A wearable approach for intraoperative physiological stress monitoring of multiple cooperative surgeons
Graphical abstract
This study illustrates the use of a wearable biomonitoring platform for the assessment of stress among neurosurgeons during surgery procedures.
Introduction
Everyday surgeons are submitted to high mental pressure in order to perform skillful surgeries where the patient’s life is frequently at risk. Amongst these professionals are neurosurgeons who carry some of the most critical and demanding surgical procedures [1]. Furthermore, some emergency situations need to be addressed as soon as the patient enters the hospital. An example of this is intracranial aneurysms. By definition, an aneurysm is a weak area in a blood vessel wall that causes it to balloon out, while being filled with blood, and it may rupture, leading to subarachnoid bleeding, which results in life threatening complications. In case an aneurysm occurs in the brain, the risk of the procedure becomes even higher, due to the difficult access to the affected area. To perform the intervention, surgeons can recur to different approaches. The standard neurosurgery method for these cases, known as “clipping”, consists in the placement of a clip in the aneurysm’s neck in order to reconstruct the vessel’s wall and stop blood from flowing in. Besides, this type of aneurysm involves careful dissection and a risk of rupture, and often the brain swelling aggravates the conditions in which the surgeons will perform the surgery. Hence, due to all the pressure induced by the abovementioned factors, neurosurgeons are exposed to high stress during these procedures [2]. Furthermore, considering the duration of this type of procedures, it is expected that neurosurgeons also experience mental fatigue. As an example, a study performed with 783 members of the American Association of Neurological Surgeons, showed that an overall rate of 56.7% of these professionals were associated with high levels of stress and burnout [3,4].
Cardiovascular strain is one of the consequences of such exposure. In order to prepare the body to “fight or flight” as a response to stress, the Autonomous Nervous System (ANS), through changes in sympathetic and parasympathetic activity, activates certain body mechanisms [5], therefore producing an autonomic imbalance. The heart is one of the affected organs, changing behavior in order to provide a better blood flow to muscles. This is done by increasing the Heart Rate (HR) and changing the variability between heartbeats (i.e. Heart Rate Variability (HRV)), inducing high levels of cardiovascular strain. Thus, low HRV and changes in signal complexity have been associated with an increased risk of cardiac events and higher probability of cardiovascular events and even death [6,7]. Besides, it has been reported that excessive levels of intra-operative stress can compromise both technical and nontechnical skills of the surgeons [8]. All these variables can result in impairments on the surgical performance and, therefore, of surgical outcome.
The novelty of this study comes from its application scenario, where neurosurgeons are monitored throughout neurosurgeries, working under real world conditions. Furthermore, the data analysis process includes both linear and nonlinear HRV metrics. Although different studies have been reported in the area of surgeon monitoring, very few have assessed individual perception of events and including psychophysiological data [1]. Only two studies have been identified investigating neurosurgeons throughout an intracranial aneurysm surgery [2,9] and an additional one that assessed the different phases of the procedure [10] which is crucial for identification of relevant moments. These studies were focused in hemodynamic changes (HR, Blood Pressure) and not in HRV. To our knowledge, no study took in consideration the neurosurgeon’s own appraisal regarding the aneurysm procedure, which is essential for the reliable assessment of psychophysiological impact.
The present study follows a preliminary short study published in a congress abstract [11] and aims to evaluate surgeons stress levels during intracranial aneurysm procedures. Furthermore, it aims to understand how these professionals respond to events according to their surgery role. A wearable approach adaptable to the demanding intra- operating room (OR) environment was developed. This system allowed for intraoperative physiological monitoring of multiple surgeons. It consists of state-of-the-art wearable and mobile technology for monitoring of clinical quality electrocardiogram (ECG) signal. Several linear and nonlinear HRV variables were extracted to measure autonomic imbalance. Surgeon’s self-appraisal of the procedures was also considered.
Section snippets
Materials and methods
The following integrated wearable system was used for the monitoring of stress and fatigue through HRV analysis among neurosurgeons (N = 2) during intracranial aneurism procedures (N = 10) consists in the use of an integrated wearable system. The Fig. 1 provides an illustration of the overall system´s architecture. This system includes wearable vital signs monitors that collect clinical-grade ECG data from each neurosurgeon (Section 2.1). The developed system enables the use of several of these
Surgery events
L’s pNN20 pattern (Fig. 4) was present in all the nine surgeries (N = 9) where he performed the clipping as main surgeon, showing significant differences between the Access and Def. Clip moments (42.1% vs 7.0%, p < 0.01). In Table 2, it can be observed that this is also followed by decreases in Poincaré Plot’s SD1 (30 ms vs 11 ms, p < 0.01), SD2 (91 ms vs 44 ms, p < 0.01) and CVI (4.6 vs. 3.7, p < 0.01). Additionally, there is an increase in the occurrence rate of 0 V (59.5% vs 74.7%,
Discussion
Regarding the physiological behavior associated to role switch between the surgeons, it can be concluded that a sympathovagal excitation occurs in surgeon L after he changes to the main surgeon role. Firstly, because the 0 V occurrence rate has been reported to be associated with increases of cardiac norepinephrine spillover (gold standard of measurement of cardiac sympathetic outflow) [30]. Secondly, stressful events tend to decrease NN variability [23]. As for the different moments, L and XL
Conclusion
Findings provide an insight on psychophysiological stress and fatigue levels of neurosurgeons when working under real world conditions and confirm the acceptability, feasibility and research potential of the method. Furthermore, this approach was complemented with the surgeons’ subjective appraisal of stress and cognitive workload, which showed to be correlated.
Role switching from assistant to main surgeon seems to induce a measurable change in autonomic balance, suggesting that the surgeon
Author statement
Gonçalo Pimentel participated in the acquisition of data, and analysis and interpretation of the collected data. All the other authors jointly participated in the conception and design of the study, drafting the article and ultimately revising it critically.
Declarations of interest
None.
Acknowledgements
This work was supported by National Funds through the FCT Fundação para a Ciência e Tecnologia (Portuguese Foundation for Science and Technology) within the project VR2Market CMUP-ERI/FIA/0031/2013. It is also partly developed under the project NanoSTIMA, funded by the North Portugal Regional Operational Program (NORTE 2020), under the PORTUGAL 2020 Partnership Agreement, and through the European Regional Development Fund (ERDF).
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