Mixed reality simulation for peripheral intravenous catheter placement training.

BACKGROUND: Despite the advantages of simulation-based training, trainees are typically unable to view internal anatomical structures. This limitation can be overcome by using mixed reality (MR) wherein 3-D virtual anatomical images can be projected. This study was designed to evaluate the efficacy of an MR trainer for peripheral intravenous catheter (PIVC) placement. METHODS: Sixty-two participants used projected images of arm veins to place a PIVC in a mannequin arm. Participants were evaluated using a checklist on their ability to successfully place the PIVC. Participants completed a survey to elicit demographic information and perceptions of the trainer. A follow-up survey at two-weeks assessed clinical experiences with PIVC placement since using the MR trainer. RESULTS: First attempt catheter placement was successful in 48 (77.4%) cases. Only 11 (17.7%) and 3 (4.8%) of participants caused 'extravasation' and 'hematoma' formation on their first attempt, respectively. Fifty-nine participants (95.2%) agreed that ability to see internal structures was useful, and 58 (93.5%, respectively) agreed that the interactivity promoted learning and that MR should be included in training. CONCLUSIONS: Results of this study showed that use of a novel MR trainer for PIVC placement appears to provide an environment conducive to successful learning. Most participants were successful at PIVC placement on their first attempt and an overwhelming number found it helpful in identifying landmarks and confirming correct needle angles for insertion. Given the increasing emphasis on simulation training, highly immersive MR tools appear to offer promise to close the gap between classroom instruction and clinical experience.

Assessing anesthesiology residents' out-of-the-operating-room (OOOR) emergent airway management.

BACKGROUND: At many academic institutions, anesthesiology residents are responsible for managing emergent intubations outside of the operating room (OOOR), with complications estimated to be as high as 39%. In order to create an OOOR training curriculum, we evaluated residents' familiarity with the content and correct adherence to the American Society of Anesthesiologists' Difficult Airway Algorithm (ASA DAA). METHODS: Residents completed a pre-simulation multiple-choice survey measuring their understanding and use of the DAA. Residents then managed an emergent, difficult OOOR intubation in the simulation center, where two trained reviewers assessed performance using checklists. Post-simulation, the residents completed a survey rating their behaviors during the simulation. The primary outcome was comprehension and adherence to the DAA as assessed by survey responses and behavior in the simulation. RESULTS: Sixty-three residents completed both surveys and the simulation. Post-survey responses indicated a shift toward decreased self-perceived familiarity with the DAA content compared to pre-survey responses. During the simulation, 22 (35%) residents were unsuccessful with intubation. Of these, 46% placed an LMA and 46% prepared for cricothyroidotomy. Nineteen residents did not attempt intubation. Of these, only 31% considered LMA placement, and 26% initiated cricothyroidotomy. CONCLUSIONS: Many anesthesiology residency training programs permit resident autonomy in managing emergent intubations OOOR. Residents self-reported familiarity with the content of and adherence to the DAA was higher than that observed during the simulation. Curriculum focused on comprehension of the DAA, as well as improving communication with higher-level physicians and specialists, may improve outcomes during OOORs.

Mechanical strain to maxillary incisors during direct laryngoscopy.

BACKGROUND: While most Direct laryngoscopy leads to dental injury in 25-39% of cases. Dental injury occurs when the forces and impacts applied to the teeth exceed the ability of the structures to dissipate energy and stress. The purpose of this study was to measure strain, (which is the change produced in the length of the tooth by a force applied to the tooth) strain rate, and strain-time integral to the maxillary incisors and determine if they varied by experience, type of blade, or use of an alcohol protective pad (APP). METHODS: A mannequin head designed to teach and test intubation was instrumented with eight single axis strain gauges placed on the four maxillary incisors: four on the facial or front surface of the incisors and four on the lingual or back, near the insertion of the incisor in the gums to measure bending strain as well as compression. Anesthesiology faculty, residents, and certified registered nurse anesthetists intubated with Macintosh and Miller blades with and without APP. Using strain-time curves, the maximum strain, strain rate, and strain time integral were calculated. RESULTS: Across the 92 subjects, strain varied 8-12 fold between the 25th and 75th percentiles for all four techniques, but little by experience, while strain rate and strain integral varied 6-13 fold and 15-26 fold, respectively, for the same percentiles. Intubators who had high strain values with one blade tended to have high strains with the other blade with and without the APP (all pairwise correlation rho = 0.42-0.63). CONCLUSIONS: Strain varies widely by intubator and that the use of the APP reduces strain rate which may decrease the risk of or the severity of dental injury.

A simulation workshop to introduce coping skills.

BACKGROUND: Experiencing clinical catastrophes can result in long-lasting emotional and psychological impacts. In other fields, crisis simulation has been used to train professionals in coping skills. APPROACH: Our workshop combined a simulated case with a clinical debrief and expert-led teaching on coping skills. The '4Rs' mnemonic, Recognise, Reflect, Reframe and Reach-out, describes the key elements. This is grounded in social, cognitive and behavioural theories of stress and coping. EVALUATION: All 96 anesthesiology residents from one residency programme participated, in small groups, and a mixed methods analysis was used. The scenario was deemed stressful. The workshop introduced new techniques, with 72/87 (82.75%) reporting new coping skills in use at 1-month follow-up. For many residents, the descriptive language regarding their performance and abilities shifted from critical, negative self-talk to positive and team-focused immediately following the workshop. A striking finding from evaluations at all timepoints was that negative comments were typically self-referencing whereas positive ones referenced colleague support and the team. IMPLICATIONS: Combining stress exposure with formal exploration of emotional responses and coping skills teaching in this workshop was feasible, with benefits at 1-month follow-up. This laid the groundwork for a resilience curriculum and wider departmental interest in the topic of coping and stress responses.

Sequential Behavioral Analysis: A Novel Approach to Help Understand Clinical Decision-Making Patterns in Extended Reality Simulated Scenarios.

SUMMARY STATEMENT: Extended reality (XR)-based simulation training offers unique features that facilitate collection of dynamic behavioral data and increased immersion/realism while providing opportunities for training health care professionals on critical events that are difficult to recreate in real life. Sequential analysis can be used to summarize learning behaviors by discovering hidden learning patterns in terms of common learning or clinical decision-making sequences. This project describes the use of sequential analysis to examine differential patterns of clinical decision-making behaviors in observed XR scenarios, allowing for new insights when using XR as a method to train for critical events and to trace clinical decision making.

Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study.

INTRODUCTION: Ultrasound (US) performed prior to percutaneous tracheostomy (PT) may be useful in avoiding injury to pretracheal vascular structures and in avoiding high placement of the tube. Bedside real-time US guidance with visualization of needle path is routinely utilized for other procedures such as central venous catheterization, and may enhance the safety and accuracy of PT without causing airway occlusion or hypercarbia. Our objective was to demonstrate that PT performed under real-time US guidance with visualization of needle path during tracheal puncture is feasible, including in patients with features that increase the technical difficulty of PT. METHODS: Mechanically ventilated patients with acute brain injury requiring tracheostomy underwent US guided PT. The orotracheal tube was withdrawn using direct laryngoscopy. The trachea was punctured under real-time US guidance (with visualization of the needle path) while using the acoustic shadows of the cricoid and the tracheal rings to identify the level of puncture. After guidewire passage the site and level of entry was verified using the bronchoscope, which was then withdrawn. Following dilatation and tube placement, placement in the airway was confirmed using auscultation and the "lung sliding" sign on US. Bronchoscopy and chest X-ray were then performed to identify any complications. RESULTS: Thirteen patients successfully underwent US guided PT. Three patients were morbidly obese, two were in cervical spine precautions and one had a previous tracheostomy. In all 13 patients bronchoscopy confirmed that guidewire entry was through the anterior wall and between the first and fifth tracheal rings. There was no case of tube misplacement, pneumothorax, posterior wall injury, significant bleeding or other complication during the procedure. CONCLUSIONS: Percutaneous tracheostomy performed under real-time ultrasound guidance is feasible and appears accurate and safe, including in patients with morbid obesity and cervical spine precautions. Larger studies are required to further define the safety and relative benefits of this technique. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000005023.

American Board of Anesthesiology Mock Standardized Oral Examination Faculty Development Workshop.

Introduction: Preparation for oral board examination is an important part of residency training. Anesthesiology programs provide mock oral exams for their trainees, but often, faculty have little guidance on the conduct of these exams. We describe a faculty development workshop for anesthesiology faculty to enhance their familiarity with the American Board of Anesthesiology Standardized Oral Examination (SOE). Methods: We created a faculty development workshop to administer to a live audience. The session consisted of didactic and practical components. A one-page tip sheet was also included to distribute to all faculty administering mock SOEs, for review and reference prior to administering an exam. Faculty and residents were surveyed before and after the session. Results: Eleven faculty participated in the live session. Eighty-two percent of faculty (nine of 11) committed to making a change in the way they delivered mock SOE as a result of attending the session. Fifty-eight percent of faculty (32 of 55) who responded to the postintervention survey reported that they used the tip sheet prior to administering a subsequent mock SOE. Residents described improvement in the clarity and organization of feedback following the intervention. Discussion: Faculty members play a vital role in preparing residents for board certification. It is therefore important that faculty are appropriately oriented to the goals and conduct of the mock SOE. After taking this workshop, faculty members will be more likely to adapt their examiner style to focus on the ABA-defined examinee attributes and to provide feedback after the mock SOE.

Virtual reality simulation for critical pediatric airway management training.

BACKGROUND: Pediatric airway emergencies are relatively rare, but have potentially devastating consequences. Simulation based education is important in providing zero-risk management experience for these critical events. AIMS: The aim of the study was to assess usability and feasibility of combined interactive instructional videos and a novel Virtual Reality (VR) trainer for healthcare professionals and to evaluate the impact of this combination on learners' knowledge of critical airway events in children. METHODS: The study population included medical students, residents, faculty, and advanced practice nurses. Participants completed a short baseline knowledge pre-test of pediatric airway emergency management, followed by these consecutive interventions: (1) Interactive instructional pediatric airway videos and (2) VR trainer (HoloLens technology), simulating a pediatric critical airway event. Participants were randomized to manage anaphylaxis or foreign body aspiration. Finally, participants completed a second knowledge test (post-test) and a survey of their perceptions of the videos and VR trainer. RESULTS: Forty-one participants were included in the study. Overall, both interventions were well received. Positive perceptions included realism, interactivity, and active learning environment. Negative comments focused on video speed and the VR trainer learning curve. Participants reported preferences for future training of pediatric airway events to include videos and VR trainers, with or without didactic lectures. Most areas of knowledge showed slight to significant improvements following the interventions. Specifically, questions on pediatric anatomy, anaphylaxis, Heimlich maneuver, and foreign body removal showed the highest improvement in scores (P < 0.05). CONCLUSIONS: Interactive videos, in combination with a VR experience, provide promising zero-risk training for pediatric critical airway events. RELEVANCE FOR PATIENTS: Pediatric airway emergencies are relatively rare, but the potential consequences are devastating. VR is established as a valued mode of education with regard to medical emergency training. Multimedia informational and instructional formats result in greater understanding of information. Results from our intervention, combining an interactive video tutorial and a VR experience, show this was well received by a cross section of health-care providers. We demonstrated improved test scores in a pediatric airways quiz.

Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training.

BACKGROUND: Early acquisition of critical competencies by novice anesthesiology residents is essential for patient safety, but traditional training methods may be insufficient. The purpose of this study was to determine the effectiveness of high-fidelity simulation training of novice residents in the initial management of critical intraoperative events. METHODS: Twenty-one novice residents participated in this 6-week study. Three hypoxemia and three hypotension scenarios were developed and corresponding checklists were validated. Residents were tested in all scenarios at baseline (0 weeks) and divided into two groups, using a randomized crossover study design. Group 1 received simulation-based training in hypoxemic events, whereas Group 2 was trained in hypotensive events. After intermediate (3 weeks) testing in all scenarios, the groups switched to receive training in the other critical event. Final testing occurred at 6 weeks. Raters blinded to subject identity, group assignment, and test date scored videotaped performances by using checklists. The primary outcome measure was composite scores for hypoxemia and hypotension scenarios, which were compared within and between groups. RESULTS: Baseline performance between groups was similar. At the intermediate evaluation, the mean hypoxemia score was higher in Group 1 compared with Group 2 (65.5% vs. 52.4%, 95% CI of difference 6.3-19.9, P < 0.003). Conversely, Group 2 had a higher mean hypotension score (67.4% vs. 45.5%, 95% CI of difference 14.6-29.2, P < 0.003). At Week 6, the scores between groups did not differ. CONCLUSIONS: Event-specific, simulation-based training resulted in superior performance in scenarios compared with traditional training and simulation-based training in an alternate event.

Modules for the Technical Skills Section of the OSCE Component of the American Board of Anesthesiology APPLIED Examination.

Introduction: To assess communication and professionalism, as well as technical skills related to patient care, the American Board of Anesthesiology (ABA) has begun administering an Objective Structured Clinical Examination (OSCE) portion of the APPLIED Examination in addition to the Standard Oral Examination component. Methods: We created video modules and a curriculum for anesthesiology resident OSCE preparation for the Interpretation of Monitors and Interpretation of Echocardiography components. The modules can be used individually by trainees or included as part of an OSCE workshop led by faculty educators with seven individual stations matching the content of the actual ABA examination. These modules are recommended for all levels of anesthesiology trainees so that they can gain exposure to the format and the fast pace of the examination. Results: Sixty-six junior and senior anesthesiology residents, fellows, and junior faculty successfully participated in these modules. Seventy-three percent of the participants agreed that after completing these modules, they now had a good understanding of the Interpretation of Monitors and Interpretation of Echocardiography technical skills stations. More than 90% of participants reported that the modules were useful, and more than 70% reported that they now felt prepared for these stations of the OSCE. Discussion: Developing technical skills stations for deliberate practice and preparation for the ABA OSCE is resource intensive. Finding time and faculty to facilitate OSCE preparation is also challenging. With the video modules and scripts included in this publication, residents can practice independently or as part of larger preparation course.

Pilot One-Hour Multidisciplinary Team Training Simulation Intervention in the Operating Room Improves Team Nontechnical Skills.

BACKGROUND: The primary objective of this study was to determine if a 1-hour simulation-based training with interdisciplinary operating room (OR) teams could improve nontechnical skills of the providers as assessed by the nontechnical skills tool (NOTECHS II). METHODS: Interprofessional otolaryngology OR teams consisting of surgery faculty and resident, anesthesiology faculty and resident, and OR nurses, scrub technician, and perioperative technician underwent a 1-hour simulation-based intervention in the OR. The teams were rated on their nontechnical skills during the intervention and throughout the clinical day following. They also completed self-reflection surveys (SRS) before the intervention and in 3 intervals after the intervention (immediately following the intervention, at the end of their shift on the day of the intervention, and again 2 weeks later). RESULTS: Four interprofessional teams with a total of 26 unique participants participated in this pilot program. Team nontechnical skills, assessed using NOTECHS II, improved from the first simulation to the second simulation during the intervention. Team NOTECHS II scores remained higher throughout the clinical day. Individual self-reflection scores (SRS) followed the same trend. CONCLUSIONS: On-site interprofessional OR team training simulation can take place in a brief time period that is dedicated for education. A brief intervention resulted in improved team nontechnical scores when assessed following intervention. In addition, participants found the intervention to be effective and beneficial to their learning.

An Analysis of the Top-cited Articles in Anesthesiology Education Literature.

BACKGROUND: In the same way that impact factor is calculated for journals, the number of citations an article receives can indicate its influence or value to a particular field. This study was designed to identify the most frequently cited articles in anesthesiology education to yield insight into which articles have been most useful for researchers in ongoing research and publication. METHODS: The Web of Science database was searched to capture the top-cited articles in anesthesiology education both in anesthesiology and nonanesthesiology journals. Results were sorted by the most frequently cited. The top 40 cited articles were identified. Articles were included if they (1) related to anesthesiology or included anesthesiologists as subjects and (2) were related to the education of current or future anesthesiologists. The full text was analyzed, and themes were identified. RESULTS: There was a total of 2923 citations of articles in anesthesiology journals and 924 citations of articles in nonanesthesiology journals. Thirty-two of 40 articles (80%) were research studies. Twenty-four of 40 (60%) were about teaching methods. Twenty-five of 40 (63%) focused on simulation, and 31 of 40 (78%) had residents as the subjects. Twenty-eight of 40 (70%) articles were about either case management (15) or learning procedures (13). CONCLUSIONS: This study identifies the most widely cited articles in anesthesiology education. Common themes included procedural learning, interventional research study designs, simulation, and studies involving residents as subjects. This article may be a resource to anesthesiology education researchers to identify what articles are widely cited by other researchers.

First-Person Point-of-View-Augmented Reality for Central Line Insertion Training: A Usability and Feasibility Study.

INTRODUCTION: The value of simulation in medical education and procedural skills training is well recognized. Despite this, many mannequin-based trainers are limited by the inability of the trainee to view the internal anatomical structures. This study evaluates the usability and feasibility of a first-person point-of-view-augmented reality (AR) trainer on needle insertion as a component of central venous catheter placement. METHODS: Forty subjects, including medical students and anesthesiology residents and faculty, participated. Augmented reality glasses were provided through which the relevant internal anatomical landmarks were projected. After a practice period, participants were asked to place the needle in the mannequin without the benefit of the AR-projected internal anatomy. The ability of the trainees to correctly place the needle was documented. Participants also completed a short survey describing their perceptions of the AR technology. RESULTS: Participants reported that the AR technology was realistic (77.5%) and that the ability to view the internal anatomy was helpful (92.5%). Furthermore, 85% and 82.1%, respectively, believed that the AR technology promoted learning and should be incorporated into medical training. The ability to successfully place the needle was similar between experienced and nonexperienced participants; however, less experienced participants were more likely to inadvertently puncture the carotid artery. CONCLUSIONS: Results of this pilot study demonstrated the usability and feasibility of AR technology as a potentially important adjunct to simulated medical skills training. Further development and evaluation of this innovative technology under a variety of simulated medical training settings would be an important next step.

A Survey of Simulation Utilization in Anesthesiology Residency Programs in the United States.

Given the evolution of competency-based education and evidence supporting the benefits of incorporating simulation into anesthesiology residency training, simulation will likely play an important role in the training and assessment of anesthesiology residents. Currently, there are little data available regarding the current status of simulation-based curricula across US residency programs. In this study, we assessed simulation-based training and assessment in US anesthesiology programs using a survey designed to elicit information regarding the type, frequency, and content of the simulation courses offered at the 132 Accreditation Council of Graduate Medical Education-certified anesthesiology training programs. The response rate for the survey was 66%. Although most of the responding programs offered simulation-based courses for interns and residents and during CA-1 orientation, the curriculum varied greatly among programs. Approximately 40% of responding programs use simulation for resident assessment and remediation. The majority of responding programs favored standard simulation-based training as part of residency training (89%), and the most common perceived obstacles to doing so were time, money, and human resources. The results from this survey highlight that there are currently large variations in simulation-based training and assessment among training programs. It also confirms that many program directors feel that standardizing some components of simulation-based education and assessment would be beneficial. Given the positive impact simulation has on skill retention and operating room preparedness, it may be worthwhile to consider developing a standard curriculum.

Perioperative management of alcohol withdrawal in an achondroplastic dwarf with an unstable cervical spine: a difficult management dilemma.

Patients presenting with alcohol withdrawal syndrome have an increased risk of perioperative events related to hemodynamic and respiratory instability. We present the case of a 49-year-old achondroplastic dwarf in alcohol withdrawal with cervical spinal cord injury and aortic dissection requiring emergency surgery. Due to conflicting perioperative management goals, a decision was made to delay surgery until the patient became clinically stable. Additional options might have been explored and resulted in better outcome.

Anesthesia for patients requiring advanced ventilatory support.

The critically ill patient who requires anesthesia is frequently a concern for the anesthesiologist. In addition to having potential hemodynamic lability and coagulopathy, the critically ill patient frequently experiences profound respiratory failure. The approach to the patient requiring advanced ventilatory support requires an understanding of respiratory failure, the pathophysiology causing respiratory failure and hypoxia, the physiology of mechanical ventilation and the advanced modes of ventilation available in the intensive care unit (ICU). This article discusses the basic definitions of hypoxia and common pathologic states, reviews the physiology of mechanical ventilation and advanced forms of ventilation available in the ICU, and concludes with recommendations for the management of patients with severe respiratory failure when they are taken to the operating room.