You’re hooked! You are thinking back to a number of cases that you think might have done better with a hybrid room. And now let’s assume you already have one in your OR suite. Now what do you do?

The key is to avoid jumping right in and sending your next eligible patient straight to that room. You absolutely must take some time to develop policies and guidelines to make sure things go smoothly.

Here are some important things to think about:

• Identify which specific patients are eligible so you don’t squander this resource
• Who calls the OR to secure the room (surgeon, resident, other)?
• Who calls the interventional radiologist?
• What if another case (TEVAR, etc) is already on the table?
• What if another case is getting ready to use the OR? How are conflicts resolved?
• Develop an initial in-room report process so all the teams know the game plan
• Assign an extra circulator to the room. You’ll need them!
• Make sure all retractor systems (abdomen, head) fit the table! Remember that little asterisk in the previous section? Some retraction systems may need adaptors to work with your table. Don’t find this out at the last minute!
• What about lithotomy position? How will this work with your hybrid table? They don’t have sections that break away.
• Ensure radiation protection for all, including thyroid shields.
• Bag the bottom x-ray detector, otherwise it will get very, very gross!
• Create an external fixator equipment cart that can be moved into the hybrid room.
• Create an embolization cart with appropriate wires, catheters, coils, etc. This stuff may not be stocked normally in the hybrid room

And I’m sure there are more details that I haven’t thought of. If you have some helpful suggestions, policies, or protocols, please share them with me!

The key to answering this question is to look at the resources that a hybrid OR brings to bear, and then determine what types of patients can take full advantage of them. Sadly, we have no guidance from the trauma literature, so we need to let our imaginations run free.

The basic concept for hybrid room use is this:

“My patient needs interventional radiology plus at least one other surgical specialty procedure”

The additional procedures don’t necessarily need to benefit from or utilize the IR capabilities. But they do need to be of an emergent nature. For example, a patient with a pelvic fracture can undergo angio-embolization and pelvic external fixation, while the gynecologic surgeons repair a vaginal laceration. Simultaneous, but not related to the embolization.

Here’s my list of possibilities. It is by no means complete or exhaustive. It’s just a start. All include the interventional radiologist for some part of it:

• Pelvic fractures with angioembolization plus:
  • Preperitoneal packing
  • Perineal / gynecologic repair
  • Laparotomy
• Liver angioembolization plus laparotomy
• Thoracic aortic injury plus laparotomy
• Angiographic assistance for management of vascular extremity injury
• Any of the previous procedures plus craniotomy*
• And don’t forget to toss REBOA in with this!
• Plus some other stuff I’m sure you will think up

Tomorrow, some details to think about while setting up your own hybrid OR!