Patient Safety in Surgery最新文献

Introduction: Regional anesthesia increases in popularity in orthopaedic surgery. It is usually applied in elective surgeries of the extremities. The aim of this study was to assess indication of the use of general anesthesia in the surgical treatment of distal radius fractures.

Methods: Patients undergoing surgical fixation for distal radius fractures between January 1st, 2020, and December 31st, 2021, were included. Exclusion criteria encompassed incomplete 12-month follow-up, transferred or multiply injured patients, those with prior upper limb fractures, or admission for revision surgeries. Patients were categorized by anesthesia type: GA or plexus block anesthesia (PA). Primary outcomes comprised tourniquet utilization and duration of surgery, while secondary outcomes encompassed complications (e.g., complex regional pain syndrome [CRPS], local wound infection, implant removal necessity) and range of motion at three, six, and twelve months post-surgery. Fractures were classified using the AO/OTA system.

Results: The study enrolled 127 patients, with 90 (70.9%) in Group GA and 37 (29.1%) in Group PA. Mean patient age was 56.95 (± 18.59) years, with comparable demographics and fracture distribution between groups. Group GA exhibited higher tourniquet usage (96.7% vs. 83.8%, p = 0.029) and longer surgery durations (85.17 ± 37.8 min vs. 65.0 ± 23.0 min, p = 0.013). Complication rates were comparable, Group GA 12.2% versus Group PA 5.4% p = 0.407, OR 2.44; 95%CI 0.51 to 11.58, p = 0.343). Short-term functional outcomes favored Group PA at three months (e.g., Pronation: 81.1° ± 13.6 vs. 74.3° ± 17.5, p = 0.046).

Conclusion: Solely classifying distal radius fractures does not dictate anesthesia choice. Complexity of injury, anticipated surgery duration, less use of tourniquet, and rehabilitation duration may guide regional anesthesia utilization over GA in distal radius fracture fixation.

Background: While existing risk calculators focus on mortality and complications, elderly patients are concerned with how operations will affect their quality of life, especially their independence. We sought to develop a novel clinically relevant and easy-to-use score to predict elderly patients' loss of independence after gastrointestinal surgery.

Methods: This retrospective cohort study included patients age ≥ 65 years enrolled in the American College of Surgeons National Surgical Quality Improvement Program database and Geriatric Pilot Project who underwent pancreatic, colorectal, or hepatic surgery (January 1, 2014- December 31, 2018). Primary outcome was loss of independence - discharge to facility other than home and decline in functional status. Patients from 2014 to 2017 comprised the training data set. A logistic regression (LR) model was generated using variables with p < 0.2 from the univariable analysis. The six factors most predictive of the outcome composed the short LR model and scoring system. The scoring system was validated with data from 2018.

Results: Of 6,510 operations, 841 patients (13%) lost independence. Training and validation datasets had 5,232 (80%) and 1,278 (20%) patients, respectively. The six most impactful factors in predicting loss of independence were age, preoperative mobility aid use, American Society of Anesthesiologists classification, preoperative albumin, non-elective surgery, and race (all OR > 1.83; p < 0.001). The odds ratio of each of these factors were used to create a sixteen-point scoring system. The scoring system demonstrated satisfactory discrimination and calibration across the training and validation datasets, with Receiver Operating Characteristic Area Under the Curve 0.78 in both and Hosmer-Lemeshow statistic of 0.16 and 0.34, respectively.

Conclusions: This novel scoring system predicts loss of independence for geriatric patients after gastrointestinal operations. Using readily available variables, this tool can be applied in the urgent setting and can contribute to elderly patients and their family discussions related to loss of independence prior to high-risk gastrointestinal operations. The applicability of this scoring tool to additional surgical sub-specialties and external validation should be explored in future studies.

Background: Hemodynamically unstable pelvic ring fractures from high-energy trauma are critical injuries in trauma care, requiring urgent intervention and precise diagnostics. With ongoing advancements in trauma management, treatment strategies have evolved, with some techniques becoming obsolete as new ones emerge. This study aimed to evaluate changes and trends in treatment algorithms for these injuries over approximately 40 years.

Methods: A systematic review of PubMed and EMBASE was conducted to include articles published over roughly four decades that presented visual treatment algorithms or workflows for managing unstable pelvic ring fractures. Identified algorithms were categorized by publication period and analyzed by initial assessment, diagnostic methods, pelvic stabilization, and hemorrhage control interventions.

Results: The search identified 5,434 publications, of which 32 met the inclusion criteria. 75% of these studies were published between 2011 and 2022, reflecting a growing focus on standardization, particularly in Europe, North America, and Asia. Physiological assessment remains essential in the initial management of hemodynamically unstable pelvic ring fractures, guiding resuscitation and influencing the selection of intervention and imaging. The use of pelvic binders or sheets has risen steadily, highlighting their role in hemorrhage control and temporary stabilization. CT scans and angiography have largely replaced pelvic X-rays in diagnostic protocols, becoming preferred radiological methods alongside focused assessment with sonography for trauma (FAST). Pelvic stabilization remains critical, with external fixation being the most commonly used technique, showing an upward trend in recent years. Laparotomy, pelvic packing, and angioembolization continue to play vital roles in hemorrhage management. Emerging techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), anterior subcutaneous internal fixation (INFIX), and rescue screws, are increasingly included in treatment algorithms, while diagnostic peritoneal lavage (DPL) has become obsolete and is no longer listed in these algorithms.

Conclusions: This review provides foundational insights toward the standardization of initial treatment for hemodynamically unstable pelvic ring fractures and holds significant importance in enhancing the consistency and efficiency of treatment. Future research should focus on accumulating higher-quality evidence to evaluate the effectiveness of standardized protocols and explore the applicability of new treatment methods.

Background: External ventricular drain (EVD) insertion is one of the most commonly performed neurosurgical procedures. Herein, we introduce a new concept of a cranial fixation device for insertion of EVDs, that reduces reliance on freehand placement and drilling techniques and provides a simple, minimally invasive approach that provides strong fixation to minimal thickness skulls.

Methods: An experimental device for catheter insertion and fixation was designed and tested in both ex-vivo and in-vivo conditions to assess accurate cannulation of the ventricle and to test the strength of fixation to the skull. The ex-vivo experiments were conducted at Ben-Gurion University of the Negev (BGU) in Be'er Sheva, Israel. These experiments included functionality bench testing and pullout force measurements for the ball mechanism and catheter fixation. For the in-vivo experiments the fixation device was initially tested at the Cincinnati Children's Hospital Medical Center (CCHMC) in Cincinnati, Ohio on one day of life 1 (DOL 1) male control lamb. Additional experiments were conducted on 3 hydrocephalic DOL 0 lambs (1 male 2 female) at the Jesús Usón Minimally Invasive Surgery Centre (JUMISC) in Caceres, Spain. The hydrocephalic animal model used for this study was created with in utero intracisternal injection of BioGlue in fetal lambs. The catheter insertion trajectory was determined using MR imaging to assess the device's impact on the placement accuracy. The fixation device was evaluated on reaching the ventricle and enabling extraction of CSF for all 7 fixations placed. For 5 of the fixation devices, post-mortem pullout force was measured. The general functionality of the device was also evaluated.

Results: In the experiments, 7/7 (100%) catheter trajectories successfully reached the ventricle without any apparent complications related to the device or the procedure. The cranial fixation device base demonstrated significant strength in withstanding an average pull-out force of 4.18kgf (STD[Formula: see text]0.72, N = 5) without detachment from the subject's skull for all 5 devices included in this test. Additionally, the EVD catheter pull test was conducted with the addition of a safety loop which did not allow movement of the EVD to a force of 3.6kgf. At this force the catheter tore but did not release from its fixation point.

Conclusion: The newly designed experimental device demonstrates initial proof of concept from ex vivo and in vivo testing. It appears suitable for accurate ventricular catheter placement and cranial fixation.

Background: Effective and reliable communication is the cornerstone of safe communication in the operating room (OR). The OR is one of the most dynamic places in the hospital where multiple disciplines must work together in perfect harmony to ultimately improve patient outcomes. To create familiarity by name regarding constantly changing team members, individual name tagging was implemented in the OR.

Methods: We analysed the impact of name tagging in the OR in a proof-of-concept study. Name tags (either first or last name), coloured according to the specific department, have been placed on the cap since March 13, 2023. On May 26, 2023, a total of 440 anaesthesiologists, general, visceral, and trauma surgeons, nurses, and service staff were invited to answer an evaluation questionnaire of nine questions. The survey period ended on August 7, 2023. 101 people answered the query which, among other things, asked for overall ratings, compliance, evaluation of specific items as well as positive and negative aspects. Statistical analyses were performed using R.

Results: Most of the interviewed staff rated the implementation of name tagging positively (median=3.4; scale from 1-5, 1=bad, 5=good). The greatest benefit was seen in communication in general, direct contact with colleagues, and delegation of tasks. Most of the staff (>90 %) adhered to the new project and used it regularly. Negative aspects mentioned included potential loss of sterility, loss of respectability, and environmental impact. Potential for improvement was seen in the bonding method of attachment or in the implementation.

Conclusion: Individual name tagging in the OR can improve interprofessional communication and is one tool to enhance patient safety by decreasing reservations or intimidations towards previously unknown colleagues. More studies are required to determine long-term effects on patient safety, outcome, or employee satisfaction.

Background: The clinical benefit of locking plates in distal fibula fractures has not yet been proven. In addition, the risk of wound complications appears to be higher than with conventional tubular plates. We hypothesize that the benefits of locking plates in terms of biomechanical properties are outweighed by a higher risk of wound complications.

Methods: We conducted a retrospective review of fibula fractures treated by osteosynthesis with either a conventional one-third tubular plate or an anatomically shaped locking plate from January 1, 2015 to December 31, 2021. We recorded baseline data and relevant comorbidities and defined the need for revision surgery due to wound-related or mechanical complications as primary endpoints.

Results: A total of 595 out of 727 patients were eligible for our study. Of these 595 fractures, 526 were fixed with a one-third tubular plate, 69 with a locking plate. Revision surgery was required in 54 patients, in 51 cases due to wound complications. Three patients required revision surgery for mechanical reasons and all of them were younger than 40 years of age, have not been diagnosed with osteoporosis, but experienced complex fracture types. As the third tubular plate and locking plate groups differed in terms of age and comorbidities, we performed a 2:1 matching based on age and gender, leaving data from 138 patients receiving a third tubular plate. While the two groups were comparable in many aspects, the rate of wound complications was significantly higher in the locking plate group. Although the locking plate group had a higher percentage of diabetes mellitus, there was no correlation between this comorbidity and the higher revision rate in this group.

Conclusions: Our data do not support the general use of locking plates in the treatment of distal fibular fractures. The risk of mechanical complications in osteoporotic ankle fractures seems to be overrated, as there were no mechanical revisions in the osteoporotic subgroup. The rate of wound-related revision surgery was significantly higher after the use of locking plates. This might be attributed to the greater thickness of locking plates.

Background: Acute compartment syndrome is a rare but serious complication following gynecological surgery in the lithotomy position, potentially resulting in permanent neuromuscular dysfunction or limb loss, making early recognition and prompt management essential.

Case presentation: A 41-year-old woman underwent a laparoscopic myomectomy for uterine fibroids, during which she was positioned in the high lithotomy and head-down position for 118 min. Six hours post-surgery, she experienced spasmodic pain and swelling in both lower extremities. Thirteen hours after surgery, her symptoms worsened, leading to the diagnosis of acute compartment syndrome in both legs. An emergency bilateral fasciotomy was performed, and the patient fully recovered within two months without any neuromuscular dysfunction.

Conclusions: ACS should be an important differential diagnosis for lower extremity pain after gynecologic surgery, especially with prolonged lithotomy positioning. Gynecologists should be vigilant for ACS signs and symptoms to prevent delayed diagnosis.

Background: Managing degenerative lumbar diseases is challenging due to the complexity of identifying symptom causes, especially when multiple pathologies coexist. This study evaluated the impact of patient-specific lumbar spine infiltrations on therapeutic strategies in patients with multiple spinal pathologies (MSP) or specific spinal pathologies (SSP).

Methods: A retrospective cohort of 176 patients treated for subacute or chronic lumbar pain with targeted spinal infiltrations was analyzed. Patients were categorized based on the presence of MSP or SSP. The primary endpoint was the relief of lumbar spine-specific symptoms following each infiltration. Secondary endpoints included epidemiological factors and comorbidities, while tertiary endpoints focused on post-treatment recommendations and performed treatments.

Results: High rates of spinal pain (97.1% in both groups) and radiating symptoms (88.2% in SSP and 92.3% in MSP) were reported. Psychological conditions were significantly more prevalent in female patients (19.4% vs. 7.7%, p = 0.0307), whereas hip osteoarthritis was more common in male patients (20.5% vs. 9.2%, p = 0.0490). Among all infiltration types, lumbar transforaminal injections were the most effective, leading to pain reduction in 80.1% of SSP patients and 72.2% of MSP patients. Facet joint and sacroiliac joint infiltrations also frequently resulted in pain reduction in both groups. Overall, conservative treatment was recommended for most patients (73.3%), while only 22.7% of all evaluated patients were recommended for surgical intervention. Additionally, seven patients received a hip prosthesis.

Conclusions: Patient-specific lumbar spine infiltrations effectively relieve pain, support therapeutic decision-making, and tend to favor conservative treatment approaches. These findings highlight the role of infiltration therapies in managing both mixed and specific lumbar spine pathologies, suggesting their potential to reduce the need for surgical interventions.