Measurement of Information Transfer During Simulated Sequential Complete Shift-to-Shift Intraoperative Handoffs.

Objective: To determine information transfer during simulated shift-to-shift intraoperative anesthesia handoffs and the benefits of using a handoff tool. Patients and Methods: Anesthesiology residents and faculty participating in simulation-based education in a simulation center on April 6 and 20, 2017, and April 11 and 25, 2019. We used a fixed clinical scenario to compare information transfer in multiple sequential simulated handoff chains conducted from memory or guided by an electronic medical record generated tool. For each handoff, 25 informational elements were assessed on a discrete 0-2 scale generating a possible information retention score of 50. Time to handoff completion and number of clarifications requested by the receiver were also determined. Results: We assessed 32 handoff chains with up to 4 handoffs per chain. When both groups were combined, the mean information retention score was 31 of 50 (P<.001) for the first clinician and declined by an average of 4 points per handoff (P<.001). The handoff tool improved information retention by almost 7 points (P=.002), but did not affect the rate of information degradation (P=.38). Handoff time remained constant for the intervention group (P=.67), but declined by 2 minutes/handoff (P<.001) in the control group, which required 7 more clarifications/handoff (P=.003). In the control group, 7 of 16 (44%) handoff chains contained one or more information retention scores below the lowest score of the entire intervention group (P=.007). Conclusion: Clinical handoffs are accompanied by degradation of information that is only partially reduced by use of a handoff tool, which appears to prevent extremes of information degradation.

Resident Preparation for the American Board of Anesthesiology Objective Standardized Clinical Examination: A Comparison of Virtual Telesimulation With In-person Simulation.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) is part of the American Board of Anesthesiology (ABA) certification process. A simulated OSCE can aid examination preparation, but the COVID-19 pandemic prevented in-person simulation training. Therefore, we adapted our in-person simulated OSCE (SOSCE) as a Zoom-based telesimulation OSCE (ZOSCE), permitting examinees to participate remotely. Comparing this process with historical in-person SOSCE cohorts, we hypothesized that this telesimulation-based format would still be well received by the trainees as a substitute when it was not possible to provide in-person practice and formative assessment. Subsequently, the ABA proposed a virtual-format OSCE. METHODS: We conducted our 7-station ZOSCE according to the ABA content outline for all graduating third-year clinical anesthesia residents (CA-3) in 2020. From a main meeting room, the facilitator paired each CA-3 with a faculty proctor, assigned them to their own breakout room for each station, and rotated standardized patients in. The faculty proctor observed the CA-3's performance in real time using an assessment tool with objectives graded on a 0-2 scale. At the conclusion of the ZOSCE, proctors reviewed the assessment tool with the CA-3 and provided personalized global feedback. Assessment tool scores were used to calculate performance data for the study group that were compared with a SOSCE historical cohort from 2017 and 2018. All parties completed a Likert-style evaluation specific to the ZOSCE. RESULTS: A total of 22 CA-3 residents participated. Mean performance scores ranged from 82.2%-94.9% (minimum = 38%, maximum = 100%). Compared with the historical SOSCE cohort, ZOSCE scores for 5 of 7 stations were not different, but scores in communication with professionals (P = .007) and ultrasound (P < .001) stations were lower. Overall, CA-3 participants rated the learning experience positively and felt it was a reasonable substitution for in-person simulation, with responses similar to those of a historical in-person SOSCE cohort. CONCLUSIONS: A telesimulation-based practice ZOSCE for formative examination preparation for the ABA OSCE resulted in similar institutional scoring for most stations compared with in-person SOSCE, but some stations may be better practiced in person or require modifications. The virtual format may permit flexible scheduling during nonclinical times or for learners in remote locations. These findings have implications for future formative exercises and the formal summative examination process.

Novel intraoperative online functional mapping of somatosensory finger representations for targeted stimulating electrode placement: technical note.

Defining eloquent cortex intraoperatively, traditionally performed by neurosurgeons to preserve patient function, can now help target electrode implantation for restoring function. Brain-machine interfaces (BMIs) have the potential to restore upper-limb motor control to paralyzed patients but require accurate placement of recording and stimulating electrodes to enable functional control of a prosthetic limb. Beyond motor decoding from recording arrays, precise placement of stimulating electrodes in cortical areas associated with finger and fingertip sensations allows for the delivery of sensory feedback that could improve dexterous control of prosthetic hands. In this study, the authors demonstrated the use of a novel intraoperative online functional mapping (OFM) technique with high-density electrocorticography to localize finger representations in human primary somatosensory cortex. In conjunction with traditional pre- and intraoperative targeting approaches, this technique enabled accurate implantation of stimulating microelectrodes, which was confirmed by postimplantation intracortical stimulation of finger and fingertip sensations. This work demonstrates the utility of intraoperative OFM and will inform future studies of closed-loop BMIs in humans.

Examining novice anaesthesia trainee simulation performance: a tale of two clusters.

Introduction: Understanding performance differences between learners may provide useful context for optimising medical education. This pilot study aimed to explore a technique to contextualise performance differences through retrospective secondary analyses of two randomised controlled simulation studies. One study focused on speaking up (non-technical skill); the other focused on oxygen desaturation management (technical skill). Methods: We retrospectively analysed data from two independent simulation studies conducted in 2017 and 2018. We used multivariate hierarchical cluster analysis to explore whether participants in each study formed homogenous performance clusters. We then used mixed-design analyses of variance and χ2 analyses to examine whether reported task load differences or demographic variables were associated with cluster membership. Results: In both instances, a two-cluster solution emerged; one cluster represented trainees exhibiting higher performance relative to peers in the second cluster. Cluster membership was independent of experimental allocation in each of the original studies. There were no discernible demographic differences between cluster members. Performance differences between clusters persisted for at least 8 months for the non-technical skill but quickly disappeared following simulation training for the technical skill. High performers in speaking up initially reported lower task load than standard performers, a difference that disappeared over time. There was no association between performance and task load during desaturation management. Conclusion: This pilot study suggests that cluster analysis can be used to objectively identify high-performing trainees for both a technical and a non-technical skill as observed in a simulated clinical setting. Non-technical skills may be more difficult to teach and retain than purely technical ones, and there may be an association between task load and initial non-technical performance. Further study is needed to understand what factors may confer inherent performance advantages, whether these advantages translate to clinical performance and how curricula can best be designed to drive targeted improvement for individual trainees.

Evaluation of 3 Cognitive Load Measures During Repeated Simulation Exercises for Novice Anesthesiology Residents.

INTRODUCTION: Maintaining an appropriate level of cognitive load during simulations is crucial to optimize learning. We evaluated 3 subjective measures of cognitive load in a simulated operating room (OR) context across multiple scenarios of varying complexity. METHODS: This observational study of 25 first-year anesthesiology residents took place during a 5-day simulation "Boot Camp." Each day, participants completed 2 different high-fidelity scenarios in a fully equipped simulated OR. After each simulation, participants completed 3 cognitive load measures: the Paas scale, NASA Task Load Index (TLX), and Cognitive Load Component (CLC) questionnaire. Two-way repeated-measures and mixed-design analyses of variance, with the cognitive load measures and scenarios as independent factors, were used to determine the effect of using different measures to report cognitive load. RESULTS: Cognitive load scores reported by all measures correlated significantly with one another (P < 0.01): TLX and Paas (r = 0.65); Paas and CLC (r = 0.63); and TLX and CLC (r = 0.61). The CLC subscale scores (intrinsic, extraneous, germane) also correlated significantly with composite TLX and Paas scores (P < 0.01). Scenarios and measures displayed significant interaction: F(10, 210) = 3.01, P = 0.001. Participants reported highest overall cognitive load using the Paas scale. CONCLUSIONS: All cognitive load measures were sensitive to scenario variability and showed similar fluctuation patterns across the 10 scenarios. The findings suggest that cognitive load measures can help create benchmarks based on learner perceptions of cognitive burden for different simulation scenarios.

The sim must go on: adapting resident education to the COVID-19 pandemic using telesimulation.

The COVID-19 pandemic and social distancing rules necessitated the suspension of all in-person learning activities at our institution. Consequently, distance learning became essential. We adapted a high-fidelity immersive case-based simulation scenario for telesimulation by using the virtual meeting platform Zoom® to meet our curricular needs. The use of telesimulation to teach a complex case-based scenario is novel. Two cohorts of anesthesiology residents participated 2 weeks apart. All learners were located at home. Four faculty members conducted the telesimulation from different locations within our simulation center in the roles of director, simulation operator, confederate anesthesiologist, and confederate surgeon. The anesthesiologist performed tasks as directed by learners. The scenario was divided into four scenes to permit reflection on interventions/actions by the participants based on the clinical events as the scenario progressed, to facilitate intermittent debriefing and learner engagement. All residents were given a medical knowledge pretest before the telesimulation and a posttest and learner satisfaction survey at the conclusion. The scenario was authentic and immersive, represented an actual case, and provided the opportunity to practice lessons that could be applied in the clinical setting. Participants rated telesimulation a reasonable substitution for in-person learning and expressed gratitude for continuation of their simulation-based education in this format during the pandemic. Participants in the second cohort reported feeling more engaged (p = 0.008) and stimulated to think critically (p = 0.003). Audio quality was the most frequently noted limitation. Fifty-three residents completed both pre- and posttests. The two cohorts did not differ in knowledge pretest scores (62% vs 60%, p = 0.80) or posttest scores (78% vs. 77%, p = 0.87). Overall, knowledge scores improved with the telesimulation intervention (pretest mean = 61% [SD = 14%]; posttest mean = 78% [SD = 12%]; t (41) = - 7.89, p < 0.001). Thus, using a Zoom format, we demonstrated the feasibility of adapting a complex case for telesimulation and effective knowledge gain. Furthermore, we improved our process in real time based on participant feedback. Participants were satisfied with their learning experience, suggesting that this format may be used in other distance learning situations.

Factors that influence flow through intravascular catheters: the clinical relevance of Poiseuille's law.

BACKGROUND: The physics of ideal fluid flow is well characterized. However, the effect of catheter size, tubing types, injection port adjuncts, and viscosity on flow is not well described. We used a simulated environment to determine how various permutations of common elements affect fluid flow. STUDY DESIGN AND METHODS: We tested 16 peripheral and central venous catheters to assess flow through several standard infusion sets and a rapid infuser set; tested flow through standard and blood infusion sets with the addition of intravenous extension tubing, stopcocks, and a needleless connector; and compared the relative viscosity of commonly used blood products and colloids to that of normal saline. RESULTS: The maximal flow rate was 200 mL/min for the standard infusion set but 800 mL/min for the rapid infusion set. Choice of infusion tubing was the rate-limiting component for many larger catheters. A 14-gauge, single-lumen central venous catheter (CVC) and 18-gauge peripheral intravenous catheter (PIV) had equivalent flow rates with all infusion sets. A 16-gauge single-lumen CVC allowed a flow rate that was slower than that of a 20-gauge PIV, and faster than that of a 22-gauge PIV. The addition of adjuncts slowed flow rate. Needleless connectors had the greatest impact, reducing flow by 75% for the blood infusion set. Packed red blood cells had a viscosity 4.5 times that of normal saline and thereby reduced flow. CONCLUSION: Catheter and tubing choice, adjuncts, and fluid viscosity influence flow rates. Our results will help inform adequate vascular access planning in the perioperative environment.

Anesthesia Simulation Boot Camp-a Decade of Experience Enhancing Self-efficacy in First-year Residents.

BACKGROUND: Novice anesthesiology residents must acquire new technical, cognitive, and behavioral skills as they transition into the high-stakes perioperative environment. Simulation-based education improves procedural skill and behavior, and it permits deliberate practice with feedback; exposure to uncommon, high-consequence events; assessment; reproducibility; and zero risk to patients. We introduced a 5-day, high-fidelity Simulation Boot Camp (SBC) in 2006 for first-year clinical anesthesia residents (CA-1s) and report over a decade of experience assessing its impact on self-efficacy, value, feasibility, and sustainability. METHODS: All CA-1s in our residency program participated in the SBC as part of orientation. Participants completed 2 individual high-fidelity simulations per day, each with a private debriefing session from an attending anesthesiologist in our simulation center. We measured their self-reported confidence, which we report as self-efficacy (SE), the belief in one's own ability to successfully execute a skill or behavior necessary for a desired outcome, for 25 basic anesthesia skills before and after course completion. Participants also completed a postcourse evaluation. RESULTS: Of the 281 CA-1s who participated in the course from 2006 to 2016, we collected data on 267 (95%). SE improved over the course of SBC for all 25 individual skills (P < .001) and remained stable over the decade-long period of study. Univariate analysis revealed a strong association between increased SE and male sex (P < .001), video gaming experience (P < .001), and completion of a prior residency (P = .018). Males were also more likely to report video gaming experience (P < .001). Multivariable analysis revealed that although women had lower SE than did men, they had a greater increase in SE attributed to participation in SBC (P = .041). Participants strongly agreed SBC was a realistic and nonjudgmental learning tool, built confidence, and should be mandatory. Most comments were positive, reflecting overall satisfaction with SBC. CONCLUSIONS: SBC increases SE, is feasible, valuable to participants, and sustainable with remarkably consistency over the study period.

Training novice anaesthesiology trainees to speak up for patient safety.

BACKGROUND: Effectively communicating patient safety concerns in the operating theatre is crucial, but novice trainees often struggle to develop effective speaking up behaviour. Our primary objective was to test whether repeated simulation-based practice helps trainees speak up about patient management concerns. We also tested the effect of an additional didactic intervention over standard simulation education. METHODS: This prospective observational study with a nested double-blind, randomised controlled component took place during a week-long simulation boot camp. Participants were randomised to receive simulation education (SE), or simulation education plus a didactic session on speaking up behaviour (SE+). Outcome measures were: changes in intrapersonal factors for speaking up (self-efficacy, social outcome expectations, and assertiveness), and speaking up performance during four simulated scenarios. Participants self-reported intrapersonal factors and blinded observers scored speaking up behaviour. Cognitive burden for each simulation was also measured using the National Aeronautics and Space Administration Task Load Index. Mixed-design analysis of variance was used to analyse scores. RESULTS: Twenty-two participants (11 per group) were included. There was no significant interaction between group and time for any outcome measure. There was a main effect for time for self-efficacy (P<0.001); for social outcome expectations (P<0.001); for assertive attitude (P=0.003); and for speaking up scores (P=0.001). The SE+ group's assertive attitude scores increased at follow-up whereas the SE group reverted to near baseline scores (P=0.025). CONCLUSIONS: In novice anaesthesia trainees, intrapersonal factors and communication performance benefit from repeated simulation training. Focused teaching may help trainees develop assertive behaviours.

Autonomic impairment of patients in coma with different Glasgow coma score assessed with heart rate variability.

PRIMARY OBJECTIVE: The objective of this study is to assess the functional state of the autonomic nervous system in healthy individuals and in individuals in coma using measures of heart rate variability (HRV) and to evaluate its efficiency in predicting mortality. DESIGN AND METHODS: Retrospective group comparison study of patients in coma classified into two subgroups, according to their Glasgow coma score, with a healthy control group. HRV indices were calculated from 7 min of artefact-free electrocardiograms using the Hilbert-Huang method in the spectral range 0.02-0.6 Hz. A special procedure was applied to avoid confounding factors. Stepwise multiple regression logistic analysis (SMLRA) and ROC analysis evaluated predictions. RESULTS: Progressive reduction of HRV was confirmed and was associated with deepening of coma and a mortality score model that included three spectral HRV indices of absolute power values of very low, low and very high frequency bands (0.4-0.6 Hz). The SMLRA model showed sensitivity of 95.65%, specificity of 95.83%, positive predictive value of 95.65%, and overall efficiency of 95.74%. CONCLUSIONS: HRV is a reliable method to assess the integrity of the neural control of the caudal brainstem centres on the hearts of patients in coma and to predict patient mortality.

Efficacy and Cost Comparison of Case-based Learning to Simulation-based Learning for Teaching Malignant Hyperthermia Concepts to Anesthesiology Residents.

BACKGROUND: Case-based learning (CBL) is a distinct classroom-based teaching format. We compare learning and retention using a CBL teaching strategy vs simulation-based learning (SBL) on the topic of malignant hyperthermia. METHODS: In this study, 54 anesthesia residents were assigned to either a CBL or SBL experience. All residents had prior simulation experience, and both groups received a pretest and a lecture on rare diseases with emphasis on malignant hyperthermia followed by a CBL or SBL session. Test questions were validated for face and construct validity. Postsession testing occurred on the same day and at 4 months. RESULTS: Twenty-seven residents completed all components of the study. The CBL group had 10 residents, and the SBL group had 17 residents. Most residents (80%) had previous exposure to malignant hyperthermia education. ANOVA for repeated measures demonstrated superior learning and long-term retention in the CBL group. In addition, our cost analysis reveals the cost of SBL to be approximately 17 times more expensive per learner than CBL. CONCLUSIONS: We found that CBL promoted learning and long-term retention for the topic of malignant hyperthermia and it is a more affordable teaching method. Affordability and effectiveness evidence may guide some programs toward CBL, particularly if access to simulation is limited. The number of participants and full validation of the examination questions are limitations of the study. Further studies are required to validate the findings of this study.

Development of a Simulated Objective Structured Clinical Exam for the APPLIED Certification Exam in Anesthesiology: A Two-Year Experience Informed by Feedback from Exam Candidates.

BACKGROUND: Program directors of anesthesiology residencies agree that it is the program's responsibility to prepare residents for primary American Board of Anesthesiology (ABA) certification, although few report an Objective Standardized Clinical Exam (OSCE) program reflective of the new ABA examination. We created an authentic simulated OSCE (SOSCE) using existing resources to prepare third-year clinical anesthesia residents for the ABA APPLIED exam before graduation and identify knowledge gaps relevant to the OSCE. METHODS: Junior anesthesiology residents and medical students acted as standardized patients for the 7 SOSCE stations. Third-year clinical anesthesia residents were evaluated on performance by faculty educators during the SOSCE and completed surveys regarding their experience. Follow-up surveys were distributed to participants after they completed the ABA APPLIED Exam. RESULTS: Mean scores ranged from 82.6% correct (echocardiogram) to 97.2% correct (ultrasonography). Knowledge gaps were present in competencies explicitly stated as objectives by the ABA. Echocardiography scores improved from 76.1% in the first year to 90.0% in the second year (P = .009). Participants found the SOSCE to be valuable in preparing for the OSCE and the standardized patients' performance to be convincing. Participants felt better prepared for the ABA exam and thought that the SOSCE was authentic in content and process. CONCLUSIONS: An SOSCE program can be developed with preexisting resources. This program was highly rated as useful and informative, an accurate reflection of the ABA OSCE, and helpful in preparation for the examination. Development of a SOSCE program is feasible, sustainable, and valuable.

Use of intraosseous hypertonic saline in critically ill patients.

BACKGROUND: Rapid administration of hypertonic saline 23.4% is crucial in treatment of herniation syndromes. Hypertonic 23.4% saline must be administered via a central line. In cases where central line access is difficult to obtain and leads to delay in therapy, placement of intraosseous access can be lifesaving. MAIN BODY: The purpose of this case series is to describe the use of intraosseous administration of 23.4% saline in critically ill patients and to assess feasibility. CONCLUSION: Intraosseous administration of 23.4% saline in 6 adult patients with neurological emergencies was feasible and should be considered in cases where obtaining intravenous access is time consuming.

Influence of Heart Rate, Age, and Gender on Heart Rate Variability in Adolescents and Young Adults.

Key autonomic functions are in continuous development during adolescence which can be assessed using the heart rate variability (HRV). However, the influence of different demographic and physiological factors on HRV indices has not been fully explored in adolescents. In this study we aimed to assess the effect of age, gender, and heart rate on HRV indices in two age groups of healthy adolescents (age ranges, 13-16 and 17-20 years) and two groups of healthy young adults (21-24 and 25-30 years). We addressed the issue using 5-min ECG recordings performed in the sitting position in 255 male and female participants. Time, frequency, and informational domains of HRV were calculated. Changes in HRV indices were assessed using a multiple linear regression model to adjust for the effects of heart rate, age, and gender. We found that heart rate produced more significant effects on HRV indices than age or gender. There was a progressive reduction in HRV with increasing age. Sympathetic influence increased with age and parasympathetic influence progressively decreased with age. The influence of gender was manifest only in younger adolescents and young adults. In conclusion, age, gender, and particularly heart rate have a substantial influence on HRV indices, which ought to be considered to avoid biases in the study of the autonomic nervous system development. The lack of the gender-related effects on HRV indices in late adolescence could be related to non-completely achieved maturity of the autonomic mechanisms, which deserves further exploration.

Multidisciplinary Difficult Airway Course: An Essential Educational Component of a Hospital-Wide Difficult Airway Response Program.

OBJECTIVE: A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). DESIGN: The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores. SETTING: Tertiary care academic hospital center PARTICIPANTS: Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists. RESULTS: Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p < 0.001. CONCLUSIONS: Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable improvement in prepost course knowledge assessment and overwhelmingly positive course evaluations (quantitative and qualitative) suggest a critical and ongoing role for the MDAC course.

Very High Frequency Oscillations of Heart Rate Variability in Healthy Humans and in Patients with Cardiovascular Autonomic Neuropathy.

Literature reports on the very high frequency (VHF) range of 0.4-0.9 Hz in heart rate variability (HRV) are scanty. The VHF presence in cardiac transplant patients and other conditions associated with reduced vagal influence on the heart encouraged us to explore this spectral band in healthy subjects and in patients diagnosed with cardiac autonomic neuropathy (CAN), and to assess the potential clinical value of some VHF indices. The study included 80 healthy controls and 48 patients with spinocerebellar ataxia type 2 (SCA2) with CAN. The electrocardiographic recordings of short 5-min duration were submitted to three different spectral analysis methods, including the most generally accepted procedure, and the two novel methods using the Hilbert-Huang transform. We demonstrated the presence of VHF activity in both groups of subjects. However, VHF power spectral density, expressed in relative normalized units, was significantly greater in the SCA2 patients than that in healthy subjects, amounting to 36.1 ± 17.4% vs. 22.9 ± 14.1%, respectively, as also was the instantaneous VHF spectral frequency, 0.58 ± 0.05 vs. 0.64 ± 0.07 Hz, respectively. These findings were related to the severity of CAN. We conclude that VHF activity of HRV is integral to the cardiovascular autonomic control.

Predicting the need for nonstandard tracheostomy tubes in critically ill patients.

PURPOSE: Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. Although nonstandard tubes can be placed over the percutaneous kit dilator, clinicians often place standard tracheostomy tubes and change to nonstandard tubes only after problems arise. This practice risks early tracheostomy tube change, possible bleeding, or loss of the airway. We sought to identify predictors of nonstandard tracheostomy tubes. MATERIALS AND METHODS: In this matched case-control study at an urban, academic, tertiary care medical center, we reviewed 1220 records of patients who received a tracheostomy. Seventy-seven patients received nonstandard tracheostomy tubes (cases), and 154 received standard tracheostomy tubes (controls). RESULTS: Sex, endotracheal tube size, severity of illness, and computed tomography scan measurement of the distance from the trachea to the skin at the level of the superior aspect of the anterior clavicle were significant predictors of nonstandard tracheostomy tubes. Specifically, trachea-to-skin distance >4.4 cm and endotracheal tube sizes ≥8.0 were associated with nonstandard tracheostomy. CONCLUSIONS: The findings suggest that clinicians should consider using nonstandard tracheostomy tubes as the first choice if the patient is male with an endotracheal tube size ≥8.0 and has a trachea-to-skin distance >4.4 cm on the computed tomography scan.

Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

BACKGROUND: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Residual vasomotor activity assessed by heart rate variability in a brain-dead case.

A patient assessed by heart rate variability (HRV) methodology, beginning just after the completion of brain death (BD) diagnosis, showed remaining very low frequency (VLF) waves for approximately 10 min. A time-varying spectral analysis showed that during the first 550 s, a significant power spectral density remained in the high-frequency (HF), low-frequency (LF) and VLF bands. From 550 to 675 s, the HF oscillations totally vanished, and a marked progressive decay of the LF and VLF power density occurred. After 700 s the VLF undulations stopped and remaining small amplitude oscillations at 0.2 Hz coincided with the ventilator frequency. The VLF oscillations recorded in our case might be related to residual sympathetic vasomotor activity that progressively disappeared due to the extension of necrosis affecting the nervous centres of the lower part of the medulla and the first 2-3 cervical spine segments.