Ethical implications of AI in robotic surgical training: A Delphi consensus statement.

CONTEXT: As the role of AI in healthcare continues to expand there is increasing awareness of the potential pitfalls of AI and the need for guidance to avoid them. OBJECTIVES: To provide ethical guidance on developing narrow AI applications for surgical training curricula. We define standardised approaches to developing AI driven applications in surgical training that address current recognised ethical implications of utilising AI on surgical data. We aim to describe an ethical approach based on the current evidence, understanding of AI and available technologies, by seeking consensus from an expert committee. EVIDENCE ACQUISITION: The project was carried out in 3 phases: (1) A steering group was formed to review the literature and summarize current evidence. (2) A larger expert panel convened and discussed the ethical implications of AI application based on the current evidence. A survey was created, with input from panel members. (3) Thirdly, panel-based consensus findings were determined using an online Delphi process to formulate guidance. 30 experts in AI implementation and/or training including clinicians, academics and industry contributed. The Delphi process underwent 3 rounds. Additions to the second and third-round surveys were formulated based on the answers and comments from previous rounds. Consensus opinion was defined as ≥ 80% agreement. EVIDENCE SYNTHESIS: There was 100% response from all 3 rounds. The resulting formulated guidance showed good internal consistency, with a Cronbach alpha of >0.8. There was 100% consensus that there is currently a lack of guidance on the utilisation of AI in the setting of robotic surgical training. Consensus was reached in multiple areas, including: 1. Data protection and privacy; 2. Reproducibility and transparency; 3. Predictive analytics; 4. Inherent biases; 5. Areas of training most likely to benefit from AI. CONCLUSIONS: Using the Delphi methodology, we achieved international consensus among experts to develop and reach content validation for guidance on ethical implications of AI in surgical training. Providing an ethical foundation for launching narrow AI applications in surgical training. This guidance will require further validation. PATIENT SUMMARY: As the role of AI in healthcare continues to expand there is increasing awareness of the potential pitfalls of AI and the need for guidance to avoid them.In this paper we provide guidance on ethical implications of AI in surgical training.

Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training.

CONTEXT: The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training. EVIDENCE ACQUISITION: This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement. EVIDENCE SYNTHESIS: There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90. CONCLUSIONS: Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation. PATIENT SUMMARY: Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence.

Tamponade Relief by Active Clearance of Chest Tubes.

PURPOSE: Chest tubes are used in every case of cardiac surgery to evacuate shed blood from around the heart and lungs. Chest tubes can become partially or totally occluded, leading to tamponade. The purpose of this article is to discuss a novel method of maintaining chest tube patency in the early recovery after cardiothoracic surgery. DESCRIPTION: The PleuraFlow Active Clearance Technology is a system to prevent chest tube clogging that can be used to help routinely maintain chest tube patency at the bedside in the intensive care unit. EVALUATION: A patient exhibited physiologic tamponade that was confirmed by transthoracic echocardiography. The chest tube was successfully reopened by actively clearing the chest tube using Active Clearance Technology, resulting in resolution of the tamponade. CONCLUSIONS: The present study reports the case of a patient with massive postoperative pericardial effusion with tamponade, successfully managed by active clearance chest tube. Further studies will help define the role for this technology in routine cardiac surgery.

Right Ventricular Depression After Cardiopulmonary Bypass for Valvular Surgery.

OBJECTIVE: To assess if right ventricular (RV) dysfunction is associated with increased mortality after cardiac surgery. DESIGN: Post-hoc analysis of a single-center double-blind randomized controlled trial. SETTING: University hospital. PARTICIPANTS: A total of 120 patients undergoing simple or complex valvular surgery. INTERVENTIONS: Patients were randomized to receive intravenous amiodarone or placebo intraoperatively. As secondary analysis, patients were divided into those requiring or not requiring postoperative inotropic agents. MEASUREMENTS AND MAIN RESULTS: After cardiopulmonary bypass (CPB), there were significant increases in heart rate, cardiac index, systolic and mean arterial pressures, central venous pressure and pulmonary capillary wedge pressure with reduction in systemic vascular resistance (p<0.05). Right ventricular end-systolic area became larger in those without inotropes and tricuspid annular plane systolic excursion was reduced in all patients; mitral annular systolic velocities were higher in patients receiving inotropes. Both right- and left-sided Doppler signals were altered significantly after CPB, which may be attributed to increased filling pressure. Inotropic agents were required in 56 patients after CPB (47%). The use of inotropic agents was associated with increased left and right atrial velocities (p<0.05). There were no differences in postoperative complications between groups; however, the number of deaths at 6 years was increased in patients who received inotropes after CPB (p = 0.0247). CONCLUSIONS: The increases in right-sided dimensions after CPB are associated with reduction in RV function and increased biventricular filling pressure, suggesting worsening biventricular function and interventricular dependence. Inotropic medications were associated with unaltered RV dimensions and increased biatrial activity.

Acute intraoperative effect of intravenous amiodarone on right ventricular function in patients undergoing valvular surgery.

BACKGROUND: Amiodarone is commonly used in the acute care setting. However the acute hemodynamic and echocardiographic effect of intravenous amiodarone administered intraoperatively on right ventricular (RV) systolic and diastolic function using transesophageal echocardiography (TEE) has not been described. METHODS: The study design was a randomized controlled trial in elective cardiac surgical patients undergoing valvular surgery. Patients received an intravenous loading dose of 300 mg of either amiodarone or placebo in the operating room, followed by an infusion of 15 mg/kg for two days. Hemodynamic profiles, echocardiographic measurement of RV and left ventricular (LV) dimensions, Doppler interrogation of tricuspid and mitral valve, hepatic and pulmonary venous flow combined with tissue Doppler imaging of the tricuspid and mitral valve annulus were obtained before and after bolus. RESULTS: Although more patients in the placebo group had chronic obstructive lung disease (14 vs 6, p=0.05) and diabetes (14 vs 5; p=0.0244), there was no difference in terms of baseline hemodynamic, 2D and Doppler variables. After bolus, a significant increase in pulmonary artery pressure, central venous pressure and pulmonary vascular resistance index (p<0.05) was observed in the amiodarone group with reduction in systolic to diastolic (S/D) ratio of the hepatic (p=0.0247) and pulmonary venous (p=0.0052) velocity. CONCLUSION: Acute administration of amiodarone is associated with alteration in RV diastolic properties and has minimal negative inotropic effect on RV systolic function in cardiac surgical patients with valvular disease.

Excellent outcomes for transcatheter aortic valve replacement within 1 year of opening a low-volume centre and consideration of requirements.

BACKGROUND: After the approval of transcatheter aortic valve replacement (TAVR) for high-risk or inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs were initiated. Contemporary outcomes from these newly initiated centres remain unknown. METHODS: In March 2013, our institution was authorized by the Québec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter heart valve (THV). In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium 2 guidelines. RESULTS: From April 2013 to January 2014, 30 consecutive high-risk (n = 16 [53.3%]) or inoperable (n = 14 [46.7%]) patients (mean age, 84.6 years; mean Society of Thoracic Surgery score, 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intraprocedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, and there were no deaths at 30 days. Disabling stroke occurred in 1 (3.3%) patient 48 hours after THV implantation. Major vascular complications and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 (1-3) days, with 8 (26.7%) patients discharged within 24 hours after the procedure. CONCLUSIONS: Excellent outcomes can be achieved in newly initiated relatively low-volume centres, which compares favorably to previously published large series. Important considerations include appropriate team training, rigorous patient screening, use of multimodality imaging techniques, a heart team approach, constant integration of lessons learned from larger published experiences, and maintaining a recommended minimum volume of 25 cases per year.

Perioperative intravenous amiodarone does not reduce the burden of atrial fibrillation in patients undergoing cardiac valvular surgery.

BACKGROUND: Atrial fibrillation is a common complication after cardiac surgery. Postoperative atrial fibrillation is associated with increased risks of morbidity and mortality, and, therefore, preventive strategies using oral amiodarone have been developed but are often unpractical. Intravenous amiodarone administered after the induction of anesthesia and continued postoperatively for 48 h could represent an effective strategy to prevent postoperative atrial fibrillation in patients undergoing cardiac valvular surgery. METHODS: Single-center, double-blinded, double-dummy, randomized controlled trial in patients undergoing valvular surgery. Patients received either an intravenous loading dose of 300 mg of amiodarone or placebo in the operating room, followed by a perfusion of 15 mg . kg(-1) . 24 h(-1) for 2 days. The primary endpoint was the development of atrial fibrillation occurring at any time within the postoperative period. RESULTS: One hundred twenty patients were randomly assigned (mean age was 65 +/- 11 yr). Overall atrial fibrillation occurred more frequently in the perioperative intravenous amiodarone group compared with the placebo group (59.3 vs. 40.0%; P = 0.035). Four preoperative factors were found to be independently associated with a higher risk of developing postoperative atrial fibrillation: older age (P = 0.0003), recent myocardial infarction (<6 months; P = 0.026), preoperative angina (P = 0.0326), and use of a calcium channel blocker preoperatively (P = 0.0078) when controlling for groups. CONCLUSION: In patients undergoing cardiac valvular surgery, a strategy using intravenous amiodarone for 48 h is not efficacious in reducing the risk of atrial fibrillation during cardiac valvular surgery.

Fulminant legionellosis in two patients treated with infliximab for Crohn's disease: case series and literature review.

Two cases of fulminant pulmonary legionellosis, complicated by prolonged intensive care unit stays and acute respiratory distress syndrome, and who were recently treated with infliximab for Crohn's disease, are described. A review of the literature revealed three additional cases in patients with inflammatory bowel disease, and a total of 22 cases of Legionella pneumophila pneumonia in the context of treatment with antitumour necrosis (TNF)-alpha medications. The median age of the patients was 49 years, and men and women were affected equally. The case fatality rate was 14% (three of 22). Early recognition and treatment of this anti-TNF-alpha-related complication would likely result in reduced mortality and morbidity. Physicians prescribing anti-TNF-alpha drugs should be aware of this association.