Getúlio Rodrigues de Oliveira Filho

Psychometric properties of the Dundee Ready Educational Environment Measure (DREEM) applied to medical residents.

The Dundee Ready Educational Environment Measure (DREEM) is a measure of students’ perceptions of the educational environment, but its performance in evaluating the educational environment in the residency setting has not yet been described. This study aimed at describing the psychometric performance of DREEM applied to medical residents. DREEM was applied to 97 residents from 12 training programs on four specialties in six institutions in three Brazilian cities. Psychometric measures included factor analysis, Cronbachs alpha coefficients, item-to-total correlations, t-test comparisons of scores between genders, institutions, specialties, and programs, correlations with the global score of the Quality of School Life Scale (concurrent validity), and test–retest reliability. Generalizability theory procedures were applied to a random subset of data. Programs (8) were the objects of measure, while institutions (6), specialties (4), raters-within-programs (40), and items-on-the-scale (50) were facets. Variance components, generalizability (G) and dependability (D) coefficients were calculated. Cronbachs alpha was 0.93. DREEM showed high discriminant and concurrent validities. Test–retest reliability was moderate. Interactions between programs, raters and items accounted for 68% of the total variance. G and D coefficients were 0.95 and 0.67, respectively. The instrument proved to be useful for relative comparisons at both resident and program level.

Learning Curves and Mathematical Models for Interventional Ultrasound Basic Skills

BACKGROUND:We aimed to construct learning curves and mathematical learning models for ultrasound basic skills: optimizing needle-ultrasound beam alignment and reaching a target inside a phantom. METHODS:Thirty subjects participated in the study. Each subject performed 25 trials. Linear ultrasound probes and a bovine muscular phantom were used. In Experiment 1, subjects tried to insert a needle parallel to the ultrasound beam with full imaging of the needle. For Experiment 2, a segment of tendon was inserted longitudinally into the phantom at a depth of 1 to 1.5 cm. Subjects tried to insert the needle until contacting the tendon. Learning curves were constructed using the cumulative sum (cusum) method. Bush and Mosteller’s mathematical learning models were constructed for each skill. RESULTS:Only 30% and 11% of subjects attained proficiency in Experiments 1 and 2, respectively. The predicted average numbers of trials to achieve 95% success rates as estimated from Bush and Mosteller’s models were 37 and 109, respectively. CONCLUSIONS:Learning interventional ultrasound basic skills may require a considerable number of trials. Cusum charts revealed that individuals acquire such abilities at variable rates. As skills were assessed in phantoms, our results do not apply to blocks given to real patients.

An instrument designed for faculty supervision evaluation by anesthesia residents and its psychometric properties.

BACKGROUND AND OBJECTIVES: We aimed 1) to develop a valid and reliable instrument for faculty supervision evaluation by anesthesia residents and 2) to disclose the sources of error in residents’ ratings. METHODS: A qualitative study involving residents and faculty identified constructs of supervisory ability, which were entered as items in a measurement instrument used by 19 residents to evaluate 39 instructors during a 6-mo period. The instrument was psychometrically tested under classical item and generalizability theories. A decision study, using the parameters of the generalizability (G) study, estimated the number of resident ratings needed to produce dependable measures of a single faculty. RESULTS: Nine dimensions emerged from the qualitative study: planning perianesthesia care, providing feedback (“the instructor provides me timely, informal, non-threatening comments on my performance and shows me ways to improve”); being available (“the instructor is promptly available to help me solve problems with patients and procedures”); giving opportunities/fostering resident autonomy; stimulating patient-based learning; demonstrating professionalism; being present during the critical events; demonstrating interpersonal skills; being concerned about safety. Residents provided 970 evaluations. The instrument exhibited internal consistency (Cronbach’s &agr; = 0.93), content and face validities, and a single-factor structure. Generalizability and dependability coefficients were 0.93. Between-instructors differences accounted for 56% of score variance. Resident-instructor interactions accounted for 44% of score variance, indicating that scores were influenced by each resident’s unique perceptions of instructors (halo effect). According to the results of the decision study, dependability of measures within the 75% to 95% range could be expected with 3 to 33 residents rating each faculty member, respectively. CONCLUSIONS: The nine-item instrument produced valid and reliable measures of faculty supervision. However, a significant amount of halo effect biased such measures. G-studies may help identify the type and magnitude of rater biases affecting resident-generated faculty supervision evaluations, and can be useful for interpreting their results, especially if personnel decisions (e.g., tenure, promotion) rely on such measures.

Problem-based learning implementation in an intensive course of anaesthesiology: a preliminary report on residents’ cognitive performance and perceptions of the educational environment

The authors describe the implementation of problem-based learning (PBL) in an introductory course to anaesthesiology (ICA) traditionally administered in teacher-centred formats. The study was performed during the 2003 and 2004 courses. Seven residents participated in ICA2003 and 5 in ICA2004. Courses covered pre- and post-anaesthesia care, airway management, pharmacology of anaesthetics, and neuraxial blocks. Lectures, demonstrations and PBL were used in ICA2003. Only PBL was used in ICA2004. ICA2003 residents’ perceptions of the contribution of learning formats to solving post-tests were assessed on 100-milimetre visual analogue scales (VASs). Pre-tests, post-tests and the Dundee Ready Education Environment Measure (DREEM) measured outcomes. Pooled mean VAS scores of the perceived contribution of learning formats to the acquisition of knowledge were significantly greater for PBL (81 ± 13.1 mm) than for lectures (71.96 ± 16.7 mm) or practical demonstrations (74 ± 16.9 mm). Pooled mean scores of pre-test and post-tests were 5.21 ± 2.18 and 8.50 ± 1.69 in ICA2003 (p < 0.05), and 5.63 ± 1.83 and 8.98 ± 1.13 in ICA2004 (p < 0.05), respectively. Pooled pre-test, post-test and DREEM global scores did not differ between courses. PBL may effectively address basic topics in anaesthesiology during intensive learning episodes.

The Relationship of Learning Environment, Quality of Life, and Study Strategies Measures to Anesthesiology Resident Academic Performance

BACKGROUND:We designed this study to determine the academic performance of anesthesia residents as related to their differential characteristics on some affective-motivational variables, represented by perceptions about their educational environment, subjective quality of life, and learning and study strategies. METHODS:The study sample consisted of 63 anesthesia residents who completed the World Health Organization Quality of Life Inventory, the Dundee Ready Educational Environment Measure, the Learning and Study Strategies Inventory, and a progress test on basic sciences on two to four measurement occasions during a 2-year period. A growth curve model was fit to the academic performance. Mantel-Haenszel tests identified independent predictors of academic performance on progress tests. RESULTS:Mean rating at the first measuring occasion was 41%. There was a statistically significant improvement over time (slope = 7% per 6-m period; P < 0.01). Analysis of the random effects showed significant individual differences in the intercept. The residents’ scores improved at an equivalent rate over the course of the residency. The independent predictors of academic performance were anxiety, motivation, and ability in selecting main ideas. CONCLUSIONS:Knowledge growth on basic sciences during anesthesia residency is significantly associated to the level of anxiety related to study and achievement, to the motivation for learning and for personal improvement, and to the ability in selecting main ideas from subject matters to which residents are exposed during learning episodes.

Bloqueios nervosos guiados por ultra-som

BACKGROUND AND OBJECTIVES Ultrasound-guided nerve blocks are based on the direct visualization of nerve structures, needle, and adjacent anatomic structures. Thus, it is possible to place the local anesthetic precisely around the nerves and follow its dispersion in real time, obtaining, therefore, more effective blockades, reduced dependency on anatomic references, decreased anesthetic volume, and increased safety. CONTENTS The aim of this paper was to review the physical mechanisms of image formation, ultrasound anatomy of the neuro axis and of the brachial and lumbosacral plexuses, equipment and materials used in the blockades, settings of the ultrasound equipment to improve the image, planes of visualization of the needles, the techniques, and training in ultrasound-guided nerve blocks. CONCLUSIONS The steps for a successful regional block include the identification of the exact position of the nerves, the precise localization of the needle, without causing injuries to adjacent structures, and, finally, the careful administration of the local anesthetic close to the nerves. Although neurostimulation is very useful in identifying nerves, it does not fulfill all those requirements. Therefore, it is believed that ultrasound-guided nerve blocks will be the technique of choice in regional anesthesia in a not too distant future.JUSTIFICATIVA E OBJETIVOS: As tecnicas de bloqueios nervosos guiados por ultra-som sao baseadas na visualizacao direta das estruturas nervosas, da agulha de bloqueio e das estruturas anatomicas adjacentes. Desta maneira, e possivel depositar a solucao de anestesico local precisamente em torno dos nervos e acompanhar a sua dispersao em tempo real, obtendo-se, assim, um bloqueio mais eficaz, de menor latencia, menor dependencia de referencias anatomicas, menor volume de solucao anestesica e maior seguranca. CONTEUDO: O artigo revisa os aspectos relativos aos mecanismos fisicos para formacao de imagens, a anatomia ultra-sonografica do neuroeixo e dos plexos braquial e lombossacral, os equipamentos e materiais empregados nos bloqueios, os ajustes do aparelho de ultra-som para melhorar as imagens, os planos de visualizacao das agulhas de bloqueio e as tecnicas e o treinamento em bloqueios guiados por ultra-som. CONCLUSOES: Os passos para se obter sucesso em anestesia regional incluem a identificacao exata da posicao dos nervos, a localizacao precisa da agulha, sem lesoes nas estruturas adjacentes e, finalmente, a injecao cuidadosa de anestesico local junto aos nervos. Embora a neuroestimulacao forneca grande auxilio na identificacao dos nervos, esta nao consegue, isoladamente, preencher todas essas exigencias. Por isso, acredita-se que os bloqueios guiados por ultra-som serao a tecnica de eleicao para anestesia regional num futuro nao muito distante.

A comparative study between ultrasound and neurostimulation guided axillary brachial plexus block

UNLABELLED Conceição DB, Helayel PE, Oliveira Filho GR - A Comparative Study between Ultrasound- and Neurostimulation-Guided Axillary Brachial Plexus Block. BACKGROUND AND OBJECTIVES The use of ultrasound in Regional Blocks is increasingly more frequent. However, very few studies comparing ultrasound and neurostimulation have been conducted. The objective of this study was to compare neurostimulation-guided axillary brachial plexus block with double injection and ultrasound-guided axillary plexus block for hand surgeries. The time to perform the technique, success rate, and complications were compared. METHODS After approval by the Ethics on Research Committee of the Hospital Governador Celso Ramos, 40 patients scheduled for elective hand surgeries under axillary plexus block were selected. Patients were randomly divided into two groups with 20 patients each: Neurostimulation (NE) and Ultrasound (US) groups. The time to perform the technique, success rate, and complication rate were compared. RESULTS Complete blockade, partial failure, and total failure rates did not show statistically significant differences between the US and NE groups. The mean time to perform the technique in the US group (354 seconds) was not statistically different than that of the NE group (381 seconds). Patients in the NE group had a higher incidence of vascular punctures (40%) when compared with those in the US group (10%, p < 0.05). The rate of paresthesia during the blockade was similar in both groups (15%). CONCLUSIONS The success rate and time to perform the blockade were similar in ultrasound- and neurostimulation-guided axillary plexus block for hand surgeries. The rate of vascular puncture was higher in neurostimulation-guided axillary plexus block.

Prevalence and predictive factors of urinary retention assessed by ultrasound in the immediate post-anesthetic period

BACKGROUND AND OBJECTIVES Urinary retention is a common condition in the post-anesthetic care unit (PACU). Vesical overdistension and consequent damage of the detrusor muscle of the urinary bladder represent situations that can be prevented. The ultrasound allows the reliable measurement of the urinary volume, determining the prevalence of postoperative vesical distension. The objective of the present study was to determine the prevalence of postoperative urinary retention and identify independent predictive factors. METHODS Two-hundred and fifty-seven patients admitted to the PACU were included prospectively in this study. Parameters collected included: age, gender, physical status, site of surgery, type of anesthesia, time of the surgery and anesthesia, use of opioids, volume of fluids administered, and history of urinary symptoms. Vesical volumes were measured by ultrasound after admission and upon discharge from the PACU. The criteria to characterize urinary retention were: vesical volume equal or higher than 600 mL associated with incapacity of spontaneous micturition for 30 minutes after the diagnosis. Univariate and multivariate analyses were used to indentify independent predictive factors. RESULTS Urinary retention was observed in 19 patients (7.39%), independent predictive factors identified included urinary volume equal to or greater than 360 mL upon admission to the PACU (Mantel-Haenszel Chi-square test (1 dF) = 18.76; p < 0.01), with an odds ratio of 9.82 (95% confidence interval = 3.26-29.55) and surgeries of the lower limbs (Mantel-Haenszel Chi-square test (1 dF) = 5.33; p = 0.02), with odds ratio of 4.33 (95% confidence interval = 1.34-14.02). CONCLUSIONS Due to the prevalence of urinary retention, we suggest that a systematic evaluation of the urinary volume at the PACU should be done, especially in those patients with predictive factors.

Comparação entre bloqueios peridural e paravertebral torácicos contínuos para analgesia pós-operatória em pacientes submetidos a toracotomias: revisão sistemática

BACKGROUND AND OBJECTIVE Thoracotomy is a procedure associated with postoperative severe pain. Epidural block (EB) is considered the gold standard for its control. Paravertebral block (PVB) is an option for the management of postoperative pain. The aim of this study was to evaluate by meta-analyses the effectiveness of continuous thoracic epidural and paravertebral blocks for pain management after thoracotomy and the incidence of adverse effects. METHOD The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. We analyzed primary (postoperative pain at rest) and secondary outcomes (urinary retention, nausea, vomiting, hypotension). We estimated the weighted mean difference for continuous variables and odds ratios for categorical variables. RESULTS We included eight prospective, randomized, controlled studies. Meta-analysis showed no statistically significant differences between the two techniques regarding the outcomes of postoperative pain at rest at four, eight, 12, 16, 20, 24, 36, and 48 hours. Incidence of urinary retention was higher in EP group (OR = 7.19, CI95 = 1.87 to 27.7). The occurrence of hypotension was higher in PVB group (OR = 10.28, 95 = 2.95 to 35.77). There was no statistically significant difference between both groups regarding the outcome nausea/vomiting (OR = 3.00, CI95 = 0.49 to 18.45). CONCLUSION There were no statistically significant differences in pain relief after thoracotomy between EB and PVB. PVB showed a lower incidence of side effects with reduced frequency of urinary retention and hypotension.

Estudo comparativo entre ultrassom e neuroestimulação no bloqueio do plexo braquial pela via axilar

JUSTIFICATIVA Y OBJETIVOS: El uso del ultrasonido en Anestesia Regional ha venido creciendo. Existen pocos estudios comparando el uso del ultrasonido con la neuroestimulacion. El objetivo de este estudio, fue comparar la ejecucion del bloqueo del plexo braquial por la via axilar, guiado por neuroestimulacion con doble inyeccion y guiado por ultrasonido en procedimientos quirurgicos en la mano. Para eso, se compararon el tiempo de realizacion, la tasa de exito y las complicaciones. METODO: Despues de la aprobacion por parte del Comite de Etica en Investigacion del Hospital Governador Celso Ramos, se seleccionaron 40 pacientes para operaciones por eleccion en la mano, con bloqueo de plexo braquial via axilar. Los pacientes se distribuyeron aleatoriamente y electronicamente en dos grupos de 20 pacientes: Grupo Neuroestimulacion (NE) y Grupo Ultrasonido (US). Se compararon el tiempo de realizacion, la tasa de exito y las complicaciones. RESULTADOS: Las tasas de bloqueo completo, falla parcial y falla total, no presentaron diferencias estadisticas significativa entre los grupos US y NE. El tiempo promedio para la realizacion del procedimiento en el grupo US (354 segundos) no presento diferencia estadistica significativa cuando se le comparo al grupo NE (381 segundos). Los pacientes del grupo NE presentaron una tasa mas elevada de puncion vascular (40%), cuando se les comparo con el grupo US (10%, p < 0,05). La tasa de presencia de parestesia durante la realizacion del bloqueo fue igual entre los dos grupos (15%). CONCLUSIONES: La tasa de exito y el tiempo para la realizacion, fueron similares entre el bloqueo de plexo braquial via axilar guiado por ultrasonido, cuando se le comparo con el guiado por neuroestimulacion con los de los estimulos en operaciones sobre la mano. Un tasa mas elevada de puncion vascular se dio en el bloqueo guiado por neuroestimulacion.