A novel hospital capacity versus clinical justification triage score (CCTS) for prioritization of spinal surgeries in the "new normal state" of the COVID-19 pandemic.

INTRODUCTION: During the Coronavirus disease 2019 outbreak, while healthcare systems and hospitals are diverting their resources to combat the pandemic, patients who require spinal surgeries continue to accumulate. The aim of this study is to describe a novel hospital capacity versus clinical justification triage score (CCTS) to prioritize patients who require surgery during the "new normal state" of the COVID-19 pandemic. METHODOLOGY: A consensus study using the Delphi technique was carried out among clinicians from the Orthopaedic Surgery, Neurosurgery, and Anaesthesia departments. Three rounds of consensus were carried out via survey and Webinar discussions. RESULTS: A 50-points score system consisting of 4 domains with 4 subdomains was formed. The CCTS were categorized into the hospital capacity, patient factors, disease severity, and surgery complexity domains. A score between 30 and 50 points indicated that the proposed operation should proceed without delay. A score of less than 20 indicates that the proposed operation should be postponed. A score between 20 and 29 indicates that the surgery falls within a grey area where further discussion should be undertaken to make a joint justification for approval of surgery. CONCLUSION: This study is a proof of concept for the novel CCTS scoring system to prioritize surgeries to meet the rapidly changing demands of the COVID-19 pandemic. It offers a simple and objective method to stratify patients who require surgery and allows these complex and difficult decisions to be unbiased and made transparently among surgeons and hospital administrators.

Ensuring Sustainability of Continuous Kidney Replacement Therapy in the Face of Extraordinary Demand: Lessons From the COVID-19 Pandemic.

With the exponential surge in patients with coronavirus disease 2019 (COVID-19) worldwide, the resources needed to provide continuous kidney replacement therapy (CKRT) for patients with acute kidney injury or kidney failure may be threatened. This article summarizes subsisting strategies that can be implemented immediately. Pre-emptive weekly multicenter projections of CKRT demand based on evolving COVID-19 epidemiology and routine workload should be made. Corresponding consumables should be quantified and acquired, with diversification of sources from multiple vendors. Supply procurement should be stepped up accordingly so that a several-week stock is amassed, with administrative oversight to prevent disproportionate hoarding by institutions. Consumption of CKRT resources can be made more efficient by optimizing circuit anticoagulation to preserve filters, extending use of each vascular access, lowering blood flows to reduce citrate consumption, moderating the CKRT intensity to conserve fluids, or running accelerated KRT at higher clearance to treat more patients per machine. If logistically feasible, earlier transition to intermittent hemodialysis with online-generated dialysate, or urgent peritoneal dialysis in selected patients, may help reduce CKRT dependency. These measures, coupled to multicenter collaboration and a corresponding increase in trained medical and nursing staffing levels, may avoid downstream rationing of care and save lives during the peak of the pandemic.

Ideal Sequence of Didactic Lectures and Simulation in Teaching Transesophageal Echocardiography Among Anesthesiologists.

OBJECTIVE: Performing a basic perioperative transesophageal echocardiography (TEE) requires 3-dimensional knowledge of cardiac anatomy, psychomotor skills, and image interpretation. Commonly, lectures followed by simulation sequence is used for teaching TEE. Differences may occur among learners when this sequencing of instructional components is altered. The authors investigated the ideal sequence of lectures and simulation in teaching basic perioperative TEE. DESIGN: Prospective randomized comparative study. SETTING: Simulation room in a large academy tertiary care center. PARTICIPANTS: Noncardiac anesthesiologists in Singapore with no prior knowledge of TEE. INTERVENTION: Comparison of acquisition and retention of knowledge and skills between the lecture followed by simulation group (LS) and the simulation followed by lecture (SL) group. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed using multiple-choice questions (MCQs) and skills using a skill test. The primary outcome measured was the MCQ scores (post-course and retest) and the skill test scores (post-course and retest). Of the 43 anesthesiologists who were recruited, 22 were randomized into the LS group and 21 to the SL group. All participants took pre-course and post-course MCQs and post-course skill tests. Post-tests were repeated 1 month after the course to assess retention. There was no significant difference in the post-course MCQ (85.87% v 81.82%) and skill test scores (85.78% v 81.55%) between the SL and LS groups, respectively. The SL group demonstrated significantly better retention of knowledge at 1 month (MCQ score 83.5% v 72.73%; p = 0.003) and skills (skill test score 85.32% v 1.90%; p = 0.016) than the other. CONCLUSION: This study showed that, for retention (at 1 month) of both knowledge and skills, it is preferable to teach practical skills followed by theoretical knowledge to anesthesiologists who are complete novices to TEE.

Can there be a place for intraoperative salvaged blood in spine tumor surgery?

BACKGROUND: Intraoperative cell salvage (IOCS) has been used in musculoskeletal surgery extensively. However, it has never found its place in musculoskeletal oncologic surgery. We have conducted the first-ever study to evaluate the feasibility of IOCS in combination with a leucocyte-depletion filter (LDF) in metastatic spine tumor surgery. This was to pave the path for use of IOCS-LDF in musculoskeletal oncologic surgery. METHODS: Patients with a known primary epithelial tumor, who were offered surgery for metastatic spinal disease, were recruited. Blood samples were collected at three different stages during the surgery: from the operative field before IOCS processing, after IOCS processing, and after IOCS-LDF processing. Three separate samples (5 mL each) were taken at each stage. Samples were examined using immunohistochemical monoclonal antibodies to identify tumor cells of epithelial origin. RESULTS: Of 30 patients in the study, 6 were excluded for not fulfilling the inclusion criteria, leaving 24 patients. Malignant tumor cells were detected in the samples from the operative field before IOCS processing in eight patients and in the samples from the transfusion bag after IOCS processing in three patients. No viable malignant cell was detectable in any of the blood samples after passage through both IOCS and LDF. CONCLUSIONS: The findings support the notion that the IOCS-LDF combination works effectively in eliminating tumor cells from salvaged blood, so this technique can be applied successfully in spine tumor surgery. This concept can then further be extended to whole musculoskeletal tumor surgery and other oncologic surgeries with further appropriate clinical studies.