Simulation-based teaching versus point-of-care teaching for identification of basic transoesophageal echocardiography views: a prospective randomised study.

In recent years, the use of transoesophageal echocardiography has increased in anaesthesia and intensive care. We explored the impact of two different teaching methods on the ability of echocardiography-naïve subjects to identify cardiac anatomy associated with the 20 standard transoesophageal echocardiography imaging planes, and assessed trainees' satisfaction with these methods of training. Fifty-two subjects were randomly assigned to one of two groups: a simulation-based and a theatre-based teaching group. Subjects undertook video-based tests comprised of 20 multiple choice questions on echocardiography views before and after receiving echocardiography teaching. Subjects in simulation- and theatre-based teaching groups scored 40% (30-40 [20-50])% and 35% (30-40 [15-55])% in the pre-test, respectively (p = 0.52). Following echocardiography teaching, subjects within both groups improved upon their pre-test knowledge (p < 0.001). Subjects in the simulation-based teaching group significantly outperformed their theatre-based group counterparts in the post-intervention test (p = 0.0002).

The impact of internet and simulation-based training on transoesophageal echocardiography learning in anaesthetic trainees: a prospective randomised study.

With the increasing role of transoesophageal echocardiography in clinical fields other than cardiac surgery, we decided to assess the efficacy of multi-modular echocardiography learning in echo-naïve anaesthetic trainees. Twenty-eight trainees undertook a pre-test to ascertain basic echocardiography knowledge, following which the study subjects were randomly assigned to two groups: learning via traditional methods such as review of guidelines and other literature (non-internet group); and learning via an internet-based echocardiography resource (internet group). After this, subjects in both groups underwent simulation-based echocardiography training. More tests were then conducted after a review of the respective educational resources and simulation sessions. Mean (SD) scores of subjects in the non-internet group were 28 (10)%, 44 (10)% and 63 (5)% in the pre-test, post-intervention test and post-simulation test, respectively, whereas those in the internet group scored 29 (8)%, 59 (10)%, (p = 0.001) and 72 (8)%, p = 0.005, respectively. The use of internet- and simulation-based learning methods led to a significant improvement in knowledge of transoesophageal echocardiography by anaesthetic trainees. The impact of simulation-based training was greater in the group who did not use the internet-based resource. We conclude that internet- and simulation-based learning methods both improve transoesophageal echocardiography knowledge in echo-naïve anaesthetic trainees.

Impact of prebriefing on emotions in a high-fidelity simulation session: A randomized controlled study.

INTRODUCTION: Medical simulation is associated with intense emotions which influence human behavior. We aim to investigate how prebriefing impacts on learners' emotions during a high-fidelity simulation (HFS) session. METHODS: This is a prospective randomized controlled study. Participants were randomly allocated to receive a standardized prebriefing (SP group) versus not receiving it (NSP group). Debriefing following the «good judgment¼ approach, structured in reactions, understanding and summary phases, was used in both groups. In order to assess emotions, we used the circumplex model of affect applying the Affect Grid scale, which was performed prior to prebriefing, following case performance and following debriefing. Debriefing times were also assessed. RESULTS: A total of 128 physicians participate in the study (64 vs. 64). Following case performance, this HFS session was experienced with significantly more pleasant emotions compared to baseline, that were maintained during debriefing (p < 0.01) while alertness increased after case performance diminishing after debriefing (p < 0.01). There were no statistical significant differences between groups. In the NSP group, total debriefing (p = 0.003) and understanding phase (p = 0.002) times were significantly longer. CONCLUSIONS: This HFS session was experienced as pleasant with high alertness with no specific emotional impact attributable to prebriefing. Prebriefing leads to a freer flowing debriefing.

[Muscle activation times facing to a perturbation in patients with early-stage Parkinson's disease]. / Tiempos de activación muscular frente a una desestabilización en pacientes con enfermedad de Parkinson en etapas iniciales.

OBJECTIVES: Parkinson's disease (PD) generates a high incidence of falls, however, there is little evidence of instabilities in the initial stages. This investigation sought to compare the muscle activation times in patients with initial PD against a postural disturbance vs. a control group. MATERIALS AND METHODS: The electromyographic activity (EMG) of 10 patients with PD in early stages (61.3 ±3.8 years) and a control group of 10 adults (62.2 ±3.0 year) was evaluated. The participants were subjected to a surface disturbance, which generated a stabilization response. The test was performed under 2conditions: eyes open (OA) v/s eyes closed (OC). Trunk (spinal erector) and lower extremity (soleus, tibialis anterior, femoral biceps, femoral rectus, adductor magnus, gluteus medius) muscle activation time was analyzed using surface EMG. RESULTS: The PD group showed faster response times compared to the control group in the soleus muscle in OC (P=.04). This same muscle showed differences when comparing OA vs. OC only in the PD group (P=.04), showing a shorter response time in the OC condition. When comparing the spinal erector muscle, the PD group showed slower response times in the OA (P=.02) and OC (P=.04) conditions compared to the control group. CONCLUSIONS: Muscle activation times show that people with PD respond slower in the trunk muscles, while activation times decrease at the distal level. In the early stages, the slower responses at the trunk level could explain the onset of instability postural in these patients.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy).

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

[Trunk kinematics during walking in stroke patients: A systematic review]. / Cinemática de tronco durante la marcha en pacientes con ictus: revisión sistemática.

The trunk and pelvis are affected after stroke, predisposing individuals to falls and dependency. The aim of this review was to describe the lineal and angular kinematics of the trunk and pelvis in patients with post-stroke sequels during walking. We included studies published up to June 2018 using a 2-3 D motion capture system during walking. We searched the Cochrane, Medline, PEDRo, Lilacs, Scielo, EBSCO, ClinicalKey and Elsevier databases. Twelve articles were selected. Linear kinematics showed greater lateral displacement and acceleration in all axes. Angular kinematics in the swing phase of the paretic segment showed the pelvis in posterior rotation, with elevation and lower velocity and the trunk in anterior flexion, with lateral inclination and ipsilateral rotation. The studies showed wide variability, making it impossible to establish of a common effect. However, the results allow description of the movement of the trunk and pelvis.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy). / Guía clínica en el manejo perioperatorio para la cirugía de resección pulmonar por videotoracoscopia (Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR; Sociedad Española de Cirugía Torácica, SECT; Asociación Española de Fisioterapia, AEF).

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Emotional response to a high-fidelity trauma simulation: An observational study. / Respuesta emocional a una simulación de alta fidelidad en trauma: Un estudio observacional.

INTRODUCTION: The emotional environment created during a simulation session can influence learning. Positive emotions improve perceptual processing and facilitate learning, while negative emotions can reduce working memory, resulting in poorer learning outcomes. OBJECTIVES: The aim of this study was to investigate the impact of simulation training on emotions during all phases of a high-fidelity simulation using standard prebriefing and «good judgement debriefing ¼ techniques. METHODS: This was an observational study that included 74 anesthesiologists participating in a simulation-based training. A standardized prebriefing was followed by «good judgement debriefing¼. In order to assess emotions, we used the circumplex model of emotion, and asked participants to complete the affect grid scale before prebriefing (Stage 1), before starting the simulation (Stage 2), before debriefing (Stage 3) and following debriefing (Stage 4). RESULTS: The affect grid scores obtained from 67 participants were analyzed. Following debriefing, the experience of the polytrauma patient simulation was significantly more pleasant compared to previous stages (P<0.01). In addition, participants perceived the activity as becoming increasingly active as it progressed (P<0.01). CONCLUSIONS: High-fidelity trauma simulation creating a safe environment using a standardized prebriefing and «good judgement debriefing¼ is experienced as a pleasant and active activity at all stages of the simulation. Further investigation is needed to assess the impact of these results on learning.

Review of difficult airway management in thoracic surgery. / Revisión del manejo de la vía aérea díficil en cirugía torácica.

The management of difficult airway (DA) in thoracic surgery is more difficult due to the need for lung separation or isolation and frequent presence of associated upper and lower airway problems. We performed an article review analysing 818 papers published with clinical evidence indexed in Pubmed that allowed us to develop an algorithm. The best airway management in predicted DA is tracheal intubation and independent bronchial blockers guided by fibroscopy maintaining spontaneous ventilation. For unpredicted DA, the use of videolaryngoscopes is recommended initially, and adequate neuromuscular relaxation (rocuronium/sugammadex), among other maneuvers. In both cases, double lumen tubes should be reserved for when lung separation is absolutely indicated. Finally, extubation should be a time of maximum care and be performed according to the safety measures of the Difficult Arway Society.

Cold blood cardioplegia or intermittent cross-clamping in coronary artery bypass grafting?

BACKGROUND: We determined that cold blood cardioplegia and intermittent ventricular fibrillation with ischemia were associated with similar enzyme and myocardial protein leakage in a randomized, prospective study of 40 patients. We have continued to use both methods in our unit, according to surgeons' preference. METHODS: In our database we have reviewed 1,923 patients who have undergone first-time elective or urgent coronary artery bypass grafting from January 1992 to May 1997. RESULTS: Five hundred seventy-eight patients underwent coronary artery bypass grafting with cold blood cardioplegia and 1,345 had ventricular fibrillation and aortic cross-clamping. The preoperative factors were virtually identical. Intraoperative differences were only those inherent to the two techniques: temperature and cross-clamp time. Mortality was 2.5% for ventricular fibrillation and aortic cross-clamping arrest and 2.1% for cardioplegia (p=0.55 by chi2 test). There was a higher use of the intraaortic balloon pump in the ventricular fibrillation and aortic cross-clamping group (2.4% versus 1.0%; p=0.04), but no other differences in outcome were detected. CONCLUSIONS: A truly randomized trial to demonstrate which technique is superior is impractical at this level of difference because it would require 37,000 patients to avoid a beta error. We have to base our practice on the retrospective data available. Each technique has its merits in practice, which are discussed.

Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality.

Over a 2-year period from January 1, 1992, to December 31, 1993, of 2,221 patients undergoing cardiac operations in our unit, 85 (3.8%) were reopened for the control of bleeding (9 patients more than once). The incidence of resternotomy in coronary cases was 2.3%, but resternotomy was more than three times as likely in valve cases (odds ratio, 3.4; 95% confidence interval, 2.1 to 5.4). Previous cardiac operation was more common among resternotomy patients than among the remainder (18% versus 9%, respectively; p = 0.018). An identifiable source of bleeding was found in 57 of the 85 patients (67%), but a concurrent coagulopathy was common (45 patients). Resternotomy patients, as a group, had higher preoperative risk scores (Parsonnet) than did the other patients (p < 0.0001), stayed longer in the intensive care unit (p < 0.0001), and had greater requirements for intraaortic balloon counterpulsation (14% versus 3%) and hemofiltration (9% versus 3%) (p < 0.0001 and p < 0.01, respectively). Nineteen resternotomy patients (22%) died in the hospital, a proportion significantly greater than the risk assigned to this group of patients preoperatively (12.8%) (p = 0.008). In contrast, the observed mortality for the other 2,136 patients (5.5%) was significantly less (8.3%) (p < 0.00006). Multiple forward stepwise logistic-regression analysis confirmed resternotomy for excessive bleeding after cardiac operation to be a significant independent predictor of a prolonged stay in the intensive care unit (p < 0.0001), the need for intraaortic balloon counterpulsation (p < 0.0001), and death (p < 0.0001).

Ion exchange resins as catalyst for the isomerization of alpha-pinene to camphene.

Camphene is an industrial intermediate compound for commercial chemicals such as isoborneol, isobornyl acetate and camphor. Industrially, the conventional process for camphene production consists of the isomerization of alpha-pinene using acidic TiO2 as catalyst. The use of this catalyst presents problems such as considerable time for preparation, reproducibility and recovery of catalyst from products after the alpha-pinene isomerization. For the first time, a commercial exchange resin was used as catalyst for this reaction. Based on the concentration of product as a function of the reaction time, the path of the alpha-pinene transformation to camphene and byproducts is proposed. Temperature and alpha-pinene/catalyst ratio were studied in order to optimize the yield to camphene production. The obtained results were comparable with those reported for acidic TiO2.

Training surgeons and safeguarding patients.

Surgical trainees need exposure to a wide variety of operations and a chance to operate under supervision. At the same time there is the over-riding responsibility to do the best for our patients. Cardiac surgery is dominated by coronary bypass surgery and the tendency has been to delegate easy coronary cases to trainees and to neglect their experience in other areas. This paper is an audit of trainee exposure and supervision in a training centre. During a 20-month period, 35.2 per cent of cases were delegated; 20.6 per cent to the senior registrar and 14.6 per cent to the registrars. Senior registrars were assisted by the consultant in 19.1 per cent of their cases and registrars were assisted by more senior colleagues in 28.5 per cent of theirs. Most cases delegated to trainees were of low perioperative risk and operations were performed with commensurate low morbidity and mortality. The delegation of valve surgery was disproportionately low in comparison to overall case mix. On the basis of this study, the delegation of cases is being reviewed in the knowledge that with appropriate selection, trainees can gain valuable operative experience without compromising patient-safety.

Cumulative risk adjusted mortality chart for detecting changes in death rate: observational study of heart surgery.

OBJECTIVE: To detect changes in mortality after surgery, with allowance being made for variations in case mix. DESIGN: Observational study of postoperative mortality from January 1992 to August 1995. SETTING: Regional cardiothoracic unit. SUBJECTS: 3983 patients aged 16 and over who had open heart operations. MAIN OUTCOME MEASURES: Preoperative risk factors and postoperative mortality in hospital within 30 days were recorded for all surgical heart operations. Mortality was adjusted for case mix using a preoperative estimate of risk based on additive Parsonnet factors. The number of operations required for statistical power to detect a doubling of mortality was examined, and control limits at a nominal significance level of P=0.01 for detection of an adverse trend were determined. RESULTS: Total mortality of 7.0% was 26% below the Parsonnet predictor (P<0.0001). There was a highly significant variation in annual case mix (Parsonnet scores 8.7-10.6, P<0.0001). There was no significant variation in mortality after adjustment for case mix (odds ratio 1-1.5, P=0.18) with monitoring by calendar year. With continuous monitoring, however, nominal 99% control limits based on 16 expected deaths were crossed on two occasions. CONCLUSIONS: Hospital league tables for mortality from heart surgery will be of limited value because year to year differences in death rate can be large (odds ratio 1.5) even when the underlying risk or case mix does not change. Statistical quality control of a single series with adjustment for case mix is the only way to take into account recent performance when informing a patient of the risk of surgery at a particular hospital. If there is an increase in the number of deaths the chances of the next patient surviving surgery can be calculated from the last 16 deaths.

Cinemática fisiológica de rodilla en futbolistas amateur: análisis 3D / Physiological kinematics of the knee in amateur soccer players: a 3D analysis

La lesión del ligamento cruzado anterior (LCA) tiene un alta prevalencia en jugadores de fútbol. En esta disciplina, las carreras con cambios de dirección son frecuentes y pueden ser un factor de riesgo para el desarrollo de lesiones del LCA sin contacto. Objetivo: Describir en futbolistas jóvenes los rangos cinemáticos fisiológicos de rodilla sometida a tareas funcionales con cambios bruscos de dirección. Método: En una muestra de ocho futbolistas con rodillas clínicamente sanas, se evaluó, mediante un sistema de análisis de movimiento 3D, la cinemática de la rodilla de apoyo durante la ejecución de tres tareas funcionales, dos de estas implicaron cambios de dirección en 90° (CD90°) y 180° (CD180°), la tercera golpear un balón (GB). Los rangos fisiológicos de movimiento (ROM) fueron registrados y comparados en la misma rodilla en tres planos diferentes (T-Transversal; F-Frontal; S-Sagital). Resultados: Los rangos fisiológicos obtenidos fueron para las tareas funcionales CD90°: T 11°(13-8), F 5.6° (11-4) y S 22°(30-17); para CD180°: T 9°(12-8), F 6.3°(8-5) y S 17.6°(21-14); y para GB: T 9°(10-5), F 3.8°(10-2), y S 9.6°(15-6). El ROM fue significativamente mayor en el plano transversal para la tarea CD90°. El el plano sagital el ROM fue mayor para CD90° comparado con GB (p<.05), sin embargo no hubo diferencias respecto a la tarea CD180°. No existen diferencias del ROM en el plano frontal. Conclusión: Se logró describir los rangos cinemáticos fisiológicos de la rodilla durante la ejecución de tres tareas funcionales que implicaron cambios bruscos de dirección en futbolistas amateur. En la muestra evaluada, la prueba que produjo una mayor exigencia de los rangos articulares de rodilla en los planos transversal y sagital fue la prueba con cambio de dirección en 90°...

Anterior cruciate ligament (ACL) lesions are frequent among soccer players. In this sport cutting movements are usually made while running and may be a risk factor in developing non-contact ACL injuries. Purpose: To describe the physiological kinematics of the knee during sudden change of direction movements in amateur soccer players. Methods:Eight amateur soccer players without previous injuries were analysed. The kinematics of the support knee were evaluated using 3D motion analysis while executing 3 common manoeuvres: two of them involved a change of direction at 90° and 180° (CD90° and CD180°), and the third while kicking a ball (GB). Physiological articular ranges of motion (ROM) were recorded and compared for the same knee in three different planes (T-Transversal; F-Frontal; S-Sagittal). Results: The physiological ranges obtained were, for manouvre CD90°: T 11°(13-8), F 5.6° (11-4) and S 22°(30-17); for CD180°: T 9°(12-8), F 6.3°(8-5) and S 17.6°(21-14); and for GB: T 9°(10-5), F 3.8°(10-2), and S 9.6°(15-6). ROM was significantly greater in the transversal plane for the CD90° manoeuvre (P<.05). In the sagittal plane, ROM was greater for the CD90° when compared to the GB (P<.05), but no differences were seen when compared to the CD180° manoeuvre (P>.05). There were no differences in ROM in the frontal plane. Conclusion: A description of the physiological kinematic ranges of the knee during three sudden changes of direction manoeuvres in amateur soccer players was presented. According to our results, change of direction in 90° demands a higher range of motion in both the transversal and sagittal planes...

Risk stratification for training in cardiac surgery.

BACKGROUND: There is a potential conflict of interest in providing the best possible outcome for patients undergoing cardiac surgery and good training for junior cardiac surgeons. METHODS: We analysed training with reference to volume of work, risk stratification and outcome for consultant and trainee procedures. The Parsonnet system was used for risk stratification. A retrospective audit was performed for a 6-year period. RESULTS: During the study period, 6037 operations were performed, of which 2166 were carried out by trainees. Direct consultant assistance in a trainee operation varied between 17% and 51% and increased towards the end of the study period. Of the operations performed by trainees, 88% were CABG. The median Parsonnet score for consultant operations was 9 compared with 4 for trainees. Actual mortality was below predicted for all surgeons. Morbidity was also lowest for trainees (10%). CONCLUSIONS: With appropriate case selection, trainees in cardiac surgery can achieve good results. As training changes in the UK, trainees should receive increased supervised exposure to a wider range of procedure to compensate for a lower volume of workload.