Matthew D. McEvoy

Aprotinin in cardiac surgery : A review of conventional and novel mechanisms of action

Induction of the coagulation and inflammatory cascades can cause multiorgan dysfunction after cardiopulmonary bypass (CPB). In light of these observations, strategies that can stabilize the coagulation process as well as attenuate the inflammatory response during and after cardiac surgery are important. Aprotinin has effects on hemostasis. In addition, aprotinin may exert multiple biologically relevant effects in the context of cardiac surgery and CPB. For example, it decreases neutrophil and macrophage activation and chemotaxis, attenuates release and activation of proinflammatory cytokines, and reduces oxidative stress. Despite these perceived benefits, the routine use of aprotinin in cardiac surgery with CPB has been called into question. In this review, we examined this controversial drug by discussing the classical and novel pathways in which aprotinin may be operative in the context of cardiac surgery.

The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest

AIM Advanced Cardiac Life Support (ACLS) algorithms are the default standard of care for in-hospital cardiac arrest (IHCA) management. However, adherence to published guidelines is relatively poor. The records of 149 patients who experienced IHCA were examined to begin to understand the association between overall adherence to ACLS protocols and successful return of spontaneous circulation (ROSC). METHODS A retrospective chart review of medical records and code team worksheets was conducted for 75 patients who had ROSC after an IHCA event (SE group) and 74 who did not survive an IHCA event (DNS group). Protocol adherence was assessed using a detailed checklist based on the 2005 ACLS Update protocols. Several additional patient characteristics and circumstances were also examined as potential predictors of ROSC. RESULTS In unadjusted analyses, the percentage of correct steps performed was positively correlated with ROSC from an IHCA (p<0.01), and the number of errors of commission and omission were both negatively correlated with ROSC from an IHCA (p<0.01). In multivariable models, the percentage of correct steps performed and the number of errors of commission and omission remained significantly predictive of ROSC (p<0.01 and p<0.0001, respectively) even after accounting for confounders such as the difference in age and location of the IHCAs. CONCLUSIONS Our results show that adherence to ACLS protocols throughout an event is correlated with increased ROSC in the setting of cardiac arrest. Furthermore, the results suggest that, in addition to correct actions, both wrong actions and omissions of indicated actions lead to decreased ROSC after IHCA.

Validation of a Detailed Scoring Checklist for Use During Advanced Cardiac Life Support Certification

Introduction: Defining valid, reliable, defensible, and generalizable standards for the evaluation of learner performance is a key issue in assessing both baseline competence and mastery in medical education. However, before setting these standards of performance, the reliability of the scores yielding from a grading tool must be assessed. Accordingly, the purpose of this study was to assess the reliability of scores generated from a set of grading checklists used by nonexpert raters during simulations of American Heart Association (AHA) Megacodes. Methods: The reliability of scores generated from a detailed set of checklists, when used by 4 nonexpert raters, was tested by grading team leader performance in 8 Megacode scenarios. Videos of the scenarios were reviewed and rated by trained faculty facilitators and a group of nonexpert raters. The videos were reviewed “continuously” and “with pauses.” The grading made by 2 content experts served as the reference standard, and 4 nonexpert raters were used to test the reliability of the checklists. Results: Our results demonstrate that nonexpert raters are able to produce reliable grades when using the checklists under consideration, demonstrating excellent intrarater reliability and agreement with a reference standard. The results also demonstrate that nonexpert raters can be trained in the proper use of the checklist in a short amount of time, with no discernible learning curve thereafter. Finally, our results show that a single trained rater can achieve reliable scores of team leader performance during AHA Megacodes when using our checklist in a continuous mode because measures of agreement in total scoring were very strong [Lin’s (Biometrics 1989;45:255–268) concordance correlation coefficient, 0.96; intraclass correlation coefficient, 0.97]. Conclusions: We have shown that our checklists can yield reliable scores, are appropriate for use by nonexpert raters, and are able to be used during continuous assessment of team leader performance during the review of a simulated Megacode. This checklist may be more appropriate for use by advanced cardiac life support instructors during Megacode assessments than the current tools provided by the AHA.

An Approach to Moderate Sedation Simulation Training

Introduction Each year millions of patients undergo procedures that require moderate sedation. These patients are at risk of complications from oversedation that can progress to respiratory depression or even death. This article describes the creation of a simulation-based medical education course for nonanesthesiologists who use sedation in their specialty practice and preliminary data from our precourse and postcourse assessments. Methods Our course combined online and lecture-based didactics with simulation education to teach moderate sedation and basic emergency airway management to nonanesthesiologists. After online precourse materials were reviewed, participants attended an 8-hour simulation-based training course focused on the recognition of different levels of sedation, medication titration, sedation reversal, and airway support and rescue. To evaluate the course, precourse, and postcourse educational impacts, cognitive and simulation tests were administered. Participants completed a postcourse survey. Results To date, 45 physicians have participated in the course. We have cognitive performance data on 19 participants and survey data for 45 participants. Postcourse simulation tests results were improved compared with precourse tests. Our course was rated “better” or “much better” in comparison to courses using lecture-only format by 100% of the participants. Conclusions A course using a combination of didactic and simulation education to teach moderate sedation is described. Our initial data demonstrated a significant increase in knowledge, skills, and clinical judgment. Future research efforts should focus on examining the validity and reliability of scenario scoring and the impact of training on clinical practice.

Effect of a Cognitive Aid on Adherence to Perioperative Assessment and Management Guidelines for the Cardiac Evaluation of Noncardiac Surgical Patients

Background:The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. Methods:Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. Results:All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). Conclusions:Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1—from the preoperative period to PACU

BackgroundWithin an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver “optimal analgesia,” which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects.MethodsWith input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients.DiscussionAs a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.

Use of an electronic decision support tool improves management of simulated in-hospital cardiac arrest

INTRODUCTION Adherence to advanced cardiac life support (ACLS) guidelines during in-hospital cardiac arrest (IHCA) is associated with improved outcomes, but current evidence shows that sub-optimal care is common. Successful execution of such protocols during IHCA requires rapid patient assessment and the performance of a number of ordered, time-sensitive interventions. Accordingly, we sought to determine whether the use of an electronic decision support tool (DST) improves performance during high-fidelity simulations of IHCA. METHODS After IRB approval and written informed consent was obtained, 47 senior medical students were enrolled. All participants were ACLS certified and within one month of graduation. Each participant was issued an iPod Touch device with a DST installed that contained all ACLS management algorithms. Participants managed two scenarios of IHCA and were allowed to use the DST in one scenario and prohibited from using it in the other. All participants managed the same scenarios. Simulation sessions were video recorded and graded by trained raters according to previously validated checklists. RESULTS Performance of correct protocol steps was significantly greater with the DST than without (84.7% v 73.8%, p<0.001) and participants committed significantly fewer additional errors when using the DST (2.5 errors vs. 3.8 errors, p<0.012). CONCLUSION Use of an electronic DST provided a significant improvement in the management of simulated IHCA by senior medical students as measured by adherence to published guidelines.

Automated near-real-time clinical performance feedback for anesthesiology residents: one piece of the milestones puzzle.

Background:Anesthesiology residencies are developing trainee assessment tools to evaluate 25 milestones that map to the six core competencies. The effort will be facilitated by development of automated methods to capture, assess, and report trainee performance to program directors, the Accreditation Council for Graduate Medical Education and the trainees themselves. Methods:The authors leveraged a perioperative information management system to develop an automated, near–real-time performance capture and feedback tool that provides objective data on clinical performance and requires minimal administrative effort. Before development, the authors surveyed trainees about satisfaction with clinical performance feedback and about preferences for future feedback. Results:Resident performance on 24,154 completed cases has been incorporated into the authors’ automated dashboard, and trainees now have access to their own performance data. Eighty percent (48 of 60) of the residents responded to the feedback survey. Overall, residents “agreed/strongly agreed” that they desire frequent updates on their clinical performance on defined quality metrics and that they desired to see how they compared with the residency as a whole. Before deployment of the new tool, they “disagreed” that they were receiving feedback in a timely manner. Survey results were used to guide the format of the feedback tool that has been implemented. Conclusion:The authors demonstrate the implementation of a system that provides near–real-time feedback concerning resident performance on an extensible series of quality metrics, and which is responsive to requests arising from resident feedback about desired reporting mechanisms.

The utility of ketamine for the preoperative management of a patient with Parkinson's disease.

Loss of dopaminergic neurons from the substantia nigra characterizes the classical pathology of Parkinsons disease, but persistent activation of N-methyl-D-aspartate receptors is also a major component. During difficult airway management in a patient with advanced Parkinsons disease, the use of low-dose (20 mg) i.v. ketamine resulted in complete abolition of severe tremor and dysarthria. This led to the current case report in which low-dose ketamine was used for preoperative sedation and dyskinesia attenuation. Prior research and our experience would suggest that low-dose ketamine, titrated to effect, may provide optimal patient comfort and perioperative control of Parkinsonian tremor.

Enhanced recovery after surgery, perioperative medicine, and the perioperative surgical home: current state and future implications for education and training.

Purpose of reviewThe purpose of this review is to summarize the current state of perioperative medicine, including the perioperative surgical home (PSH) and enhanced recovery after surgery pathways (ERAS) as well as the educational implications of these concepts for current and future anesthesiology trainees. Recent findingsAlthough there is significant, ongoing discussion surrounding the structural concept of the PSH, there remains little clinical evidence to support its development. On the other hand, publications surrounding ERAS principles continue to show clinical benefit in reducing length of stay, cost, and perioperative complications for a variety of surgical populations. In this milieu, perioperative medicine is increasingly being recognized as its own specialty in perioperative care that encompasses, but is larger than, ERAS. SummaryThere is sufficient evidence to support widespread adoption of ERAS principles, although the specifics of local implementation may vary from site to site. There is significant uncertainty as to what the PSH actually is. However, perioperative medicine is a defined specialty in medicine that overlaps significantly with anesthesiology core training and practice and will be a significant focus in future education, research, and clinical care provided by anesthesiologists.