High-fidelity simulation demonstrates the influence of anesthesiologists' age and years from residency on emergency cricothyroidotomy skills.

BACKGROUND: Age-related deterioration in both cognitive function and the capacity to control fine motor movements has been demonstrated in numerous studies. However, this decline has not been described with respect to complex clinical anesthesia skills. Cricothyroidotomy is an example of a complex, lifesaving procedure that requires competency in the domains of both cognitive processing and fine motor control. Proficiency in this skill is vital to minimize time to reestablish oxygenation during a "cannot intubate, cannot ventilate" scenario. In this prospective, controlled, single-blinded study, we tested the hypothesis that age affects the learning and performance of emergency percutaneous cricothyroidotomy in a high-fidelity simulated cannot intubate/cannot ventilate scenario. METHODS: Thirty-six staff anesthesiologists (19 aged younger than 45 years and 17 older than 45 years) managed a high-fidelity cannot intubate/cannot ventilate scenario in a high-fidelity simulator before and after a 1-hour standardized training session. The group division cutoff age of 45 years was based on the median age of our sample subject population before enrollment. The scenarios required the insertion of an emergency percutaneous cricothyroidotomy. We compared cricothyroidotomy skills in the older group with those in the younger group using procedural time, 5-point task-specific checklist score, and global rating scale score. Correlation based on age, years from residency, weekly clinical hours worked, previous continuing medical education in airway management, and previous simulation experience was also performed. RESULTS: In both prestandardization and poststandardization, age and years from residency correlated with procedural time, checklist scores, and global rating scores. Baseline, prestandardization variables were all better for the younger group, with a mean age of 37 years, compared with the older group, with a mean age of 58 years. Procedural time was 100 (72-128) seconds versus 152 (120-261) seconds. Checklist scores were 7.0 (6.1-8.0) versus 6.0 (4.8-8.0). Global rating scale scores were 22.0 (17.8-29.8) versus 17.5 (10.4-20.6). After the 1-hour standardized training session, the younger group continued to perform better than the older group with procedural time of 75 (66-91) seconds versus 87 (78-123) seconds, checklist scores of 10.0 (9.1-10.0) versus 9.0 (8.0-10.0), and global rating scale scores of 35.0 (32.1-35.0) versus 32.0 (29.0-33.8). Regression analysis was performed on the poststandardization data. Both age and years from residency independently affected procedural time, checklist scores, and global rating scale scores (all P < 0.05). CONCLUSIONS: Baseline proficiency with simulated emergency cricothyroidotomy is associated with age and years from residency. Despite standardized training, operator age and years from residency were associated with decreased proficiency. Further research should explore the potential of using age and years from residency as factors for implementing periodic continuing medical education.

Incomplete adherence to the ASA difficult airway algorithm is unchanged after a high-fidelity simulation session.

PURPOSE: Although guidelines for difficult airway management have been published, the extent to which consultant anesthesiologists follow these guidelines has not been determined. The purpose of this study is to observe how consultant anesthesiologists manage a "cannot intubate, cannot ventilate" (CICV) scenario in a high-fidelity simulator and to evaluate whether a simulation teaching session improves their adherence to the American Society of Anesthesiologists (ASA) difficult airway algorithm. METHODS: With Ethics Board approval and informed consent, all staff anesthesiologists in a single tertiary care institution were invited to enrol in this study where they managed a simulated unanticipated CICV scenario in a high-fidelity simulator. The scenario involved a patient with a difficult airway whose trachea could not be intubated and where it was impossible to ventilate the patient's lungs. Airway management options, including laryngeal mask airway, a fibreoptic bronchoscope, and a Glidescope were available for use but scripted to fail. A percutaneous cricothyroidotomy was required to re-establish adequate ventilation. Following the scenario, there was a personalized one-hour video-assisted expert debriefing focusing on the ASA difficult airway guidelines and "hands-on" cricothyroidotomy teaching. The second scenario followed immediately with an identical CICV scenario. The content to either scenario was not revealed beforehand. Outcome measures included: 1) major deviations from the ASA difficult airway guidelines; 2) time to start cricothyroidotomy; and 3) time to achieve ventilation. RESULTS: Thirty-eight anesthesiologists agreed to participate. The number of major deviations from the ASA algorithm was similar in the first and second sessions. These deviations included: multiple laryngoscopies (0 vs 2 pre-post; P = 0.49), use of fibreoptic bronchoscope (8 vs 7 pre-post; P = 1.0), bypass of laryngeal mask airway attempt (7 vs 13 pre-post; P = 0.19), and failure to call for anesthetic help (12 vs 8 pre-post; P = 0.43). However, more participants failed to call for surgical help in the second session (7 vs 16; P = 0.04). The times to start cricothyroidotomy and the times to achieve ventilation were significantly shorter in the second session (205.5 +/- 61.3 sec vs 179.7 +/- 65.1 sec; P = 0.01 and 356.9 +/- 117.2 sec vs 269.4 +/- 77.43 sec; P = 0.0002, respectively). CONCLUSION: No substantial changes in airway management in a CICV scenario were observed after an intense one-hour personalized video-assisted airway-focused simulation debriefing session with an expert. It appears that multiple factors other than airway algorithms come into play in emergency airway decision-making processes, including one's personal clinical experience with the many available airway devices.

Attenuation of neuropathy-induced allodynia following intraplantar injection of pregabalin.

PURPOSE: Pregabalin exhibits potent anticonvulsant, analgesic, and anxiolytic activity in animal models. However, few studies have evaluated pregabalin's potential peripheral effects on neuropathic pain. The aim of this study was to evaluate the peripheral analgesic effects of pregabalin in a rat model of neuropathic pain. METHODS: Male Sprague-Dawley rats were prepared by ligating the left L5 and L6 spinal nerves to produce neuropathic pain. Sixty rats with neuropathic pain were randomly assigned to six groups. Normal saline (control) and pregabalin (10, 20, 30, and 50 mg.kg(-1)) were administered to the plantar surface of the affected left hind paw. Pregabalin (50 mg.kg(-1)) was administered into the unaffected contralateral paw in order to determine its systemic effect. Responses to mechanical, cold, and heat stimulation were recorded at 15, 30, 60, 90, 120, 150, and 180 min after drug administration. Rotarod performance was measured to detect drug-induced side effects, including sedation and reduced motor coordination. RESULTS: Saline injected into the affected paw and a pregabalin dose of 50 mg.kg(-1) injected into the contralateral paw showed no differences for mechanical, cold, and heat allodynia. Administration of pregabalin to the affected left hind paw in the dose range of 10-50 mg.kg(-1) resulted in a dose-dependent increase in thresholds to mechanical, cold, and heat stimulation. CONCLUSION: Peripherally administered pregabalin attenuates mechanical, cold, and heat allodynia in a rat model of neuropathic pain.

Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery.

BACKGROUND: Simulation-based training is useful in improving physicians' skills. However, no randomized controlled trials have been able to demonstrate the effects of simulation teaching in real-life patient care. This study aimed to determine whether simulation-based training or an interactive seminar resulted in better patient care during weaning from cardiopulmonary bypass (CPB)-a high stakes clinical setting. METHODS: This study was conducted as a prospective, single-blinded, randomized controlled trial. After institutional research board approval, 20 anesthesiology trainees, postgraduate year 4 or higher, inexperienced in CPB weaning, and 60 patients scheduled for elective coronary artery bypass grafting were recruited. Each trainee received a teaching syllabus for CPB weaning 1 week before attempting to wean a patient from CPB (pretest). One week later, each trainee received a 2-h training session with either high-fidelity simulation-based training or a 2-h interactive seminar. Each trainee then weaned patients from CPB within 2 weeks (posttest) and 5 weeks (retention test) from the intervention. Clinical performance was measured using the validated Anesthesiologists' Nontechnical Skills Global Rating Scale and a checklist of expected clinical actions. RESULTS: Pretest Global Rating Scale and checklist performances were similar. The simulation group scored significantly higher than the seminar group at both posttest (Global Rating Scale [mean +/- standard error]: 14.3 +/- 0.41 vs. 11.8 +/- 0.41, P < 0.001; checklist: 89.9 +/- 3.0% vs. 75.4 +/- 3.0%, P = 0.003) and retention test (Global Rating Scale: 14.1 +/- 0.41 vs. 11.7 +/- 0.41, P < 0.001; checklist: 93.2 +/- 2.4% vs. 77.0 +/- 2.4%, P < 0.001). CONCLUSION: Skills required to wean a patient from CPB can be acquired through simulation-based training. Compared with traditional interactive seminars, simulation-based training leads to improved performance in patient care by senior trainees in anesthesiology.

Personalized oral debriefing versus standardized multimedia instruction after patient crisis simulation.

BACKGROUND: Simulation experience alone without debriefing is insufficient for learning. Standardized multimedia instruction has been shown to be useful in teaching surgical skills but has not been evaluated for use as an adjunct in crisis management training. Our primary purpose in this study was to determine whether standardized computer-based multimedia instruction is effective for learning, and whether the learning is retained 5 wk later. Our secondary purpose was to compare multimedia instruction to personalized video-assisted oral debriefing with an expert. METHODS: Thirty anesthesia residents were recruited to manage three different simulated resuscitation scenarios using a high-fidelity patient simulator. After the first scenario, subjects were randomized to either a computer-based multimedia tutorial or a personal debriefing of their performance with an expert and videotape review. After their respective teaching, subjects managed a similar posttest resuscitation scenario and a third retention test scenario 5 wk later. Performances were independently rated by two blinded expert assessors using a previously validated assessment system. RESULTS: Posttest (12.22 +/- 2.19, P = 0.009) and retention (12.80 +/- 1.77, P < 0.001) performances of nontechnical skills were significantly improved in the standardized multimedia instruction group compared with pretest (10.27 +/- 2.10). There were no significant differences in improvement between the two methods of instruction. CONCLUSION: Computer-based multimedia instruction is an effective method of teaching nontechnical skills in simulated crisis scenarios and may be as effective as personalized oral debriefing. Multimedia may be a valuable adjunct to centers when debriefing expertise is not available.

Perceived sleepiness in Canadian anesthesia residents: a national survey.

PURPOSE: To compare the self-perceived sleepiness of Canadian anesthesia residents providing modified on-call duties (12-16 h) vs. traditional on-call duties (24 h). METHODS: A 25-item online survey was distributed to all Canadian anesthesia residents who, at that time, were on anesthesia rotations. The survey assessed resident demographics, perceived work patterns, and sleepiness, as well as their opinions on resident work hour reform. Self-perceived sleepiness was quantified using the validated Epworth sleepiness scale (ESS). RESULTS: Three hundred eight of 400 (77%) eligible Canadian anesthesia residents completed the survey. Forty-three percent of residents who worked traditional on-call (duration 24.1 +/- 0.5 h) shifts and 48% of residents who worked modified on-call (duration 15.5 +/- 1.8 h) shifts met ESS criteria for excessive daytime sleepiness. Overall mean ESS scores did not differ significantly between the traditional (9.1 +/- 4.9) and the modified call groups (9.5 +/- 4.8). Residents with an on-call frequency of >or=1:4 days or those who slept

Fiberoptic oral intubation: the effect of model fidelity on training for transfer to patient care.

BACKGROUND: Previous studies have indicated that fiberoptic orotracheal intubation (FOI) skills can be learned outside the operating room. The purpose of this study was to determine which of two educational interventions allows learners to gain greater capacity for performing the procedure. METHODS: Respiratory therapists were randomly assigned to a low-fidelity or high-fidelity training model group. The low-fidelity group was guided by experts, on a nonanatomic model designed to refine fiberoptic manipulation skills. The high-fidelity group practiced their skills on a computerized virtual reality bronchoscopy simulator. After training, subjects performed two consecutive FOIs on healthy, anesthetized patients with predicted "easy" intubations. Each subject's FOI was evaluated by blinded examiners, using a validated global rating scale and checklist. Success and time were also measured. RESULTS: Data were analyzed using a two-way mixed design analysis of variance. There was no significant difference between the low-fidelity (n = 14) and high-fidelity (n = 14) model groups when compared with the global rating scale, checklist, time, and success at achieving tracheal intubation (all P = not significant). Second attempts in both groups were significantly better than first attempts (P < 0.001), and there was no interaction between "fidelity of training model" and "first versus second attempt" scores. CONCLUSIONS: There was no added benefit from training on a costly virtual reality model with respect to transfer of FOI skills to intraoperative patient care. Second attempts in both groups were significantly better than first attempts. Low-fidelity models for FOI training outside the operating room are an alternative for programs with budgetary constraints.

Fibreoptic airway training: correlation of simulator performance and clinical skill.

PURPOSE: Simulation centres, where trainees can practise technical procedures on models of varying fidelity, provide a training option that allows them to acquire skills in a controlled environment prior to clinical performance. It has been proposed that the time to complete a simulator task may translate to proficiency in the clinical setting. The objective of this study was to determine whether time to complete a simulator task translates to clinical fibreoptic manipulation (FOM) performance. METHODS: Thirty registered respiratory therapists at a teaching hospital were recruited as subjects for a single-blinded randomized trial. Subjects were randomized to training on either a low fidelity (n = 15) or high fidelity (n = 15) model. After training, each subject was tested for the time required to complete a specific task on his/her respective model. Subjects then performed a fibreoptic orotracheal intubation (FOI) on healthy, consenting, and anesthetised patients requiring intubation for elective surgery. Performance was measured independently by blinded examiners using a checklist and global rating scale (GRS); and time was measured from insertion of the fibreoptic scope to visualization of the carina. Data were analyzed using Spearman rank order correlation coefficients. RESULTS: There was no correlation between the time to complete a task on either the high or low fidelity simulators, and the clinical FOI performance as assessed by a checklist, GRS, and time to complete the FOM (all P = NS). CONCLUSION: These results suggest that simulator-based, task-orientated time measurement may not be a good indicator of FOI performance in the clinical setting.

Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback.

BACKGROUND: The debriefing process during simulation-based education has been poorly studied despite its educational importance. Videotape feedback is an adjunct that may enhance the impact of the debriefing and in turn maximize learning. The purpose of this study was to investigate the value of the debriefing process during simulation and to compare the educational efficacy of two types of feedback, oral feedback and videotape-assisted oral feedback, against control (no debriefing). METHODS: Forty-two anesthesia residents were enrolled in the study. After completing a pretest scenario, participants were randomly assigned to receive no debriefing, oral feedback, or videotape-assisted oral feedback. The debriefing focused on nontechnical skills performance guided by crisis resource management principles. Participants were then required to manage a posttest scenario. The videotapes of all performances were later reviewed by two blinded independent assessors who rated participants' nontechnical skills using a validated scoring system. RESULTS: Participants' nontechnical skills did not improve in the control group, whereas the provision of oral feedback, either assisted or not assisted with videotape review, resulted in significant improvement (P < 0.005). There was no difference in improvement between oral and video-assisted oral feedback groups. CONCLUSIONS: Exposure to a simulated crisis without constructive debriefing by instructors offers little benefit to trainees. The addition of video review did not offer any advantage over oral feedback alone. Valuable simulation training can therefore be achieved even when video technology is not available.

Evaluation of patient simulator performance as an adjunct to the oral examination for senior anesthesia residents.

BACKGROUND: Patient simulators possess features for performance assessment. However, the concurrent validity and the "added value" of simulator-based examinations over traditional examinations have not been adequately addressed. The current study compared a simulator-based examination with an oral examination for assessing the management skills of senior anesthesia residents. METHODS: Twenty senior anesthesia residents were assessed sequentially in resuscitation and trauma scenarios using two assessment modalities: an oral examination, followed by a simulator-based examination. Two independent examiners scored the performances with a previously validated global rating scale developed by the Anesthesia Oral Examination Board of the Royal College of Physicians and Surgeons of Canada. Different examiners were used to rate the oral and simulation performances. RESULTS: Interrater reliability was good to excellent across scenarios and modalities: intraclass correlation coefficients ranged from 0.77 to 0.87. The within-scenario between-modality score correlations (concurrent validity) were moderate: r = 0.52 (resuscitation) and r = 0.53 (trauma) (P < 0.05). Forty percent of the average score variance was accounted for by the participants, and 30% was accounted for by the participant-by-modality interaction. CONCLUSIONS: Variance in participant scores suggests that the examination is able to perform as expected in terms of discriminating among test takers. The rather large participant-by-modality interaction, along with the pattern of correlations, suggests that an examinee's performance varies based on the testing modality and a trainee who "knows how" in an oral examination may not necessarily be able to "show how" in a simulation laboratory. Simulation may therefore be considered a useful adjunct to the oral examination.

Management of simulated oxygen supply failure: is there a gap in the curriculum?

In this study we evaluated, in our residency program, the understanding and management of a simulated oxygen pipeline failure. Performances of 20 residents were evaluated by 2 raters. Fourth-year residents did not perform better than second-year residents (P = NS). The majority of the participants either did not have the knowledge to change the oxygen cylinder or did not attempt to change the oxygen, even after prompting. We conclude that the delegation of gas machine maintenance to perioperative personnel, such as respiratory therapists and technicians, may have created a new gap in knowledge and resulted in inadequate training.

Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education.

BACKGROUND: Critical incident reporting and observational studies have identified nontechnical skills that are vital to successful anesthesia crisis management. Examples of such skills include task management, team working, situation awareness, and decision making. These skills are not necessarily acquired through clinical experience and may need to be specifically taught. This study uses a high-fidelity patient simulator to assess the effect of repeated exposure to simulated anesthesia crises on the nontechnical skills of anesthesia residents. METHODS: After institutional research board approval and informed consent, 20 anesthesia residents were recruited. Each resident was randomized to participate as the primary anesthesiologist in the management of three different simulated anesthesia crises using a high-fidelity patient simulator. After each session, videotaped footage was used to facilitate debriefing of their nontechnical skills. The videotapes were later reviewed by two expert blinded independent assessors who rated each resident's nontechnical skills by using a previously validated and reliable marking system. RESULTS: : A significant improvement in the nontechnical skills of residents was demonstrated from their first to second session and from their first to third session (both P < 0.005). However from their second to third session, no significant improvement was observed. Interrater reliability between assessors was modest (single rater intraclass correlation = 0.53). CONCLUSION: A single exposure to anesthesia crises using a high-fidelity patient simulator can improve the nontechnical skills of anesthesia residents. However, an additional simulation session may confer little or no additional benefit.

The value of screening preoperative chest x-rays: a systematic review.

PURPOSE: Chest x-ray (CXR) is the most frequently ordered radiological test in Canada. Despite published guidelines, variable policies exist amongst different hospitals for ordering of preoperative CXRs. The purpose of this study was to systematically review the literature on the value of screening CXRs and establish evidence to support guidelines for the use of preoperative screening CXRs. SOURCE: Medline and Embase were searched under set terms for all English language articles published during 1966-2004. All eligible studies were reviewed and data were extracted individually by two authors. Of the 513 articles identified, 14 studies met both inclusion and exclusion criteria. PRINCIPAL FINDINGS: The quality of published evidence was modest as only six of the studies were rated as fair and eight as poor. Of the reported studies, diagnostic yield increased with age. However, most of the abnormalities consisted of chronic disorders such as cardiomegaly and chronic obstructive pulmonary disease (up to 65%). The rate of subsequent investigations was highly variable (4-47%). When further investigations were performed, the proportion of patients who had a change in management was low (10% of investigated patients). Postoperative pulmonary complications were also similar between patients who had preoperative CXRs (12.8%) and patients who did not (16%). CONCLUSION: An association between preoperative screening CXRs and decrease in morbidity or mortality could not be established. As the prevalence of CXR abnormalities is low in patients under the age of 70, there is fair evidence that routine CXRs should not be performed for patients in this age group without risk factors. For patients over 70, there is insufficient evidence for or against performance of routine CXRs. The current recommendation from the Guidelines Association Committee that routine CXRs should not be performed for patients over 70 without risk factors is supported by this study.

Parker Flex-Tip are not superior to polyvinylchloride tracheal tubes for awake fibreoptic intubations.

PURPOSE: Difficulty can be encountered during advancement of the tracheal tube (TT) over the bronchoscope after successful endotracheal bronchoscopy due to impingement on laryngeal structures. A new TT, the Parker Flex-Tip (PFT), has been shown to be superior to polyvinylchloride (PVC) TTs in anesthetized, paralyzed patients with normal airways. However, no study to date has shown the superiority of the new tapered tip design in patients with difficult airways during awake fibreoptic intubations (AFOI). The purpose of this study was to compare the PFT with PVC TTs for AFOI in patients with difficult airways or unstable c-spines. CLINICAL FEATURES: In this prospective observational study, 111 patients with predicted or documented difficult airways, or unstable c-spines were assessed for ease of TT advancement during AFOI. First attempt success rates were 91% for PFT TTs and 84% for PVC TTs (P = NS). Resistance to TT advancement was none to mild and similar in both groups. Advancement without the need to rotate the TT 180 degrees was also similar in both groups (57% vs 53%). CONCLUSION: For AFOI in patients with difficult airways, the PFT is not superior to conventional PVC TTs.

Comparison of bolus remifentanil versus bolus fentanyl for induction of anesthesia and tracheal intubation in patients with cardiac disease.

OBJECTIVE: Large bolus-dose remifentanil may be advantageous for use during induction of anesthesia because of its short duration of effect. Currently, there are little data on the use of large bolus-dose remifentanil because of reports of severe bradycardia and hypotension. The purpose of this study is to compare the hemodynamic effects of bolus remifentanil versus fentanyl with glycopyrrolate for induction of anesthesia in patients with heart disease. DESIGN: A randomized, double-blinded study. SETTING: A tertiary-care academic medical center. PARTICIPANTS: One hundred patients for coronary artery bypass or valvular surgery. INTERVENTION: Subjects received either (1) remifentanil, 5 microg/kg, with glycopyrrolate, 0.2 mg, or (2) fentanyl, 20 microg/kg, with 0.2 mg of glycopyrrolate, and both groups also received midazolam, 70 microg/kg, for induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Heart rate, mean arterial pressure, systemic vascular resistance, and cardiac output were similar between the 2 groups during induction of anesthesia and tracheal intubation. The incidence of adverse events such as bradycardia (remifentanil 10%, fentanyl 10%), hypotension (remifentanil 16%, fentanyl 10%), and ischemia (remifentanil 0%, fentanyl 2%) were also similar. A greater percentage of patients in the remifentanil group lost consciousness within 1 minute of opioid administration (86% v 66%, p = 0.034). CONCLUSION: Remifentanil with glycopyrrolate is associated with rapid and predictable clinical anesthetic effect, cardiac stability, and the ability to blunt the hemodynamic responses to tracheal intubation. Bolus remifentanil may be a feasible alternative to bolus fentanyl for induction of anesthesia in patients with heart disease because of its short duration of action and its ability to blunt the hemodynamic responses to tracheal intubation.

PVC tracheal tubes exert forces and pressures seven to ten times higher than silicone or armoured tracheal tubes--an in vitro study.

PURPOSE: Many types of tracheal tubes (TT) including silicone, polyvinylchloride (PVC) and armoured have been used for blind tracheal intubation (TI) via the intubating laryngeal mask airway (ILMA) and may cause trauma to the airway. We examined the maximal in vitro forces and pressures exerted by the tip of various TT as it exits the ILMA. METHODS: Silicone, PVC and armoured TT were studied. A #5 ILMA was secured on a wooden platform. With the use of a Harvard pump, force was applied to push the TT through the ILMA at 0.34 cm*sec(-1). Forces exerted to push the TT and forces exerted by the TT tips on distal objects were calculated using proximal and distal pressure manometres. The areas of contact between the distal TT tips and the distal objects were measured by planimetry of an imprint. The final pressures exerted by the TT tips on a fixed distal object were calculated by dividing the forces exerted by the areas of contact. RESULTS: When compared to silicone and armoured TT, PVC TT exerted seven to ten times higher forces and pressures on distal objects. (P < 0.05). Heating PVC TT and inserting PVC TT with reverse curvature to the ILMA did not decrease the forces and pressures exerted by the distal tip. CONCLUSION: The high forces and pressures exerted by PVC TT may theoretically contribute to increased morbidity to patients' airway and esophagus. Caution should be exercised before attempting blind TI via the ILMA with a PVC TT.