Background
While the operating room (OR) has significantly benefited from aviation strategies to improve safety, the rate of avoidable human errors remains relatively high. One key aviation strategy ...that has yet to be formally established in the OR is the “sterile cockpit” rule, which prohibits all non-essential behaviours during critical moments of a flight. Applying this rule to the OR may enhance patient safety, but the critical moments of surgery need to be defined first.
Methods
This study used a modified Delphi methodology to determine critical moments during surgery according to OR team members across institutions, professions, and specialties. Analysis occurred after each round. The stopping criterion was consensus on 80% of survey items or no change in the mean score for any individual item between two consecutive rounds.
Results
The first round included 304 respondents. Of these, 115 completed the second-round survey, and 75 completed all three rounds (27 nurses, 29 anesthesiologists, 19 surgeons). Critical moments obtained by consensus were: induction of anesthesia; emergence from anesthesia; preoperative briefing; final counts at the end of the procedure; anesthesiologist- or surgeon-relevant intraoperative event; handovers; procedure-specific high-risk surgical moments; crisis resource management situations; medication and equipment preparation; and key medication administration.
Conclusions
By defining the most critical moments of surgery, future research can determine the relative importance of behaviour and actions at each stage and target interventions to these stages.
Introduction: Booster sessions can improve cardiopulmonary resuscitation (CPR) skill retention among healthcare providers; however, the optimal timing of these sessions is unknown. This study aimed ...to explore differences in skill retention based on booster session timing.
Methods: After ethics approval, healthcare providers who completed an initial CPR training course were randomly assigned to either an early booster, late booster, or no booster group. Participants’ mean resuscitation scores, time to initiate compressions, and time to successfully provide defibrillation were assessed immediately post-course and four months later using linear mixed models.
Results: Seventy-three healthcare professionals were included in the analysis. There were no significant differences by randomization in the immediate post-test (9.7, 9.2, 8.9) or retention test (10.2, 9.8, and 9.5) resuscitation scores. No significant effects were observed for time to compression. Post-test time to defibrillation (mean ± SE: 112.8 ± 3.0 sec) was significantly faster compared to retention (mean ± SE: 120.4 ± 2.7 sec) (p = 0.04); however, the effect did not vary by randomization.
Conclusion: No difference was observed in resuscitation skill retention between the early, late, and no booster groups. More research is needed to determine the aspects of a booster session beyond timing that contribute to skill retention.
Teamwork is a critical competency in high-risk settings like the operating room (OR). While conventional approaches focus on describing and learning from negative performance, there may be value in ...learning from high-performing behaviour, particularly in specialties where serious safety events are relatively rare. This study aimed to explore both the positive and negative use of non-technical skills by anesthesia practitioners in the OR and situate them within the clinical OR context.
This study employed a prospective observational design. Following research ethics approval, a sample of surgical cases in a tertiary hospital were recorded using the OR Black Box®. Data related to surgical phase timing, non-technical skills, team factors, and environmental factors were identified by analysts according to a modified Systems Engineering Initiative for Patient Safety model. We performed descriptive statistics and qualitative description of these observations.
We observed 25 surgical cases capturing 242 instances of positive non-technical skills among anesthesiologists in the operating room and 9 instances of negative demonstrations. Situational awareness was most frequently (n = 160) observed, followed by communication and teamwork skills (n = 82), and were most often demonstrated in the context of potential environmental distractions (e.g., doors opening, unnecessary interruptions). The least common category of positive non-technical skills observed was leadership (n = 3).
Our findings show anesthesiologists are doing a lot “right” and there may be many opportunities for learning from positive practice in the clinical setting. These findings can inform future work to better understand and standardize best practices for non-technical performance in anesthesia.
•The anastomotic leakage rate was 12% and the stricture rate was 22%.•Patients with higher anastomotic complications rates had a significant higher mean dose of radiation to the esophagus below the ...level of the azygous vein.•We did not find a difference in mean gastric doses in patients who did/did not have an anastomotic complication.•Anastomotic complications did not affect survival outcomes.
There is conflicting evidence with respect to the correlation between neoadjuvant chemoradiation and anastomotic complications following trimodality therapy in patients with esophageal cancer. We aimed to analyze the relationship between their dosimetry and any resulting anastomotic complications.
The medical records of 51 consecutive patients who underwent trimodality therapy between 2007 and 2014 were retrospectively reviewed. We analyzed the differences in the mean dose received by regions of the esophagus relative to the landmark of the azygous vein and the stomach to correlate the development of an anastomotic complication using nonparametric rank-sum tests.
Anastomotic leakage and stricture rates were 12% and 22%, respectively. Patients with anastomotic complications received a statistically significant higher mean dose to the esophagus at the level of the azygous vein (0.0 cm) and lower (up to −2.7 cm) (28.4–42.2 Gy vs. 10.3–27.6 Gy, p < 0.04). There were no differences noted in mean gastric doses. Median follow up time was 30.9 months. Median overall survival and disease free survival of our patient cohort was 34.4 months and 22.5 months, respectively. The development of an anastomotic complication did not affect survival outcomes.
Patients who experienced anastomotic complication after trimodality therapy for esophageal cancer were more likely to have received a higher mean esophageal dose around the proximity of the azygous vein, where intrathoracic anastomoses most commonly occur. Communication between surgical and radiation oncologists regarding the anastomotic location may be an important consideration in planning for trimodality therapy in reducing potential anastomotic complications.
Background
Illicit drug use (IDU) is often encountered in patients undergoing elective ambulatory surgical procedures such as endoscopy. Given the variety of systemic effects of these drugs, sedation ...and anesthetics are believed to increase the risk of cardiopulmonary complications during procedures. Procedural cancelations are common, regardless of the drug type, recency of use, and total dosage consumed. There is a lack of institutional and society recommendations regarding the optimal approach to performing outpatient endoscopy on patients with IDU.
Aim
To review the literature for current recommendations regarding the optimal management of outpatient elective endoscopic procedures in patients with IDU. Secondary aim is to provide guidance for clinicians who encounter IDU in endoscopic practice.
Methods
Systematic review of PubMed, CINAHL, Embase, and Google Scholar for articles presenting data on outcomes of elective procedures in patients using illicit drugs.
Results
There are no clinically relevant differences in periprocedural complications or mortality in cannabis users compared to non-users. Endoscopy in patients with remote cocaine use was also found to have similar outcomes to recent use.
Conclusions
Canceling endoscopic procedures in patients with recent IDU without consideration of the type of drug, dosage, and chronicity may lead to unnecessary delays in care and increased patient morbidity. Healthcare systems would benefit from additional guidelines for evaluating the patient with recent illicit drug use for acute intoxication and consider proceeding with procedures in the non-toxic population.
BACKGROUND:Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality ...of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI.
METHODS:This review adheres to the Cochrane Collaboration’s diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model.
RESULTS:A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 IL-6 level, CRP level, and erythrocyte sedimentation rate ESR) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above.
CONCLUSIONS:The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI.
LEVEL OF EVIDENCE:Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Vilazodone has high affinity for the human 5-hydroxytryptamine1A (h5-HT1A) receptor and for the serotonin transporter (5-HTT). A previous in vivo microdialysis experiment showed that a single ...administration of vilazodone, dose-dependently increases extracellular 5-HT but not norepinephrine (NE) or dopamine (DA) levels in rat medial prefrontal cortex and ventral hippocampus. The effects of vilazodone on monoaminergic systems were assessed using single-unit extracellular recordings and microiontophoresis in the rat brain. Following depletion of 5-HT with para-chlorophenylalanine methyl-ester hydrochloride (PCPA), vilazodone still suppressed neuronal firing of dorsal raphe nucleus (DRN) 5-HT neurons to a similar extent than controls, indicating that this inhibition is via 5-HT1A receptors activation. Following 2-day intraperitoneal administration of vilazodone (5 mg/kg/day), there was a significant decrease in 5-HT neuronal firing which recovered to baseline levels by day 14 of administration, likely due to 5-HT1A autoreceptor desensitization. Two- and 14-day administration of vilazodone decreased the mean firing and bursting activities of ventral tegmental area (VTA) DA neurons, while only its repeated administration significantly dampened the mean firing rate of locus coeruleus (LC) NE neurons. Vilazodone acted as an agonist at 5-HT1A receptors, while showing a 5-HTT blocking capacity when injected acutely. After repeated vilazodone regimen, while there was no change in sensitivity of 5-HT1A receptors, the enhancement in 5-HT transmission yielded an increase in the tonic activation of these receptors located in the hippocampus.
•The antidepressant vilazodone has high affinity for 5-HT1A receptors and the 5-HT transporter (5-HTT).•Inhibition of 5-HT neuronal firing is due to the action of vilazodone on 5-HT1A receptors but not 5-HTT.•Administration of vilazodone for 14 days resulted in normalization of firing activity of 5-HT neurons.•The same regimen increased the tonic activation of 5-HT1A receptors of CA3 pyramidal neurons of hippocampus.•Repeated administration of vilazodone significantly dampened firing activity of NE and DA neurons firing.
Background
Surgical resection remains a critical component of esophageal cancer treatment with curative-intent. The aim of this study was to compare open (OE) to minimally invasive Ivor Lewis ...esophagectomy (MIE) with respect to perioperative and oncologic outcomes.
Methods
Retrospective single-institution review of MIE and OE patients operated between 2001 and 2015 was conducted. Univariable and multivariable models were created using Cox regression. The Kaplan–Meier method was used to compare oncologic outcomes. Propensity score matching was used to compare oncological outcomes in MIE and OE patients.
Results
Of 210 esophageal resection patients, 47% had OE (137/291) and 25% had MIE (73/291). The MIE and OE groups were comparable with respect to patient factors and operative details. Fewer OE patients received neoadjuvant chemoradiation. MIE was associated with improved lymph node yield, (MIE = 30 IQR:22–39; OE = 14 IQR:7–19,
p
< 0.001), less intraoperative blood loss (MIE = 312 mL 100–400; OE = 657 mL 350–700,
p
< 0.001), and shorter median length of stay (MIE = 10 days IQR = 8–14; OE = 14 days IQR = 11–22
p
< 0.01). The OE group had significantly more adverse events resulting in reoperation or intensive care unit admission (MIE = 21%; OE = 34%;
p
< 0.01). On multivariable analysis, age and positive resection margins were associated with decreased odds of survival. The number of lymph nodes retrieved, positive resection margins, and pathologic stage were significant predictors of disease-free survival. Analysis of 69 matched pairs showed equivalent median overall survival (MIE = 49 months 18–67; OE = 29 months 17–69;
p
= 0.26) and disease-free survival (MIE = 9 6–22; OE = 13 6–22;
p
= 0.45) between the two groups.
Conclusions
Although long-term oncologic outcomes appear to be similar, MIE is associated with significantly less intraoperative blood loss, improved lymph node yield, less risk of severe postoperative adverse events, and shorter length of stay.
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