A Paradigm Shift in Critical Care Infrastructure in Complex Settings: Evaluating an Ultraportable Operating Room to Improve Field Surgical Safety

Military Medicine, vol. 186, pp. 295–299

Abstract

INTRODUCTION: Scarcity of operating rooms and personal protective equipment in far-forward field settings make surgical infections a potential concern for combat mortality and morbidity. Surgical and transport personnel also face infectious risks from bodily fluid exposures. Our study aimed to describe the serial, proof-of-concept testing of the SurgiBox technology: an inflatable sterile environment that addresses the aforementioned problems, fits on gurneys and backpacks, and drapes over incisions. MATERIALS AND METHODS: The SurgiBox environmental control unit and inflatable enclosure were optimized over five generations based on iterative feedback from stakeholders experienced in surgery in austere settings. The airflow system was developed by analytic modeling, verified through in silico modeling in SOLIDWORKS, and confirmed with prototype smoke-trail checking. Particulate counts evaluated the enclosure's ability to control and mitigate users' exposures to potentially infectious contaminants from the surgical field in various settings. SurgiBox enclosures were setup over a mannequin's torso, in a configuration and position for either thoracic or abdominal surgery. A particle counter was serially positioned in sternotomy and laparotomy positions, as well as bilateral flank positions. This setup was repeated with open ports exposing the enclosure to the external environment. To simulate stress scenarios, sampling was repeated with enclosure measurements during an increase in external particulate concentration. RESULTS: The airflow technology effectively kept contaminants away from the incision and maintained a pressure differential to reduce particle entry. Benchtop testing demonstrated that even when ports were opened or the external environment had high contaminant burden, the enclosed surgical field consistently registered 0 particle count in all positions. Time from kit opening to incision averaged 54.5 seconds, with the rate-limiting step being connecting the environmental control unit to the enclosure. The portable kit weighted 5.9 lbs. CONCLUSIONS: Analytic, in silico, and mechanical airflow modeling and benchtop testing have helped to quantify the SurgiBox system's reliability in creating and maintaining an operating room-quality surgical field within the enclosure as well as protecting the surgical team outside the enclosure. More recent and ongoing work has focused on specifying optimal use settings in the casualty chain of care, expanding support for circumferential procedures, automating airflow control, and accelerating system setup. SurgiBox's ultimate goal is to take timely, safe surgery to patients in even the most austere of settings.

Authors 7

1. Debbie Lin Teodorescu

   United States Department of Defense · Harvard University · Defense Health Agency · Massachusetts General Hospital · Massachusetts Institute of Technology

   Affiliation as printed

   D-Lab, Massachusetts Institute of Technology, Cambridge, MA 02139, USA

   Department of Defense, National Capital Consortium, Defense Health Agency, Washington DC 20307, USA

   Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA

   Department of Research and Development, Surgi Box Inc, Cambridge, MA 02139, USA

2. Stephen M. Okajima

   Massachusetts Institute of Technology

   Affiliation as printed

   D-Lab, Massachusetts Institute of Technology, Cambridge, MA 02139, USA

   Department of Research and Development, Surgi Box Inc, Cambridge, MA 02139, USA

3. Asad Moten

   United States Department of Defense · Harvard University · Defense Health Agency · Massachusetts General Hospital

   Affiliation as printed

   Center on Genomics, Vulnerable Populations, and Health Disparities; Harvard/Massachusetts General Hospital, Boston, MA 02114, USA

   Department of Defense, National Capital Consortium, Defense Health Agency, Washington DC 20307, USA

   Department of Lab, Health Novations International, Houston, TX 70089, USA

   Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA

   Department of Research and Development, Surgi Box Inc, Cambridge, MA 02139, USA

   Center on Genomics, Vulnerable Populations, and Health Disparities

4. Mike Horia Teodorescu

   Boston College · Massachusetts Institute of Technology

   Affiliation as printed

   D-Lab, Massachusetts Institute of Technology, Cambridge, MA 02139, USA

   Department of Information Systems, Boston College, Chestnut Hill, MA 02467, USA

   Department of Research and Development, Surgi Box Inc, Cambridge, MA 02139, USA

5. Majed W. El Hechi

   Harvard University · Massachusetts General Hospital

   Affiliation as printed

   Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA

   Division of Trauma, Emergency Surgery and Surgical Critical Care; Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA

   Division of Trauma, Emergency Surgery and Surgical Critical Care

6. Samantha Gutierrez-Arango

   Massachusetts Institute of Technology

   Affiliation as printed

   Center for Extreme Bionics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA

   D-Lab, Massachusetts Institute of Technology, Cambridge, MA 02139, USA

7. Karien Meier Aachen

   Leiden University Medical Center

   Affiliation as printed

   Leiden University Medical Center, Leiden, ZA 2333, Netherlands