Michael A. Olympio

Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study.

Background Anesthesia simulators can generate reproducible, standardized clinical scenarios for instruction and evaluation purposes. Valid and reliable simulated scenarios and grading systems must be developed to use simulation for evaluation of anesthesia residents. Methods After obtaining Human Subjects approval at each of the 10 participating institutions, 99 anesthesia residents consented to be videotaped during their management of four simulated scenarios on MedSim or METI mannequin-based anesthesia simulators. Using two different grading forms, two evaluators at each department independently reviewed the videotapes of the subjects from their institution to score the residents’ performance. A third evaluator, at an outside institution, reviewed the videotape again. Statistical analysis was performed for construct- and criterion-related validity, internal consistency, interrater reliability, and intersimulator reliability. A single evaluator reviewed all videotapes a fourth time to determine the frequency of certain management errors. Results Even advanced anesthesia residents nearing completion of their training made numerous management errors; however, construct-related validity of mannequin-based simulator assessment was supported by an overall improvement in simulator scores from CB and CA-1 to CA-2 and CA-3 levels of training. Subjects rated the simulator scenarios as realistic (3.47 out of possible 4), further supporting construct-related validity. Criterion-related validity was supported by moderate correlation of simulator scores with departmental faculty evaluations (0.37–0.41, P < 0.01), ABA written in-training scores (0.44–0.49, P < 0.01), and departmental mock oral board scores (0.44–0.47, P < 0.01). Reliability of the simulator assessment was demonstrated by very good internal consistency (&agr; = 0.71–0.76) and excellent interrater reliability (correlation = 0.94–0.96;P < 0.01; &kgr; = 0.81–0.90). There was no significant difference in METI versus MedSim scores for residents in the same year of training. Conclusions Numerous management errors were identified in this study of anesthesia residents from 10 institutions. Further attention to these problems may benefit residency training since advanced residents continued to make these errors. Evaluation of anesthesia residents using mannequin-based simulators shows promise, adding a new dimension to current assessment methods. Further improvements are necessary in the simulation scenarios and grading criteria before mannequin-based simulation is used for accreditation purposes.

Avoiding Catastrophic Complications of Stroke and Death Related to Shoulder Surgery in the Sitting Position

The beach-chair position in shoulder surgery provides advantages to the surgeon and anesthesiologist. However, cautious interpretation of the patients blood pressure is essential, especially when the blood pressure cuff is placed at the calf. The calf pressure should be interpreted relative to the heart-level pressure to avoid iatrogenic cerebral hypoperfusion related to hypotensive anesthesia. Possible complications of cerebral hypoperfusion are permanent neurologic impairment, stroke, and death.

The importance of the postoperative anesthetic visit : Do repeated visits improve patient satisfaction or physician recognition ?

This study evaluates whether repeated postoperative visits by the anesthesiologist improve patient ability to recall the anesthesiologists name and the patients perception of and satisfaction with anesthesia services.In a randomized, prospective trial, 144 patients with an anticipated postoperative length of stay of at least three days were enrolled in three groups: Group A patients (n = 48) had one postoperative visit, Group B (n = 48) had two postoperative visits, and Group C (n = 48) had three postoperative visits. All postoperative visits were performed by the attending anesthesiologist on consecutive postoperative days. Patients were contacted two days after their last postoperative visit to complete a study questionnaire. Patients were able to recall the anesthesiologists name significantly less frequently than the surgeons name, and there was no difference in name recall among groups. Recall was not affected by patient age, sex, or ASA physical status; the mode of contact (telephone versus personal visit); the anesthesiologists gender; the presence of preoperative medication; or the identity of the preoperative evaluator. Patients could identify the anesthesiologists gender approximately 85% of the time, regardless of group, and were more likely to identify female anesthesiologists (P = 0.026, odds ratio 3.3). Patient evaluation of hospital, surgical, and anesthesia care was favorable in all groups and did not vary with group. Increasing the number of postoperative visits does not improve patient name recognition of the anesthesiologist or increase patient satisfaction with or perception of anesthesia services. (Anesth Analg 1996;83:793-7)

Postanesthetic delirium: historical perspectives

Postanesthetic delirium is a type of postoperative emotional response occurring immediately after emergence from general anesthesia. Associated with excitement and confusion, the alternative terms emergence delirium or postanesthetic excitement are frequently used. Historically, the more encompassing term postoperative psychosis is used interchangeably but more frequently refers to those conditions occurring after a lucid interval of 24 to 48 hours. Either phenomenon may arise from a variety of disturbances, with drug reactions, hypoxemia, or reaction to pain being common, or it may arise from psychological causes. Reported is a case of postanesthetic delirium in a healthy young man. An historical overview of this potentially harmful condition, with specific recommendations for diagnosis and treatment, also is presented.

Electromyography monitoring for percutaneous placement of iliosacral screws

OBJECTIVE To report our experience with the use of continuous electromyography (EMG) for placement of iliosacral screws. DATA SOURCES Concurrently acquired data as well as patient charts, intraoperative EMG records, x-rays, and pelvic computed tomography (CT) scans. DESIGN The monitored group of twenty-nine patients was studied prospectively. The control group consisted of twenty-two patients studied retrospectively. SETTING Level One trauma center. METHODS Continuous electromyograms were recorded for twenty-nine patients and compared with those from a group of twenty-two antecedent patients who were not monitored. The primary parameter of interest of this study was the presence or absence of neurologic change after iliosacral screw placement. This information was obtained prospectively in the study group and by retrospective review in the historical control. RESULTS Four patients in the control group had postoperative and/or sensory motor changes prompting a postoperative CT scan; in each of these patients, a misdirected screw was identified and subsequently removed in a second procedure. There were no neurologic changes subsequent to placement in the twenty-nine patients who were monitored (7.5 percent versus 0 percent; p = 0.029, Fishers exact test). All monitored patients had postoperative CT scans and showed the screw in a safe position with no significant violations of the S1 tunnel. CONCLUSION Continuous EMG monitoring during iliosacral screw placement may be a useful neuroprotective tool.

Hypertonic/hyperoncotic fluid resuscitation after hemorrhagic shock in dogs

We compared canine systemic and cerebral hemodynamics after resuscitation from hemorrhagic shock with 4 mL/kg (a volume approximating 12% of shed blood volume) of 7.2% saline (HS; 1233 mEq/L sodium), 20% hydroxyethyl starch (HES) in 0.8% saline, or a combination fluid consisting of 20% hydroxyethyl starch in 7.2% saline (HS/HES). Eighteen endotracheally intubated mongrel dogs (18-24 kg) were ventilated to maintain normocarbia with 0.5% halothane in nitrous oxide and oxygen (60:40). After a 30-min period of hemorrhagic shock (mean arterial blood pressure = 40 mm Hg), extending from time T0 to T30, animals received one of three randomly assigned intravenous resuscitation fluids: HS, HES, or HS/HES. Data were collected at baseline, at the beginning and end of the shock period (T0 and T30), immediately after fluid infusion (T35), and at 60-min intervals for 2 h (T95, T155). After resuscitation, mean arterial blood pressure and cardiac output increased similarly in all groups, but failed to return to baseline. Intracranial pressure decreased during shock and increased slightly, immediately after resuscitation in all groups. During shock, cerebral blood flow (cerebral venous outflow method) declined in all groups. After resuscitation, cerebral blood flow increased, exceeding baseline in the HS and HS/HES groups but remaining low in the HES group (P less than 0.05 HS vs HES at T35). We conclude that small-volume resuscitation (4 mL/kg) with HS, HS/HES, or HES does not effectively restore or sustain systemic hemodynamics in hemorrhaged dogs. In dogs without intracranial pathology, the effects on cerebral hemodynamics are also comparable, except for transiently greater cerebral blood flow in the HS group in comparison with the HES group.

Emergence from Anesthesia in the Prone versus Supine Position in Patients Undergoing Lumbar Surgery

BackgroundConventional supine emergence in patients undergoing prone lumbar surgery frequently results in tachycardia, hypertension, coughing, and loss of monitoring as the patient is rolled supine. The prone position might facilitate a smoother emergence because the patient is not disturbed. No data describe this technique. MethodsFifty patients were anesthetized with fentanyl, nitrous oxide, isoflurane, and rocuronium. By the conclusion of surgery, all patients achieved spontaneous ventilation and full reversal of neuromuscular blockade in the prone position, as the volatile anesthetic level was reduced. Baseline heart rate and mean arterial pressure were recorded. Patients were then randomized at time 0 to the supine (n = 24) or prone (n = 21) position as 100% oxygen was administered. Patients in the supine position were then rolled over, while those in the prone position remained undisturbed. Heart rate, mean arterial pressure, and coughs were recorded until extubation. Tracheas were extubated on eye opening or purposeful behavior. ResultsWhen compared with the supine group, prone patients had significantly less increase in heart rate (P = 0.0003, maximum increase 9.3 vs. 25 beats/min), less increase in mean arterial pressure (P = 0.0063, maximum increase 4.8 vs. 19 mmHg), less coughing (P = 0.0004, 7.0 vs. 23 coughs), and fewer monitor disconnections (P < 0.0001). Time to extubation from time 0 was similar (4.0 vs. 3.7 min, prone vs. supine). No one required airway rescue. There was no significant difference in need for restraint (three prone, four supine). ConclusionsProne emergence and extubation is associated with less hemodynamic stimulation, less coughing, and less disruption of monitors, without specifically observed adverse effects, when compared with conventional supine techniques.

Venous air embolism after craniotomy closure: tension pneumocephalus implicated.

The authors present a case of venous air embolism occurring immediately upon skin closure after craniotomy in the prone position. This 5-year-old patient had a third ventricle tumor resected with bipolar cautery via a frontal trans-collosal approach into the lateral ventricle and through the foramen of Monroe. Doppler monitoring was utilized during the case since the patients head was extended upwards in 10 degrees reverse Trendelenburg position. No air was detected during the operation. The ventricles were filled with saline presumably displacing air, prior to dural closure. However, with an increase in nitrous oxide from 55 to 68% prior to skin closure, venous air embolism was subsequently detected by Doppler and confirmed by end-tidal/arterial pCO2 gradient. The authors speculate that tension pneumocephalus caused the venous air embolism and describe the probable route of entry into the venous system.

Postoperative visual loss after robotic pelvic surgery

Introduction Postoperative visual loss (POVL), typically blindness, is a very rare (0.02–0.1%) but devastating complication that has recently been reported after robotic urological surgery [1,2]. The issue was first analysed in 2011 by Lee [2] in the Anesthesia Patient Safety Foundation (APSF) Newsletter, while her team systematically investigated the risk factors for 80 other cases of POVL after major prone spine surgery [1]. Those 80 had been reported to the American Society of Anesthesiologists (ASA) POVL Registry. Lee described three reported cases of robotic radical prostatectomy occurring between 2006 and 2011 that awakened with posterior ischaemic optic neuropathy (PION) after 8–10 h of surgery. Interestingly, she compared these with three other instances of POVL that occurred after open radical prostatectomy, but the open patients had developed anterior ION (AION) instead. Furthermore, this author has located three published reports of POVL after laparoscopic (and/or robotic) prostatectomy and one after laparoscopic nephrectomy, but it is not known whether these represent the same cases in the databank.

Dynamic left ventricular outflow obstruction during lumbar laminectomy as an unexpected cause of intraoperative hypotension.

We present a case of previously undiagnosed hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow obstruction in a woman anesthetized for lumbar hemilaminectomy and diskectomy. The treatment of her sudden unexplained hypotension was initially confounded by a diagnosis of compensated congestive heart failure and diuretic therapy. Swift intervention with transesophageal echocardiography revealed the tru pathology altering her intraoperative treatment and her subsequent chronic treatment for her heart condition.