Tag Archives: hybrid

Utility Of The Hybrid OR For Trauma: Recent Literature

As I mentioned in the last post, the early literature on the use of the hybrid OR for trauma patients was just so-so. However, additional work has been done, and the real benefits are becoming clearer. Today, I’ll describe a pair of more recent, related papers that examined trauma outcomes in the hybrid OR.

The research was performed at the University of Florida Health, Gainesville. The group published an initial paper analyzing 106 adult trauma patients managed in a regular OR, comparing them with another 186 who were taken to a newly repurposed hybrid OR. This room was a remodeled angiography suite that was located within the OR complex.

Here are the factoids:

  • Overall demographics of the two groups were similar
  • Initial hemoglobin in the hybrid group was about 1g/dL lower (10.2 vs 11.1)
  • Nine times as many hybrid patients had a REBOA balloon placed (9% vs 1%)
  • The time to hemorrhage control was significantly shorter in the hybrid group
  • The hybrid OR patients required fewer blood and plasma transfusions between 4 and 24 hours after arrival
  • Infectious complications and ventilator days were significantly lower in the hybrid OR group
  • Mortality was similar (13% hybrid vs 10% conventional)

The authors published a follow-up paper three years later in which they analyzed the original data to determine the cost-utility and value. They did this by examining the clinical outcomes relative to the cost of this new resource. They found that the costs across the patient admission were similar in the hybrid and conventional groups ($55K vs $51K).  The authors concluded that the better outcomes described in their first paper came with no significant increase in cost.

Bottom line: There is still precious little data on the benefits of the hybrid OR for trauma patients. Even though the total numbers appear to be small, it is difficult to amass the hybrid group sizes described here. It is the best US data we have so far, and shows promising results for minimal extra cost.

In my next post, I’ll conclude with some tips and tricks for setting up your own hybrid room.

References:

  1. Clinical Impact of a Dedicated Trauma Hybrid Operating Room. Journal Am Col Surg 232(4):560-570, 2020.
  2. Retrospective Value Assessment of a Dedicated, Trauma Hybrid Operating Room. J Trauma 94(6):814-822, 2023.

 

Why Use A Hybrid OR For Trauma?

Trauma is a surgical disease, and specifically, a disease of bleeding. So many of the tools and processes we have developed for its management revolve around the control of hemorrhage.

When a major trauma patient arrives in the resuscitation room, the initial management involves rapid assessment and correction of life-threatening conditions. Recognition of bleeding is paramount. A rapid decision must be made about the source of hemorrhage and the best way to control it.

Traditionally, bleeding control has been relegated to the operating room. Body cavities are opened as appropriate, and exsanguination is controlled by clamping, repairing, and/or suturing.

However, some body regions are much more challenging. The most notable is the pelvis, and specifically, the unstable pelvis. In the old days, after wrapping or applying an external fixator, the best we could do was to ligate the internal iliac arteries bilaterally and hope the bleeding would slow down sufficiently (it never really stopped) so that internal packing might have a chance.

As the use of interventional radiography grew in trauma, it became possible to occlude the internal iliacs noninvasively. Then, the radiologists became skilled enough to selectively identify and embolize more distal bleeding vessels that would dramatically shut down pelvic bleeding.

But this introduced a conundrum. OR vs IR? Where to go after the trauma bay? I’ve long said that the only place an unstable trauma patient can go is to the OR. Not CT, and certainly not the radiology department.

Only the OR, because that’s the only place that something can actually be done about the bleeding. However, that’s not entirely true now.

Here’s the traditional algorithm for a patient with hemorrhage from pelvic fractures:

They go to the operating room or interventional radiology. If they start in the operating room and can be stabilized (think external fixation and/or preperitoneal packing), then they might be able to be packaged and taken to IR for embolization. Likewise, if they were initially stable enough to go to IR but crashed there, then they must immediately be taken to OR.

But what if you could do both in one room with interventional radiology capabilities and a full resuscitation team with surgical instruments?! That’s the beauty of the hybrid room! It is entirely possible to do two, three, and maybe more cases on the same patient in the same room. Hence, the hybrid OR.

Next post: Is the hybrid OR for trauma useful?

The Hybrid OR For Trauma

A hybrid operating room is a special OR suite that allows advanced imaging to be carried out simultaneously with one or more additional operative procedures. It’s that simple. It contains specialized imaging equipment, including fluoroscopy and infusion equipment for radiographic dye administration. Some also contain CT and/or MRI capabilities, but the shielding required for these makes them rare. It is generally stocked with a variety of endovascular

devices and supplies. The usual anesthesia circuits are available, as are selected surgical packs, typically related to vascular and CV surgery.

These suites are typically large and can easily accommodate multiple operating teams. However, they are costly in several ways.

First, they take up a great deal of space. Many have the square footage of two or more standard operating rooms. Initial construction costs are very high, as are remodeling and maintenance costs. They can also tax the hospital engineering infrastructure, from electrical to plumbing to ventilation.

However, if a hybrid room is available, it can deliver significant benefits to the hospital and patient care. Intraoperative imaging can provide immediate quality assurance, and patients can undergo more complex procedures and enjoy a shorter length of stay.

Next post: Why use a hybrid room for trauma?

Using Your Hybrid OR For Trauma

Every hospital wants some gadget or other. First, it was a robot. Or two. Now, it’s a hybrid operating room.

lourdes-hybrid-or1

What is this, you ask? It’s a mashup of an operating room and an interventional radiology suite. It’s new. It’s big. It’s cool (literally, which is an issue for trauma surgeons).

More and more hospitals are adding hybrid rooms at the request of their vascular surgery teams. These rooms allow for both angiographic and open operative procedures, potentially at the same time. They are perfect for endovascular procedures that need some degree of hands-in work as well. They are frequently used for thoracic endovascular repair of the aorta (TEVAR), repair of abdominal aortic aneurysm (AAA), and transcatheter aortic valve replacement (TAVR).

These rooms would seem to be perfect for some trauma cases as well. Some injuries require a mix of interventional work and open surgery. Think complex pelvic fractures and extremity vascular injuries.

But before you go rushing off to the hybrid room with the next patient you think might benefit from it, consider these issues:

  • You must first secure access to the hybrid room. Just because you want it doesn’t mean you can get it. This room was probably built with other services in mind. You must work with them closely to set up rules and priorities. Consider questions like, can a trauma case bump an elective one?
  • Decide what specific cases can be done in the room. Don’t waste it on procedures that can be done in any old OR. Ideally, it is for multi-team cases and must take advantage of the radiographic capabilities of the hybrid room. If it doesn’t, it should be done in any other room of appropriate size.
  • Check your hardware. Make sure that anything you might attach to the hybrid table actually will attach to it. Frequently, the side rails are missing and the table thickness is different than a standard OR table. Check all of your retractor systems for compatibility. If your neurosurgeons use a skull clamp like a Mayfield, make sure it will attach to the table. If they do not, look for adapters to make it possible. Don’t discover this on your first trip to the room.
  • Watch for hypothermia! These are big rooms, and are difficult to heat up uniformly. In addition, the electronics in the room may be heat sensitive, so you may not be able to raise the temperature to the levels you are accustomed. Place heating systems under and around the patient as much as possible, warm everything that goes into them, and monitor their temp closely.
  • Treat the equipment with respect.  This stuff is delicate, and must be used by other surgeons for sensitive procedures. Don’t break it!

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