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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







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?




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


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