Placement of a customised load-bearing titanium plate for prevention of iatrogenic mandibular fracture in surgical removal of odontogenic keratocyst recurrence

A 72-year-old woman with a history of removal of a right hemimandibular keratocyst 10 years ago was referred to our attention for a large swelling of the right cheek. The orthopantomography and the CT scan showed a huge osteolytic area of the right mandibular ramus and angle. The patient’s refusal to resection and reconstruction with a free flap pushed us towards a conservative treatment. The high probability of a iatrogenic mandibular fracture during and after surgery required the design of a customised titanium plate to be preliminary placed through cervical incision along the posterior border of the mandible. The patient successfully underwent the surgical positioning of the customised plate and subsequent removal of the keratocyst. She was discharged fit and well 5 days after surgery. She did not experience any infections, pathological fractures or relapse in the 6-month follow-up.

An exploratory study of risk factors for pressure injury in patients undergoing spine surgery

Background: Perioperative patients are potentially at risk for pressure injuries due to anesthetic agents and surgical positioning. Pressure injury increases discomfort and pain in patients and causes complications, which lead to an increase in mortality and hospitalization duration. Most previous studies did not focus on specific types of surgery or surgical positioning. We tried to identify the incidence of perioperative pressure injury during spinal surgery and perioperative risk factors that contribute to pressure injury.Methods: We retrospectively analyzed electronic medical records of 663 patients who underwent spinal surgery between March 2016 and May 2018. The primary outcome was occurrence of pressure injury. Potential risk factors of pressure injury were selected based on previous studies and expert opinion, and divided into two sub-categories: preoperative and intraoperative risk factors. We compared the clinical characteristics of patients in the pressure injury and non-injury groups. Perioperative risk factors for pressure injury were analyzed by logistic regression.Results: Among 663 patients, the incidence of all stages of pressure injury was 5.9%. The face and inguinal regions were the most injured sites (both 28.6%). The pressure injury group showed a 13% longer hospitalization period. Preoperative plasma concentration of protein was associated with 0.5-fold lower pressure injury (OR: 0.50; 95% CI: 0.27 to 0.95; P = 0.034).Conclusions: The incidence of pressure injury was similar to that previously reported and occurred in the direct weight-bearing areas, which led to longer hospitalization. We found that a lower preoperative serum protein level is significantly associated with intraoperative pressure injury occurrence during spinal surgery.

Proposta de implantação da escala de avaliação de risco para o desenvolvimento de lesões decorrentes do posicionamento cirúrgico (ELPO) - relato de experiência

Este estudo teve como objetivo relatar a experiência de uma proposta de implantação da escala de avaliação de risco para o desenvolvimento de lesões decorrentes do posicionamento cirúrgico (ELPO). Tratou-se de estudo descritivo, do tipo relato de experiência, realizado com 49 profissionais (44 técnicos de enfermagem e 5 enfermeiros) do Centro Cirúrgico de um Hospital Universitário, localizado no interior de São Paulo. A proposta foi realizada em 3 etapas: avaliar o conhecimento dos profissionais sobre a ELPO; oficinas para capacitação e apresentação do instrumento proposto; avaliação referente ao instrumento proposto. Os resultados demonstraram ausência de conhecimento sobre a ELPO; interesse da maior parte dos profissionais, vontade de apreender e de mudar atitudes e conceitos; 100% referiram não haver necessidade de alteração do instrumento e que o mesmo é importante e possível de ser aplicado. Logo, é fundamental o conhecimento sobre a importância do posicionamento cirúrgico, visando a prevenção de complicações.Descritores: Segurança do Paciente, Enfermagem de Centro Cirúrgico, Posicionamento do Paciente. Proposal for the implementation of the risk assessment scale for the development of injuries arising from the surgical positioning - experience reportAbstract: The purpose of this study was to report the experience of a proposal to implement the risk assessment scale for the development of lesions resulting from surgical positioning (ELPO). This was a descriptive, experience-based study of 49 professionals (44 nursing technicians and 5 nurses) from the Surgical Center of a University Hospital, located in the interior of São Paulo. The proposal was carried out in three stages: to evaluate the professionals' knowledge about ELPO; workshops for training and presentation of the proposed instrument; evaluation of the proposed instrument. The results demonstrated lack of knowledge about ELPO; interest of most professionals, willingness to learn and change attitudes and concepts; 100% stated that there is no need to change the instrument and that it is important and possible to be applied. Therefore, it is fundamental knowledge about the importance of surgical positioning, aiming at the prevention of complications.Descriptors: Patient Safety, Surgical Center Nursing, Patient Positioning. Propuesta de implantación de la escala de evaluación de riesgo para el desarrollo de lesiones derivadas del posicionamiento quirúrgico - relato de experienciaResumen: Este estudio tuvo como objetivo relatar la experiencia de una propuesta de implantación de la escala de evaluación de riesgo para el desarrollo de lesiones derivadas del posicionamiento quirúrgico (ELPO). Se trató de estudio descriptivo, del tipo relato de experiencia, realizado con 49 profesionales (44 técnicos de enfermería y 5 enfermeros) del Centro Quirúrgico de un Hospital Universitario, ubicado en el interior de São Paulo. La propuesta se realizó en 3 etapas: evaluar el conocimiento de los profesionales sobre la ELPO; talleres para capacitación y presentación del instrumento propuesto; evaluación del instrumento propuesto. Los resultados demostraron la ausencia de conocimiento sobre la ELPO; interés de la mayoría de los profesionales, voluntad de aprehender y de cambiar actitudes y conceptos; El 100% indicó que no había necesidad de modificar el instrumento y que es importante y posible aplicarlo. Por lo tanto, es fundamental el conocimiento sobre la importancia del posicionamiento quirúrgico, buscando la prevención de complicaciones.Descriptores: Seguridad del Paciente, Enfermería de Centro Quirúrgico, Posicionamiento del Paciente.

Operative Technique and Lessons Learned From Surgical Implantation of the NeuroPace Responsive Neurostimulation® System in 57 Consecutive Patients

BACKGROUND The Responsive Neurostimulation (RNS)® System (NeuroPace, Inc) is an implantable device designed to improve seizure control in patients with medically refractory focal epilepsy. Because it is relatively new, surgical pearls and operative techniques optimized from experience beyond a small case series have yet to be described. OBJECTIVE To provide a detailed description of our operative technique and surgical pearls learned from implantation of the RNS System in 57 patients at our institution. We describe our method for frame-based placement of amygdalo-hippocampal depth leads, open implantation of cortical strip leads, and open installation of the neurostimulator. METHODS We outline considerations for patient selection, preoperative planning, surgical positioning, incision planning, stereotactic depth lead implantation, cortical strip lead implantation, craniotomy for neurostimulator implantation, device testing, closure, and intraoperative imaging. RESULTS The median reduction in clinical seizure frequency was 60% (standard deviation 63.1) with 27% of patients achieving seizure freedom at last follow up (median 23.1 mo). No infections, intracerebral hemorrhages, or lead migrations were encountered. Two patients experienced lead fractures, and four lead exchanges have been performed. CONCLUSION The techniques set forth here will help with the safe and efficient implantation of these new devices.