Jenny Lam-McCulloch

Applying theory to practice in undergraduate education using high fidelity simulation

High-fidelity patient simulation allows students to apply their theoretical knowledge of pharmacology and physiology to practice. The purpose of this study was to determine if experiential education using high-fidelity simulation improves undergraduate performance scores on simulation-based and written examinations. After receiving research ethics board approval, students completed a consent form and then answered a ten question multiple-choice quiz to identify their knowledge regarding the management of cardiac arrhythmias. Four simulation scenarios were presented and students worked through each scenario as a team. Faculty facilitated the sessions and feedback was given using students’ videotaped performances as a template for discussion. Performance evaluation scores using predetermined checklists and global rating scales were completed. Students then reviewed the American Heart Association guidelines for the management of unstable cardiac arrhythmias. The afternoon session involved repetition of the four case scenarios with the same teams involved but different team leaders. Students then repeated the quiz they received in the morning. Descriptive statistics, paired t-test and repeated measures analysis of variance (ANOVA) were used to analyse results. Two hundred and ninety-nine students completed the study. There was a statistically significant improvement in performance on the pharmacology written test. Simulation team performance also statistically improved and a good correlation between checklist and global rating scores were demonstrated in all but one scenario. Student evaluation of the experience was extremely positive. High-fidelity simulation can be used to allow students to apply theoretical knowledge to practice in a safe and realistic environment. Results of this study indicate that simulation is a valuable learning experience and bridges the gap between theory and practice. Simulation technology has the potential to provide an enriching venue to examine the role of communication and dynamics of novice learners in team environments.

Rectal indomethacin reduces postoperative pain and morphine use after cardiac surgery.

PurposeTo evaluate the combination of rectal indomethacin with patient controlled intravenous morphine analgesia (PCA) on postoperative pain relief and opioid use after cardiac surgery.MethodsWith institutional ethics approval, 57 consenting adults undergoing elective aortocoronary bypass surgery were randomly assigned preoperatively in a double-blind fashion to receive either placebo (n = 26) or indomethadn 100 mg suppositories (n = 31), 2–3 hr postoperatively, and 12 hr later. Both groups utilized PCA morphine. Pain scores in the two treatment groups were assessed on a 10-cm visual analogue scale (VAS) (at rest and with cough) at 4, 6, 12, 18 and 24 hr after initial dosing, and were analyzed through a 2 × 5 repeated measures of variance. The 24 hr analgesic consumption, 12 and 24 hr chest tube blood loss, and time to tracheal extubation were also recorded, and compared for the two treatment arms through Student’s t test on independent samples.ResultsPostoperative morphine consumption in the first 24 hr was 38% less in the indomethadn group (22.40 ± 12.55 mg) than the placebo group (35.99 ± 25.84 mg), P= 0.019. Pain scores, measured with a VAS, were 26% to 66% lower in the indomethacinvs placebo group at rest (P=0.006), but not with cough, for all times assessed. There was no difference in blood loss (at 12 hr) or time to tracheal extubation for both groups.ConclusionThe combination of indomethacin with morphine after cardiac surgery results in reduced postoperative pain scores and opioid use without an increase in side effects.RésuméObjectifÉvaluer l’action combinée d’indométhacine rectale et d’analgésie contrôlée par le patient (ACP) avec de la morphine intraveineuse sur la douleur postopératoire et l’usage d’opioïde en cardiochirurgie.MéthodeAyant obtenu l’approbation du comité d’éthique de l’hôpital, 57 adultes consentants qui devaient subir un pontage aortocoronarien électif ont été répartis au hasard avant l’opération afin de recevoir en double insu, soit un placebo (n = 26), soit de l’indométhacine (n = 31) en suppositoires de 100 mg, 2–3 h après l’opération et 12 h plus tard. Tous ont utilisé de la morphine pour l’ACP. Les scores de douleur ont été évalués à l’aide d’une échelle visuelle analogue (EVA) de 10 cm (au repos et lors de la toux) à 4, 6, 12, 18 et 24 h après le dosage initial et analysés selon un plan 2 × 5 de mesures répétées de la variance. La consommation d’analgésique à 24 h, la perte sanguine au drain thoracique à 12 et 24 h et le moment de l’extubation endotrachéale ont été notés et comparés d’un groupe à l’autre par le test t de Student sur des échantillons indépendants.RésultatsLa demande postopératoire de morphine des 24 premières h a été de 38% moindre avec l’indométhacine (22,40 ± 12,55 mg) qu’avec le placebo (35,99 ± 25,84 mg),P = 0,019. Les scores de douleur de l’EVA ont été de 26% à 66% plus faibles pour l’indométhacine vs le placebo, au repos (P = 0,006), non lors de la toux, et ce, pour tous les temps de mesures. La perte sanguine a été semblable dans les deux groupes (à 12 h) ainsi que le temps total d’intubation.ConclusionAdministrée après une intervention cardiaque, la combinaison d’indométhacine et de morphine a réduit les douleurs et l’usage d’opioïdes sans augmenter les effets secondaires.

Comparison of maternal satisfaction between epidural and spinal anesthesia for elective Cesarean section

Purpose: Epidural anesthesia was a commonly used technique for elective Cesarean section. Recently, because of the availability of non-cutting spinal needles, many institutions have changed from epidural to spinal anesthesia. The purpose of this study was to compare maternal satisfaction between epidural and spinal anesthesia for elective Cesarean section with a new satisfaction tool.Methods: We studied healthy parturients in a randomized, double-blinded pilot study in which patients were assigned to receive either epidural (n=13) or spinal (n=14) anesthesia for elective Cesarean section. Two and 24 hr postoperatively, patients completed a validated 22-point maternal satisfaction questionnaire and a 10-cm visual analog score (VAS) for satisfaction. Maternal satisfaction scores were compared between groups.Results: There was no difference in demographics, complications or technical failures between groups. Mean satisfaction scores on the questionnaire (0–154) at two and 24 hr were 130.23±11.36 and 129.54±16.70 for the epidural group and 116.92±18.47 and 115.92±15.71 for the spinal group (P=0.04 andP=0.03 respectively). No difference in VAS scores was noted. The presence of minor side effects including pruritus contributed to the lower satisfaction in the spinal group at 24 hr.Conclusion: This pilot study demonstrated higher maternal satisfaction with epidural than with spinal anesthesia for elective Cesarean section. This may be related to the increased side effects caused by neuraxial morphine. The satisfaction questionnaire was able to elucidate differences not detected with a global VAS for satisfaction. Further study with a larger patient population is required to confirm these data.RésuméObjectif: L’anesthésie péridurale était une technique couramment utilisée pour la césarienne. Récemment, avec l’arrivée des aiguilles mousses, de nombreuses institutions ont préféré la rachianesthésie. La présente étude voulait comparer, avec un nouvel outil de mesure, le degré de satisfaction de la mère pendant la césarienne sous anesthésie péridurale ou rachidienne.Méthode: Des parturientes en bonne santé ont fait l’objet d’une étude pilote randomisée et à double insu. Elles ont reçu soit une anesthésie péridurale (n=13), soit une rachianesthésie (n=14), pendant une césarienne planifiée. Après l’opération, 2 h et 24 h, la satisfaction des patientes a été évaluée à l’aide d’un questionnaire validé de 22 items et d’une échelle visuelle analogique (EVA) de 10 cm. On a comparé les scores de satisfaction maternelle.Résultats: Les données démographiques, complications ou défaillances techniques étaient similaires dans les deux groupes. Les scores moyens au questioonnaire sur la satisfaction (0–154), 2 h et 24 h après l’intervention, ont été de 130,23±11,36 et 129,54±16,70 avec l’anesthésie péridurale, et de 116,92±18,47 et 115,92±15,71 avec la rachianesthésie (P=0,04 etP=0,03 respectivement). Aucune différence de score à l’EVA n’a été notée. Des effets secondaires mineurs, comme le prurit, ont fait baisser le taux de satisfaction 24 h après la rachianesthésie.Conclusion: Cette étude pilote a démontré que les mères préfèrent l’anesthésie péridurale à la rachianesthésie pendant la césarienne. Ce qui peut dépendre d’effets secondaires plus importants causés par la morphine médullaire. Le questionnaire sur la satisfaction a mis en évidence des différences non détectées avec l’EVA globale sur le même sujet. Une étude supplémentaire comprenant un grand nombre de patientes demeure nécessaire pour confirmer ces données.

Consensus and controversy in hepatic surgery: A survey of Canadian surgeons

Heterogeneity in practice provides an opportunity for further study, as it may [IRT Rev 1] reflect deficiencies in knowledge translation or knowledge gaps. This survey aimed to assess practice patterns for the surgical treatment of malignancies of the liverwith the goal of identifying areas of variability.

Systemic effects of subcutaneous and topical epinephrine administration during burn surgery

removed and the PLMA railroaded into position using the digital technique with a midline approach. On this occasion, ventilation was easy with no air leakage and the bite block was correctly located between the teeth. The GEB was removed whilst holding the PLMA. Subsequent passage of a gastric tube was easy. By guiding the PLMA tip towards the hypopharynx the GEB ensures that the PLMA is correctly positioned. The GEB may also help prevent impaction in the back of the mouth and should prevent the cuff folding over. Drolet and Girard1 recently described a similar technique using a gastric tube. We speculate that the GEB is a better guide than the gastric tube because of its greater stiffness.