Role of 3D printing for the protection of surgical and critical care professionals in the COVID-19 pandemic. / Papel de la impresión 3D para la protección de los profesionales del área quirúrgica y críticos en la pandemia de COVID-19.

BACKGROUND AND OBJECTIVE: There is a shortage of supplies for the protection of professionals during the COVID-19 pandemic. 3D printing offers the possibility to compensate for the production of some of the equipment needed. The objective is to describe the role of 3D printing in a health service during the COVID-19 pandemic, with an emphasis on the process to develop a final product ready to be implemented in the clinical environment. METHODS: A working group was formed between the healthcare administration, clinicians and other public and private institutions in Cantabria, Spain coordinated by the Valdecilla Virtual Hospital. The process included receiving the printing proposals, learning about the printing resources in the region, selecting the devices, creating a team for each project, prototyping, evaluation and redesign, manufacturing, assembly and distribution. RESULTS: The following supplies are produced: 1) devices that help protect providers: face protection screens (2,400 units), personalized accessories for photophores (20 units) and ear-protection forks for face-masks (1,200 units); 2) products related to the ventilation of infected patients: connectors for non-invasive ventilation systems; and 3) oral and nasopharyngeal swabs (7,500 units) for the identification of coronavirus carriers with the aim of designing action protocols in clinical areas. CONCLUSIONS: 3D printing is a valid resource for the production of protective material for professionals whose supply is reduced during a pandemic.

[Simulation as a tool to facilitate change in healthcare organisations]. / La simulación como herramienta para facilitar el cambio en las organizaciones sanitarias.

OBJECTIVE: To describe the use of simulation as a tool to support the strategic management of change in the Cantabrian Regional Health Service in Spain. METHODS: A working group was created to: 1) define the strategic areas of innovation and change; 2) establish criteria for the selection of proposals that can be addressed with simulation; 3) analyse and select the proposals; 4) design and implement the simulation programs, and 5) evaluate results. RESULTS: The constantly changing needs of the regional health system enabled 6 strategic areas to be identified during 2017-208: 1) efficient use of resources; 2) implementation of health plans of interest in the community; 3) patient safety improvement; 4) management of health personnel; 5) development of new professional skills, and 6) selection and implementation of new technology. CONCLUSIONS: Clinical simulation is a useful tool to promote innovation strategies in healthcare, facilitating the adaptation of professionals and patients to change.

[Innovation in healthcare processes and patient safety using clinical simulation]. / Innovando en procesos asistenciales y seguridad del paciente mediante simulación clínica.

OBJECTIVE: Many excellent ideas are never implemented or generalised by healthcare organisations. There are two related paradigms: thinking that individuals primarily change through accumulating knowledge, and believing that the dissemination of that knowledge within the organisation is the key element to facilitate change. As an alternative, a description and evaluation of a simulation-based inter-professional team training program conducted in a Regional Health Service to promote and facilitate change is presented. MATERIAL AND METHODS: The Department of Continuing Education completed the needs assessment using the proposals presented by clinical units and management. Skills and behaviors that could be learned using simulation were selected, and all personnel from the units participating were included. Experiential learning principles based on clinical simulation and debriefing, were used for the instructional design. The Kirkpatrick model was used to evaluate the program. RESULTS: Objectives included: a) decision-making and teamwork skills training in high prevalence diseases with a high rate of preventable complications; b) care processes reorganisation to improve efficiency, while maintaining patient safety; and, c) implementation of new complex techniques with a long learning curve, and high preventable complications rate. Thirty clinical units organised 39 training programs in the 3 public hospitals, and primary care of the Regional Health Service during 2013-2014. Over 1,559 healthcare professionals participated, including nursing assistants, nurses and physicians. CONCLUSION: Simulation in healthcare to train inter-professional teams can promote and facilitate change in patient care, and organisational re-engineering.

The making of expert clinicians: reflective practice.

Debriefing is a rigorous reflection process which helps trainees recognize and resolve clinical and behavioral dilemmas raised by a clinical case. This approach emphasizes eliciting trainees'assumptions about the situation and their reasons for performing as they did (mental models). It analyses their impact on actions, to understand if it is necessary to maintain them or construct new ones that may lead to better performance in the future. It blends evidence and theory from education research, the social and cognitive sciences, and experience drawn from conducting and teaching debriefing to clinicians worldwide, on how to improve professional effectiveness through "reflective practice".

[Bringing clinical simulation into anesthesiology and postoperative recovery care residency training]. / Integración de la simulación clínica en el programa formativo de la especialidad de anestesiología y reanimación.

This article describes the use of clinical simulations for training residents in anesthesiology and postoperative recovery care at Hospital Universitario Marqués de Valdecilla. A working group defined criteria for the competencies residents would acquire by means of simulation training, designed the scenarios to be used, and took responsibility for coordinating and funding the program. We used the platform of the Critical Events Training Center of the Marcelino Botin Foundation, now part of our center's virtual hospital. The simulation-based training modules include 4 activities in the residents' first year, 3 in each of the second and third years, and 4 in the fourth year; all center on acquisition of the identified competencies and take into consideration the time availability of residents and instructors and the budget. We have concluded that integrating clinical simulations into residency training is a challenge for educators, given that a large part of the benefit derived from this tool comes from complementing it with other instructional resources and adapting it to the syllabus. More studies are required to establish criteria to guide the integration of this tool into the curriculum in those areas of the specialty where it can work most efficiently; the effectiveness of the approach also needs to be assessed. Simulations facilitate training without putting patients at risk and provide residents with early exposure to situations that might otherwise be difficult to observe. This tool also encourages the practice of reflective clinical decision-making.

Perioperative response of leptin and the tumor necrosis factor alpha system in morbidly obese patients. Influence of cortisol inhibition by etomidate.

BACKGROUND: Leptin, tumor necrosis factor alpha (TNFalpha) and soluble TNFalpha receptors are secreted by the adipose tissue. Surgery induces a complex cytokine and neurohormonal response. The aim of our study was to investigate the perioperative response of leptin and the TNFalpha system in morbidly obese patients submitted to gastroplasty, and the possible involvement of cortisol in their responses. METHODS: Serum cortisol, adrenocorticotropic hormone (ACTH), leptin, TNFalpha and soluble TNFalpha receptor I were measured in 22 morbidly obese women (11 anesthetized with thiopental and 11 with etomidate, a well known inhibitor of cortisol synthesis). Samples were collected before anesthesia induction, just before surgical incision, and 2, 4, 6, 12, 24 and 48 h after the start of surgery. RESULTS: Baseline serum leptin correlated with body mass index (r=0.567, P=0.007). Baseline serum leptin and TNFalpha were higher than normal. Cortisol release was inhibited in the etomidate group with a subsequent higher stimulation of ACTH release. A statistically significant decrease in serum leptin levels was observed in both groups at 2, 4, 6 and 48 h, compared with basal values. A similar decrease in serum TNFalpha levels was observed in both groups, but the decrease reached significance only in the etomidate group. Serum soluble TNFalpha receptor I did not decrease. No differences were found between the two groups in leptin, TNFalpha or soluble TNFalpha receptor I concentrations at any time. CONCLUSION: Serum leptin and TNFalpha levels decrease in obese patients during gastroplasty. Transitory inhibition of cortisol release does not alter this response.

[Simulators in anesthesiology]. / Simuladores en anestesia.

The work of an anesthesiologist and that of a flight pilot share certain attributes. As pilots use simulators to obtain risk-free practice in recognizing and controlling situations that might lead to disaster, simulation programs are now emerging as a new way to learn and train anesthesiology is being conceived as a new task that integrates scientific knowledge and human factors. Simulators have been introduced into teaching and training programs as a powerful tools that allow anesthesiologists to learn, practice and train in a multitude of situations without putting human life at risk. Experience is limited so far, but acceptance has been high and simulators seem to accelerate the acquisition of skills and knowledge, although their effect on performance in critical situations has not been proven yet. Two types have been applied in anesthesiology: computer screen and mannequin. The usefulness of simulators ranges from training for situations that require the systematic application of protocols and the understanding of new drugs being introduced into clinical practice to the practice of how to use resources for managing anesthetic emergencies. It is still too early to use simulators for certifying and evaluating clinical performance, as further studies are needed to identify the type of events that reflect typical situations and to determine which procedures should be evaluated.

[Perioperative response of phosphorus and calcium metabolism and of bone remodeling markers during heart surgery under extracorporeal circulation]. / Respuesta perioperatoria del metabolismo fosfocálcico y de los marcadores de remodelación ósea en la cirugía cardíaca con circulación extracorpórea.

HYPOTHESIS AND OBJECTIVES: Cardiovascular surgery with extracorporeal circulation (ECC) is highly stressful, inducing marked changes in calcium and magnesium homeostasis. Nevertheless, no studies have assessed osteoblastic/osteoclastic activity during and after heart surgery with ECC. Our objective was to analyze changes in serum levels of parameters reflecting phosphorus and calcium metabolism and markers of bone remodelling in this context. PATIENTS AND METHODS: Changes in serum levels of calcium, phosphorus, whole parathyroid hormone (PTH), magnesium, cortisol, interleukin-6, total alkaline phosphatase, osseous alkaline phosphatase (OAP), osteocalcin, propeptide of type 1 procollagen (PCP1), and carboxyl-terminal telopeptide of type 1 collagen (CTT1) during the 24 perioperative hours in 16 patients undergoing cardiac surgery with ECC. RESULTS: Total calcium decreased during ECC, triggering acute release of PTH. Osteocalcin decreased at 24 hours in a way that was not accounted for by hemodilution. OAP changes, on the other hand, were consistent with albumin levels and blood cell counts. PCP1 and CTT1 did not change, although correcting for dilution shows that these factors can in fact be considered to have increased. CONCLUSIONS: The parathyroid gland is activated during ECC. Markers of bone metabolism behave differently over time in response to heart surgery. The data suggest that heart surgery induces discordant responses in various bone cell functions.

Patients with poor preoperative ejection fraction have a higher plasma response of adrenomedullin in response to open heart surgery.

BACKGROUND: Adrenomedullin (AM) is a potent vasodilator peptide. Plasma AM levels are increased in heart diseases and in sepsis. Heart surgery under cardiopulmonary bypass (CPB) induces a systemic inflammatory response. METHODS: We measured plasma AM, cAMP (the second messenger of AM), C-reactive protein (CRP) and haemodynamic parameters in 29 patients undergoing elective open heart surgery, before, during and after anaesthesia and CPB as well as on the first morning after surgery. RESULTS: Basal AM levels were higher than normal and correlated with systolic pulmonary pressure and pulmonary capillary pressure, but not with other haemodynamic parameters. AM increased during CPB and remained elevated 24 h after the start of surgery. Plasma cAMP increased only at the end of CPB. CRP was increased only in the last sample. At the end of CPB and at the end of surgery AM levels were higher in patients with basal ejection fraction<40% compared with those with ejection fraction >60% [456+/-386 vs 252+/-343 (P<0.03) and 832+/-781 vs 391+/-356 pg/ml (P<0.05), respectively]. CONCLUSION: We conclude that AM, as inflammation-related cytokines, increases during and after CPB, that cAMP response is unrelated to AM and that AM response is higher in those patients with worse basal ejection fraction.