Dear Editor,
Anaesthesia for neurosurgical procedures presents significant challenges due to restricted patient access, complex ergonomics, and the risk of life-threatening complications such as venous air embolism (VAE). Early recognition of these events is essential. This report presents an observational human-factors insight into the role of a microscope-integrated smart screen as a supplementary visual aid for enhancing anaesthetic awareness.
The anaesthesia workstation is frequently compared to a cockpit as it requires the simultaneous processing of multiple visual and auditory inputs while avoiding cognitive overload. Ergonomics are particularly important in neurosurgery, where patient access is limited by positioning and draping, and the operating room layout and equipment configuration can significantly influence anaesthetic management and team communication.[1,2] While smart screens integrated with operating microscopes improve surgical visualisation and documentation, their potential role in improving situational awareness for the anaesthesiologist has not been previously described.
A female patient in her early forties with a right temporal high-grade glioma underwent emergency craniotomy and tumour excision. Due to the tumour size and cerebral oedema, invasive arterial and central venous monitoring were implemented. The procedure utilised an operating microscope with an integrated smart screen positioned adjacent to the anaesthesia workstation. Shortly after dural exposure, the screen was obscured by significant bleeding resulting from dural sinus injury. This event drew the anaesthesiologist’s attention and prompted early communication with the surgical team before any physiological instability was observed.
Within seconds, end-tidal carbon dioxide decreased from 33 to 19 mmHg, followed by tachycardia (70–110 beats/min), a reduction in mean arterial pressure (82–55 mmHg), and arterial desaturation (100%–88%). Given these features suggestive of VAE, the head end was immediately flattened and the surgical field packed. Nitrous oxide was avoided to prevent intravascular air expansion, and controlled ventilation was maintained with careful application of positive end-expiratory pressure (PEEP). Aspiration through the central venous catheter (CVC) revealed micro air bubbles which supported the diagnosis in conjunction with physiological changes. Immediate resuscitation with 100% oxygen, fluids, blood products, and inotropic support achieved haemodynamic stabilisation, permitting the surgery to proceed without further incident. Dedicated VAE detection modalities, such as precordial Doppler or transoesophageal echocardiography, were not available. The CVC was inserted with the intention of positioning the tip near the superior vena cava–right atrial junction for aspiration, although the exact tip position could not be confirmed intra-operatively.
VAE is a recognised complication of neurosurgery, particularly in cases involving head-up positioning or proximity to venous sinuses, with a reported incidence of 15–76%.[3,4] Detection typically relies on physiological changes or specialised monitoring, which may not always be accessible.
The operating room layout features the smart screen positioned adjacent to the anaesthesia workstation, within the anaesthesiologist’s line of sight. This arrangement allows for simultaneous observation of patient monitors and the surgical field [Figure 1].
Figure 1.
Conceptual illustration of the smart screen functioning as a visual aid during neurosurgery. The display links the operating microscope and anaesthesia workstation, creating a shared visual interface that enhances anaesthesiologist’s awareness
Human-factors research shows that during critical events, anaesthesia providers primarily focus on key monitors, and excessive reliance on alarms may delay recognition.[5] In this case, the smart screen functioned as an immediate visual aid, connecting a visible surgical event with impending physiological deterioration and allowing the anaesthesiologist to act before the situation worsened. Although surgical communication remains essential, a shared visual display may enhance situational awareness. Such a display should not replace clinical judgment or established monitoring systems but rather support them. Positioning surgical screens within the anaesthesiologist’s line of sight may offer a practical addition to existing monitoring and communication.
This observation does not advocate for smart screens as substitutes for established monitoring, but rather as adjuncts, particularly in settings where advanced VAE monitoring is unavailable. Incorporating human-factor principles into operating room design is essential for patient safety.[6] Strategic placement of surgical displays within the anaesthesiologist’s line of sight may reduce cognitive load and facilitate earlier crisis recognition. However, the availability of an integrated screen with an operating microscope may not always be feasible.
This report is limited by its single-case nature and the absence of systematic evidence correlating smart-screen obscuration with critical events. Obscuration is a non-specific finding that may result from bleeding, lens contamination, or technical issues and should be interpreted in conjunction with clinical and monitoring parameters. Nevertheless, this observation suggests that existing technology, when considered from a human-factors perspective, may provide safety benefits that were not originally intended. Whenever available, the anaesthesiologists may use smart screens to enhance patient monitoring. Further studies are required to determine whether such integration can improve intra-operative vigilance and response.
Author contributions
KG: Conceptualisation, literature search, data acquisition, manuscript preparation, manuscript review, and guarantor of the study. KS: Literature search, manuscript preparation, and data analysis. AA: Conceptualisation, definition of intellectual content, data analysis, manuscript preparation, overall supervision and critical review of the manuscript. RY: Literature search, data acquisition, and manuscript editing. All authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.
Disclosure of use of artificial intelligence (AI)-assistive or generative tools
These tools were not used.
Declaration of use of permitted tools
Microsoft Office PowerPoint was used to make Figure 1.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Suryawanshi CM, Shah B, Khanna S, Ghodki P, Bhati K, Ashok KV. Anaesthetic management of robot-assisted laparoscopic surgery. Indian J Anaesth. 2023;67:117–22. doi: 10.4103/ija.ija_966_22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ellsworth WA, Iverson RE. Patient safety in the operating room. Semin Plast Surg. 2006;20:214–8. [Google Scholar]
- 3.Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, et al. Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position. J Neurosurg. 2017;127:182–8. doi: 10.3171/2016.5.JNS152328. [DOI] [PubMed] [Google Scholar]
- 4.Ganslandt O, Merkel A, Schmitt H, Tzabazis A, Buchfelder M, Eyupoglu I, et al. The sitting position in neurosurgery: Indications, complications and results. A single institution experience of 600 cases. Acta Neurochir (Wien) 2013;155:1887–93. doi: 10.1007/s00701-013-1822-x. [DOI] [PubMed] [Google Scholar]
- 5.Roche TR, Maas EJC, Said S, Braun J, Machado C, Spahn DR, et al. Anesthesia personnel’s visual attention regarding patient monitoring in simulated non-critical and critical situations, an eye-tracking study. BMC Anesthesiol. 2022;22:167. doi: 10.1186/s12871-022-01705-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Chee D, Tan TK. Patient safety in the operating theatre: An ongoing endeavour. Proc Singapore Healthc. 2025:34. doi: 10.1177/20101058251342344. [Google Scholar]