Lukas P. Mileder

Reference Ranges for Cerebral Tissue Oxygen Saturation Index in Term Neonates during Immediate Neonatal Transition after Birth.

Background: Non-invasive monitoring of the brain with near-infrared spectroscopy (NIRS) during immediate transition after birth is of growing interest. Objective: The aim of this work was to define reference ranges and centile charts for a regional cerebral tissue oxygenation index (cTOI), measured with the NIRO 200NX (NIRO, Hamamatsu, Japan), and cerebral fractional tissue oxygen extraction (cFTOE) during the first 15 min after birth in preterm and term neonates without any medical support. Methods: cTOI was measured with the NIRO 200NX during the first 15 min after delivery via Caesarean section in preterm and term infants. The NIRS-sensor was placed on the right forehead. Peripheral arterial oxygen saturation (SpO2) and heart rate were continuously measured by pulse oximetry. cFTOE was calculated out of cTOI and SpO2. Neonates with a requirement for any medical support were excluded. Results: A total of 230 neonates were enrolled, from which 90 had to be excluded. Therefore, 140 term neonates were included and data were used to define reference ranges and centile charts. The 50th centile (10th to 90th centiles) of cTOI was 56% (39-75) at 2 min, 66% (50-78) at 5 min, 75% (62-85) at 10 min and 73% (61-84) at 15 min after birth. The 50th centile of cFTOE was 0.24 (0.11-0.44) at 2 min, 0.20 (0.10-0.35) at 5 min, 0.21 (0.09-0.35) at 10 min and 0.24 (0.13-0.37) at 15 min after birth. Conclusion: The present observational study adds the reference ranges and centile charts of cTOI measured with the NIRO 200NX and cFTOE calculated out of cTOI and SpO2 in neonates during the immediate neonatal transition. Centiles for each instrument will be necessary for future clinical application, since the differences between cTOI and cerebral regional tissue oxygen saturation measured with INVOS 5100C change with increasing regional oxygenation.

Clinicians should be aware of their responsibilities as role models: a case report on the impact of poor role modeling.

Background Role modeling is an important and valuable educational method. It is predominant throughout (under-)graduate medical education, and attributes of exemplary medical role models are manifold. Aim This article describes the impact of poor role modeling on medical students’ professional and personal development on the basis of a singular incident at an associated teaching hospital. In addition, scientific literature studying the effect of and the reasons behind poor role modeling in undergraduate and graduate medical education is analyzed and discussed. Results To maximize the educational potential of clinical role modeling, medical schools have to consider strategies both on the individual as well as on the institutional level. Several suggestions are offered on both levels. Discussion/conclusion Based on a case report of significantly poor role modeling, this article outlines strategies through which academic medical institutions may maximize the educational potential of role modeling and lastingly enhance teaching proficiency of clinical faculty.

Are medical schools hesitant to teach undergraduate students teaching skills? A medical student’s critical view

Junior medical staff provides a large proportion of undergraduate student education. However, despite increasing numbers of resident-as-teacher training programs, junior doctors may still not be sufficiently prepared to teach medical students. Hence, medical schools should consider implementing formal teaching skills training into undergraduate curricula.Junior medical staff provides a large proportion of undergraduate student education. However, despite increasing numbers of resident-as-teacher training programs, junior doctors may still not be sufficiently prepared to teach medical students. Hence, medical schools should consider implementing formal teaching skills training into undergraduate curricula.

Compliance with Guidelines Recommending the Use of Simulation for Neonatal and Infant Resuscitation Training in Austria

BACKGROUND Current international resuscitation guidelines recommend simulation for the training of neonatal and infant resuscitation. We aimed at assessing compliance rates with these recommendations in Austria. METHOD We performed a national questionnaire survey among 31 neonatal institutions in Austria. RESULTS 25 questionnaires (80.6%) were analyzed. 22/25 institutions (88%) used simulation as an instructional modality. 8 institutions (32%) had access to medical simulation centers, with 6/8 being used for neonatal and infant resuscitation training. Simulation equipment was available at 17/25 institutions (68%), with a median of 1 part-task trainer (0-2), 2 low-fidelity resuscitation mannequins (0-10), and 0 high-fidelity patient simulators (0-7). Resuscitation training frequency varied widely, ranging from one training per month to one training per year. 5 simulation centers utilized interdisciplinary resuscitation training with other medical specialties and team training including physicians and nursing staff. Of the 17 institutions with simulation equipment at their disposal, 8 (47.1%) carried out interdisciplinary training and 13 (76.5%) performed team-oriented training sessions. DISCUSSION/CONCLUSION The majority of surveyed institutions adopted simulation for neonatal and infant resuscitation training according to current guidelines and had simulation equipment at their disposal. However, educational practice varied widely, especially in regard to training frequency. Therefore, we suggest a national consensus agreement on best practices in simulation-based neonatal and infant resuscitation training.

Peripheral Muscle Near-Infrared Spectroscopy in Neonates: Ready for Clinical Use? A Systematic Qualitative Review of the Literature

Background: Peripheral muscle near-infrared spectroscopy (NIRS) measurements are of increasing interest especially in the care of critically ill patients. Objective: The aim was to perform a systematic qualitative review on peripheral muscle NIRS measurements in the clinical care of term and preterm neonates. Methods: A systematic search of PubMed and Ovid Embase was performed using the following terms: neonate, neonates, newborn, newborns, infant, infants, near-infrared spectroscopy, NIRS, oxygenation, perfusion, oxygen extraction, peripheral, tissue, muscle, calf, forearm and thigh. Additional articles were identified by a manual search of the cited references. Only human studies were included. Results: Twenty-one studies were identified to use peripheral muscle NIRS measurements as a single method, 17 studies combined cerebral and peripheral muscle NIRS measurements and 1 study used multi-site NIRS measurements in human neonates. Two randomized studies were identified. Two additional publications were included because they provided important general information about peripheral muscle NIRS measurements. Conclusion: In the care of critically ill neonates peripheral muscle NIRS measurements alone or in combination with cerebral or multi-site NIRS measurements provide useful additional information about peripheral circulation and oxygenation. This method is a promising tool in the recognition of early states of centralization (compensated shock) in this vulnerable group of patients. However, before this method can be used in the clinical routine it has to be tested as monitoring to guide interventions in further studies.

Teaching first-year medical students in basic clinical and procedural skills--a novel course concept at a medical school in Austria.

Introduction: Clerkships are still the main source for undergraduate medical students to acquire necessary skills. However, these educational experiences may not be sufficient, as there are significant deficiencies in the clinical experience and practical expertise of medical students. Project description: An innovative course teaching basic clinical and procedural skills to first-year medical students has been implemented at the Medical University of Graz, aiming at preparing students for clerkships and clinical electives. The course is based on several didactic elements: standardized and clinically relevant contents, dual (theoretical and virtual) pre-course preparation, student peer-teaching, small teaching groups, hands-on training, and the use of medical simulation. This is the first course of its kind at a medical school in Austria, and its conceptual design as well as the implementation process into the curriculum shall be described. Evaluation: Between November 2011 and January 2013, 418 students have successfully completed the course. Four online surveys among participating students have been performed, with 132 returned questionnaires. Students’ satisfaction with all four practical course parts was high, as well as the assessment of clinical relevance of contents. Most students (88.6%) strongly agreed/agreed that they had learned a lot throughout the course. Two thirds of the students were motivated by the course to train the acquired skills regularly at our skills laboratory. Narrative feedbacks revealed elements contributing most to course success. Conclusions: First-year medical students highly appreciate practical skills training. Hands-on practice, peer-teaching, clinically relevant contents, and the use of medical simulation are valued most.

Simulation-based training: the missing link to lastingly improved patient safety and health?

Patient harm resulting from medical care is common, with 25.1 harms per 100 hospital admissions and 10.9% of harms being life threatening and causing or contributing to a patients death.1 One study found at least 210 000 deaths of hospitalised patients to be associated with preventable harm per year.2 Factors contributing most frequently to patient safety incidents are active failures including cognitive and technical errors as well as deviations from policies, individual factors (eg, inexperience and stress), communication, equipment and supplies, and management of staff and staffing levels.3 As factors contributing to safety incidents are manifold, a multitude of strategies—involving the continuum from individuals to healthcare systems—has to be considered when aiming at improving the quality of healthcare and patient safety. A strategy certainly at the forefront of this process is active improvement of quality and effectiveness in medical education and training.4 Medical education has traditionally relied on on-the-job training. However, the often used ‘see one, do one, teach one’ approach may be detrimental to patient safety and health, as it exposes patients to inexperienced healthcare practitioners.5 In an effort to reduce human errors and improve operational safety, simulation-based training (SBT) has been recognised as an effective methodology.6 It is well documented that aviation, aerospace and nuclear power have developed a remarkable safety culture. Because of the profound safety awareness, these professions represent high-reliability industries and provide a ‘benchmark safety record for medicine to emulate’.7 In hindsight, first initiatives to implement SBT into medical education in the 1960s and 1970s have to be considered as pioneer work. From these initial efforts incorporated mainly by anaesthesiologists, the use of simulation—defined as ‘a technique to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully …

Blood Pressure during the Immediate Neonatal Transition: Is the Mean Arterial Blood Pressure Relevant for the Cerebral Regional Oxygenation?

Background: Measurement of mean arterial blood pressure (MABP) is feasible during neonatal transition. Objective: The objective of this study was to investigate a potential influence of MABP on the cerebral regional oxygen saturation (crSO2) in preterm and term infants during the immediate neonatal transition. Materials and Methods: Preterm and term infants were included in this observational study. The crSO2 was measured by near-infrared spectroscopy with the INVOS 5100C (Somanetics Corp., Troy, MI, USA) during the immediate neonatal transition (15 min after birth). The near-infrared spectroscopy sensor was applied to the left forehead. Furthermore, a pulse oximeter was applied to monitor arterial oxygen saturation (SpO2) and heart rate (HR). Fifteen minutes after birth, blood pressure was measured noninvasively at the left upper arm. Cerebral fraction tissue oxygen extraction (cFTOE) was calculated from SpO2 and crSO2. To investigate a potential association between crSO2/cFTOE and MABP, we performed a correlation analysis. Results: A total of 462 preterm and term infants (186/292) were included. Mean gestational age was 31.0 ± 3.5 weeks for preterm infants and 38.9 ± 0.8 weeks for full term infants. Mean birth weight was 1.591 ± 630 g in preterm infants and 3.331 ± 461 g in term infants. There was a significant negative correlation between MABP and cFTOE (ρ = -0.19, p = 0.03) in preterm infants but not in term infants (ρ = 0.05, p = 0.39). There was no significant correlation between MABP and crSO2 in either group. Conclusion: MABP has an impact on cerebral oxygenation in preterm infants. Therefore, blood pressure monitoring during the immediate neonatal transition might be relevant for improving cerebral oxygenation especially in preterm infants.

One day on duty: Recreating an emergency department for medical students.

Past decades have seen continuous changes in medical education, with patient safety becoming a point of emphasis and bedside training opportunities being limited by duty hour restrictions. Therefore, traditional training has been steadily augmented by simulationbased training (SBT), facilitating on-demand training without exposing patients to harm while offering trainees systematic and objective learning experiences.

Simulation and its role in airway management training.

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