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Koo AY, Rodgers DK, Hohman MH, Muise JR, Couperus KS, Phelps JF. Lessons Learned: Large-Scale Perfused Cadaver Training in Three Different Curricular Environments. Mil Med 2024:usae110. [PMID: 38554274 DOI: 10.1093/milmed/usae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/04/2024] [Accepted: 03/04/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Perfused cadavers are viable training models for operating room surgical skills, increasing fidelity of vascular anatomy, dissection, and tissue handling. In addition, perfused cadavers may have benefits in military medical training environments with a focus on hemorrhage control and vascular access. OBJECTIVES We created a large-scale training exercise with perfused cadavers in three different environments and aim to share the curricular design and feedback from the exercise. METHODS We conducted a 4-day simulation training exercise with 13 perfused cadavers in 3 different environments: hospital environment, the austere echelons of care environment, and a controlled-settings tent for hemorrhage control and needle decompression training. Through an anonymous online survey and an after-action review (AAR), we elicited feedback on advantages, disadvantages, costs, and comparison to models of porcine and fresh cadavers for procedures and existing courses. RESULTS A total of 324 participants were trained with 13 perfused cadavers for over 4 days from a variety of specialties and on different procedures and surgical skills. Based on 130 respondents to the survey and the AAR, perfused cadavers were rated to have realistic arterial bleeding and bleeding control training. In addition, perfused cadavers provided increased realism and fidelity for surgical skills. There were disadvantages of logistical requirements, cleanup, costs, and mobility. CONCLUSION Perfused cadavers can be implemented effectively for hemorrhage control training, surgical and procedure skills, and even exercises in austere environments, but require significant logistical and planning considerations. The training value is maximized with a progressive curriculum from hemorrhage control iterations to more invasive surgical procedures, such as thoracotomy and exploratory laparotomy.
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Affiliation(s)
- Alex Y Koo
- Department of Emergency Medicine, Georgetown University, Washington, DC 20010, USA
- Charles A. Andersen Simulation Center, Madigan Army Medical Center, JBLM, WA 98431, USA
| | - David K Rodgers
- Department of Emergency Medicine, Madigan Army Medical Center, JBLM, WA 98431, USA
| | - Marc H Hohman
- Charles A. Andersen Simulation Center, Madigan Army Medical Center, JBLM, WA 98431, USA
- Department of Otolaryngology, Madigan Army Medical Center, JBLM, WA 98431, USA
| | - Jason R Muise
- Department of Emergency Medicine, Madigan Army Medical Center, JBLM, WA 98431, USA
| | - Kyle S Couperus
- Department of Emergency Medicine, Madigan Army Medical Center, JBLM, WA 98431, USA
| | - Jillian F Phelps
- Charles A. Andersen Simulation Center, Madigan Army Medical Center, JBLM, WA 98431, USA
- Department of Emergency Medicine, Madigan Army Medical Center, JBLM, WA 98431, USA
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Mancha F, Martinez MA, Sifuentes D, Mendez J, Arana AA, Maddry JK, Schauer SG. Comparative Analysis of Whole Blood Infusion Effects: Assessing LifeFlow Versus Pressure Bag in a Sus scrofa Model. Mil Med 2024; 189:e527-e531. [PMID: 37625036 DOI: 10.1093/milmed/usad324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/22/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND To improve survival for hemorrhagic shock treatment, guidelines emphasize two patient care priorities: (1) immediate hemorrhage control and (2) early resuscitation with whole blood or blood products. The LifeFlow device is designed to rapidly infuse blood products. However, the effects of using this device compared to pressure-bag systems remain unclear. We hypothesize that there will be no laboratory-measured difference with the blood when infused through the LifeFlow versus the current standard pressure bag system. METHODS Two units of fresh whole blood were obtained from a sus scrofa model. One unit was "infused" using the LifeFlow with the other unit used as a control through a standard pressure bag system into an empty bag. The "before" measurements were obtained from blood samples from a standard fresh whole blood collection bag. The blood was "infused" into a whole blood bag devoid of storage solution from which the "after" measurements were obtained. RESULTS This study utilized 22 clinically healthy sus scrofa. Blood units were primarily obtained from a left subclavian central line (50.0%). The median time to acquire and administer a unit of blood was similar for both the LifeFlow device (8.4 min and 8.1 min) and the pressure bag (8.7 min and 7.4 min). No significant differences were found in the total time to acquire or administer blood between the two devices. The median volume of blood acquired was 500 mL for both groups. While no significant differences in blood parameters were observed between the two devices, significant differences were noted when comparing pre- and post-transfusion values within each device. For the LifeFlow device, an increase in hemoglobin and chloride levels and a decrease in thromboplastin time and glucose levels were observed. With the pressure bag, only a decrease in blood urea nitrogen was observed. CONCLUSIONS In comparing the LifeFlow to the pressure bag, there were no significant differences noted in the total time to acquire or administer a whole unit of blood. However, there were differences with several laboratory parameters of unclear clinical significance.
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Affiliation(s)
- Fabiola Mancha
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Metis Foundation, San Antonio, TX 78216, USA
| | - Melody A Martinez
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Metis Foundation, San Antonio, TX 78216, USA
| | - Dayana Sifuentes
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Metis Foundation, San Antonio, TX 78216, USA
| | - Jessica Mendez
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Metis Foundation, San Antonio, TX 78216, USA
| | | | - Joseph K Maddry
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- 59th Medical Wing, JBSA, Lackland, TX 78236, USA
| | - Steven G Schauer
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- 59th Medical Wing, JBSA, Lackland, TX 78236, USA
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Beya R, Jérôme D, Tanguy V, My-Van N, Arthur R, Jean-Pierre R, Thierry H, Cyril B, Jean-Pierre F. Morphodynamic study of the corona mortis using the SimLife ® technology. Surg Radiol Anat 2023; 45:89-99. [PMID: 36585462 DOI: 10.1007/s00276-022-03067-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/20/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE Open book pelvic ring fractures are potentially life-threatening, due to their instability and major hemorrhage risk. During the open reduction and internal fixation, the pelvic approach remains a technical challenge, as the surgeon wants to prevent any iatrogenic damage of the vascular loop located in the retro-pubic area called corona mortis (CMOR). Recently, the cadaver perfused SimLife® technology has been developed to improve the surgeon training, out of the operating room. This study aimed to compare two models of cadaveric dissection, to assess the interest of the perfused SimLife® in providing dynamic aspect of anatomy in the identification of CMOR and its topography. METHODS Twelve human cadaveric pelvises have been dissected, following two protocols. 12 hemi-pelvises of the dissections were performed without perfusion (Model A), whereas the 12 other hemi-pelvises have been prepared with the SimLife® pulsatile perfusion (Model B). The prevalence and morphologic parameters determined: length, diameter and distance between the CMOR and the pubic symphysis. RESULTS The CMOR has been found in 66.67% of the cases. The length, the diameter, and the distance between the CMOR and the pubic symphysis were significantly higher in model B (respectively p = 0.029, p = 0.01, and p = 0.022). CONCLUSION These results suggest that the CMOR is easier to identify and to dissect with the SimLife® perfusion. As part of the surgical training of any trauma surgeon, this model could help him to keep in mind the CMOR topography, to improve the open book lesion management.
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Affiliation(s)
- Robert Beya
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France. .,INSERM U1313-IRMETIST Unity, Research Institute, University, Poitiers, France.
| | - Danion Jérôme
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France.,INSERM U1313-IRMETIST Unity, Research Institute, University, Poitiers, France
| | - Vendeuvre Tanguy
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France.,INSERM U1313-IRMETIST Unity, Research Institute, University, Poitiers, France
| | - Nguyen My-Van
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France
| | - Renault Arthur
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France
| | - Richer Jean-Pierre
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France.,INSERM U1313-IRMETIST Unity, Research Institute, University, Poitiers, France
| | - Hauet Thierry
- INSERM U1313-IRMETIST Unity, Research Institute, University, Poitiers, France
| | - Breque Cyril
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France
| | - Faure Jean-Pierre
- A B S Lab, UFR Medicine and Pharmacy, Bat D1-Porte J 6, Milétrie Street, TSA 51115, 86073, Poitiers Cedex 9, France.,INSERM U1313-IRMETIST Unity, Research Institute, University, Poitiers, France
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Development of a post-mortem human specimen flow model for advanced bleeding control training. Injury 2023; 54:214-222. [PMID: 35948510 DOI: 10.1016/j.injury.2022.07.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prompt and effective hemorrhage control is paramount to improve survival in patients with catastrophic bleeding. In the ever-expanding field of bleeding control techniques, there is a need for a realistic training model to practice these life-saving skills. This study aimed to create a realistic perfused post-mortem human specimen (PMHS) flow model that is suitable for training various bleeding control techniques. MATERIALS AND METHODS This laboratory study was conducted in the SkillsLab & Simulation Center of Erasmus MC, University Medical Center Rotterdam, the Netherlands. One fresh frozen and five AnubiFiX® embalmed PMHS were used for the development of the model. Subsequent improvements in the exact preparation and design of the flow model were made based on model performance and challenges that occurred during this study and are described. RESULTS Circulating arteriovenous flow with hypertonic saline was established throughout the entire body via inflow and outflow cannulas in the carotid artery and jugular vein of embalmed PMHS. We observed full circulation and major hemorrhage could be mimicked. Effective bleeding control was achieved by placing a resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter in the model. Regional perfusion significantly reduced the development of tissue edema. CONCLUSION Our perfused PMHS model with circulating arterial and venous flow appears to be a feasible method for the training of multiple bleeding control techniques. Regional arteriovenous flow successfully reduces tissue edema and increases the durability of the model. Further research should focus on reducing edema and enhancing the durability of the model.
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Wannatoop T, Ratanalekha R, Wongkornrat W, Keorochana K, Piyaman P. Efficacy of a perfused cadaver model for simulated trauma resuscitation in advanced surgical skills training. BMC Surg 2022; 22:306. [PMID: 35941680 PMCID: PMC9361587 DOI: 10.1186/s12893-022-01754-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022] Open
Abstract
Background To develop a perfused cadaveric model for trauma surgery simulation, and to evaluate its efficacy in trauma resuscitation advanced surgical skills training. Methods Fourteen fourth-year general surgery residents attended this workshop at Siriraj Hospital (Bangkok, Thailand). Inflow and outflow cannulae and a cardiopulmonary bypass pump were used to create the perfusion circuit. Inflow was achieved by cannulating the right common carotid artery, and outflow by cannulation of both the right common femoral artery and the internal jugular vein. Arterial line monitoring was used to monitor resuscitation response and to control perfusion pressure. The perfusion solution comprised saline solution mixed 1:1 with glycerol (50%) and water with red food dye added. Advanced surgical skills during life-threatening injuries and damage control resuscitation operations were practiced starting from the airway to the neck, chest, peripheral vessels, abdomen, and pelvis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was also practiced. Post-workshop survey questions were grouped into three categories, including comparison with previous training methods; the realism of anatomical correlation and procedures; and, satisfaction, safety, and confidence. All questions and tasks were discussed among all members of the development team, and were agreed upon by at least 90% of experts from each participating medical specialty/subspecialty. Results The results of the three main groups of post-workshop survey questions are, as follows: (1) How the training compared with previous surgical training methods—mean score: 4.26/5.00, high score: 4.73/5.00; (2) Realism of anatomical correlation and procedures—mean score: 4.03/5.00, high score: 4.60/5.00; and, (3) Satisfaction, safety, and confidence—mean score: 4.24/5.00, high score: 4.47/5.00. Conclusion The developed perfused cadaveric model demonstrated potential advantages over previously employed conventional surgical training techniques for teaching vascular surgery at our center as evidenced by the improvement in the satisfaction scores from students attending perfused cadaveric training compared to the scores reported by students who attended earlier training sessions that employed other training techniques. Areas of improvement included ‘a more realistic training experience’ and ‘improved facilitation of decision-making and damage control practice during trauma surgery’.
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Affiliation(s)
- Tongporn Wannatoop
- Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Rosarin Ratanalekha
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wanchai Wongkornrat
- Division of Cardio-Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kris Keorochana
- Division of Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Parkpoom Piyaman
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Borger van der Burg BLS, Keijzers P, van Dongen TTCF, van Waes OJF, Hoencamp R. For debate: advanced bleeding control potentially saves lives in armed forces and should be considered. BMJ Mil Health 2019; 166:e43-e46. [PMID: 31208988 DOI: 10.1136/jramc-2019-001231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Advanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel. METHODS The trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control. RESULTS There were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61). CONCLUSION Retrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.
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Affiliation(s)
| | - P Keijzers
- Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - T T C F van Dongen
- Surgery, Alrijne Ziekenhuis locatie Leiderdorp, Leiderdorp, The Netherlands.,Defense Healthcare Department, Ministry of Defence, Utrecht, The Netherlands
| | - O J F van Waes
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - R Hoencamp
- Surgery, Alrijne Ziekenhuis locatie Leiderdorp, Leiderdorp, The Netherlands.,Defense Healthcare Department, Ministry of Defence, Utrecht, The Netherlands.,Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Leiden University Medical Centre, Leiden, The Netherlands
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