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Table 3 Intra-operative demands for surgeon, nurse, and anesthetist (example sub-step “inject cement”)

From: Stepwise development of a simulation environment for operating room teams: the example of vertebroplasty

Categories Profession
Surgeon Nurse Anesthetist
Objectives for this sub-step?
Inject cement evenly and adequately to stabilize fractured vertebral body Assist surgeon to inject cement Ensure patient safety
Party responsible
Who is responsible?
Surgeon Surgeon Anesthetist
Course of action
How do you proceed?
Inject cement slowly under lateral C-Arm guidance Hand over injection system to surgeon; provide feedback on cement’s time status Monitoring vital signs
What decisions do you need to take?
(1) When to apply cement
(2) Amount of cement to inject
(3) Pressure and speed of injection
(1) Can cement be applied
(2) How long can cement be applied
(1) Increase oxygen saturation
Basis for decisions
On what base do you take these decisions?
(1) Time since cement was mixed, tactile cement probing (like “chewing gum”), experience;
(2) Volume of vertebral body, type of fracture;
(3) Leakages, experience
(1) Cement should “curl” instead of falling down
(2) Depends on type, temperature, and mixing container
(1) Existing risk factors
Focus of attention?
C-arm guidance, cement amount and flow direction, fracture line Time Vital signs; signs of reactions to cement
Important information?
X-ray picture, injected amount (in mm2) on syringe Pitch of oxygen saturation
What feedback do you get?
No haptic feedback through injection, vital signs from anesthetist
Tools and equipment in use?
Syringe or filler, trocar, C-arm, 2nd monitor Applicators or syringes Monitoring devices (ECG, blood pressure, oxygen saturation, temperature)
What communication is necessary?
To anesthetist that cement injection starts, to circulating nurse to reposition C-arm, to scrub nurse how long since cement has been mixed Scrub nurse asks what material is needed for the step “cutaneous suture” (if not already arranged) To surgeon if vital signs change significantly
What coordination takes place?
Handing of syringe from scrub nurse to surgeon Handing of syringe from surgeon to scrub nurse; empty syringes into waste If surgeon needs longer, anesthetist may give medication that supports circulation
Is this sub step time-sensitive?
Yes, as cement can only be injected within a limited duration Yes, cement hardening needs to be monitored
Importance/patient risks
Is this a high-risk sub step?
Critical phase with higher patient risks Higher risk Critical phase with higher patient risks
Automated action
Is this action automated?
Non-automated action Time has to be monitored actively
Potential complications
What kind of complications could occur?
Cement leakage into vessels, spinal canal, or intervertebral disk; too much injected cement; pulmonary embolism Blood pressure may fall if surgical stimulus is missing for too long
Are there any variations to your approach?
Different types of cement, different cement injection systems