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Resilient Front-Line Management of the Operating Room Floor: The Role of Boundaries and Coordination
Published in Jeffrey Braithwaite, Erik Hollnagel, Garth S Hunte, Working Across Boundaries, 2019
The ‘perioperative’ environment is a term used for an integrated care system, consisting of units for the three primary phases of surgery: pre-operative (prior to surgery), intra-operative (during surgery) and post-operative (following surgery). Each phase involves coordination of tasks, resources and information between multiple caregiver groups, including surgeons, anaesthesiologists, nurses, nurse anaesthetists and residents. The perioperative environment has an inherent dynamic variability, often reflected in changes in case volume, staff availability and case acuities. Accordingly, the overall schedule of the operating rooms (ORs) needs to be monitored, and adjusted or manipulated, and the limited staffing resources need to coordinate accordingly across the OR floor. Anaesthesiologists, in particular, are shared resources, in that one anaesthesiologist may be assigned to as many as three ORs simultaneously, each with a supervised anaesthesia resident or a nurse anaesthetist. In that sense, their availability is a limiting factor for OR teams in terms of progressing from case to case or for scheduling additional cases during the day.
S-ICDs: advantages and opportunities for improvement
Published in Expert Review of Medical Devices, 2022
The initial implantation technique consisted of three incisions [23] but many centers currently use the two-incision technique, which dispenses for the need of a superior parasternal incision [24]. This is simpler and more esthetic, although the rate of inappropriate shocks has been shown to be slightly higher, presumably due to migration of the electrode tip, which is not fixated using this technique [8]. The procedure is performed under general anesthesia or deep sedation, optionally with ultrasound-guided serratus anterior plane block. After having determined lead and generator positioning under fluoroscopy, an oblique incision is performed below the left axilla. An intermuscular pocket between the anterior surface of the serratus anterior muscle and the posterior surface of the latissimus dorsi muscle is created for the pulse generator. A 2-cm horizontal incision at the level of the xiphoid process is performed and the lead is tunneled subcutaneously to the pocket and in the left or right parasternal region. It is important to tunnel the lead deeply, close to the sternum, and position the generator posteriorly, to ensure low defibrillation thresholds [25]. The lead sleeve and the generator are then anchored to the fascia to avoid migration. The two-incision technique is as safe and effective as the three-incision technique while reducing procedure time [26]. The learning curve is short, stabilizing after 13 implants [27]. Perioperative complications are rare and include hematoma, infection and lead displacement, all occurring at rates of <1% [8].