Georges Savoldelli

The value of screening preoperative chest x-rays: a systematic review

PurposeChestx-ray (CXR) is the most frequently ordered radiological test in Canada. Despite published guidelines, variable policies exist amongst different hospitals for ordering of preoperative CXRs. The purpose of this study was to systematically review the literature on the value of screening CXRs and establish evidence to support guidelines for the use of preoperative screening CXRs.SourceMedline and Embase were searched under set terms for all English language articles published during 1966–2004. All eligible studies were reviewed and data were extracted individually by two authors. Of the 513 articles identified, 14 studies met both inclusion and exclusion criteria.Principal findingsThe quality of published evidence was modest as only six of the studies were rated as fair and eight as poor. Of the reported studies, diagnostic yield increased with age. However, most of the abnormalities consisted of chronic disorders such as cardiomegaly and chronic obstructive pulmonary disease (up to 65%). The rate of subsequent investigations was highly variable (4–47%). When further investigations were performed, the proportion of patients who had a change in management was low (10% of investigated patients). Postoperative pulmonary complications were also similar between patients who had preoperative CXRs (12.8%) and patients who did not (16%).ConclusionAn association between preoperative screening CXRs and decrease in morbidity or mortality could not be established. As the prevalence of CXR abnormalities is low in patients under the age of 70, there is fair evidence that routine CXRs should not be performed for patients in this age group without risk factors. For patients over 70, there is insufficient evidence for or against performance of routine CXRs. The current recommendation from the Guidelines Association Committee that routine CXRs should not be performed for patients over 70 without risk factors is supported by this study.RésuméObjectifLa radiographie pulmonaire (RXP) est le test radiologique le plus demandé au Canada. Malgré les directives publiées, différentes politiques de demande de RXP préopératoires existent dans les hôpitaux. Nous voulions faire une revue systématique des documents sur la valeur des RXP de dépistage préopératoire et établir une preuve appuyant les directives sur leur usage.SourceNous avons passé en revue les bases Medline et Embase sous des termes déterminés pour tous les articles en anglais publiés de 1966 à 2004. Toutes les études admissibles ont été revues et les données extraites isolément par deux auteurs. Des 513 articles retenus, 14 études répondaient aux critères d’inclusion et d’exclusion.Constatations principalesLa qualité de la preuve publiée était modeste, car seulement six études ont été cotées acceptables et huit pauvres. Dans ces études, le rendement diagnostique augmentait avec l’âge. Cependant, la majorité des anomalies étaient des troubles chroniques comme la cardiomégalie et la maladie pulmonaire obstructive chronique (jusqu’à 65 %). Le taux d’examens subséquents était très variable (4–47 %). Quand d’autres tests étaient effectués, une faible proportion (10 % des patients testés) de patients voyaient leur traitement modifié. Les complications pulmonaires postopératoires étaient aussi similaires chez les patients qui avaient eu (12,8 %) ou non (16 %) des RXP préopératoires.ConclusionUne association entre les RXP de dépistage préopératoire et une baisse de la morbidité ou de la mortalité n’a pas pu être établie. Comme la prévalence des anomalies détectées lors des RXP était faible chez les patients de moins de 70 ans, il semble évident que des RXP de routine ne devraient pas être réalisés pour les patients de ce groupe d’âge sans facteurs de risque. Pour les patients de plus de 70 ans, la preuve est insuffisante pour décider s’il y a lieu de procéder à des RXP de routine. La recommandation actuelle du Comité des directives de l’Association voulant que les RXP de routine ne soient pas réalisés pour les patients de plus de 70 ans sans facteurs de risque est soutenue par notre étude.

Barriers to use of simulation-based education.

PurposeBarriers to simulation-based education in postgraduate and continuing education for anesthesiologists have not been well studied. We hypothesized that the level of training may influence attitudes towards simulation-based education and impact on the use of simulation. This study investigated this issue at the University of Toronto which possesses two sites equipped with high-fidelity patient simulators.MethodsA 40-question survey of experiences, perceptions, motivations and perceived barriers to simulation-based education, was distributed to 154 anesthesiologists attending a departmental conference. Data were analyzed using descriptive statistics and associations between responses were assessed using either the Chi-Square statistic or a one-way analysis of variance.ResultsThe rate of response was 58%. Residents had experienced simulation-based education (96%) more often than staff (58%) and fellows (36%), (P < 0.001 respectively). Residents had also attended more simulation sessions than staff and fellows (mean 2.8 vs 1.05 and 1.04, P < 0.001 respectively). Residents and fellows found simulation-based education more relevant for their training than staff (88% vs 65%, P < 0.05). Eighty-one percent of the respondents identified at least one significant barrier that prevents or limits them from attending simulator sessions. Staff anesthesiologists perceived multiple barriers and identified ‘time’ and ‘financial issues’ as significant barriers.ConclusionAnesthesiologist’ level of training influences their attitudes towards and their perceptions of simulation-based education. This survey has identified perceived barriers that may limit a wider utilization of simulation. These results may be used to implement targeted actions such as course design, incentives, and information strategies, which could improve access and future use of simulation.RésuméObjectifLes barriéres à la formation fondée sur la simulation en enseignement universitaire supérieur et en formation continue pour les anesthésiologistes ne sont pas bien connues. Nous avons émis ľhypothése que le niveau de formation pouvait influencer ľattitude face à ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre étude a été réalisée à ľuniversité de Toronto qui posséde deux sites équipés de simulateurs de haute fidélité.MéthodeUn questionnaire de 40 questions sur les expériences, les perceptions, les motivations et les barriéres perçues de la formation par simulation a été distribué à 154 anesthésiologistes en réunion départementale. Les données ont été analysées par des statistiques descriptives et les liens entre les réponses par le test chi-deux ou une analyse simple de la variance.RésultatsLe taux de réponses a été de 58 %. Les résidents avaient plus ďexpérience de la simulation (96 %) que les spécialistes (58 %) et les boursiers (36 %), (P < 0,001 respectivement). Les résidents avaient aussi assisté à plus de sessions de simulation que les spécialistes et les boursiers (moyenne de 2,8 vs 1,05 et 1,04, P < 0,001 respectivement). Les résidents et les boursiers ont trouvé la simulation plus pertinente que les anesthésiologistes (88 % vs 65 %, P < 0,05). Parmi les répondants, 81 % ont reconnu au moins une barriére importante qui empêche ou limite la participation à des sessions de simulation. Les spécialistes ont perçu de multiples barriéres significatives dont le «temps» et «les questions financiéres».ConclusionLe niveau de formation des anesthésiologistes influence ľattitude face à la simulation et leurs perceptions de la formation par simulation. Les limites à un plus grand usage de la simulation, reconnues dans ľenquête, pourraient servir à des interventions ciblées comme ľorganisation ďun cours, des incitatifs et des stratégies ďinformations pour améliorer ľaccés à la simulation et son usage futur.Objectif nLes barrieres a la formation fondee sur la simulation en enseignement universitaire superieur et en formation continue pour les anesthesiologistes ne sont pas bien connues. Nous avons emis ľhypothese que le niveau de formation pouvait influencer ľattitude face a ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre etude a ete realisee a ľuniversite de Toronto qui possede deux sites equipes de simulateurs de haute fidelite.

Les barriéres à ľutilisation de la formation basée sur simulateur

PurposeBarriers to simulation-based education in postgraduate and continuing education for anesthesiologists have not been well studied. We hypothesized that the level of training may influence attitudes towards simulation-based education and impact on the use of simulation. This study investigated this issue at the University of Toronto which possesses two sites equipped with high-fidelity patient simulators.MethodsA 40-question survey of experiences, perceptions, motivations and perceived barriers to simulation-based education, was distributed to 154 anesthesiologists attending a departmental conference. Data were analyzed using descriptive statistics and associations between responses were assessed using either the Chi-Square statistic or a one-way analysis of variance.ResultsThe rate of response was 58%. Residents had experienced simulation-based education (96%) more often than staff (58%) and fellows (36%), (P < 0.001 respectively). Residents had also attended more simulation sessions than staff and fellows (mean 2.8 vs 1.05 and 1.04, P < 0.001 respectively). Residents and fellows found simulation-based education more relevant for their training than staff (88% vs 65%, P < 0.05). Eighty-one percent of the respondents identified at least one significant barrier that prevents or limits them from attending simulator sessions. Staff anesthesiologists perceived multiple barriers and identified ‘time’ and ‘financial issues’ as significant barriers.ConclusionAnesthesiologist’ level of training influences their attitudes towards and their perceptions of simulation-based education. This survey has identified perceived barriers that may limit a wider utilization of simulation. These results may be used to implement targeted actions such as course design, incentives, and information strategies, which could improve access and future use of simulation.RésuméObjectifLes barriéres à la formation fondée sur la simulation en enseignement universitaire supérieur et en formation continue pour les anesthésiologistes ne sont pas bien connues. Nous avons émis ľhypothése que le niveau de formation pouvait influencer ľattitude face à ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre étude a été réalisée à ľuniversité de Toronto qui posséde deux sites équipés de simulateurs de haute fidélité.MéthodeUn questionnaire de 40 questions sur les expériences, les perceptions, les motivations et les barriéres perçues de la formation par simulation a été distribué à 154 anesthésiologistes en réunion départementale. Les données ont été analysées par des statistiques descriptives et les liens entre les réponses par le test chi-deux ou une analyse simple de la variance.RésultatsLe taux de réponses a été de 58 %. Les résidents avaient plus ďexpérience de la simulation (96 %) que les spécialistes (58 %) et les boursiers (36 %), (P < 0,001 respectivement). Les résidents avaient aussi assisté à plus de sessions de simulation que les spécialistes et les boursiers (moyenne de 2,8 vs 1,05 et 1,04, P < 0,001 respectivement). Les résidents et les boursiers ont trouvé la simulation plus pertinente que les anesthésiologistes (88 % vs 65 %, P < 0,05). Parmi les répondants, 81 % ont reconnu au moins une barriére importante qui empêche ou limite la participation à des sessions de simulation. Les spécialistes ont perçu de multiples barriéres significatives dont le «temps» et «les questions financiéres».ConclusionLe niveau de formation des anesthésiologistes influence ľattitude face à la simulation et leurs perceptions de la formation par simulation. Les limites à un plus grand usage de la simulation, reconnues dans ľenquête, pourraient servir à des interventions ciblées comme ľorganisation ďun cours, des incitatifs et des stratégies ďinformations pour améliorer ľaccés à la simulation et son usage futur.Objectif nLes barrieres a la formation fondee sur la simulation en enseignement universitaire superieur et en formation continue pour les anesthesiologistes ne sont pas bien connues. Nous avons emis ľhypothese que le niveau de formation pouvait influencer ľattitude face a ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre etude a ete realisee a ľuniversite de Toronto qui possede deux sites equipes de simulateurs de haute fidelite.

Parker Flex-Tip™ are not superior to polyvinylchloride tracheal tubes for awake fibreoptic intubations

PurposeDifficulty can be encountered during advancement of the tracheal tube (TT) over the bronchoscope after successful endotracheal bronchoscopy due to impingement on laryngeal structures. A new TT, the Parker Flex-Tip (PFT), has been shown to be superior to polyvinylchloride (PVC) TTs in anesthetized, paralyzed patients with normal airways. However, no study to date has shown the superiority of the new tapered tip design in patients with difficult airways during awake fibreoptic intubations (AFOI). The purpose of this study was to compare the PFT with PVC TTs for AFOI in patients with difficult airways or unstable c-spines. Clinical features: In this prospective observational study, 1 1 1 patients with predicted or documented difficult airways, or unstable c-spines were assessed for ease of TT advancement during AFOI. First attempt success rates were 91 % for PFT TTs and 84% for PVC TTs (P = NS). Resistance to TT advancement was none to mild and similar in both groups. Advancement without the need to rotate the TT 180° was also similar in both groups (57% vs 53%). Conclusion: For AFOI in patients with difficult airways, the PFT is not superior to conventional PVC TTs.ObjectifIl peut être difficile d’avances le tube endotrachéal (TET) le long du bronchoscope lors d’une intubation fibroscopique à cause d’un contact avec des structures laryngées. Un nouveau TET, le Parker Flex-Tip (PFT), s’est révélé supérieur aux TET de polychlorure de vinyle (PCV) chez les patients anesthésiés et paralysés aux voies aériennes normales. Mais aucune étude à ce jour n’a montré la supériorité de ce tube à pointe effilée dans les cas de problèmes de voies aériennes pen-dant l’intubation fibroscopique vigile (IFOV). Notre étude compare le PFT avec les TET de PCV pour l’IFOV en cas d’anomalies des voies aériennes ou d’instabilité de la colonne cervicale. Éléments cliniques : Notre étude observationnelle prospective a évalué 111 patients avec des problèmes de voies aériennes prévus ou documentés ou une instabilité de la colonne cervicale, quant à la faci-lité d’avancer le TET pendant l’IFOV. Les succès du premier essai ont été de 91 % pour le TET PFT et de 84 % pour le TET de PCV (P = NS). La résistance à l’avancement du TET a été de nulle à légère dans les deux groupes. L’avancement sans nécessité de rotation de 180° du TET a aussi été comparable dans les deux groupes (57 % vs 53 %).ConclusionPour l’IFOV chez les patients qui ont des problèmes de voies aériennes, le PFT n’est pas supérieur au TET de PCV traditionnel.

Non-technical skills: Repeated exposure to simulation

INTRODUCTION: Critical incident reporting and observational studies have identified nontechnical skills that are vital to successful anesthesia crisis management. Examples of such skills include task management, team working, situation awareness and decision making. These qualities are not necessarily acquired through clinical experience and may need to be specifically taught. This study uses a high fidelity patient simulator to assess the effect of repeated exposure to simulated anesthesia crises on the non-technical skills of anesthesia residents. No published studies have addressed this issue.

The oral examination process — gold standard or fool’s gold

is believed that the oral examination can be used to evaluate problem solving ability, communication and collaboration skills and expert content knowledge skills. In spite of its widespread acceptance, this examination has been criticized for its lack of reliability and validity and the high cost of its administration. Reliability is the measure of both the consistency and precision of a testing tool. The three main sources of variability (decreased reliability) in the oral examination process are: 1) examiner related variability; 2) examination related variability; and 3) candidate related variability. In their paper entitled “Poor interrater reliability on mock anesthesia oral examinations” in this edition of the Journal, Jacobsohn, Klock, Avidan and the Oral Examination Group present a study which demonstrates poor inter-rater reliability in a mock oral examination context with raters grading in true isolation. 2 Twenty-five residents were examined in a mock examination process resembling the American Board of Anesthesiology (ABA) format on two occasions six weeks apart (E1 and E2). The examinations were videotaped and scored by three experienced ABA examiners and three experienced Royal College of Physicians and Surgeons of Canada (RCPSC) examiners in isolation. The examiners were provided with a standardized scoring system and an educational package to aid with standard setting. The inter-rater reliability as determined by using intraclass correlation coefficients was poor: 0.243 (0.177– 0.305) for E1 and 0.405 (0.331–0.470) for E2. For 48% of the candidates examined, the chance of passing or failing was examiner dependent. Previous studies have demonstrated significantly better inter-rater reliability in the anesthesia oral examination process. Schubert reported inter-rater reliability as generalized reliability coefficients for both final grade received and pass-fail determination on 441 practice oral examinations given to 190 residents using the ABA format. 3 Inter-rater reliability was 0.72 for the final grade received and 0.68 for the pass-fail determination. This compares favourably with the results found by Kearney in a study using a structured oral examination format for practice examinations similar to that currently used by the RCPSC. 4 Twenty faculty examined 26 residents from two Canadian residency programs (sites A and B). Standardized questions were scored using global rating scales with anchored performance criteria. Each candidate was scored by a pair of examiners at the initial session and again subsequently from a videotaped recording. Inter-rater agreement was 0.51 for time 1 and .79 at time 2 for site A, 0.71 at time 1 and .48 at time 2 for site B. These results were classified as fair to good inter-rater reliability and the wide range of correlations found was felt to be due to several study limitations. The residents examined were at different levels of training with 25% presenting for their first practice oral examination. Evidence suggests that examiners are less consistent when rating poor performances. 5

Patient simulation: An adjunct to the oral examination

INTRODUCTION: Anesthesiologists increasingly regard realistic patient simulators as invaluable educational and research tools for the study of human performance. However, their use in the assessment of residents’ performance and competence is controversial. Concerns regarding the reliability, the validity, and the “added value” of simulator-based examinations over traditional examinations have not been adequately addressed (1). The present study investigated the potential for assessing clinical performance of senior anesthesia residents with a simulator as compared with the traditional oral examination.