John Pawlowski

Simulated laparoscopic operating room crisis: An approach to enhance the surgical team performance

ObjectiveDiminishing human error and improving patient outcomes is the goal of task training and simulation experience. The fundamentals of laparoscopic surgery (FLS) is a validated tool to assess technical laparoscopic skills. We hypothesize that performance in a crisis depends on technical skills and team performance. The aim of this study was to develop and validate a high-fidelity simulation model of a laparoscopic crisis scenario in a mock endosuite environment.MethodsTo establish the feasibility of the model as well as its face and construct validity, the scenario evaluated the performances of FLS-certified surgeon experts (n = 5) and non-FLS certified novices (n = 5) during a laparoscopic crisis scenario, in a mock endosuite, on a simulated abdomen. Likert scale questionnaires were used for validity assessments. Groups were compared using previously validated rating scales on technical and nontechnical performance. Objective outcome measures assessed were: time to diagnose bleeding (TD), time to inform the team to convert (TT), and time to conversion to open (TC). SAS software was used for statistical analysis.ResultsMedian scores for face validity were 4.29, 4.43, 4.71 (maximum 5) for the FLS, non-FLS, and nursing groups, respectively, with an inter-rater reliability of 93%. Although no difference was observed in Veress needle safety and laparoscopic equipment set up, there was a significant difference between the two groups in their overall technical and nontechnical abilities (p < 0.05), specifically in identifying bleeding, controlling bleeding, team communication, and team skills. There was a trend towards a difference between the two groups for TD, TT, and TC. While experts controlled bleeding in a shorter time, they persisted longer laparoscopically.ConclusionsOur evidence suggests that face and construct validity are established for a laparoscopic crisis simulation in a mock endosuite. Technical and nontechnical performance discrimination is observed between novices and experts. This innovative multidisciplinary simulation aims at improving error/problem recognition and timely initiation of appropriate and safe responses by surgical teams.

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

Objective:To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives. Background:Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale. Methods:A malpractice insurer convened a collaborative with 4 Harvard-affiliated simulation programs to develop a standardized operating room teamwork training curriculum, including principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. Participant teams were compensated for lost operative time via malpractice premium discounts, continuing education credits, and compensation for lost wages. The course was delivered through a simulation program involving the management of intraoperative emergency scenarios. Participants were surveyed for their perceptions of the program and of its impact on clinical practice. Results:A total of 221 active operating room staff members participated in the program. Each team contained at least 1 attending surgeon, 1 attending anesthesiologist, and 1 operating room nurse (mean size per team: 7 ± 2 participants). No study dates were cancelled because of lack of attendance. The survey response rate was 99% (218/221). Overall, the vast majority of participants found the scenarios realistic [94% (95% confidence interval: 90.9%, 97.2%)], appropriately challenging [95.4% (92.6%, 98.2%)], relevant to their practice [96.3% (93.8%, 98.8%)], and found the training would help them provide safer patient care [92.6% (89.1%, 96.1%)]. Surgeons reported their greatest personal deficit as communication skills. Operating room nurses and anesthesiologists reported a greater need than surgeons to work on personal assertiveness. Conclusions:A standardized multicenter team training program involving full operative teams is feasible with high-fidelity simulation and modest compensation for lost time. The vast majority of the multidisciplinary participants believed the course to have had a meaningful impact on their approach to clinical practice.

Transesophageal Echocardiography Simulator: A New Learning Tool

RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)is a minimally invasive monitoring modality. The initialuse of TEE was limited to the acquisition of images in patientswith suboptimal echo windows during transthoracic echocar-diography. Its role has exponentially expanded to become al-most a standard of care during cardiac surgery and a valuableprocedural adjunct.

Early bedside care during preclinical medical education: can technology-enhanced patient simulation advance the Flexnerian ideal?

Flexner wanted medical students to study at the patient bedside—a remarkable innovation in his time—so that they could apply science to clinical care under the watchful eye of senior physicians. Ever since his report, medical schools have reserved the latter years of their curricula for such an “advanced” apprenticeship, providing clinical clerkship experiences only after an initial period of instruction in basic medical sciences. Although Flexner codified the segregation of preclinical and clinical instruction, he was committed to ensuring that both domains were integrated into a modern medical education. The aspiration to fully integrate preclinical and clinical instruction continues to drive medical education reform even to this day. In this article, the authors revisit the original justification for sequential preclinical–clinical instruction and argue that modern, technology-enhanced patient simulation platforms are uniquely powerful for fostering simultaneous integration of preclinical–clinical content in a way that Flexner would have applauded. To date, medical educators tend to focus on using technology-enhanced medical simulation in clinical and postgraduate medical education; few have devoted significant attention to using immersive clinical simulation among preclinical students. The authors present an argument for the use of dynamic robot-mannequins in teaching basic medical science, and describe their experience with simulator-based preclinical instruction at Harvard Medical School. They discuss common misconceptions and barriers to the approach, describe their curricular responses to the technique, and articulate a unifying theory of cognitive and emotional learning that broadens the view of what is possible, feasible, and desirable with simulator-based medical education.

How do clinical clerkship students experience simulator-based teaching? A qualitative analysis.

Objectives: To critically analyze the experience of clinical clerkship students exposed to simulator-based teaching, in order to better understand student perspectives on its utility. Methods: A convenience sample of clinical students (n = 95) rotating through an emergency medicine, surgery, or longitudinal patient-doctor clerkship voluntarily participated in a 2-hour simulator-based teaching session. Groups of 3-5 students managed acute scenarios including respiratory failure, myocardial infarction, or multisystem trauma. After the session, students completed a brief written evaluation asking for free text commentary on the strengths and weaknesses of the experience; they also provided simple satisfaction ratings. Using a qualitative research approach, the textual commentary was transcribed and parsed into fragments, coded for emergent themes, and tested for inter-rater agreement. Results: Six major thematic categories emerged from the qualitative analysis: The “Knowledge & Curriculum” domain was described by 35% of respondents, who commented on the opportunity for self-assessment, recall and memory, basic and clinical science learning, and motivation. “Applied Cognition and Critical Thought” was highlighted by 53% of respondents, who commented on the value of decision-making, active thought, clinical integration, and the uniqueness of learning-by-doing. “Teamwork and Communication” and “Procedural/Hands-On Skills” were each mentioned by 12% of subjects. Observations on the “Teaching/Learning Environment” were offered by 80% of students, who commented on the realism, interactivity, safety, and emotionality of the experience; here they also offered feedback on format, logistics, and instructors. Finally, “Suggestions for Use/Place in Undergraduate Medical Education” were provided by 22% of subjects, who primarily recommended more exposure. On a simple rating scale, 94% of students rated the quality of the simulator session as “excellent,” whereas 91% felt the exercises should be “mandatory.” Conclusion: Full-body simulation promises to address a wide range of pedagogical objectives using a unified educational platform. Students value experiential “practice without risk” and want more exposure to simulation. In this study, students thought that that an integrated simulation exercise could help solidify knowledge across domains, foster critical thought and action, enhance technical-procedural skills, and promote effective teamwork and communication.

Mechanisms of intrinsic tone in ferret vascular smooth muscle.

1. Circular strips from ferret aorta were used to investigate the mechanism of the intrinsic basal tone. 2. Determinations of stiffness using small sinusoidal length changes showed an abolition of both stiffness and force with cooling, but the temperature dependence of the change in active stiffness did not parallel that of force. At temperatures below 22 degrees C there appeared to be a relatively large population of attached, non‐force‐generating cross‐bridges, indicating that separate mechanisms are involved in regulating cross‐bridge attachment and the force per cross‐bridge. 3. Active intrinsic tone was not affected by removal of extracellular Ca2+ or removal of endothelium. 4. Intracellular ionized Ca2+ concentrations ([Ca2+]i) as measured with the photoprotein aequorin, did not significantly change when intrinsic tone was abolished by cooling. 5. Myosin light chain phosphorylation, as measured by 2‐dimensional polyacrylamide gel electrophoresis, significantly decreased on cooling, but the temperature dependence of phosphorylation did not parallel that of force. The change in phosphorylation in the absence of a change in [Ca2+]i suggests the presence of a constitutively active Ca(2+)‐independent form of myosin light chain kinase. 6. Maximal concentrations of staurosporine inhibited but did not eliminate intrinsic tone. 7. Changes in myosin light chain kinase and protein kinase C activities may explain part but not all of the intrinsic tone.

Minimally invasive direct coronary artery bypass grafting: Changes in anesthetic management and surgical procedure

OBJECTIVE The authors hypothesized that changes in surgical procedures for minimally invasive direct coronary artery bypass grafting (MIDCAB) have led to changes in anesthetic management with a resultant decrease in the complexity of care. DESIGN Retrospective observational study. SETTING University teaching hospital. PARTICIPANTS Review of the records of 60 patients who underwent MIDCAB surgery. MEASUREMENTS AND MAIN RESULTS Data included preoperative demographics, perioperative anesthetic management, and postoperative cardiac and noncardiac issues and complications. Two groups were formed: in group I, a coronary stabilizer (CS) was not used, and in group II, it was. With the exception of a greater incidence of those with no preoperative comorbidities in group II (CS), there were no differences between the two groups with respect to demographics or preoperative variables. A surgical design called H-graft was used in a greater number of group II (CS) patients, whereas a direct anastomosis was performed in the majority of group I patients. Use of pharmacologically induced bradycardia/asystole has not been performed after the introduction of the CS. The use of central venous catheters (instead of pulmonary artery catheters) and single-lumen (v double-lumen) endotracheal tubes was greater in group II (CS) patients. Despite changes in intraoperative management, there was no significant change in the incidence of postoperative complications, intensive care unit stay, and hospital stay between groups I and II. New-onset atrial fibrillation was the most common postoperative complication (13 of 56 patients; 23%). Three of 24 patients (12.5%) who received intraoperative magnesium experienced atrial fibrillation compared with 10 of 32 patients (31%) who did not receive magnesium. CONCLUSIONS The complexity of anesthetic technique has decreased since the onset of MIDCAB surgery. The decrease in complexity may be related to changes in surgical design and technology.

Anesthetic considerations for interventional pulmonary procedures.

Purpose of review To discuss the anesthetic considerations of various procedures now performed by the interventional pulmonologist. With recent technological advances, many of these procedures represent acceptable alternatives to the invasive surgical procedures. For example, the placement of endobronchial valves can substitute for lung reduction surgery and can greatly reduce the postoperative recovery period. However, many of these complex procedures require anesthesia services. The nature and indication for the procedure as well as the patients overall health will have an impact on the anesthetic choice. Recent findings New studies have documented common complications from interventional pulmonology procedures and recent ways to avoid these complications have been suggested. Strategies to avoid obstruction, bleeding, pneumothorax and air embolism are discussed in this article. Potential benefits of high frequency jet ventilation in reducing airway pressures and, perhaps, barotraumas are cited. Novel interventional pulmonary procedures are described. Summary As the array of diagnostic and therapeutic pulmonary interventions is expanding, the types of anesthetic techniques and ventilatory modes are varying to fit the procedural requirements. Some pulmonary procedures are best accomplished in the lightly sedated patient, who is breathing spontaneously, whereas procedures that use the working channel of a rigid bronchoscope are better performed in the patient under general anesthesia and mechanical ventilation that often use jet ventilation to minimize respiratory movements.

Anesthesia for interventional pulmonology procedures: a review of advanced diagnostic and therapeutic bronchoscopy

PurposeInterventional pulmonology is a growing subspecialty of pulmonary medicine with flexible and rigid bronchoscopies increasingly used by interventional pulmonologists for advanced diagnostic and therapeutic purposes. This review discusses different technical aspects of anesthesia for interventional pulmonary procedures with an emphasis placed on pharmacologic combinations, airway management, ventilation techniques, and common complications.SourceRelevant medical literature was identified by searching the PubMed and Google Scholar databases for publications on different anesthesia topics applicable to interventional pulmonary procedures. Cited literature included case reports, original research articles, review articles, meta-analyses, guidelines, and official society statements.Principal findingsInterventional pulmonology is a rapidly growing area of medicine. Anesthesiologists need to be familiar with different considerations required for every procedure, particularly as airway access is a shared responsibility with pulmonologists. Depending on the individual case characteristics, a different selection of airway method, ventilation mode, and pharmacologic combination may be required. Most commonly, airways are managed with supraglottic devices or endotracheal tubes. Nevertheless, patients with central airway obstruction or tracheal stenosis may require rigid bronchoscopy and jet ventilation. Although anesthetic approaches may vary depending on factors such as the length, complexity, and acuity of the procedure, the majority of patients are anesthetized using a total intravenous anesthetic technique.ConclusionsIt is fundamental for the anesthesia provider to be updated on interventional pulmonology procedures in this rapidly growing area of medicine.RésuméObjectifLa pneumologie interventionnelle est une sous-spécialité de la pneumologie en progression grâce à l’utilisation croissante des bronchoscopes souples et rigides par les pneumologues interventionnels à des fins diagnostiques et thérapeutiques avancées. Cette analyse aborde les différents aspects techniques de l’anesthésie pour les procédures interventionnelles en pneumologie en insistant sur les combinaisons pharmacologiques, la gestion des voies respiratoires, les techniques de ventilation et les complications fréquentes.SourceLa littérature médicale pertinente a été identifiée par une recherche des publications sur différents sujets d’anesthésie applicables aux procédures interventionnelles en pneumologie dans les bases de données PubMed et Google Scholar. Les publications citées ont inclus des rapports de cas, des articles de recherche originale, des articles de synthèse, des méta-analyses, des lignes directrices et les déclarations officielles de sociétés savantes.Constatations principalesLa pneumologie interventionnelle est une branche de la médecine qui se développe rapidement. Les anesthésiologistes ont besoin de se familiariser avec les différents problèmes soulevés par chaque procédure, en particulier dans la mesure où la responsabilité de l’accès aux voies respiratoires est partagée avec les pneumologues. La méthode de gestion des voies aériennes, le mode de ventilation et la combinaison pharmacologique pourront être choisis en fonction des caractéristiques de chaque cas particulier. Le plus souvent, les voies respiratoires sont gérées avec des dispositifs supraglottiques ou des tubes endotrachéaux. Néanmoins, les patients présentant une obstruction centrale des voies respiratoires ou une sténose de la trachée peuvent nécessiter le recours à un bronchoscope rigide et à une jet-ventilation. Bien que la démarche anesthésique puisse varier en fonction de facteurs tels que la durée, la complexité et la gravité de la procédure, la majorité des patients sont anesthésiés en employant une technique intraveineuse totale.ConclusionsIl est essentiel que le professionnel assurant l’anesthésie connaisse les plus récentes procédures interventionnelles en pneumologie dans ce domaine rapidement croissant de la médecine.

Soft drug strategies in anesthesiology.

Although a host of medications exist that can rapidly cause a patient to become insensible and enter a state of anesthesia, the actual dose and timing of metabolism can vary greatly. Certain populations, such as the elderly, show increased sensitivity to anesthetic medications and often have exaggerated effects. Decreased rates of metabolism and excretion in the elderly can prolong the half-lives of anesthetics and postpone recovery from anesthesia. One strategy by which to avoid these predictable problems with medications is making the medicines more “soft.” “Soft drugs” refer to the development of newer compounds that have the properties of dependable degradation. In his editorial, Talmage Egan defines soft drugs as “novel active compound [that] are specifically designed to be vulnerable to rapid biotransformation to inactive metabolites.” This vulnerability to biotransformation can occur in a number of ways but needs to be relatively ubiquitous in all types of populations to be reliably degraded. For example, drugs that undergo rapid biotransformation only in patients who are rapid acetylators would only be soft drugs for a small minority of patients. A ubiquitous system often resides in the blood plasma, rather than being confined to a single organ. Nonspecific esterases are a common route of metabolic biotransformation. A familiar technique that is used to manufacture a soft drug is providing a substitution of an ester linkage to an existing active compound to make it vulnerable to hydrolysis by esterases. Several novel compounds will be discussed that utilize this method to become “soft.” Another feature of a “soft” drug is that its metabolites must result in inactive compounds. In general, these inactive metabolites have value potencies that are at least 100 times greater than the parent compound.