Assessment of clinical performance during simulated crises using both technical and behavioral ratings.

BACKGROUND: Techniques are needed to assess anesthesiologists' performance when responding to critical events. Patient simulators allow presentation of similar crisis situations to different clinicians. This study evaluated ratings of performance, and the interrater variability of the ratings, made by multiple independent observers viewing videotapes of simulated crises. METHODS: Raters scored the videotapes of 14 different teams that were managing two scenarios: malignant hyperthermia (MH) and cardiac arrest. Technical performance and crisis management behaviors were rated. Technical ratings could range from 0.0 to 1.0 based on scenario-specific checklists of appropriate actions. Ratings of 12 crisis management behaviors were made using a five-point ordinal scale. Several statistical assessments of interrater variability were applied. RESULTS: Technical ratings were high for most teams in both scenarios (0.78 +/- 0.08 for MH, 0.83 +/- 0.06 for cardiac arrest). Ratings of crisis management behavior varied, with some teams rated as minimally acceptable or poor (28% for MH, 14% for cardiac arrest). The agreement between raters was fair to excellent, depending on the item rated and the statistical test used. CONCLUSIONS: Both technical and behavioral performance can be assessed from videotapes of simulations. The behavioral rating system can be improved; one particular difficulty was aggregating a single rating for a behavior that fluctuated over time. These performance assessment tools might be useful for educational research or for tracking a resident's progress. The rating system needs more refinement before it can be used to assess clinical competence for residency graduation or board certification.

Anaesthesia crisis resource management training: an intimidating concept, a rewarding experience.

PURPOSE: This two-part study was performed to identify and address anaesthetists' concerns regarding anaesthesia simulation and to evaluate the response of practitioners to simulation-based Anaesthesia Crisis Resource Management Training (ACRM). METHODS: First, 150 survey questionnaires were distributed to participants of the Anaesthesia Practice '94 meeting in Toronto and to staff and resident anaesthetists at the Sunnybrook Health Science Centre. In the second part of the study, 35 anaesthetists from the Toronto area who participated in Anaesthesia Crisis Resource Management (ACRM) workshops at the Canadian Simulation Centre completed an anonymous exit evaluation questionnaire. RESULTS: Among staff anaesthetists (n = 42), 19% of the surveyed respondents had never heard about anaesthesia simulation, whereas all residents (n = 17) had heard of, or seen an anaesthesia simulator. Horizontal numerical scale ratings (from 1-10, with 10 being extremely supportive) indicated support for the purchase of a simulator (8.3 +/- 2.0 for staff, 9.2 +/- 1.1 for residents). Staff and residents anticipated substantial anxiety while training with a simulator (6.8 +/- 2.4 and 7.6 +/- 1.4 respectively, with 10 indicating extreme anxiety). Participants in the ACRM workshops at the Canadian Simulation Centre enjoyed the course (1.2 +/- 0.6, on a scale form 1 through 5, with 1 indicating total support and 5 representing no support), felt that it would be beneficial to most anaesthetists (1.2 +/- 0.5) and should be taken, on average, every 18 mo. CONCLUSIONS: Even though the majority of respondents have not been exposed to anaesthesia simulators, they appear to support their use in education strongly. Whereas substantial anxiety could delay the introduction of simulation based education, participants of ACRM workshops enjoy the courses and perceive them as very educational.

Isolation and characterization of human casein kinase I epsilon (CKI), a novel member of the CKI gene family.

The casein kinase I (CKI) gene family is a rapidly enlarging group whose members have been implicated in the control of cytoplasmic and nuclear processes, including DNA replication and repair. We report here the cloning and characterization of a novel isoform of CKI from a human placental cDNA library. The cDNA for this isoform, hCKI epsilon, predicts a basic polypeptide of 416 amino acids and a molecular mass of 47.3 kDa. It encodes a core kinase domain of 285 amino acids and a carboxyl-terminal tail of 123 amino acids. The kinase domain is 53-98% identical to the kinase domains of other CKI family members and is most closely related to the delta isoform. Localization of the hCKI epsilon gene to chromosome 22q12-13 and the hCKI delta gene to chromosome 17q25 confirms that these are distinct genes in the CKI family. Northern blot analysis shows that hCKI epsilon is expressed in multiple human cell lines. Recombinant hCKI epsilon is an active enzyme that phosphorylates known CKI substrates including a CKI-specific peptide substrate and is inhibited by CKI-7, a CKI-specific inhibitor. A budding yeast isoform of CKI, HRR25, has been implicated in DNA repair responses. Expression of hCKI epsilon but not hCKI alpha rescued the slow-growth phenotype of a Saccharomyces cerevisiae strain with a deletion of HRR25. Human CKI epsilon is a novel CKI isoform with properties that overlap those of previously described CKI isoforms.

Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents.

The authors have developed a course in Anesthesia Crisis Resource Management (ACRM) analogous to courses in Crew (Cock-pit) Resource Management (CRM) conducted in commercial and military aviation. Anesthesiologists do not typically receive formal training in crisis management although they are called upon to manage life-threatening crises at a moment's notice. Two model demonstration courses in ACRM were conducted using a realistic anesthesia simulation system to test the feasibility and acceptance of this kind of training. Anesthesiologists received didactic instruction in dynamic decision-making, human performance issues in anesthesia, and in the principles of anesthesia crisis resource management. After familiarization with the host institution's operating rooms and with the simulation environment, they underwent a 2-h simulation session followed by a debriefing session which used a videotape of their simulator performance. Participants rated the course as intense, helpful to their practice of anesthesiology, and highly enjoyable. Several aspects of the course were highly rated, including: videotapes of actual anesthetic mishaps, simulation sessions, and debriefing sessions. Scores on written tests of knowledge about anesthesia crisis management showed a significant improvement following the first course (residents) but not the second course (experienced anesthesiologists). Although the ultimate utility of this training for anesthesiologists cannot easily be determined, the course appeared to be a useful method for addressing important issues of anesthesiologist performance which have previously been dealt with haphazardly. The authors believe that ACRM training should become a regular part of the initial and continuing education of anesthesiologists.

Neuropsychological dysfunction after cardiopulmonary bypass: a comparison of two institutions.

The authors compared perioperative neuropsychologic dysfunction in patients participating in two studies conducted in institutions using different strategies to manage cardiopulmonary bypass. These differences included hypothermia versus normothermia, presence versus absence of arterial microfilters, and the presence versus absence of glucose-containing solution in the pump prime. Other differences between the two institutions included the type of surgery (intracardiac v extracardiac), the mean duration of cardiopulmonary bypass, and degree of low perfusion pressure during bypass. Despite these major differences, perioperative neuropsychologic dysfunction measured by the two-part Trail-Making psychometric test was similar in the two institutions. Several factors were analyzed for their possible contribution to development of dysfunction, including institution, anesthetic management, age, sex, degree of low perfusion pressure during bypass, and duration of bypass; only age was significant. These results suggest that differences in surgical procedure and management of cardiopulmonary bypass previously thought to contribute to the development of subtle cognitive deficits after cardiac surgery may have been overemphasized.

Metabolism of halothane in obese Fischer 344 rats.

Halothane is metabolized by an oxidative pathway to stable, nonvolatile end products, trifluoroacetic acid (TFAA) and bromide (Br-), and by reductive pathways to Br-and inorganic fluoride (F-). There is evidence that both oxidatively and reductively formed intermediates may produce hepatotoxicity, although the exact etiology of the fulminant hepatic necrosis seen in humans is unproven. Obese patients receiving volatile anesthetics exhibit higher serum anesthetic metabolite concentrations than do normal-weight patients, and thus might be at greater risk of hepatotoxicity because of higher concentrations of reactive intermediates from halothane metabolism. To eliminate the variables inherent in human clinical studies leading to confounding interpretation of data, this study determined the contributions of oxidative and reductive pathways to halothane metabolism in an animal model of human hypertrophic obesity, the most common form of human obesity. Eight pairs of obese (high-fat diet) and normal-weight (standard chow), male Fischer 344 rats were anesthetized with halothane for 4 h at an inspired concentration of 0.78%. Serum and urinary concentrations of TFAA, Br-, and F-were measured. Thirty-six hours following halothane anesthesia, mean serum TFAA concentrations peaked at 7.3 +/- 1.1 mM in obese rats and 4.7 +/- 0.7 mM in nonobese rats. TFAA urinary excretions during the 180-h period postanesthesia were 519 +/- 69 and 336 +/- 22 mumol, respectively. Peak serum Br- concentrations were 9.1 +/- 1.0 and 6.9 +/- 0.6 mM for obese and nonobese rats, respectively, and Br-urinary excretions were 127 +/- 30 and 79 +/- 14 mumol, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro hepatic drug and anesthetic metabolism of rats with dietary-induced obesity.

The mechanism for enhanced metabolism of inhaled anesthetics in obese rats and humans is unknown. In this study, hepatic microsomes from normal-weight chow-fed rats and rats fed a high fat diet for approximately 54 weeks to induce obesity were examined for their ability to metabolize fluorinated inhalation anesthetics. Body composition of rats on diet for 54 weeks revealed a significantly elevated lipid content of both the whole body and liver in obese compared to normal-weight rats. Protein per g liver was not significantly different. The hepatic microsomal content of cytochromes b5 and P-450 per mg protein was not different between obese and normal-weight rats. Hepatic microsomal defluorination rates of the anesthetics, methoxyflurane, enflurane and isoflurane, were not altered by high fat diets of 54 weeks duration. The activity rate of aminopyrine N-demethylase was not changed by the diet; however, p-nitroanisole O-demethylase activity was significantly increased in microsomes from obese rats to approximately 150% of control activity. Thus the enhanced in vivo anesthetic metabolism of obese Fischer 344 rats does not appear to be the result of an increase in the specific activity of anesthetic metabolizing enzymes.

Contrasting effects of etomidate and propylene glycol upon enflurane metabolism and adrenal steroidogenesis in Fischer 344 rats.

This study was designed to investigate the effects of etomidate and its solubilizing agent (propylene glycol) upon enflurane metabolism and adrenal steroidogenesis in Fischer 344 rats. A central venous catheter was placed using pentobarbital anesthesia, and rats were randomized to one of four groups for treatment several days later. Group 1 animals received normal saline, 3 ml/kg, given via the central venous catheter. The other three groups were administered equivalent volumes of either: crystalline etomidate (group 2), 0.4 mg/ml, in saline and 1.1% ethanol; propylene glycol (group 3), 7%, in saline; or etomidate (group 4), 0.4 mg/ml in saline with 7% propylene glycol. In the first part of this study, after an intravenous bolus of one of these four solutions, animals were immediately placed in a 200-liter chamber and received 1 h of 2% enflurane. Serum and urine were assayed for inorganic fluoride (F-) before and after anesthesia. Two hours after enflurane anesthesia, groups 1 and 2 had the highest mean peak serum F- concentrations (13.2 and 13.5 uM, respectively). Groups 3 and 4 had significantly lower mean peak serum F- concentrations (4.7 and 4.5 uM, respectively). In the second part of this study, additional animals were randomized into four groups and received the same intravenous medications as above. Thirty minutes later, they received an intravenous bolus of ACTH. Blood samples were drawn and serum aldosterone levels were measured. Animals in groups 1 and 3 had significantly greater increases in peak serum aldosterone levels 30 minutes after ACTH (peak levels: 0.80 and 0.77 ng/ml, respectively) than animals in groups 2 and 4 (peak levels: 0.60 and 0.58 ng/ml, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective, randomized study of the effects of prostacyclin on neuropsychologic dysfunction after coronary artery operation.

This randomized, double-blind study was designed to evaluate the effect of prostacyclin (epoprostenol) on the incidence and severity of postoperative neuropsychologic dysfunction in patients undergoing coronary artery operation. Four days before operation and 1 week after operation, 100 patients having coronary artery bypass grafting underwent detailed neurologic and psychologic examinations and computed tomographic scans of the brain. The psychologic examination was repeated 2 months after operation. During cardiopulmonary bypass, all patients received 300 U/kg of heparin and then either buffer-diluent or prostacyclin (12.5 ng/kg/min from the time of heparinization until onset of cardiopulmonary bypass and 25 ng/kg/min during cardiopulmonary bypass). No deaths or major neurologic complications occurred in this series. Ninety-six patients completed the psychologic and neurologic evaluations 1 week after operation; 74 of these patients were evaluated psychologically 2 months after operation. Psychologic testing demonstrated similar declines in postoperative performance in both the prostacyclin-treated and the control groups; these changes were no longer present in either group 2 months after operation. Results of neurologic examinations and computed tomographic scans of the brain were unchanged. We conclude that the administration of prostacyclin during cardiopulmonary bypass in patients undergoing routine coronary artery operation has no effect on perioperative cognitive changes.

Anesthetic metabolism and renal function in obese and nonobese Fischer 344 rats following enflurane or isoflurane anesthesia.

This study was designed to determine the nephrotoxic potential of prolonged anesthesia with enflurane or isoflurane in obese and nonobese Fischer 344 rats. Weight-paired rats received either a regular chow diet or Potter's high fat diet for 16 weeks. The chow-fed (nonobese) rats gained 20% in body weight compared with 45% for the Potter's-fed (obese) rats. Exposure of nine pairs of rats to 2.0% enflurane for 4 h resulted in significantly elevated peak serum F-levels (62 +/- 11 microM vs. 27 +/- 6 microM; P less than 0.001) in obese compared with nonobese rats and clinical signs of F(-)-induced nephrotoxicity (i.e., polyuria) confirmed by decreased creatinine and urea nitrogen clearances in the obese rats. Exposure of nine pairs of rats to 1.4% isoflurane for 4 h produced significantly elevated peak serum F-levels (27 +/- 8 microM vs. 9 +/- 0.4 microM; P less than 0.001) in obese compared with nonobese rats and subclinical nephrotoxicity in obese rats manifested by significantly decreased creatinine and urea nitrogen clearances, but without polyuria. This study suggest that obese patients may be at risk of developing F(-)-induced nephrotoxicity following prolonged enflurane anesthesia. Isoflurane may have significant potential for subclinical F(-)-induced nephrotoxicity in obese patients, to a degree that might affect renal clearance of some drugs in the postoperative period.

A prospective, randomized study of the effects of prostacyclin on platelets and blood loss during coronary bypass operations.

A randomized, double-blind study was designed to evaluate the therapeutic effect and safety of prostacyclin (epoprostenol) in patients undergoing cardiopulmonary bypass. One hundred patients having isolated coronary bypass grafting received 300 units/kg of heparin and then either prostacyclin (12.5 ng/kg/min from heparinization until cardiopulmonary bypass, 25 ng/kg/min during bypass) or buffer/diluent in a similar manner. Standardized anesthetic, perfusion, and surgical techniques were used. Drug and placebo groups were similar in demographic data and bypass times, and there were no deaths. Activated coagulation time and platelet count were significantly higher during cardiopulmonary bypass in patients receiving prostacyclin. Platelet count remained significantly higher 24 hours after bypass in the active drug group. Immediately after operation, there was significantly less prolongation of bleeding time (1.3 versus 2.9 minutes; p = 0.009) in the patients receiving prostacyclin. Blood loss was significantly reduced during the first 4 hours postoperatively in the prostacyclin group (261 +/- 159 versus 347 +/- 197 ml; p = 0.02). There was no significant difference between the groups when total blood loss was compared (710 +/- 351 versus 869 +/- 498 ml; p = 0.07). Patients receiving prostacyclin required an average of 257 ml less blood transfused in the intensive care unit (p = 0.02). We conclude that the clinical impact of prostacyclin in patients undergoing coronary artery operations was demonstrable, but small. Prostacyclin may provide clinical benefits in patients undergoing cardiopulmonary bypass when there are contraindications to or other difficulties with blood transfusion. With prostacyclin, reduced heparin dose is possible and therefore reduced protamine requirement would offer a potential benefit of less cardiovascular depression immediately after bypass. However, the advantages offered by prostacyclin are not sufficient to recommend its routine use during cardiopulmonary bypass.

Halothane inhibits metabolism of enflurane in Fischer 344 rats.

The authors investigated the effect of prior administration of halothane upon the metabolism of enflurane. Twenty-four, one-year-old male, Fischer 344 rats were assigned randomly to four anesthetic exposure groups. Groups 1 and 2 were controls exposed only to halothane and enflurane, respectively. Group 3 was exposed for 1 h to 0.3% halothane, followed by 2 h of 1% enflurane. Group 4 was exposed for 1 h to 1% halothane and then to 2 h of 1% enflurane. Blood samples were taken prior to, immediately following, and 1, 24, and 48 h after anesthetic exposure. Serum was assayed for inorganic fluoride (F-), SGOT and SGPT. Twenty-four-hour urinary collections were assayed for F excretion. Group 1 rats exposed to halothane alone had the lowest peak mean serum F- (5.0 microM). Group 2 rats exposed to enflurane alone had the highest serum F concentration 4 h after anesthesia (18.7 microM). Peak serum F in Group 3 rats (9.5 microM) was significantly lower than in Group 2 rats (enflurane control). In Group 4 rats, serum F- was not significantly different from Group 1 rats (halothane control) at any time. In the first 24 h after anesthetic exposure, urinary F- excretion in Groups 2 and 3 was significantly higher than in Groups 1 and 4. This study demonstrated that prior exposure to halothane reduced the metabolism of enflurane; previous work suggested that this was due to an interaction of halothane with hepatic cytochrome P-450.(ABSTRACT TRUNCATED AT 250 WORDS)

A method for the gas chromatographic analysis of inhalation anaesthetics in whole blood by direct injection into a simple precolumn device.

A simple heated precolumn device constructed from standard gas chromatographic components is described and evaluated. The device permits the analysis of concentrations of anaesthetic agents by direct injection of whole blood containing a suitable internal standard. A method is described for the analysis of halothane, chloroform, trichloroethylene, and methoxyflurane. The procedure is rapid and of acceptable accuracy.