Patient Safety in Surgery最新文献

Background: Awake colorectal surgery is an alternative to general anesthesia, especially in high-risk patients with significant cardiopulmonary comorbidities. Continuous segmental spinal anesthesia offers stable intraoperative conditions while avoiding the complications of cardio depressant effects, airway manipulation and sedation. Despite its advantages, this approach remains underreported in major colorectal procedures.

Case presentation: We present the case of a 73-year-old male with a history of ischemic cardiomyopathy, chronic heart failure (ejection fraction 25-30%), chronic kidney disease, and pulmonary complications, classified as American Society of Anesthesiologists (ASA) Risk Class V. The patient was admitted to a tertiary hospital in Palestine with a recurrent sigmoid volvulus, and due to the high risk associated with general anesthesia, the surgical, cardiology and anesthesia teams decided for an awake open sigmoidectomy under continuous segmental spinal anesthesia. The patient remained fully conscious and hemodynamically stable throughout the procedure. Postoperative recovery was uncomplicated apart from a superficial wound infection, which was managed conservatively. At six-month follow-up, the patient remained asymptomatic, tolerated a normal diet, had no recurrent bowel obstruction, and showed complete wound healing without late infectious or anastomotic complications.

Conclusion: This case illustrates the feasibility, safety, and potential benefits of awake sigmoidectomy in fragile, multimorbid patients. To our knowledge, it represents the first reported case in Palestine. The successful outcome emphasizes the importance of advanced regional techniques and multidisciplinary collaboration in managing high-risk surgical patients, especially in settings with limited resources.

Introduction: Retained surgical items are rare yet serious complications that may occur despite correct instrument and sponge counts. Surgical sponges remain the most frequently retained items, with gauze marker strand retention being an uncommon mechanism.

Case presentation: A 69-year-old male with severe mitral regurgitation and triple-vessel coronary artery disease underwent mitral valve replacement with coronary artery bypass grafting. All surgical counts were verified as correct at the conclusion of surgery. Postoperative chest radiography, however, revealed two linear radio-opaque foreign bodies near the left lower sternum. Mediastinal re-exploration identified two radio-opaque strands, measuring 3.0 cm and 2.0 cm, attached to the left lower chest wall near the internal mammary artery stump. These were confirmed to be detached marker strands from Raytec gauzes. The patient's recovery was uneventful and he was discharged well.

Conclusion: This case illustrates that retained gauze fragments can occur despite correct counts due to fragmentation of radiopaque markers. Surgeons and operating room nurses should inspect gauzes for integrity, maintain vigilance when manipulating sponges in confined operative fields, and consider adjunct technologies such as radiofrequency or barcode tracking. In high-risk surgeries, postoperative imaging may be warranted even with accurate counts to ensure patient safety.

Over three decades, randomized controlled trials (RCTs) for critical care syndromes such as acute respiratory distress syndrome (ARDS), sepsis, and community acquired pneumonia (CAP) have repeatedly produced non-reproducible results, at times leading to high-impact reversals of global protocols when later studies revealed harm. These trials enroll patients using expert-derived threshold sets intended to define the syndrome. This analytic review presents the first historical and formal methodological review and mathematical analysis of such RCT using causal symbolic modeling (cSM), directed acyclic graphs (DAGs), and do-calculus. The review includes landmark publications, task-force threshold sets, and case examples, including the 2025 REMAP-CAP corticosteroid domain, to model the causal structure of standard RCTs applied to threshold-defined syndromes. PubMed searches and ChatGPT were used to assist in this process. The historical inquiry uncovered that the critical care syndromes of ARDS and sepsis are guessed synthetic constructs, devised in the twentieth century by Thomas Petty and Roger Bone as heuristic groupings of diverse but similar appearing diseases. However a much more striking discovery was that Petty and Bone introduced a streamlined variant of the Bradford Hill RCT method, here termed the "Petty-Bone RCT', which conditions enrollment on a triage threshold set that functions as a cohort-level collider. This design yields results valid only for the unstable mixture of diseases enrolled. The "Petty-Bone RCT" preserves the outward form of a randomized trial but lacks the causal structure needed for transportability, making it an RCT mimic. The cSM analysis in this review shows that while potentially internally valid, such trials cannot produce reliable treatment protocols and often cause harm. These findings compel the abandonment of the Petty-Bone RCT framework, the integration of cSM into the Consolidated Standards of Reporting Trials (CONSORT), and prioritizing mechanistically grounded, investigator-led designs in critical care research. These provocative discoveries indicate that not one more patient, not one more investigator, not one more grant should be sacrificed to the next iteration of a Petty and Bone's synthetic syndrome RCT.

Background: Bilateral humeral shaft fractures are rare injuries that present significant management challenges, particularly in resource-constrained settings. This case report highlights the complexities of treating bilateral humeral shaft fractures in a 40-year-old male patient from southwestern Nigeria, whose treatment was initially complicated by failed plate osteosyntheses. The objectives of this report are (1) to illustrate the unusual injury patterns that result from inadequate transportation infrastructure in developing countries, (2) to highlight the challenges patients and surgeons face in managing fractures in resource-constrained environments, and (3) to emphasize the critical role humanitarian organizations play in enhancing orthopedic care and achieving positive patient outcomes in these settings.

Case presentation: A 40-year-old male patient, the primary earner for his family, presented to our facility three months after a road traffic crash with bilateral upper limb dysfunction. While driving with his seatbelt fastened, a trailer truck struck his car on the driver's side, resulting in bilateral closed humeral shaft fractures, a mild traumatic brain injury, and minor skin abrasions. Initial plate osteosynthesis at a private peripheral hospital failed, resulting in bilateral nonunions. Upon presentation at our facility, the patient had normal vital signs and preserved neurovascular function, but limited upper-limb mobility. He underwent staged treatment, which involved removal of the plates, Surgical Implant Generation Network (SIGN) nail (Richland, WA, USA) fixation, and cancellous autografting. Despite financial constraints and infection complications, both fractures achieved union and functional recovery after two years.

Conclusions: This case underscores the challenges of managing complex orthopaedic trauma in low-resource settings, where inadequate healthcare infrastructure, limited access to suitable implants, and insufficient health insurance coverage exacerbate treatment difficulties. The successful outcome in this case was achieved through staged treatment, collaboration with the patient, and the use of donated SIGN nails. The report emphasizes the necessity for innovative solutions, collaborative efforts, and policy reforms to enhance fracture management outcomes and prevent long-term disabilities in resource-constrained settings. The role of humanitarian organizations in bridging the gap in orthopaedic care is also highlighted, demonstrating the potential for positive outcomes despite significant challenges.

Background: Spinal anesthesia is a widely used and effective regional technique, yet its failure can occur, potentially leading to patient discomfort and requiring alternative methods. Therefore, this systematic review and meta-analysis aimed to assess the pooled incidence of spinal anesthesia failure and identify associated factors.

Methods: This systematic review was prospectively registered in PROSPERO (CRD420251101582). A comprehensive literature search was conducted across PubMed, Embase, the Cochrane Library, Web of Science, and Google Scholar for studies published between January 2015 and May 2025. Using a random-effects model, we calculated the pooled incidence of failed spinal anesthesia and the pooled odds ratios (ORs) for potential predictors. Heterogeneity among studies was assessed using the I² statistic.

Results: Twenty-one studies involving 44,790 participants were analyzed. The pooled incidence of failed spinal anesthesia was found to be 8.36% (95% CI: 6.94-9.78). Significant predictors included bar city and dose of local anesthetics, provider inexperience, bloody cerebrospinal fluid, emergency surgery, history of anesthesia, body mass index, lumbar puncture performed at the L4-L5 interspaces, and absence of free CSF flow.

Conclusion: The failure rate of spinal anesthesia is significant. Our findings highlight the importance of standardized techniques, optimization of local anesthetic dosage, and continuous training to reduce failures, particularly in resource-limited settings. Key associated factors considered to reduce failures.