Erez Ben-Menachem

Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: results from the israeli board of anesthesiologists.

BACKGROUND:Cardiac arrest in the parturient is often fatal, but appropriate resuscitation in this special situation may save the lives of the mother and/or unborn baby. Concern has arisen as to application of recommended techniques for resuscitation in the obstetric patient. The Israel Board of Anesthesiology has incorporated simulation assessment into accreditation examinations. The candidates represent a unique national cohort in which we were able to assess competence in the simulated scenario of cardiorespiratory arrest in the parturient. METHODSA simulated scenario of preeclampsia with magnesium toxicity leading to cardiac arrest in a pregnant patient was performed by 25 senior anesthesiology residents. A unique two-stage simulation examination consisting of high fidelity simulation followed immediately by oral debriefing was conducted. The assessment was scored using a predetermined checklist of key actions and answers to clarifying questions. Simulation performance was compared to debriefing performance. RESULTSDuring the board examination, resuscitation not specific to the pregnant patient was performed well (commencing chest compressions, bag-mask ventilation, cardiac defibrillation); however actions specific to the parturient were performed poorly. Left uterine displacement, cricoid pressure during bag-mask ventilation, and instructing preparations to be made for perimortem cesarean delivery within 5 minutes were performed by 68%, 48%, and 40% of candidates respectively (lower 99% confidence limit 42%, 25%, and 19%, respectively). Cricoid pressure during bag-mask ventilation was performed by 48% (25%) but described in debriefing by 80% of candidates (53%) (P = 0.08), and time setting for perimortem cesarean delivery was performed by 40% (29%) but described by 80% (53%) (P = 0.05) of examinees. CONCLUSIONSSenior anesthesiology residents have poor knowledge of resuscitation of the pregnant patient. The results suggest 2-stage simulation including an oral component may reveal disparities in knowledge not assessed by simulation alone, but definitive conclusions require further study.

Objective Structured Clinical Examination-based assessment of regional anesthesia skills: the Israeli National Board Examination in Anesthesiology experience.

Simulation techniques are increasingly being used in anesthesia training programs and to a lesser extent in evaluation of residents. We describe 7 years of experience with Objective Structured Clinical Examination–based regional anesthesia assessment in the Israeli National Board Examinations in Anesthesiology. We believe this is the first use of such mock scenarios for the assessment of regional anesthesia for the important purpose of national accreditation. During the study period, 308 candidates were examined in 1 of 8 different blocks. The total pass rate was 83%(257 of 308), ranging from 73% to 91%. The interrater correlation for total, critical, and global scores were 0.84, 0.88, and 0.75, respectively. Technological and cost constraints preclude actual assessment of regional anesthesia. However, testing formats that more closely reflect clinical practice are potentially valuable adjuncts to traditional examinations.

Identifying and Managing Technical Faults in the Anesthesia Machine: Lessons Learned from the Israeli Board of Anesthesiologists

BACKGROUND:The potential for catastrophe resulting from anesthetic equipment failure and the failure of training programs to adequately prepare residents to detect and manage equipment failure prompted the Israel Board of Anesthesiologists to include simulation-based testing in the Objective Structured Clinical Evaluation component of the Israeli Board Examination in Anesthesiology. METHODS:We used simulation-based scenarios to measure the performance of residents while (a) checking the anesthesia machine before the first morning case, (b) checking the anesthesia machine between cases, (c) managing an oxygen pipeline failure, and (d) managing an expiratory valve failure. RESULTS:During board examination, 3 of 28 examinees failed to correctly check at least 70% of the items on the anesthesia machine checkout list before the first morning case and 3 of 30 failed to correctly check 70% of the items between cases. Although all examinees recognized inadequate oxygen cylinder pressure and a malfunctioning valve, 1 of 31 examinees failed to open the O2 cylinder, 6 of 31 did not disconnect the anesthesia machine from the central oxygen supply, 14 of 31 could not explain how to minimize the use of oxygen, 2 of 30 failed to find the faulty valve, and 15 of 30 could not give the correct differential diagnosis. CONCLUSIONS:During simulation-based board examination most senior anesthesia residents became aware of equipment failures but many failed to correctly diagnosis and manage the failure.

Depth of anesthesia monitoring: a survey of attitudes and usage patterns among Australian anesthesiologists.

BACKGROUND:Utility of depth of anesthesia (DoA) monitors is contentious as evidence appears ambiguous regarding their clinical effectiveness and exact role. We conducted a survey of Australian anesthesiologists to determine their attitudes toward, and how and why they use, DoA monitors. METHODS:A random sample of 963 anesthesiologists was invited to participate in an anonymous online survey. RESULTS:The overall response rate was 30% (289 respondents). Twenty-nine percent (95% confidence interval, 24%–34%) of respondents thought DoA monitoring was indicated in all cases under relaxant general anesthesia. During total IV anesthesia with muscle relaxants, 74% of respondents (69%–79%) opined that DoA monitoring should be mandatory. DoA usage was never used by 5% of respondents (3%–8%), used in less than one-third of cases by 66% (61%–72%), and in more than one-third of cases by 29% (24%–35%). Belief in the usefulness of DoA monitoring for prevention of awareness was strongly associated with higher usage (P < 0.0001, Pearson correlation 0.32). Anesthesiologists were more influenced by higher DoA numbers than lower ones. In comparison with end-tidal anesthetic concentration monitoring, 30% (25%–35%) of respondents felt that DoA monitoring was more effective for prevention of intraoperative awareness. Thirty percent (25%–36%) of respondents reported having a previous case of awareness. CONCLUSIONS:The relatively frequent use of DoA monitoring contrasts with patterns in the UK, suggesting greater acceptance by Australian anesthesiologists. “Awareness prevention” rather than “recovery enhancement” appears to be the primary driver in DoA monitoring use in Australia. Highly variable usage patterns of DoA monitoring in the context of the current body of evidence suggest the need for greater education on the appropriate use of these monitors.

Intravenous sodium bicarbonate verifies intravenous position of catheters in ventilated children.

BACKGROUND: Extravasation is the unintentional injection or leakage of fluids into the perivascular or subcutaneous space resulting in potential tissue injury. In this 2-part prospective, controlled study, we assessed the safety of subcutaneously injected sodium bicarbonate in rats first. In the second part, the diagnostic utility of using IV diluted sodium bicarbonate to confirm placement of IV catheters in endotracheally intubated and ventilated rats and patients was tested. Diluted sodium bicarbonate was created using undiluted standard 8.4% (1 mEq/mL) sodium bicarbonate mixed in a 1:1 ratio with sterile water to achieve a final diluted concentration of 4.2% (0.5 mEq/mL). METHODS: Sodium bicarbonate (8.4% and 4.2%) was injected subcutaneously into 10 rats, and skin samples were evaluated. The hemodynamic and ventilatory effects of IV bicarbonate (2 mL/kg) in ventilated rats were measured. Subsequently, in 20 ASA physical status I and II mechanically ventilated patients, the effects of 50 mL of diluted 4.2% sodium bicarbonate or 0.9% normal saline, injected in a randomized order, were analyzed. RESULTS: Part 1: Undiluted (8.4%) subcutaneous sodium bicarbonate resulted in a small area of skin necrosis in 10% of skin samples (3 of 30) taken from rats. Minimal effects (mild scale crust and foci of regenerative epidermis beneath) were detected when a diluted solution was used. In ventilated rats, IV injection of diluted bicarbonate caused a significant increase in end-tidal carbon dioxide, whereas subcutaneous injection had no effect. In humans, diluted bicarbonate resulted in an end-tidal carbon dioxide increase (mean of 38 ± 5 to 45 ± 7 mm Hg) within 7 breaths. Injected normal saline did not result in any changes. Sodium bicarbonate was easily differentiated from normal saline injection by anesthesiologists observing the change in end-tidal carbon dioxide concentrations immediately after injection. CONCLUSION: The injection of diluted sodium bicarbonate (in mechanically ventilated patients) can be used to reliably identify the correct location of an IV catheter by an increase in the exhaled carbon dioxide concentration. Although we found no skin damage with 4.2% (0.5 mEq/mL) sodium bicarbonate, safety and efficacy should be further evaluated in future studies.

A Simple Diagnostic Test to Confirm Correct Placement of Dysfunctional Central Venous Catheters Before Chemotherapy in Children.

Background: In children undergoing intravenous chemotherapy, partial dysfunction of the central venous catheter (CVC) is common. Fluids can be infused into the catheter; however, blood cannot be aspirated. In those situations, chemotherapy is withheld and a catheter investigation is performed. Usually, a radiographic study with contrast media or therapy with thrombolytic drugs followed by rechecking for blood return is undertaken. Aim: To evaluate if a previously described method using dilute sodium bicarbonate injection and the resultant rise in measured end-tidal carbon dioxide tracing can confirm correct intravascular placement of a dysfunctional CVC in children at the bedside. Patients: Cohort group of 22 children scheduled for chemotherapy with partial dysfunction of a CVC in a tertiary hematology-oncology care facility. Results: All children with a partial dysfunctional CVC that was proven to be intravascular after venogram or thrombolytic therapy had a distinct and predictable increase in end-tidal carbon dioxide response to injected bicarbonate. Conclusion: Injection of 1 mL/kg (maximum 20 mL) of 4.2% dilute sodium bicarbonate is a quick, simple, bedside test allowing confirmation of intravascular location of dysfunctional CVC.

Electroencephalography for children with autistic spectrum disorder: a sedation protocol

To report the effectiveness and efficiency of a predetermined sedation protocol for providing sedation for electroencephalograph (EEG) studies in children with autism.

A simple diagnostic test to confirm correct placement of intravenous catheters before chemotherapy.

Purpose To determine the feasibility and effectiveness of using a single injection of diluted sodium bicarbonate, while monitoring exhaled carbon dioxide changes, to reliably confirm correct placement of intravenous (IV) catheters. Methods The study was conducted in the oncology day care clinic at a tertiary care center and included a selected group of patients with various oncological conditions who required IV chemotherapy. In each patient a newly inserted peripheral IV catheter or newly accessed central line was deemed positively intravascular if they had good blood return or most probably intravascular if there was no blood return but they flushed easily. This clinical diagnosis of correct positioning, was correlated with the results of a single injection of dilute sodium on the exhaled carbon dioxide, and with the ability of a blinded observer to report whether sodium bicarbonate or saline was injected. Results A total of 67 patients were enrolled in the study; 56 had positively intravascular IV catheter while 11 had most probably intravascular IV catheter. A single injection of 20 mL 4.2% sodium bicarbonate had a positive and clinically detectable response that was diagnosed with high sensitivity and specificity. Conclusions IV injection of 20 mL of 4.2% sodium bicarbonate with exhaled carbon dioxide monitoring can be used to reliably confirm correct intravascular placement of a catheter intended to be used for chemotherapy.