The feasibility and usability of mixed reality teaching in a hospital setting based on self-reported perceptions of medical students.

BACKGROUND: Clinical teaching during encounters with real patients lies at the heart of medical education. Mixed reality (MR) using a Microsoft HoloLens 2 (HL2) offers the potential to address several challenges: including enabling remote learning; decreasing infection control risks; facilitating greater access to medical specialties; and enhancing learning by vertical integration of basic principles to clinical application. We aimed to assess the feasibility and usability of MR using the HL2 for teaching in a busy, tertiary referral university hospital. METHODS: This prospective observational study examined the use of the HL2 to facilitate a live two-way broadcast of a clinician-patient encounter, to remotely situated third and fourth year medical students. System Usability Scale (SUS) Scores were elicited from participating medical students, clinician, and technician. Feedback was also elicited from participating patients. A modified Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions Questionnaire (mETELM) was completed by medical students and patients. RESULTS: This was a mixed methods prospective, observational study, undertaken in the Day of Surgery Assessment Unit. Forty-seven medical students participated. The mean SUS score for medical students was 71.4 (SD 15.4), clinician (SUS = 75) and technician (SUS = 70) indicating good usability. The mETELM Questionnaire using a 7-point Likert Scale demonstrated MR was perceived to be more beneficial than a PowerPoint presentation (Median = 7, Range 6-7). Opinion amongst the student cohort was divided as to whether the MR tutorial was as beneficial for learning as a live patient encounter would have been (Median = 5, Range 3-6). Students were positive about the prospect of incorporating of MR in future tutorials (Median = 7, Range 5-7). The patients' mETELM results indicate the HL2 did not affect communication with the clinician (Median = 7, Range 7-7). The MR tutorial was preferred to a format based on small group teaching at the bedside (Median = 6, Range 4-7). CONCLUSIONS: Our study findings indicate that MR teaching using the HL2 demonstrates good usability characteristics for providing education to medical students at least in a clinical setting and under conditions similar to those of our study. Also, it is feasible to deliver to remotely located students, although certain practical constraints apply including Wi-Fi and audio quality.

Delivering clinical tutorials to medical students using the Microsoft HoloLens 2: A mixed-methods evaluation.

BACKGROUND: Mixed reality offers potential educational advantages in the delivery of clinical teaching. Holographic artefacts can be rendered within a shared learning environment using devices such as the Microsoft HoloLens 2. In addition to facilitating remote access to clinical events, mixed reality may provide a means of sharing mental models, including the vertical and horizontal integration of curricular elements at the bedside. This study aimed to evaluate the feasibility of delivering clinical tutorials using the Microsoft HoloLens 2 and the learning efficacy achieved. METHODS: Following receipt of institutional ethical approval, tutorials on preoperative anaesthetic history taking and upper airway examination were facilitated by a tutor who wore the HoloLens device. The tutor interacted face to face with a patient and two-way audio-visual interaction was facilitated using the HoloLens 2 and Microsoft Teams with groups of students who were located in a separate tutorial room. Holographic functions were employed by the tutor. The tutor completed the System Usability Scale, the tutor, technical facilitator, patients, and students provided quantitative and qualitative feedback, and three students participated in semi-structured feedback interviews. Students completed pre- and post-tutorial, and end-of-year examinations on the tutorial topics. RESULTS: Twelve patients and 78 students participated across 12 separate tutorials. Five students did not complete the examinations and were excluded from efficacy calculations. Student feedback contained 90 positive comments, including the technology's ability to broadcast the tutor's point-of-vision, and 62 negative comments, where students noted issues with the audio-visual quality, and concerns that the tutorial was not as beneficial as traditional in-person clinical tutorials. The technology and tutorial structure were viewed favourably by the tutor, facilitator and patients. Significant improvement was observed between students' pre- and post-tutorial MCQ scores (mean 59.2% Vs 84.7%, p < 0.001). CONCLUSIONS: This study demonstrates the feasibility of using the HoloLens 2 to facilitate remote bedside tutorials which incorporate holographic learning artefacts. Students' examination performance supports substantial learning of the tutorial topics. The tutorial structure was agreeable to students, patients and tutor. Our results support the feasibility of offering effective clinical teaching and learning opportunities using the HoloLens 2. However, the technical limitations and costs of the device are significant, and further research is required to assess the effectiveness of this tutorial format against in-person tutorials before wider roll out of this technology can be recommended as a result of this study.

Ultrasound guided interscalene brachial plexus block.

Peripheral nerve blocks have long been established as a crucial part of the enhanced recovery pathways after surgery. Interscalene brachial plexus block (ISB) is mainly indicated for anaesthesia and analgesia during shoulder and proximal arm surgery. Ultrasound technology has remarkably improved the efficacy and success rates of the ISB while limiting its potential complications.

Ultrasound guided sciatic nerve blockade - subgluteal and popliteal approaches.

Sciatic nerve blocks are commonly performed regional anaesthetic blocks used for lower limb surgery. The two most common sciatic nerve blocks are briefly reviewed in this article, with particular reference to ultrasound guidance.

Ultrasound guided Interpectoral, Pectoserratus and Serratus anterior plane blocks.

Interpectoral, Pectoserratus and Serratus anterior plane blocks are relatively recent fascial plane blocks performed with ultrasound guidance to provide analgesia of the anterior thoracic wall. They have been mainly used in breast surgery and are both safe and easy to perform. This review will focus on the technique of ultrasound guided Interpectoral, Pectoserratus and Serratus anterior plane blocks.

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Accuracy of ultrasonography predicting spread location following intraneural and subparaneural injections: a scoping review.

INTRODUCTION: Ultrasonography is useful for detecting intraneural injections. However, the reliability of the sonographic findings of intraneural and subparaneural injections in terms of true spread location and their association with intrafascicular deposits has not been systematically evaluated. EVIDENCE ACQUISITION: Our objectives were: 1) to explore the reliability of sonographic findings of intraneural and subparaneural injections when validated with tests of true spread such as histology, dissection, or imaging; and 2) to evaluate their association with intrafascicular deposits. A scoping review was conducted according to Joanna Briggs guidelines. Cinahl, PubMed, ProQuest, ScienceDirect, Scopus and Cochrane databases were searched for studies on adults, cadavers, and animal models. Pediatric studies were excluded. EVIDENCE SYNTHESIS: The search strategy found 598 citations. Following screening, 19 studies were selected. Intraneural injections occurred in the brachial plexus, sciatic, femoral, and median nerves. Subparaneural injections in popliteal, supraclavicular and interscalene blocks. Sixteen different ultrasound findings were used to label injection location. Subepineural deposits within individual nerves occurred occasionally following subparaneural injections, regardless of nerve expansion. Overall, five studies reported intrafascicular deposits, two of which frequently, following intraneural and subparaneural injections. None of the currently used ultrasound findings was predictive of intrafascicular deposits. CONCLUSIONS: Our results suggest that sonographic parameters of intraneural and subparaneural injections are reliable in terms of detecting spread location. Intrafascicular injectate deposition may occur, albeit infrequently, particularly in the proximal brachial plexus. Our findings support the judicious interrogation of sonographic parameters suggestive of incipient intraneural injection.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies.

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Effects of local anaesthetic dilution on the characteristics of ultrasound guided axillary brachial plexus block: a randomised controlled study.

AIMS: Ultrasound guidance has led to marked improvement in the success rate and characteristics of peripheral nerve blocks. However, effects of varying the volume or concentration of a fixed local anaesthetic dose on nerve block remains unclear. The purpose of our study was to evaluate whether at a fixed dose of lidocaine, altering the volume and concentration will have any effect on the onset time of ultrasound-guided axillary brachial plexus block. MATERIAL AND METHODS: Twenty patients were randomised to receive an ultrasound-guided axillary brachial plexus block with either lidocaine 2% with epinephrine (20 ml, Group 2%) or lidocaine 1% with epinephrine (40 ml, Group 1%). The primary endpoint was block onset time. Secondary outcomes included duration of the block, performance time, number of needle passes, incidence of paraesthesia and vascular puncture. RESULTS: The median [IQR] onset time of surgical anaesthesia was shorter in Group 1% when compared to Group 2% (6.25 [5-7.5] min vs 8.75 [7.5-10] min; p=0.03). The mean (SD) overall duration of surgical anaesthesia was significantly shorter in Group 1% compared to Group 2% (150.9±17.2 min vs 165.1±5.9 min; p=0.02). Group 1% had a shorter performance time with fewer needle passes. The incidence of vascular puncture and paraesthesia was similar in the two groups. CONCLUSION:  Ultrasound-guided axillary brachial plexus blocks performed using a higher volume of lower concentration lidocaine was associated with shorter onset time and duration of surgical anaesthesia.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures.

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Effects of Clonidine as an Adjuvant to Lidocaine with Epinephrine in Ultrasound Guided Axillary Brachial Plexus Block: A Randomised Controlled Trial.

This study evaluated the effects of adding adjuvant clonidine to lidocaine with epinephrine on the characteristics of ultrasound-guided axillary brachial plexus block (ABPB) for upper extremity surgery. Twenty-four patients were randomised to receive an ultrasound guided ABPB with 20 mL of lidocaine 2% with 1:200,000 epinephrine plus 2 mL of either normal saline 0.9% (Group 1) or a mixture of clonidine 1 µg/kg and normal saline 0.9% (Group 2). The outcome measures that were recorded were the overall onset time and the duration of sensory and motor block. The median (IQR) overall onset time of sensory and motor block was significantly shorter in Group 2 vs. Group 1 (5 (5-7.5) min vs. 10 (8.8-12.5) min; p < 0.001) and (5 (2.5-7.5) min vs. 7.5 (6.3-7.5) min; p = 0.001), respectively. The median (IQR) overall duration of sensory and motor block was significantly longer in Group 2 vs. Group 1 (225 (200-231) min vs. 168 (148-190) min; p < 0.001) and (225 (208-231) min vs. 168(148-186) min; p < 0.001), respectively. In ultrasound-guided ABPB, the addition of clonidine to lidocaine with epinephrine resulted in shorter onset time and prolonged duration of sensory and motor block.

Pain after upper limb surgery under peripheral nerve block is associated with gut microbiome composition and diversity.

Gut microbiota play a role in certain pain states. Hence, these microbiota also influence somatic pain. We aimed to determine if there was an association between gut microbiota (composition and diversity) and postoperative pain. Patients (n = 20) undergoing surgical fixation of distal radius fracture under axillary brachial plexus block were studied. Gut microbiota diversity and abundance were analysed for association with: (i) a verbal pain rating scale of < 4/10 throughout the first 24 h after surgery (ii) a level of pain deemed "acceptable" by the patient during the first 24 h following surgery (iii) a maximum self-reported pain score during the first 24 h postoperatively and (iv) analgesic consumption during the first postoperative week. Analgesic consumption was inversely correlated with the Shannon index of alpha diversity. There were also significant differences, at the genus level (including Lachnospira), with respect to pain being "not acceptable" at 24 h postoperatively. Porphyromonas was more abundant in the group reporting an acceptable pain level at 24 h. An inverse correlation was noted between abundance of Collinsella and maximum self-reported pain score with movement. We have demonstrated for the first time that postoperative pain is associated with gut microbiota composition and diversity. Further work on the relationship between the gut microbiome and somatic pain may offer new therapeutic targets.

Clinician Monitoring.

Since the first public demonstration of general anesthesia in 1846, anesthesiology has seen major advancements as a specialty. These include both important technological improvements and the development and implementation of internationally accepted patient safety standards. Together, these ultimately resulted in the recognition of anesthesiology as the leading medical specialty advocating for patient safety. Modern-day anesthesiology faces a new challenge of automated anesthesia delivery. Despite evidence for a more refined and precise delivery of anesthesia through this platform, there is currently no substitute for the presence of an appropriately trained anesthesia clinician to manage the complex interplay of human factors and patient safety in the perioperative setting.

A sono-anatomical and cadaveric study of ultrasound-guided retrolaminar block.

AIM: Retrolaminar block (RB) is known to confer chest wall analgesia but, its mechanism has not been established. Our primary objective was to determine if the spread of injectate following RB extends to the paravertebral space (PVS). Second-ary objectives were to determine the predefined anatomical areas and nervous tissues contacted by injectate; the effect of volume on spread; and the extent to which experts can predict PVS spread based on examination of US videos of the injection. MATERIAL AND METHODS: US-guided RB was performed on cadavers using a single injection technique of 10, 20 or 30 ml dye. Anatomical dissection was performed to identify the extent of spread of injectate to the retrolaminar, intercostal and PVS. Ultrasound recordings of the injection were independently evaluated by experts in US-guided regional anaesthesia. RESULTS: Spread of injectate to the ipsilateral PVS was identified in 6/10 dissected regions (0/1, 1/3 and 5/6 when injectate volumes of 10, 20 and 30ml were administered respectively). The extent of cephalad-caudad spread within the PVS varied from 1 to 3 levels. Expert interpretation of ultrasound images regarding spread to the PVS demonstrated poor correlation with dye staining observed on dissection. CONCLUSIONS: Injectate spread following RB demonstrated substantial variability. Inconsistent spread to the ipsilateral PVS may account for clinically occurring incomplete blocks. The likelihood of spread to the ipsilateral PVS was greater when a larger volume was injected. Expert evaluation of the dynamic ultrasound images obtained at injection can-not reliably predict spread to the PVS.

Determination of the initial minimum effective dose of 0.5% bupivacaine with 20 µg of fentanyl for an operative fixation of fractured neck of femur: a prospective, observational trial.

BACKGROUND: Fractured neck of femur (FNF) is a common cause of morbidity and mortality in elderly. Spinal catheter allows fractionation of local anesthetic dose which combined with intrathecal opioid leads to a dose reduction and better hemodynamic stability. The primary objective of this paper was to investigate the initial minimum local anesthetic dose (iMLAD) of 0.5% isobaric bupivacaine with 20 µg of fentanyl administered via spinal catheter in order to commence the operative fixation of FNF. METHODS: A prospective, single-blinded, adaptive clinical trial with patients undergoing dynamic hip screw implantation (DHS) or hemiarthroplasty (HEMI) due to FNF. The Dixon and Massey's up and down method was used to determine the ED50 of intrathecal bupivacaine. This figure was confirmed with Probit analysis, in addition to the ED95. RESULTS: Using the Dixon and Massey's approach, the iMLADED50 for DHS was 0.29 mL (1.45 mg) and the iMLADED50 for HEMI was 0.33 mL (1.65 mg) of 0.5% isobaric bupivacaine. The Probit analyses demonstrated that the iMLADED95 for DHS and HEMI were 0.32 mL (1.6 mg) and 0.34 mL (1.7 mg) respectively. The mean cumulative dose of 0.5% bupivacaine for the whole surgery was 0.67 mL (3.35 mg) and 0.87 mL (4.35 mg) in the DHS and HEMI groups, respectively. CONCLUSIONS: This study demonstrates that the placement of a spinal catheter allows for careful titration of local anesthetic, enabling a reduction of the initial intrathecal dose of 0.5% isobaric bupivacaine below 0.4 mL (2 mg) and leading to a significant reduction of a dose required for the whole surgery when combined with an intrathecal opioid.

A modified ultrasound-guided supraclavicular brachial plexus block for the operative fixation of the humerus head and shaft fractures.

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