Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction

Introduction Enhanced recovery after surgery (ERAS) protocols at our institution have led to an expected decrease in hospital length of stay and opioid consumption for patients treated with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. We look to examine the economic patterns across these years to see the impact of costs for the patient and institution. Methods This study retrospectively evaluated consecutive patients treated with bilateral DIEP flaps for breast reconstruction between October 2015 and August 2020. We categorized the cases into three categories: pre-ERAS, ERAS, ERAS + bupivacaine. Primary outcomes observed included the contribution margin per operating suite case minute and total cost to the patient. An analysis of variance determined whether there was a difference between the three groups and a Tukey post-hoc analysis made pairwise comparisons. A p-value < 0.05 was significant. Results A total of 268 cases of bilateral DIEPs performed by the two senior authors were analyzed in this study. Seventy-four cases were pre-ERAS, 72 were ERAS, and 122 were ERAS + bupivacaine. There was a statistical difference between the contribution margin per operating minute. A Tukey post hoc test revealed that the average contribution margin per operating suite case minute was significantly higher for the ERAS and ERAS + bupivacaine compared with the pre-ERAS groups.There was a statistically significant difference between the total cost to the patients. A Tukey post hoc test revealed that the average total cost to the patient was statistically significantly lower for the ERAS and ERAS + bupivacaine compared with the pre-ERAS group. Conclusion Implementation of ERAS and continued improvements in ERAS resulted in significantly decreased costs for the patient and increased profitability for the hospital. Investing in improvements to ERAS protocols can improve profitability for the institution while simultaneously improving costs and access to care for patients in need of breast reconstruction.

Evaluation of microbial contamination on cuff syringe, cuff pressure gauge, and their surroundings in the operating room

Background Some institutions reuse cuff syringes and do not periodically sterilize cuff pressure gauges. Pathogenic bacterial contamination of such equipment may increase the probability of pathogen transmission to patients during anesthetic procedures. Therefore, microbial contamination on cuff syringes, cuff pressure gauges, and their surroundings was assessed in the operating rooms of a university-affiliated tertiary care hospital in Japan. Methods This study was conducted between April and May 2019 in 14 operating suites at a hospital. The following sites in each operating suite were sampled: cuff syringe (inner/outer components), outer components of cuff pressure gauge, cuff syringe and cuff pressure gauge storage drawers, and computer mice. The swabs were directly streaked onto agar plates and incubated. Then, the bacterial species were identified using mass spectrometry. Results The highest bacterial isolation was observed in computer mice, followed by the outside of cuff pressure gauges and the drawers of cuff pressure gauges (92.9, 78.6, and 64.3%, respectively). Most of the identified bacteria belonged to the Bacillus species, with colonization rates of 85.7, 57.1, and 57.1% on computer mice, cuff pressure gauges, and cuff pressure gauge storage drawers, respectively. Coagulase-negative Staphylococcus was found in 35.7% of the specimens and was more prevalent on computer mice (71.4%), followed by on cuff pressure gauges (64.3%). Conclusion Anesthesiologists should be aware of the possible pathogen contamination risk from cuff syringes, cuff pressure gauges, or associated equipment and take appropriate infection control measures to minimize the risk of pathogenic transmission.

Recurrent Chordoma Resection in the Advanced Multimodality Image Guided Operating Suite: 2-Dimensional Operative Video

Recurrent skull base chordomas are challenging lesions. They already had maximum radiation, and in the absence of any effective medical treatment, surgical resection is the only treatment.1,2 Surgery on recurrent previously radiated chordomas, however, carries much higher risk and the likelihood of subtotal resection. Maximizing tumor resection allows longer tumor control.3-5 The Advanced Multimodality Image Guided Operating Suite developed at the Brigham and Women's Hospital, Harvard Medical School, with the support of the National Institutes of Health, provides an optimal environment to manage these tumors. It offers the capability to obtain and integrate multiple modalities during surgery, including magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT), endoscopy, ultrasound, fluoroscopy, and the ability to perform emergent endovascular procedures.5-7 The patient is a 39-yr-old male, presenting after 19 yr follow-up of a surgical resection and proton beam treatment for a skull base chordoma. He developed progressive ophthalmoplegia due to recurrence of his chordoma at the right petrous apex and cavernous sinus. Preoperative angiography demonstrated narrowing of the petrous segment of the right carotid artery suspect of radiation-induced angiopathy. The presence of radiation-induced angiopathy increases the risk of intraoperative carotid rupture, and the availability of endovascular intervention in the operative suite added favorable preparedness to deal with such complications if they happen. Given the clinical and radiological progression, surgical intervention was carried out through the prior zygomatic approach with the goal of performing maximum resection.8 The patient had an uneventful postoperative course and remained stable until he had a second recurrence 4 yr later. The patient consented to the procedure.

Deep Learning-Based Trajectory Tracking Control forUnmanned Surface Vehicle

Trajectory tracking control based on waypoint behavior is a promising way for unmanned surface vehicle (USV) to achieve autonomous navigation. This study is aimed at the guidance progress in the kinematics; the artificial intelligence method of deep learning is adopted to improve the trajectory tracking level of USV. First, two deep neural network (DNN) models are constructed to evaluate navigation effects and to estimate guidance law parameters in real time, respectively. We then pretrain the DNN using a Gaussian–Bernoulli restricted Boltzmann machine to further improve the accuracy of predicting navigation effect. Finally, two DNNs are connected in parallel with the control loop of USV to provide predictive supervision and auxiliary decision making for traditional control methods. This kind of parallel way conforms to the ship manipulation of habit. Furthermore, we develop a new application on the basis of Mission Oriented Operating Suite Interval Programming named “pDeepLearning.” It can predict the navigation effect online by DNN and adjust the guidance law parameters according to the effect level. The experimental results show that, compared with the original waypoint behavior of USV, the prediction model proposed in this study reduces the trajectory tracking error by 19.0% and increases the waypoint behavior effect level.

Use of GlideScope in Patients Undergoing NIM Thyroidectomy

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.

Asleep Deep Brain Stimulator Placement in the Intraoperative Magnetic Resonance Imaging System Hybrid Operating Suite: 2-Dimensional Operative Video

Asleep, image-guided deep brain stimulation (DBS) placement is rapidly gaining popularity because it offers greater patient comfort and comparable accuracy with frame-based methods using microelectrode recording.1 In this video, we demonstrate our protocol to use the frameless, stereotactic ClearPoint system (MRI Interventions Inc, Irvine, California) to place DBS electrodes within an intraoperative magnetic resonance imaging hybrid operating suite (IMRIS; Deerfield Imaging Inc, Minnetonka, Minnesota).1-4 This system uses a skull-mounted aiming device coupled with sequential, intraoperative magnetic resonance imaging guidance to direct DBS lead placement to subcortical targets.2,5 Importantly, this method allows the patient to remain asleep during the operation and does not require medication holidays or additional microelectrode recording equipment. The literature indicates it has comparable accuracy1,6 and outcomes2 with the awake method. We demonstrate this technique with the case of a patient with Parkinson disease who required lead placement in the bilateral subthalamic nuclei.7-9 The patient consented to the procedure and publication. Patient positioning, draping nuances, initial indirect targeting, and final direct targeting are demonstrated. Risks of the operation include a risk of hemorrhage, hardware failure, and infection.10 DBS is currently an underutilized treatment option for patients with Parkinson disease.11 Offering the asleep option may be more tolerable for many patients who are wary of awake surgery.