Simulation training results in performance retention for the management of airway fires: A prospective observational study.

Given the severity of the consequences of operating room fires, it is recommended that every anaesthesiologist master fire safety protocols and periodically participate in operating room fire drills. The aim of the present study was to evaluate skill retention one year after an airway fire training programme. Anaesthesiology residents were evaluated using an airway fire simulation-based scenario one year after an educational programme that included a one-h long problem-based learning session, a simulation-based airway fire drill with debriefing, and a formal group discussion. The same simulation scenario was used for both the initial training and the one-year assessment. Thirty-eight anaesthesiology residents participated as pairs in the initial training programme. Of these, 36 participated in the evaluation a year later. Performance after one year was better than performance during the initial simulation. Time to removal of tracheal tube was 7.0 (4.0-12.8) s (median (interquartile range)) at the one-year assessment compared with 22.0 (18.5-52.5) s at the time of initial training (P < 0.001). Performance improvement was also demonstrated by a higher incidence of performance of crucial action items (cessation of airway gases, removal of sponges and pouring of saline), as well as shorter duration of time necessary to perform these tasks. After controlling the fire, the time to re-establish ventilation by bag-mask ventilation or intubation was shorter at one year: 18.0 (11.0-29.0 ) s, compared with initial training 54.0 s (36.2-69.8) s (P = 0.001). We conclude that skills are effectively retained for a year after an airway fire management training session.

What are we missing? The quality of intraoperative handover before and after introduction of a checklist.

PURPOSE: Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer. METHODS: From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer. RESULTS: Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P < 0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P < 0.01). CONCLUSION: Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.

RéSUMé: OBJECTIF: Les transferts peropératoires sont fréquents dans la pratique de l'anesthésie et sont associés à une augmentation de la morbidité et de la mortalité des patients. Les listes de vérification pourraient améliorer le transfert d'informations pendant les transitions. Cette étude avant-après a cherché à examiner l'effet d'une liste de vérification sur les transferts peropératoires. Nous avons émis l'hypothèse que l'introduction d'une liste de vérification de transfert améliorerait notre critère d'évaluation principal, nommément la complétude du transfert des informations. MéTHODE: De février à août 2016, des prestataires d'anesthésie (résidents, fellows et consultants) d'un seul centre universitaire tertiaire ont participé à une étude sur les transferts. Les transferts de base entre les fournisseurs de soins d'anesthésie ont été filmés, analysés et comparés aux dossiers d'anesthésie. Une liste de contrôle de transfert peropératoire a ensuite été introduite, et les transferts réalisés avec celle-ci ont été filmés. La complétude des transferts a été comparée entre les groupes faisant un transfert normal de base et ceux utilisant la liste de vérification. Le critère d'évaluation principal était la complétude du transfert d'informations. RéSULTATS: Soixante-sept fournisseurs d'anesthésie ont participé à l'étude. L'utilisation de la liste de vérification de transfert peropératoire a amélioré la complétude du transfert de 6 % (intervalle de confiance [IC] à 95 %, 2 à 10; P < 0,01). Aucune relation n'a été observée entre le fournisseur (consultants/fellows) vs résidents) responsable des transferts et le degré de complétude du transfert (IC 95 %, 3 à 8; P = 0,33). La complexité a eu un impact significatif sur la complétude du transfert, les cas de basse ou haute complexité étant transférés de manière plus complète que les cas de complexité moyenne, tant avant qu'après l'intervention ­ avec une augmentation de 6 % pour les cas de faible complexité (IC 95 %, 1 à 11; P = 0,02) et une augmentation de 9 % pour les cas de complexité élevée (IC 95 %, 3 à 14; P < 0,01). CONCLUSION: L'utilisation d'une liste de vérification lors des transferts peropératoires a amélioré la complétude du transfert des informations. Les listes de vérification de transfert devraient être envisagées pour améliorer la complétude des transferts.

Investigating faculty assessment of anesthesia trainees and the failing-to-fail phenomenon: a randomized controlled trial.

PURPOSE: A growing body of evidence has shown that supervisors may "fail to fail" trainees even when they have judged their performance unsatisfactory. This has significant implications for the implementation of a nationwide competency-based education model of residency training. The objective of this study was to determine the incidence of "failing to fail" clearly underperforming residents. METHODS: Study participants were recruited via an email invitation sent to all departments of anesthesia at each of the hospitals affiliated with the University of Toronto. They were randomized into a high-stakes (assessment would affect the resident's progress) or low-stakes (assessment would not affect the resident's progress) group and asked to assess the performance (fail or pass grade) of a struggling resident. Participants assessed a video depicting an actor managing a scripted simulation scenario. It contained several critical clinical mistakes constituting a clear fail performance. The purpose of the study was only disclosed following the assessment. RESULTS: Of the 288 email invitations sent (144 in each group), 158 (54%) participants completed the study, with 93 in the high-stakes group and 65 in the low-stakes group. Twenty-eight participants (17.7%) failed to issue a failing grade, including 23.1% (15/65) in the high-stakes group and 13.9% (13/93) in the low-stakes group (P = 0.14). CONCLUSIONS: Though often discussed, this is the first study to quantitatively show that the "failing-to-fail" phenomenon likely occurs during residency training performance evaluations. Passing underperforming learners can potentially affect patient safety and result in severe personal consequences to the learner. The results indicate the need for better performance assessment training for faculty members.

RéSUMé: OBJECTIF: Des données probantes de plus en plus nombreuses ont montré que les superviseurs pourraient « échouer à échouer ¼ des résidents même s'ils ont jugé leur performance insatisfaisante. Cela a d'importantes répercussions sur la mise en œuvre d'un modèle national de formation en résidence axé sur les compétences. L'objectif de cette étude était de déterminer l'incidence d' « échouer à échouer ¼ les résidents dont les résultats sont clairement inadéquats. MéTHODE: Les participants à l'étude ont été recrutés au moyen d'une invitation par courriel envoyée à tous les départements d'anesthésie de chacun des hôpitaux affiliés à l'Université de Toronto. Ils ont été randomisés en un groupe à enjeu élevé (l'évaluation aurait une incidence sur la progression académique du résident) et un groupe à faible enjeu (l'évaluation n'affecterait pas la progression académique du résident) et on leur a demandé d'évaluer la performance (échec ou passage) d'un résident en difficulté. Les participants ont évalué une vidéo montrant un acteur prenant en charge un cas de simulation scénarisé. La vidéo comportait plusieurs erreurs cliniques critiques constituant clairement un échec. L'objectif de l'étude n'a été divulgué qu'après l'évaluation. RéSULTATS: Sur les 288 invitations par courriel envoyées (144 dans chaque groupe), 158 (54 %) participants ont terminé l'étude, dont 93 dans le groupe à enjeu élevé et 65 dans le groupe à faible enjeu. Vingt-huit participants (17,7 %) n'ont pas donné de note d'échec, dont 23,1 % (15/65) dans le groupe à enjeu élevé et 13,9 % (13/93) dans le groupe à enjeu faible (P = 0,14). CONCLUSION: Bien que cette question soit souvent discutée, il s'agit de la première étude à montrer quantitativement que le phénomène d' « échouer à échouer ¼ survient probablement lors des évaluations pendant la formation en résidence. Le fait de laisser passer des résidents n'ayant pas acquis les compétences peut potentiellement affecter la sécurité des patients et entraîner de graves conséquences personnelles pour le résident. Les résultats indiquent la nécessité d'une meilleure formation à l'évaluation des performances pour les membres du corps professoral.

Utilizing Patient E-learning in an Intervention Study on Preoperative Smoking Cessation.

BACKGROUND: Patients who smoke put themselves at increased risk for serious surgical complications, yet it is not currently routine practice to educate patients about the risk of complications due to smoking. Computer-based smoking cessation programs are increasingly being utilized in the general population and may overcome some of the barriers such as lack of time, knowledge, and training to provide interventions. Our objective was to develop and implement a patient e-learning program designed for surgical patients as part of a multifaceted program aimed at assisting them to quit smoking and to determine the factors cross-sectionally and longitudinally associated with abstinence. METHODS: In this prospective multicenter study, smokers undergoing elective noncardiac surgery participated in a preoperative smoking cessation program consisting of a patient e-learning program, brief advice, educational pamphlet, tobacco quitline referral, letter to the primary care physician, and pharmacotherapy. The patient e-learning program described (1) the benefits of quitting smoking before surgery; (2) how to quit smoking; and (3) how to cope while quitting. The 7-day point prevalence (PP) abstinence on the day of surgery and at 1, 3 and 6 six months after surgery was separately assessed, and factors most associated with abstinence were identified using multivariable logistic regression analysis. Generalized estimating equation methods were used to estimate effect of the factors associated with abstinence longitudinally. The reach of the program was assessed with the number of smokers who participated in the program versus the number of patients who were referred to the program. RESULTS: A total of 459 patients (68.9% of eligible patients) participated. The 7-day PP abstinence at day of surgery, 1 month, 3 months, and 6 months was 22%, 29%, 25%, and 22%, respectively. The variables predicting abstinence at 6 months were use of pharmacotherapy (odds ratio [OR], 7.32; 95% confidence interval [CI], 3.71-14.44; P < .0001) and number of contacts with a tobacco quitline (OR, 1.60; 95% CI, 1.35-1.90; P < .0001). Presence of other smokers in the household (OR, 0.39; 95% CI, 0.21-0.72; P = .0030) and amount spent on cigarettes weekly at baseline (per $10 increase) (OR, 0.73; 95% CI, 0.61-0.87; P = .0004) were barriers to abstinence. CONCLUSIONS: Our preoperative smoking cessation program resulted in a 7-day PP abstinence of 22% at 6 months. A multifaceted intervention including a patient e-learning program may be a valuable tool to overcome some of the barriers to help surgical patients quit smoking.

The Effect of Gabapentin on Delayed Discharge from the Postanesthesia Care Unit: A Retrospective Analysis.

BACKGROUND: Enhanced recovery after surgery programs has incorporated gabapentin as part of a multimodal analgesia protocol. The preemptive use of gabapentin was found to be beneficial due to its opioid-sparing effect. However, excessive sedation and delayed discharge from postanesthesia recovery units are of concern. The aim of this study was to investigate whether preoperative gabapentin increased the length of stay in the recovery unit. METHODS: This retrospective cross-sectional study was carried out over a period of 2 months in the postanesthesia care unit (PACU) of a tertiary care hospital in Canada. Two hundred and twenty-eight consecutive patients who underwent elective surgical procedures and who required a longer than 2-hour stay in the PACU were included. Prolonged stays caused by respiratory inadequacy, hemodynamic instability, nausea, vomiting, pain, and loss of consciousness were recorded. The data were collected from patients' charts and nursing flow sheets. RESULTS: All patients were grouped into those who received 300 mg gabapentin (n = 108), 600 mg gabapentin (n = 41), and no gabapentin (n = 139). No significant difference was observed between the groups in terms of opioid consumption, respiratory inadequacy, nausea, vomiting, and hemodynamic parameters. Gabapentin administration groups had significantly lower postoperative pain scores (P < 0.001). Decreased level of consciousness occurred significantly more often in a dose-dependent fashion in the gabapentin groups and led to a longer stay in the PACU (P < 0.001). CONCLUSION: In the setting of enhanced recovery after surgery, gabapentin did reduce pain scores, but at the cost of delayed discharge from the recovery room. Future studies are needed to evaluate the efficacy of gabapentin in this setting.

Effective learning environments - the process of creating and maintaining an online continuing education tool.

Continuing medical education (CME) is an indispensable part of maintaining physicians' competency. Since attending conferences requires clinical absenteeism and is not universally available, online learning has become popular. The purpose of this study is to conduct a retrospective analysis examining the creation process of an anesthesia website for adherence to the published guidelines and, in turn, provide an illustration of developing accredited online CME. Using Kern's guide to curriculum development, our website analysis confirmed each of the six steps was met. As well, the technical design features are consistent with the published literature on efficient online educational courses. Analysis of the database from 3937 modules and 1628 site evaluations reveals the site is being used extensively and is effective as demonstrated by the participants' examination results, content evaluations and reports of improvements in patient management. Utilizing technology to enable distant learning has become a priority for many educators. When creating accredited online CME programs, course developers should understand the educational principles and technical design characteristics that foster effective online programs. This study provides an illustration of incorporating these features. It also demonstrates significant participation in online CME by anesthesiologists and highlights the need for more accredited programs.

Challenging Authority During an Emergency-the Effect of a Teaching Intervention.

OBJECTIVES: Previous research has shown that residents were unable to effectively challenge a superior's wrong decision during a crisis situation, a problem that can contribute to preventable mortality. We aimed to assess whether a teaching intervention enabled residents to effectively challenge clearly wrong clinical decisions made by their staff. SUBJECTS AND INTERVENTION: Following ethics board approval, second year residents were randomized to a teaching intervention targeting cognitive skills needed to challenge a superior's decision, or a control group receiving general crisis management instruction. Two weeks later, subjects participated in a simulated crisis that presented them with opportunities to challenge clearly wrong decisions in a can't-intubate-can't-ventilate scenario. It was only disclosed that the staff was a confederate during the debriefing. Performances were video recorded and assessed by two raters blinded to group allocation using the modified Advocacy-Inquiry Score. MEASUREMENTS AND MAIN RESULTS: Fifty residents completed the study. The interrater reliability of the modified Advocacy-Inquiry Scores (intraclass correlation coefficient = 0.87) was excellent. The median (interquartile range) best modified Advocacy-Inquiry Score was significantly better in the intervention group 5.0 (4.50-5.62 [4-6]) than in the control group 3.5 (3.0-4.75 [3-6]) (p < 0.001). CONCLUSIONS: A short targeted teaching intervention was effective in significantly improving residents' ability to challenge a wrong decision by a superior. This suggests that residents are not given the proper tools to challenge authority during a life-threatening crisis situation. This educational gap can have significant implications for patients' safety.

Physician and Patient Survey of Taper Schedule and Family Physician Letters Following Discharged from the Acute Pain Service.

PURPOSE: Following discharge, patients requiring high opioid doses may be at risk for both under- and overdosing, posing a major challenge to community physicians. The aim of this study was to examine the effectiveness and degree of satisfaction with a personalized taper schedule and physician letter through interviews of patients and physicians. METHODS: This was a 1-year prospective study. Following ethics approval and informed written consent, patients admitted for elective surgery, 18 to 60 years of age, receiving opioid analgesics, were recruited. Prior to discharge, the acute pain service team provided patients with a taper schedule explained in detail. Individualized physician letters were faxed to treating family physicians. Patients were contacted by phone 2, 4, and 6 weeks after discharge. Physicians were contacted once, a month after discharge. Patients and physicians were asked to grade the taper schedule on a 1- to 5-point Likert scale. Questions pertained to clarity, usefulness, ability to follow the instructions, and general satisfaction. RESULTS: Twenty-six patients and 21 physicians completed the study. Physicians were generally satisfied with both the taper schedule and letter and rated all aspects between 3.76 and 4.38 of 5. Similarly, patients were satisfied with the taper schedule and rated all aspects between 4.08 and 4.5. CONCLUSIONS: Both physicians and patients generally found the taper schedule and letter helpful in assisting them to taper off their opioid use. This is one way of bridging the gap in continuity of care between the acute and primary care providers while reducing the risk to patients during the transition period.

Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial.

BACKGROUND: Misidentification of the cricothyroid membrane in a "cannot intubate-cannot oxygenate" situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy. METHODS: A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1-easy = visual landmarks; 2-moderate = requires light palpation of landmarks; 3-difficult = requires deep palpation of landmarks; and 4-impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time. RESULTS: Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult-impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001). CONCLUSION: Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

Role of contextualizing a crisis scenario on the performance of a cricothyrotomy procedural task.

PURPOSE: Simulation is an important alternative to evaluate cricothyrotomy, a rare life-saving procedure. This crossover study aimed to determine whether contextualization of a crisis scenario would impact the performance of a cricothyrotomy procedural task. METHODS: Sixty-five anesthesia assistants and emergency medicine and anesthesia residents underwent a teaching session in surgical cricothyrotomy using one of two sets of cricothyrotomy kits: the Portex 6.0 and Melker 3.5 (n = 32) or the Portex 6.0 and Melker 5.0 (n = 33). Within six weeks following the session, the participants performed cricothyrotomies on a full-body patient mannequin simulator coupled with a porcine larynx (tissue-mannequin simulator) using the assigned two kits in a "cannot intubate, cannot ventilate" (CICV) contextualized scenario (CS) and in a CICV verbalized non-contextualized scenario (NCS). Each participant performed a total of four cricothyrotomies using the two kits in the two scenarios. The primary outcome measure was insertion time, and secondary outcome measures were severity of injuries and failure rate. Outcome measures were compared between scenarios for each kit. RESULTS: Mean (SD) insertion time for a successful cricothyrotomy was not significantly different between NCS and CS for the Melker 3.5 [83.0 (45.0) sec vs 63.3 (36.1) sec, respectively; P = 0.96; mean difference (MD), 19.7 sec; 95% confidence interval (CI), -1.9 to 41.3], the Melker 5.0 [86.5 (36.8) sec vs 107.1 (55.6) sec, respectively; P = 0.11; MD, -20.6 sec; 95% CI, -44.9 to 3.7], and the Portex 6.0 [59.5 (35.5) sec vs 59.0 (35.0) sec, respectively; P = 0.95; MD, 0.5 sec; 95% CI, -13.2 to 14.2]. Failure rate and severity of injuries, measured as mean average injury score for each kit, were also similar between scenarios. CONCLUSIONS: Contextualization of a crisis scenario did not affect the performance of a cricothyrotomy procedural task on a tissue-mannequin simulator. These findings may have implications when considering the feasibility and cost-effectiveness for assessing the performance of cricothyrotomy procedural tasks.

Substance abuse: a national survey of Canadian residency program directors and site chiefs at university-affiliated anesthesia departments.

PURPOSE: The abuse of substances available to anesthesiologists in their workspace is a potentially lethal occupational hazard. Our primary objective was to define the prevalence of substance abuse cases among Canadian anesthesiologists at university-affiliated hospitals. Our secondary aim was to describe the current management of confirmed cases, rehabilitation procedures being offered, and preventative strategies being employed. METHODS: We conducted a cross-sectional electronic survey of all Canadian anesthesia residency program directors and site chiefs at university-affiliated hospitals. Data analysis was performed using descriptive statistics. RESULTS: The survey response rate was 54% (53/98). Substance abuse was reported as 1.6% for residents and 0.3% for clinical fellows over a ten-year period ending in June 2014. Fentanyl was abused in nine of 24 reported cases. At present, one of 22 respondents (4.5%) reported a formal education program on substance abuse for faculty members, and 72% described mandatory education for residents. The majority of participants did not perceive substance abuse as a growing problem. Seventy-one percent of respondents indicated that methods for controlled-drug handling had changed in the previous ten years; however, 66% did not think that the incidence of controlled substance abuse could be decreased further by more stringent measures. Only 21% of respondents supported the introduction of random urine drug testing. CONCLUSION: The prevalence of substance abuse among Canadian anesthesiologists and the substances abused appear comparable with data from the United States, with residents being the group most often affected. Early recognition and treatment of chemically dependent anesthesiologists remain imperfect.

Residents' reluctance to challenge negative hierarchy in the operating room: a qualitative study.

PURPOSE: Our aim was to clarify how hierarchy influences residents' reluctance to challenge authority with respect to clearly erroneous medical decision-making. METHODS: After research ethics approval, we recruited 44 anesthesia residents for a high-fidelity simulation scenario at two Ontario universities. During the scenario, an actor, whom the residents were told was an actual new staff anesthesiologist at their university, asked the trainees to give blood to a Jehovah's Witness in contradiction to the patient's explicitly stated wishes. Following the case, the trainees were debriefed and were interviewed for 30-40 min. The interviews were audio recorded and transcribed verbatim, and the text was coded using a qualitative approach informed by grounded theory. RESULTS: Qualitative analysis of the participants' interviews yielded rich descriptive accounts of hierarchical influences often characterized by fear and intimidation. Residents spoke about their coping strategies, which included adaptability, avoiding conflict, using inquiry as a method for patient advocacy, and relying on a diffusion of responsibility within the larger operating room team. CONCLUSIONS: Study results showed that hierarchy played a dominant role in the functioning of the operating room. Participants spoke of both the positive and negative effects of such a hierarchical learning environment. The majority of participants described a negative perception of hierarchy as the norm, and they employed many coping strategies. This study provides insight into how a negative hierarchical culture can adversely impact patient safety, resident learning, and team functioning. We propose a theoretical model to describe challenging authority in this context.

Cricothyrotomy training increases adherence to the ASA difficult airway algorithm in a simulated crisis: a randomized controlled trial.

PURPOSE: Non-adherence to airway guidelines in a 'cannot intubate-cannot oxygenate' (CICO) crisis situation is associated with adverse patient outcomes. This study investigated the effects of hands-on training in cricothyrotomy on adherence to the American Society of Anesthesiologists difficult airway algorithm (ASA-DAA) during a simulated CICO scenario. METHODS: A total of 21 postgraduate second-year anesthesia residents completed a pre-test teaching session during which they reviewed the ASA-DAA, became familiarized with the Melker cricothyrotomy kit, and watched a video on cricothyrotomy. Participants were randomized to either the intervention 'Trained' group (n = 10) (taught and practiced cricothyrotomy) or the control 'Non-Trained' group (n = 11) (no extra training). After two to three weeks, performances of the groups were assessed in a simulated CICO scenario. The primary outcome measure was major deviation from the ASA-DAA. Secondary outcome measures were (1) performance of the four categories of non-technical behaviours using the validated Anaesthetists' Non-Technical Skills scale (ANTS) and (2) time to perform specific tasks. RESULTS: Significantly more non-trained than trained participants (6/11 vs 0/10, P = 0.012) committed at least one major ASA-DAA deviation, including failure to insert an oral airway, failure to call for help, bypassing the laryngeal mask airway, and attempting fibreoptic intubation. ANTS scores for all four categories of behaviours, however, were similar between the groups. Trained participants called for help faster [26 (2) vs 63 (48) sec, P = 0.012] but delayed opening of the cricothyrotomy kit [130 (50) vs 74 (36) sec, P = 0.014]. CONCLUSION: Hands-on training in cricothyrotomy resulted in fewer major ASA-DAA deviations in a simulated CICO scenario. Training in cricothyrotomy may play an important role in complying with the ASA-DAA in a CICO situation but does not appear to affect non-technical behaviours such as decision-making.

The effect of gowning on labor epidural catheter colonization rate: a randomized controlled trial.

BACKGROUND: The need to gown for labor epidural catheter insertion is controversial. The American Society of Regional Anesthesia and Pain Medicine has identified a lack of randomized controlled trials investigating this issue. The purpose of this study was to examine the effect of gowning on colonization rates following epidural catheter insertion for labor analgesia. METHODS: Following research ethics board approval and informed written consent, parturients were randomized to undergo epidural analgesia with the anesthesiologist either ungowned or wearing a sterile gown. Cultures were obtained from each of the operator forearms, the work area under the insertion site, and from the epidural catheter tip as well as from the catheter segment adjacent to the insertion site. The primary outcome was growth of any microbial organisms from the cultured sites. RESULTS: Two hundred fourteen patients completed the study. There were no significant differences in catheter-tip colonization rates between the ungowned and gowned groups (9.2% vs 7.6%, respectively). The most common microorganism that was cultured was coagulase-negative Staphylococcus. CONCLUSIONS: The use of gowns in the current study did not affect catheter colonization rate. Overall, there was a relatively high incidence of catheter-tip colonization in both groups, which underscores the need for strict aseptic technique.