Impact of COVID-19 pandemic-induced surgical restrictions on operational performance: a case study at the University Hospital of Ulm.

INTRODUCTION: The operating room (OR) is a high-cost and high-revenue area in a hospital comprising extremely complex process steps to treat patients. The perioperative process quality can be optimized through an efficiency-oriented central OR management based on performance indices. However, during the COVID-19 pandemic with the corresponding OR restrictions, there was a significant nation- and worldwide decline in the performance, which may have a lasting impact. Therefore, we proposed the hypothesis that COVID-19 pandemic-related OR restrictions could reduce operative performance in the long term. METHODS: A retrospective, descriptive analysis of perioperative processing times was conducted exemplarily at the University Hospital Ulm using a pre-post design, examining the corresponding second quarters of 2019 to 2022. In total, n = 18,489 operations with n = 314,313 individual time intervals were analyzed. The statistical analyses included the Kruskal-Wallis test adjusted for multiple testing, and the significance level was set at p < 0.01. RESULTS: The results revealed not only a significant decrease in the case volume by 31% (2020) and 23% (2021) during the COVID-19 crisis years, but also significant time delays in various process steps; e.g. the median patient's OR occupancy time (column time) rose from 65 min (2019) to 87 min (2020) and remained elevated (72 min in 2021 and 74 min in 2022, respectively). Even in 2022, beyond the pandemic, the net anaesthesia time was permanently enhanced by 9 min per case. Furthermore, both, the incision-to-closure time and surgeon attachment time were each significantly prolonged by 7 additional minutes, and the time from the end of anaesthesia to the release of the next patient was extended by 4 min. Selected standardized index operations showed only a trend towards these changes, even with a decrease in the incision-to-closure time over time. CONCLUSION: Overall, long-term changes were found in essential perioperative process times even after retraction of the COVID-19 restrictions, indicating some processual "slow down" after the Covid-19-induced "shut down". Further analyses are needed to determine the appropriate targeted control measures to improve processing times and increase the process quality.

Spine surgery in the International Security Assistance Force Role 3 combat support hospital in Mazar-e-Sharif, northern Afghanistan, 2007-2014.

OBJECTIVESince 2007, a continuous neurosurgery emergency service has been available in the International Security Assistance Force (ISAF) field hospital in Mazar-e-Sharif (MeS), Afghanistan. The object of this study was to assess the number and range of surgical procedures performed on the spine in the period from 2007 to 2014.METHODSThis is a retrospective analysis of the annual neurosurgical caseload statistics from July 2007 to October 2014 (92 months). The distribution of surgical urgency (emergency, delayed urgency, or elective), patient origin (ISAF, Afghan National Army, or civilian population), and underlying causes of diseases and injuries (penetrating injury, blunt injury/fracture, or degenerative disease) was analyzed. The range and pattern of diagnoses in the neurosurgical outpatient department from 2012 and 2013 were also evaluated.RESULTSA total of 341 patients underwent neurosurgical operations in the period from July 2007 to October 2014. One hundred eighty-eight (55.1%) of the 341 procedures were performed on the spine, and the majority of these surgeries were performed for degenerative diseases (127/188; 67.6%). The proportion of spinal fractures and penetrating injuries (61/188; 32.4%) increased over the study period. These spinal trauma diagnoses accounted for 80% of the cases in which patients had to undergo operations within 12 hours of presentation (n = 70 cases). Spinal surgeries were performed as an emergency in 19.8% of cases, whereas 17.3% of surgeries had delayed urgency and 62.9% were elective procedures. Of the 1026 outpatient consultations documented, 82% were related to spinal issues.CONCLUSIONSCompared to the published numbers of cases from neurosurgery units in the rest of the ISAF area, the field hospital in MeS had a considerably lower number of operations. In addition, MeS had the highest rates of both elective neurosurgical operations and Afghan civilian patients. In comparison with the field hospital in MeS, none of the other ISAF field hospitals showed such a strong concentration of degenerative spinal conditions in their surgical spectrum. Nevertheless, the changing pattern of spine-related diagnoses and surgical therapies in the current conflict represents a challenge for future training and material planning in comparable missions.

Pediatric Neurosurgical Care in a German Field Hospital in Afghanistan.

Background and Study Objectives Children are commonly found among the injured in war settings. Prognosis often depends on the presence of brain injury. Not all neurosurgery departments of German Armed Forces hospitals, however, have experience in the care of children with neurosurgical conditions. Against this background, we assessed the group of pediatric neurosurgical patients in a German (Role 3) field hospital in Mazar-e-Sharif, Afghanistan. Patients/Materials and Methods We analyzed the operative logbooks from January 1, 2008, to December 31, 2013, to assess the number of neurosurgical procedures that were performed on children (< 18 years of age) at the field hospital of Mazar-e-Sharif. Results During the study period, 327 neurosurgical procedures were performed at the German field hospital. Of these, 29 (9%) were performed on children. The mean age of the pediatric patients (7 girls and 22 boys) was 11.7 years (median age: 12 years; range: 5-17 years). Only three procedures were performed for conditions other than trauma. Pediatric patients accounted for almost 10% of all patients who underwent neurosurgery during a recent military deployment in Mazar-e-Sharif. This percentage is similar to those reported by other nations. These findings show that a considerable number of children underwent neurosurgical treatment. Conclusions Military planners should be aware that Role 3 medical treatment facilities must provide care for pediatric emergencies and must therefore be staffed and equipped accordingly. For military hospitals at home, this means that the management of pediatric patients is an opportunity for medical personnel to receive important pediatric training that enables them to provide care to children in deployed medical facilities.

Fatal thromboembolism to the left pulmonary artery by locally applied hemostatic matrix after surgical removal of spinal schwannoma: a case report.

Locally applied hemostatic agents, mostly consisting of gelatinous granules with admixed human or bovine thrombin, are used in various surgical procedures. In our case, a 78-year-old woman underwent neurosurgical removal of an extraforaminal schwannoma of the L5 dorsal root ganglion. During the procedure, the hemostatic matrix consisting of a meshwork of bovine gelatinous granules admixed with human thrombin was locally applied to control diffuse paravertebral bleeding. Eight hours after surgery, the patient developed dyspnea with right heart failure and finally died. At autopsy, we found complete occlusion of the left pulmonary artery with a large thromboembolus. Histologically, that thromboembolus consisted of gelatinous granules with only a thin rim of surrounding, classic parietal thrombus. To our knowledge, this is the first description of fatal pulmonary embolization of a major lung artery with this material. The report depicts a possible life-threatening complication associated with the local application of hemostatic agents.

Comparative kinetics of organophosphates and oximes with erythrocyte, muscle and brain acetylcholinesterase.

There is an ongoing debate whether oximes can effectively counteract the effects of organophosphorus compounds (OP) on brain acetylcholinesterase (AChE) activity and whether there are differences in the kinetic properties of brain and erythrocyte AChE. In order to investigate the kinetics of AChE from different tissues and species the well established dynamically working in vitro model with real-time determination of membrane-bound AChE activity was adapted for use with brain AChE. The enzyme reactor, that was loaded with brain, erythrocyte or muscle AChE, was continuously perfused with substrate and chromogen while AChE activity was on-line analyzed in a flow-through detector. It was possible to determine the Michaelis-Menten constants of human erythrocyte, muscle and brain AChE which were almost identical. In addition, the inhibition kinetics of sarin and paraoxon as well as the reactivation kinetics of obidoxime and HI 6 were determined with human, swine and guinea pig brain and erythrocyte AChE. It was found that the inhibition and reactivation kinetics of brain and erythrocyte AChE were highly comparable in all tested species. These data support the view that AChE from different tissue has similar kinetic properties and that brain AChE is comparably susceptible toward reactivation by oximes.

Cardiac-gated phase-contrast magnetic resonance imaging of cerebrospinal fluid flow in the diagnosis of idiopathic syringomyelia.

OBJECTIVE: Syringomyelia without an obvious cause, such as a Chiari malformation, a tumor, or a spinal injury, is rare and may be associated with an arachnoid web or cyst. In the literature, conventional myelography is the diagnostic method of choice. In this retrospective study, we evaluated the diagnostic value of magnetic resonance imaging (MRI) cerebrospinal fluid (CSF) flow studies as compared with conventional myelography in patients with syringomyelia. METHODS: From early 2003 to late 2006, 320 patients with syringomyelia underwent cardiac-gated phase-contrast MRI of CSF flow in the brain and spine. We assessed the presence of CSF flow blockage as well as syrinx site, shape, and size. Additional myelography was performed in 8 patients. CSF flow blockage and progressive neurological symptoms or progression of syringomyelia were indications for surgery. RESULTS: Syringomyelia without an obvious cause was found in 125 patients. CSF flow blockage was detected in 33 patients. Seven of these patients underwent cyst wall resection and decompression of the subarachnoid space via a unilateral approach without laminectomy. Myelography revealed CSF flow blockage in only 2 of 8 cases. In the other 6 patients, MRI detected a blockage and surgery revealed arachnoid cysts or webs. Postoperative CSF flow studies revealed free CSF flow in all 10 surgically treated patients. In 6 of these patients, syrinx size was reduced after surgery. CONCLUSION: Myelography should not be the method of choice for the diagnosis of idiopathic syringomyelia. MRI CSF flow studies were found to be more reliable.