Central venous catheterization using a perfused human cadaveric model: application to surgical education.

OBJECTIVE: The purpose of this article is to present a unique training model using a perfused human cadaver for central line placement training with the ultimate goal of reducing central venous catheter mechanical complications. DESIGN: The applicability of the fresh tissue cadaver model for central line placement was assessed using a 10-item questionnaire with a 5-point Likert-type scale. Respondents were asked to rate their opinions as strongly agree, agree, neutral, disagree, or strongly disagree. SETTING: All participants received a didactic lecture followed by supervised practice on a commercially available simulator. The students were then relocated to the Fresh Tissue Dissection Laboratory where they practiced central vein catheterization on a fresh perfused human cadaver. PARTICIPANTS: Course participants included 87 physicians from various medical specialties at different stages of training. RESULTS: Results of the survey demonstrated that 91% of the participating physicians found the perfused cadaveric model to be a true simulation of conditions that exist in live patients, and 98% reported that the use of this model promoted acquisition of technical skills. CONCLUSION: The integration of central line placement training on perfused cadavers into residency and fellowship training provides an unparalleled realistic simulation to participants. Further study is needed to assess whether realistic simulation translates into objective end points such as decreased mechanical complications.

Intracranial pressure versus cerebral perfusion pressure as a marker of outcomes in severe head injury: a prospective evaluation.

BACKGROUND: Intracranial pressure (ICP) monitoring is a standard of care in severe traumatic brain injury when clinical features are unreliable. It remains unclear, however, whether elevated ICP or decreased cerebral perfusion pressure (CPP) predicts outcome. METHODS: This is a prospective observational study of patients sustaining severe blunt head injury, admitted to the surgical intensive care unit at the Los Angeles County and University of Southern California Medical Center between January 2010 and December 2011. The study population was stratified according to the findings of ICP and CPP. Primary outcomes were overall in-hospital mortality and mortality because of cerebral herniation. Secondary outcomes were development of complications during the hospitalization. RESULTS: A total of 216 patients met Brain Trauma Foundation guidelines for ICP monitoring. Of those, 46.8% (n = 101) were subjected to the intervention. Sustained elevated ICP significantly increased all in-hospital mortality (adjusted odds ratio [95% confidence interval]: 3.15 [1.11, 8.91], P = .031) and death because of cerebral herniation (adjusted odds ratio [95% confidence interval]: 9.25 [1.19, 10.48], P = .035). Decreased CPP had no impact on mortality. CONCLUSIONS: A single episode of sustained increased ICP is an accurate predictor of poor outcomes. Decreased CPP did not affect survival.

Trauma airway management: transition from anesthesia to emergency medicine.

BACKGROUND: Trauma airway management is commonly performed by either anesthesiologists or Emergency Physicians (EPs). OBJECTIVE: Our aim was to evaluate the impact of switching from one group of providers to the other, focusing on outcomes and complications. METHODS: Medical records were used to identify all patients during a 3-year period who were intubated emergently after traumatic injury. Before November 1, 2007, airway management was supervised by anesthesiologists, after that date airways were supervised by EPs. Complications evaluated included failure to obtain a secure airway, multiple attempts at airway placement, new or worsening hypoxia or hypotension during the peri-intubation period, bronchial intubations, dysrhythmia, aspiration with development of infiltrate on chest x-ray study within 48 h, and facial trauma. RESULTS: Of the 490 tracheal intubations, 250 were attended by EPs and 240 were attended by anesthesiologists. The groups were well matched with respect to age and sex, but the EP group treated more severely injured patients on average. Intubation was accomplished in one attempt 98.3% of the time in the anesthesia group; those requiring multiple attempts went on to need surgical airways 2.1% of the time. EPs accomplished intubation in one attempt 98.4% of the time, with an overall success rate of 96.8%; surgical airways were needed in 3.2% of patients. The complication rate was 18.3% for the anesthesia group and 18% for the EP group. There were no statistically significant differences between the EP and anesthesia groups with regard to complication rates, although the EP patients had a higher Injury Severity Score on average. CONCLUSIONS: EPs can safely manage the airways of trauma patients with rates of complication and failure comparable with those of anesthesiologists.