Stress Management Training Improves Overall Performance during Critical Simulated Situations: A Prospective Randomized Controlled Trial.

BACKGROUND: High-fidelity simulation improves participant learning through immersive participation in a stressful situation. Stress management training might help participants to improve performance. The hypothesis of this work was that Tactics to Optimize the Potential, a stress management program, could improve resident performance during simulation. METHODS: Residents participating in high-fidelity simulation were randomized into two parallel arms (Tactics to Optimize the Potential or control) and actively participated in one scenario. Only residents from the Tactics to Optimize the Potential group received specific training a few weeks before simulation and a 5-min reactivation just before beginning the scenario. The primary endpoint was the overall performance during simulation measured as a composite score (from 0 to 100) combining a specific clinical score with two nontechnical scores (the Ottawa Global Rating Scale and the Team Emergency Assessment Measure scores) rated for each resident by four blinded independent investigators. Secondary endpoints included stress level, as assessed by the Visual Analogue Scale during simulation. RESULTS: Of the 134 residents randomized, 128 were included in the analysis. The overall performance (mean ± SD) was higher in the Tactics to Optimize the Potential group (59 ± 10) as compared with controls ([54 ± 10], difference, 5 [95% CI, 1 to 9]; P = 0.010; effect size, 0.50 [95% CI, 0.16 to 0.91]). After specific preparation, the median Visual Analogue Scale was 17% lower in the Tactics to Optimize the Potential group (52 [42 to 64]) than in the control group (63 [50 to 73]; difference, -10 [95% CI, -16 to -3]; P = 0.005; effect size, 0.44 [95% CI, 0.26 to 0.59]. CONCLUSIONS: Residents coping with simulated critical situations who have been trained with Tactics to Optimize the Potential showed better overall performance and a decrease in stress level during high-fidelity simulation. The benefits of this stress management training may be explored in actual clinical settings, where a 5-min Tactics to Optimize the Potential reactivation is feasible prior to delivering a specific intervention.

Clinical Complications of Continuous Renal Replacement Therapy.

The various complications of continuous renal replacement therapy (CRRT) are mostly preventable. Hemodynamic disturbances are dominated by hypotension due to the modification of volume status, myocardial dysfunction, cardiac arrhythmia, or modification of systemic vascular resistances, which are correlated with body temperature changes. Metabolic complications remain at the forefront and have profoundly changed with the use of regional citrate anticoagulation (RCA). RCA may lead to two distinct situations: citrate overload and citrate accumulation, respectively, responsible for metabolic alkalosis and metabolic acidosis. Electrolyte imbalance is also a classic occurrence with RCA. The chelation of cations by citrate results in hypocalcemia and hypomagnesemia in case of inappropriate substitution. Hemorrhagic complications have been drastically reduced mostly for two reasons: the use of systematic ultrasound guidance for the insertion of dialysis catheters and the use of RCA instead of systemic heparin anticoagulation. Hypothermia induced by CRRT and complications associated with prolonged bed rest are also better controlled today. Finally, the removal of undesired substances remains a major issue, especially when it comes to antibiotics, vitamins and micronutrients, molecules for which the intake should be adapted in case of CRRT.