Does prior exposure to clinical critical events influence stress reactions to simulation session in nursing students: A case-control study.

BACKGROUND: Simulation is a pedagogical method known to be a generator of stress, that could be influenced by previous stressful experiences. OBJECTIVES: The purpose of this study was to determine the impact of previous experience with a clinical critical event on the stress experienced by nursing students during simulation session of critical events, and on the stress experienced during clinical critical events subsequent to the training. DESIGN: Observational case-control study. SETTINGS: Four critical event scenarios were created using full-scale simulation. PARTICIPANTS: Two hundred and fifteen undergraduate nursing students of semester four. The control group (n = 112) consisted of learners who had not previously experienced a critical event. The prior exposure group (n = 103) consisted of learners who had experienced a critical event prior to the course. METHODS: Stress levels were assessed using the self-report stress numerical rating scale-11. RESULTS: There was no significant difference in the level of stress between the prior exposure group and the control group before, during or expected after the simulation session. A significant decrease in stress was observed in both groups from before the course to during the session (p < 0.05) and expected after the session (p < 0.05). There was no significant difference between the expected post-session stress level and the stress levels reported four months after the training (p = 0.966). At four months, there was no significant difference in stress levels between the groups (p = 0.212). CONCLUSIONS: The prior experience of a clinical critical event before a simulation course did not influence their reported stress level during the simulation session. Conversely, simulation-based training of critical situations appears to reduce the level of self-assessed stress during critical events in clinical practice after the training.

Training in intraoperative handover and display of a checklist improve communication during transfer of care: An interventional cohort study of anaesthesia residents and nurse anaesthetists.

BACKGROUND: Handovers during anaesthesia are common, and failures in communication may lead to morbidity and mortality. OBJECTIVES: We hypothesised that intraoperative handover training and display of a checklist would improve communication during anaesthesia care transition in the operating room. DESIGN: Interventional cohort study. SETTING: Single-centre tertiary care university hospital. PARTICIPANTS: A total of 204 random observations of handovers between anaesthesia providers (residents and nurse anaesthetists) over a 6-month period in 2016. INTERVENTION: Two geographically different hospital sites were studied simultaneously (same observations, but no training/checklist at the control site): first a 2-week 'baseline' observation period; then handover training and display of checklists in each operating room (at the intervention site only) followed by an 'immediate' second and finally a third (3 months later) observation period. MAIN OUTCOME MEASURES: A 22-item checklist was created by a modified DELPHI method and a checklist score calculated for each handover by adding the individual scores for each item as follows: -1, if error in communicating item; 0, unreported item; 0.5, if partly communicated item; 1, if correctly communicated item. RESULTS: Before training and display of the checklist, the scores in the interventional and the control groups were similar. There was no improvement in the control group's scores over the three observation periods. In the interventional group, the mean (95% confidence interval) score increased by 43% [baseline 7.6 (6.7 to 8.4) n = 42; 'immediate' 10.9 (9.4 to 12.4) n = 27, P < 0.001]. This improvement persisted at 3 months without an increase in the mean duration of handovers. CONCLUSION: Intraoperative handover training and display of a checklist in the operating room improved the checklist score for intraoperative transfer of care in anaesthesia.

Guidelines to the Practice of Anesthesia - Revised Edition 2016.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2016 (the guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2016 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Simulation as a new tool to establish benchmark outcome measures in obstetrics.

BACKGROUND: There are not enough clinical data from rare critical events to calculate statistics to decide if the management of actual events might be below what could reasonably be expected (i.e. was an outlier). OBJECTIVES: In this project we used simulation to describe the distribution of management times as an approach to decide if the management of a simulated obstetrical crisis scenario could be considered an outlier. DESIGN: Twelve obstetrical teams managed 4 scenarios that were previously developed. Relevant outcome variables were defined by expert consensus. The distribution of the response times from the teams who performed the respective intervention was graphically displayed and median and quartiles calculated using rank order statistics. RESULTS: Only 7 of the 12 teams performed chest compressions during the arrest following the 'cannot intubate/cannot ventilate' scenario. All other outcome measures were performed by at least 11 of the 12 teams. Calculation of medians and quartiles with 95% CI was possible for all outcomes. Confidence intervals, given the small sample size, were large. CONCLUSION: We demonstrated the use of simulation to calculate quantiles for management times of critical event. This approach could assist in deciding if a given performance could be considered normal and also point to aspects of care that seem to pose particular challenges as evidenced by a large number of teams not performing the expected maneuver. However sufficiently large sample sizes (i.e. from a national data base) will be required to calculate acceptable confidence intervals and to establish actual tolerance limits.

Guidelines to the practice of anesthesia--revised edition 2015.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2015 (the guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2015 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Assessment of brain midline shift using sonography in neurosurgical ICU patients.

INTRODUCTION: Brain midline shift (MLS) is a life-threatening condition that requires urgent diagnosis and treatment. We aimed to validate bedside assessment of MLS with Transcranial Sonography (TCS) in neurosurgical ICU patients by comparing it to CT. METHODS: In this prospective single centre study, patients who underwent a head CT were included and a concomitant TCS performed. TCS MLS was determined by measuring the difference between the distance from skull to the third ventricle on both sides, using a 2 to 4 MHz probe through the temporal window. CT MLS was measured as the difference between the ideal midline and the septum pellucidum. A significant MLS was defined on head CT as > 0.5 cm. RESULTS: A total of 52 neurosurgical ICU patients were included. The MLS (mean ± SD) was 0.32 ± 0.36 cm using TCS and 0.47 ± 0.67 cm using CT. The Pearson's correlation coefficient (r(2)) between TCS and CT scan was 0.65 (P < 0.001). The bias was 0.09 cm and the limits of agreements were 1.10 and -0.92 cm. The area under the ROC curve for detecting a significant MLS with TCS was 0.86 (95% CI = 0.74 to 0.94), and, using 0.35 cm as a cut-off, the sensitivity was 84.2%, the specificity 84.8% and the positive likelihood ratio was 5.56. CONCLUSIONS: This study suggests that TCS could detect MLS with reasonable accuracy in neurosurgical ICU patients and that it could serve as a bedside tool to facilitate early diagnosis and treatment for patients with a significant intracranial mass effect.

Predicting preload responsiveness using simultaneous recordings of inferior and superior vena cavae diameters.

INTRODUCTION: Echocardiographic indices based on respiratory variations of superior and inferior vena cavae diameters (ΔSVC and ΔIVC, respectively) have been proposed as predictors of fluid responsiveness in mechanically ventilated patients, but they have never been compared simultaneously in the same patient sample. The aim of this study was to compare the predictive value of these echocardiographic indices when concomitantly recorded in mechanically ventilated septic patients. METHODS: Septic shock patients requiring hemodynamic monitoring were prospectively enrolled over a 1-year period in a mixed medical surgical ICU of a university teaching hospital (Toulouse, France). All patients were mechanically ventilated. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax - Dmin)/Dmax for ΔSVC and (Dmax - Dmin)/Dmin for ΔIVC, where Dmax and Dmin are the maximal and minimal diameters of SVC and IVC. Measurements were performed at baseline and after a 7-ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in cardiac index ≥15%) and nonresponders (increase in cardiac index <15%). RESULTS: Among 44 included patients, 26 (59%) patients were responders (R). ΔSVC was significantly more accurate than ΔIVC in predicting fluid responsiveness. The areas under the receiver operating characteristic curves for ΔSVC and ΔIVC regarding assessment of fluid responsiveness were significantly different (0.74 (95% confidence interval (CI): 0.59 to 0.88) and 0.43 (95% CI: 0.25 to 0.61), respectively (P = 0.012)). No significant correlation between ΔSVC and ΔIVC was found (r = 0.005, P = 0.98). The best threshold values for discriminating R from NR was 29% for ΔSVC, with 54% sensitivity and 89% specificity, and 21% for ΔIVC, with 38% sensitivity and 61% specificity. CONCLUSIONS: ΔSVC was better than ΔIVC in predicting fluid responsiveness in our cohort. It is worth noting that the sensitivity and specificity values of ΔSVC and ΔIVC for predicting fluid responsiveness were lower than those reported in the literature, highlighting the limits of using these indices in a heterogeneous sample of medical and surgical septic patients.

Guidelines to the Practice of Anesthesia--Revised Edition 2014.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2014 (the guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2014 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

Technical communication: the effect of the double mask on anesthetic waste gas levels during pediatric mask inductions in dental offices.

A significant portion of office-based general anesthesia for pediatric patients is performed in dental offices and involves mask inductions with inhaled drugs. This can lead to significant pollution with waste gases. We assessed occupational exposure to anesthetic drugs during pediatric general anesthesia in dental offices and assessed the effectiveness of the "double mask." Nine freestanding dental offices had measurements of anesthetic waste gas levels taken before and immediately after implementation of a double-mask system. Levels of nitrous oxide decreased from a median of 40.0 parts per million (ppm; interquartile range [IQR] = 23.0-46.0 ppm, n = 9) to 3.0 ppm, (IQR = 2.3-4.7 ppm, n = 9, P = 0.0055) and exceeded 25 ppm in 0% of the 9 offices (upper 95% confidence limit 34%) when using the double mask. Levels of sevoflurane decreased from a median of 4.60 ppm (IQR = 3.10-7.00 ppm, n = 9) to 0 ppm (IQR = 0-0.39 ppm, n = 9, P = 0.0024) and exceeded 2 ppm in 0% of the 9 offices (upper 95% confidence limit 34%) when using the double mask. We demonstrated in our study that the double-mask system, when used with dental "high-volumes" suctions (high-volume evacuators producing approximately 12 m(3)/h) in freestanding dental offices, was sufficient to decrease the exposure to anesthetic waste gas during pediatric mask induction in at least two thirds of offices when compared with the traditional mask.

Nontechnical skills assessment after simulation-based continuing medical education.

INTRODUCTION: Human factors have been identified as root causes of human error in medicine. The "Anesthetists' Non-Technical Skills (ANTS) system" evaluates the effect of simulation training and debriefing on nontechnical skills (NTS). Studies suggest that residents' NTS may improve after simulation training but the effect on NTS of practicing anesthesiologists is unclear. The purpose of this study was to determine whether high-fidelity simulation training and debriefing improved the NTS of practicing anesthesiologists using the ANTS tool. METHODS: In a previous study, 67 practicing anesthesiologists managed a 45-minute standardized anesthetic case using high-fidelity simulation and returned 5 to 9 months later to manage a second case. After Research Ethics Board approval, two blinded video reviewers, trained in the use of the ANTS system, evaluated archived videotapes of the 59 subjects who completed both sessions. Results were analyzed with a mixed-design analysis of variance. Interrater reliability was calculated using the intraclass correlation coefficient. RESULTS: Interrater reliability for the ANTS scoring was 0.436, P < 0.05. Overall, ANTS scores improved approximately 5% from session 1 to 2 (P < 0.01), but there was no effect due to debriefing. The situational awareness ANTS category showed a statistically significant effect of debriefing (P < 0.05). CONCLUSIONS: The relatively short simulation intervention, the length of time until the posttest was completed, well-developed NTS in practicing physicians, and a tool that might not be the optimal method of measurement may all account for the lack of improvement in NTS of practicing anesthesiologists as demonstrated in this study.

Morbidity in patients with or at high risk for obstructive sleep apnea after ambulatory laparoscopic gastric banding.

Considerable controversy exists about the perioperative management of patients at high risk for obstructive sleep apnea (OSA) in free-standing clinics. Eighty-eight percent of an American Society of Anesthesiologists expert panel felt that upper abdominal laparoscopic surgery could not be performed safely on an outpatient basis. We sought to review the incidence of major adverse events after outpatient laparoscopic adjustable gastric banding (LAGB) in a high risk population for OSA at a free-standing facility. Research Ethics Board approval was obtained and charts were reviewed retrospectively for 2,370 LAGB performed at a free-standing clinic between 2005 and 2009. In this observational cohort study, patients were classified as high risk for OSA if they received continuous positive airway pressure (CPAP) treatment for OSA pre-operatively or had a history of at least three STOP-BANG criteria. Follow-up was verified and adverse events reviewed, including death, unanticipated transfer or admission to hospital within 30 days. A total of 746 of the 2,370 patients (31%) met criteria for or were at high risk for OSA (357 received CPAP for OSA and 389 by STOP-BANG criteria). The incidence of transient desaturation to less than 93% was 39.5%. There were no deaths and no cases of respiratory failure or re-intubation. The 30-day mortality was zero and the 30-day anesthesia related morbidity was less than 0.5%. For patients at high risk for OSA after LAGB, the significance of transient oxygen desaturation and the need to develop monitoring and admission standards remain to be determined.

Office-based anesthesia: how to start an office-based practice.

Ambulatory, office-based anesthesia (OBA) has experienced an exponential growth in the last decade, and is popular among patients and health care providers alike. About 17% to 24% of all elective ambulatory procedures in the United States are currently being performed in an office-based setting. Special considerations must be made when comparing OBA to a hospital setting, particularly with respect to facility and environment, administration, and accreditation. Increasing regulation will ensure that patient safety remains the primary focus. In the meantime, the anesthesia provider must take adequate steps to ensure that the quality of care in OBA is comparable to that in a hospital.

Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery.

BACKGROUND: Simulation-based training is useful in improving physicians' skills. However, no randomized controlled trials have been able to demonstrate the effects of simulation teaching in real-life patient care. This study aimed to determine whether simulation-based training or an interactive seminar resulted in better patient care during weaning from cardiopulmonary bypass (CPB)-a high stakes clinical setting. METHODS: This study was conducted as a prospective, single-blinded, randomized controlled trial. After institutional research board approval, 20 anesthesiology trainees, postgraduate year 4 or higher, inexperienced in CPB weaning, and 60 patients scheduled for elective coronary artery bypass grafting were recruited. Each trainee received a teaching syllabus for CPB weaning 1 week before attempting to wean a patient from CPB (pretest). One week later, each trainee received a 2-h training session with either high-fidelity simulation-based training or a 2-h interactive seminar. Each trainee then weaned patients from CPB within 2 weeks (posttest) and 5 weeks (retention test) from the intervention. Clinical performance was measured using the validated Anesthesiologists' Nontechnical Skills Global Rating Scale and a checklist of expected clinical actions. RESULTS: Pretest Global Rating Scale and checklist performances were similar. The simulation group scored significantly higher than the seminar group at both posttest (Global Rating Scale [mean +/- standard error]: 14.3 +/- 0.41 vs. 11.8 +/- 0.41, P < 0.001; checklist: 89.9 +/- 3.0% vs. 75.4 +/- 3.0%, P = 0.003) and retention test (Global Rating Scale: 14.1 +/- 0.41 vs. 11.7 +/- 0.41, P < 0.001; checklist: 93.2 +/- 2.4% vs. 77.0 +/- 2.4%, P < 0.001). CONCLUSION: Skills required to wean a patient from CPB can be acquired through simulation-based training. Compared with traditional interactive seminars, simulation-based training leads to improved performance in patient care by senior trainees in anesthesiology.

Office-based anesthesia.

PURPOSE: Ambulatory office-based anesthesia (OBA) is a relatively new but rapidly growing field. OBA requires a different approach than that used in the hospital, because there are unique considerations that must be recognized when administering anesthesia in a free-standing office facility. This review provides a summary of the important issues and aspects of safe patient care. METHODS: The Medline, Embase, Biological Abstract, Science Citation Index, and Healthstar databases were searched under the key words "office-based anesthesia" for relevant English language articles from 1966 to December 2008. Relevant publications were queried from governing institutions, such as the American Society of Anesthesiologists (ASA), as well as from colleges in various provinces across Canada. PRINCIPAL FINDINGS: Office-based anesthesia remains poorly regulated in many parts of Canada (and the US). Despite continuing concerns regarding patient safety, the rates of death and reported major complications for OBA appear to be very low, especially in accredited facilities. Multiple considerations for facility design, administration, and patient care need to be taken into account. CONCLUSION: Appropriately so, an increasing number of provinces (Canada) and states (US) are beginning to regulate office-based facilities and require accreditation.