Jeffrey B. Riley

The successful application of simulation-based training in thoracic surgery residency

OBJECTIVE We developed and tested a clinical simulation program in the principles and conduct of cardiopulmonary bypass with the aim of improving confidence and proficiency in this critical aspect of cardiac surgical care. METHODS Fifteen residents from 6 resident-training programs who reported no prior cardiopulmonary bypass observation or simulation-based perfusion experience participated in a cardiopulmonary bypass course involving both didactic lectures and hands-on simulation. A computer-controlled hydraulic model of the human circulation was used in a specifically designed multidisciplinary simulation center environment to give the participants hands-on training with both basic operations and specific perfusion crisis scenarios. Pretraining and posttraining assessments concerning confidence, knowledge, and applications with regard to cardiopulmonary bypass were administered and compared. RESULTS Likert scale scores on confidence-related items increased significantly (P < .001), from 59% +/- 16% to 92% +/- 8%. Pretraining versus posttraining scores (72% +/- 14%) on similar cognitive items were not significantly different (P=.3636). Scores on similar open-ended application items before and after training improved from 62% +/- 25% to 85+/-10% (P < .0001). All subjects agreed that simulation-based cardiopulmonary bypass training was superior to classroom- and clinic-based education and that the scenarios enhanced their learning experience. CONCLUSIONS Simulation-based cardiopulmonary bypass training appears to be an effective technique to build the confidence of thoracic surgery residents regarding knowledge and applications. Scenario-based practice in a specifically designed simulated environment is a valuable adjunct to traditional educational methods and has the potential to improve the training of thoracic residents.

Simulation-Based Postcardiotomy Extracorporeal Membrane Oxygenation Crisis Training for Thoracic Surgery Residents

BACKGROUND We developed and tested a clinical simulation program in the principles and conduct of postcardiotomy extracorporeal membrane oxygenation (ECMO) with the aim of improving confidence, proficiency, and crisis management. METHODS Twenty-three thoracic surgery residents from unique residency programs participated in an ECMO course involving didactic lectures and hands-on simulation. A current postcardiotomy ECMO circuit was used in a simulation center to give residents training with basic operations and crisis management. Pretraining and posttraining assessments concerning confidence and knowledge were administered. Before and after the training, residents were asked to identify components of the ECMO circuit and manage crisis scenarios, including venous line collapse, arterial hypertension, and arterial desaturation. RESULTS In the hands-on portion, residents had difficulty identifying the gas source and flow rate, centrifugal pump head inlet, and oxygenator outflow line. Timely and accurate ECMO component identification improved significantly after training. The arterial desaturation crisis scenario gave the residents difficulty, with only 22% providing the appropriate treatment recommendations in a timely and accurate fashion. At the end of the simulation training, most residents were able to manage the crises correctly in a timely manner. Posttraining confidence-related scores increased significantly. Most of the residents strongly recommended the course to their peers and reported simulation-based training was helpful in their postcardiotomy ECMO education. CONCLUSIONS We developed a simulation-based postcardiotomy ECMO training program that resulted in improved ECMO confidence in thoracic surgery residents. Crisis management in a simulated environment enabled residents to acquire technical and behavioral skills that are important in managing critical ECMO-related problems.

Topical Hemostatic Therapy in Surgery: Bridging the Knowledge and Practice Gap

Hemorrhage is a leading cause of preventable morbidity and mortality in and out of the operating room. Surgical bleeding can have a significant impact on both patient outcomes and health care costs. Poor hemorrhage control is strongly linked with untoward outcomes and drives clinicians to use treatment methods that may further lead to increased morbidity and mortality. 1,2 Adverse events related to bleeding and blood transfusion are dosedependent, with increased transfusion rates associated with higher morbidity. 3,4 A retrospective analysis of more than 1 million surgical procedures of varying types found that bleeding-related surgical complications occurred in 29.9% of patient operations, translating into a 6-day average increase in hospital length of stay. 5 In this study,

Update on safety equipment for extracorporeal life support (ECLS) circuits.

Though much has been surveyed and written about the equipment aspects of extracorporeal life support (ECLS) in the past 10 years, there is value in reviewing the use and nonuse of multiple safety devices and techniques. Minimally equipped ECLS circuits for adult and pediatric bridge to decision during cardiac and respiratory failure are rapidly gaining popularity to maintain simplicity and portability. ECLS circuits employed for long-term therapy are outfitted differently and should include more safety devices. The purpose of this review is to compare and contrast the spectrum of minimally equipped ECLS circuits to circuits with maximum flexibility and safety device protection. Due to the lack of high-level, well-controlled scientific studies regarding ECLS equipment and safety devices, this study reviews the basis for how we use ECLS circuits and devices in our institution to provide safe patient support.

A novel approach for monitoring volatile anesthetic concentration during cardiopulmonary bypass

To the Editor, Awareness and recall during general anesthesia is a rare yet serious complication that has been reported to occur in an estimated one in 8,600 cases of cardiothoracic anesthesia. There are numerous potential causes for awareness during cardiovascular operations. During cardiopulmonary bypass (CPB), general anesthesia is often a collaborative effort between the anesthesiologist and the perfusionist. Standard monitoring of the depth of anesthesia with end-tidal volatile concentration from the respiratory circuit is not feasible during CPB due to cessation of ventilation and lack of pulmonary blood flow. Various techniques are used to monitor the state of anesthesia during CPB, including serum volatile anesthetic concentration, end-tidal volatile anesthetic concentration at the CPB pump oxygenator exhaust line, and the bispectral index (BIS; Minneapolis, MN, USA). Each of the above techniques has limitations that make universal application challenging. Analysis of serum volatile anesthetic concentration is not available for point-of-care testing, making real-time utilization impractical. Sampling end-tidal volatile anesthetic concentration at the CPB oxygenator exhaust line does not correlate well with serum plasma volatile anesthetic concentration due to the ‘‘leakiness’’ engineered into the membrane oxygenator. Furthermore, it can also vary with the utilization of vacuum scavenger gas systems that can further entrain room air into the exhaust line. The use of BIS during cardiac surgery is common; however, displayed numerical values cannot always reliably predict the depth of anesthesia and thus far have failed to prevent awareness in large studies. We present a novel technique for monitoring volatile anesthetic concentration at the fresh gas inflow line prior to insertion into the membrane oxygenator. A gas sampling line with a flow restrictor connects the inflow gas line on the bypass circuit to the gas analyzer on the anesthesia machine (Figure). The inspired volatile anesthetic concentration is displayed on the anesthesia machine monitor, and low volatile alarms can be activated. Monitoring inspired volatile anesthetic concentration via this method allows for rapid detection of changes in inspired volatile anesthetic concentration, such as would occur if the vaporizer were turned off, malfunctioning, or exhausted during CPB. Unfortunately, extrapolating expiratory or ‘‘end-tidal’’ volatile anesthetic concentration data from the inspired concentration is not possible in patients with mechanical ventilation or during CPB. Volatile anesthetic uptake can vary during CPB depending on a number of factors, including oxygenator type and duration of usage. It can also vary in patients requiring mechanical ventilation due to ventilationperfusion (V/Q) mismatch, shunt, and fresh gas flow rate. A point to consider is that modern gas analyzers sample at a flow of 180-200 mL min, which should not be problematic in adult patients with CPB sweep flow in excess of 2 L min. Nevertheless, in pediatric cases, the sweep flow can be as low as 500 mL min, risking underventilation if continuous real-time blood gas monitoring is not utilized. Again, the limitation of this sampling method is a lack of known correlation between inspired anesthetic concentration at the oxygenator inflow line and depth of anesthesia. Nevertheless, monitoring volatile concentration at the oxygenator inflow line serves M. M. Smith, MD (&) J. B. Riley, CCP W. R. Levenick, CCP N. M. Dietz, MD Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN, USA e-mail: smith.mark2@mayo.edu