Lego® bricks assisted training of the novice debriefers.

Lego® Serious Play® is a guided workshop in which participants construct Lego creations to represent symbolic and metaphorical ideas in response to assignments. How to encourage inexperienced debriefers to concentrate on dialogue and communications strategies rather than engage in an unstructured debate on technical or behavioral abilities is one of the main challenges in training people to debrief a high-fidelity simulation session. We explore the use of Lego bricks in this study to build straightforward, standardised situations that debriefers in training can use to practice leading discussion. With this method, the different debriefing methodologies may be practiced focusing exclusively on method and dialogue, without getting involved or having to concentrate on the technical aspects.

Improving learning by playing with an app: The FantaTraining ® experience with anesthesia trainees.

Background: FantaTraining ® is an app that simulates a football league. Each participant represents a team, and the game is played with the opposing team by answering a questionnaire. In the intervals between games, participants can practice by consulting the educational material (films, short texts, or slides) in the app. Various prizes are offered to the winners of the championship. In this study, we aimed to evaluate whether the use of the FantaTraining ® app could improve the learning of anesthesia trainees registered in an online obstetric anesthesia course. Methods: The study involved 282 trainees in anesthesia, from five Italian universities, registered in the Online Obstetric Anesthesia Course (OOAC) who were given the app. They were randomly allocated into two groups according to whether the app had been enabled to allow the participant to play the league (study group, n=137), or not (control group, n=145). All the trainees underwent entry and final tests, consisting of the same 40 multiple choice questions, respectively before and after completing the OOAC course. Results: There were no differences in the scores obtained in the pre-course test between the groups. The mean score obtained in the final test was significantly greater than that obtained in the entry one in both groups (P<0.05) but the final test score obtained by the participants of the study group was significantly greater than that obtained by the control group. (P<0.001), regardless of the university of origin and year of specialization. Trainees stated that the app had helped their study, improving understanding and motivation, without increasing the intensity of study. Conclusions: Using the FantaTraining ® app greatly improved trainees' final exam performance after the online obstetric anesthesia course. The FantaTraining ® app seems a promising tool to improve learning outcomes by strengthening learning behaviors and attitudes towards learning.

Achieving Lumbar Epidural Block Competency in Inexperienced Trainees after a Structured Epidural Teaching Model: A Randomized, Single Blind, Prospective Comparison of CUSUM Learning Curves.

Aim: The aim of this randomized, prospective study was to investigate whether the use of the structured epidural teaching model (SETM) may affect the learning curve for lumbar epidural block in novice trainees when compared with a standard teaching module. Introduction: There is a paucity of literature regarding the efficacy of teaching epidural blocks and comparisons between the different educational approaches. Method: Forty-four PGY3 anesthesia trainees were randomized to receive (study group) or to not receive (control group) the SDM (structured didactic model) before the beginning of their 6 months clinical practice rotation in labor and delivery suites. A CUSUM learning curve was built for every trainee. The scores were assigned by the staff instructor, who was unaware of the group to which the trainee belonged. Results: The number of subjects who achieved an improvement in performance was 8 trainees from the control group and 14 from the study group. The probability of achieving an improvement was higher (p < 05) in the study group than in the control group, with an aOR of 3.25 (CI: 1.01; 12.1). The proportion of subjects in the study group who completed the epidural without help was 1.21 (1.05-1.41) times the proportion of subjects who completed the epidural without help in the control group. The probability of completing the epidural block without any assistance was 21% higher in the study group than in the control group (p < 05). Conclusion: We have demonstrated that the use of the structured epidural teaching model (SETM) may improve the learning curve (CUSUM) for lumbar epidural block in novice, entirely inexperienced, anesthesia trainees.

Analysis of Epidural Waveform to Determine Correct Epidural Catheter Placement After CSE Labor Analgesia.

BACKGROUND: The epidural pressure is pulsatile and synchronized with arterial pulsations. Monitoring the epidural waveform has been suggested as a technique to reliably confirm the appropriate localization of the epidural catheter. OBJECTIVE: The aim of this study was to evaluate the sensitivity and specificity of the Computer Controlled Drug Delivery System with continuous pressure and waveform sensing technology (CCDDS) (CompuFlo® CathCheck™) as an instrument to assess the correct placement of the catheter in the epidural space in parturients who have received combined spinal-epidural technique (CSE) for labor analgesia. METHODS: We enrolled 40 consecutive healthy patients undergoing CSE labor analgesia with successful analgesia. All the cases in which pulsatile waveforms in synchrony with heart rate were detected were considered to be true positives; all the cases in which there was the absence of pulsatile waves were followed up. If these patients had to eventually relocate or manipulate the epidural catheter, they were considered to be true negative. If the absence of pulse waves was observed in the presence of successful analgesia during labor, the patients were considered to be false negatives. RESULTS: Pulsatile waveforms synchronous with heart rate were observed in 33 cases associated with adequate analgesia. In 5 cases, the pulsatile waveforms were absent due to unilateral analgesia or catheter occlusion (true negatives). In 2 cases, the patients had effective analgesia but we were not able to observe a distinct pulsatile waveform. The pressure waveform analysis through the epidural catheter had a sensitivity of 95%, a positive predictive value of 100%, a specificity of 100% and a negative predictive value of 60%. CONCLUSION: Pulsatile pressure waveform recording with CCDDS through the epidural catheter resulted in high sensitivity and positive predictive value which can help the proper placement of the epidural catheter.

Eye tracking metrics and leader's behavioral performance during a post-partum hemorrhage high-fidelity simulated scenario.

BACKGROUND: The use of eye tracking in the simulated setting can help improve our understanding of what sources of information clinicians are using as they deliver routine patient care. The aim of this simulation study was to observe the differences, if any, between the eye tracking patterns of leaders who performed best in a simulated postpartum hemorrhage (PPH) high-fidelity scenario, in comparison with those who performed worst. METHODS: Forty anesthesia trainees from the University of Catania Medical School were divided into eight teams, to enact four times the same scenario of a patient with postpartum hemorrhage following vaginal delivery. Trainees who were assigned the leader's role wore the eye tracking glasses during the scenario, and their behavioral skills were evaluated by two observers, who reviewed the video recordings of the scenarios using a standardized checklist. The leader's eye tracking metrics, extracted from 27 selected areas of interest (AOI), were recorded by a Tobii Pro Glasses 50 Hz wearable wireless eye tracker. Team performance was evaluated using a PPH checklist. After completion of the study, the leaders were divided into two groups, based on the scores they had received (High-Performance Leader group, HPL, and Low-Performance Leader group, LPL). RESULTS: In the HPL group, the duration and number of fixations were greater, and the distribution of gaze was uniformly distributed among the various members of the team as compared with the LPL group (with the exception of the participant who performed the role of the obstetrician). The HPL group also looked both at the patient's face and established eye contact with their team members more often and for longer (P < .05). The team performance (PPH checklist) score was greater in the HPL group (P < .001). The LPL group had more and/or longer fixations of technical areas of interest (P < .05). CONCLUSIONS: Our findings suggest that the leaders who perform the best distribute their gaze across all members of their team and establish direct eye contact. They also look longer at the patient's face and dwell less on areas that are more relevant to technical skills. In addition, the teams led by these best performing leaders fulfilled their clinical task better. The information provided by the eye behaviors of "better-performing physicians" may lay the foundation for the future development of both the assessment process and the educational tools used in simulation. TRIAL REGISTRATION: Clinical.Trial.Gov ID n. NCT04395963 .

The evolution of self and hetero-evaluation of repeated high fidelity simulation scenarios of post-partum hemorrhage with anesthesia trainees.

This article was migrated. The article was marked as recommended. Introduction Evidence for self-assessment in medicine is controversialwith participants under-rating or overestimating their performance. It is also unclear whether this under or overestimation changes during the process of repeated simulation experience. In this study, the authors analyzed the evolution of the behavioral skills of anesthesia trainees during four consecutive standardized postpartum hemorrhages (PPH) high-fidelity simulation scenarios. They compared the self-assessment made by the leader himself and the assessment made by his teammates individually with the assessment made by two expert observers. Methods The authors enrolled forty anesthesia trainee volunteers and divided them into eight teams of five participants each. Each team enacted the same scenario of a patient with atonic PPH following vaginal delivery four times so that all the trainees, except the one assigned the leader's role, could rotate through the roles of anesthesia trainee, obstetrician, midwife, and nurse. The participants themselves and two expert observers, using standardized checklists and questionnaires, carried out an evaluation of the technical (diagnosis and treatment of atonic PPH) and behavioral (leadership, communication, situational awareness, and overall appraisal) skills evidenced in the scenarios. Results The authors noted a progressive improvement in the behavioral scores given to the leader by the examiners, his team, and himself, from the first to the fourth scenario. The scores given by the participants and by the leader himself were greater than those given by the independent observers in the first two scenarios but these differences were no longer significant during the last two scenarios. Discussion Participants overestimated their performances but this overestimation disappeared after the completion of the first two scenarios. The authors suggested that improving the skills of participants throughout the scenarios, most likely improved their metacognitive competence, helping them to better recognize their abilities.

COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought.

BACKGROUND: The world is facing a massive burden from the coronavirus disease 2019 (COVID-19) pandemic. Governments took the extraordinary step of locking down their own countries to curb the spread of the coronavirus. After weeks of severe restrictions, countries have begun to relax their strict lockdown measures. However, reopening will not be back to normal.Simulation facilities (SF) are training spaces that enable health professionals and students to learn skills and procedures in a safe and protected environment. Today's clinicians and students have an expectation that simulation laboratories are part of lifelong healthcare education. There is great uncertainty about how COVID-19 will impact future training in SF. In particular, the delivery of training activities will benefit of adequate safety measures implemented for all individuals involved.This paper discusses how to safely reopen SF in the post-lockdown phase. MAIN BODY: The paper outlines 10 focus points and provides operational tips and recommendations consistent with current international guidelines to reopen SF safely in the post-lockdown phase. Considering a variety of national advices and regulations which describe initial measures for the reopening of workplaces as well as international public health recommendations, we provide points of reflection that can guide decision-makers and SF leaders on how to develop local approaches to specific challenges. The tips have been laid out taking also into account two main factors: (a) the SF audience, mainly consisting of undergraduate and postgraduate healthcare professionals, who might face exposure to COVID-19 infection, and (b) for many simulation-based activities, such as teamwork training, adequate physical distancing cannot be maintained. CONCLUSIONS: The planning of future activities will have to be based not only on safety but also on flexibility principles.Sharing common methods consistent with national and international health guidelines, while taking into account the specific characteristics of the different contexts and centres, will ultimately foster dissemination of good practices.This article seeks to further the conversation. It is our hope that this manuscript will prompt research about the impact of such mitigation procedures and measures in different countries.

The strategic debriefing. Incorporating strategic dialogue in the standard debriefing after the scenario.

This article was migrated. The article was marked as recommended. The most common debriefing structure usually includes at least three phases, a time to confront reactions and/or emotions felt during the scenario, an analysis of events and a summary or application phase, in which the learning acquired throughout the debriefing is solidified and the major take- home messages condensed. However, using only open-ended questions and/or the puls/delta method, participants' attitudes may remain unchanged and result in only superficial reflections of the scenario. The purpose of this article is to describe and propose incorporating strategic dialogue after the healthcare high fidelity scenario in the standard debriefing. Strategic dialogue alternates analogical and digital language and uses metaphors and paraphrases, guiding the participant to live a corrective emotional experience, the primary cause of the change. The structure of the strategic dialogue is based on the use of questions with the illusion of alternatives, restructuring paraphrases, the evocation of sensations and summary redefinitions, in order to reach the discovery that leads to change. The simulation method is well suited and integrated with strategic communication. Both aim at change, which must first be experienced and then explained. The central focus of strategic short therapy is the corrective emotional experience in which the patient modifies his or her vision of reality through concrete emotional experiences. The change, in order to be rapid and effective, must primarily produce a real personal experience of transformation on a perceptive-emotional level and only then can it be the subject of cognitive reasoning. The change must first pass from the experience phase and only then to the level of cognitive awareness. The strategic language, an effective tool in strategic psychotherapy and business problem solving, is ideal and complementary to the standard debriefing methods, making them more performing and functional because, next to common logic, it makes use of non-ordinary logical language.

Differentiating False Loss of Resistance from True Loss of Resistance While Performing the Epidural Block with the CompuFlo® Epidural Instrument.

BACKGROUND: The occurrence of false losses of resistance may be one of the reasons for inadequate or failed epidural block. A CompuFlo® epidural instrument has been introduced to measure the pressure of human tissues in real time at the orifice of a needle and has been used as a tool to identify the epidural space. The aim of this study was to investigate the sensitivity and the specificity of the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance encountered during the epidural space identification procedure. METHOD: We performed epidural block with the CompuFlo® epidural instrument in 120 healthy women who requested labor epidural analgesia. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase in the pitch of the audible tone) was followed by a sudden and sustained drop in pressure for more than 5 seconds accompanied by a sudden decrease in the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau. We evaluate the sensitivity, specificity, and positive and negative predictive values of the ability of CompuFlo® recordings to correctly identify the true LOR from the false LOR. RESULTS: The drop in pressure associated with the epidural space identification was significantly greater than that recorded after the false loss of resistance (73% vs 33%) (P=0.000001). The sensitivity was 0.83, and the AUC was 0.82. DISCUSSION: We have confirmed the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance and established its specificity and sensitivity. CONCLUSION: An easier identification of dubious losses of resistance during the epidural procedure is essential to reduce the number of epidural attempts and/or needle reinsertions with the potential of a reduced risk of accidental dural puncture especially in difficult cases or when the procedure is performed by trainees.

Objective Evaluation of a New Epidural Simulator by the CompuFlo® Epidural Instrument.

BACKGROUND: In this study, we describe a custom-made new epidural simulator, created by modifying the inner structure of a commercially available one, in the attempt to make it adequately realistic. To validate and evaluate the realism of our device, we used the Computerized Epidural Instrument CompuFlo. METHOD: The Compuflo CompuFlo curves obtained from 64 experiments on the epidural simulator were compared to 64 curves obtained from a previous human study, from consecutive laboring parturients requesting epidural analgesia. RESULTS: Epidural simulator and human pressure curves were very similar. There was a significant difference between the drop of pressure due to false and true loss of resistance (LOR) in both the groups. DISCUSSION: Our simulator can realistically reproduce the anatomical layers the needle must pass as demonstrated by the similarity between the simulator and human pressure curves and the small differences of pressure values recorded. CompuFlo may be used as an objective tool to create and assess and compare objectively the epidural task trainers.

Techniques for the maintenance of epidural labor analgesia.

PURPOSE OF REVIEW: After initiating neuraxial labor analgesia, there are many techniques that can be used to maintain analgesia for the duration of labor. In this review, we have examined the new techniques of maintenance of epidural labor analgesia recently proposed to overcome the undesirable effects of continuous infusion and patient-controlled epidural analgesia (PCEA). RECENT FINDINGS: As labor progresses, there is a greater need for analgesia. PCEA with basal infusion, automated intermittent mandatory boluses, programmed intermittent epidural boluses and computer-integrated PCEA have been introduced to combine the advantages of a manual bolus and continuous infusion, thus matching infusion rate and bolus modality to the patient's analgesic needs. Increased maternal satisfaction, reduced anesthetic consumption and decreased incidence of motor block are features of these new maintenance techniques. SUMMARY: Technology has now provided us with more advanced drug delivery systems that may have the potential to fulfill the maternal requirements of a safe, natural, and painless childbirth, tailoring the analgesic regimen for each parturient's need.

Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: the effects on maternal motor function and labor outcome. A randomized double-blind study in nulliparous women.

BACKGROUND: Programmed intermittent epidural anesthetic bolus (PIEB) technique may result in reduced total local anesthetic consumption, fewer manual boluses, and greater patient satisfaction compared with continuous epidural infusion (CEI). In this randomized, double-blind study, we compared the incidence of motor block and labor outcome in women who received PIEB or CEI for maintenance of labor analgesia. The primary outcome variable was maternal motor function and the secondary outcome was mode of delivery. METHODS: Nulliparous, term women with spontaneous labor and cervical dilation <4 cm were eligible to participate in the study. Epidural analgesia was initiated and maintained with a solution of levobupivacaine 0.0625% with sufentanil 0.5 µg/mL. After an initial epidural loading dose of 20 mL, patients were randomly assigned to receive PIEB (10 mL every hour beginning 60 minutes after the initial dose) or CEI (10 mL/h, beginning immediately after the initial dose) for the maintenance of analgesia. Patient-controlled epidural analgesia (PCEA) using a second infusion pump with levobupivacaine 0.125% was used to treat breakthrough pain. The degree of motor block was assessed in both lower extremities using the modified Bromage score at regular intervals throughout labor; the end point was any motor block in either limb. We also evaluated PCEA bolus doses and total analgesic solution consumption. RESULTS: We studied 145 subjects (PIEB = 75; CEI = 70). Motor block was reported in 37% in the CEI group and in 2.7% in the PIEB group (P < 0.001; odds ratio = 21.2; 95% CI: 4.9-129.3); it occurred earlier (P = 0.008) (hazard ratio = 7.8; 95% CI: 1.9-30.8; P = 0.003) and was more frequent at full cervical dilation in the CEI group (P < 0.001). The incidence of instrumental delivery was 20% for the CEI group and 7% for the PIEB group (P = 0.03). Total levobupivacaine consumption, number of patients requiring additional PCEA boluses, and mean number of PCEA boluses per patient were lower in the PIEB group (P < 0.001). No differences in pain scores and duration of labor analgesia were observed. CONCLUSIONS: Maintenance of epidural analgesia with PIEB compared with CEI resulted in a lower incidence of maternal motor block and instrumental vaginal delivery.

Effect of sex and pregnancy on the potency of intrathecal bupivacaine: determination of ED50 for motor block with the up-down sequential allocation method.

BACKGROUND AND OBJECTIVE: The up-down sequential allocation model has been adapted to estimate the relative potency ratios for analgesia and motor block of the most commonly used epidural and intrathecal local anaesthetics. The aim of this study was to establish the median effective doses (ED50) for motor block with intrathecal bupivacaine and to estimate the ED50 ratios of these in male, female and pregnant patients. METHODS: In this prospective, double-blind, parallel group, up-down sequential allocation study, we enrolled 30 male patients, 30 female, non-pregnant patients and 30 pregnant patients undergoing elective surgery under combined spinal-epidural anesthesia. The first two groups consisted of male or female patients undergoing elective lower limb surgery and the third group consisted of pregnant women at term (>36 and <41 weeks) with singleton pregnancies undergoing elective caesarean delivery. Patients received intrathecal isobaric bupivacaine 0.5% as part of the spinal-epidural anaesthesia technique. The initial dose was 4 mg and the testing interval was 1 mg with subsequent doses being determined by the outcome in the previous patient in the same group. The end point for efficacy was the occurrence of motor block in the lower limbs within 5 min. RESULTS: There were significant (P < 0.0001) differences in ED50 estimates for motor block with intrathecal bupivacaine: 6.9 mg for men [95% confidence interval (CI), 5.2-8.6), 5.2 mg for women (95% CI, 4.5-5.8) and 3.4 mg for pregnant women (95% CI, 2.9-4.0). CONCLUSION: We have demonstrated a hierarchy of potencies for motor block with intrathecal bupivacaine for men, women and pregnant women suggesting possible relevant differences owing to the effects of both sex and pregnancy.

The relative potencies for motor block after intrathecal ropivacaine, levobupivacaine, and bupivacaine.

BACKGROUND: In this study, we sought to determine the median effective dose (ED50) for motor block of intrathecal ropivacaine, levobupivacaine, and bupivacaine and to define their motor-blocking potency ratios. METHODS: We enrolled 104 parturients undergoing elective cesarean delivery with combined spinal-epidural anesthesia and randomized them to one of three groups to receive intrathecal 0.5% (wt/vol) ropivacaine, levobupivacaine, or bupivacaine. The initial dose was 4 mg, and the testing interval was set at 1 mg. Efficacy was determined by the occurrence of any motor block in either lower limb (modified Bromage and hip motor function scale) within 5 min after the spinal injection. RESULTS: As assessed using up-down analysis, intrathecal ED50 for motor block was 5.79 mg for ropivacaine (95% CI 4.62-6.96), 4.83 mg for levobupivacaine (95% CI 4.35-5.32) and 3.44 mg for bupivacaine (95% CI 2.55-4.34) (P < 0.0007). The relative motor blocking potency ratios were ropivacaine/bupivacaine 0.59 (95% CI, 0.42-0.82), ropivacaine/levobupivacaine 0.83 (95% CI 0.64-1.09), and levobupivacaine/bupivacaine 0.71 (95% CI 0.51-0.98). CONCLUSIONS: There is a clinical profile of potency for motor block for the pipecolylxylidines when administered spinally: low, intermediate, and high for ropivacaine, levobupivacaine, and bupivacaine, respectively.

Minimum local analgesic doses of ropivacaine, levobupivacaine, and bupivacaine for intrathecal labor analgesia.

BACKGROUND: Doses for intrathecal opioid-local anesthetic mixtures have been arbitrarily chosen. The aim of this study was to compare the analgesic efficacies of intrathecal ropivacaine, levobupivacaine, and bupivacaine for labor analgesia and to determine the analgesic potency ratios for these three drugs. For this purpose, the authors used the up-down sequential allocation model, which estimates the minimum local analgesic dose for intrathecal local anesthetic. METHODS: Ninety-seven nulliparous term parturients in spontaneous labor, requesting combined spinal-epidural analgesia, were randomly allocated to one of three groups to receive 0.25% spinal ropivacaine, levobupivacaine, or bupivacaine. The initial dose of the local anesthetic drug was chosen to be 2.5 mg, and the testing interval was set at 0.25 mg. The subsequent doses were determined by the response of the previous parturient. Efficacy was accepted if the visual analog pain score decreased to 10 mm or less on a 100-mm scale within 30 min. The minimum local analgesic dose was calculated using the method of Dixon and Massey. RESULTS: The intrathecal minimum local analgesic dose was 3.64 mg (95% confidence interval, 3.33-3.96 mg) for ropivacaine, 2.94 (2.73-3.16) mg for levobupivacaine, and 2.37 (2.17-2.58) mg for bupivacaine. The relative analgesic potency ratios were 0.65 (0.56-0.76) for ropivacaine:bupivacaine, 0.80 (0.70-0.92) for ropivacaine:levobupivacaine, and 0.81 (0.69-0.94) for levobupivacaine:bupivacaine. There were significant trends (P levobupivacaine > ropivacaine.

Epidural analgesia for childbirth: effects of newer techniques on neonatal outcome.

New low-dose, local anesthetic-opioid combinations, combined spinal epidural analgesia, and new anesthetic drugs, such as ropivacaine and levobupivacaine, have modified the anesthetic practice in obstetric labor analgesia. These new analgesic techniques have less or no neonatal effects when compared with traditional epidural labor analgesia. They also have less effect on mode of delivery, which may in turn affect neonatal outcome. The use of very diluted or low concentrations of local anesthetic solutions may reduce their placental passage and thus the possible subtle neonatal effects. Small doses of epidural or spinal opioids alone or combined with low doses of local anesthetics does not affect the well-being of the neonate at birth. When considering the neonatal outcome, combined spinal epidural analgesia is as well tolerated as low-dose epidural analgesia. Transient fetal heart rate changes have been described immediately after the administration of intrathecal or epidural opioids. Maternal hypotension may also occur at the onset of epidural analgesia. Whether the occurrence of transient fetal heart rate changes or maternal hypotension immediately after the epidural block may influence the neonatal outcome at birth needs verification.