Objectives for this sub-step?
|Inject cement evenly and adequately to stabilize fractured vertebral body||Assist surgeon to inject cement||Ensure patient safety|
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||Time||Vital signs; signs of reactions to cement|
|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||–|
Is this a high-risk sub step?
|Critical phase with higher patient risks||Higher risk||Critical phase with higher patient risks|
Is this action automated?
|Non-automated action||Time has to be monitored actively||–|
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||–||–|