We Are Going to Name Names and Call You Out! Improving the Team in the Academic Operating Room Environment.

INTRODUCTION: Communication failures between multidisciplinary teams can impact efficiency, performance, and morale. Academic operating rooms (ORs) often have surgical, anesthesia, and nursing teams, each teaching multiple trainees. Incorrectly identifying name and "rank" (postgraduate year [PGY]) of resident trainees can disrupt performance evaluations and team morale and even potentially impair delivery of quality care when miscommunication errors proliferate. METHODS: Our OR-based survey asked 50 participants (18 surgeons, 14 anesthesiologists, and 18 nursing members), to recall basic identification data including provider names and PGY levels from their recent collaborating OR teams. Participants also weighed in on the importance of using accurate "names and ranks" for all OR participants. RESULTS: Each service reliably knew their own team members' names and rank. However, surgery and anesthesia teams displayed decreased knowledge about their lower level trainees, whereas nursing teams performed best, identifying all level nurses present. Deficits occurred whenever participants tried recalling basic identifying data about contributors from any other collaborating team. Typically, misidentified participants were lower level PGY residents working on other teams' services. All survey respondents desired improving systems to better remember "names and ranks" identifications among OR participants, citing both safety and team morale benefits. CONCLUSIONS: Many fail to know the names and ranks of contributors among members of different OR teams. Even our most reliable nursing team was inconsistent at identification information from collaborating practitioners. Despite universally acknowledged benefits, participants rarely learned basic background identification data beyond their own team. Those surveyed all desired improving identifications with suggestions including sterile name and rank tags and proper notification of entry and exit from the OR. Because successful collaborations require appropriate level task delegations, participants believed knowing a resident's name and rank is important not only for team bonding but also for safety. Academia furthermore demands fair performance evaluations, and displaying them clearly improves recall. Refining our own identified gaps in OR communications may demonstrate improved teamwork and safer task delegations and perhaps even stimulate other performance benefits for academic ORs.

Negative Pressure Wound Therapy with Instillation in a Chronic Non-Healing Right Hip Trochanteric Pressure Ulcer.

Complex pressure ulcer wound sites often present with a wide scope of barriers to healing ranging from high colonization of multi-drug-resistant pathogens to tortuous internal anatomy which make the wound recalcitrant to traditional wound care including standard negative pressure wound therapy (NPWT). Negative pressure wound therapy with instillation (NPWTi-d) provides an opportunity to manage and heal wounds with indications not met by standard NPWT such as cavitating wounds with complex undermining and tunneling. In this clinical case report, a patient who presented with a chronic, non-healing Stage IV pressure ulcer underwent a tensor fascia lata flap reconstruction that was complicated by a partial flap-tip nonadherence with associated partial dehiscence of the flap incision that proved unresolvable until application of adjunctive NPWTi-d which allowed the wound to experience a robust rate of granulation, contraction, and closure.

Lateral gastrocnemius myocutaneous flap transposition to the midlateral femur: extending the arc of rotation.

We report the successful use of an extended lateral gastrocnemius myocutaneous flap for coverage of the midlateral femur using successive delayed elevations. A 62-year-old man underwent wide resection of a liposarcoma of the right anterior thigh with free flap reconstruction and subsequent radiation therapy 10 years before. Four years later, the patient fractured his irradiated femur and was treated with a retrograde intramedullary nail, which subsequently became infected, causing osteomyelitis of the distal femur, septic arthritis of the knee joint, and nonunion of his pathologic fracture. Although advised by numerous surgeons to undergo above-knee amputation, we offered our motivated patient a multidisciplinary approach to clear his infection and pathology; implanted new orthopedic hardware; performed delayed flap reconstruction; and rehabilitated him back to painless, unassisted ambulation. The extended lateral gastrocnemius myocutaneous flap used provided perfused soft tissues and durable coverage for the patient's exposed orthopedic hardware of the midlateral femur, 14 cm above the joint line of the knee. By using this flap to cover a femur defect well above published heights, our patient avoided amputation after years of worsening incapacitation.

Nonsyndromic craniosynostosis: current treatment options.

The significance and etiology of abnormal skull shape have been under investigation since ancient times. Nonsyndromic, or isolated, craniosynostosis predominates and is defined as suture fusion that creates functional impairments related to local effects of the fusion. The purpose of this article is to present our current approach to patients with nonsyndromic craniosynostosis, outlining the place of both open, conventional approaches and newer, minimally invasive, endoscopic assisted craniosynostosis correction.

Clinical experience with the Fraxel SR laser: 202 treatments in 59 consecutive patients.

BACKGROUND: The authors investigated postprocedure patient satisfaction after fractional photothermolysis with the Fraxel SR laser. METHODS: All patients were surveyed with respect to their satisfaction with the results using a Likert scale ranging from 1 to 5, with 5 = extremely satisfied and 1 = extremely dissatisfied. Fraxel SR laser treatment was performed for categories of skin abnormalities that included dyschromia, scarring, and texture abnormalities. Most patients had more than one concern. Univariate and multivariate analyses were performed. Logistic regression was used to explore predictors of a satisfaction score of 4 or 5. RESULTS: Fifty-nine patients (median age, 52 years; range, 30 to 71 years) underwent Fraxel SR laser resurfacing and completed the survey. A total of 202 treatments (median, four; range, one to six) were performed. Seventy-five percent of all patients were very satisfied (4 or 5 rating) with treatment. Seventy-five percent with dyschromia, 74 percent with texture abnormalities, and 100 percent with scarring had a satisfaction score of 4 or 5. Multivariate analysis found scarring, four or more treatments, and age older than 56 years to be associated with a score of 4 or 5. The odds of giving a satisfaction score of 4 or 5 increased approximately two-fold for each additional treatment a patient received. CONCLUSIONS: This study reports the largest experience to date with the clinical use of the Fraxel SR laser and is the first report of patient satisfaction after fractional photothermolysis. Patients reported high satisfaction rates for improvements in texture, dyschromia, and scarring.

Comparison of open versus minimally invasive craniosynostosis procedures from the perspective of the parent.

Craniosynostosis, or the premature closure of the sutures of the skull, has historically been repaired in an open manner and included extensive cranial reconstruction. In recent years, technological advancements have given surgeons the ability to perform repairs with minimal surgical invasion. With the advent of endoscopy and bioresorbable plates, recent reports [J Craniofac Surg 2002;13(4):578-82] have emphasized attempts at decreased morbidity. Recently, researchers have been able to compare the results of traditional open and minimally invasive techniques in 45 craniosynostosis cases, demonstrating decreased operating room time, blood loss, transfusions, complications, and hospital stay in minimally invasive patients [Clin Plast Surg 2004;31(3):429-42]. Many of the parameters comparing the 2 types of procedures are easily quantified and comparable, but a variety of other considerations, such as the parent's reaction to the stress of surgery, arise. The purpose of this study was to compare the effects of these surgical procedures on the parent's level of stress at the time of operation. To accomplish this, we measured stress postoperatively using the Parenting Stress Index-Short Form. Subjects undergoing surgical treatment of craniosynostosis were placed into 2 groups: open versus minimally invasive. To test for confounding factors, subjects were subcategorized for sex, parent's sex, ethnicity, and parent's marital status. Analysis of our data reveals a statistically significant decrease in total stress in the households of minimally invasive patients.

An overview of permanent and semipermanent fillers.

The demand for safe, effective, long-lasting, biocompatible dermal filler materials is increasing. Many products that include synthetic polymers and autologous tissue have emerged that attempt to meet these criteria. An overview of injectable permanent fillers, including ArteFill, Aquamid, and silicone, and semipermanent fillers, including Radiesse, Sculptra, and autologous fat, is presented. A discussion of their composition, histologic characteristics, antigenicity, U.S. Food and Drug Administration approval status, indications for use, efficacy, injection technique, and adverse effects is provided.

Case report: the stone-basket nidus.

A 55-year-old man presented with intermittent right-flank pain 6 months after ureteroscopic stone extraction with holmium laser lithotripsy. A distal-ureteral stone was removed that contained fragments of a stone basket. Diligent inspection of endourologic accessories is critical to ensuring no fragments are left in patients, especially when a laser has been used.

ArteFill: a permanent skin filler.

The ideal soft-tissue filler for wrinkles and skin defects should be safe, biocompatible, resistant to phagocytosis, persist and maintain its volume without being resorbed or degraded. ArteFill, an improved, next-generation derivative of Artecoll, is expected to become the first and only FDA-approved permanent filler for use in the USA in 2006 and will be available worldwide. ArteFill consists of polymethylmethacrylate microspheres suspended in a 3.5% solution of bovine collagen containing 0.3% lidocaine. In this article, the pathophysiology, efficacy and safety of ArteFill are discussed and details of its injection technique are provided. Insight into the pharmacoeconomic value of ArteFill over nonpermanent fillers and ArteFill's unique role in the growing world market of dermal fillers is provided.

Clinical experience with a new fast-resorbing polymer for bone stabilization in craniofacial surgery.

Polylactic acid (PLA) and polyglycolic acid have been successfully used as suture material during the past 30 years and have been successfully used in various orthopedic and craniofacial applications, with increasing frequency during the past 15 years. To eliminate some of the problems seen with the longer-lasting Macropore PLA product and other longer-lasting resorbable systems, a new fast-resorbing polymer (FRP) was manufactured by Macropore-Medtronic Neurologic Technologies, Inc. from commercially available 85:15 poly(D,L-lactide-co-glycolide) raw material using traditional melt-processing techniques. The delivery system is easily used and uses essentially the same instrumentation. One hundred and sixty eight patients who had implantation of the FRP were studied. Detailed clinical evaluation was completed after surgery and at each postoperative visit. Overall, there was a 2.1% implant-related complication rate, which compared favorably to the 8.5% implant-related complication rate associated with the longer-lasting PLA product. All patients who received FRP implants have had maintenance of stable bony fixation, followed by bony healing and satisfactory or excellent cosmetic results. The results from the FRP study indicate that the FRP material and implants are safe and effective in craniomaxillofacial applications.

Intracoronary macrothrombus formation during percutaneous coronary intervention despite optimal activated clotting time using bivalirudin--a case report.

The occurrence of intracoronary thrombus during percutaneous coronary intervention (PCI) is a well-known complication. It has been estimated that it complicates approximately 6% of all coronary procedures. Patients at highest risk for this complication include those with acute ischemic syndromes or with angiographically apparent thrombus. Since the development of PCI, intravenous unfractionated heparin (UFH) has remained the primary antithrombotic therapy for the prevention of periprocedural ischemic complications. The availability of a rapid "point of care'' test for dose individualization (the activated clotting time [ACT]) has facilitated this process. Other forms of antithrombotic therapies such as direct thrombin inhibitors or low-molecular-weight heparin have been proposed as more effective anticoagulants during PCI. Bivalirudin is a direct thrombin inhibitor proven to decrease post-PCI ischemic complication rate compared with UFH and have a lower vascular complication rate compared with glycoprotein IIb/IIIa receptor antagonists. We herein report a case of acute macrothrombus formation during PCI despite adequate ACT achieved with bivalirudin.

Hand-assisted laparoscopic nephrectomy for renal masses >9.5 cm: series comparison with open radical nephrectomy.

OBJECTIVE: To assess the feasibility of hand-assisted laparoscopic nephrectomy (HALN) for large renal masses (stage T2, mean size 9.7 cm) and compare outcomes with a similar cohort undergoing open radical nephrectomy (ORN). METHODS: A nonrandomized comparison of 19 consecutive patients who underwent nephrectomy for renal masses >or=7 cm was performed. The HALN group was compared to the ORN group regarding demographic parameters and perioperative data, including blood loss, operating time, narcotic usage, hematocrit change, return to standard oral intake, length of hospital stay, and complications. Data collected prospectively and statistics used 2-tailed t-test analysis. RESULTS: Patients underwent either ORN (mean tumor size 12.3 cm) or HALN (mean tumor size 9.7cm). Tumors up to 14 cm (n = 2) and pT3b, with renal vein thrombosis (n = 2), could be safely excised with HALN. There were no differences between the HALN and ORN groups regarding any demographic parameter. Blood loss, operating time, length of stay, parenteral narcotic use, and time to tolerating regular diet were all less statistically significant in the HALN group as compared to the ORN group (P < 0.05). Tumors >15 cm necessitated ORN. CONCLUSIONS: HALN is technically feasible even for tumors with mean size >9.5 cm. There is a significant advantage to HALN over ORN regarding the intraoperative and postoperative morbidity. Tumors >or=15 cm should, in most cases, be performed with an open approach.

Clinical experience with linezolid in conjunction with wound coverage techniques for skin and soft-tissue infections and postoperative osteomyelitis.

Gram-positive organisms are emerging as possibly the most important nosocomial pathogens during the past decade. Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of infection in the postoperative patient. Burn victims are at high risk for developing vancomycin-resistant Enterococcus (VRE) and other multidrug-resistant microbial infections as a result of the immunocompromising effects of burn injury, prolonged intensive care unit stays, and broad-spectrum antibiotic therapy. To prevent serious and dreaded complications such as skin graft breakdown, delayed wound healing, loss of a limb, and even death, these infections require a combination of extensive antibiotic therapy and plastic surgical intervention. The objectives of this study were to report clinical experience with linezolid in addition to wound care, debridement, and wound coverage techniques for the treatment of S. aureus (including MRSA) and VRE infections. Forty patients received linezolid for infections of wound coverage such as an infected graft or flap, or received linezolid in conjunction with wound coverage techniques for a S. aureus or VRE infection. The median patient age was 53 years (range, 14-85 years), 55% were female, 28% of patients received intravenous (i.v.) linezolid only, 45% received i.v. with a switch to the oral formulation, and 28% received the oral formulation only. The clinical success rate of linezolid with adjuvant wound coverage techniques was 90.0% for osteomyelitis and was 100% for skin and soft-tissue infections. For infections of wound coverage, the clinical success rate was 83.3%. In conclusion, linezolid was an effective antibiotic for the treatment of S. aureus (including MRSA) and VRE infections in conjunction with wound coverage techniques. In addition, linezolid offers the option of treating these infections with an oral agent that is 100% bioavailable.