Sepsis and Clinical Simulation: What Is New? (and Old).

BACKGROUND: Sepsis is a critical and potentially fatal condition affecting millions worldwide, necessitating early intervention for improved patient outcomes. In recent years, clinical simulation has emerged as a valuable tool for healthcare professionals to learn sepsis management skills and enhance them. METHODS: This review aims to explore the use of clinical simulation in sepsis education and training, as well as its impact on how healthcare professionals acquire knowledge and skills. We conducted a thorough literature review to identify relevant studies, analyzing them to assess the effectiveness of simulation-based training, types of simulation methods employed, and their influence on patient outcomes. RESULTS: Simulation-based training has proven effective in enhancing sepsis knowledge, skills, and confidence. Simulation modalities vary from low-fidelity exercises to high-fidelity patient simulations, conducted in diverse settings, including simulation centers, hospitals, and field environments. Importantly, simulation-based training has shown to improve patient outcomes, reducing mortality rates and hospital stays. CONCLUSION: In summary, clinical simulation is a powerful tool used for improving sepsis education and training, significantly impacting patient outcomes. This article emphasizes the importance of ongoing research in this field to further enhance patient care. The shift toward simulation-based training in healthcare provides a safe, controlled environment for professionals to acquire critical skills, fostering confidence and proficiency when caring for real sepsis patients.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol.

INTRODUCTION: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results. PATIENTS AND METHODS: Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. RESULTS: A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. CONCLUSION: Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care.

Enhanced recovery after low- and medium-risk liver transplantation. A single-center prospective observational cohort study.

BACKGROUND & AIMS: Few studies have fully applied an enhanced recovery after surgery (ERAS) protocol to liver transplantation (LT). Our aim was to assess the effects of a comprehensive ERAS protocol in our cohort of low- and medium-risk LT patients. METHODS: The ERAS protocol included pre-, intra-, and post-operative steps. During the five-year study period, 181 LT were performed in our institution. Two cohorts were identified: low risk patients (n = 101) had a laboratory model for end-stage liver disease (MELD) score of 20 points or less at the time of LT, received a liver from a donor after brain death, and had a balance of risk score of 9 points or less; medium-risk patients (n = 15) had identical characteristics except for a higher MELD score (21-30 points). In addition, we analyzed the remaining patients (n = 65) who were transplanted over the same study period separately using the ERAS protocol. RESULTS: The low-risk cohort showed a low need for packed red blood cells transfusion (median: 0 units) and renal replacement therapy (1%), as well as a short length of stay both in the intensive care unit (13 h) and in the hospital (4 days); morbidity during one-year follow-up, and probability of surviving to one year (89.30%) and five years (76.99%) were in line with well-established reference data. Similar findings were observed in the medium-risk cohort. CONCLUSIONS: This single-center prospective observational cohort study provides evidence that ERAS is feasible and safe for low- and medium-risk LT.

Disección axilar dirigida utilizando carbón vegetal como marcador en paciente con cáncer de mama tratada con quimioterapia neoadyuvante. Técnica quirúrgica / Targeted axillary dissection using charcoal as a marker in a patient with breast cancer treated with neoadjuvant chemotherapy. Surgical technique

Describir la técnica quirúrgica de la disección axilar dirigida (DAD) usando carbón vegetal como marcador del ganglio linfático axilar metastásico al momento del diagnóstico conjuntamente con la biopsia del ganglio centinela en paciente con cáncer de mama tratada con quimioterapia neoadyuvante con respuesta completa clínica y ecográficamente, demostrando su seguridad y eficacia. Material y Métodos: Estudio retrospectivo y descriptivo. Paciente con cáncer de mama y ganglio linfático metastásico en axila ipsilateral marcado con carbón vegetal al confirmarse ese diagnóstico y tratada con quimioterapia neoadyuvante con posterior negativización tanto clínica como ecográfica del ganglio linfático metastásico. Se planificó para disección axilar dirigida (extirpación del ganglio marcado con carbón vegetal y biopsia de ganglio centinela) con el fin de demostrar la eficacia del marcador utilizado y su relación o no con el ganglio centinela. Resultados: Se comprobó la identificación certera del ganglio afectado marcado con carbón vegetal el cual no presentó migración del colorante o reacción inflamatoria local coincidiendo además con dos ganglios centinelas todos con respuesta patológica completa. El carbón permaneció 153 días desde su administración hasta la cirugía axilar. Conclusión: Esta experiencia admite el marcaje con carbón vegetal del ganglio axilar metastásico al momento de su diagnóstico como un método seguro, sencillo, económico y accesible en relación a otros métodos de marcaje, además su asociación con la biopsia del ganglio centinela nos permite prescindir de la disección axilar en caso de respuesta patológica completa, sin embargo, es importante resaltar que se necesitan evaluar más casos para obtener conclusiones determinantes(AU)

To describe the surgical technique of targeted axillary dissection using charcoal marking of the metastatic lymph node at the time of diagnosis together with sentinel node biopsy in a breast cancer patient who received neoadjuvant chemotherapy with complete clinical and sonographical response, demonstrating its safety and efficacy. Material and Methods: Retrospective and descriptive study. Patient with breast cancer and metastatic lymph node in the ipsilateral axilla which was marked with charcoal upon confirmation of this diagnosis and treated with neoadjuvant chemotherapy with subsequent clinical and sonographical negativization of the metastatic lymph node. It was planned for targeted axillary dissection (removal of charcoal-marked lymph node and sentinel node biopsy) in order to demonstrate the efficacy of the marker used and its relationship or not with the sentinel node. Results: The correct identification of the affected lymph node marked with charcoal was verified, which did not present dye migration or local inflammatory reaction, also coinciding with two sentinel nodes, all of them with a complete pathological response. The charcoal remained 153 days from its administration until the axillary surgery. Conclusion: This experience supports charcoal marking of the metastatic lymph node at the time of diagnosis as a safe, simple, inexpensive and accessible method in relation to other marking methods, in addition its association with sentinel node biopsy allows us to dispense with axillary dissection in case of complete pathological response, however it is important to highlight that more cases need to be evaluated to obtain decisive conclusions(AU)

Management of Intraoperative Crisis During Nonintubated Thoracic Surgery.

Nonintubated video-assisted thoracoscopic surgery programs have gradually spread all over the world. The benefits are based on less invasiveness and earlier recovery. However, complications may appear. For the correct prevention and management of all these potentially critical situations, the principles of crisis resource management (CRM) must be followed. They should also include clinical simulation as a tool to generate different scenarios to improve teamwork. The purpose of this special issue is to appraise and summarize the design, implementation, and efficacy of simulation-based CRM training programs for a specific surgery, including the management of specific surgical and medical critical scenarios.

Anatomic Segmentectomy in Nonintubated Video-Assisted Thoracoscopic Surgery.

Thoracic surgery has evolved into minimally invasive surgery, in terms of not only surgical approach but also less aggressive anesthesia protocols and lung-sparing resections. Nonintubated anatomic segmentectomies are challenging procedures but can be safely performed if some essentials are considered. Strict selection criteria, previous experience in minor procedures, multidisciplinary cooperation, and the 4 cornerstones (deep sedation, regional analgesia, oxygenation support and vagal blockade) should be followed. Better outcomes in postoperative recovery, including resumption of oral intake, chest tube duration, and hospital stay, and low complication and conversion rates, are encouraging but should be checked in larger multicenter prospective randomized trials.

Non-intubated uniportal left-lower lobe upper segmentectomy (S6).

Worldwide accepted indications of anatomical segmentectomies are mainly early stage primary adenocarcinomas, pulmonary metastasis and benign conditions. Their performance through uniportal VATS has become more and more popular due to the less invasiveness of the whole procedure under this approach. Recently, many efforts have focused on non-intubated spontaneously breathing management of lobectomies and anatomical segmentectomies, although specific selection criteria and main advantages are not completely standardized. In a 62-year-old thin man with two pulmonary residual metastasis from sigma adenocarcinoma, after chemotherapy plus antiangiogenic treatment, we indicated a single-incision video-assisted left-lower lobe (LLL) upper segmentectomy (S6) under spontaneous breathing and intercostal blockade. Total operation time was 240 minutes. Chest tube was removed at 24 hours and the patient was discharge on postoperative day 2 without any complication. Non-intubated uniportal VATS is a safe and reasonable approach for lung-sparing resections in selected patients, although more evidence is required for selecting which patients can benefit more over standard intubated procedures.

Nonintubated uniportal VATS pulmonary anatomical resections.

Nonintubated procedures have widely developed during the last years, thus nowadays major anatomical resections are performed in spontaneously breathing patients in some centers. In an attempt for combining less invasive surgical approaches with less aggressive anesthesia, nonintubated uniportal video-assisted thoracic surgery (VATS) lobectomies and segmentectomies have been proved feasible and safe, but there are no comparative trials and the evidence is still poor. A program in nonintubated uniportal major surgery should be started in highly experienced units, overcoming first a learning period performing minor procedures and a training program for the management of potential crisis situations when operating on these patients. A multidisciplinary approach including all the professionals in the operating room (OR), emergency protocols and a comprehensive knowledge of the special physiology of nonintubated surgery are mandatory. Some concerns about regional analgesia, vagal block for cough reflex control and oxygenation techniques, combined with some specific surgical tips can make safer these procedures. Specialists must remember an essential global concept: all the efforts are aimed at decreasing the invasiveness of the whole procedure in order to benefit patients' intraoperative status and postoperative recovery.

Non-intubated single-incision video-assisted thoracic surgery: a two-center cohort of 188 patients.

BACKGROUND: Non-intubated single-incision procedures are slowly expanding because of high experience and skill required, and stricter selection criteria. The aim of this study is to present the first retrospective two-center series in Taiwan and Spain. METHODS: We performed a retrospective analysis of 188 patients undergoing non-intubated single-incision video-assisted thoracic surgery (NI-SI-VATS) procedures between July 2013 to November 2015 in two centers in Taiwan (170 patients) and Spain (18 patients) with two different anesthetic methods. Demographic data, clinicopathological features, preoperative tests, and final outcomes were analyzed to compare the outcomes with the two different techniques. RESULTS: Of the 188 patients, 147 (78%) were women, with a mean body mass index (BMI) of 22.7. Of the 196 specimens, 145 (74%) were malignancies with a mean size of 9.7 mm. Wedge resection was performed in 172 patients (91.4%), anatomical segmentectomy with lymphadenectomy in 8 (4.7%), and lobectomy with lymphadenectomy in 5 (2.6%). Three patients (1.6%) required conversion to orotracheal intubation, while 5 patients (2.7%) required additional ports. Complications appeared in 16 patients (8.5%) with air leak as the most frequent in 7 cases (3.7%). Median chest drainage was 1 day, and median postoperative stay was 3 days. There was neither perioperative death nor postoperative readmission. CONCLUSIONS: Non-intubated single-incision procedures can be feasible and safe in expert hands and experienced teams, even for anatomical resections. Strict selection criteria, skill and experience are mandatory. Comparative cohorts and randomized trials are needed.

Single-incision video-assisted anatomical segmentectomy with handsewn bronchial closure for endobronchial lipoma.

Endobronchial lipomas are rare benign tumors whose symptoms are usually confused with recurrent infections or even asthma diagnosis, and mostly caused by endobronquial obstructive component which also conditions severity. We report a case of a 60-year-old man with a right-lower lobe upper-segment endobronchial myxoid tumor with uncertain diagnosis. We performed a single incision video-assisted anatomical segmentectomy and wedge bronchoplasty with handsewn closure to achieve complete resection and definitive diagnosis. During the postoperative air leak was not observed and there was no complication, with low pain scores and complete recovery. Final pathological exam showed endobronchial lipoma. Single-incision (SI) anatomical segmentectomies are lung-sparing resections for benign or low-grade malignancies with diagnostic and therapeutic value, and the need for a wedge bronchoplasty is not a necessary indication for conversion to multiport or open thoracotomy.

Socket seal surgery: Clinical uses in implant dentistry and guided bone regeneration procedures for single tooth replacement in the esthetic zone.

Restoring failing anterior teeth with a dental implant is considered a complex treatment even with thorough biologic knowledge of the situation. The goal is to produce a result in which the labial soft tissues and the papillae remain stable over time. Treatment of the fresh extraction socket in the alveolar ridge presents a challenge in everyday clinical practice. Regardless of the subsequent treatment, maintenance of the ridge contour will frequently facilitate all further therapeutic steps. Socket seal surgery and socket preservation in combination with immediate, early, or delayed implant placement can be valuable procedures for single tooth replacement. However, their potential as ridge preservation techniques in these different situations still needs to be demonstrated. The use of these procedures is illustrated in three consecutive cases.

Non-intubated video-assisted thoracic surgery management of secondary spontaneous pneumothorax.

Secondary spontaneous pneumothorax (SSP) is serious entity, usually due to underlying disease, mainly chronic obstructive pulmonary disease (COPD). Its morbidity and mortality is high due to the pulmonary compromised status of these patients, and the recurrence rate is almost 50%, increasing mortality with each episode. For persistent or recurrent SSP, surgery under general anesthesia (GA) and mechanical ventilation (MV) with lung isolation is the gold standard, but ventilator-induced damages and dependency, and postoperative pulmonary complications are frequent. In the last two decades, several groups have reported successful results with non-intubated video-assisted thoracic surgery (NI-VATS) with thoracic epidural anesthesia (TEA) and/or local anesthesia under spontaneous breathing. Main benefits reported are operative time, operation room time and hospital stay reduction, and postoperative respiratory complications decrease when comparing to GA, thus encouraging for further research in these moderate to high risk patients many times rejected for the standard regimen. There are also reports of special situations with satisfactory results, as in contralateral pneumonectomy and lung transplantation. The aim of this review is to collect, analyze and discuss all the available evidence, and seek for future lines of investigation.

Intraoperative crisis resource management during a non-intubated video-assisted thoracoscopic surgery.

The management of surgical and medical intraoperative emergencies are included in the group of high acuity (high potential severity of an event and the patient impact) and low opportunity (the frequency in which the team is required to manage the event). This combination places the patient into a situation where medical errors could happen more frequently. Although medical error are ubiquitous and inevitable we should try to establish the necessary knowledge, skills and attitudes needed for effective team performance and to guide the development of a critical event. This strategy would probably reduce the incidence of error and improve decision-making. The way to apply it comes from the application of the management of critical events in the airline industry. Its use in a surgical environment is through the crisis resource management (CRM) principles. The CRM tries to develop all the non-technical skills necessary in a critical situation, but not only that, also includes all the tools needed to prevent them. The purpose of this special issue is to appraise and summarize the design, implementation, and efficacy of simulation-based CRM training programs for a specific surgery such as the non-intubated video-assisted thoracoscopic surgery.

Benefits of awake uniportal pulmonary resection in a patient with a previous contralateral lobectomy.

Surgical resection of a contralateral recurrence of non-small cell lung cancer (NSCLC) is indicated in patients without evidence of disseminated disease and considered functionally operable. General anesthesia and double-lumen intubation involves one lobe ventilation in a patient treated with a previous lobectomy, thus increasing the risks of ventilator-induced injuries and the morbidity. Awake procedures facilitate the surgery decreasing the anesthetic and surgical times, keeping the diaphragm motion and diminishing the ventilator-induced injuries into the remaining contralateral lobe. We present a 43-year-old woman with a previous left-lower lobectomy for a 3.1-cm mucinous adenocarcinoma 15 months before without nodal involvement, who presents a right-lower lobe 8-mm cavitated nodule, with evident radiological growth and fine-needle aspiration concordant with mucinous adenocarcinoma. We suggest an awake procedure with locoregional epidural anesthesia.