Epidemiology and complications of anaesthesia in the French centres that participated to NECTARINE: A secondary analysis.

INTRODUCTION: Neonatal and infant anaesthesia are associated with a high risk of perioperative complications. The aim of the current study was to describe those risks in France using the French data from the NECTARINE study. MATERIAL AND METHODS: Data from the French centres that participated to the NECTARINE study were analysed. The primary goal of the study was the description of patients' characteristics, procedures and perioperative management and their comparison with the results of the European NECTARINE study. Secondary outcomes were the description of major perioperative complications and death. RESULTS: Overall, 926 procedures collected in 15 centres (all teaching hospitals) were analysed. Comparison between the French and European NECTARINE cohorts found few differences related to patients' characteristics and procedures. The rate of interventions for critical events (respiratory, haemodynamic, and metabolic) was similar between the two cohorts. Near-infrared spectroscopy monitoring was used in 12% of procedures. Nearly none of the thresholds for these interventions met the published standards. By day 30, complications (respiratory, haemodynamic, metabolic, renal, and liver failure) and death were observed in 14.4% [95% CI 11.6-16.4]% and 1.8% [95% CI 1.1-2.9] of cases, respectively. DISCUSSION: Although the health status of the patients in the French cohort was less severe, procedures, management and postoperative complications and mortality rates were similar to the European cohort. However, thresholds for interventions were often inadequate in both cohorts. Efforts should be undertaken to improve the knowledge and use of new monitoring devices in this population.

External Cardiac Massage Training of Medical Students: A Randomized Comparison of Two Feedback Methods to Standard Training.

BACKGROUND: The most recent recommendations support learning of external cardiac massage (ECM) through feedback devices. OBJECTIVES: The objective was to compare the effects on immediate and 3-month retention of ECM technical skills when using feedback devices compared with training without feedback as part of a half-day training session in medical students. METHODS: This randomized study was performed using the Resusci Anne QCPR manikin in 64 medical students. We compared the quality of ECM with nonfeedback training in the control group (group 1) vs. 2 feedback learning methods (group 2, PocketCPR and group 3, Skill Reporter each used with visual display available to the trainee). At the end of the training session and 3 months later, students performed chest compressions blindly during a 2-min assessment session. The median compression score was the primary outcome for assessing immediate and long-term retention. RESULTS: Regarding immediate retention, the median compression score was significantly lower in group 1 (23%) than in groups 2 (81%) and 3 (72%) (p < 0.05) with no difference between the 2 feedback methods. At 3 months, mean compression scores remained high but not significantly different between the 2 feedback groups. CONCLUSION: The use of a feedback device used for ECM training improves the quality of immediate retention of technical ECM skills compared with traditional teaching in medical students. At 3 months, the 2 groups with feedback retained a high level of performance. No significant difference could be demonstrated between the 2 feedback methods.

Impact of learners' role (active participant-observer or observer only) on learning outcomes during high-fidelity simulation sessions in anaesthesia: A single center, prospective and randomised study.

AIM: The increasing use of high-fidelity simulation is limited by the imbalance between the growing number of students and the human resources available in such a way that all residents cannot play a role during scenarios. The learning outcomes of observers need to be studied. METHODS: This prospective randomised study was approved by the institutional review board. Anaesthesia residents attending a one-day training session were enrolled. In each of the four scenarios, three residents played an active role while others observed in a separate room. All participants attended debriefing sessions. Residents were randomised between active participant-observer group (AP-O group) and observer group (O group). A similar questionnaire was distributed before, immediately after the session and after three months and included self-reported assessment of satisfaction, medical knowledge (noted 0-16), and non-technical skills. RESULTS: A hundred and four questionnaires were analysed. Immediately after the simulation, a significant increase in medical knowledge was recorded but was higher in the AP-O group (6 [5-8] to 10 [8-11]/16) than in the O group (7 [5-8] to 9 [7-10]/16). High scores for non-technical skills were similarly observed in both groups. Satisfaction was high in both groups but was higher in the AP-O group (9 [8-9] versus 8 [8-9]/10, P=0.019). Decay of knowledge was observed for most main outcomes at three months. CONCLUSION: This study suggests an immediate improvement of learning outcomes for both roles after immersive simulation but some learning outcomes may be better for residents engaged as players in scenarios.

Physiological and self-assessed psychological stress induced by a high fidelity simulation course among third year anesthesia and critical care residents: An observational study.

INTRODUCTION: The use of high fidelity simulators in Medicine can improve knowledge, behaviour and practice but may be associated with significant stress. Our objective was to measure physiological and psychological self-assessed intensity of stress before and after a planned simulation training session among third year anaesthesia and critical care residents. METHODS: A convenience sample of 27 residents participating in a simulation training course was studied. Stress was evaluated by self-assessment using a numerical scale and by salivary amylase concentration before and after the session. Technical and non-technical (using the Aberdeen Anaesthetists' Non Technical Skills scale) performances were assessed through videotapes analysis. RESULTS: The median stress score was 5 (2-8) before and 7 (2-10) after the simulation session (P<0.001). For 48% of residents studied, the stress score after the session was superior or equal to 8/10. Salivary amylase concentration increased significantly after the session compared to before the session, respectively (1,250,440±1,216,667 vs. 727,260±603,787IU/L, P=0.008). There was no significant correlation between stress parameters and non-technical performance. DISCUSSION: Simulation-induced stress, as measured by self-assessment and biological parameter, is high before the session and increases significantly during the course. While this stress did not seem to impact performance negatively, it should be taken into account.

Comparison of monitoring performance of bioreactance versus esophageal Doppler in pediatric patients.

BACKGROUND AND AIMS: Cardiac output (CO) monitoring and goal-directed therapy during major abdominal surgery is currently used to decrease postoperative complications. However, few monitors are currently available for pediatric patients. Nicom(®) is a noninvasive CO monitoring technique based on the bioreactance principle (analysis of frequency variations of a delivered oscillating current traversing the thoracic cavity). Nicom(®) may be a useful monitor for pediatric patients. SUBJECTS AND METHODS: Pediatric patients undergoing major abdominal surgery under general anesthesia with cardiac monitoring by transesophageal Doppler (TED) were included. Continuously recorded hemodynamic variables obtained from both bioreactance and TED were compared. Data were analyzed using the Bland-Altman method. RESULTS: A total of 113 pairs of cardiac index (CI) measurments from 16 patients were analyzed. Mean age was 59 months (95% CI: 42-75) and mean weight was 17 kg (95% CI: 15-20). In the overall population, Bland-Altman analysis revealed a bias of 0.4 L/min/m(2), precision of 1.55 L/min/m(2), limits of agreement of -1.1 to 1.9 L/min/m(2) and a percentage error of 47%. For children weighing >15 kg, results were: Bias 0.51 L/min/m(2), precision 1.17 L/min/m(2), limits of agreement -0.64 to 1.66 L/min/m(2) and percentage error 34%. CONCLUSION: Simultaneous CI estimations made by bioreactance and TED showed high percentage of errors that is not clinically acceptable. Bioreactance cannot be considered suitable for monitoring pediatric patients.

Prophylactic endoscopic sclerotherapy of large esophagogastric varices in infants with biliary atresia.

BACKGROUND: Esophageal varices-related GI bleeding occurs frequently and early in life in children with biliary atresia and it may be life threatening. OBJECTIVE: We report the results of prophylactic sclerotherapy in 13 infants with biliary atresia and large varices. PATIENTS: Mean age was 13 months, mean weight was 8.2 kg, mean total serum bilirubin was 258 mumol/L, and mean prothrombin time was 78%. Esophageal varices were grade III (11 patients) or II (2 patients), with red signs in all infants and gastric varices in 12. None had GI bleeding. INTERVENTION: Sclerotherapy was performed with the patient under continuous intravenous octreotide therapy in 7 infants. RESULTS: In 8 children a complete or almost complete eradication of varices was obtained; none of these children bled later, 4 underwent liver transplantation, 3 are alive without liver transplantation, and 1 died of sepsis after 9 months awaiting liver transplantation. In 4 children a partial eradication was obtained and liver transplantation was performed. None of these children bled. One other child bled to death after 2 sessions of sclerotherapy. LIMITATIONS: Four ulcers and 2 stenoses occurred in 6 children with no octreotide versus no ulcer and 1 stenosis in 7 children receiving octreotide. CONCLUSION: These results (1) indicate that primary prevention of GI bleeding by sclerotherapy of esophageal varices is technically feasible and fairly effective in infants with biliary atresia and large varices, even in those with end-stage liver disease, (2) suggest that decreasing the risk of bleeding may allow liver transplantation under better conditions, and (3) further suggest that octreotide associated with sclerotherapy lowers the rate of complications.