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Culture of safety and error traps in pediatric thoracoscopy
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Error traps and culture of safety and in pediatric thoracoscopy Sarah W. Lai , Steven S. Rothenberg PII: DOI: Reference:
S1055-8586(19)30057-5 https://doi.org/10.1053/j.sempedsurg.2019.04.021 YSPSU 50815
To appear in:
Seminars in Pediatric Surgery
Please cite this article as: Sarah W. Lai , Steven S. Rothenberg , Error traps and culture of safety and in pediatric thoracoscopy, Seminars in Pediatric Surgery (2019), doi: https://doi.org/10.1053/j.sempedsurg.2019.04.021
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Title Error traps and culture of safety and in pediatric thoracoscopy Authors Sarah W. Lai and Steven S. Rothenberg
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Affiliations
Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, 2055 High Street, Suite 370, Denver, Colorado, USA 80205 Email Addresses
Corresponding Author
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Sarah W. Lai Rocky Mountain Pediatric Surgery Rocky Mountain Hospital for Children 2055 High Street, Suite 370 Denver, Colorado, USA 80205 Phone: 303-839-6001 Fax: 303-839-6033 Email: [email protected]
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Sarah W. Lai ([email protected]) Steven S. Rothenberg ([email protected])
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Abstract
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Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise. This article serves to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm and improve quality of care. Key Words
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Thoracoscopy, minimally invasive surgery, complications, errors, safety
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Introduction
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Since the introduction of thoracoscopy into pediatric surgery in 1976, there have been significant advances in technology, with progressive miniaturization of equipment, enhanced optics, as well as improvements in pediatric anesthesia management1-13. Pediatric surgeons have embraced the new techniques, leading to an expansion in the volume and complexity of thoracoscopic cases performed worldwide14. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications15,16. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise17,18. The objective of this article is to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm.
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Culture of safety
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A culture of safety is necessary in thoracoscopy, as with all surgeries, to minimize medical errors and improve quality of care17,18. Multidisciplinary communication and teamwork are fundamental for every patient, every procedure, every time to ensure safe outcomes. The entire surgical team, including surgeons, anesthesiologists, nurses and technicians, must discuss their needs and concerns before, during and after any operation. Given the proximity of the heart, lungs and great vessels, complications of thoracoscopy can acutely progress to a life threatening state and require rapid conversion to thoracotomy. Knowledge of the patient’s condition, surgical procedure, patient position required, predicted operative time, expected intraoperative difficulties and need for blood products as it relates to multiple perspectives will contribute to success with the minimally invasive approach. Openness by all team members with regards to complications, errors and near misses in a non-punitive environment facilitates learning and development of standardized protocols and care bundles to minimize recurrence and lessen harm. Within a culture of safety, error traps, when encountered, may be recognized earlier, dealt with more expeditiously, and reported to mitigate future similar events.
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Error trap 1. Increased risks of airway management and anesthesia in infants compared to older children.
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While single lung ventilation (SLV) in older adolescents is similar in approach to adults, its use in infants may involve mainstem intubation or bronchial blockers10-13. SLV is more apt to failure in infants due to equipment size relative to the airways. Tubes may displace back into the trachea from short mainstem bronchi, cuffs and balloons may damage the airways, while small luminal diameters of both tubes and airways are easily obstructed by secretions and blood, yet are less amenable to suctioning. As these challenges can preclude the use of SLV, many surgeons opt to generate a mild, temporary tension pneumothorax using carbon dioxide chest insufflation (pressure 4 to 6 mmHg, flow 1 to 2 L/min) instead, whilst compressing the lung with instruments to create adequate domain for visualization. Ventilatory settings with smaller tidal volumes, lower peak pressures and higher respiratory rates minimize lung inflation and loss of
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domain, while increasing oxygenation, reducing hypercapnia and risks of barotrauma. There is ongoing evidence that thoracoscopic carbon dioxide insufflation in neonates is associated with hypercapnia and acidosis, though reports on consequent effects on cerebral oxygen saturation and long term neurocognitive changes remain unclear19-24. These potential risks can be minimized when ventilatory settings are optimized, as insufflation can be reduced or turned off altogether. The impact of prolonged anesthesia on the developing brain has also been examined with concerns of increased apoptosis in animal studies, and conflicting human data on effects on learning and behavioural disorders25. Until further prospective long-term studies are completed examining the neurotoxic effects of prolonged anesthesia, hypercapnia and acidosis, it behooves surgeons to complete these procedures efficiently to minimize operative times and anesthetic exposure. Error trap 2. Injury during trocar placement and chest insufflation.
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Visualization during thoracoscopy is dependent on the degree of lung collapse with pneumothorax and compression with instruments, with or without SLV12. Initial creation of pneumothorax is passive with insertion of an open Veress needle, typically at the fifth intercostal space or higher (well away from the nipple and breast bud), followed by insufflation to a pressure of 4 to 8 mmHg and flow of 1 to 2 L/min with carbon dioxide. Veress needle insertion should be well communicated and timed with the anesthesiologist between ventilations, and placed to a depth consistent with the expected thickness of the chest wall. These measures will minimize lung injury caused by subsequent blind trocar placement at the site of Veress needle puncture, which usually presents with an abrupt rise in insufflation pressure. Previous thoracic procedures and infections exacerbate this risk secondary to adhesions tethering the lung to the chest wall. Another circumstance that results in deviation from the usual anatomy, predisposing the patient to lung injury, includes the presence of a large pulmonary cystic lesion that may be pierced by a trocar and insufflated. Insufflation of cysts that communicate with the tracheobronchial tree have been reported, leading to significant oxygen desaturations and rapid elevation in end-tidal carbon dioxide26. This complication may be prevented by thorough review of preoperative imaging to determine safe port placement away from a large, thin walled cyst. For procedures that require an inferiorly placed scope trocar, such as pectus bar insertion, it is still necessary to insufflate through a higher Veress needle puncture site. This technique will avoid a penetrating injury to an otherwise elevated diaphragm and its underlying intraabdominal organs. Diaphragmatic depression facilitated by pneumothorax may be confirmed by aspiration of air bubbles using a saline syringe at the planned trocar insertion point. Good communication with the anesthesiologist, and an understanding of the patient’s anatomy on collapsibility of the lung and level of the diaphragm, are vital to reduce harm. Error trap 3. Injury secondary to overconfidence with equipment. Evolution of new technology has enabled the performance of increasingly complex thoracoscopy3,7-9,12. Although the use of clips, vessel sealing devices and staplers have decreased operative times, they are not guaranteed to be free of failure, potentially leading to
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Error trap 4. Misinterpretation of anatomy.
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life threatening hemorrhage and air leaks. Clips can dislodge or scissor through vessels. Sealing devices are limited by vessel caliber and sealed ends can be disrupted if grasped. Stapler firings may fail on thick and inflamed tissue. Vessels controlled by any of these techniques should be well exposed proximally and distally prior to division in anticipation of device failure (Figure 1). Improper combination of different instruments may also be problematic. Use of clips may preclude the use of a stapler on the same tissue. Use of clips and a sealing device on the same vessel may lead to weakening at the level of the clip and disruption27. If the surgeon is unable to manage acute hemorrhage thoracoscopically, then he or she must be prepared to perform an emergency thoracotomy for vascular control. Surgeons who use sealing devices for tissue dissection must also be mindful of the energy spread on nearby structures, as injuries to the vagus, phrenic and recurrent laryngeal nerves are possible. Correct and careful use of technology with knowledge of their shortcomings is essential in anticipating failure and eliminating preventable injury.
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The thoracic cavity houses several structures in close proximity that, if injured, can cause acute cardiorespiratory instability and sepsis. Primum non nocere -- first, to do no harm, critical structures must be recognized early, namely major vessels, airways, the esophagus and nerves. If not immediately evident, clues can assist surgeons in structure identification, such as visualization of arterial pulsations or palpation of a nasogastric tube in the esophagus, to avoid injury. Localization of landmarks can pinpoint adjacent anatomy, such as the azygos vein for a tracheoesophageal fistula, the trachea and bronchi; or the aorta and vagus nerve for a patent ductus arteriosus and the recurrent laryngeal nerve (Figure 2). Misinterpretation of this anatomy can lead to disastrous ligation and division of these vital adjacent structures. The orientation of pulmonary arteries, veins and bronchi are all the more intricate, with misperception commonly resulting in inadvertent compromise of the right middle lobe bronchus during a right lower lobectomy, or arterial injury while opening an incomplete fissure (Figure 3)28. Surgeons must be vigilant in the dissection of segmental vessels as the apical branches to the lower lobes and the lingular branch to the left upper lobe are prone to avulsion. A thorough understanding of thoracic anatomy is necessary for safe completion of complex thoracoscopy.
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Error trap 5. Aggressive apical placement of chest tube causing Horner’s syndrome. Chest tubes are commonly inserted during pediatric thoracoscopic procedures to evacuate air, blood and fluid. The tip of the chest tube is typically oriented towards the apex of the lung to drain air, or towards the costodiaphragmatic recess for blood and fluid, though exact position is not crucial with pleural contents in constant motion with breathing. Placement of an apically directed chest tube is a rare cause of Horner’s syndrome, characterized by ptosis, miosis and anhidrosis29-31. Nerve fibers near the apex of the lung, leading to the superior cervical ganglion, are prone to injury with excessive pressure applied by the tip of a chest tube. It is critical for the surgeon to confirm that no resistance is encountered whilst placing the chest tube, and that its position on radiography (anteroposterior and lateral) is appropriate. The chest tube must be
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repositioned if the tip is far into the apex of the thoracic cavity, or if the patient shows signs of nerve compression, in order to mitigate this morbidity. Error trap 6. Biopsy of lung nodules without radiologic localization.
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Thoracoscopic wedge resections of lung nodules generally yield adequately sized tissue for diagnosis, provided the lesion is included in the specimen12. Unlike thoracotomy, thoracoscopy does not provide tactile sensation to palpate deeper nodules or small superficial lesions obscured by atelectasis. Surgeons must anticipate the proclivity for thoracoscopy to fail in detecting these types of lesions. Preoperative planning with radiology may allow for localization of nodules with blood patches, methylene blue, wires or coils (Figure 4)32,33. Injection of methylene blue to tattoo lesions often results in spillage of dye over multiple surfaces and exacerbates visualization. Device failure may occur with wires and coils dislodging due to chest insufflation, thus examination of preoperative chest computed tomography (CT) scans and creation of three-dimensional reconstructions of lung views may provide an additional road map to identify the adjacent anatomy (Figure 4)34. Intraoperative planning with pathology for frozen sections will also confirm if the lesion is included within the tissue. Multidisciplinary care and reliance on multiple methods of localization will enable the surgeon to avoid false negative specimens.
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Error trap 7. Biopsy of anterior mediastinal masses without adequate preoperative evaluation for airway and cardiovascular compression.
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Thoracoscopy provides excellent visualization for biopsying mediastinal masses. Despite the accessibility, it is mandatory to evaluate anterior masses for airway compression, obstruction of venous return and cardiac output, which could result in cardiorespiratory collapse under general anesthesia35,36. Respiratory symptoms (orthopnea, wheezing, stridor) and upper body edema may or may not be evident. A CT chest should be examined thoroughly for compression on the trachea, bronchi, carina, superior vena cava and pulmonary artery. An echocardiogram may identify cardiac and great vessel compression, pericardial and pleural effusions, and evaluate ventricular function. The importance of multidisciplinary discussions to identify cases at risk of cardiorespiratory collapse cannot be understated as induction of general anesthesia could be life threatening. In high-risk individuals, biopsy under local anesthesia or neoadjuvant empiric therapy to shrink the tumor may be more appropriate alternatives. If a thoracoscopic biopsy is necessary, general anesthesia with spontaneous ventilations and rigid bronchoscopy available to secure the airway in anticipation of cardiorespiratory collapse is essential. A culture of safety consisting of a full work up for every patient with a mediastinal mass, along with multidisciplinary discussions to determine the necessity of thoracoscopy is vital to eliminating mortality from cardiorespiratory collapse. Error trap 8. Prolonged bronchoscopy for identification of a tracheoesophageal fistula. Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common anatomic variation of this congenital anomaly. Preoperative bronchoscopy is performed based
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Error trap 9. Acute injuries during pectus bar insertion.
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on surgeon preference and is used to localize the TEF, identify multiple TEFs, and allow for potential placement of an occlusive Fogarty catheter37,38. We have found that thoracoscopic control of the azygos vein invariably reveals the underlying distal TEF that can be dissected and ligated expeditiously, facilitating mechanical ventilation. Moreover, while thoracoscopic mobilization of the proximal esophageal pouch high into the thoracic inlet will help to reduce anastomotic tension on the repair, this technique will also identify the rare presence of a proximal TEF. Although bronchoscopy can be a helpful adjunct prior to thoracoscopic repair, prolonged airway manipulation has inherent risks, including significant desaturations, bronchospasm and acute gastric distension with an uncontrolled TEF. Surgeons should be vigilant with respect to bronchoscopy times, while balancing the risks and benefits of the procedure in each individual case prior to definitive thoracoscopic control of the TEF.
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Pectus excavatum is commonly treated by placement of a substernal pectus bar. Pectus bar insertion has been shown to improve the cosmesis of the chest wall deformity, as well as potentially mitigate associated cardiorespiratory compressive effects39,40. Acute postoperative hypotension is rare, with hemorrhagic shock secondary to cardiac perforation considered the most fearsome etiology, though occlusion of the inferior vena cava (IVC) is another less well known yet equally concerning possibility41-43. Management of mild perioperative hypotension by the anesthesiologist often begins with fluid resuscitation, and weaning of anesthetics and narcotics. More severe or persistent hypotension demands rapid assessment, chest radiography, echocardiography, CT abdomen and/or reoperation to rule out tension pneumothorax, hemopericardium, cardiac perforation and liver laceration (with associated diaphragmatic injury as described in “Error trap 2”), and may require concurrent treatment with vasopressors to maintain perfusion. A chest tube should be placed immediately if a pneumothorax exists. Hemorrhage into the chest may result from vascular injury (intercostal, internal mammary, and great vessels) or cardiac perforation, and may require exploration to seal smaller vessels (potentially thoracoscopically) or to repair the great vessels and heart (by emergency sternotomy). Ready access to and experience with a sternal saw, along with prompt mobilization of the cardiothoracic surgical team, can be lifesaving. These cardiovascular injuries may possibly be avoided through the use of an additional subxiphoid incision or sternal elevating device44,45. Liver lacerations may be treated by observation, embolization or emergency laparotomy depending on the patient’s hemodynamics and evidence of peritonitis46,47. Diaphragmatic penetrations may be repaired thoracoscopically if stable. If no significant hemopneumothorax, pericardial effusion or intraabdominal injury is identified, surgeons must consider IVC occlusion as a possible cause of hypotension. When a pectus bar is inserted, correction of the chest wall deformity places traction on the pericardium, which may subsequently cause cardiac rotation and kinking of the IVC42,43,48. This rare complication may be corroborated with Doppler ultrasound of the IVC, CT chest and abdomen, and echocardiography. Immediate correction of hypotension with removal of the pectus bar confirms the diagnosis. Depending on the duration of IVC occlusion, it is imperative to perform intraoperative echocardiography after bar removal to rule out thrombus development due to prolonged venous obstruction. Currently, it is unclear if severity of the deformity or other
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patient factors predispose to IVC occlusion during pectus bar insertion, thus awareness of this potential complication is vital for early recognition and containment of harm. Rapid detection of shock, critical thinking and decision-making, and the ability to deviate from a standard pectus bar insertion are necessary to prevent further lethal decompensation from these acute injuries. Conclusion
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Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. With a greater armamentarium of procedures, techniques and equipment, surgeons must remain vigilant in anticipating sources of error. Within a culture of safety, complications and near misses can be identified, addressed and reported to minimize recurrence. Good communication and multidisciplinary teamwork where surgeons, anesthesiologists, radiologists, pathologists and oncologists are freely able to raise concerns are vital to ensure quality of care and decrease injury. The entire team ought to review patient anatomy and physiology to determine the optimal surgical approach -- is it unsafe to proceed with thoracoscopy or would an open thoracotomy produce a better outcome? A thorough understanding of thoracoscopic technique and equipment is required for effective intraoperative troubleshooting in anticipation of unexpected procedural errors and device failure. Efficiency and a sense of urgency in the operating room are necessary to lessen operative and anesthetic times, minimizing potential harm from prolonged exposure. Recognition of error traps, critical thinking during acute complications, and the flexibility to deviate from routine practice to mitigate harm can be taught and come with experience. Although it is impossible to eliminate all complications, each of these measures provide a safety net and together decrease the burden of error from any individual variable, improving the quality of care for all.
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Funding None
Disclosures
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Dr. Steven Rothenberg is a consultant for Just Right Surgical. His role is not in conflict with any aspect of this manuscript. Just Right Surgical has not had (and will not have) any impact on manuscript preparation. No competing financial interests exist for Dr. Sarah Lai.
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Reprint Requests
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Sarah W. Lai Rocky Mountain Pediatric Surgery Rocky Mountain Hospital for Children 2055 High Street, Suite 370 Denver, Colorado, USA 80205 Email: [email protected]
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Figure 1. Vessels exposed proximally and distally (A) prior to sealing (B) and division (C) in anticipation of device failure. A similar technique should be employed when using clips or a stapler.
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Figure 2. Anatomy of tracheoesophageal fistula ligation (A) with cut ends of azygos vein demonstrating the underlying fistula ligated with clip, and adjacent esophagus, trachea and right mainstem bronchus. Anatomy of patent ductus arteriosus ligation (B) with aorta and vagus nerve dissection demonstrating the underlying patent ductus arteriosus, and adjacent left subclavian vein and recurrent laryngeal nerve. Abbreviations: azygos vein (azy), tracheoesophageal fistula (tef), esophagus (eso), trachea (tra), right mainstem bronchus (bro), aorta (aor), vagus nerve (vag), patent ductus arteriosus (pda), left subclavian vein (scv), recurrent laryngeal nerve (rln).
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Figure 3. Pulmonary anatomy with common areas of injury during thoracoscopic lobectomy: right middle lobe bronchus (green circle) during right lower lobectomy; apical/superior segmental vessels (red circle) to the lower lobes and the lingular vessels (yellow circle) to the left upper lobe while opening an incomplete fissure. Abbreviations: right upper lobe (RUL), right middle lobe (RML), right lower lobe (RLL), left upper lobe (LUL), left lower lobe (LLL).
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Figure 4. Lung nodules localized preoperatively using wires (A, black arrow), coils (B, white arrows) and three-dimensional reconstruction of computed tomography scans34 (C, black arrowhead). Figure 4B courtesy P. Paul Beaudry, MD.
Error traps and culture of safety and in pediatric thoracoscopy Sarah W. Lai , Steven S. Rothenberg PII: DOI: Reference:
S1055-8586(19)30057-5 https://doi.org/10.1053/j.sempedsurg.2019.04.021 YSPSU 50815
To appear in:
Seminars in Pediatric Surgery
Please cite this article as: Sarah W. Lai , Steven S. Rothenberg , Error traps and culture of safety and in pediatric thoracoscopy, Seminars in Pediatric Surgery (2019), doi: https://doi.org/10.1053/j.sempedsurg.2019.04.021
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title Error traps and culture of safety and in pediatric thoracoscopy Authors Sarah W. Lai and Steven S. Rothenberg
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Affiliations
Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children, 2055 High Street, Suite 370, Denver, Colorado, USA 80205 Email Addresses
Corresponding Author
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Sarah W. Lai Rocky Mountain Pediatric Surgery Rocky Mountain Hospital for Children 2055 High Street, Suite 370 Denver, Colorado, USA 80205 Phone: 303-839-6001 Fax: 303-839-6033 Email: [email protected]
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Sarah W. Lai ([email protected]) Steven S. Rothenberg ([email protected])
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Abstract
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Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise. This article serves to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm and improve quality of care. Key Words
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Thoracoscopy, minimally invasive surgery, complications, errors, safety
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Introduction
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Since the introduction of thoracoscopy into pediatric surgery in 1976, there have been significant advances in technology, with progressive miniaturization of equipment, enhanced optics, as well as improvements in pediatric anesthesia management1-13. Pediatric surgeons have embraced the new techniques, leading to an expansion in the volume and complexity of thoracoscopic cases performed worldwide14. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications15,16. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise17,18. The objective of this article is to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm.
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Culture of safety
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A culture of safety is necessary in thoracoscopy, as with all surgeries, to minimize medical errors and improve quality of care17,18. Multidisciplinary communication and teamwork are fundamental for every patient, every procedure, every time to ensure safe outcomes. The entire surgical team, including surgeons, anesthesiologists, nurses and technicians, must discuss their needs and concerns before, during and after any operation. Given the proximity of the heart, lungs and great vessels, complications of thoracoscopy can acutely progress to a life threatening state and require rapid conversion to thoracotomy. Knowledge of the patient’s condition, surgical procedure, patient position required, predicted operative time, expected intraoperative difficulties and need for blood products as it relates to multiple perspectives will contribute to success with the minimally invasive approach. Openness by all team members with regards to complications, errors and near misses in a non-punitive environment facilitates learning and development of standardized protocols and care bundles to minimize recurrence and lessen harm. Within a culture of safety, error traps, when encountered, may be recognized earlier, dealt with more expeditiously, and reported to mitigate future similar events.
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Error trap 1. Increased risks of airway management and anesthesia in infants compared to older children.
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While single lung ventilation (SLV) in older adolescents is similar in approach to adults, its use in infants may involve mainstem intubation or bronchial blockers10-13. SLV is more apt to failure in infants due to equipment size relative to the airways. Tubes may displace back into the trachea from short mainstem bronchi, cuffs and balloons may damage the airways, while small luminal diameters of both tubes and airways are easily obstructed by secretions and blood, yet are less amenable to suctioning. As these challenges can preclude the use of SLV, many surgeons opt to generate a mild, temporary tension pneumothorax using carbon dioxide chest insufflation (pressure 4 to 6 mmHg, flow 1 to 2 L/min) instead, whilst compressing the lung with instruments to create adequate domain for visualization. Ventilatory settings with smaller tidal volumes, lower peak pressures and higher respiratory rates minimize lung inflation and loss of
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domain, while increasing oxygenation, reducing hypercapnia and risks of barotrauma. There is ongoing evidence that thoracoscopic carbon dioxide insufflation in neonates is associated with hypercapnia and acidosis, though reports on consequent effects on cerebral oxygen saturation and long term neurocognitive changes remain unclear19-24. These potential risks can be minimized when ventilatory settings are optimized, as insufflation can be reduced or turned off altogether. The impact of prolonged anesthesia on the developing brain has also been examined with concerns of increased apoptosis in animal studies, and conflicting human data on effects on learning and behavioural disorders25. Until further prospective long-term studies are completed examining the neurotoxic effects of prolonged anesthesia, hypercapnia and acidosis, it behooves surgeons to complete these procedures efficiently to minimize operative times and anesthetic exposure. Error trap 2. Injury during trocar placement and chest insufflation.
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Visualization during thoracoscopy is dependent on the degree of lung collapse with pneumothorax and compression with instruments, with or without SLV12. Initial creation of pneumothorax is passive with insertion of an open Veress needle, typically at the fifth intercostal space or higher (well away from the nipple and breast bud), followed by insufflation to a pressure of 4 to 8 mmHg and flow of 1 to 2 L/min with carbon dioxide. Veress needle insertion should be well communicated and timed with the anesthesiologist between ventilations, and placed to a depth consistent with the expected thickness of the chest wall. These measures will minimize lung injury caused by subsequent blind trocar placement at the site of Veress needle puncture, which usually presents with an abrupt rise in insufflation pressure. Previous thoracic procedures and infections exacerbate this risk secondary to adhesions tethering the lung to the chest wall. Another circumstance that results in deviation from the usual anatomy, predisposing the patient to lung injury, includes the presence of a large pulmonary cystic lesion that may be pierced by a trocar and insufflated. Insufflation of cysts that communicate with the tracheobronchial tree have been reported, leading to significant oxygen desaturations and rapid elevation in end-tidal carbon dioxide26. This complication may be prevented by thorough review of preoperative imaging to determine safe port placement away from a large, thin walled cyst. For procedures that require an inferiorly placed scope trocar, such as pectus bar insertion, it is still necessary to insufflate through a higher Veress needle puncture site. This technique will avoid a penetrating injury to an otherwise elevated diaphragm and its underlying intraabdominal organs. Diaphragmatic depression facilitated by pneumothorax may be confirmed by aspiration of air bubbles using a saline syringe at the planned trocar insertion point. Good communication with the anesthesiologist, and an understanding of the patient’s anatomy on collapsibility of the lung and level of the diaphragm, are vital to reduce harm. Error trap 3. Injury secondary to overconfidence with equipment. Evolution of new technology has enabled the performance of increasingly complex thoracoscopy3,7-9,12. Although the use of clips, vessel sealing devices and staplers have decreased operative times, they are not guaranteed to be free of failure, potentially leading to
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Error trap 4. Misinterpretation of anatomy.
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life threatening hemorrhage and air leaks. Clips can dislodge or scissor through vessels. Sealing devices are limited by vessel caliber and sealed ends can be disrupted if grasped. Stapler firings may fail on thick and inflamed tissue. Vessels controlled by any of these techniques should be well exposed proximally and distally prior to division in anticipation of device failure (Figure 1). Improper combination of different instruments may also be problematic. Use of clips may preclude the use of a stapler on the same tissue. Use of clips and a sealing device on the same vessel may lead to weakening at the level of the clip and disruption27. If the surgeon is unable to manage acute hemorrhage thoracoscopically, then he or she must be prepared to perform an emergency thoracotomy for vascular control. Surgeons who use sealing devices for tissue dissection must also be mindful of the energy spread on nearby structures, as injuries to the vagus, phrenic and recurrent laryngeal nerves are possible. Correct and careful use of technology with knowledge of their shortcomings is essential in anticipating failure and eliminating preventable injury.
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The thoracic cavity houses several structures in close proximity that, if injured, can cause acute cardiorespiratory instability and sepsis. Primum non nocere -- first, to do no harm, critical structures must be recognized early, namely major vessels, airways, the esophagus and nerves. If not immediately evident, clues can assist surgeons in structure identification, such as visualization of arterial pulsations or palpation of a nasogastric tube in the esophagus, to avoid injury. Localization of landmarks can pinpoint adjacent anatomy, such as the azygos vein for a tracheoesophageal fistula, the trachea and bronchi; or the aorta and vagus nerve for a patent ductus arteriosus and the recurrent laryngeal nerve (Figure 2). Misinterpretation of this anatomy can lead to disastrous ligation and division of these vital adjacent structures. The orientation of pulmonary arteries, veins and bronchi are all the more intricate, with misperception commonly resulting in inadvertent compromise of the right middle lobe bronchus during a right lower lobectomy, or arterial injury while opening an incomplete fissure (Figure 3)28. Surgeons must be vigilant in the dissection of segmental vessels as the apical branches to the lower lobes and the lingular branch to the left upper lobe are prone to avulsion. A thorough understanding of thoracic anatomy is necessary for safe completion of complex thoracoscopy.
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Error trap 5. Aggressive apical placement of chest tube causing Horner’s syndrome. Chest tubes are commonly inserted during pediatric thoracoscopic procedures to evacuate air, blood and fluid. The tip of the chest tube is typically oriented towards the apex of the lung to drain air, or towards the costodiaphragmatic recess for blood and fluid, though exact position is not crucial with pleural contents in constant motion with breathing. Placement of an apically directed chest tube is a rare cause of Horner’s syndrome, characterized by ptosis, miosis and anhidrosis29-31. Nerve fibers near the apex of the lung, leading to the superior cervical ganglion, are prone to injury with excessive pressure applied by the tip of a chest tube. It is critical for the surgeon to confirm that no resistance is encountered whilst placing the chest tube, and that its position on radiography (anteroposterior and lateral) is appropriate. The chest tube must be
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repositioned if the tip is far into the apex of the thoracic cavity, or if the patient shows signs of nerve compression, in order to mitigate this morbidity. Error trap 6. Biopsy of lung nodules without radiologic localization.
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Thoracoscopic wedge resections of lung nodules generally yield adequately sized tissue for diagnosis, provided the lesion is included in the specimen12. Unlike thoracotomy, thoracoscopy does not provide tactile sensation to palpate deeper nodules or small superficial lesions obscured by atelectasis. Surgeons must anticipate the proclivity for thoracoscopy to fail in detecting these types of lesions. Preoperative planning with radiology may allow for localization of nodules with blood patches, methylene blue, wires or coils (Figure 4)32,33. Injection of methylene blue to tattoo lesions often results in spillage of dye over multiple surfaces and exacerbates visualization. Device failure may occur with wires and coils dislodging due to chest insufflation, thus examination of preoperative chest computed tomography (CT) scans and creation of three-dimensional reconstructions of lung views may provide an additional road map to identify the adjacent anatomy (Figure 4)34. Intraoperative planning with pathology for frozen sections will also confirm if the lesion is included within the tissue. Multidisciplinary care and reliance on multiple methods of localization will enable the surgeon to avoid false negative specimens.
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Error trap 7. Biopsy of anterior mediastinal masses without adequate preoperative evaluation for airway and cardiovascular compression.
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Thoracoscopy provides excellent visualization for biopsying mediastinal masses. Despite the accessibility, it is mandatory to evaluate anterior masses for airway compression, obstruction of venous return and cardiac output, which could result in cardiorespiratory collapse under general anesthesia35,36. Respiratory symptoms (orthopnea, wheezing, stridor) and upper body edema may or may not be evident. A CT chest should be examined thoroughly for compression on the trachea, bronchi, carina, superior vena cava and pulmonary artery. An echocardiogram may identify cardiac and great vessel compression, pericardial and pleural effusions, and evaluate ventricular function. The importance of multidisciplinary discussions to identify cases at risk of cardiorespiratory collapse cannot be understated as induction of general anesthesia could be life threatening. In high-risk individuals, biopsy under local anesthesia or neoadjuvant empiric therapy to shrink the tumor may be more appropriate alternatives. If a thoracoscopic biopsy is necessary, general anesthesia with spontaneous ventilations and rigid bronchoscopy available to secure the airway in anticipation of cardiorespiratory collapse is essential. A culture of safety consisting of a full work up for every patient with a mediastinal mass, along with multidisciplinary discussions to determine the necessity of thoracoscopy is vital to eliminating mortality from cardiorespiratory collapse. Error trap 8. Prolonged bronchoscopy for identification of a tracheoesophageal fistula. Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common anatomic variation of this congenital anomaly. Preoperative bronchoscopy is performed based
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Error trap 9. Acute injuries during pectus bar insertion.
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on surgeon preference and is used to localize the TEF, identify multiple TEFs, and allow for potential placement of an occlusive Fogarty catheter37,38. We have found that thoracoscopic control of the azygos vein invariably reveals the underlying distal TEF that can be dissected and ligated expeditiously, facilitating mechanical ventilation. Moreover, while thoracoscopic mobilization of the proximal esophageal pouch high into the thoracic inlet will help to reduce anastomotic tension on the repair, this technique will also identify the rare presence of a proximal TEF. Although bronchoscopy can be a helpful adjunct prior to thoracoscopic repair, prolonged airway manipulation has inherent risks, including significant desaturations, bronchospasm and acute gastric distension with an uncontrolled TEF. Surgeons should be vigilant with respect to bronchoscopy times, while balancing the risks and benefits of the procedure in each individual case prior to definitive thoracoscopic control of the TEF.
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Pectus excavatum is commonly treated by placement of a substernal pectus bar. Pectus bar insertion has been shown to improve the cosmesis of the chest wall deformity, as well as potentially mitigate associated cardiorespiratory compressive effects39,40. Acute postoperative hypotension is rare, with hemorrhagic shock secondary to cardiac perforation considered the most fearsome etiology, though occlusion of the inferior vena cava (IVC) is another less well known yet equally concerning possibility41-43. Management of mild perioperative hypotension by the anesthesiologist often begins with fluid resuscitation, and weaning of anesthetics and narcotics. More severe or persistent hypotension demands rapid assessment, chest radiography, echocardiography, CT abdomen and/or reoperation to rule out tension pneumothorax, hemopericardium, cardiac perforation and liver laceration (with associated diaphragmatic injury as described in “Error trap 2”), and may require concurrent treatment with vasopressors to maintain perfusion. A chest tube should be placed immediately if a pneumothorax exists. Hemorrhage into the chest may result from vascular injury (intercostal, internal mammary, and great vessels) or cardiac perforation, and may require exploration to seal smaller vessels (potentially thoracoscopically) or to repair the great vessels and heart (by emergency sternotomy). Ready access to and experience with a sternal saw, along with prompt mobilization of the cardiothoracic surgical team, can be lifesaving. These cardiovascular injuries may possibly be avoided through the use of an additional subxiphoid incision or sternal elevating device44,45. Liver lacerations may be treated by observation, embolization or emergency laparotomy depending on the patient’s hemodynamics and evidence of peritonitis46,47. Diaphragmatic penetrations may be repaired thoracoscopically if stable. If no significant hemopneumothorax, pericardial effusion or intraabdominal injury is identified, surgeons must consider IVC occlusion as a possible cause of hypotension. When a pectus bar is inserted, correction of the chest wall deformity places traction on the pericardium, which may subsequently cause cardiac rotation and kinking of the IVC42,43,48. This rare complication may be corroborated with Doppler ultrasound of the IVC, CT chest and abdomen, and echocardiography. Immediate correction of hypotension with removal of the pectus bar confirms the diagnosis. Depending on the duration of IVC occlusion, it is imperative to perform intraoperative echocardiography after bar removal to rule out thrombus development due to prolonged venous obstruction. Currently, it is unclear if severity of the deformity or other
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patient factors predispose to IVC occlusion during pectus bar insertion, thus awareness of this potential complication is vital for early recognition and containment of harm. Rapid detection of shock, critical thinking and decision-making, and the ability to deviate from a standard pectus bar insertion are necessary to prevent further lethal decompensation from these acute injuries. Conclusion
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Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. With a greater armamentarium of procedures, techniques and equipment, surgeons must remain vigilant in anticipating sources of error. Within a culture of safety, complications and near misses can be identified, addressed and reported to minimize recurrence. Good communication and multidisciplinary teamwork where surgeons, anesthesiologists, radiologists, pathologists and oncologists are freely able to raise concerns are vital to ensure quality of care and decrease injury. The entire team ought to review patient anatomy and physiology to determine the optimal surgical approach -- is it unsafe to proceed with thoracoscopy or would an open thoracotomy produce a better outcome? A thorough understanding of thoracoscopic technique and equipment is required for effective intraoperative troubleshooting in anticipation of unexpected procedural errors and device failure. Efficiency and a sense of urgency in the operating room are necessary to lessen operative and anesthetic times, minimizing potential harm from prolonged exposure. Recognition of error traps, critical thinking during acute complications, and the flexibility to deviate from routine practice to mitigate harm can be taught and come with experience. Although it is impossible to eliminate all complications, each of these measures provide a safety net and together decrease the burden of error from any individual variable, improving the quality of care for all.
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Funding None
Disclosures
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Dr. Steven Rothenberg is a consultant for Just Right Surgical. His role is not in conflict with any aspect of this manuscript. Just Right Surgical has not had (and will not have) any impact on manuscript preparation. No competing financial interests exist for Dr. Sarah Lai.
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Sarah W. Lai Rocky Mountain Pediatric Surgery Rocky Mountain Hospital for Children 2055 High Street, Suite 370 Denver, Colorado, USA 80205 Email: [email protected]
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Figure 1. Vessels exposed proximally and distally (A) prior to sealing (B) and division (C) in anticipation of device failure. A similar technique should be employed when using clips or a stapler.
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Figure 2. Anatomy of tracheoesophageal fistula ligation (A) with cut ends of azygos vein demonstrating the underlying fistula ligated with clip, and adjacent esophagus, trachea and right mainstem bronchus. Anatomy of patent ductus arteriosus ligation (B) with aorta and vagus nerve dissection demonstrating the underlying patent ductus arteriosus, and adjacent left subclavian vein and recurrent laryngeal nerve. Abbreviations: azygos vein (azy), tracheoesophageal fistula (tef), esophagus (eso), trachea (tra), right mainstem bronchus (bro), aorta (aor), vagus nerve (vag), patent ductus arteriosus (pda), left subclavian vein (scv), recurrent laryngeal nerve (rln).
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Figure 3. Pulmonary anatomy with common areas of injury during thoracoscopic lobectomy: right middle lobe bronchus (green circle) during right lower lobectomy; apical/superior segmental vessels (red circle) to the lower lobes and the lingular vessels (yellow circle) to the left upper lobe while opening an incomplete fissure. Abbreviations: right upper lobe (RUL), right middle lobe (RML), right lower lobe (RLL), left upper lobe (LUL), left lower lobe (LLL).
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Figure 4. Lung nodules localized preoperatively using wires (A, black arrow), coils (B, white arrows) and three-dimensional reconstruction of computed tomography scans34 (C, black arrowhead). Figure 4B courtesy P. Paul Beaudry, MD.