Association Between Nil Per Os Status and Intubated Patients Undergoing Surgery.

INTRODUCTION: Patient outcomes heavily rely on nutritional support. However, holding enteric feeds prior to surgical operations in critically ill patients is still a common practice in intensive critical units. Our objective is to describe the relationship between duration of nil per os (NPO) and respiratory outcomes in intubated, critically ill patients requiring operative intervention. METHODS: We conducted a retrospective analysis on intubated, critically ill patients who underwent operative intervention between January 1, 2016, and December 31, 2018, to investigate how the duration of NPO status may affect respiratory outcomes. We compared adverse respiratory events among patients who maintain NPO ≥6 h (NPO group) versus those who were NPO <6 h (non-NPO group) prior to surgery. RESULTS: Two hundred patients met inclusion criteria: 104 for NPO and 96 for non-NPO. Aspiration event was found in 5.8% of NPO patients and 7.3% in non-NPO patients, P = 0.66. Desaturation event was found in 16.3% for NPO and 14.6% in non-NPO, P = 0.73. Pneumonia was found in 18.3% of NPO patients and 19.8% in non-NPO patients, P = 0.78. Reintubated rates were 13.5% for NPO and 16.7% for non-NPO, P = 0.57. Median (range) hours of NPO for non-NPO was 1.0 h (0-3.0) and 13.0 h (6.0-20.0) for NPO, P < 0.05. CONCLUSIONS: For intubated, critically ill patients requiring operative intervention, there was no difference observed in adverse respiratory events between those kept NPO for 6 h or greater compared to those kept NPO for less than 6 h. Patients were commonly without enteric nutrition for periods of time much greater than the American Society of Anesthesia's recommended 6-h period.

Expert laparoscopist performance on virtual reality simulation tasks with and without haptic features.

BACKGROUND: Virtual reality (VR) simulation for laparoscopic training is available with and without haptic feedback features. Currently, there is limited data on haptic feedback's effect on skill development. Our objective is to compare expert laparoscopists' skills characteristics using VR delivered laparoscopic tasks via haptic and nonhaptic laparoscopic surgical interfaces. METHODS: Five expert laparoscopists performed seven skills tasks on two laparoscopic simulators, one with and one without haptic features. Tasks consisted of 2-handed instrument navigation, retraction and exposure, cutting, electrosurgery, and complicated object positioning. Laparoscopists alternated platforms at default difficulty settings. Metrics included time, economy of movement, completed task elements, and errors. Progressive change in performance for the final three iterations were determined by repeated measures ANOVA. Iteration quartile means were determined and compared using paired t-tests. RESULTS: No change in performance was noted in the last three iterations for any metric. There were no significant differences between platforms on the final two quartiles for most metrics except avoidance of over-stretch error for retraction; and cutting task was significantly better with haptics on all iteration quartiles (p < 0.03). Economy of movement was significantly better with haptics for both hands for clip application (p < 0.01) and better for right hand on complex object positioning (p < 0.05). Accuracy was better with haptics for retraction and cutting (p < 0.05) and clip application (p < 0.05). CONCLUSION: Results showed higher performance in accuracy, efficient instrument motion, and avoidance of excessive traction force on selected tasks performed on VR simulator with haptic feedback compared to those performed without haptics feedback. Laparoscopic surgeons interpreted machine-generated haptic cues appropriately and resulted in better performance with VR task requirements. However, our results do not demonstrate an advantage in skills acquisition, which requires additional study.

Impact of Telemedicine on Extended Focused Assessment With Sonography for Trauma Performance and Workload by Critical Care Transport Personnel.

INTRODUCTION: There are currently no reports on whether telementoring for extended focused assessment with sonography for trauma (eFAST) improves critical care transport providers' performance in prehospital settings. Our objective was to determine the impact of teleguidance on eFAST performance and quantify workload experience. METHODS: Eight trauma injury modules were selected on simulated patients. Critical care transport (CCT) providers were tasked to complete one independent and one emergency physician-telementored eFAST. The time to completion and the percent of correct findings were obtained. Participants completed the NASA Task Load Index after each iteration to assess workload. RESULTS: Eight independent and 8 telementored eFASTs were completed. The mean times to complete the independent and telementored eFAST were 5 minutes 16 seconds (95% confidence interval [CI], 3 minutes 32 seconds, 6 minutes 59 seconds) and 8 minutes 27 seconds (95% CI, 5 minutes 14 seconds, 11 minutes 39 seconds), respectively (P = .06). The percentage of correctly identified injuries for the independent versus the teleguided eFAST was 65% versus 92.5% (P = .01). The CCT providers experienced higher mental (P = .004), temporal (P = .01), and effort (P = .004) demands; greater frustration (P = .001); and subjective lower performance (P = .003) during independent trials. The emergency physician experienced higher mental (P = .001), temporal (P = .02), effort (P = .005), and frustration (P = .001) demands than the CCT members. CONCLUSION: The teleguided eFAST yielded higher accuracy than the independent eFAST. The CCT providers relied on teleguidance of the remote physician when performing the eFAST. Teleguidance may improve the accuracy of ultrasounds performed by prehospital personnel in real-life scenarios.

Feasibility and Acceptance of a Teletrauma Surgery Consult Service to Rural and Community Hospitals: A Pilot Study.

BACKGROUND: Many trauma patients currently transferred from rural and community hospitals (RCH) to Level I trauma centers (LITC) for trauma surgery evaluation may instead be appropriate for immediate discharge or admission to the local facility after evaluation by a trauma and acute care surgery (TACS) surgeon. Unnecessary use of resources occurs with current practice. We aimed to demonstrate the feasibility and acceptance of a teletrauma surgery consultation service between LITC and RCH. STUDY DESIGN: LITC TACS surgeons provided telehealth consults on trauma patients from 3 local RCHs. After consultation, appropriate patients were transferred to LITC; selected patients remained at or were discharged from RCH. Participating TACS surgeons and RCH physicians were surveyed. RESULTS: A total of 28 patients met inclusion criteria during the 5-month pilot phase, with 7 excluded due to workflow issues. The mean ± SD age was 63 ± 17 years. Of 21 patients, 7 had intracranial hemorrhage; 12 had rib fractures. The mean ± SD Injury Severity Score was 8.1 ± 4.0). A total of 6 patients were discharged from RCH, 4 admitted to RCH hospitalist service, 2 transferred to a LITC emergency room, and 9 transferred to LITC as direct admission. There was one 30-day readmission and no missed injuries or complications, or deaths. RCH providers were highly satisfied with the teletrauma surgery consultation service, TACS surgeons, and equipment used. Mental demand and effort of consulting TACS surgeons decreased significantly as the consult number increased. CONCLUSIONS: Teletrauma surgery consultation involving 3 RCH within our system is feasible and acceptable. A total of 10 transfers and 19 emergency department visits were avoided. There was favorable acceptance by RCH providers and TACS surgeons.

Routine Assessment of Surgical Resident Wellness-Related Concerns During Biannual Review.

BACKGROUND: Surgery residency confers stress burdens on trainees. To monitor and mitigate areas of concerns, our education team implemented a 6-item biannual survey querying potential stressors. We reviewed the initial 5-year experience to assess for trends and improve efforts in maintaining resident well-being. STUDY DESIGN: Surgery residents from all postgraduate years were asked to complete a survey of common concerns, prioritizing them in order of importance. The items to be ranked were: needs of family/friends; nonwork time for study; financial concerns; personal well-being needs; concerns for clinical performance; and administrative demands. Changes in ranking were trended across 10 review periods. Results were analyzed using a Kruskal-Wallis test. RESULTS: A completion rate of 96.5% was rendered from the completion of 333 surveys. Rankings changed significantly for nonwork time for study (p = 0.04), personal well-being needs (p = 0.03) and concerns for clinical performance (p = 0.004). Nonwork time for study and concerns on clinical performance were consistently ranked as top two stressors over study period, except for spring 2020. Personal well-being needs ranked highest in spring 2020; 41% of residents placed this as top 2 rankings. A decrease in concerns for clinical performance was observed in spring 2020, corresponding to the coronavirus disease 2019 (COVID-19) pandemic emergency declaration. CONCLUSIONS: Surgery residents generally prioritized time for study and concerns for assessment of clinical performance as highest areas of concern. With the occurrence of a pandemic, increased prioritization of personal well-being was observed. Used routinely with biannual reviews, the survey was able to identify plausible changes in resident concerns. Determination of levels of actual stress and actual association with the pandemic requires additional study.

Spatial Volume Necessary to Perform Open Appendectomy in a Spacecraft.

BACKGROUND: With the increase in crewed commercial spaceflight and expeditions to the Moon and Mars, the risk of critical surgical problems and need for procedures increases. Appendicitis and appendectomy are the most common surgical pathology and procedure performed, respectively. The habitable volume of current spacecraft ranges from 4 m³ (Soyuz) to 425 m³ (International Space Station). We investigated the minimum volume required to perform an appendectomy and compared that to habitable spacecraft volumes.METHODS: The axes of a simulated operating room were marked and cameras placed to capture movements. An expert surgeon, chief surgical resident, junior surgical resident, and a nonsurgeon physician each performed a Focused Assessment with Sonography for Trauma and an appendectomy on a simulated patient. Dimensions and volume needed were collected and compared using unpaired t-tests.RESULTS: Mean volume (± SD) needed was 3.83 m³ ± 0.47 m³ for standing and 3.68 m³ ± 0.49 m³ for kneeling (P = 0.638). Minimal volume needed was 3.20 m³ for standing and 3.26 m³ for kneeling. Minimal theoretical volume was 2.99 m³ for standing and 2.87 m³ for kneeling.DISCUSSION: The unencumbered volume needed for an appendectomy is between 2.87 m³ and 4.3 m³. It may be technically feasible to perform an open appendectomy inside the smallest of currently operating spacecraft, at 4 m³ (Soyuz-MS). Space vessels operating without rapid evacuation to Earth will need to consider this volume for potential surgical emergencies. Additional investigation on microgravity and standardization of procedures for novices must be completed.Kamine TH, Siu M, Kramer K, Kelly E, Alouidor R, Fernandez G, Levin D. Spatial volume necessary to perform open appendectomy in a spacecraft. Aerosp Med Hum Perform. 2022; 93(10):760-763.

Time Cost of Provider Skill: A Pilot Study of Medical Officer Occupied Time By Knowledge, Skill, and Ability Level.

INTRODUCTION: On space missions one must consider the operating cost of the medical system on crew time. Medical Officer Occupied Time (MOOT) may vary significantly depending on provider skill. This pilot study assessed the MOOT Skill Effect (MOOTSkE).METHODS: An expert surgeon (ES), fifth year surgical resident (PGY5), second year surgical resident (PGY2), and an expert Emergency Physician (EP) with only 4 mo direct surgical training each performed two simulated appendectomies. The completion times for endotracheal intubation, appendectomy, and two subprocedures (multilayer tissue repair and single layer tissue repair) were recorded.RESULTS: The ES performed the appendectomy in 410 s, the PGY-5 in 498 s, the PGY-2 in 645 s, and the EP in 973 s on average. The PGY-2 and EP time difference was significant compared to the expert. The PGY-5 was not. The EP's time was significantly longer for the appendectomy and the multilayer repair than either surgical resident. For the single layer repair, only the EP-ES difference was significant. A single intubation attempt by the PGY-2 took 73 s while the EP averaged 27 s. The average recorded MOOTSkE between novice and expert was 2.5 (SD 0.34).DISCUSSION: This pilot study demonstrates MOOTSkE can be captured using simulated procedures. It showed the magnitude of the MOOTSkE is likely substantial, suggesting that a more highly trained provider may save substantial crew time. Limitations included small sample size, limited number of procedures, a simulation that may not reflect real world conditions, and suboptimal camera angles.Levin DR, Siu M, Kramer K, Kelly E, Alouidor R, Fernandez G, Kamine T. Time cost of provider skill: a pilot study of medical officer occupied time by knowledge, skill, and ability level. Aerosp Med Hum Perform. 2022; 93(11):816-821.

Analysis of Presentation and Outcomes in Acute Limb Ischemia Patients During COVID-19 State of Emergency.

BACKGROUND: During the COVID-19 pandemic, cardiovascular patients were found to be presenting to hospitals with myocardial infarctions and cerebrovascular accidents at progressed disease states. We noticed a parallel in acute limb ischemia (ALI) patients presenting during Massachusetts' COVID-19 State of Emergency declaration. We question whether patients developed a hesitancy to seek medical attention at hospitals due to fear of COVID-19. Our objective was to compare acuity of ALI, interventions, and limb survival in patients presenting before, during, and after a state of emergency. METHODS: Four timeframes were set to compare patients presenting peri-2020 COVID-19 State of Emergency and patients presenting during a pre-pandemic era at a tertiary, academic institution. A reference period from 2019, Pre-State of Emergency period, State of Emergency period, and Post-State of Emergency period were designated. Patient characteristics, interventions, and outcomes data were collected. Unpaired t-test, ANOVA, and Chi-square statistical analyses were used. RESULTS: A total of 95 patients presenting with ALI were identified. Compared to Reference group, state of emergency group had more patients presenting with Rutherford Class III, 12.9% vs 35%, and less patient presenting with Class I, 45.1% vs 0%, P = .02. State of emergency group had more delayed presentations with ≥6 hours after symptom onset, 45% vs 85%, P = .01. Above-knee amputations were performed in 20% of patients during state of emergency and 31.6% for Post-State of Emergency, vs 6.5% in the Reference group; P = .03. There was no difference in intensive care unit admission, length of stay, or mortality between patients from different groups. CONCLUSION: During a state of emergency, ALI patients were noted to present later from symptom onset, have greater disease severity, and more likely to undergo amputations. We suspect delay in presentation and limb lost to be attributed to reluctance to seek immediate medical attention.

Prophylactic Splenectomy and Hyposplenism in Spaceflight.

BACKGROUND: There is debate whether astronauts traveling to space should undergo a prophylactic splenectomy prior to long duration spaceflight. Risks to the spleen during flight include radiation and trauma. However, splenectomy also carries significant risks.METHODS: Systematic review of data published over the past 5 decades regarding risks associated with splenectomies and risks associated with irradiation to the spleen from long duration spaceflight were analyzed. A total of 41 articles were reviewed.RESULTS: Acute risks of splenectomy include intraoperative mortality rate (from hemorrhage) of 3-5%, mortality rate from postoperative complications of 6%, thromboembolic event rate of 10%, and portal vein thrombosis rate of 5-37%. Delayed risks of splenectomy include overwhelming postsplenectomy infection (OPSI) at 0.5% at 5 yr post splenectomy, mortality rate as high as 60% for pneumococcal infections, and development of malignancy with relative risk of 1.53. The risk of hematologic malignancy increases significantly when individuals reach 40 Gy of exposure, much higher than the 0.6 Gy of radiation experienced from a 12-mo round trip to Mars. Lower doses of radiation increase the risk of hyposplenism more so than hematologic malignancy.CONCLUSION:For protection against hematologic malignancy, the benefits of prophylactic splenectomy do not outweigh the risks. However, there is a possible risk of hyposplenism from long duration spaceflight. It would be beneficial to prophylactically provide vaccines against encapsulated organisms for long duration spaceflight to mitigate the risk of hyposplenism.Siu M, Levin D, Christiansen R, Kelly E, Alouidor R, Kamine TH. Prophylactic splenectomy and hyposplenism in spaceflight. Aerosp Med Hum Perform. 2022; 93(12):877-881.

A systematic review of penetrating extracranial vertebral artery injuries.

BACKGROUND: Penetrating vertebral artery injuries (VAIs) are rare. Because of their rarity, complex anatomy, and difficult surgical exposures, few surgeons and trauma centers have developed significant experience with their management. The objectives of this study were to review their incidence, clinical presentation, radiologic identification, management, complications, and outcomes and to provide a review of anatomic exposures and surgical techniques for their management. METHODS: A literature search on MEDLINE Complete-PubMed, Cochrane, Ovid, and Embase for the period of 1893 to 2018 was conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Our literature search yielded a total of 181 potentially eligible articles with 71 confirmed articles, consisting of 21 penetrating neck injury series, 13 VAI-specific series, and 37 case reports. Operative procedures and outcomes were recorded along with methods of angiographic imaging and operative management. All articles were reviewed by at least two independent authors, and data were analyzed collectively. RESULTS: There were a total of 462 patients with penetrating VAIs. The incidence of VAI in the civilian population was 3.1% vs 0.3% in the military population. More complete data were available from 13 collected VAI-specific series and 37 case reports for a total of 362 patients. Mechanism of injury data were available for 341 patients (94.2%). There were gunshot wounds (178 patients [49.2%]), stab wounds (131 [73.6%]), and miscellaneous mechanisms of injury (32 [8.8%]). Anatomic site of injury data were available for 177 (49%) patients: 92 (25.4%) left, 84 (23.2%) right, and 1 (0.3%) bilateral. Anatomic segment of injury data were available for 204 patients (56.4%): 28 (7.7%) V1, 125 (34.5%) V2, and 51 (14.1%) V3. Treatment data were available for 212 patients. Computed tomography angiography was the most common imaging modality (163 patients [77%]). Injuries were addressed by operative management (94 [44.3%]), angiography and angioembolization (72 [34%]), combined approaches (11 [5.2%]), and observation (58 [27.4%]). Stenting and repair were less frequently employed (10 [4.7%]). The incidence of aneurysms or pseudoaneurysms was 18.5% (67); the incidence of arteriovenous fistula was 16.9% (61). The calculated mortality in VAI-specific series was 15.1%; in the individual case report group, it was 10.5%. CONCLUSIONS: The majority of VAIs present without neurologic symptoms, although some may present with exsanguinating hemorrhage. Computed tomography angiography should be considered first line to establish diagnosis. Gunshot wounds account for most injuries. The most frequently injured segment is V2. Surgical ligation is the most common intervention, followed by angioembolization, both of which constitute important management approaches.