Marcia Corvetto

To die or not to die? A review of simulated death.

Summary Statement Simulation as an educational technique is increasingly used in health care to teach about managing critical events and life-threatening situations and, infrequently, to teach about death. There is considerable controversy over whether to allow the simulator to die during a session when death is not a predefined learning objective. Some educators never allow the simulator to die unless death is the objective of the scenario, and others allow the simulator to die unexpectedly during any scenario. We do not know whether such a fatal event may affect a student’s learning process and emotions, and no randomized trials have been conducted to determine the impact of simulated death. In this narrative review, we survey the literature on simulated death during health care training, present arguments for and against the broad incorporation of such training in curricula for health care providers, and outline recommendations for using death scenarios in health care simulation.

Inserción de la simulación clínica en el currículum de Anestesiología en un hospital universitario. Evaluación de la aceptabilidad de los participantes

INTRODUCTION Clinical simulation is currently an integral part of the curriculum of the Anesthesiology residency programs in other countries. We aimed to describe and evaluate the insertion of simulation in an anesthesia residency training program. METHODS Activities feasible to be used for training in a simulated environment were classified into 2 modules: workshops for technical skills conducted with first year residents, and high fidelity simulation scenarios performed with second and third year residents. After each activity, and using an anonymous questionnaire, residents assessed their satisfaction and objectives accomplished. RESULTS A total of 18 activities: 6 skills workshops and 12 high fidelity scenarios were assessed. A total of 206 questionnaires were analyzed, corresponding to 41 residents. Almost all (96%) of respondents agreed or strongly agreed that workshops met the objectives and should be mandatory in the anesthesia curriculum; however, 11% agreed that the activity caused anxiety and/or nervousness. The high fidelity scenarios were considered realistic and consistent with the objectives by 97% of residents, and 42% felt that workshops caused anxiety and/or nervousness. CONCLUSIONS The inclusion of simulation has been well accepted by the residents. The activities have been described as realistic, and limited to the objectives, essential points in adult education, as according to Kolbs learning model this is associated with profound, useful and long lasting knowledge.

The Sensitivity of Motor Responses for Detecting Catheter-Nerve Contact During Ultrasound-Guided Femoral Nerve Blocks with Stimulating Catheters

BACKGROUND: We determined the sensitivity of motor responses evoked by stimulating catheters in determining catheter-nerve contact using ultrasonography as reference. METHODS: Femoral nerves were contacted using stimulating catheters under ultrasonography scanning in 25 patients. The output current was increased from its minimum until quadriceps muscle contraction occurred. The sensitivity of the motor response in determining catheter-nerve contact was calculated using 0.5 mA as current threshold. RESULTS: The current required for catheter stimulation to evoke a motor response ranged between 0.18 and 2.0 mA. Muscle contraction in response to 0.5 mA occurred in 16 of 25 subjects. The sensitivity of motor response for nerve stimulation was 64% (95% confidence interval: 0.43, 0.82). CONCLUSIONS: The absence of muscle responses at a stimulating current ⩽0.5 mA does not necessarily indicate the absence of catheter-nerve contact.

Which types of peripheral nerve blocks should be included in residency training programs

BackgroundDespite the increasing use of regional anesthesia, specific recommendations regarding the type of procedures to be included in residency training programs are not currently available. We aimed to determine the nerve block techniques that practicing Chilean anesthesiologists perceived as essential to master during residency training.MethodsAfter institutional ethics committee approval, an online survey was sent to 154 anesthesiologists that graduated between 2005–2012, from the two largest university residency programs in Chile. Multiple-choice questions elicited responses concerning the use of regional anesthesia.ResultsA total of 109 questionnaires were completed, which corresponded to a response rate of 70.8%. Almost all (98.2%) of the respondents used regional anesthesia in their clinical practice, 86.7% regularly performed peripheral nerve blocks (PNBs) and 51% used continuous PNB techniques. Residency programs represented their primary source of training. The most common PNB techniques performed were interscalene (100%), femoral (98%), popliteal sciatic (93%), and Bier block (90%). Respondents indicated that they were most confident performing femoral (98%), Bier block (90%), interscalene (90%), and popliteal sciatic (85%) blocks. The PNBs perceived as essential for their actual clinical practice were femoral (81%), interscalene (80%), popliteal sciatic (76%), and Bier blocks (62%).ConclusionsRequesting information from former anesthesiology residents may be a source of information, guiding the specific types of PNBs that should be included in residency training. Other groups can easily replicate this methodology to create their own evidence and clinical practice based guidelines for residency training programs.

Fire in the operating room.

CURRICULAR INFORMATION Educational Rationale Fire in the operating room (OR) is a rare but critical event. According to the Anesthesia Patient Safety Foundation, hundreds of fires occur in the United States yearly.1 The majority of fires occur during head and neck surgery due to the presence of oxygen and the extensive use of lasers.2 Surgical fires can be prevented by educating staff about risk and prevention strategies. Prevention depends on understanding how the elements of the fire triad interact, recognizing how standard operating room equipment can initiate a fire, and vigilance monitoring for the circumstances that increase the likelihood of fire.3 Education on fire prevention and mitigation should be a part of all undergraduate medical, nursing, and other allied health profession education.4 Using a case report from Barker and Polson5 as our inspiration, we designed this scenario to have learners reflect on preventing and effectively managing an OR fire.6 Learning Objectives Learners will be assessed on the following Accreditation Council for Graduate Medical Education general competencies:

Recognizing and treating malignant hyperthermia.

DEMOGRAPHICS Case Title: Malignant Hyperthermia Patient Name: Jose Perez Scenario Name: Recognizing and treating malignant hyperthermia Simulation Developers: Marcia Corvetto, M.D., and Jeffrey M. Taekman, M.D. Simulator: Laerdal Simman Date of Development: October 2009 Appropriate for following learning groups: • Residents: Postgraduate years 2, 3, and 4 • Specialties: Anesthesiology • Nurse Anesthesia Students: 1 and 2

Mixing and using dantrolene for simulated malignant hyperthermia crisis.

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The "Simulation Roulette" game.

Introduction: “Simulation Roulette” is a new method of “on-the-fly” simulation scenario creation that incorporates a game-like approach to critical scenarios and emphasizes prescenario preparation. We designed it to complement our traditional anesthesia simulation curriculum, in which residents are exposed to predefined “critical” scenarios. During typical scenarios, trainees are often given minimum preparatory information; they then start the scenario knowing only that “something bad” is going to happen. As a result, trainees often report anxiety, which can be a barrier to learning. To overcome this barrier and to augment traditional critical incident training, we developed the “Simulation Roulette” game. Methods: “Simulation Roulette” consists of premade cards that are randomly selected to create a patient, another set of premade cards to assist in selecting “complications,” worksheets to guide a thorough “prebrief” discussion before the scenario, and scoresheets to facilitate the “debrief” discussion at the end. Similar to traditional scenarios, it requires coordination by a facilitator to ensure plausible scenarios and evaluation of trainee performance. Results: Although we have not conducted formal testing, we believe that (1) incorporating an element of random chance to scenario selection, (2) using a game-like framework, and (3) emphasizing the “prebrief” portion of simulation all have the potential to decrease trainee anxiety. Conclusions: We present the rationale for designing such a game; examples of instructions, cards, and scoresheets; and our initial experience with implementing this game within our simulation curriculum.

Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

BACKGROUND Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. METHODS Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. RESULTS Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. CONCLUSIONS Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Pharmacokinetics of levobupivacaine with epinephrine in transversus abdominis plane block for postoperative analgesia after Caesarean section

Background Transversus abdominis plane block is increasingly used for post‐Caesarean section analgesia. Cases of toxicity and the limited pharmacokinetic information during pregnancy motivated this study. The objective of the study was to characterise and compare the pharmacokinetics of levobupivacaine with epinephrine in tranversus abdominis plane block, in post‐Caesarean section patients and healthy volunteers. Methods After approval by the Ethics Committee, we collected data from 12 healthy parturients after elective Caesarean section (Study 1) and data from 11 healthy male volunteers from a previous study (Study 2). Transversus abdominus plane block was performed under ultrasound guidance. The following injectates were used: levobupivacaine 0.25%, 20 ml with epinephrine 5 &mgr;g ml−1 (Study 1) per side; 20 ml of the same solution (unilateral block) (study 2). The plasma venous concentration of levobupivacaine was measured serially for 90 min. Pharmacokinetic parameters (volume of distribution, clearance, and absorption half‐life) were estimated using a non‐linear mixed effects model (NONMEM). Simulation in 1000 patients estimated the maximum concentration and the time to reach it after bilateral transversus abdominis plane block. Results Venous concentrations were below toxic levels (2.62 mg L−1). Levobupivacaine volume of distribution after Caesarean section was higher than in healthy volunteers [172 L (70 kg)−1 (95% confidence interval: 137–207) vs 94.3 L (70 kg)−1 (95% CI: 62–128); P<0.01]. Clearance and absorption half‐life were similar. The simulation showed that maximum levobupivacaine concentration is lower and occurs later in postpartum patients (P<0.01). Postoperative analgesia was effective. Conclusions Postpartum women reached relatively low plasma concentrations of levobupivacaine after transversus abdominal plane block given a volume of distribution 80% higher than volunteers, which could confer a greater margin of safety. Clinical trial registration NCT02852720.