Influence of pre-course assessment using an emotionally activating stimulus with feedback: a pilot study in teaching Basic Life Support.

BACKGROUND: Cardiopulmonary resuscitation (CPR) mastery continues to challenge medical professionals. The purpose of this study was to determine if an emotional stimulus in combination with peer or expert feedback during pre-course assessment effects future performance in a single rescuer simulated cardiac arrest. METHODS: First-year medical students (n=218) without previous medical knowledge were randomly assigned to one of the study groups and asked to take part in a pre-course assessment: Group 1: after applying an emotionally activating stimulus an expert (instructor) gave feedback on CPR performance (Ex). Group 2: after applying the same stimulus feedback was provided by a peer from the same group (Pe); Group 3: standard without feedback (S). Following pre-course assessment, all subjects received a standardized BLS-course, were tested after 1 week and 6 months later using single-rescuer-scenario, and were surveyed using standardized questionnaires (6-point-likert-scales: 1=completely agree, 6=completely disagree). RESULTS: Participants exposed to stimulus demonstrated superior performance concerning compression depth after 6 months independent of feedback-method (Ex: 65.85% [p=0.0003]; Pe: 57.50% [p=0.0076] vs. 21.43%). The expert- more than the peer-group was emotionally more activated in initial testing, Ex: 3.26 ± 1.35 [p ≤ 0.0001]; Pe: 3.73 ± 1.53 [p=0.0319]; S: 4.25 ± 1.37) and more inspired to think about CPR (Ex: 2.03 ± 1.37 [p=0.0119]; Pe: 2.07 ± 1.14 [p=0.0204]; S: 2.60 ± 1.55). After 6 months this activation effect was still detectable in the expert-group (p=0.0114). CONCLUSIONS: The emotional stimulus approach to BLS-training seems to impact the ability to provide adequate compression depth up to 6 months after training. Furthermore, pre-course assessment helped to keep the participants involved beyond initial training.

Recognition and treatment of anaphylaxis.

The aim of this paper is to discuss the recognition, treatment and investigation of anaphylaxis. Anaphylaxis is a severe, life-threatening, generalized or systemic hypersensitivity reaction. It is characterized by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and/or mucosal changes. The incidence of anaphylaxis appears to be increasing. A wide range of triggers can cause anaphylaxis. Drugs are the commonest cause of anaphylaxis in hospital and foods in the out-of-hospital setting. Patients having anaphylaxis should be treated using the airway, breathing, circulation, disability, exposure (ABCDE) approach. Early treatment with intramuscular adrenaline is the treatment of choice for patients having anaphylaxis. Intravenous adrenaline must only be used when the patient is monitored and only by those skilled and experienced in its use. A raised serum mast cell tryptase suggests a diagnosis of anaphylaxis. All those who are suspected of having anaphylaxis should be referred to a specialist in allergy. Individuals at high risk of anaphylaxis where the trigger is difficult to avoid should carry an adrenaline auto-injector and receive training and support in its use.

Care of the intubated patient in the PACU: the 'ABCDE' approach.

This paper discusses airway management in the post anaesthetic care unit (PACU). Many patients will be extubated on arrival to the PACU, however a small number will need further support with tracheal intubation. Patient assessment is a key role for the PACU staff and using the ABCDE approach will provide a systematic method for assessing the patient and determining suitability for extubation. Care of the patient following extubation is also described.

Commentary: Saline versus Albumin Fluid Evaluation (SAFE) Investigators (2006). Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study.

The objectives of this study were to determine whether outcomes of resuscitation with albumin or saline in the intensive care unit (ICU) depend on patients' baseline serum albumin concentration. In this study we analyse data from a double-blind, randomized controlled trial. ICUs of 16 hospitals in Australia and New Zealand were included. There was a total of 6045 participants in the saline versus albumin fluid evaluation study. Fluid resuscitation with 4% albumin or saline was observed in patients with a baseline serum albumin concentration of 25 g/L or less or more than 25 g/L. Primary outcome was all-cause mortality at 28 days. Secondary outcomes were length of stay in the ICU, length of stay in hospital, duration of renal replacement therapy and duration of mechanical ventilation. The odds ratios for death for albumin compared with saline for patients with a baseline serum albumin concentration of 25 g/L or less and more than 25 g/L were 0.87 and 1.09, respectively (ratio of odds ratios 0.80, 95% confidence interval 0.63 to 1.02); P= 0.08 for heterogeneity. No significant interaction was found between baseline serum albumin concentration as a continuous variable and the effect of albumin and saline on mortality. No consistent interaction was found between baseline serum albumin concentration and treatment effects on length of stay in the ICU, length of hospital stay, duration of renal replacement therapy or duration of mechanical ventilation. The outcomes of resuscitation with albumin and saline are similar irrespective of patients' baseline serum albumin concentration.

Correcting arterial blood gases for temperature: (when) is it clinically significant?

Interpreting arterial blood gases (ABGs) is a common practice in intensive care units. The use of the temperature correction facility, however, is not standardized, and the effects of temperature correction on the ABG result may affect the overall management of the patient. The aim of this study was to discuss the significance of temperature correction. Current practice in the UK and Australia is discussed along with a review of physiological principles of oxygenation and acid-base balance. The alpha-stat and pH-stat methods of blood gas analysis are presented, with arguments for and against using the temperature correction facility for blood gas analysis. The study concludes with recommendations for practice.