Construction and Evaluation of a Realistic Low-Cost Model for Training in Chest-Tube Insertion.

INTRODUCTION: Emergency thoracostomy is applied in life-threatening situations. Simulation plays a pivotal role in training in invasive techniques used mainly in stressful situations. Currently available commercial simulation models for thoracostomy have various drawbacks. METHODS: We designed a thoracostomy phantom from discarded hospital materials and pigskin with underlying flesh. The phantom can be used alone for developing technical skills or mounted on an actor in simulation scenarios. Medical students, intensive care unit (ICU) and emergency department teams, and thoracostomy experts evaluated its technical fidelity and usefulness for achieving learning objectives in workshops. RESULTS: The materials used to construct the phantom cost €47. A total of 12 experts in chest-tube placement and 73 workshop participants (12 ICU physicians and nurses, 20 emergency physicians and nurses, and 41 fourth-year medical students) evaluated the model. All groups rated the model's usefulness and the sensation of perforating the pleura highly. Experts rated the air release after pleura perforation lower than other groups. Lung reexpansion was the lowest rated item in all groups. Ratings of the appearance and feel of the model correlated strongly among all groups and experts. The ICU professionals rated the resistance encountered in introducing the chest drain lower than the other groups. CONCLUSIONS: This low-cost, reusable, transportable, and highly realistic model is an attractive alternative to commercial models for training in chest-tube insertion skills.

Perioperative Management for the First Uterine Transplant in Southern Europe: A Case Report.

BACKGROUND: The aim of this study was to describe perioperative management concerning the living donor uterine transplantation program at the Hospital Clinic (Barcelona, Spain), in the first successful procedure in Southern Europe. METHODS: Before the date of surgery, both the donor and the recipient are evaluated in the outpatient clinic to detect any possible comorbidities that might complicate or altogether disallow the procedure. In the donor, with a robotically performed surgery, complications regarding cerebral and upper airway edema, as well as reduced access to the patient once docking occurs, are of utmost importance. An aggressive antithrombotic regimen must be in place that includes heparin administered both to the donor and the recipient and aspirin to the recipient. Different strategies to reduce ischemia-reperfusion injury have been studied, with reduced ischemia times currently being the most effective. RESULTS: After surgery, both donor and recipient were taken to the intensive care unit overnight, transferred to the conventional ward the following day and discharged from the hospital within the week. The recipient had her first menstrual period 47 days after the surgery. CONCLUSIONS: The description of challenges regarding perioperative care of women who undergo uterine transplant programs and the rationale in anesthetic management may help other teams implant this program as a solution for a disease that profoundly impairs quality of life.

Donor robotic-assisted laparoscopy for uterus transplantation.

OBJECTIVE: Uterine transplantation has proven to be a viable solution in cases of absolute uterine factor infertility. Performing uterine explant surgery is one of the most difficult gynecologic surgical challenges owing to the complexity of the uterine vascular system. The goal of this video is to demonstrate uterine explant surgery and highlight the critical anatomy involved in this procedure. DESIGN: In this video, we display, narrate, and illustrate key portions of right pelvic dissection, which was subsequently performed bilaterally to achieve hysterectomy from a living donor for the purpose of uterine transplantation. SETTING: University hospital. PATIENT(S): The donor was a 39-year-old woman, and the receptor sister suffers from Rokitansky syndrome. A careful right site pelvic dissection was visualized in this operation during a hysterectomy with the aim of performing a uterine graft implantation in a living donor (Research Ethics Committee and the Assistance Ethics Committee of Hospital Clínic de Barcelona [HCB/2016/0111] and Bioethics Committee of Catalunya Study included in ClinicalTrials.org registry [NCT04314869]). INTERVENTION(S): The donor's surgery was performed entirely using robotic surgery (DaVinci Xi, Intuitive Survival Inc.). MAIN OUTCOME MEASURE(S): Assessment of uterine graft transplant viability. RESULT(S): Good quality arterial and venous pedicles were obtained during the surgery. The difficulty of this procedure is the extensive vascular dissection that has to be done to isolate the veins that drain the uterus until the hypogastric vein. CONCLUSION(S): Pelvic anatomy dissection for obtaining the graft from the donor in uterus transplantation is complex, and robotic-assisted laparoscopic surgery may help to provide a clear and more precise visualization.

Factores pronósticos en las paradas cardiorrespiratorias intrahospitalarias. Revisión de 760 casos / Prognostic factors for in-hospital cardiopulmonary arrests. A review of 760 cases

Fundamento y objetivo: Analizar las paradas cardiorrespiratorias (PCR) intrahospitalarias acontecidas en las salas de hospitalización convencional y evaluar los factores pronósticos de las mismas. Pacientes y método: Revisión retrospectiva de las PCR intrahospitalarias acontecidas en nuestro hospital durante un período de 9 años. Fueron excluidas las PCR en áreas de intensivos, quirófanos y urgencias. Datos recogidos: características demográficas, etiología y ritmo inicial de la PCR, datos de control interno, horario, lugar, métodos y resultados tras la reanimación cardiopulmonar (RCP) (recuperación de la circulación espontánea [RCE] y supervivencia al alta hospitalaria [SAH]) y estado neurológico al alta. Los resultados se analizaron con el paquete estadístico SPSS® v. 20. Resultados: Edad media 66,9 ± 17,5 años; 63,5% hombres. Tiempo medio de llegada del equipo de PCR = 1,75 ± 0,74 min, con una duración media de RCP = 25,8 ± 16,10 min. Ritmo inicial: a) desfibrilable = 22,1%; b) asistolia = 66,2%, y c) actividad eléctrica sin pulso = 11,7%. RCE = 51% y SAH = 24,8%. Factores asociados a un mejor pronóstico (p < 0,05): edad, motivo de ingreso hospitalario, estado previo del paciente, etiología y mecanismo principal de la PCR, número de desfibrilaciones y duración media de la RCP. Conclusiones: A pesar de haber estudiado diversas variables como factores pronósticos de la RCP y haber obtenido significación estadística en alguna de ellas, la predicción precoz de la supervivencia ante una PCR intrahospitalaria sigue siendo incierta. En cualquier caso, nuestro estudio evidencia que mediante una aplicación racional de medidas organizativas, el 25% de las PCR intrahospitalarias podrían llegar a ser dadas de alta en buenas condiciones, por lo que deberían generalizarse planteamientos organizativos y docentes similares en los grandes hospitales (AU)

Background and objective: The aim of this study is to analyse in-hospital cardiopulmonary arrests (CA) that took place in conventional wards and evaluate their prognostic factors. Patients and method: Retrospective review of in-hospital CA which occurred in our hospital over a 9-year period. CA that took place in intensive care areas, emergency rooms and operating theatres were excluded from the study. The following data were collected: demographic data, cause and initial rhythm of CA, internal control data, time, place, methods and results after cardiopulmonary resuscitation (CPR) (recovery of spontaneous circulation, [ROSC], and survival at discharge [SAD]) and neurologic performance at discharge. Results were analysed with SPSS® v. 20 predictive analytics software. Results: Average age was 66.9 ± 17.5 years; 63.5% male. CA team arrived in 1.75 ± 0.74 min on average, and the average length of CPR was 25.8 ± 16.10 min. First rhythm: a) shockable rhythms = 22.1%; b) asystole = 66.2%, and c) pulseless electrical activity = 11.7%. ROSC = 51% and SAD = 24.8%. Factors associated with a better prognostic (P < .05): age, reason for hospital admission, patient's previous physical condition, principal cause of CA, number of defibrillations and average length of CPR. Conclusions: Despite having studied several variables as prognostic factors for CA and some of them being statistically significant, early prediction for survival for an in-hospital CA remains uncertain. Our study suggests that applying rational organisational measures, 25% of in-hospital CA could be discharged from hospital in good condition, and therefore, these organisational and educational measures should be extended to large hospitals (AU)

[Prognostic factors for in-hospital cardiopulmonary arrests. A review of 760 cases]. / Factores pronósticos en las paradas cardiorrespiratorias intrahospitalarias. Revisión de 760 casos.

BACKGROUND AND OBJECTIVE: The aim of this study is to analyse in-hospital cardiopulmonary arrests (CA) that took place in conventional wards and evaluate their prognostic factors. PATIENTS AND METHOD: Retrospective review of in-hospital CA which occurred in our hospital over a 9-year period. CA that took place in intensive care areas, emergency rooms and operating theatres were excluded from the study. The following data were collected: demographic data, cause and initial rhythm of CA, internal control data, time, place, methods and results after cardiopulmonary resuscitation (CPR) (recovery of spontaneous circulation, [ROSC], and survival at discharge [SAD]) and neurologic performance at discharge. Results were analysed with SPSS(®) v. 20 predictive analytics software. RESULTS: Average age was 66.9±17.5 years; 63.5% male. CA team arrived in 1.75±0.74min on average, and the average length of CPR was 25.8±16.10min. First rhythm: a) shockable rhythms=22.1%; b) asystole=66.2%, and c) pulseless electrical activity=11.7%. ROSC=51% and SAD=24.8%. Factors associated with a better prognostic (P<.05): age, reason for hospital admission, patient's previous physical condition, principal cause of CA, number of defibrillations and average length of CPR. CONCLUSIONS: Despite having studied several variables as prognostic factors for CA and some of them being statistically significant, early prediction for survival for an in-hospital CA remains uncertain. Our study suggests that applying rational organisational measures, 25% of in-hospital CA could be discharged from hospital in good condition, and therefore, these organisational and educational measures should be extended to large hospitals.

Use of therapeutic hypothermia and extracorporeal life support after an unusual response to the ajmaline challenge in a patient with Brugada syndrome.

BACKGROUND: Brugada syndrome is a cardiac disorder associated with a high risk of sudden cardiac death, especially in young subjects. The incidence and prevalence are likely underestimated. The diagnosis is based on a characteristic electrocardiography (ECG) pattern. The most commonly performed confirmatory test in cases of equivocal ECG is the intravenous ajmaline challenge. Although relatively safe, it carries the risk of ventricular arrhythmias that could potentially degenerate into a refractory electrical storm. CASE REPORT: A 27-year-old man developed sustained ventricular fibrillation after ajmaline challenge. He was rescued on extracorporeal life support after 108 min of cardiopulmonary resuscitation. Extracorporeal life support allowed recovery of spontaneous circulation and resulted in a positive neurological outcome..

Viabilidad de los donantes a corazón parado y capnografía / Feasibility of donors-after-cardiac-death and capnography

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Ultrasound-guided ankle block for forefoot surgery: the contribution of the saphenous nerve.

BACKGROUND: Ankle blocks typically include the block of 5 nerves, the 4 branches that trace their origin back to the sciatic nerve plus the saphenous nerve (SaN). The sensory area of the SaN in the foot is variable. Based on our clinical experience, we decided to study the sensory distribution of the SaN in the foot and determine whether the block of this nerve is necessary as a component of an ultrasound-guided ankle block for bunion surgery. METHODS: One hundred patients scheduled for bunion surgery under ankle block were prospectively studied. We performed ultrasound-guided individual blocks of the tibial, deep peroneal, superficial peroneal, and sural nerves. After obtaining complete sensory block of these nerves, we mapped the SaN sensory territory as such area without anesthesia on the medial side of the foot. RESULTS: Every nerve block was successful within 10 minutes of injection. The saphenous territory extended into the foot to 57 ± 13 mm distal to the medial malleolus. This distal margin was 22 ± 11 mm proximal to the first tarsometatarsal joint. The proximal end of the surgical incision was located 1 cm distal to the first tarsometatarsal joint. In only 3 patients (3%), the area of SaN innervation reached the proximal end of the planned incision. CONCLUSIONS: Ultrasound-guided ankle block is a highly effective technique for bunion surgery. The sensory territory of the SaN in the foot seems to extend only to the midfoot. According to our sample, 97% of the patients undergoing bunion surgery under an ankle block would not benefit from having a SaN block.