressure sensor mat inside the mattress connected to a display tablet mounted at the foot of the bed. This tablet displays their body image with continuous pressure readings utilizing a color gradient to exhibit pressure values. Patients were educated on the colors reflective of high- low pressures on their individual body image. The color display indicates specific pressure measurements: ‘red’ is >75mmHg, orange is 60-74mmgHg, yellow is 45-59mmHg, green is 30-44mmHg, light blue is 15-29mmHg and dark blue 1-14mmHg. Patients were asked to reposition themselves, or request repositioning assistance from the health care team, to an area of lesser pressure color when areas of high pressure colors (red, orange or yellow) were noted. Data from the APV device was utilized to determine reduction in peak pressure with patient repositioning. Data from 10 patients and 20 repositions were identified. Initial peak pressures shown by APV images, averaged 73.5 mmHg. The average reduction in peak pressure after the ten patients self-repositions was 41.25 mmHg. The National Pressure Ulcer Advisory Panel prevention and treatment guidelines encourage patients to work with the health care team to develop an individualized pressure ulcer prevention plan. With APV, the patient can easily identify high areas of pressure and actively participate in pressure reduction measures. While patient engagement in this population resulted in reduced pressure, further research related to APV and patient engagement for the prevention of pressure injury is warranted.

V06-08 INTRODUCTION OF SUPINE EXTRAPERITONEAL LAPAROSCOPIC NEPHROURETERECTOMY WITHOUT PATIENT REPOSITIONING

You have accessJournal of UrologyAdrenal, Testis, UTUC Oncology & More1 Apr 2018V06-08 INTRODUCTION OF SUPINE EXTRAPERITONEAL LAPAROSCOPIC NEPHROURETERECTOMY WITHOUT PATIENT REPOSITIONING Jun Miki, Takafumi Yanagisawa, Seiro Tanaka, Yuzo Inaba, Kosuke Iwatani, Hajime Onuma, Kagenori Ito, Takahiro Kimura, Koichi Kishimoto, and Shin Egawa Jun MikiJun Miki More articles by this author , Takafumi YanagisawaTakafumi Yanagisawa More articles by this author , Seiro TanakaSeiro Tanaka More articles by this author , Yuzo InabaYuzo Inaba More articles by this author , Kosuke IwataniKosuke Iwatani More articles by this author , Hajime OnumaHajime Onuma More articles by this author , Kagenori ItoKagenori Ito More articles by this author , Takahiro KimuraTakahiro Kimura More articles by this author , Koichi KishimotoKoichi Kishimoto More articles by this author , and Shin EgawaShin Egawa More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1587AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephroureterectomy (NUx) with ipsilateral bladder cuff excision is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC). Despite several advantages of laparoscopic and robotic NUx as a minimally invasive surgery, technical difficulties include patient or port repositioning, management of bladder cuff and lymphadenectomy (LND). Our objective is to introduce a novel technique - supine extraperitoneal laparoscopic nephroureterectomy (SELNUx) - that allows for completion of all of NUx, bladder cuff excision and LND in a complete supine position, without patient repositioning. METHODS Between January 2016 and October 2017, eighteen consecutive patients with UTUC underwent SELNUx performed by a single surgeon. We excluded patients with previous pelvic surgery, invasive tumor (cT3/T4 and/or cN+/M+) or severe hydronephrosis. The patients were placed in the complete supine without tilt position with tucking the contralateral side of arm. The surgeon and the assistants stood on the affected side of the patient. A 4-cm pararectal skin incision was placed just caudal to the anterior superior iliac spine, the extraperitoneal space was developed. We demonstrated a unique port placement that allows for complete access for NUx, bladder cuff excision and concomitant LND. Operative parameters and pathologic data were analyzed. RESULTS Median age was 70 (range 49 to 82), mean operative time was 243 minutes (range 194 to 293) and mean estimated blood loss was 67ml (range 50 to 150ml). There were no intraoperative complications, transfusion requirement or open conversion. All of the 18 cases showed urothelial carcinoma. Tumor location was renal pelvis in 10 patients (55%) and ureter in 8 patients (45%). The pathological grade was high grade in 10 patients (55%) and low grade in 8 patients (45%). The pathological stage was pTa in 9 patients (50%), pT1 in 7 patients (39%), pT2 in 1 patient (5.5%), and pT3 in 1 patient (5.5%). The median number of removed lymph nodes was 10, and only one patient had lymph node metastasis. CONCLUSIONS We describe a novel technique of SELNUx which enables completion of all of Nux, bladder cuff excision and LND without patient repositioning. Our technique is safe and feasible. We believe this approach may become a standard option for patients with UTUC that minimizes surgical invasion and operative time, while maintaining oncological efficacy. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e663 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jun Miki More articles by this author Takafumi Yanagisawa More articles by this author Seiro Tanaka More articles by this author Yuzo Inaba More articles by this author Kosuke Iwatani More articles by this author Hajime Onuma More articles by this author Kagenori Ito More articles by this author Takahiro Kimura More articles by this author Koichi Kishimoto More articles by this author Shin Egawa More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Stereotactic radiotherapy for choroidal melanoma: analysis of eye movement during treatment

This study aims to analyse the eye’s movement during radiotherapy treatment for choroidal melanoma, as well as the methodology used in the repositioning of the patient between treatments sessions. For this purpose, the procedures used by the hospital staff were analysed on site and videos were recorded during the treatments. The methodology for the fixation of the eye is correct in its objective. However, the repositioning needs improvements in its reproducibility. It is recommended the study to fix the eye by the healthy eye and the feasibility study for the development of a software that assists in patient repositioning.

Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study)

ImportanceThough theoretically sound, studies have failed to demonstrate the benefit of routine repositioning of at-risk patients for the prevention of hospital acquired pressure injuries. ObjectiveTo assess the clinical effectiveness of a wearable patient sensor to improve care delivery and patient outcomes by increasing the total time with turning compliance and preventing pressure injuries in acutely ill patients. DesignPragmatic, investigator initiated, open label, single site, randomized clinical trial. SettingTwo Intensive Care Units in a large Academic Medical Center in California. ParticipantsConsecutive adult patients admitted to one of two Intensive Care Units between September 2015 to January 2016 were included (n = 1564). Of the eligible patients, 1312 underwent randomization. InterventionPatients received either turning care relying on traditional turn reminders and standard practices (control group, n = 653), or optimal turning practices, influenced by real-time data derived from a wearable patient sensor (treatment group, n = 659). Main outcome(s) and Measure(s)The primary and secondary outcomes of interest were occurrence of hospital acquired pressure injury and turning compliance. Sensitivity analysis was performed to compare intention-to-treat and per-protocol effects. ResultsThe mean age was 60 years (SD, 17 years); 55% were male. We analyzed 103,000 h of monitoring data. Overall the intervention group had significantly fewer Hospital Acquired Pressure Injuries during Intensive Care Unit admission than the control group (5 patients [0.7%] vs. 15 patients [2.3%] (OR = 0.33, 95%CI [0.12, 0.90], p = 0.031). The total time with turning compliance was significantly different in the intervention group vs. control group (67% vs 54%; difference 0.11, 95%CI [0.08, 0.13], p < 0.001). Turning magnitude (21°, p = 0.923) and adequate depressurization time (39%, p = 0.145) were not statistically different between groups. Conclusions and RelevanceAmong acutely ill adult patients requiring Intensive Care Unit admission, the provision of optimal turning was greater with a wearable patient sensor, increasing the total time with turning compliance and demonstrated a statistically significant protective effect against the development of hospital acquired pressure injuries. These are the first quantitative data on turn quality in the Intensive Care Unit and highlight the need to reinforce optimal turning practices. Additional clinical trials leveraging technologies like wearable sensors are needed to establish the appropriate frequency and dosing of individualized turning protocols to prevent pressure injuries in at-risk hospitalized patients.

A 100 patient clinical evaluation of an alternating pressure replacement mattress in a home-based setting.

alternating pressure air mattresses (APAMs) support the prevention and management of pressure ulcers. A health and care NHS trust was seeking an APAM that would improve clinical outcomes in relation to pressure ulcers while considering financial cost. An APAM existed that could meet the trust's needs but there was a lack of evidence over its use in a community/home setting. This study examined the effect of using the Dual Professional (IQ Medical) APAM for patients at a high risk of pressure ulceration. It also determined patient and family satisfaction, and the views of clinicians in relation to clinical outcomes. Additionally, infection prevention and control, servicing, maintenance and electrical biomechanical engineer input were considered. a prospective observational study was undertaken of 100 patients in their own homes following a pilot study of 10 patients. The period of the evaluation was from one day up to 295 days, with a mean average of 83 days, and a total of 5809 bed days. with a regimen of regular repositioning of patients and a good diet, the APAM was effective in preventing pressure ulceration in the 100 patients who were at a high or very high risk of skin breakdown and pressure ulceration. selection of pressure redistributing surfaces should be based on holistic patient assessment, including risk assessment, mobility levels, grade of pressure damage and clinical judgment.

A Three-Dimensional Study of Midfacial Changes Following Le Fort II Distraction With Zygomatic Repositioning in Syndromic Patients.

Le Fort II distraction with zygomatic repositioning introduced the ability to restore central midfacial height and convexity independent of changes in orbital morphology. This study analyzes midfacial and orbital morphology before and after Le Fort II distraction with zygomatic repositioning.All patients who underwent Le Fort II Distraction with zygomatic repositioning between 2013 and 2015 were included. Two- and 3-dimensional measurements were made using 3dMD Vultus software to assess canthal tilt, nasolabial angle, ratio of midfacial to lower facial height, and absolute change in nasal length. Presence of an open bite and Angle classification were assessed before and after surgery.Four patients underwent segmental midface advancement using Le Fort II distraction with zygomatic repositioning. Associated diagnoses included Apert syndrome, Goldenhar syndrome, and achondroplasia. Changes in facial dimensions included: 3.19° improvement in canthal tilt (range -4.7° to 8.4°), 9° change in nasolabial angle (range -1.0° to 19°), and 0.69 cm increase in absolute nasal length (range 0.2-0.94 cm). Mean ratio of midfacial to lower facial height was 0.79 preoperatively and 0.89 postoperatively. Preoperatively, all patients demonstrated Angle class III with 3 of 4 patients demonstrating anterior open bite. All achieved closure of open bite and demonstrated class I or II occlusion. No complications were observed.Le Fort II distraction with zygomatic repositioning resulted in normalization of midfacial soft tissue landmarks. This form of advancement demonstrates the ability to selectively improve midfacial height and canthal tilt while restoring normal occlusion.

Single injection dual phase CBCT technique ameliorates results of trans-arterial chemoembolization for hepatocellular cancer.

Cone-beam CT (CBCT) application to the field of trans-arterial chemoembolization has been recently the focus of several researches. This imaging modality is performed with a rotation of the C-arm around the patient, without needs of patient repositioning. Datasets are immediately processed, obtaining volumetric CT-like images with the possibility of post-processing and reconstruction of images. Dual phase CBCT recently introduced in clinical practice consists in a first arterial acquisition followed by a delayed acquisition corresponding to a venous phase. The introduction of this feature has overcome the limit of single-phase acquisitions, allowing lesions characterization. Moreover these recent advantages have several intra-procedural implications. Detailed technical and acquisition parameters will be widely exposed in this review with particular attention to: catheter positioning, acquisition delay, injection parameters, patient positioning and contrast dilution. Comparison with standard of practice second line imaging [multidetector computer tomography (MDCT) and MDCT/arteriography] demonstrate the capability of detecting occult nodules providing some clinical implications thus potentially identifying a sub set of patients with aggressive disease behaviour. Other intra-procedural advantages of dual phase CBCT usage consist in a better tumor feeder visualization, reduction of proper DSA and fluoroscopic time, suggestion the presence of an extrahepatic parasitic feeder thus resulting in a more accurate treatment. Finally, the volumetrical intraprocedural evaluation of accumulation of embolic agent has proved to be correlate with treatment response if compared with MRI.

White cell and marrow imaging: subtracting uncertainty.

A subtraction method for assessments of dual-isotope indium-111 (In)-labelled white cell and Tc-nanocoll was proposed, and following a pilot study was introduced in routine service to improve the confidence of reporters. This technical note describes a simple technique to produce subtraction images from routinely acquired images to investigate and exclude post joint replacement infection. Labelled leucocytes (with In) show areas of increased white cell accumulation, whereas Tc-nanocoll images show bone marrow distribution. Images resulting from the subtraction protocol highlight any areas of white cell activity which is not concurrent with the marrow distribution indicative of infection. Fusion images produced from these images sets also assists in localization of white cell accumulation(s). Key to the success of this technique is the use of simultaneous acquisition of both white cell and marrow images; thus removing any issues with patient movement and/or repositioning. Reporting clinicians convey a clear preference for the inclusion of the subtracted and fused images at clinical review.

Anterior and Posterior Ankle Impingement by One-Step Arthroscopic Treatment: 10years Follow-up Prospective Study by Standard Anterior and Double Postero-Medial Portals

Simultaneous anterior and posterior ankle impingement is preferably treated by 2steps surgery. Aiming to avoid postponing further surgery in prone position, authors focused a procedure which addresses posterior ankle disorders through 2postero-medial portals, after anterior arthroscopic step without changing patient's assessment. They present this 10years follow-up prospective study. In period January 2001-January 2015 78 ankle affected with both side pathology, were submitted to arthroscopic treatment by standard anterior portals and double postero-medial approach, maintaining supine position and addressing simultaneously one-step surgery anteriorly and posteriorly. Reproducing same posterior portals of prone procedure, peroneal approach is rotated 90°medially lying 5cm superiorly to medial one along Achilles' tendon. FHL tendon landmark prevents damage to posterior tibial bundle. Patients were evaluated with pre-op and post-op x-ray scan and AOFAS scale. At final survey 71patients have been evaluated, being 7 lost. Wilcoxon test was utilized to compare score values reported at admission time, after 12months and after 10years. AOFAS scale, steady improved from preoperative mean 38.73(range21-51) to 1year postoperative=89.87 and to further 95.4 at 10years. The preop vs/postop 12months was p-value=0.00051 and postop 12months vs/10years p-value was =0.03628. Big improvement was reported in study group at 10years follow-up compared to control group (the former p-value=0.0004883, the lesser p-value=0.0009766, inferior to threshold p=0.05). None patient reported any complication, any problem to posterior tibial nerve territory or to medial talus skin sensitivity. Varicose veins caused in 3patients posterior ankle swelling and oedema for 3weeks. Four patients have been submitted to new surgical procedure for same disorder. In open surgery as in arthroscopic procedure, supine assessment made impossible to reach both the joint spaces without intra-operative patient's repositioning. Maintaining supine assessment during arthroscopy, this technique allowed to reach disorders in posterior ankle compartment after anterior treatment by standard portals. Absence of neurovascular lesions confirmed safety and reproducibility of this procedure providing anatomical landmarks respect.

V3-03 ROBOTIC LEFT-SIDED LEVEL II CAVAL THROMBECTOMY AND NEPHRECTOMY: PRIMARY DESCRIPTION OF NOVEL SUPINE, SINGLE-DOCK APPROACH

You have accessJournal of UrologyRenal Oncology1 Apr 2017V3-03 ROBOTIC LEFT-SIDED LEVEL II CAVAL THROMBECTOMY AND NEPHRECTOMY: PRIMARY DESCRIPTION OF NOVEL SUPINE, SINGLE-DOCK APPROACH Monty Aghazadeh, Spencer Craven, and Alvin Goh Monty AghazadehMonty Aghazadeh More articles by this author , Spencer CravenSpencer Craven More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.718AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Initial descriptions of robotic management of renal cell carcinoma with Inferior Vena Cava (IVC) thrombus employ a lateral approach predicated on early IVC exposure and control. However, for left-sided renal masses and associated tumor thrombi, this approach requires re-positioning and re-docking steps, as well as pre-operative left renal artery embolization. Herein, we describe a novel supine, single dock technique for robotic left nephrectomy and caval thrombectomy. METHODS We perform robotic nephrectomy and caval thrombectomy on a 79 y.o. male with a 6cm left renal mass and level II IVC thrombus. The patient is placed supine, in steep trendelenburg. We employ a 6-port trans-peritoneal technique and dock the robot such that arms are directed cephalad. Key steps critical to the procedure include: 1) Exposure of the retroperitoneum 2) IVC exposure and control 3) Left Renal Hilar Control 4) Cavotomy, thrombectomy, and reconstruction 5) Nephrectomy and lymph node dissection (LND). Peri-operative outcomes are reported and compared to previously published case series. RESULTS Robotic left nephrectomy and level II caval thrombectomy was performed successfully via a single-dock, supine approach. This method yielded excellent and early access to the IVC and left renal hilum, and allowed for concomitant nephrectomy/LND without re-positioning. Total operative time was 420 minutes with 330 minutes robotic console time (174 minutes for exposure, 27 minutes IVC clamp time, 84 minutes for nephrectomy/LND). EBL was 500cc without need for peri-operative transfusions and no intraoperative complications. Length of stay was 5 days and no major perioperative complications were noted. Outcomes compare favorably to previously reported robotic caval thrombectomy procedures employing the lateral approach. CONCLUSIONS We demonstrate successful robotic left nephrectomy with Level II caval thrombectomy using a supine, single-dock approach. To our knowledge, this is the first description of this approach for robotic caval thrombectomy. In appropriately selected patients, this versatile approach allows for rapid caval control, bilateral renal hilar access, and obviates the need for patient re-positioning. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e288-e289 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Monty Aghazadeh More articles by this author Spencer Craven More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Initial Results of an Evidence-Based Safe Patient Handling and Mobility Program to Decrease Hospital Worker Injuries.

The rate for musculoskeletal injuries among health care workers is one of the highest for all industrial sectors in the United States; these injuries often occur during manual handling (i.e., lifting, moving, transferring, and repositioning) of patients. The following article describes the process used to complete a comprehensive assessment, as well as the planning, implementation, and initial evaluation of a quality improvement program to reduce work-related musculoskeletal disorders (WMSD) among health care workers employed by a rural Midwest hospital. Key elements for WMSD injury reduction were identified and compared across literature sources, national standards, and current state and federal legislative requirements for hospitals. The program used a multi-factor design that included evidence-based interventions (i.e., those supported by emerging evidence) to create a comprehensive Safe Patient Handling and Mobility (SPHM) program intended to address the unique needs of the organization. Initial program results are reviewed as well as significant considerations and challenges for SPHM programs.

Pressure RElieving Support SUrfaces: a Randomised Evaluation 2 (PRESSURE 2): study protocol for a randomised controlled trial.

BackgroundPressure ulcers represent a major burden to patients, carers and the healthcare system, affecting approximately 1 in 17 hospital and 1 in 20 community patients. They impact greatly on an individual’s functional status and health-related quality of life. The mainstay of pressure ulcer prevention practice is the provision of pressure redistribution support surfaces and patient repositioning. The aim of the PRESSURE 2 study is to compare the two main mattress types utilised within the NHS: high-specification foam and alternating pressure mattresses, in the prevention of pressure ulcers.Methods/DesignPRESSURE 2 is a multicentre, open-label, randomised, double triangular, group sequential, parallel group trial. A maximum of 2954 ‘high-risk’ patients with evidence of acute illness will be randomised on a 1:1 basis to receive either a high-specification foam mattress or alternating-pressure mattress in conjunction with an electric profiling bed frame. The primary objective of the trial is to compare mattresses in terms of the time to developing a new Category 2 or above pressure ulcer by 30 days post end of treatment phase. Secondary endpoints include time to developing new Category 1 and 3 or above pressure ulcers, time to healing of pre-existing Category 2 pressure ulcers, health-related quality of life, cost-effectiveness, incidence of mattress change and safety. Validation objectives are to determine the responsiveness of the Pressure Ulcer Quality of Life-Prevention instrument and the feasibility of having a blinded endpoint assessment using photography. The trial will have a maximum of three planned analyses with unequally spaced reviews at event-driven coherent cut-points. The futility boundaries are constructed as non-binding to allow a decision for stopping early to be overruled by the Data Monitoring and Ethics Committee.DiscussionThe double triangular, group sequential design of the PRESSURE 2 trial will provide an efficient design through the possibility of early stopping for demonstrating either superiority, inferiority of mattresses or futility of the trial. The trial optimises the potential for producing robust clinical evidence on the effectiveness of two commonly used mattresses in clinical practice earlier than in a conventional design.Trial registration ISRCTN01151335. Registered on 14 May 2013. Protocol version: 5.0, dated 25 September 2015Trial sponsor: Clare Skinner, Faculty Head of Research Support, University of Leeds, Leeds, LS2 9JT; 0113 343 4897; C.E.Skinner@leeds.ac.uk.

9. Prostate CBCT dose optimization: From an iterative mAs reduction to a systematic exposure reduction

Introduction A daily repositioning Cone Beam Computed Tomography image (CBCT) for prostate radiotherapy is realized using exposure templates (mAs, kV) which affect image quality and imaging dose. Settings should be optimized to minimize patient exposure while maintaining sufficient image quality to register the initial planning CT with CBCT using soft tissue matching. Methods 20 prostate patients (without hip prosthesis) with daily CBCT (40 fractions) acquired on a TrueBeam™ (Varian Medical Systems) machine were selected. After the first fraction using the standard pelvis template (125 kV 1080 mAs CTDIw 14 mGy), the therapists manually applied, day after day, a low mAs reduction and assessed if the CBCT image quality was good enough for patient repositioning. The iterative process stopped when image quality was assessed too bad and the last proper mAs were selected. The link between the mAs reduction and corpulence (patient volume inside CBCT FOV) was studied. For one example patient 23 therapists registered CBCT images with CT for 3 fractions: the first fraction (S 0% ), a fraction with 50% mAs reduction (S −50% ) and the fraction with maximum mAs reduction (S −71% ). Fisher’s test was applied to every direction, to compare the variance between S 0% /S −50% and S 0% /S −71% . Results The median mAs reduction for all patients was 64% (13–85%). Patient corpulence was not correlated to the mAs reduction achieved (Spearman’s correlation r s = 0.465). Variance analysis, for every direction, shows no significant difference ( p 0% /S −50% and S 0% /S −71% . Conclusion mAs reductions recorded across the 20 patients are highly variable, due to the subjective assessment of CBCT image quality, but a median reduction of 64% indicates a great potential for reducing imaging dose. For one patient it has been demonstrated that image quality deterioration has no impact on interobserver variability. A 50% mAs reduction for the Pelvis CBCT template is therefore considered.

Repositioning a passive patient in bed: Choosing an ergonomically advantageous assistive device

Repositioning of passive patients in bed creates health risks to the nursing personnel. Therefore, appropriate assistive devices should be used. Our aim was to find the optimal assistive device for reducing musculoskeletal load while moving a passive patient in bed. Torso kinematic inputs evaluated by the Lumbar Motion Monitor (LMM) and perceived load (Borg scale) were measured in female nurses performing 27 patient transfers [represented by a mannequin weighing 55 (12 nurses), 65 (24 nurses) and 75 kg (12 nurses) in bed] using a regular sheet, a sliding sheet and a carrier. The lowest rates of perceived exertion were found when the sliding sheet and/or carrier were used, for all tasks (p ≤ 0.009). According to the predicted risk for Low Back Disorder (LBD) based on the LMM inputs, negligible differences between assistive devices were found. In a 75 kg mannequin, the participants were able to perform all tasks only by using a sliding sheet. Utilizing sliding sheets is an advantageous technique in comparison to traditional cotton sheets and even carriers.