Teamwork matters: team situation awareness to build high-performing healthcare teams, a narrative review.

Healthcare today is the prerogative of teams rather than of individuals. In acute care domains such as anaesthesia, intensive care, and emergency medicine, the work is complex and fast-paced, and the team members are diverse and interdependent. Three decades of research into the behaviours of high-performing teams provides us with clear guidance on team training, demonstrating positive effects on patient safety and staff wellbeing. Here we consider team performance through the lens of situation awareness. Maintaining situation awareness is an absolute requirement for safe and effective patient management. Situation awareness is a dynamic process of perceiving cues in the environment, understanding what they mean, and predicting how the situation may evolve. In the context of acute clinical care, situation awareness can be improved if the whole team actively contributes to monitoring the environment, processing information, and planning next steps. In this narrative review, we explore the concept of situation awareness at the level of the team, the conditions required to maintain team situation awareness, and the relationship between team situation awareness, shared mental models, and team performance. Our ultimate goal is to help clinicians create the conditions required for high-functioning teams, and ultimately improve the safety of clinical care.

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century.

We review the development of technology in anaesthesia over the course of the past century, from the invention of the Boyle apparatus to the modern anaesthetic workstation with artificial intelligence assistance. We define the operating theatre as a socio-technical system, being necessarily comprised of human and technological parts, the ongoing development of which has led to a reduction in mortality during anaesthesia by an order of four magnitudes over a century. The remarkable technological advances in anaesthesia have been accompanied by important paradigm shifts in the approach to patient safety, and we describe the inter-relationship between technology and the human work environment in the development of such paradigm shifts, including the systems approach and organisational resilience. A better understanding of emerging technological advances and their effects on patient safety will allow anaesthesia to continue to be a leader in both patient safety and in the design of equipment and workspaces.

Digitally-enabled remote critical care: the challenges of geography and history?

The COVID-19 pandemic has rejuvenated interest in the possibility of using telemedicine as an approach to providing critical care services to patients in remote areas. Conceptual and governance considerations remain unaddressed. We summarise the first steps in a recent collaborative effort between key organisations in Australia, India, New Zealand, and the UK, and call for an international consensus on standards with due considerations to governance and regulation of this emerging clinical practice.

The evolution of the British Journal of Anaesthesia: the first 100 years.

At this centenary of the British Journal of Anaesthesia (BJA) in 2023, six of its 12 editors/editors-in-chief detail developments over the decades that have led to the BJA becoming a high-impact international scientific journal. As a charity, the BJA supports academic research and training in anaesthesia, critical care, and pain medicine including funding of research grants and postgraduate education. Building on this foundation, the BJA continues to innovate as it aims to become fully electronic, expand into open access publishing, and increase the diversity of its editorial board.

Management of Complex Upper Extremity Trauma with Associated Vascular Injury.

Introduction Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.

Management of Post-Traumatic Composite Bone and Soft Tissue Defect of Leg.

Management of composite defects of leg following trauma requires a planned ortho-plastic approach right from the outset. Timely, planned intervention results in reduced amputation rates and improved limb salvage and function. Right from the time of presentation of the patient to the emergency with such injury, the process of decision making in terms of salvage or amputation, local flap cover/free flap cover, bone reconstruction first or soft tissue or both combined, come into play. Guidelines on management are unclear for such defects, a literature search yielding various methods being used by different authors. This article is a review of current literature on management of composite leg defects. A summary of the literature search in terms of various management options given by various authors including the rationale, advantages and disadvantages of each strategy has been provided in this article. The management protocol and method followed by the author in his institute for management of such composite defects have been described in detail. The article seeks to provide readers with an understanding of the management strategies so that appropriate method could be chosen to provide best result.

Review of Cross-Leg Flaps in Reconstruction of Posttraumatic Lower Extremity Wounds in a Microsurgical Unit.

Since the advent of microsurgery, and expanding expertise in the field, extensive traumatic wounds of leg have been managed successfully with free tissue transfer. Various patient-related factors may preclude the use of free flaps even in units with available expertise and infrastructure. It is in such situations that the "cross-leg flap" comes into play. In these cases, instead of attempting complicated anastomotic techniques or anastomosis in the zone of trauma, it is better to perform the simpler and more reliable cross-leg flap. In this study, we try to show the utility of a cross-leg flap based on a retrospective study of 198 patients who underwent cross-leg flap in our institute over a period of 15 years extending from November 2003 to March 2018. MATERIALS AND METHODS: Case sheets of all patients who underwent cross-leg flap from November 2003 to March 2018 were reviewed. The location of defect in the leg, the indication for cross-leg flap, the pattern of cross-leg flap, and perioperative complications were noted. RESULTS: A total of 198 patients underwent cross-leg flap for traumatic soft tissue injury of leg during this period. The most common reason for performing cross-leg flap was poor pulsatility of the recipient artery as seen intraoperatively, followed by the economics of the procedure wherein the initial cost of free flap was found significantly higher compared with cross-leg flap. All flaps survived with partial necrosis occurring in 23 patients. All flaps settled well by 2 years' time. Bony union/fracture healing evaluation was not a part of this study. CONCLUSION: Cross-leg flap is still a useful tool for leg wound coverage even in microsurgical unit in situations precluding free flap coverage.

Nasopharyngeal Dermoids and Cleft Palate.

Nasopharyngeal dermoids associated with cleft palate present as intraoral protruding masses. Only 5 cases of nasopharyngeal dermoids associated with cleft palate have been reported in the literature. We are reporting 4 such cases encountered by us in the last 10 years in our series of 900 cleft palate surgeries. Imaging studies were done to know the extension of dermoid and to look for any associated congenital intracranial anomalies. We observed that nasopharyngeal dermoids are usually nonmalignant and can be easily managed by complete local excision followed by palatal closure after 6 months.

A retrospective analysis of incidence and management of palatal fistula.

BACKGROUND: Cleft palate repair may be compromised by a number of complications, most commonly the development of a fistula. Fistulas may cause hypernasal speech, articulation problems and food or liquid regurgitation from the nose. OBJECTIVE: The study determines the incidence and management of cleft palatal fistulas in a series of primary cleft palate repair surgeries. It is a retrospective analysis of total 185 palatal fistula cases operated at our hospital from the year 2004 to 2016. SUBJECTS AND METHODS: Of 185 palatal fistulas, 132 cases had been operated at our institute for primary palatoplasty, and the rest 53 were the outside-operated cases. The patients with bilateral as well as unilateral cleft lip and palate were included. Isolated cleft palate patients were also included in the study. Palatal fistulas were subdivided into three types depending on their size. Anterior palatal fistulas were mostly treated by using tongue flap (65.57%), followed by local flaps (34.43%). Middle and posterior palatal fistulas were mostly treated by von Langenbeck Palatoplasty. One patient (>5 mm fistula) was treated using free radial forearm flap. RESULTS: Anterior palatal fistulas (65.57%) were most commonly reported, followed by middle (24.86%) and posterior (9.18%). Most commonly, the size of the fistulas ranged from 2 mm to 5 mm. The complication rate was reported to be 3.75% in case of tongue flap and 11.9% complications were reported in case of local flaps. CONCLUSION: Tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulas compared to local flaps.

A retrospective analysis of latissimus dorsi-serratus anterior chimeric flap reconstruction in 47 patients with extensive lower extremity trauma.

BACKGROUND: Many flaps have been described for reconstruction of lower extremity defects, including, Latissimus Dorsi, Rectus abdominis, Anterolateral thigh perforator flaps, each having advantages and disadvantages. The defect location, size and specific geometric pattern of defect influences the type of flap that can be used. In this case series, we describe the specific situations where the use of chimeric latissimus dorsi-serratus anterior (LD + SA) free flaps are of advantage in providing complete wound cover. MATERIALS AND METHODS: Case records of all patients who underwent LD + SA free flap transfer for lower extremity trauma at Amandeep Hospital, from Feb 2006 to Feb 2017 were reviewed. Patients were categorised based on the anatomical location and size of defect. The method of usage of the chimeric segments, recipient vessels and type of anastomosis were noted. Flap complications, if any were reviewed. RESULT: 47 patients with lower limb defects were included in the study. All cases were post traumatic in nature. Defect size ranged from 180 sq cm to 1050 sq cm. Average defect size was 487.70 sq cm. All patients underwent soft tissue reconstruction with LD + SA flap. Complete wound cover was obtained. CONCLUSION: Latissimus dorsi + Serratus anterior free tissue transfer is an effective, reliable method of providing cover to extensive lower limb traumatic defects with minimal donor site morbidity, with added freedom of inset and flap positioning. Specific use is seen in patients with broad proximal defect, long defect in the leg, defects involving adjacent anatomical areas and in large defect with dead space.

Retesting the Hypothesis of a Clinical Randomized Controlled Trial in a Simulation Environment to Validate Anesthesia Simulation in Error Research (the VASER Study).

BACKGROUND: Simulation has been used to investigate clinical questions in anesthesia, surgery, and related disciplines, but there are few data demonstrating that results apply to clinical settings. We asked "would results of a simulation-based study justify the same principal conclusions as those of a larger clinical study?" METHODS: We compared results from a randomized controlled trial in a simulated environment involving 80 cases at three centers with those from a randomized controlled trial in a clinical environment involving 1,075 cases. In both studies, we compared conventional methods of anesthetic management with the use of a multimodal system (SAFERsleep; Safer Sleep LLC, Nashville, Tennessee) designed to reduce drug administration errors. Forty anesthesiologists each managed two simulated scenarios randomized to conventional methods or the new system. We compared the rate of error in drug administration or recording for the new system versus conventional methods in this simulated randomized controlled trial with that in the clinical randomized controlled trial (primary endpoint). Six experts were asked to indicate a clinically relevant effect size. RESULTS: In this simulated randomized controlled trial, mean (95% CI) rates of error per 100 administrations for the new system versus conventional groups were 6.0 (3.8 to 8.3) versus 11.6 (9.3 to 13.8; P = 0.001) compared with 9.1 (6.9 to 11.4) versus 11.6 (9.3 to 13.9) in the clinical randomized controlled trial (P = 0.045). A 10 to 30% change was considered clinically relevant. The mean (95% CI) difference in effect size was 27.0% (-7.6 to 61.6%). CONCLUSIONS: The results of our simulated randomized controlled trial justified the same primary conclusion as those of our larger clinical randomized controlled trial, but not a finding of equivalence in effect size.

Role of tongue flap in palatal fistula repair: A series of 41 cases.

INTRODUCTION: Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair. MATERIALS AND METHODS: We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done. OBSERVATION AND RESULT: None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases. CONCLUSION: Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae.

Prehabilitation: A proactive approach to enhancing outcomes in joint replacement surgery.

Prehabilitation is an emerging proactive and preventive approach to healthcare that focuses on preparing individuals for upcoming medical interventions or procedures. It aims to optimize physical and mental health before the planned medical and surgical interventions. By integrating exercise, psychological support, and lifestyle modifications, prehabilitation empowers individuals to face medical interventions with increased resilience and a higher likelihood of successful outcomes. Prehabilitation helps patients build strength and endurance, which can enhance their ability to withstand the physical stress of surgery and contribute to faster recovery. It plays a crucial role in optimizing outcomes for patients undergoing joint replacement surgery, by enhancing postoperative recovery, reducing complications, and improving the overall quality of life for patients. As the field of orthopaedics continues to evolve, the integration of prehabilitation into standard care protocols has the potential to redefine the landscape of joint replacement surgeries, ultimately improving patient outcomes, and hence more research is required from diverse population groups from developed and developing countries to collate required data and formulate evidence-based clinical guidelines.

A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial.

BACKGROUND: Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment. METHOD: The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site. DISCUSSION: We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe. TRIAL REGISTRATION: ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

Effects of subanesthetic dose of nitrous oxide on cerebral blood flow and metabolism: a multimodal magnetic resonance imaging study in healthy volunteers.

BACKGROUND: Nitrous oxide, in a concentration of 50% or more, is a known cerebral vasodilator. This study investigated whether a lower dose (30%) of nitrous oxide would also increase cerebral blood flow. In addition, the authors wished to study whether the increase in cerebral blood flow was accompanied by an increase in cerebral metabolism. METHODS: Multimodal Magnetic Resonance Imaging at 3T was performed, and data were obtained in 17 healthy volunteers during three inhalation conditions: medical air, oxygen-enriched medical air (40% oxygen), and 30% nitrous oxide with oxygen-enriched medical air (40% oxygen). Arterial spin labeling was used to derive the primary tissue specific hemodynamic outcomes: cerebral blood flow, arterial blood volume and arterial transit times. Magnetic Resonance Susceptometry and proton Magnetic Resonance Spectroscopy were used for secondary metabolic outcomes: venous oxygenation, oxygen extraction fraction, cerebral metabolic oxygen rate and prefrontal metabolites. RESULTS: Nitrous oxide in 40% oxygen, but not 40% oxygen alone, significantly increased gray matter cerebral blood flow (22%; P < 0.05) and arterial blood volume (41%; P < 0.05). Venous oxygenation increased in both oxygen and nitrous oxide conditions. Compared with medical air inhalation, nitrous oxide condition caused a significantly larger decrease in oxygen extraction fraction than 40% oxygen alone (mean [SD] 11.3 [5.6]% vs. 8.3 [5.9]% P < 0.05), while global cerebral metabolic rate and prefrontal metabolites remained unchanged. CONCLUSIONS: This study demonstrates that 30% nitrous oxide in oxygen-enriched air (40% oxygen) significantly increases cerebral perfusion, and reduces oxygen extraction fraction, reflecting a strong arterial vasodilatory effect without associated increases in metabolism.

Functional outcome of patients undergoing replantation of hand at wrist level-7 year experience.

BACKGROUND: Replantation is defined as reattachment of amputated limb using neurovascular and musculoskeletal structures in order to obtain recovery of limb. Re-vascularisation involves all the above steps in case of limb injuries that result in a near total amputation. AIM AND OBJECTIVE: To study the functional outcome of patients undergoing replantation of hand at wrist level. MATERIAL AND METHODS: This is a retrospective study of patients who underwent replantation of total amputation of hand at wrist level within a period of Jan 2003-June 2010. We evaluated post operative functional outcome compared to uninjured hand taking into consideration: 1. The patient's overall satisfaction with the hand. 2. Recovery of flexor and extensor function of thumb and fingers. 3. Recovery of thumb opposition. 4. Recovery of sensations in the median and ulnar nerve distribution. 5. Ability of surviving hand to perform daily tasks. RESULTS: There were total seventeen patients and age range was two years to 55 years. Out of 17 patients,16 were males. All the replantations were successful except for one. SUMMARY: The results showed that, although the replanted hands were never functionally as good as the contralateral hand the patients were able to perform most of the daily activities.

Novel events in the molecular regulation of muscle mass in critically ill patients.

Critically ill patients experience marked skeletal muscle atrophy, but the molecular mechanisms responsible for this are largely unresolved. Therefore, we investigated key genes and proteins, identified from cell and animal studies to control protein synthesis and breakdown, in vastus lateralis biopsy samples obtained from 10 patients and 10 age- and sex-matched healthy controls. Muscle cytokines IL-6 and TNF-α mRNA were higher in patients than in controls(6.5-fold; P < 0.001 and 2-fold; P < 0.01). From the perspective of muscle protein breakdown, muscle-specific E3-ligases (MAFbx and MuRF1) were higher in patients at mRNA (4.5-fold; P < 0.05 and 2.5-fold; P < 0.05) and protein (5-fold; P < 0.001 and 4.5-fold; P < 0.001) level. Furthermore, 20S proteasome mRNA and protein were higher in patients (5-fold; P < 0.001 and 2.5-fold; P < 0.01). Cathepsin-L mRNA was 2-fold higher (P < 0.01), whilst calpain-3 mRNA(2-fold; P < 0.01) and protein (4-fold; P < 0.01)were lower inpatients. Another novel observation was the 3-fold (P < 0.05) and 8.5-fold (P < 0.001) higher expression of myostatin mRNA and protein in patients. Widespread dephosphorylation (inactivation) of proteins regulating translation initiation factor activation and protein synthesis (Akt1, GSK3α,ß, mTOR, p70S6K and 4E-BP1) was observed in patients, which was paralleled by increases in their mRNAs. Finally, PDK4 mRNA and protein was 2-fold (P < 0.05) and 2.6-fold (P < 0.01), respectively, higher inpatients. In conclusion, we showed comprehensive alterations in molecular events thought to reduce muscle mass and carbohydrate (CHO) oxidation in critically ill patients. Nevertheless,these catabolic events were matched by a cellular programme of anabolic restoration at the transcriptional level. This shows a high molecular plasticity in the muscle of patients, and strategies to preserve muscle mass and metabolic function should focus on maintaining Akt phosphorylation and inhibiting myostatin expression.C

Anesthesia and patient safety: have we reached our limits?

PURPOSE OF REVIEW: To provide recent evidence of safety in anesthesia and appraise the role of established tools of safety improvement in anesthesia practice. RECENT FINDINGS: The current incidence of minor events or complications during anesthesia is estimated at 18-22%, for severe complications 0.45-1.4%, and for mortality of 1: 100 000. Evidence suggests that despite such low complication rates, further improvements can still be made by addressing systemic factors which are known to set up conditions for adverse events. In particular, improvements can be made in the areas of drug errors, and inadequate or lack of communication between different clinical teams during the process of handovers. In addition, the evidence is growing which highlights the importance of established tools such as critical incident reporting, quality management using plan-do-check-act cycles, use of checklists and use of simulation in training clinical staff in the areas of nontechnical skills. SUMMARY: Anesthesia is one of the safest clinical specialties and remains at the top among leaders of patient safety. This review provides evidence for the areas in which further progress can be made, and usefulness of certain tools, such as critical incident reporting, checklists, plan-do-check-act cycles and simulation, can be used for continued improvements.