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Intraoperative neurophysiological monitoring (IONM) is shown to be useful in surgeries when the nervous system is at risk. Its success in part relies upon proper setup of often dozens of electrodes correctly placed and secured upon patients and inserted in specific stimulating and recording receptacles. Given the complicated setups and the demanding operating room environment, errors in setup are bound to occur. These have led to false negatives associated with new patient morbidities including, at times, paralysis. No studies quantify the prevalence of these types of setup errors. Approximately 800,000 operations annually utilize intraoperative neuromonitoring in the US alone, so even a small percentage of errors suggests clinical significance. In addition, these types of errors hinder the overall effectiveness of IONM and may result in lower reported sensitivities and lower cost-effectiveness of this important service. We sought to discover through a prospective study and verification through chart review the prevalence of "electrode-swap" errors (when recording and/or stimulating electrodes are incorrectly placed on the patient or in the IONM equipment during setup) across all procedures monitored. We found recording and/or stimulating electrode set up errors in 24 of 454 cases (5.3%). These data and examples of how errors were discovered intraoperatively are reported. We also offer techniques to help reduce this error rate. This study demonstrates a significant potential avoidable error in IONM diagnostic utility, patient outcome, and sensitivity/specificity of alert criteria. The value of identifying and correcting these errors is consequential, multifaceted, and far-reaching. [ABSTRACT FROM AUTHOR]

Purpose: Surgical intervention for lateral compression (LC) 1 and 2 pelvic ring fractures is controversial. Posterior ring stabilization remains the most common mode of initial fixation. However, greater mechanical instability is observed in the anterior component of LC pelvic fractures. This study tested whether reduction and percutaneous superior ramus fixation will decrease the instability of LC pelvic fractures on intraoperative fluoroscopic imaging. Methods: All adult patients (≥ 18 years) presenting with either a Young–Burgess LC1 or LC2 pelvic ring disruption treated operatively with percutaneous anterior followed by posterior fixation by a single surgeon from July 2021 to June 2023 were retrospectively reviewed. Displacement of the anterior ring to intraoperative manual internal rotation stress examination under fluoroscopy was compared before and after anterior pelvic ring reduction and fixation and prior to posterior pelvic ring fixation. Pre- and post-operative visual analog scores (VAS) for pain were also compared. Results: Twenty-one patients with a mean age of 48.7 years were included. Fifteen patients (71.4%) presented with an LC1, and six (28.6%) with an LC2 injury patterns. Anterior pelvic fixation alone provided 7.5mm reduction in mean displacement of the anterior pelvic ring (pre-operative = 9.2 mm vs. post-operative = 1.6 mm, p < 0.001). VAS significantly decreased from 7.2 one-day pre-operatively to 2.2 twenty-four h post-operatively (p < 0.001). Conclusions: Reduction and fixation of the anterior pelvic ring prior to posterior fixation for LC1 and LC2 pelvic ring disruptions substantially improves mechanical stability on intraoperative stress examination. Combination of percutaneous anterior and posterior fixation significantly decreased VAS above the MCID 24 h after stabilization. [ABSTRACT FROM AUTHOR]

Effective teamwork is essential in almost every job, and can even mean life, death, or disability in some jobs. Intraoperative neurophysiological monitoring (IONM) is a career in which effective teamwork and accurate communication are of utmost importance, yet it comes with a unique set of challenges in which to achieve those goals. Operating rooms can be very stressful environments, even if a surgical neurophysiologist (SNP) works in the same hospital every day. Often an SNP is required to travel from hospital to hospital and work with different teams each day. In addition, communication with the IONM oversight professional (IONM-P) can be challenging by nature of the telemedicine model which is becoming the most commonly applied IONM model in the United States. It is unfortunate that such critical skills are assumed and are rarely formally trained. In this article, we present evidence-based recommendations for establishing effective team function. We also provide several tools designed to help create effective and efficient teams. Teams cannot function at their best without outstanding communication, so improving teamwork also means improving communication. This article also provides several techniques for excellent communication, regardless of the situation or context. [ABSTRACT FROM AUTHOR]

Objectives: Thyroidectomy and parathyroidectomy using the nerve integrity monitor (NIM) require proper placement of the endotracheal tube with electrodes aligned correctly within the larynx. The purpose of this study is to determine the percentage of patients who require positional adjustments of the endotracheal tube prior to beginning surgery and to understand the value of using the GlideScope to assure proper NIM tube placement within the larynx. Methods: This prospective study examines operative data from 297 patients who underwent NIM thyroidectomy and parathyroidectomy. After routine orotracheal intubation by an anesthesiologist and positioning of the patient for surgery, a GlideScope was used to check the position of the tube in 2 planes: depth of tube placement and rotation of the tube within the larynx assuring proper placement of the electromyogram electrodes within the glottis. Results: Tube adjustment was required for 66.5% of patients. In 48.1% of cases, tube retraction or advancement to a proper depth was needed. Tube rotation was required for 30.1% of patients, and 11.8% of patients required both adjustment of tube depth and tube rotation to properly align electrodes. Conclusions: After the anesthesiologist places the NIM endotracheal tube, and the patient is positioned for surgery, additional tube adjustment is often needed prior to the start of surgery. The GlideScope is readily available in the operating suite, its use adds little time to the procedure, and assures proper NIM tube placement. The use of the GlideScope is recommended. [ABSTRACT FROM AUTHOR]

Intraoperative nerve monitoring (IONM) is a tool used during thyroid surgery to assist in the identification of the recurrent laryngeal nerve (RLN). Multiple IONM systems that exist for thyroidectomy require intubation with an endotracheal tube. Given that one of the advantages of thermal ablation procedures, such as radiofrequency ablation, is that they can be done safely without the use of general anesthesia, nerve monitoring systems that utilize cutaneous surface electrodes have been developed, though are not widely available in the United States. This article will review the use of IONM for RFA including the cutaneous surface electrode system. [ABSTRACT FROM AUTHOR]

Background Cardiac surgical interventions, extracorporeal membrane oxygenation, transcutaneous coronary-artery angioplasty, and stenting are carried out while patients are being treated with the anticoagulation drug heparin. Monitoring the level and reversal of heparinization during and at the conclusion of medical and surgical procedures is a critical issue in patient care. Methods We performed parallel testing of the ACCRIVA Hemochron Signature Elite ACT+ and Hemochron Response analyzer, iSTAT platform, and 2 Hepcon Hemostasis Management System (HMS) Plus analyzers for monitoring intraoperative heparin treatment. Laboratory anti-Xa assay was used as the criterion standard for heparin measurement. Results Poor correlation between the 2 Hemochron analyzers was identified at 0.78. Correlation between the analyzers on the i-STAT platform was 0.97. Regression analysis revealed that i-STAT values were generally lower, by 43 seconds, than Hemochron values. The correlation between Hepcon and i-STAT activated clotting time (ACT) results was 0.94. The i-STAT ACT results were generally 23 seconds lower than the Hepcon ACT values. Correlation coefficients on comparing Hepcon ACT and i-STAT ACT using laboratory anti-Xa assay were 0.83 and 0.87, respectively. The correlation between Hepcon heparin concentration and anti-Xa results was 0.85. Conclusions ACT monitoring with iSTAT offers good correlation between instruments and with the Hepcon ACT. Hepcon occupies a specific niche in cardiac operating departments because of its ability to provide additional information regarding heparin concentration; however, lack of suitable proficiency testing may impair its use. The iSTAT is a more reliable platform for broader, hospital-wide application. [ABSTRACT FROM AUTHOR]

The article discusses the need to quickly recognize deeper levels of sedation among young children and to rescue them from potential adverse responses as of 2018. Topics covered include the death of a 6-year-old child following general anesthesia in a tooth extraction procedure, and the common use of the single operator model of sedation by dentists. Also noted is the need to follow American Academy of Pediatrics and American Society of Pediatric Dentistry (AAP/AAPD) guidelines on the matter.

Postoperative vision loss following a major spine operation is a rare but life-changing event. Most of reports have been linked to ischemic optic neuropathy, and patients undergoing surgery for scoliosis correction or posterior lumbar fusion seem to be at the highest risk. Despite that some key risk factors have been identified, much of the pathophysiology still remain unknown. In fact, whereas only a minority of patients at high risk will present this complication, others with similar risk factors undergoing different procedures may not develop it at all. On the other hand, even when all preventive measures have been taken, ischemic optic neuropathy may still occur. Therefore, it is appropriate for clinicians involved in these cases to inform their patients about the existence of a small but unpredictable risk of vision loss. Since ischemic optic neuropathy is deemed to be the leading cause of vision loss in the context of major spine surgery in prone position, this review will be focused on its main aspects related to the frequency, diagnosis, predisposing factors, and prevention. Regrettably, no treatment has been proved to be effective for this condition. [ABSTRACT FROM AUTHOR]

Purpose: How changes in the surgical team's culture can potentially reduce operating room (OR) traffic. Introduction: Excessive OR traffic during surgical procedures can present a risk to the patient's safety and recovery. Data suggest that limiting the number of OR personnel during the intraoperative period can reduce excessive OR traffic. However, it is unclear whether the surgeon's verbal intervention can also successfully reduce intraoperative OR traffic. This study compares traffic rates in hip and knee arthroplasty cases against traffic rates during nonarthroplasty cases to examine the effects of verbal interventions implemented by the surgeon to reduce intraoperative traffic. Method: The study consisted of 16 orthopedic surgeons in a noninterventional group and 1 orthopedic surgeon in the interventional group. The surgeon in the interventional group implemented verbal protocols to OR staff to limit excessive intraoperative traffic. Operating room traffic was monitored for 3 consecutive months (January-March 2015) with the use of infrared automated door counters that tracked door openings when someone entered or left the OR. Results: A total of 50 hip and knee arthroplasties cases and 157 nonarthroplasty cases were tracked during the study period. A total of 134 hours and 4482 movements were collected for the hip and knee arthroplasty cases. A total of 498 hours and 22 902 movements were collected for the nonarthroplasty cases. Comparing the 2 groups, the interventional group averaged 33 movements per hour while the noninterventional group averaged 46 movements per hour (P < .001). Conclusions: These results suggest that operative room traffic can be reduced through simple verbal protocols established by the surgical team. [ABSTRACT FROM AUTHOR]

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time., (Copyright © 2023 The Author(s). Published by Wiley Periodicals LLC on behalf of American Association of Neuromuscular & Electrodiagnostic Medicine, Inc.)

This article provides a systematic review of awareness with recall, also called intraoperative awareness. Major topics of this review include the incidence and causes of this phenomenon, in addition to an examination of current strategies for prevention of intra-operative awareness. Awareness with recall creates substantial physical and/or psychological distress for the patient, representing a continued threat to patient safety. Factors related to cases of awareness include those of the patient, surgical procedure, anesthesia provider, and system in which providers deliver care. Anesthesia providers today consider use of electro-encephalographic depth-of-anesthesia monitors such as the bispectral index monitor (BIS, Covidien, now Medtronic), as a potential tool for preventing awareness. This Journal course explores evidence related to the utility and limitations of this monitor in clinical practice. It also reviews evidence-based practices that may decrease the incidence of awareness with recall, including avoidance of muscle relaxants and protocol-driven approaches to awareness prevention. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) has been introduced as an endoscopic alternative to surgical myotomy. The endoluminal functional lumen imaging probe (endoFLIP) evaluates esophagogastric junction (EGJ) distensibility based on cross-sectional area and pressure in response to volume distension. The aim of this study was to evaluate whether there is a correlation between endoFLIP measurements during POEM and postoperative clinical outcomes in terms of symptom relief and development of post-procedure reflux.Methods: We conducted a retrospective review of achalasia patients who underwent POEM and intraoperative endoFLIP at three tertiary centers. Patients were divided into two groups based on clinical response measured by Eckardt score (ES): good response (ES < 3) or poor response (ES ≥ 3). Post-procedure reflux was defined as the presence of esophagitis and/or abnormal pH study. EGJ diameter, cross-sectional area, and distensibility measured by endoFLIP were compared.Results: Of the 63 treated patients, 50 had good and 13 had poor clinical response. The intraoperative final EGJ cross-sectional area was significantly higher in the good-response group versus poor-response group; median (interquartile range): 89.0 (78.5-106.7) versus 72.4 (48.8-80.0) mm(2) [p = 0.01]. The final EGJ cross-sectional area was also significantly higher in patients who had reflux esophagitis after POEM: 99.5 (91.2-103.7) versus 79.3 (57.1-94.2) mm(2) [p = 0.02].Conclusion: Intraoperative EGJ cross-sectional area during POEM for achalasia correlated with clinical response and post-procedure reflux. Impedance planimetry is a potentially important tool to guide the extent and adequacy of myotomy during POEM. [ABSTRACT FROM AUTHOR]

Background: Low bispectral index values frequently reflect EEG suppression and have been associated with postoperative mortality. This study investigated whether intraoperative EEG suppression was an independent predictor of 90 day postoperative mortality and explored risk factors for EEG suppression.Methods: This observational study included 2662 adults enrolled in the B-Unaware or BAG-RECALL trials. A cohort was defined with >5 cumulative minutes of EEG suppression, and 1:2 propensity-matched to a non-suppressed cohort (≤5 min suppression). We evaluated the association between EEG suppression and mortality using multivariable logistic regression, and examined risk factors for EEG suppression using zero-inflated mixed effects analysis.Results: Ninety day postoperative mortality was 3.9% overall, 6.3% in the suppressed cohort, and 3.0% in the non-suppressed cohort {odds ratio (OR) [95% confidence interval (CI)]=2.19 (1.48-3.26)}. After matching and multivariable adjustment, EEG suppression was not associated with mortality [OR (95% CI)=0.83 (0.55-1.25)]; however, the interaction between EEG suppression and mean arterial pressure (MAP) <55 mm Hg was [OR (95% CI)=2.96 (1.34-6.52)]. Risk factors for EEG suppression were older age, number of comorbidities, chronic obstructive pulmonary disease, and higher intraoperative doses of benzodiazepines, opioids, or volatile anaesthetics. EEG suppression was less likely in patients with cancer, preoperative alcohol, opioid or benzodiazepine consumption, and intraoperative nitrous oxide exposure.Conclusions: Although EEG suppression was associated with increasing anaesthetic administration and comorbidities, the hypothesis that intraoperative EEG suppression is a predictor of postoperative mortality was only supported if it was coincident with low MAP.Clinical Trial Registration: NCT00281489 and NCT00682825. [ABSTRACT FROM AUTHOR]

Elevated intraocular pressure (IOP) and venous congestion may produce a low ocular perfusion state that can lead to postoperative visual loss (POVL). The literature cites the importance of early IOP reduction to prevent optic nerve damage and visual loss. This study examined dorzolamide hydrochloride and timolol maleate (Cosopt) eyedrops on reducing elevated IOP during laparoscopic surgery with the patient in steep Trendelenburg position. A quasi-experimental study design was used. Subjects involving robotic urologic and gynecologic procedures at 3 separate medical centers were included. The medication was administered topically to both eyes at time points when IOP approached 40 mm Hg. The IOP was measured at 30-minute intervals compared with a supine, anesthetized baseline and final postprocedure supine measurements. A total of 194 patients were recruited, and 63 patients received dorzolamide-timolol treatment when IOP levels reached 38 to 40 mm Hg. Repeated-measures analysis of variance showed that IOP values dropped significantly after drug intervention at 60, 90, and 120 minutes (P < .001). Effect sizes of pharmacologic intervention on IOP reduction were strong (partial n2 of 0.60 to 0.66). Treatment with dorzolamide-timolol eyedrops significantly reduces elevated IOP of patients who undergo lengthy laparoscopic surgery in the steep Trendelenburg position. [ABSTRACT FROM AUTHOR]

Approximately 5.7 million people in the United States have a diagnosis of heart failure, and more than 3,100 patients are awaiting a heart transplant. A temporary total artificial heart (TAH-t, SynCardia Systems Inc, Tucson, Arizona) is approved by the US Food and Drug Administration (FDA) as a bridge to transplant in patients at risk of dying of biventricular heart failure. Currently, TAH-t recipients awaiting transplant are hospital-bound and attached to a large pneumatic driver. In 2010, the FDA gave conditional approval for an Investigational Device Exemption clinical study of the portable Freedom driver (SynCardia). This case report describes a 61-year-old man admitted with acute decompensated heart failure, which progressively worsened, eventually requiring implantation of a TAH-t. Following stabilization, the patient was switched to the Freedom driver. After the patient and his wife proved competence in managing the device, they were able to take several daylong excursions outside the hospital. The patient considered discharge from the hospital while awaiting a transplant but ultimately received a heart transplant while still an inpatient. Higher rates of survival to transplant have already been proved with the TAH-t. Potential benefits for the portable Freedom driver include increased mobility, decreased cost, and improved quality of life. [ABSTRACT FROM AUTHOR]

Swine are a frequent species of choice for testing new surgical procedures and for transplantation studies. However, information concerning best practice to prepare pigs for surgery and postoperative treatment and monitoring is limited, despite a perception that preoperative socialization is beneficial. Therefore we examined the effect of preoperative visits by project personnel on compliance of 26 National Institutes of Health (NIH) minipigs subject to corneal transplantation. We briefly describe sedation and anaesthesia protocols developed for surgery and multiple postoperative interventions in order to facilitate interpretation of data relating to pig compliance. Preoperative visit variables and measures of preoperative socialization were correlated with postoperative outcome. Principal component analysis (PCA) of postoperative outcome variables identified a factor accounting for 53.5% of the variance that was significantly associated with two factors derived from PCA of preoperative factors (accounting, respectively, for 54.7% and 26.0% of the variance; P = 0.019 for the overall model, P = 0.041 and 0.040 for factors 1 and 2, respectively), such that more time spent with pigs before surgery and higher socialization scores were associated with less postoperative stress and difficulty of eye medication. Moreover, two of the preoperative visit variables, time spent with only one person in the pen and time spent with two or more people in the pen, contributed predominantly to PCA factors 1 and 2, respectively, indicating that they were fulfilling two qualitatively different requirements for socialization. We conclude that NIH minipigs are fully compliant with anaesthetic and postoperative experimental procedures provided they are well-socialized to project personnel before surgery. [ABSTRACT FROM AUTHOR]

Objectives: Zenker's diverticulum (ZD) is a common source of dysphagia with a well-established surgical treatment history. Variations may exist between practitioners in the preoperative, intraoperative, and postoperative management of patients with ZD because of recent evolutions in surgical approach toward an endoscopic technique. Methods: An online survey instrument was prepared and forwarded to the membership of the American Broncho-Esophagological Association ( ABEA) to ascertain the current practice patterns of its members regarding numerous care parameters for patients with ZD. Results: Data on preoperative evaluation, operative care, postoperative management, and recalled incidence of complications, including mediastinitis, were evaluated. Subgroup analysis demonstrated significant differences in multiple care parameters for those surgeons who predominantly perform endoscopic operations (more than 80% willingness to perform endoscopic operations) compared to those who occasionally perform endoscopic operations (less than 80%), including average case number, advancement of oral intake, hospital discharge, use of antibiotics, and views on the efficacy of endoscopic surgical techniques. These changes were noted despite similar times since graduation from training for the two groups. Conclusions: These data present a contemporary snapshot of clinical care patterns of the ABEA membership for patients with ZD and suggest differences in care patterns for surgeons with a higher enthusiasm for endoscopic techniques and larger case volumes. [ABSTRACT FROM AUTHOR]

Examines the use of magnetic resonance spectroscopic imaging (MRSI) in the intraoperative optimization planning system for prostate cancer patients in the United States. Effectiveness of MRSI in the distinction between regions of cancer and normal prostatic epithelium; Dose escalation in intraprostatic tumor deposits; Assessment of implant quality.

Alarms in the operating room remain a major source of annoyance and confusion. Nearly all alarms result from a transgression of certain alarm limits. We surveyed manufacturers at a major meeting of anesthesiologists for their default alarm limits. We also conducted a mail survey of anesthesiologists in the United States, Finland, and The Netherlands, to learn their chosen alarm limits, reasons for turning off the alarms, and estimates of the number of false alarms. The surveys of medical monitoring manufacturers demonstrated a wide variety of default alarm settings. Anesthesiologists' chosen alarm limits tended to parallel the manufacturers' defaults. Fewer than 30% of anesthesiologists stated that they did not turn off the alarms. The leading reason for turning off alarms was the large number of false alarms. Estimates of the number of false alarms varied from 30% to 76%. The desired role of alarms in anesthetic practice and some suggestions for the general improvement of alarms are discussed. [ABSTRACT FROM AUTHOR]

Assesses the quality of autotransfused blood through intraoperative monitoring in the United States. Clinical significance of the blood; Components of salvaged blood; Materials and blood extraction methods used in the research; Findings and analysis of results; Advantages of intraoperative blood salvage and autotransfusion; Conclusions; Commentaries of several medical doctors on the research findings.

Inguinal hernia repair is commonplace in general surgery practice and an estimated 700 000 are performed each year in the USA. The presence of the vermiform appendix contained in the hernia sac, or an Amyand's hernia, is exceedingly rare, occurring in 1% of inguinal hernia patients. We report the intra-operative findings of a standard inguinal hernia repair and discuss the management of the four types of Amyand's hernia. [ABSTRACT FROM AUTHOR]

The article offers news briefs as of March 15, 2012. A U.S. District Court ruled that the FDA did not exceed its authority on approval of Sandoz Inc.'s application to market generic enoxaparin sodium injection. The Anesthesia Patient Safety Foundation in a 17-minute video shows improvements in medication safety in operating rooms are possible. Edgar N. Duncan, the first pharmacist promoted to the rank of Assistant Surgeon General in the U.S. Public Health Service, died on December 17, 2011.

The article discusses research which was conducted on post-operative mortality rates at Veterans Affairs hospitals in the U.S. and found that hospitals that had implemented a Medical Team Training program saw reduced levels of post-operative mortality.

A calendar of seminars and the annual conference of the American Society of Electroneurodiagnostic Technologists (ASET) from October 2008 to August 2009 is presented which includes a seminar on electroencephalography (EEG) technology in Pittsburgh, Pennsylvania, a seminar on intraoperative neuromonitoring in Dallas, Texas and its 50th Annual Conference in Phoenix, Arizona.

The article offers information on several conferences of interest to members of the American Society of Electroneurodiagnostic Technologists (ASET) from April 2008 to December 2008 which include its "49th Annual Conference" in New Orleans, Louisiana, "Evoked Potentials: A Comprehensive Review" in Pittsburgh, Pennsylvania, and "Excelling in Intraoperative Neuromonitoring" in Dallas, Texas.

Presents a letter to the author on the accuracy of intraoperative frozen-section analysis of axillary nodes in the United States. Possibility of lymph nodes in a patient with breast cancer; Necessity of surgical axillary clearance; Use of positive lymph nodes as an index of potential generalized spread.