Comparison of 2 resident learning tools-interactive screen-based simulated case scenarios versus problem-based learning discussions: a prospective quasi-crossover cohort study.

STUDY OBJECTIVE: Simulation-based learning is emerging as an alternative educational tool in this era of a relative shortfall of teaching anesthesiologists. The objective of the study is to assess whether screen-based (interactive computer simulated) case scenarios are more effective than problem-based learning discussions (PBLDs) in improving test scores 4 and 8 weeks after these interventions in anesthesia residents during their first neuroanesthesia rotation. DESIGN: Prospective, nonblinded quasi-crossover study. SETTING: Cleveland Clinic. PATIENTS: Anesthesiology residents. INTERVENTIONS: Two case scenarios were delivered from the Anesoft software as screen-based sessions, and parallel scripts were developed for 2 PBLDs. Each resident underwent both types of training sessions, starting with the PBLD session, and the 2 cases were alternated each month (ie, in 1 month, the screen-based intervention used case 1 and the PBLD used case 2, and vice versa for the next month). MEASUREMENTS: Test scores before the rotation (baseline), immediately after the rotation (4 weeks after the start of the rotation), and 8 weeks after the start of rotation were collected on each topic from each resident. The effect of training method on improvement in test scores was assessed using a linear mixed-effects model. MAIN RESULTS: Compared to the departmental standard of PBLD, the simulation method did not improve either the 4- or 8-week mean test scores (P = .41 and P = .40 for training method effect on 4- and 8-week scores, respectively). Resident satisfaction with the simulation module on a 5-point Likert scale showed subjective evidence of a positive impact on resident education. CONCLUSIONS: Screen-based simulators were not more effective than PBLD for education during the neuroanesthesia rotation in anesthesia residency.

High-fidelity simulation as an experiential model for teaching root cause analysis.

PURPOSE: The purpose of this study was to assess the effectiveness of high-fidelity simulation for teaching root cause analysis (RCA) in graduate medical education. METHODS: Thirty clinical anesthesiology-1 through clinical anesthesiology-3 residents were randomly assigned to 2 groups: group A participants received a 10-minute lecture on RCA and participated in a simulation exercise where a medical error occurs, and group B participants received the 10-minute lecture on RCA only. Participants completed baseline, postintervention, and 6-month follow-up assessments, and they were evaluated on their attitude toward as well as understanding of RCA and "systems-based" care. RESULTS: All 30 residents completed the surveys. Baseline attitudes and knowledge scores were similar between groups. Postintervention knowledge scores were also similar between groups; however, group B was significantly more skeptical (P < .001) about the use of RCA and "systems improvement" strategies. Six months later, group A demonstrated retained knowledge scores and unchanged attitude, whereas group B demonstrated significantly worse knowledge scores (P  =  .001) as well as continued skepticism toward a systems-based approach (P < .001) to medical error reduction. CONCLUSION: High-fidelity simulation in conjunction with focused didactics is an effective strategy for teaching RCA and systems theory in graduate medical education. Our findings also suggest that there is greater retention of knowledge and increased positive attitude toward systems improvement when focused didactics are coupled with a high-fidelity simulation exercise.

The influence of neurophysiologic monitoring on the management of pediatric cardiopulmonary bypass.

We describe a process by which we sought to determine how the addition of intraoperative neurophysiologic monitoring (IONM) impacted the management of cardiopulmonary bypass (CPB) during pediatric cardiac surgery. While maintaining a consistent team of surgeons, anesthesiologists, nurses, and perfusionists, a multi-modal, IONM program was established consisting of Near Infrared Spectroscopy, Transcranial Doppler, and eight channel electroencephalography. A retrospective review of cases from 1 year before the institution of the IONM program was compared with data obtained from cases performed after neurophysiologic monitoring was established as a standard of care for pediatric patients on CPB. This comparative analysis of CPB management revealed a significant increase in the use of donor blood added to the CPB circuit prime as well as in the maintenance of a higher hematocrit during the bypass period after the implementation of IONM. These changes in the management of pediatric CPB correlated with recommendations of previous studies that examined postoperative neurophysiologic outcomes, suggesting that these changes were not only consistent with best practices, but that the presence of IONM data facilitated a transition to evidence-based practice.

Plasma biomarkers in pediatric patients undergoing cardiopulmonary bypass.

It is critical to identify at-risk patients and minimize the deleterious effects of cardiopulmonary bypass (CPB) procedures in pediatric populations. The present study screened the plasma proteome of pediatric patients undergoing CPB procedures to identify potential clinical biomarkers related to tissue damage, inflammation, or other pathologies. Blood samples were collected at five different time points from 10 children undergoing a CPB procedure. Plasma was isolated and analyzed using two-dimensional differential in-gel electrophoresis and matrix-assisted laser desorption ionization time of flight mass spectrometry. Levels of differentially regulated proteins identified by two-dimensional differential in-gel electrophoresis, and related proteins were then measured in all time points and patients. As well, associated small molecules and ions were measured. The present study identified 13 proteins and protein isoforms altered in expression, including hemopexin, ceruloplasmin, inter-alpha inhibitor H4, and alpha-2-macroglobulin. Immunoblot analysis revealed significant decreases in each of these proteins during the CPB procedure. Significant changes in the levels of copper, iron, Hb, epinephrine, norepinephrine, and serotonin were observed. The potential markers of pathology (inflammation, oxidative stress) identified during this preliminary study may illuminate opportunities for preventative measures and/or treatments during and following CPB procedures in pediatric patients.

A Model for Developing ACGME Competencies in an Academic Anesthesiology Department.

In response to the American College of Graduate Medical Education's Outcomes Project and its mandate for a transition to a competency based curriculum, the Department of Anesthesiology at the Penn State Milton S. Hershey Medical Center executed a focused 18 month program which engaged the entire faculty and effected not only curricular, but cultural change in how anesthesiology residents are taught and evaluated. This article describes the process through which the department leadership educated, engaged, and focused the department's efforts and created an environment that sustained progress and provided incentives for performance. This process also resulted in the development of a novel web based evaluation tool tailored to meet the challenge of evaluating performance in the context of a competency based curriculum. This model, which proved effective for transition to a competency based curriculum, is one which can be applied to any large scale departmental education initiative.

Plasma proteomics: a noninvasive window on pathology and pediatric cardiac surgery.

A challenge of pediatric research is the limited ability to obtain tissue samples from small patients. To confront this problem, blood biomarkers can be used as surrogate markers of disease processes and aid in patient monitoring and disease detection. Furthermore, proteomic analysis of plasma samples is one approach for large-scale discovery of disease biomarkers. This study examined the use of plasma for disease process biomarkers in pediatric patients undergoing cardiopulmonary bypass (CPB) surgery. Proteomic studies of plasma are limited by the presence of a few high abundance proteins that mask the presence of lower abundance proteins of interest. Plasma immunoaffinity depletion (removing 6 of the highest abundance proteins of little pathological importance) increases sensitivity of detection for proteins such as those related to inflammation, remodeling, and damage. Using two-dimensional in-gel fluorescence electrophoresis, changes in the expression levels of proteins that occur as a result of CPB can be identified. In the present study, plasma depletion removed 83% of the plasma protein mass, allowing approximately 1400 spots to be observed by two-dimensional in-gel fluorescence electrophoresis. Of the detected spots, 79 (5.7%) were altered by CPB. These data illuminate the strength of plasma proteomics in identification of candidate biomarkers of CPB-associated disease processes.

Transcranial Doppler-revealed retrograde cerebral artery flow during Norwood 1 operation.

We describe a 6-week-old girl with a hypoplastic left heart syndrome in whom multimodal neuromonitoring was used during Norwood stage I palliation. After placement of modified Blalock-Taussig shunt, transcranial Doppler measurements revealed retrograde flow in the right middle cerebral artery throughout the cardiac cycle. Further examination showed that the change in cerebral blood flow was secondary to shunt runoff and clinical correlation was noted in near infrared spectroscopy measurements of regional cerebral oxygenation saturation. The surgical procedure was subsequently modified with a return of antegrade flow. We offer this case as one of the first (if not the first) documented case reports of an intraoperative modification of surgical procedure driven by changes identified by multimodal neuromonitoring.