Identifying intraoperative events in a simulated laparotomy video: a multinational study of inattentional blindness among anesthesiologists.

PURPOSE: Medical errors may be occasionally explained by inattentional blindness (IB), i.e., failing to notice an event/object that is in plain sight. We aimed to determine whether age/experience, restfulness/fatigue, and previous exposure to simulation education may affect IB in the anesthetic/surgical setting. METHODS: In this multicentre/multinational study, a convenience sample of 280 anesthesiologists watched an attention-demanding video of a simulated trauma patient undergoing laparotomy and (independently/anonymously) recorded the abnormalities they noticed. The video contained four expected/common abnormalities (hypotension, tachycardia, hypoxia, hypothermia) and two prominently displayed unexpected/rare events (patient's head movement, leaky central venous line). We analyzed the participants' ability to notice the expected/unexpected events (primary outcome) and the proportion of expected/unexpected events according to age group and prior exposure to simulation education (secondary outcomes). RESULTS: Anesthesiologists across all ages noticed fewer unexpected/rare events than expected/common ones. Overall, younger anesthesiologists missed fewer common events than older participants did (P = 0.02). There was no consistent association between age and perception of unexpected/rare events (P = 0.28), although the youngest cohort (< 30 yr) outperformed the other age groups. Prior simulation education did not affect the proportion of misses for the unexpected/rare events but was associated with fewer misses for the expected/common events. Self-perceived restfulness did not impact perception of events. CONCLUSION: Anesthesiologists noticed fewer unexpected/rare clinical events than expected/common ones in an attention-demanding video of a simulated trauma patient, in keeping with IB. Prior simulation training was associated with an improved ability to notice anticipated/expected events, but did not reduce IB. Our findings may have implications for understanding medical mishaps, and efforts to improve situational awareness, especially in acute perioperative and critical care settings.

RéSUMé: OBJECTIF: Les erreurs médicales peuvent parfois s'expliquer par la cécité d'inattention, soit le fait de ne pas remarquer un événement/objet qui est à la vue de tous et toutes. Notre objectif était de déterminer si l'âge/l'expérience, le repos/la fatigue et l'exposition antérieure à l'enseignement par simulation pouvaient affecter la cécité d'inattention dans le cadre de l'anesthésie/chirurgie. MéTHODE: Dans cette étude multicentrique/multinationale, un échantillon de convenance de 280 anesthésiologistes ont visionné une vidéo exigeant l'attention portant sur un patient de trauma simulé bénéficiant d'une laparotomie et ont enregistré (de manière indépendante/anonyme) les anomalies qu'ils et elles ont remarquées. La vidéo contenait quatre anomalies attendues/courantes (hypotension, tachycardie, hypoxie, hypothermie) et deux événements inattendus/rares bien en vue (mouvement de la tête du patient, fuite du cathéter veineux central). Nous avons analysé la capacité des participant·es à remarquer les événements attendus/inattendus (critère d'évaluation principal) et la proportion d'événements attendus/inattendus selon le groupe d'âge et l'exposition antérieure à l'enseignement par simulation (critères d'évaluation secondaires). RéSULTATS: Les anesthésiologistes de tous âges ont remarqué moins d'événements inattendus/rares que d'événements attendus/courants. Globalement, les anesthésiologistes plus jeunes ont manqué moins d'événements courants que leurs congénères plus âgé·es (P = 0,02). Il n'y avait pas d'association constante entre l'âge et la perception d'événements inattendus ou rares (P = 0,28), bien que la cohorte la plus jeune (< 30 ans) ait surpassé les autres groupes d'âge. La formation antérieure par simulation n'a pas eu d'incidence sur la proportion d'inobservation des événements inattendus ou rares, mais a été associée à moins de cécité d'inattention envers les événements attendus ou courants. Le repos perçu n'a pas eu d'impact sur la perception des événements. CONCLUSION: Les anesthésiologistes ont remarqué moins d'événements cliniques inattendus/rares que d'événements attendus/courants dans une vidéo exigeant l'attention portant sur la simulation d'un patient traumatisé, ce qui s'inscrit dans la cécité d'inattention. La formation préalable par simulation était associée à une meilleure capacité à remarquer les événements anticipés/attendus, mais ne réduisait pas la cécité d'inattention. Nos résultats peuvent avoir des implications pour la compréhension des accidents médicaux et les efforts visant à améliorer la conscience situationnelle, en particulier dans les contextes de soins périopératoires aigus et de soins intensifs.

A retrospective analysis of blood loss with combined topical and intravenous tranexamic acid after coronary artery bypass graft surgery.

OBJECTIVE: Intravenous antifibrinolytics are the gold standard for blood conservation during cardiac surgery. Recent evidence suggests that topical tranexamic acid administration also is effective, although the efficacy of combined topical and intravenous administration has never been reported. Combined administration may offer superior hemostasis while decreasing side effects. The current study explores the use of combined topical and intravenous tranexamic acid as a blood conservation strategy in cardiac surgery. DESIGN: Retrospective cohort. SETTING: A single-center, academic, tertiary care hospital. PARTICIPANTS: One hundred sixty elective coronary artery bypass graft patients. INTERVENTION: A practice change allowed a retrospective comparison of postoperative chest tube drainage in patients with intravenous or combined (intravenous and topical) tranexamic acid. MEASUREMENTS AND MAIN RESULTS: Chest tube drainage was decreased in the combined group at 3 (164.8 ± 102.2 v 242.7 ± 148.9 mL, p < 0.001), 6 (265.6 ± 163.7 v 358.8 ± 247.2 mL, p = 0.006), and 12 hours (374.3 ± 217.1 v 498.5 ± 336.6 mL, p = 0.006) postoperatively compared with the intravenous group. The tranexamic acid dose was higher in the combined group (5.1 ± 1.1 v 4.1 ± 1.3 g, p < 0.001), but less was administered intravenously (3.1 ± 1.1 v 4.1 ± 1.3 g, p < 0.001). No differences were observed in adverse events. CONCLUSIONS: This study suggested that combined tranexamic acid administration may be superior for blood conservation, but fully powered randomized controlled trials will be required to confirm these findings and determine the safety advantage and clinical relevance of adding topical tranexamic acid to existing blood conservation strategies.

Retraction speed and chronic poststernotomy pain: A randomized controlled trial.

OBJECTIVES: Approximately 30% of patients develop chronic poststernotomy pain (CPSP) following cardiac surgery with sternal retraction. Risk factors have been described but no causal determinants identified. Investigators hypothesized that opening the sternum slowly would impart less force (and thereby less nerve/tissue damage) and translate to a reduced incidence of CPSP. The main objectives were to determine whether or not slower sternal retraction would reduce the incidence of CPSP and improve health-related quality of life. METHODS: Patients undergoing coronary artery bypass graft surgery were recruited to this randomized controlled trial. Patients were randomized to slow or standard retraction (ie, sternum opened over 15 minutes vs 30 seconds, respectively). Although the anesthesiologist and surgeon were aware of the randomization, the patients, assessors, and postoperative nursing staff remained blinded. Sternotomy pain and analgesics were measured in hospital. At 3, 6, and 12 months postoperatively, all patients completed the Medical Outcomes Survey Short Form and reported on CPSP and complications requiring rehospitalization. Thirty-day rehospitalizations and mortality were recorded. RESULTS: In total, 326 patients consented to participate and 313 were randomized to slow (n = 159) versus standard retraction (n = 154). No clinically relevant differences were detected in acute pain, analgesic consumption, or the incidence of CPSP or health-related quality of life. Although the slow group had significantly more hospitalizations at 3 and 12 months postoperatively, the reasons were unrelated to retraction speed. No differences were observed in 30-day rehospitalizations or mortality. CONCLUSIONS: All outcomes were consistent with previous reports, but no clinically significant differences were observed with retraction speed.

Postictal Trismus Complicating Electroconvulsive Therapy: A Case Report.

We report a case of a 72-year-old woman who experienced postictal episodes of trismus lasting several minutes on 6 occasions during a series of 18 episodes of electroconvulsive therapy (ECT). There was no clear relationship between the development of trismus and any medications used during the treatments. The patient had no adverse outcomes or discomfort, but the development of trismus can put patients at significant risk.

The use of FEIBA for refractory bleeding in cardiac surgery - a systematic review.

INTRODUCTION: Significant blood loss during cardiac surgery is associated with a dramatic increase in morbidity and mortality. Factor Eight Inhibitor Bypassing Activity (FEIBA), a hemostatic bypassing agent mainly used in hemophiliac patients, has also been used for intractable bleeding during cardiac surgical procedures in non-hemophiliac patients. However, concerns exist that its use may be linked to increased incidence of perioperative adverse effects including thrombotic complications. AREAS COVERED: A systematic literature search was performed on MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for all studies that reported the administration of FEIBA for treatment of bleeding during adult cardiac surgery in non-hemophiliac patients. After selecting the title and abstracts, two authors assessed the methodological quality of the full-text articles prior to final inclusion in the manuscript. EXPERT OPINION: The safety profile of FEIBA was determined through an aggregate count of adverse events. Major complications included renal failure, re-operation for unresolved bleeding, postoperative mortality, and thromboembolic events. Overall, there is insufficient robust evidence to make a definitive conclusion about the safety or efficacy of using of FEIBA as a hemostatic agent in the setting of cardiac surgery.

Systematic review and meta-analysis of the 2010 ASGE non-invasive predictors of choledocholithiasis and comparison to the 2019 ASGE predictors.

In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) guideline on the endoscopic management of choledocholithiasis modified the individual predictors of choledocholithiasis proposed in the widely referenced 2010 guideline to improve predictive performance. Nevertheless, the primary literature, especially for the 2019 iteration, is limited. We performed a systematic review with meta-analysis to examine the diagnostic performance of the 2010, and where possible the 2019, predictors. PROSPERO protocol CRD42020194226. A comprehensive literature search from 2001 to 2020 was performed to identify studies on the diagnostic performance of any of the 2010 and 2019 ASGE choledocholithiasis predictors. Identified studies underwent keyword screening, abstract review, and full-text review. The primary outcomes included multivariate odds ratios (ORs) and 95% confidence intervals for each criterion. Secondary outcomes were reported sensitivities, specificities, and positive and negative predictive value. A total of 20 studies met inclusion criteria. Based on reported ORs, of the 2010 guideline "very strong" predictors, ultrasound with stone had the strongest performance. Of the "strong" predictors, CBD > 6 mm demonstrated the strongest performance. "Moderate" predictors had inconsistent and/or weak performance; moreover, all studies reported gallstone pancreatitis as non-predictive of choledocholithiasis. Only one study examined the new predictor (bilirubin > 4 mg/dL and CBD > 6 mm) proposed in the 2019 guideline. Based on this review, aside from CBD stone on ultrasound, there is discordance between the proposed strength of 2010 choledocholithiasis predictors and their published diagnostic performance. The 2019 guideline appears to do away with the weakest 2010 predictors.

Perspectives of Recent Graduates on Clerkship Procedural Skill Training at a Canadian Medical School: an Exploratory Study.

The implementation of competency-based medical education in Canada has presented both unique opportunities and challenges for improving undergraduate procedural skills curricula. Despite the recognized importance of procedural skills, there remains a lack of national congruency in procedural training across medical schools that must be addressed. When undertaking such curricular development, obtaining learner feedback is a crucial step that can facilitate practical changes and address disparities. The purpose of the current study is to explore the perspectives and insights of recent medical graduates surrounding the clerkship procedural skills curriculum at a Canadian medical school. Six residents from a variety of program specialties participated in a semi-structured focus group interview discussing key aspects of procedural skill training. The focus group was later transcribed and qualitatively analyzed for themes. The results highlight barriers to competency-based procedural skill training involving time constraints and obtaining required evaluations, and the ability of students to self-advocate for learning opportunities. Participants note few opportunities to practice nasogastric tube insertion and casting in particular. Recommendations for curricular improvement are discussed, including options for curricular remediation and resident perspectives on which procedural skills undergraduate trainees should achieve competency in by graduation.

Cholesterol-lowering drugs reduce APP processing to Aß by inducing APP dimerization.

Amyloid beta (Aß) is a major component of amyloid plaques, which are a key pathological hallmark found in the brains of Alzheimer's disease (AD) patients. We show that statins are effective at reducing Aß in human neurons from nondemented control subjects, as well as subjects with familial AD and sporadic AD. Aß is derived from amyloid precursor protein (APP) through sequential proteolytic cleavage by BACE1 and γ-secretase. While previous studies have shown that cholesterol metabolism regulates APP processing to Aß, the mechanism is not well understood. We used iPSC-derived neurons and bimolecular fluorescence complementation assays in transfected cells to elucidate how altering cholesterol metabolism influences APP processing. Altering cholesterol metabolism using statins decreased the generation of sAPPß and increased levels of full-length APP (flAPP), indicative of reduced processing of APP by BACE1. We further show that statins decrease flAPP interaction with BACE1 and enhance APP dimerization. Additionally, statin-induced changes in APP dimerization and APP-BACE1 are dependent on cholesterol binding to APP. Our data indicate that statins reduce Aß production by decreasing BACE1 interaction with flAPP and suggest that this process may be regulated through competition between APP dimerization and APP cholesterol binding.

Double-blind, randomized, placebo-controlled crossover trial of alpha-lipoic acid for the treatment of fibromyalgia pain: the IMPALA trial.

ABSTRACT: Fibromyalgia is a common and challenging chronic pain disorder with few, if any, highly effective and well-tolerated treatments. Alpha-lipoic acid (ALA) is a nonsedating antioxidant with evidence of efficacy in the treatment of symptomatic diabetic neuropathy that has not been evaluated in the setting of fibromyalgia treatment. Thus, we conducted a single-centre, proof-of-concept, randomized, placebo-controlled, crossover trial of ALA for the treatment of fibromyalgia. Twenty-seven participants were recruited, and 24 participants completed both treatment periods of the trial. The median maximal tolerated dose of ALA in this trial was 1663 mg/day. Treatment-emergent adverse events with ALA were infrequent and not statistically different from placebo. For the primary outcome of pain intensity, and for several other validated secondary outcomes, there were no statistically significant differences between placebo and ALA. A post hoc exploratory subgroup analysis showed a significant interaction between gender and treatment with a significant favourable placebo-ALA difference in pain for men, but not for women. Overall, the results of this trial do not provide any evidence to suggest promise for ALA as an effective treatment for fibromyalgia, which is predominantly prevalent in women. This negative clinical trial represents an important step in a collective strategy to identify new, better tolerated and more effective treatments for fibromyalgia.

Pain and haemorrhage are the most common reasons for emergency department use and hospital admission in adults following ambulatory surgery: results of a population-based cohort study.

BACKGROUND: Advances in healthcare delivery have allowed for the increase in the number of ambulatory surgery procedures performed in Canada. Despite these advances, patients return to hospital following discharge. However, the reason for unplanned healthcare use after ambulatory surgery in Canada is not well understood. AIMS: To examine unplanned healthcare use, specifically emergency department visit and hospital admissions, in the 3 days after ambulatory surgery in Ontario, Canada. METHODS: This population-based retrospective cohort study was conducted using de-identified administrative databases. Participants were residents in the province of Ontario, Canada; 18 years and older; and underwent common ambulatory surgical procedures between 2014 and 2018. The outcomes included emergency department (ED) visit and hospital admission. Incidence rates were calculated for the total cohort, for each patient characteristic and for surgical category. The odds ratios and 95% confidence intervals were calculated for each outcome using bivariate and multivariate logistic regression. RESULTS: 484,670 adults underwent select common surgical procedures during the study period. Patients had healthcare use in the first 3 days after surgery, with 14,950 (3.1%) ED visits and 14,236 (2.9%) admissions. The incidence of ED use was highest after tonsillectomy (8.1%), cholecystectomy (4.2%) and appendectomy (4.0%). Incidence of admissions was highest after appendectomy (21%). Acute pain (19.7%) and haemorrhage (14.2%) were the most frequent reasons for an ED visit and "convalescence following surgery" (49.2%) followed by acute pain (6.2%) and haemorrhage (4.5%) were the main reasons for admission. CONCLUSIONS: These findings can assist clinicians in identifying and intervening with patients at risk of healthcare use after ambulatory surgery. Pain management strategies that can be tailored to the patient, and earlier follow-up for some patients may be required. In addition, administrative decision-makers could use the results to estimate the impact of specific ambulatory procedures on hospital resources for planning and allocation of resources.

[Knowledge retention after focused cardiac ultrasound training: a prospective cohort pilot study]. / Retenção do conhecimento após treinamento de ultrassonografia cardíaca focada: estudo­piloto prospectivo de coorte.

BACKGROUND AND OBJECTIVES: Focused Cardiac Ultrasound (FoCUS) has proven instrumental in guiding anesthesiologists' clinical decision-making process. Training residents to perform and interpret FoCUS is both feasible and effective. However, the degree of knowledge retention after FoCUS training remains a subject of debate. We sought to provide a description of our 4-week FoCUS curriculum, and to assess the knowledge retention among anesthesia residents at 6 months after FoCUS rotation. METHODS: A prospective analysis involving eleven senior anesthesia residents was carried out. At end of FoCUS Rotation (EOR) participants completed a questionnaire (evaluating the number of scans completed and residents' self-rated knowledge and comfort level with FoCUS), and a multiple-choice FoCUS exam comprised of written- and video-based questions. Six months later, participants completed a follow-up questionnaire and a similar exam. Self-rated knowledge and exam scores were compared at EOR and after 6 months. Spearman correlations were conducted to test the relationship between number of scans completed and exam scores, perceived knowledge and exam scores, and number of scans and perceived knowledge. RESULTS: Mean exam scores (out of 50) were 44.1 at EOR and 43 at the 6-month follow-up. Residents had significantly higher perceived knowledge (out of 10) at EOR (8.0) than at the 6-month follow-up (5.5), p=0.003. At the EOR, all trainees felt comfortable using FoCUS, and at 6 months 10/11 still felt comfortable. All the trainees had used FoCUS in their clinical practice after EOR, and the most cited reason for not using FoCUS more frequently was the lack of perceived clinical need. A strong and statistically significant (rho=0.804, p=0.005) correlation between number of scans completed during the FoCUS rotation and 6-month follow-up perceived knowledge was observed. CONCLUSION: Four weeks of intensive FoCUS training results in adequate knowledge acquisition and 6-month knowledge retention.

Perioperative Management for Abdominal Surgery in Bilateral Diaphragmatic Paralysis: A Case Report and Literature Review.

The optimal approach to postoperative analgesia in patients with bilateral diaphragmatic paralysis undergoing abdominal surgery remains unclear. We report a 69-year-old woman with bilateral diaphragmatic paralysis who underwent a laparoscopic hernia repair and an open laparotomy for reversal of a Hartmann procedure under general anesthesia. Postoperative analgesia was provided by intravenous opioid and epidural local anesthetic and opioid, respectively. The patient's trachea was successfully extubated at the end of both surgical procedures. Epidural analgesia was associated with better pain control and shorter intensive care unit stay.

Innovations in the Management of Musculoskeletal Pain With Alpha-Lipoic Acid (IMPALA Trial): Study protocol for a Double-Blind, Randomized, Placebo-Controlled Crossover Trial of Alpha-Lipoic Acid for the Treatment of Fibromyalgia Pain.

BACKGROUND: Fibromyalgia is a common disorder characterized by chronic widespread pain, sleep disturbance, fatigue, depression, and cognitive dysfunction, resulting in substantial disability. As current analgesics provide incomplete relief and disabling side effects that aggravate fatigue and cognitive dysfunction, there is a need for new pain treatments with better efficacy and tolerability. Alpha-lipoic acid (ALA) is an antioxidant proven effective in painful diabetic neuropathy with minimal side effects. OBJECTIVE: We hypothesize that this agent will provide benefits in fibromyalgia because of several similarities with neuropathic pain and also because it does not cause sedation, fatigue, or mental-slowing. To test this, we have designed a clinical trial that will assess pain, side effects, and other outcomes in participants with fibromyalgia. METHODS: Using a crossover design, 24 adults with fibromyalgia will be randomly allocated to 1 of the 2 sequences of ALA and placebo. Participants will take capsules containing ALA or placebo for 4 weeks followed by a 1-week washout followed by a second 4-week treatment and 1-week washout period. ALA (or matching placebo) capsules will be titrated to 1800 mg/day over each 4-week period. The primary outcome will be mean daily pain intensity (0-10) during week 4 of each period. Secondary outcomes, assessed during week 4 of each period, will include global improvement, adverse events, mood, and quality of life. RESULTS: This trial was registered in the International Standard Randomized Controlled Trial registry March 15, 2016 (Number ISRCTN58259979), and it attained ethics approval on December 3, 2016 (Queen's University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board protocol number ANAE-287-15). The recruitment started in February 2017. CONCLUSIONS: This trial will provide evidence for the efficacy of ALA in fibromyalgia. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 58259979; www.isrctn.com/ISRCTN58259979 (Archived by WebCite at http://www.webcitation.org/6og9JdiyZ).

Retrograde Extrusion of Coronary Thrombus During Urgent Aortocoronary Bypass Surgery: A Case Report.

A 73-year-old man underwent urgent coronary artery bypass grafting after an acute myocardial infarction. An angiogram had revealed multivessel disease with a circumflex artery lesion suspected as the primary culprit. On separation from cardiopulmonary bypass, transesophageal echocardiography revealed a new mobile mass in the aortic root. Cardiopulmonary bypass was reinstituted and a large thrombus emanating from the left coronary ostium was surgically removed. We hypothesize that the thrombus had originated from coronary retrograde extrusion during venous grafting. This case illustrates an unusual source of emboli during coronary artery bypass grafting and emphasizes the importance of perioperative transesophageal echocardiography for the prevention of potentially catastrophic outcomes.

"Debriefing-on-Demand": A Pilot Assessment of Using a "Pause Button" in Medical Simulation.

INTRODUCTION: Simulation is an effective tool in medical education with debriefing as the cardinal educational component. Alternate debriefing strategies might further enhance the educational value of simulation. Here, we pilot a novel strategy that allows trainees to initiate debriefing at any point during the scenario, when they consider it necessary. METHODS: With ethics approval, 8 postgraduate year 1 anesthesia residents (with no previous exposure to high-fidelity simulation) were randomly assigned to lead 2 of 8 scenarios with 2 debriefing strategies. With "debriefing-on-demand," residents had the option to initiate debriefing at any point in the scenario by activation of a "pause button"-in addition to undergoing conventional debriefing at the end of the scenario. Those randomized to "conventional debriefing" were debriefed only at the end of the scenario. All were allocated as team leader with both debriefing strategies and as a participant in remaining scenarios. Residents provided feedback regarding each method using Likert scales and completion of open-ended statements. RESULTS: Debriefing-on-demand was easily integrated into all scenarios, and most learners (88%) supported its use in future simulation sessions. The following 4 themes emerged from qualitative analyses: (1) improvements in the clarification and integration of knowledge, (2) reductions in stress/anxiety, (3) facilitated reflection on action, and (4) maintained realism comparable with conventional debriefing. CONCLUSIONS: Debriefing-on-demand was easily integrated into all scenarios and well received by these trainees new to simulation. Larger trials that use validated tools are needed to determine the absolute impact of debriefing-on-demand on stress levels and the overall learning value of simulation for trainees at different levels of training.

Knowledge retention after focused cardiac ultrasound training: a prospective cohort pilot study / Retenção do conhecimento após treinamento de ultrassonografia cardíaca focada: estudo-piloto prospectivo de coorte

Abstract Background and objectives: Focused Cardiac Ultrasound (FoCUS) has proven instrumental in guiding anesthesiologists' clinical decision-making process. Training residents to perform and interpret FoCUS is both feasible and effective. However, the degree of knowledge retention after FoCUS training remains a subject of debate. We sought to provide a description of our 4-week FoCUS curriculum, and to assess the knowledge retention among anesthesia residents at 6 months after FoCUS rotation. Methods: A prospective analysis involving eleven senior anesthesia residents was carried out. At end of FoCUS Rotation (EOR) participants completed a questionnaire (evaluating the number of scans completed and residents' self-rated knowledge and comfort level with FoCUS), and a multiple-choice FoCUS exam comprised of written- and video-based questions. Six months later, participants completed a follow-up questionnaire and a similar exam. Self-rated knowledge and exam scores were compared at EOR and after 6 months. Spearman correlations were conducted to test the relationship between number of scans completed and exam scores, perceived knowledge and exam scores, and number of scans and perceived knowledge. Results: Mean exam scores (out of 50) were 44.1 at EOR and 43 at the 6-month follow-up. Residents had significantly higher perceived knowledge (out of 10) at EOR (8.0) than at the 6-month follow-up (5.5), p = 0.003. At the EOR, all trainees felt comfortable using FoCUS, and at 6 months 10/11 still felt comfortable. All the trainees had used FoCUS in their clinical practice after EOR, and the most cited reason for not using FoCUS more frequently was the lack of perceived clinical need. A strong and statistically significant (rho = 0.804, p = 0.005) correlation between number of scans completed during the FoCUS rotation and 6-month follow-up perceived knowledge was observed. Conclusion: Four weeks of intensive FoCUS training results in adequate knowledge acquisition and 6-month knowledge retention.

Resumo Justificativa e objetivos: A ultrassonografia cardíaca no local de atendimento (USCLA) provou ser importante para orientar o processo de tomada de decisão clínica dos anestesiologistas. Treinar os residentes para fazer e interpretar uma USCLA é viável e eficaz. No entanto, o grau de retenção do conhecimento após o treinamento permanece um assunto de debate. Procuramos fornecer uma descrição do currículo de quatro semanas do treinamento de USCLA e avaliar a retenção do conhecimento entre os residentes de anestesia seis meses após a rotação em USCLA. Métodos: Uma análise prospectiva foi realizada com 11 residentes seniores de anestesia. Ao final da rotação em USCLA, os participantes preencheram um questionário (avaliando o número de exames ultrassonográficos concluídos, o conhecimento adquirido e o nível de conforto dos residentes com a USCLA) e fizeram um exame de múltipla escolha para USCLA, composto por perguntas escritas e baseadas em vídeo. Seis meses depois, os participantes preencheram um questionário de acompanhamento e um exame similar. A autoavaliação do conhecimento e os escores do exame foram comparados no final da rotação e após seis meses. Correlações de Spearman foram usadas para testar a relação entre o número de exames concluídos e os escores dos exames, o conhecimento percebido, os escores dos exames, o número de exames e o conhecimento percebido. Resultados: Os escores médios dos exames (50) foram: 44,1 no final da rotação e 43 após seis meses. Os residentes tiveram conhecimento percebido significativamente maior (10) no final da rotação (8,0) que após seis meses (5,5), p = 0,003. No final da rotação, todos os residentes se sentiram confortáveis usando o aparelho de USCLA e, aos seis meses, 10/11 ainda se sentiam confortáveis. Todos os residentes haviam usado o USCLA em sua prática clínica após o final da rotação e a razão mais citada para não usar o USCLA com mais frequência foi a falta de necessidade clínica percebida. Uma correlação forte e estatisticamente significativa (rho = 0,804, p = 0,005) foi observada entre o número de exames realizados durante a rotação em USCLA e o conhecimento percebido em seis meses de seguimento. Conclusão: Quatro semanas de treinamento intensivo de USCLA resultaram em aquisição e retenção adequadas do conhecimento por seis meses.

Left ventricular dysfunction after acute intracranial hypertension is associated with increased hydroxyl free radical production, cardiac ryanodine hyperphosphorylation, and troponin I degradation.

BACKGROUND: In addition to generating free radicals, stress-induced activation of the sympathetic nervous system results in hyperphosphorylation of the cardiac ryanodine receptor (RyR2)/calcium (Ca2+) release channel on the sarcoplasmic reticulum, causing leaky channels. These events may contribute to cytosolic Ca2+ overload and activation of Ca2+-dependent cytotoxic processes. Because myocardial dysfunction associated with intracranial hypertension is catecholamine mediated, we sought to determine in a rat model if hemodynamic changes are associated with an increase in oxidative stress, hyperphosphorylation of RyR2, and degradation of myofilament protein cardiac troponin I (TnI). METHODS: In halothane-anesthetized rats treated with saline, dimethyl sulfoxide (DMSO), or the synthetic calpain inhibitor calpeptin (3,500 microg), a subdural balloon catheter was inflated to induce intracranial hypertension. Hearts were excised, and RyR2 phosphorylation status and TnI degradation was determined with Western blot analysis. In separate experiments, treated rats were challenged with increasing doses of dobutamine 30 minutes after subdural balloon inflation. RESULTS: Elevating the intracranial pressure resulted in an increase in plasma catecholamines, as well as in 3,4-dihydroxybenzoic acid (DHBA), an indirect marker of HO. radical production, and left ventricular dysfunction in rats treated with saline or DMSO. There was evidence of hyperphosphorylation of RyR2 and TnI degradation (27 kD immunoreactive band). Calpeptin treatment improved left ventricular function; however, this had no effect on the phosphorylation status of RyR2 or TnI degradation levels. In addition, the myocardial responsiveness to dobutamine was augmented in rats with depressed myocardial function. CONCLUSION: The present findings demonstrate that hemodynamic instability after intracranial hypertension is associated with oxidative stress and post-translational changes to RyR2 and TnI degradation. Despite this, the myocardial responsiveness to beta1 adrenergic stimulation is preserved in rats with depressed myocardial function.

A demand-based assessment of the Canadian anesthesia workforce - 2002 through 2007.

PURPOSE: The number of anesthesia providers required by the Canadian health care system remains controversial. Questions persist regarding both the adequacy of the current supply and what the future demand will be. The purpose of this study was to quantify the number and adequacy of anesthesia providers in 2002, and predict the same for the year 2007. METHODS: All licensed health care facilities potentially employing anesthetic services were identified. On February 1(st), 2002 a questionnaire was mailed to each institution. On April 1(st), a second mailing was sent to non-responders. Those facilities that did not respond to either mailing were contacted by telephone. RESULTS: Responses were obtained from 831 of 891 (93%) health care facilities. Four hundred and twenty-six of the facilities employed anesthetic services. There were 1,610 operating rooms (ORs) in use daily, and 2,134 full-time equivalent (FTE) anesthesia providers were available to the institutions surveyed. Respondents identified an immediate need for 228 additional FTEs. Hospitals with less than five ORs or five FTEs reported higher vacancy rates than hospitals with greater than five ORs or five FTEs (P < 0.0001). Ontario (n = 85) and Quebec (n = 69) had the largest absolute deficits of FTEs and significantly greater odds of vacancies than western provinces (Ontario OR = 1.84, Quebec OR = 2.50). The projected need for 2007 was an additional 560 FTEs. CONCLUSION: This is the first study to survey a national census of "consumers" of anesthetic services: Canadian health care facilities. The results indicate substantial current and worsening future shortages of anesthesia providers in Canada.