Control-flow analysis of procedural skills competencies in medical training through process mining.

BACKGROUND: Procedural skills are key to good clinical results, and training in them involves a significant amount of resources. Control-flow analysis (ie, the order in which a process is performed) can provide new information for those who train and plan procedural training. This study outlines the steps required for control-flow analysis using process mining techniques in training in an ultrasound-guided internal jugular central venous catheter placement using a simulation. METHODS: A reference process model was defined through a Delphi study, and execution data (event logs) were collected from video recordings from pretraining (PRE), post-training (POST) and expert (EXP) procedure executions. The analysis was performed to outline differences between the model and executions. We analysed rework (activity repetition), alignment-based fitness (conformance with the ideal model) and trace alignment analysis (visual ordering pattern similarities). RESULTS: Expert executions do not present repetition of activities (rework). The POST rework is lower than the PRE, concentrated in the steps of the venous puncture and guidewire placement. The adjustment to the ideal model measure as alignment-based fitness, expressed as a median (25th-75th percentile) of PRE 0.74 (0.68-0.78) is less than POST 0.82 (0.76-0.86) and EXP 0.87 (0.82-0.87). There are no significant differences between POST and EXP. The graphic analysis of alignment and executions shows a progressive increase in order from PRE to EXP executions. CONCLUSION: Process mining analysis is able to pinpoint more difficult steps, assess the concordance between reference mode and executions, and identify control-flow patterns in procedural training courses.

Intra-operative lidocaine in the prevention of vomiting after elective tonsillectomy in children: A randomised controlled trial.

BACKGROUND: Postoperative vomiting (POV) is a frequent complication of tonsillectomy in children. In adult patients undergoing abdominal surgeries, the use of intravenous lidocaine infusion can prevent POV. OBJECTIVE: To evaluate the anti-emetic effect of an intravenous lidocaine infusion used as an adjuvant to general anaesthesia, in children undergoing elective ear, nose and throat surgery. DESIGN: Double-blind, randomised, controlled study. SETTING: Hospital-based, single-centre study in Chile. PATIENTS: ASA I-II children, aged 2 to 12 years, scheduled for elective tonsillectomy. INTERVENTION: We standardised the induction and maintenance of anaesthesia. Patients were randomly allocated to lidocaine (1.5 mg kg intravenous lidocaine over 5 min followed by 2 mg kg h) or 0.9% saline (at the same rate and volume). Infusions were continued until the end of the surgery. MAIN OUTCOME MEASURES: Presence of at least one episode of vomiting, retching or both in the first 24 h postoperatively (POV). SECONDARY OUTCOMES: Plasma concentrations of lidocaine and postoperative pain. RESULTS: Ninety-two children were enrolled. Primary outcome data were available for 91. In the Lidocaine group, 28 of 46 patients (60.8%) experienced POV, compared with 37 of 45 patients (82.2%) in the Saline group [difference in proportions 21.3% (95% confidence interval (CI) 2.8 to 38.8), P = 0.024]. The intention-to-treat analysis showed that when we assumed that the patient in the Saline group lost to follow-up did not have POV, the difference in proportions decreased to 19.6% (95% CI, 0.9 to 37.2), with an unadjusted odds ratio of 0.38 (95% CI, 0.15 to 0.97, P = 0.044). The odds of having POV were 62% less likely in those patients receiving lidocaine compared with patients in the Saline group. The mean lidocaine plasma concentration was 3.91 µg ml (range: 0.87 to 4.88). CONCLUSION: Using an intravenous lidocaine infusion as an adjuvant to general anaesthesia decreased POV in children undergoing elective tonsillectomy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01986309.

Validation of the imperial college surgical assessment device for spinal anesthesia.

BACKGROUND: Traditionally, technical proficiency for spinal anesthesia has been assessed using observational scales such as global rating scales or task specific checklists. However more objective metrics are required in order to improve novice's training programs. The aim of this study is to validate the hand motion analysis of the Imperial College Surgical Assessment Device (ICSAD) in a simulated model of spinal anesthesia. METHODS: Three groups of physicians with different levels of experience were video recorded performing a spinal anesthesia in a simulated lumbar puncture torso. Participants' technical performance was assessed with ICSAD, a Global Rating Scale (GRS) and a specific Checklist. Differences between the 3 groups were determined by Kruskal-Wallis test with post hoc Dunn's correction for multiple comparisons. Spearman correlation coefficient between ICSAD variables and the scores of the observational scales were calculated to establish concurrent validity. RESULTS: Thirty subjects participated in the study: ten novice (first year residents), 10 intermediate (third year residents) and 10 experts (attending anesthesiologists). GRS scores were significantly higher in experts, than intermediates and novices. Regarding total path length, number of movements and procedural time measured with ICSAD, all groups had significant differences between them (p = 0.026, p = 0.045 and p = 0.005 respectively). Spearman correlation coefficient was -0,46 (p = 0.012) between total path length measured with ICSAD and GRS scores. CONCLUSIONS: This is the first validation study of ICSAD as an assessment tool for spinal anesthesia in a simulated model. Using ICSAD can discriminate proficiency between expert and novices and correlates with previously validated GRS. Its use in the assessment of spinal anesthesia proficiency provides complementary data to existing tools. Our results could be used to design future training programs with reliable goals to accomplish.

Levobupivacaine absorption pharmacokinetics with and without epinephrine during TAP block: analysis of doses based on the associated risk of local anaesthetic toxicity.

PURPOSE: Cases of local anaesthetic systemic toxicity (LAST) periodically occur following transversus abdominal plane (TAP) blocks. The aim of this study was to characterize levobupivacaine absorption pharmacokinetics, with and without epinephrine, and estimate the risk of LAST, based on a previously reported toxic threshold. METHODS: Previously reported data from 11 volunteers receiving ultrasound-guided TAP blocks with and without epinephrine on two independent occasions were analysed. Serial venous concentrations were measured for 90 min. A pharmacokinetic analysis was performed using the NONMEM statistical programme. The use of epinephrine in the solution was included in the analysis of covariates. The associated risk of LAST symptoms associated with different levobupivacaine dose schemes with and without epinephrine was estimated in 1000 simulated subjects. RESULTS: A one-compartment first-order input and elimination model adequately fit the levobupivacaine data. Epinephrine prolonged the levobupivacaine absorption half-life {4.22 [95 % confidence interval (CI) 2.53-6.50] vs. 7.02 [95 % CI 3.74-14.1]; p < 0.05} and reduced its relative bioavailability (0.84; 95 % CI 0.72-0.97; p < 0.05) The derived model predicts that levobupivacaine dose schemes should be halved from 3 mg kg(-1) body weight with epinephrine to 1.5 mg kg(-1) without epinephrine to obtain a comparable risk of anaesthetic toxicity symptoms of approximately 0.1 %. CONCLUSIONS: Our results strongly support the addition of epinephrine to the local anaesthetic solution, especially when doses of levobupivacaine of >1.5 mg kg(-1) are required. Recommendations regarding the maximum allowable doses of local anaesthetics should consider population analysis to determine safer dosage ranges.

Which types of peripheral nerve blocks should be included in residency training programs?

BACKGROUND: Despite the increasing use of regional anesthesia, specific recommendations regarding the type of procedures to be included in residency training programs are not currently available. We aimed to determine the nerve block techniques that practicing Chilean anesthesiologists perceived as essential to master during residency training. METHODS: After institutional ethics committee approval, an online survey was sent to 154 anesthesiologists that graduated between 2005-2012, from the two largest university residency programs in Chile. Multiple-choice questions elicited responses concerning the use of regional anesthesia. RESULTS: A total of 109 questionnaires were completed, which corresponded to a response rate of 70.8%. Almost all (98.2%) of the respondents used regional anesthesia in their clinical practice, 86.7% regularly performed peripheral nerve blocks (PNBs) and 51% used continuous PNB techniques. Residency programs represented their primary source of training. The most common PNB techniques performed were interscalene (100%), femoral (98%), popliteal sciatic (93%), and Bier block (90%). Respondents indicated that they were most confident performing femoral (98%), Bier block (90%), interscalene (90%), and popliteal sciatic (85%) blocks. The PNBs perceived as essential for their actual clinical practice were femoral (81%), interscalene (80%), popliteal sciatic (76%), and Bier blocks (62%). CONCLUSIONS: Requesting information from former anesthesiology residents may be a source of information, guiding the specific types of PNBs that should be included in residency training. Other groups can easily replicate this methodology to create their own evidence and clinical practice based guidelines for residency training programs.

Simulation-Based Training Program for Peripherally Inserted Central Catheter Placement: Randomized Comparative Study of in-Person Training With Synchronous Feedback Versus Distance Training With Asynchronous Feedback.

INTRODUCTION: Simulation training that includes deliberate practice is effective for procedural skill training. Delivering feedback remotely and asynchronously has been examined for more cost-efficient training. This prospective randomized study aimed to compare 2 feedback techniques for simulation training: synchronous direct feedback versus asynchronous distance feedback (ASYNC). METHODS: Forty anesthesia and internal medicine residents were recruited after study approval by the institutional ethics committee. Residents reviewed instructional material on an online platform and performed a pretraining assessment (PRE) for peripherally inserted central catheter (PICC) placement. Each resident was then randomly assigned to 1 of 2 training types, practice with synchronous direct feedback (SYNC) or practice with ASYNC. Training consisted of four, 1-hour practice sessions; each was conducted once per week. Both groups underwent posttraining evaluation (POST). The PRE and POST assessments were videotaped and evaluated by 2 independent, blinded reviewers using a global rating scale. RESULTS: Thirty-five residents completed the training program and both evaluations. Both groups had significantly improved global rating scale scores after 4 sessions. The SYNC group improved from 28 to 45 points (P < 0.01); the ASYNC group improved from 26.5 to 46 points (P < 0.01). We found no significant between-group differences for the PRE (P = 0.42) or POST assessments (P = 0.13). CONCLUSION: This simulation-based training program significantly improved residents' peripherally inserted central venous catheter placement skills using either modality. With these results, we are unable to demonstrate the superiority of synchronous feedback over ASYNC. Asynchronous feedback training modality represents a new, innovative approach for health care procedural skills training.

Validation and piloting of direct observation of practical skills tool to assess intubation in the Chilean context.

BACKGROUND: The use of Workplace-Based Assessment (WBA) has increased in recent years. AIMS: To create a modified version of Direct Observation of Procedural Skills (DOPS) adapted to the Chilean context and establish its psychometric properties. METHODS: The content validity of DOPS was established through interviews and consensus survey. To be included in the new version, the respective domain should have been considered by over 80% of interviewers and it should have a Content Validity Index (CVI and kappa statistic over 0.78 and 0.6, respectively. For four months, the new DOPS was used to assess the intubation skills of the anesthesia trainees. Generalizability theory was used to establish reliability and internal consistency. RESULTS: The interview suggested a DOPS with twelve domains. All were included in the final version as the CVI and kappa values were above 0.9 and 0.8, respectively. 585 procedures were assessed. The G coefficient was 0.90. The intubation needs to be assessed with DOPS at least six times to obtain a G coefficient of 0.80. CONCLUSIONS: The modified DOPS was a valid, reliable and practical tool for assessing the intubation procedure. Effort needs to be made to improve the staff's feedback skills.

Health Care Simulation as a Training Tool for Epidemic Management: A Systematic Review.

SUMMARY STATEMENT: The objective of this research was to identify and review studies that have evaluated the impact of simulation-based training on health care professionals during epidemics.All studies in health care simulation-based training published during the last 5 epidemics with a global impact (SARS-CoV, H1N1, MERS, Ebola, SARS-CoV-2; through July 2021) were selected from a systematic search of PUBMED, EMBASE, and key journals.The search strategy identified 274 studies; 148 met the inclusion criteria and were included. Most of the studies were developed in response to SARS-CoV-2 infection (n = 117, 79.1%), used a descriptive approach (n = 54, 36.5%), and were used to train technical skills (n = 82, 55.4%).This review demonstrates a growing interest in publications related to health care simulation and epidemics. Most of the literature is marked by limited study designs and outcome measurements, although there is a trend toward the use of more refined methodologies in the most recent publications. Further research should seek the best evidence-based instructional strategies to design training programs in preparation for future outbreaks.

Cross-cultural adaptation and validation of the Spanish version of the Anesthetists' Non-Technical Skills (ANTS) assessment tool.

STUDY OBJECTIVE: Establish the transcultural validity of Anesthetists Non-Technical Skills (ANTS) in a Spanish-speaking country. DESIGN: Prospective cohort. SETTING: Clinical simulation center. SUBJECTS: Forty-two Anesthesia PY2 and PY3 residents participated in the study. INTERVENTIONS: Four clinical scenarios simulating anesthesia crises were assessed with a Spanish version of ANTS. Every simulated scenario was run twice with a time span of 3 to 4 months between them. MEASUREMENTS: Two anesthesiologists independently assessed all simulated sessions using ANTS. The ANTS indicators of construct validity were obtained by confirmatory factor analysis. Various goodness-of-fit indices of the factorial model were calculated: Comparative Fit Index (CFI); Tucker-Lewis Adjustment Index (TLI) and Root Mean Square Error of Approximation (RMSEA). The standardized factor loadings and the determination coefficient (R2) was also estimated. MAIN RESULTS: A total of 212 clinical scenarios were analyzed. The specified factorial model had the same grouping of elements in four domains as the original version of ANTS. The CFI index and the TLI were 0.99 and the RMSEA reached 0.07 (95% CI 0.06-0.08). All the standardized factor loadings were found to be >0.4. Also, the elements obtained an R2 value that fluctuated between 0.54 and 0.92. CONCLUSIONS: The Spanish version of ANTS is a valid, reliable and a useful tool to assess non-technical skills in Spanish-speaking countries. The applicability of the instrument was comparable to the original setting. The high reliability of ANTS in our setting allows us to propose its use not just in an educational and research setting; it can be used as an assessment tool of non-technical skills.

Designing Sustainable Solutions to Implement a Distance-Based Simulation Basic Life Support Training Program During COVID-19 Pandemic in Low-Income Countries.

SUMMARY STATEMENT: The global pandemic of COVID-19 had strong repercussions in healthcare simulation-based education around the world. Different adaptations to imposed restraints such as social distancing have been developed to address the educational needs of healthcare professionals. However, the lack of access to simulators in low-income countries or rural areas may restrict the access to distance simulation-based training.

Brief report: The sensitivity of motor responses for detecting catheter-nerve contact during ultrasound-guided femoral nerve blocks with stimulating catheters.

BACKGROUND: We determined the sensitivity of motor responses evoked by stimulating catheters in determining catheter-nerve contact using ultrasonography as reference. METHODS: Femoral nerves were contacted using stimulating catheters under ultrasonography scanning in 25 patients. The output current was increased from its minimum until quadriceps muscle contraction occurred. The sensitivity of the motor response in determining catheter-nerve contact was calculated using 0.5 mA as current threshold. RESULTS: The current required for catheter stimulation to evoke a motor response ranged between 0.18 and 2.0 mA. Muscle contraction in response to 0.5 mA occurred in 16 of 25 subjects. The sensitivity of motor response for nerve stimulation was 64% (95% confidence interval: 0.43, 0.82). CONCLUSIONS: The absence of muscle responses at a stimulating current≤0.5 mA does not necessarily indicate the absence of catheter-nerve contact.

[Acquiring skills in malignant hyperthermia crisis management: comparison of high-fidelity simulation versus computer-based case study]. / Adquirir habilidades no manejo de crises de hipertermia maligna: comparação de simulação de alta­fidelidade versus estudo de caso em computador.

INTRODUCTION: The primary purpose of this study was to compare the effect of high fidelity simulation versus a computer-based case solving self-study, in skills acquisition about malignant hyperthermia on first year anesthesiology residents. METHODS: After institutional ethical committee approval, 31 first year anesthesiology residents were enrolled in this prospective randomized single-blinded study. Participants were randomized to either a High Fidelity Simulation Scenario or a computer-based Case Study about malignant hyperthermia. After the intervention, all subjects' performance in was assessed through a high fidelity simulation scenario using a previously validated assessment rubric. Additionally, knowledge tests and a satisfaction survey were applied. Finally, a semi-structured interview was done to assess self-perception of reasoning process and decision-making. RESULTS: 28 first year residents finished successfully the study. Resident's management skill scores were globally higher in High Fidelity Simulation versus Case Study, however they were significant in 4 of the 8 performance rubric elements: recognize signs and symptoms (p = 0.025), prioritization of initial actions of management (p = 0.003), recognize complications (p = 0.025) and communication (p = 0.025). Average scores from pre- and post-test knowledge questionnaires improved from 74% to 85% in the High Fidelity Simulation group, and decreased from 78% to 75% in the Case Study group (p = 0.032). Regarding the qualitative analysis, there was no difference in factors influencing the student's process of reasoning and decision-making with both teaching strategies. CONCLUSION: Simulation-based training with a malignant hyperthermia high-fidelity scenario was superior to computer-based case study, improving knowledge and skills in malignant hyperthermia crisis management, with a very good satisfaction level in anesthesia residents.

[Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial]. / Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado.

BACKGROUND: Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. METHODS: Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. RESULTS: Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. CONCLUSIONS: Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Remifentanil requirements during propofol administration to block the somatic response to skin incision in children and adults.

BACKGROUND: During sevoflurane administration, children require a remifentanil infusion rate twofold higher than adults to block responses to skin incision. Similar data concerning remifentanil requirements are unavailable during total IV anesthesia. METHODS: We prospectively determined the infusion rate (IR) of remifentanil necessary to block the somatic response to skin incision in 50% (IR50) of adults (n = 20, aged 20-60 yr) and children (n = 20, aged 3-11 yr) during propofol anesthesia. In each patient undergoing lower abdominal surgery, a remifentanil infusion was initiated, followed by target-controlled infusion of propofol set at a plasma concentration of 6 mug/mL. After tracheal intubation, propofol was reduced to 3 microg/mL until the end of the study. Remifentanil IR was determined according to Dixon's up-and-down method, with the first patient in each group receiving 0.2 microg x kg(-1) x min(-1) followed by the consecutive patient receiving 0.02 microg x kg(-1) x min(-1) modifications according to the response of the previous patient. The remifentanil IR was kept unchanged for at least 20 min before surgery. At the beginning of surgery, only the skin incision was performed, and the somatic response was observed. If there was any gross movement of extremity the response was considered positive. RESULTS: The IR50 (CI(95%)) was 0.08 (0.06-0.12) microg x kg(-1) x min(-1) in adults and 0.15 (0.13-0.17) microg x kg(-1) x min(-1) in children (P < 0.001). CONCLUSION: These results demonstrate that, similar to sevoflurane anesthesia, during total IV anesthesia with propofol, children require a remifentanil IR almost twofold higher than adults to block the somatic response to skin incision.

Effect of acute arterial hypertension on morphine requirements and postsurgical pain.

STUDY OBJECTIVE: The study objective was to establish the impact of acute hypertension on morphine's requirements after laparoscopic cholecystectomy. DESIGN: The design was a randomized, simple blinded study. SETTING: The settings were operating room, postoperative recovery area, and first postoperative day. PATIENTS: There were 50 patients, American Society of Anesthesiologists I-II, aged 18-50 years, undergoing elective laparoscopic cholecystectomy with general anesthesia. INTERVENTIONS: Anesthetic management was standardized using propofol for induction, isoflurane for bispectral index (BIS) ranging between 40 and 60, and remifentanil maintained at a constant rate of 0.4 µg kg per minute throughout surgery in all patients. Once intubated, patients were randomly allocated to 1 of 2 groups: hypertensive group: systolic arterial blood pressure was maintained with phenylephrine infusion 20%-30% over baseline; control group: systolic arterial blood pressure was maintained 20%-30% below baseline. All surgical incisions were infiltrated with bupivacaine 0.5%, and every patient received ketorolac 60 mg intravenous. Patient-controlled analgesia with morphine intravenous was used for postoperative analgesia. MEASUREMENTS: Pain visual analogue scale scores, arterial blood pressure, and hyperalgesia were assessed at recovery room every 15 minutes during the first 2 postoperative hours and then at 6, 12, and 24 postoperative hours. Cumulative morphine consumption was registered at 2 and 24 postoperative hours. MAIN RESULTS: The cumulative morphine consumption in the control group was around 18 mg compared with 6 mg in the hypertensive group (P = .019). During the first 75 minutes after surgery, the control group had higher visual analogue scale score pain compared with hypertensive group (P = .005). CONCLUSIONS: The intraoperative acute generation of mild hypertension with phenylephrine reduced postoperative morphine consumption and pain scores after laparoscopic cholecystectomy.