Orthogonal external ventricular drain (EVD) trajectory from burr holes sited by junior neurosurgical staff is superior to freehand placement: An in-silico model

External ventricular drain (EVD) or ventriculostomy placement is one of the most common neurosurgical procedures performed worldwide and is associated with complications including haemorrhage, malposition and infection. Several authors have attempted to define an ideal trajectory for placement, and scalp-mounted guidance devices have been devised to exploit the theoretical ideal orthogonal trajectory from the scalp to the lateral ventricles. However, uptake has been limited due to lack of demonstrated superiority to freehand placement. Previous modelling studies have failed to include a true-to-life sample of patients undergoing EVD insertion and excluded cases with midline shift or non-hydrocephalus indications. Further, none have attempted to model the orthogonal insertion of EVD via actual burr holes placed by junior neurosurgical staff. In our report of 58 cases of frontal EVD insertion in a low-volume Australian neurosurgical unit freehand EVD insertion resulted in acceptable placement in the ipsilateral frontal horn in 62% of cases, any ventricle in 22%, and in eloquent or non-eloquent brain in 16% of cases. The modelled orthogonal trajectory from the same burr holes, using post-procedural computed tomography scans and the S8 Stealth Station (Medtronic), resulted in superior placement; 80% in the ipsilateral frontal horn and 20% contralateral (p = 0.007). There were no significant malpositions associated with the modelled trajectories. In our series, 18% of freehand catheters required multiple placement attempts. In conclusion, our data suggests that an orthogonal trajectory may result in improved EVD positioning compared to freehand placement.     

Accuracy of freehand external ventricular drain placement in patients after a large decompressive hemicraniectomy

Our study aim is to evaluate the accuracy of freehand external ventricular drain (EVD) placement, without the use of adjuncts to placement, immediately following a large decompressive hemicraniectomy (DC). We performed a retrospective cohort analysis comparing patients who underwent freehand EVD placement immediately after a DC, to those who underwent freehand EVD placement without DC. Computed tomography (CT) studies were used to assess accuracy based on catheter tip location. Intracranial catheter length, pre- and post-operative Evan’s Index, and midline shift pre- and post-operatively were analysed as separate variables in each group. A previously described grading system was used to assess the accuracy of free hand EVD placement. There were a total 110 patients overall; DC group, n = 50; non-DC group, n = 60. There was a significant reduction from pre-operative midline shift to post-operative midline shift in the DC group (9.13 vs 6.02 mm; p = 0.0064). There was no significant difference in accuracy between the two groups (p = 0.8917), and similar rates of Grade 1 – i.e. optimal – catheter tip location (DC = 78% vs non-DC = 81%) were found. All analysed variables comparing both Grade 1 subgroups (pre- and postoperative Evan’s Index, and midline shift) showed significant differences between them. Mean catheter length in Grade 1 EVD placement showed a statistically significant difference between the DC and non-DC groups (63.78 vs 59.96 mm, respectively; p = 0.009). An EVD, after DC for traumatic and non-traumatic intracranial pathologies, can be accurately placed by freehand.     

颅脑创伤患者侧脑室穿刺置管精准度的相关影响因素分析

目的探讨影响颅脑创伤患者侧脑室穿刺置管精准度的相关因素。方法回顾性分析111例颅脑创伤患者,经侧脑室穿刺置管术后行CT薄层扫描,通过Logistic回归分析影响置管精准度的相关因素。结果穿刺置管位置良好并能通畅引流脑脊液79例,置管成功率为71.17%,穿刺置管精准度与医生手术操作因素有明显相关性,而与患者性别、年龄、术前GCS评分、脑外伤诊断类型、术前是否中线移位及穿刺点位置(左/右侧)等无统计学意义。结论医生手术操作是影响置管成功率的关键因素,提高手术操作精度还可通过设备辅助来提高置管成功率。     

Duration of indwelling drain following instrumented posterolateral fusion of the lumbar spine does not predict surgical site infection requiring reoperation

The objective of this study was to determine the incidence and predictors of reoperation for surgical site infections (SSI) among patients whose lumbar, closed wound suction drains were removed in the inpatient setting prior to hospital discharge (pre-discharge cohort) versus after inpatient discharge during the first follow up visit (post-discharge cohort). All patients who were admitted for first-time, posterolateral decompression and fusion for degenerative lumbar spine disease were retrospectively reviewed at a single institution. In order to eliminate biases, neither the pre-discharge nor post-discharge cohorts experienced any intra-/postoperative sentinel events other than the primary outcome measure: reoperation for SSI. Of 209 patients in the pre-discharge (n = 130) and post-discharge (n = 79) cohorts, 15 patients required reoperation for SSI. Although time to drain discontinuation was significantly longer in the post-discharge (8.28 days) than the pre-discharge (4.65 days) cohorts (p < 0.001), the incidences of reoperation for SSI did not significantly differ (6.33 vs 7.69%, respectively, p = 0.711). In a multivariable regression, only smoking (OR = 5.75, p = 0.007) and depression (OR = 4.11, p = 0.040) predicted reoperation for SSI. Neither time to drain removal nor setting of drain removal was a predictor of reoperation for SSI. Although time to drain discontinuation was expectedly longer in the post-discharge versus pre-discharge cohorts, the incidences of reoperation for SSI did not significantly differ. Neither time to drain removal nor setting of drain removal predicted reoperation for SSI. These results suggest that patients may be safely discharged from the hospital with the surgical drain in place.     

Is there an ideal position and size of chest drain following anatomical lung resection?

BackgroundChest drains are placed after surgery to enable lung re-expansion. However, there remains little guidance on optimal placement. This study aims to identify the ideal size and position for chest drain insertion with regards to post-operative outcomes.Methods383 patients undergoing lobectomy in 1-year had their chest drain size and x-ray position noted (1 (apical), 2 (mid-zone) or 3 (basal)). Primary outcome was residual air space on immediate post-operative x-ray. Secondary outcomes were length of drain in situ (<72 versus ≥72 h), persisting pleural effusion, surgical emphysema, post-operative pneumonia (POP), and length of hospital stay (<5 versus ≥5 days). Fisher's exact analysis for the primary outcome and binary logistic regression analysis for all outcomes were used. Results presented as odds ratios (OR±95%CI).ResultsUnivariate analysis for residual air space showed increased risk in area 2 (OR = 1.61, p = 0.041) and 3 (OR = 2.59, p = 0.0043) compared with area 1. Multivariate analysis for residual air space showed increased risk in area 2 (OR = 2.39, p < 0.001) and 3 (OR = 2.86, p < 0.001) compared with area 1. Drain size had no impact on residual air space in univariate or multivariate analysis. Multivariate analysis showed area 2 drains remained in situ for >72 h (OR = 1.49, p = 0.017), had persisting effusions (OR = 2.03, p = 0.004) and POP (OR = 2.10, p = 0.023) compared with area 1. This risk is magnified further for drains in area 3. Drains ≥28F had reduced risk of surgical emphysema (OR = 0.23, p = 0.027) in multivariate analysis.ConclusionA ≥28F, apical chest drain reduces the risk of post-operative complications, allowing early removal and discharge.     

Closed–suction compared with Penrose drainage after free flap reconstruction in the head and neck

Microsurgical free flaps are common in head and neck reconstruction, and their techniques and outcomes have continuously improved during the past decades. However, there are variations in practice among surgeons between the use of closed-suction drainage systems and Penrose drains. The proponents of Penrose drains propose that the negative pressure generated by the closed-suction drainage system may harm the microvascular anastomosis. We know of no previous studies that have compared the two drains for microvascular free flap reconstruction, so our aim was to compare them in a single-centre, retrospective review of all patients who had microvascular free flap reconstruction of the head and neck region in our department between 1 November 2010 and 1 September 2017. During this period 84 patients had 87 free flap reconstructions in the head and neck, 43 of which had Penrose, and 44 closed-suction, drainage. We compared the number of complications between the groups including haematomas, seromas, wound infections, anastomostic thrombosis, anastomotic revision, and need for re-exploration. There were no significant differences between the groups, despite a trend toward fewer negative explorations in the closed-suction group. There were no differences in complications between suction and passive drainage systems after microvascular free flaps, which suggests that closed suction drainage could be safely used after free flap reconstruction in the head and neck.     

军队医院聘用制人员流失预警管理

目的 降低军队医院聘用制人员流失率,稳定和规范人才队伍的管理,保持军队医院的竞争优势.方法 基于“推拉理论”分析人员流失规律,借鉴与运用“预警管理理论”.结果 初步构建了军队医院聘用制人员流失的预警管理系统.结论 建立预警管理机制,对军队医院预防与减少聘用制人员流失具有重要意义.     

Treatment of 78 type II and type IIIa open fractures by primary closure on suction drain: a prospective study

The purpose of this study was to assess if primary closure of wounds on a suction drain can be performed in open fractures after debridement and to determine the risk of infection and nonunion. A total of 78 type II and type IIIa open fractures were managed with primary closure on a suction drain. They were followed until union. Rates of infection, delayed union and nonunion were determined and compared with rates reported in the literature. Overall, 16 fractures (20.5%) were complicated with superficial infections and 8 fractures (10.2%) had deep infections. Delayed union was observed in 11 fractures (14.1%) and nonunion in 12 fractures (15.3%). Primary closure of a wound on a suction drain seems to cause no significant increase in rates of infection, nonunion or delayed union.     

Unusual site for oesophageal perforation in an extremely low birth weight infant

A male infant born at 26 weeks gestation became unwell at 10 days of age with blood-stained pharyngeal aspirates. The chest radiograph revealed a feeding tube in the right pleural cavity, indicating a perforation of the thoracic oesophagus. The infant had had a chest drain inserted on the right side on two previous occasions. These had been allowed to remain across the mediastinum at the site of the subsequent perforation. The infant was successfully managed conservatively with no long-term sequelae The unusual site of the perforation led us to conclude that pressure necrosis from the drains was a contributing factor in the aetiology. Conclusion Oesophageal perforations in the neonate, in contrast to the adult, can be managed conservatively. Received: 11 March 1997 and in revised form 24 February 1998 / Accepted: 3 March 1998     

Patients' experiences of having an underwater seal chest drain: a replication study

The nursing management of patients who have a chest drain in situ has received little attention. The findings of a single small-scale study previously indicated that such patients' needs for information are not always fully met and pain control is inadequate. This small-scale study was replicated to produce broadly similar findings in a second hospital 2 years later. Despite some differences in the approach to management it was apparent that patients were still not well prepared pre-operatively and there was scope for improving pain control. All the patients reported considerable discomfort and pain of moderate to severe intensity. The type of pain described is typical of deep somatic/visceral pain.