Simulating high-fidelity emergency front-of-neck access: Training in an obstetric setting.

Introduction: In a cannot intubate, cannot oxygenate scenario (CICO), emergency front of neck access (eFONA) is the final lifesaving step in airway management to reverse hypoxia and prevent progression to brain injury, cardiac arrest and death. The Difficult Airway Society (DAS) guidelines advise the scalpel cricothyroidotomy method for eFONA. Anatomical and physiological changes in pregnancy exacerbate the already challenging obstetric airway. We aim to assess the impact made by introducing formal eFONA training to the perioperative medicine department of an obstetric hospital. Methods: Ethical approval and written informed consent were obtained. 17 anesthetists participated, (two consultants, one senior registrar, four registrars and eight senior house officers). Study design was as follows: Initial participant survey and performance of a timed scalpel cricothyroidotomy on Limbs & Things AirSim Advance X cricothyroidotomy training mannikin. Difficulty of the attempt was rated on a Visual Analogue Scale (VAS). Participants then watched the DAS eFONA training video. They then re-performed a scalpel cricothyroidotomy and completed a repeat survey. The primary endpoint was duration of cricothyroidotomy attempt, measured as time from CICO declaration to lung inflation confirmed visually. After a three-month period, participants were reassessed. Results: Four anesthetists had previous eFONA training with simulation, only one underwent training in the previous year. The mean time-to-lung inflation pre-intervention was 123.6 seconds and post-intervention was 80.8 seconds. This was statistically significant (p = 0.0192). All participants found training beneficial. Mean improvement of VAS was 3. All participants' confidence levels in identifying when to perform eFONA and ability to correctly identify anatomy improved. On repeat assessment, 11/13 participants successfully performed a surgical cricothyroidotomy, mean improvement from first attempt was 12 seconds (p = 0.68) which was not statistically significant. Conclusion: This method of training is an easily reproducible way to teach a rarely performed skill in the obstetric population.

A desktop systems analysis of critical incidents within a university hospital department of anaesthesia.

INTRODUCTION: Medical error is frequently the result of latent systems factors. Incident reporting systems face many challenges including inability of the system to process reports adequately, inadequate feedback mechanisms and lack of staff engagement especially from doctors. This paper describes a pragmatic physician-led desktop approach to a systems analysis of anaesthesia-related critical incidents which could be used to enhance incident reporting processing within the existing national incident reporting system. METHODS: Anaesthesiologists within a university teaching hospital were encouraged to report incidents anonymously during the 6-month study period from July 2019 to January 2020. Information was collected on incident details, outcome and preventability. A desktop systems analysis was performed to categorise incidents and to determine contributory factors. Latent errors were considered according to the level of the organisational hierarchy at which they occurred and solutions directed accordingly. RESULTS: Seventy cases were included giving a reporting rate of 1.76%. Airway/breathing circuit problems (34%) were most frequently cited incidents, followed by other equipment (27%), medication errors (20%) and airway events (19%). The vast majority of events were considered preventable. Most incidents were near misses or of negligible adverse effect with only 6% requiring more than minor treatment. Organisational and strategic contributory factors were identified in 83% of cases, 93% of which were addressable within the department. CONCLUSION: Implementing local incident reporting systems can be used to complement existing systems at the macro and mesolevel and can be used to improve system processing, create a phased response to latent errors and enhance engagement.

Adaptive risk-based targeted surveillance for foreign animal diseases at the wildlife-livestock interface.

Animal disease surveillance is an important component of the national veterinary infrastructure to protect animal agriculture and facilitates identification of foreign animal disease (FAD) introduction. Once introduced, pathogens shared among domestic and wild animals are especially challenging to manage due to the complex ecology of spillover and spillback. Thus, early identification of FAD in wildlife is critical to minimize outbreak severity and potential impacts on animal agriculture as well as potential impacts on wildlife and biodiversity. As a result, national surveillance and monitoring programs that include wildlife are becoming increasingly common. Designing surveillance systems in wildlife or, more importantly, at the interface of wildlife and domestic animals, is especially challenging because of the frequent lack of ecological and epidemiological data for wildlife species and technical challenges associated with a lack of non-invasive methodologies. To meet the increasing need for targeted FAD surveillance and to address gaps in existing wildlife surveillance systems, we developed an adaptive risk-based targeted surveillance approach that accounts for risks in source and recipient host populations. The approach is flexible, accounts for changing disease risks through time, can be scaled from local to national extents and permits the inclusion of quantitative data or when information is limited to expert opinion. We apply this adaptive risk-based surveillance framework to prioritize areas for surveillance in wild pigs in the United States with the objective of early detection of three diseases: classical swine fever, African swine fever and foot-and-mouth disease. We discuss our surveillance framework, its application to wild pigs and discuss the utility of this framework for surveillance of other host species and diseases.

Robotic versus laparoscopic anterior resections for rectal and rectosigmoid cancer: an institutional experience.

INTRODUCTION: Colorectal surgery has evolved with the advent of laparoscopic techniques and now robotic-assisted surgery. There is significant literature supporting the use of laparoscopic techniques over open surgery with evidence of enhanced post-operative recovery, reduced use of opioids, smaller incisions and equivalent oncological outcomes. Robotic minimally invasive surgery addresses some of the limitations of laparoscopic surgery, providing surgical precision and improvements in perception and dexterity with a resulting decrease in tissue damage. METHODS: We retrospectively reviewed the medical records of patients who underwent robotic-assisted anterior resection for cancer of the rectum or rectosigmoid junction in our institution since our robotic programme began in 2017. Patient demographics were identified via electronic databases and patient charts. A matched cohort of laparoscopic cases was identified. RESULTS: A total of 51 consecutive robotic-assisted anterior resections were identified and case matched with laparoscopic resections for comparison. Robotic-assisted surgery was associated with a shorter length of stay (p = 0.04), reduced initial post-operative analgesia requirements (p < 0.01) and no significant difference in time to bowel movement or stoma functioning (p = 0.84). All patients had an R0 resection, and there was no statistical difference in lymph node yield between the groups (p = 0.14). Robotic surgery was associated with a longer operative duration (p < 0.001). CONCLUSION: In this early experience, robotic surgery has proven feasible and safe and is comparable to laparoscopic surgery in terms of completeness of resection and recovery. As costs and operating times decline and as technology progresses, robotic surgery may one day replace traditional laparoscopic techniques.

Current opinions and practices for the management of acute appendicitis: an international survey.

BACKGROUND: In recent decades the management of acute appendicitis has evolved significantly. Improved access to early imaging and better clinical scoring algorithms have resulted in less negative appendicectomy rates. In addition, non-operative management has become increasingly utilized. The aim of this study was to assess the variability of management of acute appendicitis globally. METHODS: This was a multi-national targeted survey of general surgeons across 39 countries. A structured set of questions was utilized to delineate nuances between management styles of consultants and trainees. Opinions on the pathological diagnosis of appendicitis, acceptable negative appendicectomy rates, and the role of non-operative treatment of appendicitis (NOTA) were surveyed. RESULTS: A total of 304 general surgeons responded to this survey, 42% of which were consultants/attendings. Sixty-nine percent advocated that a histologically normal appendix was the most appropriate definition of a negative appendicectomy, while 29% felt that anything other than inflammation, necrosis, gangrene, or perforation was more appropriate. Forty-three percent felt that negative appendicectomy rates should be less than 10%, with 41% reporting that their own negative appendicectomy rate was < 5%. Interestingly, only 17% reported routinely using NOTA for uncomplicated appendicitis, with one-fifth stating that they would undergo NOTA if they themselves had uncomplicated appendicitis. CONCLUSION: This study represents the largest sampling of management strategies for acute appendicitis. It shows substantial global heterogeneity between clinicians regarding what constitutes a negative appendicectomy as well as the appropriateness of non-operative management.

Predictive value of CRP/albumin ratio in major abdominal surgery.

INTRODUCTION: Surgical site infection (SSI) is a major cause of morbidity, resulting in significant healthcare and economic implications. The ability to predict patients at high risk of SSI may enable targeted follow-up and management. This study sought to examine the relationship between the CRP/albumin ratio in the prediction of SSI in patients undergoing emergency major abdominal surgery. METHODS: A retrospective study of all patients who underwent emergency major abdominal surgery in our institution over 2 years was performed. Patients were identified from a prospectively maintained database of SSI's and cross-referenced with hospital records. Patient demographics including age, gender, ASA grade, and wound classification (clean, clean/contaminated, contaminated, and dirty) were collated. RESULTS: CRP preoperatively of greater than 5 was statistically significant in predicting an SSI (P < 0.05). In addition, preoperative serum albumin of < 32 was also significant in predicting a superficial site infection. Interestingly, preoperative CRP/albumin ratio did not predict SSI, but postoperative CRP/albumin ratio was predictive at both 24 and 48 hour time points (P < 0.05). Median length of stay in the SSI group was statistically significantly longer at 27.88 days (range 7-76) versus 18.32 days (1-56) (P < 0.01). CONCLUSIONS: Though CRP and albumin have merit in isolation in preoperative identification of patients at risk of SSI, CRP/albumin ratio is a useful postoperatively adjunct in predicting SSI postoperatively at 24 and 48hrs postoperatively.