A. Chuan

Are changes in cerebrovascular autoregulation following cardiac arrest associated with neurological outcome? Results of a pilot study.

PURPOSE To investigate the association between impaired cerebrovascular autoregulation (CVAR) and outcome in comatose survivors of cardiac arrest. METHODS The correlation in the time domain between cerebral tissue oxygenation (cStO2) using near infrared spectroscopy (NIRS) and mean arterial pressure was used to determine the tissue oxygenation index (TOx) as a reflection of normal (TOx<0) or impaired (TOx>0) CVAR. Daily measurements (>1h recording time) were performed in the first three days post cardiac arrest. Survival and neurological outcome was assessed at three months following cardiac arrest. A control group of healthy volunteers was also investigated. RESULTS 23 patients and 28 volunteers were studied. All survivors (n=8) of cardiac arrest had a good neurological outcome. The TOx (median [interquartile range] for days 1-3) was higher (Mann Whitney test, p<0.001) in non-survivors (0.04 [-0.02 to -0.16]) compared to survivors (-0.11 [-0.19 to -0.02]) and healthy volunteers (-0.15 [-0.27 to -0.04]) on every day and for days 1-3 following cardiac arrest. The TOx was not significantly different between survivors and healthy volunteers. The cStO2 did not discriminate survivors (67 [62-72]%) from non-survivors (71 [65-75]%). Logistic regression analysis demonstrated TOx to be independently associated with survival at three months post cardiac arrest (odds ratio [95% confidence interval] 0.01 [0.01-0.50], p=0.04). CONCLUSIONS Early impairment of CVAR following cardiac arrest is independently associated with mortality at three months follow-up. Assessments of CVAR could add to the management and prognostication during post-resuscitation care and should be further investigated as a guide to optimise cerebral perfusion pressure.

Evaluation of a task-specific checklist and global rating scale for ultrasound-guided regional anesthesia.

Background and Objectives Checklists and global rating scales (GRSs) are used for assessment of anesthesia procedural skills. The purpose of this study was to evaluate the reliability and validity of a recently proposed assessment tool comprising a checklist and GRS specific for ultrasound-guided regional anesthesia. Methods In this prospective, fully crossed study, we videotaped 30 single-target nerve block procedures performed by anesthesia trainees. Following pilot assessment and observer training, videos were assessed in random order by 6 blinded, expert observers. Interrater reliability was evaluated with intraclass correlation coefficients (ICCs) based on a 2-way random-effects model that took into account both agreement and correlation between observer results. Construct validity and feasibility were also evaluated. Results The ICC between assessors’ total scores was 0.44 (95% confidence interval, 0.27–0.62). All 6 observers scored “experienced trainees” higher than “inexperienced trainees” (median total score 76.7 vs 54.2, P = 0.01), supporting the test’s construct validity. The median time to assess the videos was 4 minutes 29 seconds. Conclusions This is the first study to evaluate the reliability and validity of a combined checklist and GRS for ultrasound-guided regional anesthesia using multiple observers and taking into account both absolute agreement and correlation in determining the ICC of 0.44 for interrater reliability. There was evidence to support construct validity.

Design and validation of the Regional Anaesthesia Procedural Skills Assessment Tool

The aim of this study was to create and evaluate the validity, reliability and feasibility of the Regional Anaesthesia Procedural Skills tool, designed for the assessment of all peripheral and neuraxial blocks using all nerve localisation techniques. The first phase was construction of a 25‐item checklist by five regional anaesthesia experts using a Delphi process. This checklist was combined with a global rating scale to create the tool. In the second phase, initial validation by 10 independent anaesthetists using a test–retest methodology was successful (Cohen kappa ≥ 0.70 for inter‐rater agreement, scores between test to retest, paired t‐test, p > 0.12). In the third phase, 70 clinical videos of trainees were scored by three blinded international assessors. The RAPS tool exhibited face validity (p < 0.026), construct validity (p < 0.001), feasibility (mean time to score < 3.9 min), and overall reliability (intraclass correlation coefficient 0.80 (95% CI 0.67–0.88)). The Regional Anaesthesia Procedural Skills tool used in this study is a valid and reliable assessment tool to score the performance of trainees for regional anaesthesia.

Psychometric evaluation of a direct observation of procedural skills assessment tool for ultrasound-guided regional anaesthesia

Assessment tools must be investigated for reliability, validity and feasibility before being implemented. In 2013, the Australian and New Zealand College of Anaesthetists introduced workplace‐based assessments, including a direct observation of a procedural skills assessment tool. The objective of this study was to evaluate the psychometric properties of this assessment tool for ultrasound‐guided regional anaesthesia. Six experts assessed 30 video‐recorded trainee performances of ultrasound‐guided regional anaesthesia. Inter‐rater reliability, assessed using absolute agreement intraclass correlation coefficients, varied from 0.10 to 0.49 for the nine individual nine‐point scale items, and was 0.25 for a ‘total score’ of all items. Internal consistency was measured by correlation between ‘total score’ and ‘overall performance’ scale item (r = 0.68, p < 0.001). Construct validity was demonstrated by the ‘total score’ correlating with trainee experience (r = 0.51, p = 0.004). The mean time taken to complete assessments was 6 min 35 s.

Visuospatial ability and novice brachial plexus sonography performance

The knowledge on the type and influence of visuospatial ability on sonography performance relevant for ultrasound‐guided regional anaesthesia remains incomplete. The aim of this study was to determine whether four different factors of visuospatial ability are important in determining proficiency and procedure time of novices performing brachial plexus sonography. These factors were spatial visualisation, flexibility of closure, spatial relations and speed of closure.

Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study

Studies have identified multiple risk factors for development of cognitive decline after surgery. Impaired cerebrovascular autoregulation may be a contributor to postoperative cognitive decline.

Competency-based assessment tools for regional anaesthesia: a narrative review

Abstract Competency‐based assessment tools are used in regional anaesthesia to measure the performance of study participants, trainees, and consultants. This narrative review was performed to appraise currently published assessment tools for regional anaesthesia. A literature search found 397 citations of which 28 peer‐reviewed studies met the inclusion criteria of primary psychometric evaluation of assessment tools for regional anaesthesia. The included studies were diverse in the type of assessment and the skill set being assessed. The types of assessments included multiple‐choice questions, hand‐motion analysis, cumulative sum, visuospatial and psychomotor screening, checklists, and global rating scales. The skill sets that were assessed included holistic regional anaesthesia technical and non‐technical performance observed at the bedside, to isolated part‐tasks, such as needle tip visualisation under ultrasound. To evaluate validity and reliability, we compared the studies against published medical education consensus statements on ideal assessment tools. We discuss the relative merits of different tools when used to assess regional anaesthesia, the importance of psychometrically robust assessment tools in competency‐based anaesthesia education, and directions for future education research in regional anaesthesia.

Regional anaesthesia assessment tools – a reply

References 1. Chuan A, Graham PL, Wong DM, et al. Design and validation of the Regional Anaesthesia Procedural Skills Assessment Tool. Anaesthesia 2015; 70: 1401–11. 2. Glance LG, Kellermann AL, Hannan EL, et al. The impact of anesthesiologists on coronary artery bypass graft surgery outcomes. Anesthesia and Analgesia 2015; 120: 526–33. 3. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. New England Journal of Medicine 2013; 369: 1434–42. 4. Gallagher AG, Ritter EM, Satava RM. Fundamental principles of validation, and reliability: rigorous science for the assessment of surgical education and training. Surgical Endoscopy 2003; 17: 1525–9. 5. Gallagher AG, O’Sullivan GC, Leonard G, Bunting BP, McGlade KJ. Objective structured assessment of technical skills and checklist scales reliability compared for high stakes assessments. Australia and New Zealand Journal of Surgery 2012; 84: 568–73.

Cerebrovascular autoregulation monitoring and patient‐centred outcomes after cardiac surgery: a systematic review

Impaired cerebrovascular autoregulation (CVAR) is observed in up to 20% of cardiac surgical patients. This systematic review aims to evaluate the association between impaired CVAR, measured by current monitoring techniques, and patient‐centred outcomes in adults following cardiac surgery.

Using graph-digitising software to retrospectively extract graphical anaesthetic monitor data

White and Pateman describe a prospective method of physiological and anaesthesia data capture for research analysis [1]. We have developed a way of reconstructing retrospective graphical data from anaesthetic charts into an electronic numeric format. This overcomes the laborious and potentially inaccurate manual transcription process that would otherwise be necessity for using such data. From a research perspective, graph digitisation enables accurate conversion and utilisation of data sets that have already been collected. A laptop, a flat bed scanner and a graph-digitising software program are required. Although commercial graph digitising software is available, a freeware program called CurveSnap (Version 1.1, developed by Xoofee) can be used [2]. Data conversion using CurveSnap is a six-step process: