Influence of anesthesia on hemodynamic assessment of mitral stenosis severity.

BACKGROUND: The treatment of choice for severe rheumatic mitral stenosis (MS) is balloon mitral valvuloplasty (BMV). Assessment of MS severity is usually performed by echocardiography. Before performing BMV, invasive hemodynamic assessment is also performed. The effect of anesthesia on the invasive assessment of MS severity has not been studied. The purpose of the present study was to assess changes in invasive hemodynamic measurement of MS severity before and after induction of general anesthesia. METHODS: The medical files of 22 patients who underwent BMV between 2014 and 2020 were reviewed. Medical history, laboratory, echocardiographic and invasive measurements were collected. Anesthesia induction was performed with etomidate or propofol. Pre-procedural echocardiographic measurements of valve area using pressure half time, and continuity correlated well with invasive measurements using the Gorlin formula. RESULTS: After induction of anesthesia the mean mitral valve gradient dropped by 2.4 mmHg (p = 0.153) and calculated mitral valve area (MVA) increased by 0.2 cm2 (p = 0.011). A wide variability in individual response was observed. While a drop in gradient was noted in 14 patients, it increased in 7. Gorlin derived MVA rose in most patients but dropped in 4. Assuming a calculated MVA of 1.5 cm2 and below to define clinically significant MS, 4 patients with pre-induction MVA of 1.5 cm2 or below had calculated MVA above 1.5 cm2 after induction. CONCLUSIONS: The impact of general anesthesia on the hemodynamic assessment of MS is heterogeneous and may lead to misclassification of MS severity.

Evaluation of Miniature Dynamic Light Scattering Technology for the Assessment of Hemodynamic Status During Graded Hemorrhage and Retransfusion in Pigs.

BACKGROUND: Hemorrhagic shock with occult hypoperfusion is a key challenge to prehospital staff during triage and transfer of patients, especially during mass casualty incidents. Recent advances in Dynamic Light Scattering (DLS), and miniaturization of this technology, has resulted in noninvasive sensors capable of continuously monitoring tissue perfusion. This study evaluated the ability of miniature DLS (mDLS) sensors to assess hemodynamic status in a porcine model of hemorrhage. METHODS: Following ethics committee approval, anesthetized and ventilated pigs underwent graded hemorrhage and then retransfusion. Standard vital signs were monitored in conjunction with a thermodilution cardiac output (CO), central venous pressure (CVP), and arterial blood gases. The mDLS sensor was attached to each animal's leg and all monitoring measurements were taken 5 minutes after completion of each period of hemorrhage and retransfusion to allow equilibration. RESULTS: All measured parameters changed during bleeding and retransfusion. During bleeding; p value were 0.011 for heart rate, 0.07 for CVP, <0.001 for both mean arterial pressure, and mDLS. During retransfusion; p values were 0.023 for heart rate, 0.008 for CVP, and <0.001 for both mean arterial pressure and mDLS. Pearson correlation between changes in mDLS and CO demonstrated r value of 0.917 during hemorrhage and 0.965 during retransfusion. Changes in hemoglobin were not statistically significant during bleeding (p = 0.331) but were during retransfusion (p = 0.0001). Changes of bicarbonate, base excess, and lactate were found to be statistically significant during both phases of the experiment (p = 0.001). CONCLUSIONS: In an animal model of hemorrhagic shock, the mDLS sensor strongly correlates with traditional measures of CO. This initial assessment supports further investigation of this technology in human studies.

Objective Structured Clinical Examination-based assessment of regional anesthesia skills: the Israeli National Board Examination in Anesthesiology experience.

Simulation techniques are increasingly being used in anesthesia training programs and to a lesser extent in evaluation of residents. We describe 7 years of experience with Objective Structured Clinical Examination-based regional anesthesia assessment in the Israeli National Board Examinations in Anesthesiology. We believe this is the first use of such mock scenarios for the assessment of regional anesthesia for the important purpose of national accreditation. During the study period, 308 candidates were examined in 1 of 8 different blocks. The total pass rate was 83%(257 of 308), ranging from 73% to 91%. The interrater correlation for total, critical, and global scores were 0.84, 0.88, and 0.75, respectively. Technological and cost constraints preclude actual assessment of regional anesthesia. However, testing formats that more closely reflect clinical practice are potentially valuable adjuncts to traditional examinations.

The confusion assessment method--a tool for delirium detection by the acute pain service.

INTRODUCTION: Delirium is an acute fluctuating disturbance in cognitive status, linked to increased morbidity and mortality. The purpose of this pilot study was to assess the feasibility in terms of required time and yield of delirium monitoring by the Acute Pain Service (APS) using the Confusion Assessment Method for Intensive Care Unit instrument. METHODS: Patients undergoing surgery requiring more than 2 days of hospital stay were recruited. Each patient was assessed daily for 2 days after surgery using the Confusion Assessment Method for Intensive Care Unit. Patients were also assessed for orientation to person, place, and time. Any notes of confusion or delirium made by physicians or nursing staff were gathered. RESULTS: 145 patients were recruited. Each patient encounter required an average 2.3 +/- 0.3 minutes for the assessment (95% CI). The incidence of delirium within 2 days after surgery was 7.6%. Only 18% of the patients diagnosed with delirium by the APS were noted as being confused by the medical or nursing staff. CONCLUSIONS: The use of this tool required little training, and only 2 minutes per patient. It detected more patients with delirium than did the standard nursing assessments or other patient-clinician interactions. The use of this instrument by the pain service was feasible in terms of time consumption and most likely would be valuable in its yield. Early detection may help in initiating prompt treatment, eliminating known risk factors and thus reducing morbidity.

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

BACKGROUND: A patient admitted to the medical step-down unit experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. METHODS: Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop. A second round of observations took place 6 to 8 weeks following training. RESULTS: The intervention demonstrated an increase in the incidence of nurses communicating crucial information during handoffs, including patient name, events that had occurred during the previous shift, and treatment goals for the next shift. However, there was no change in the incidence of checking the monitor alarms and the mechanical ventilator. CONCLUSIONS: Simulation-based training can be incorporated into the risk management process and can contribute to patient safety practice.

A simple, low-cost platform for basic laparoscopic skills training.

Laparoscopic basic skills' training relies mainly on costly video trainers. The aim of this study was to evaluate a simple, low-cost devise for laparoscopic training. In all, 32 participants with varying levels of skill were recruited. A Simulab LapTrainer (Simulab, Seattle, Washington), using a simple plastic box, a webcam, and a Universal Serial Bus 2 card, was used together with standard operating tools. Participants performed 3 tasks (rope passing, peg transfer, and intracorporeal knot tying), which were video recorded and blindly assessed by 2 experts using error scores, checklists, and time. Statistical analysis included nonparametric tests and Cronbach alpha for inter-rater reliability. A P <.05 was deemed significant. Highly significant differences were noted between groups in all tasks and for all parameters (P = .001). Inter-rater reliability was 0.88. Simulator ratings were good: 63%, excellent: 28%, and only 9% rated it as average. The Simulab LapTrainer provides a valid alternative for skills training. Its simplicity, portability, and relatively low cost make it an attractive surgical training tool.

Training and assessment of trauma management: the role of simulation-based medical education.

Simulation-based medical education (SBME) offers a safe and "mistake-forgiving" environment to teach and train medical professionals. The diverse range of medical simulation modalities enables trainees to acquire and practice an array of tasks and skills. SBME offers the field of trauma training multiple opportunities to enhance the effectiveness of the education provided in this challenging domain. In this article, the authors describe the possible roles of simulated patients, skills trainers, computerized patient simulators, and web-based teaching in trauma training, and describe some practical aspects of using simulation for trauma training.

The use of recombinant factor VIIa (NovoSeven) for treatment of active or impending bleeding in brain injury: broadening the indications.

We report three patients with severe traumatic brain injury, both open and closed, who were treated with recombinant activated factor VII. This treatment was given in a desperate, last-ditch effort to save the life of patient 1, as a preventive or early treatment of a developing hematoma in patient 2, and as treatment of a threatening hematoma in patient 3. One of the three patients survived. During the past few years we have broadened the indications for recombinant activated factor VII and started using it as a preventive measure rather than as a "last line of defense." However, the potential complications of disseminated intravascular coagulation and thrombotic events, as well as the cost-effectiveness in view of the available evidence-based medicine, should be considered.

An assessment of a point-of-care information system for the anesthesia provider in simulated malignant hyperthermia crisis.

In this prospective, controlled study we compared the ability of anesthesia residents to diagnose and treat a simulated malignant hyperthermia (MH) scenario with and without the ability to use the On-Line Electronic Help (OLEH) information system or any other written guidelines. The OLEH is a point-of-care information system for the anesthesia provider in the operating room. The score for MH treatment after diagnosis based on clinical actions was significantly higher (P = 0.018) in the OLEH-user group (21.5 +/- 4.9) compared with a control group (15.5 +/- 7.6). This study demonstrates the possible value of a point-of-care information system in patient care; however, the significance of the results may be limited by the participants' anticipation of an acute event during training requiring the use of the OLEH.