Comparación de dos estrategias educacionales para la enseñanza del procedimiento de manejo de vía aérea en programas de práctica deliberada aplicados a estudiantes de medicina: ensayo randomizado

Background: Clinical simulation allows the acquisition of procedural skills among medical students. The anticipatory study of these skills may improve the efficiency of simulation sessions. Aim: To Compare two anticipatory study guides in the simulation of airway management, in a cohort of medical students from Chile. Material and Methods: Fifth year medical students were randomly assigned to prepare the simulation of tracheal intubation with a theoretical guide, an audiovisual guide, and a control group without study. The skills acquired were evaluated in a simulated scenario. Results: All groups increased their successful orotracheal intubation (OTI) rate and decreased the time to achieve a successful OTI after each attempt. The study group with a theoretical guide had the higher rate of success in the 1st OTI attempt without feedback. In contrast, the group without any anticipatory study had more failed attempts (1st and 2nd attempt), achieving their first successful OTI in the 3rd attempt after feedback. Conclusions: Study guides improve practice effectiveness. Our results indicate that the best results are obtained by simulation accompanied with immediate directed feedback and opportunities to repeat the procedures, independent of the type of anticipatory study.

[Simulation of tracheal intubation for medical students. The effects of anticipatory study]. / Comparación de dos estrategias educacionales para la enseñanza del procedimiento de manejo de vía aérea en programas de práctica deliberada aplicados a estudiantes de medicina: ensayo randomizado.

BACKGROUND: Clinical simulation allows the acquisition of procedural skills among medical students. The anticipatory study of these skills may improve the efficiency of simulation sessions. AIM: To Compare two anticipatory study guides in the simulation of airway management, in a cohort of medical students from Chile. MATERIAL AND METHODS: Fifth year medical students were randomly assigned to prepare the simulation of tracheal intubation with a theoretical guide, an audiovisual guide, and a control group without study. The skills acquired were evaluated in a simulated scenario. RESULTS: All groups increased their successful orotracheal intubation (OTI) rate and decreased the time to achieve a successful OTI after each attempt. The study group with a theoretical guide had the higher rate of success in the 1st OTI attempt without feedback. In contrast, the group without any anticipatory study had more failed attempts (1st and 2nd attempt), achieving their first successful OTI in the 3rd attempt after feedback. CONCLUSIONS: Study guides improve practice effectiveness. Our results indicate that the best results are obtained by simulation accompanied with immediate directed feedback and opportunities to repeat the procedures, independent of the type of anticipatory study.

Cxs and Panx- hemichannels in peripheral and central chemosensing in mammals.

Connexins (Cxs) and Pannexins (Panx) form hemichannels at the plasma membrane of animals. Despite their low open probability under physiological conditions, these hemichannels release signaling molecules (i.e., ATP, Glutamate, PGE2) to the extracellular space, thus subserving several important physiological processes. Oxygen and CO2 sensing are fundamental to the normal functioning of vertebrate organisms. Fluctuations in blood PO2, PCO2 and pH are sensed at the carotid bifurcations of adult mammals by glomus cells of the carotid bodies. Likewise, changes in pH and/or PCO2 of cerebrospinal fluid are sensed by central chemoreceptors, a group of specialized neurones distributed in the ventrolateral medulla (VLM), raphe nuclei, and some other brainstem areas. After many years of research, the molecular mechanisms involved in chemosensing process are not completely understood. This manuscript will review data regarding relationships between chemosensitive cells and the expression of channels formed by Cxs and Panx, with special emphasis on hemichannels.

Shifting from hypoxia to hyperoxia to assess the peripheral chemosensory drive of ventilation.

The study of the initial effects of a sudden and brief replacement of air by pure oxygen has been proposed as a tool (Dejours' test) to determine the tonic influence that arterial (peripheral) chemoreceptors were exerting upon ventilation under previous normoxic conditions. Therefore, the acute ventilatory response to transient hyperoxia should be used to assess the level of hypoxic chemosensory drive. In spontaneously ventilated pentobarbitone-anesthetized cats, we observed that the degree of ventilatory depression provoked by hyperoxia was correlated to the degree of previous hypoxia. Minimal tidal volumes (V(T)) or transient apnea were reached between second to fourth cycles after switching from 5% to 100% O(2) breathing. Continuous recordings of chemosensory discharges from one carotid (sinus) nerve allowed correlation of the falls in frequency of chemosensory discharges to the degree of hyperoxia-induced ventilatory depression and provided an accurate measure of the prevailing chemosensory drive of ventilation exerted during hypoxic steady-state conditions.

LPS-induced c-Fos activation in NTS neurons and plasmatic cortisol increases in septic rats are suppressed by bilateral carotid chemodenervation.

Lipopolysaccharide (LPS) administered I.P. increases significantly the activation of c-Fos in neurons of the nucleus of the solitary tract (NTS), which in turn activates hypothalamus-pituitary-adrenal axis. The vagus nerve appears to play a role in conveying cytokines signals to the central nervous system (CNS), since -in rodent models of sepsis- bilateral vagotomy abolishes increases in plasmatic glucocorticoid levels, but does not suppress c-Fos NTS activation. Considering that NTS also receives sensory inputs from carotid body chemoreceptors, we evaluated c-Fos activation and plasmatic cortisol levels 90 min after I.P. administration of 15 mg/kg LPS. Experiments were performed in male Sprague-Dawley rats, in control conditions and after bilateral carotid neurotomy (BCN). LPS administration significantly increases the number of c-Fos positive NTS neurons and plasmatic cortisol levels in animals with intact carotid/sinus nerves. When LPS was injected after BCN, the number of c-Fos positive NTS neurons, and plasmatic cortisol levels were not significantly modified. Our data suggest that carotid body chemoreceptors might mediate CNS activation during sepsis.

Lipopolysaccharide-induced carotid body inflammation in cats: functional manifestations, histopathology and involvement of tumour necrosis factor-alpha.

In the absence of information on functional manifestations of carotid body (CB) inflammation, we studied an experimental model in which lipopolysaccharide (LPS) administration to pentobarbitone-anaesthetized cats was performed by topical application upon the CB surface or by intravenous infusion (endotoxaemia). The latter caused: (i) disorganization of CB glomoids, increased connective tissue, and rapid recruitment of polymorphonuclear cells into the vascular bed and parenchyma within 4 h; (ii) increased respiratory frequency and diminished ventilatory chemoreflex responses to brief hypoxia (breathing 100% N(2) for 10 s) and diminished ventilatory chemosensory drive (assessed by 100% O(2) tests) during normoxia and hypoxia; (iii) tachycardia, increased haematocrit and systemic hypotension in response to LPS i.v.; and (iv) increased basal frequency of carotid chemosensory discharges during normoxia, but no change in maximal chemoreceptor responses to brief hypoxic exposures. Lipopolysaccharide-induced tachypnoea was prevented by prior bilateral carotid neurotomy. Apoptosis was not observed in CBs from cats subjected to endotoxaemia. Searching for pro-inflammatory mediators, tumour necrosis factor-alpha (TNF-alpha) was localized by immunohistochemistry in glomus and endothelial cells; reverse transcriptase-polymerase chain reaction revealed that the CB expresses the mRNAs for both type-1 (TNF-R1) and type-2 TNF-alpha receptors (TNF-R2); Western blot confirmed a band of the size expected for TNF-R1; and histochemistry showed the presence of TNF-R1 in glomus cells and of TNF-R2 in endothelial cells. Experiments in vitro showed that the frequency of carotid nerve discharges recorded from CBs perfused and superfused under normoxic conditions was not significantly modified by TNF-alpha, but that the enhanced frequency of chemosensory discharges recorded along responses to hypoxic stimulation was transiently diminished in a dose-dependent manner by TNF-alpha injections. The results suggest that the CB may operate as a sensor for immune signals, that the CB exhibits histological features of acute inflammation induced by LPS, that TNF-alpha may participate in LPS-induced changes in chemosensory activity and that some pathophysiological reactions to high levels of LPS in the bloodstream may originate from changes in CB function.

Are there interactions between acetylcholine- and ATP-induced responses at the level of a visceral sensory ganglion?

We investigate possible interactions between acetylcholine (ACh)- and adenosine 5'-triphosphate (ATP)-induced responses of petrosal ganglion, where the perikarya of most sensory neurons of the glossopharyngeal nerve are located. Experiments were performed on petrosal ganglia excised from pentobarbitone-anesthetized cats, desheathed and perfused in vitro. Separate applications of ACh and ATP to the exposed surface of the ganglion induced bursts of antidromic potentials recorded from the carotid (sinus) nerve branch of the glossopharyngeal nerve, which frequencies were dependent on the dose of the applied agonists. The simultaneous application of previously determined ED50s of ACh and ATP provoked responses corresponding closely to the simple addition of the responses elicited by the separate application of each agent. Responses usually subsided within 1 min of stimuli application but were followed by periods of refractoriness to subsequent application of the same agent. After determining the timing for recovering from desensitization to the ED50s of ACh and ATP applied separately, ACh was applied while the preparation had been desensitized to ATP and then ATP was applied during desensitization to ACh, but responses obtained were similar to control responses induced by each agent separately. In summary, ACh- and ATP-induced responses of petrosal ganglion neurons are simply additive, followed by a few minute lasting desensitization, but cross-desensitization was not observed. Thus, ACh and ATP seem to operate through independent receptors, activating separate ionic channels, whose coincident currents do not interfere each other.