Patient Safety in Surgery最新文献

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.

Smart digital technologies are rapidly transforming perioperative care through tools such as clinical decision support systems, wearable sensors, and electronic checklists. Despite growing adoption, their specific impact on patient safety in the operating room remains insufficiently understood. This narrative review explores recent advancements in perioperative digital health and examines how innovations like AI-assisted systems, electronic WHO checklists, and physiological monitoring wearables contribute to safer surgical care. The evidence suggests that these tools can enhance complication detection, protocol adherence, and team communication. However, their effectiveness is tempered by challenges including alert fatigue, fragmented data systems, and added digital workload for healthcare staff. To realize their full potential, future implementations must prioritize usability, interoperability, and seamless workflow integration. Rigorous clinical trials and cost-effectiveness studies are also needed to establish the true value of smart technologies in improving surgical patient outcomes.

Background: A foreign body left behind during an operation is a medico-legal issue. It is an infrequent but avoidable surgical complication, which must be kept in mind in any postoperative patient who presents with pain, infection, or palpable mass. The author presents a rare case of chronic gossypiboma following a Cesarean delivery in a 40-year-old woman, who was a Para III patient from Western Ethiopia. She had been experiencing dull, aching pain since her previous Cesarean section four years prior. To address her complaints, she visited multiple health facilities where she was prescribed pain relief medications and antibiotics. The patient was eventually taken to the operating room with a preliminary diagnosis of a mature cystic teratoma. However, during laparotomy, surgical gauze was discovered and successfully removed.

Conclusion: In patients who have previously undergone surgery for obstetric or other gynecological procedures and present with vague abdominal complaints, it is important to consider the possibility of a chronic gossypiboma mimicking a mass of unknown origin. Following established surgical protocols and implementing new preventive measures, such as using tagged gauze/ radio-opaque markers, and ongoing staff training could help reduce or prevent the occurrence gossypiboma. Additionally, the author advises performing delicate surgical procedures to remove retained gauze to prevent bleeding and tissue damage. The gauze should be gently lifted, and the wound must be examined for any damage.

Background: Postoperative delirium is a frequent complication following surgery in elderly patients. Despite its strong association with poor health outcomes the literature in Nigeria has been limited to a few case-reports. A major barrier to improving delirium care in elderly individuals is its poor detection, particularly in surgical populations. We aimed to determine the incidence, detection rate and risk factors for postoperative delirium in our cohort of elderly surgical patients.

Methods: We conducted a prospective cohort study in a regional orthopedic and plastic surgical center in Enugu, Southeast Nigeria, between April 2020 and March 2024. The participants were patients aged 65 years and above, who underwent surgical procedures. Each patient was visited daily by a trained nonpsychiatrist physician during the first three days after surgery and was assessed for delirium during each visit. The "Confusion Assessment Method" algorithm was used for the diagnosis of delirium. The motor subtypes were classified on the basis of the predominant psychomotor disturbance (hyperactive, hypoactive, mixed, or none). Multivariate analysis via binary logistic regression was used to determine the predictors of delirium. The level of statistical significance was determined by a p value of < 0.05.

Results: Data from 304 patients (mean age, 71.7 ± 6.4 years) were analyzed. The incidence of postoperative delirium was 24.0% (73/304). The delirium subtype manifestations were "hypoactive" 35.6%, "hyperactive" 35.6%, "mixed" 20.5%, and "none" 8.2%. Approximately 92% (67/73) of the delirious cases presented within 48 h following surgery. Among the delirious cases, 90.4% (66/73) were undetected by the managing surgical teams and nursing personnel. The predictors of delirium were perioperative anaemia (AOR = 4.6; 95% CI: 1.3-16.5), impaired preoperative cognitive status; (AOR = 4.5; 95% CI: 2.0-9.9), perioperative blood transfusion (AOR = 2.1; 95% CI: 1.1-4.2), and surgery lasting between 120 and 179 min (AOR = 0.3; 95% CI: 0.1-0.8).

Conclusion: Postoperative delirium was grossly underrecognized by the managing surgical teams and nursing personnel. Education of the healthcare providers, with implementation of routine monitoring for postoperative delirium using validated tools is recommended. Perioperative anaemia and blood transfusion were modifiable risk factors for postoperative delirium in these patients, and improvements in patient blood management offer great potential for safer care.