Pamela J. Morgan

Guidelines to the Practice of Anesthesia Revised Edition 2010.

OverviewThe Guidelines to the Practice of Anesthesia Revised Edition 2013 (the guidelines) were prepared by the Canadian Anesthesiologists’ Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2013 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient’s circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.RésuméLe Guide d’exercice de l’anesthésie, version révisée 2013 (le guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le guide étant soumis à révision, des versions mises à jour sont publiées chaque année. Le Guide d’exercice de l’anesthésie, version révisée 2013, remplace toutes les versions précédemment publiées de ce document. La SCA incite les anesthésiologistes du Canada à se conformer à son guide d’exercice pour assurer une grande qualité des soins dispensés aux patients, mais elle ne peut garantir les résultats d’une intervention. Chaque anesthésiologiste doit exercer son jugement professionnel pour déterminer la méthode d’intervention la mieux adaptée à l’état du patient. La SCA n’accepte aucune responsabilité de quelque nature que ce soit découlant d’erreurs ou d’omissions ou de l’utilisation des renseignements contenus dans son Guide d’exercice de l’anesthésie.

The Effects of an Increase of Central Blood Volume Before Spinal Anesthesia for Cesarean Delivery: A Qualitative Systematic Review

We evaluated in this qualitative systematic review the efficacy of increasing central blood volume on the incidence of hypotension after spinal anesthesia for elective cesarean delivery. Randomized controlled trials investigating any method of increasing central blood volume before the initiation of obstetric spinal anesthesia were sought by using MEDLINE (1966–2000), Embase (January 1988–April 2000), and the Cochrane Library (Issue 1, 2000). Additional reports from retrieved and review articles, hand searching of non-MEDLINE journals, and abstracts of major anesthesia meetings (1994–1999) were located. The primary outcome was the incidence of hypotension. Secondary outcomes included: ephedrine use, Apgar scores, umbilical cord pH values, and maternal nausea and vomiting. Twenty-three articles met our inclusion criteria with the use of crystalloid preload, colloid preload, and mechanical methods of increasing central volume. Crystalloid preload was inconsistent in preventing hypotension, whereas colloid appeared to be effective in all but one study. Leg wrapping and thromboembolic stockings decreased the incidence of hypotension compared with leg elevation or control. Few differences in fetal outcomes or maternal nausea and vomiting were reported. Increasing central blood volume by using colloid and leg wrapping decreases but does not abolish the incidence of hypotension before spinal anesthesia for elective cesarean delivery.

Simulation technology: a comparison of experiential and visual learning for undergraduate medical students.

Background The availability of simulator technology at the University of Toronto (Toronto, Ontario, Canada) provided the opportunity to compare the efficacy of video-assisted and simulator-assisted learning. Methods After ethics approval from the University of Toronto, all final-year medical students were invited to participate in the current randomized trial comparing video-based to simulator-based education using three scenarios. After an introduction to the simulator environment, a 5-min performance-based pretest was administered in the simulator operating room requiring management of a critical event. A posttest was administered after students had participated in either a faculty-facilitated video or simulator teaching session. Standardized 12-point checklist performance protocols were used for assessment purposes. As well, students answered focused questions related to the educational sessions on a final examination. Student opinions regarding the value of the teaching sessions were obtained. Results One hundred forty-four medical students participated in the study (scenario 1, n = 43; scenario 2, n = 48; scenario 3, n = 53). There was a significant improvement in posttest scores over pretest scores in all scenarios. There was no statistically significant difference in scores between simulator or video teaching methods. There were no differences in final examination marks when the two educational methods were compared. Student opinions indicated that the experiential simulator sessions were more enjoyable and valuable than the video teaching sessions. Conclusions Both simulator and video types of faculty-facilitated education offer a valuable learning experience. Future work is needed that addresses the long-term effects of experiential learning in the retention of knowledge and acquired skills.

Barriers to use of simulation-based education.

PurposeBarriers to simulation-based education in postgraduate and continuing education for anesthesiologists have not been well studied. We hypothesized that the level of training may influence attitudes towards simulation-based education and impact on the use of simulation. This study investigated this issue at the University of Toronto which possesses two sites equipped with high-fidelity patient simulators.MethodsA 40-question survey of experiences, perceptions, motivations and perceived barriers to simulation-based education, was distributed to 154 anesthesiologists attending a departmental conference. Data were analyzed using descriptive statistics and associations between responses were assessed using either the Chi-Square statistic or a one-way analysis of variance.ResultsThe rate of response was 58%. Residents had experienced simulation-based education (96%) more often than staff (58%) and fellows (36%), (P < 0.001 respectively). Residents had also attended more simulation sessions than staff and fellows (mean 2.8 vs 1.05 and 1.04, P < 0.001 respectively). Residents and fellows found simulation-based education more relevant for their training than staff (88% vs 65%, P < 0.05). Eighty-one percent of the respondents identified at least one significant barrier that prevents or limits them from attending simulator sessions. Staff anesthesiologists perceived multiple barriers and identified ‘time’ and ‘financial issues’ as significant barriers.ConclusionAnesthesiologist’ level of training influences their attitudes towards and their perceptions of simulation-based education. This survey has identified perceived barriers that may limit a wider utilization of simulation. These results may be used to implement targeted actions such as course design, incentives, and information strategies, which could improve access and future use of simulation.RésuméObjectifLes barriéres à la formation fondée sur la simulation en enseignement universitaire supérieur et en formation continue pour les anesthésiologistes ne sont pas bien connues. Nous avons émis ľhypothése que le niveau de formation pouvait influencer ľattitude face à ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre étude a été réalisée à ľuniversité de Toronto qui posséde deux sites équipés de simulateurs de haute fidélité.MéthodeUn questionnaire de 40 questions sur les expériences, les perceptions, les motivations et les barriéres perçues de la formation par simulation a été distribué à 154 anesthésiologistes en réunion départementale. Les données ont été analysées par des statistiques descriptives et les liens entre les réponses par le test chi-deux ou une analyse simple de la variance.RésultatsLe taux de réponses a été de 58 %. Les résidents avaient plus ďexpérience de la simulation (96 %) que les spécialistes (58 %) et les boursiers (36 %), (P < 0,001 respectivement). Les résidents avaient aussi assisté à plus de sessions de simulation que les spécialistes et les boursiers (moyenne de 2,8 vs 1,05 et 1,04, P < 0,001 respectivement). Les résidents et les boursiers ont trouvé la simulation plus pertinente que les anesthésiologistes (88 % vs 65 %, P < 0,05). Parmi les répondants, 81 % ont reconnu au moins une barriére importante qui empêche ou limite la participation à des sessions de simulation. Les spécialistes ont perçu de multiples barriéres significatives dont le «temps» et «les questions financiéres».ConclusionLe niveau de formation des anesthésiologistes influence ľattitude face à la simulation et leurs perceptions de la formation par simulation. Les limites à un plus grand usage de la simulation, reconnues dans ľenquête, pourraient servir à des interventions ciblées comme ľorganisation ďun cours, des incitatifs et des stratégies ďinformations pour améliorer ľaccés à la simulation et son usage futur.Objectif Les barrieres a la formation fondee sur la simulation en enseignement universitaire superieur et en formation continue pour les anesthesiologistes ne sont pas bien connues. Nous avons emis ľhypothese que le niveau de formation pouvait influencer ľattitude face a ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre etude a ete realisee a ľuniversite de Toronto qui possede deux sites equipes de simulateurs de haute fidelite.

Applying theory to practice in undergraduate education using high fidelity simulation

High-fidelity patient simulation allows students to apply their theoretical knowledge of pharmacology and physiology to practice. The purpose of this study was to determine if experiential education using high-fidelity simulation improves undergraduate performance scores on simulation-based and written examinations. After receiving research ethics board approval, students completed a consent form and then answered a ten question multiple-choice quiz to identify their knowledge regarding the management of cardiac arrhythmias. Four simulation scenarios were presented and students worked through each scenario as a team. Faculty facilitated the sessions and feedback was given using students’ videotaped performances as a template for discussion. Performance evaluation scores using predetermined checklists and global rating scales were completed. Students then reviewed the American Heart Association guidelines for the management of unstable cardiac arrhythmias. The afternoon session involved repetition of the four case scenarios with the same teams involved but different team leaders. Students then repeated the quiz they received in the morning. Descriptive statistics, paired t-test and repeated measures analysis of variance (ANOVA) were used to analyse results. Two hundred and ninety-nine students completed the study. There was a statistically significant improvement in performance on the pharmacology written test. Simulation team performance also statistically improved and a good correlation between checklist and global rating scores were demonstrated in all but one scenario. Student evaluation of the experience was extremely positive. High-fidelity simulation can be used to allow students to apply theoretical knowledge to practice in a safe and realistic environment. Results of this study indicate that simulation is a valuable learning experience and bridges the gap between theory and practice. Simulation technology has the potential to provide an enriching venue to examine the role of communication and dynamics of novice learners in team environments.

Efficacy of high-fidelity simulation debriefing on the performance of practicing anaesthetists in simulated scenarios

BACKGROUND Research into adverse events in hospitalized patients suggests that a significant number are preventable. The purpose of this randomized, controlled study was to determine if simulation-based debriefing improved performance of practicing anaesthetists managing high-fidelity simulation scenarios. METHODS The anaesthetists were randomly allocated to Group A: simulation debriefing; Group B: home study; and Group C: no intervention and secondary randomization to one of two scenarios. Six to nine months later, subjects returned to manage the alternate scenario. Facilitators blinded to study group allocation completed the performance checklists (dichotomously scored checklist, DSC) and Global Rating Scale of Performance (GRS). Two non-expert raters were trained, and assessed all videotaped performances. RESULTS Interim analysis indicated no difference between Groups B and C which were merged into one group. Seventy-four subjects were recruited, with 58 complete data sets available. There was no significant effect of group on pre-test scores. A significant improvement was seen between pre- and post-tests on the DSC in debriefed subjects (pre-test 66.8%, post-test 70.3%; F(1,57)=4.18, P=0.046). Both groups showed significant improvement in the GRS over time (F(1,57)=5.94, P=0.018), but no significant difference between the groups. CONCLUSIONS We found a modest improvement in performance on a DSC in the debriefed group and overall improvement in both control and debriefed groups using a GRS. Whether this improvement translates into clinical practice has yet to be determined.

Validity and reliability of undergraduate performance assessments in an anesthesia simulator

Purpose: To examine the validity and reliability of performance assessment of undergraduate students using the anethesia simulator as an evaluation tool.Methods: After ethics approval and informed consent, 135 final year medical students and 5 elective students participated in a videotaped simulator scenario with a Link-Med Patient Simulator (CAE-Link Corporation). Scenarios were based on published educational objectives of the undergraduate curriculum in anesthesia at the University of Toronto. During the simulator sessions, faculty followed a script guiding student interaction with the mannequin. Two faculty independently viewed and evaluated each videotaped performance with a 25-point criterion-based checklist. Means and standard deviations of simulator-based marks were determined and compared with clinical and written evaluations received during the rotation. Internal consistency of the evaluation protocol was determined using inter-item and item-total correlations and correlations of specific simulator items to existing methods of evaluation.Results: Mean reliability estimates for single and average paired assessments were 0.77 and 0.86 respectively. Means of simulator scores were low and there was minimal correlation between the checklist and clinical marks (r=0.13), checklist and written marks (r=0.19) and clinical and written marks (r=0.23). Inter-item and item-total correlations varied widely and correlation between simulator items and existing evaluation tools was low.Conclusions: Simulator checklist scoring demonstrated acceptable reliability. Low correlation between different methods of evaluation may reflect reliability problems with the written and clinical marks, or that different aspects are being tested. The performance assessment demonstrated low internal consistency and further work is required.RésuméObjectif: Vérifier la validité et la fiabilité de l’évaluation de la performance des étudiants de médecine à l’aide d’un simulateur d’anesthésie.Méthode: Le comité d’éthique et les participants à l’étude ayant donné leur consentement, 135 étudiants de dernière année en médecine et 5 étudiants choisis ont participé à une simulation vidéo à l’aide du Link-Med Patient Simulator (CAE-Link Corporation). Les scénarios étaient fondés sur les objectifs pédagogiques du programme d’enseignement en anesthéside de l’université de Toronto. Pendant les sessions de simulation, les examinateurs ont utilisé un scénario pour guider les interactions de l’étudiant avec le mannequin. Deux examinateurs ont visionné et évalué indépendamment la performance enregistrée sur chacune des cassettes vidéo selon une liste de 25 critères. Les écarts types et moyens des points accordés selon le simulateur ont été déterminés et comparés avec les évaluations clinique et écrites reçues pendant la rotation. La conformité interne du protocole d’évaluation a été définie à l’aide de corréaltions des éléments entre eux, et des éléments avec l’ensemble, ainsi que des corrélations d’éléments spécifiques du simulateur avec des méthodes existantes d’évaluation.Résultats: Les estimations moyennes de fiabilité pour les évaluations individuelles et appariées moyennes ont été de 0,77 et 0,86 respectivement. Les moyennes des scores au simulateur ont été basses et il n’y a eu qu’une corrélation minimale entre la liste et les rendements cliniques (r=0,13), entre la liste et les évaluations écrites (r=0,19) et entre le rendement clinique et l’examen écrit (r=0,23). Les corrélations des éléments entre eux et des ĺéments avec l’ensemble ont varié fortement et la corrélation entre les unités du simulateur et les outils d’évaluation existant a été faible.Conclusion: La cotation selon les critères liés au simulateur a démontré une fiabilité acceptable. Une faible corrélation entre différentes méthodes d’évaluation peut traduire des problèmes de fiabilité avec les notes obtenues aux examens écrits et cliniques, ou le fait que d’autres aspects sont testés. L’évaluation de la performance a démontré une faible conformité interne et la nécessité d’expérimentation ultérieure.

Les barriéres à ľutilisation de la formation basée sur simulateur

PurposeBarriers to simulation-based education in postgraduate and continuing education for anesthesiologists have not been well studied. We hypothesized that the level of training may influence attitudes towards simulation-based education and impact on the use of simulation. This study investigated this issue at the University of Toronto which possesses two sites equipped with high-fidelity patient simulators.MethodsA 40-question survey of experiences, perceptions, motivations and perceived barriers to simulation-based education, was distributed to 154 anesthesiologists attending a departmental conference. Data were analyzed using descriptive statistics and associations between responses were assessed using either the Chi-Square statistic or a one-way analysis of variance.ResultsThe rate of response was 58%. Residents had experienced simulation-based education (96%) more often than staff (58%) and fellows (36%), (P < 0.001 respectively). Residents had also attended more simulation sessions than staff and fellows (mean 2.8 vs 1.05 and 1.04, P < 0.001 respectively). Residents and fellows found simulation-based education more relevant for their training than staff (88% vs 65%, P < 0.05). Eighty-one percent of the respondents identified at least one significant barrier that prevents or limits them from attending simulator sessions. Staff anesthesiologists perceived multiple barriers and identified ‘time’ and ‘financial issues’ as significant barriers.ConclusionAnesthesiologist’ level of training influences their attitudes towards and their perceptions of simulation-based education. This survey has identified perceived barriers that may limit a wider utilization of simulation. These results may be used to implement targeted actions such as course design, incentives, and information strategies, which could improve access and future use of simulation.RésuméObjectifLes barriéres à la formation fondée sur la simulation en enseignement universitaire supérieur et en formation continue pour les anesthésiologistes ne sont pas bien connues. Nous avons émis ľhypothése que le niveau de formation pouvait influencer ľattitude face à ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre étude a été réalisée à ľuniversité de Toronto qui posséde deux sites équipés de simulateurs de haute fidélité.MéthodeUn questionnaire de 40 questions sur les expériences, les perceptions, les motivations et les barriéres perçues de la formation par simulation a été distribué à 154 anesthésiologistes en réunion départementale. Les données ont été analysées par des statistiques descriptives et les liens entre les réponses par le test chi-deux ou une analyse simple de la variance.RésultatsLe taux de réponses a été de 58 %. Les résidents avaient plus ďexpérience de la simulation (96 %) que les spécialistes (58 %) et les boursiers (36 %), (P < 0,001 respectivement). Les résidents avaient aussi assisté à plus de sessions de simulation que les spécialistes et les boursiers (moyenne de 2,8 vs 1,05 et 1,04, P < 0,001 respectivement). Les résidents et les boursiers ont trouvé la simulation plus pertinente que les anesthésiologistes (88 % vs 65 %, P < 0,05). Parmi les répondants, 81 % ont reconnu au moins une barriére importante qui empêche ou limite la participation à des sessions de simulation. Les spécialistes ont perçu de multiples barriéres significatives dont le «temps» et «les questions financiéres».ConclusionLe niveau de formation des anesthésiologistes influence ľattitude face à la simulation et leurs perceptions de la formation par simulation. Les limites à un plus grand usage de la simulation, reconnues dans ľenquête, pourraient servir à des interventions ciblées comme ľorganisation ďun cours, des incitatifs et des stratégies ďinformations pour améliorer ľaccés à la simulation et son usage futur.Objectif Les barrieres a la formation fondee sur la simulation en enseignement universitaire superieur et en formation continue pour les anesthesiologistes ne sont pas bien connues. Nous avons emis ľhypothese que le niveau de formation pouvait influencer ľattitude face a ce type de formation et avoir un effet sur ľutilisation de la simulation. Notre etude a ete realisee a ľuniversite de Toronto qui possede deux sites equipes de simulateurs de haute fidelite.

Ultrasound-guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection

Background:Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection. Methods:Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time. Results:Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced. Conclusion:Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Simulation performance checklist generation using the delphi technique

Purpose: Performance assessment using high fidelity simulation is problematic, due to the difficulty in developing valid and reliable evaluation tools. The Delphi technique is a consensus based content generation method used for multiple purposes such as policy development, best-evidence practice guidelines and competency assessments. The purpose of this study was to develop checklists using a modified Delphi technique to evaluate the performance of practicing anesthesiologists managing two simulated scenarios.Methods: The templates for two simulation scenarios were emailed to five anesthesiologists who were asked to generate performance items. Data were collated anonymously and returned. Ana priori decision was made to delete items endorsed by ≤ 20% of participants. This process of collection, collation and re-evaluation was repeated until consensus was reached. Four independent raters used the checklist to assess three subjects managing the two simulation scenarios. Inter-rater reliability was assessed using average measures intraclass correlation (ICC) and repeated measures analysis of variance (ANOVA) was used to assess differences in difficulty between scenarios.Results: The final checklists included 131 items for scenario 1 and 126 items for scenario 2. The mean inter-rater reliability was 0.921 for scenario 1 and 0.903 for scenario 2. Repeated measures ANOVA revealed no statistically significant difference in difficulty between scenarios.Discussion: The Delphi technique can be very useful to generate consensus based evaluation tools with high content and face validity compared to subjective evaluative tools. Since there was no difference in scenario difficulty, these scenarios can be used to determine the effect of educational interventions on performance.RésuméObjectif: L’évaluation de la performance est problématique lorsqu’on a recours à une simulation de haute fidélité, ceci en raison de difficultés rencontrées lors du développement d’outils d’évaluation valables et fiables. La méthode Delphi est une méthode de génération de contenu qui se base sur un consensus ; elle est utilisée dans divers contextes tels que le développement de directives, des guides de pratique basés sur les meilleures données probantes, et l’évaluation des compétences. L’objectif de cette étude était de développer des listes de vérification en utilisant une méthode Delphi modifiée et ce, afin d’évaluer la performance des anesthésiologistes actifs gérant deux scénarios simulés.Méthode: Les modèles pour deux scénarios de simulation ont été envoyés par courriel à cinq anesthésiologistes, auxquels on a demandé de générer des rubriques de performance. Les données ont été rassemblées de façon anonyme et renvoyées. Une décision a priori a été prise d’effacer les rubriques approuvées par ≤ 20 % des participants. Ce processus de récolte, de comparaison et de réévaluation a été répété jusqu’à ce que l’on atteigne un consensus. Quatre évaluateurs indépendants ont utilisé la liste de contrôle pour évaluer trois sujets prenant en charge les deux scénarios de simulation. La crédibilité inter-évaluateurs a été évaluée à l’aide de mesures de corrélation intraclasse (ICC) moyennes et des mesures répétées de l’analyse de variance (ANOVA) ont été utilisées afin d’évaluer les différences de difficulté entre les scénarios.Résultats: Les listes de contrôle finales comprenaient 131 rubriques pour le scénario no. 1 et 126 rubriques pour le scénario no. 2. La crédibilité inter-évaluateurs moyenne était de 0,921 pour le scénario no. 1 et de 0,903 pour le scénario no. 2. Les mesures répétées ANOVA n’ont pas révélé de différence statistiquement significative de la difficulté entre les scénarios.Discussion: La méthode Delphi peut être très utile pour générer des outils d’évaluation basés sur un consensus avec un contenu élevé et une validité apparente par rapport à des outils d’évaluation subjectifs. Etant donné qu’il n’y a pas eu de différence de difficulté entre les scénarios, ces derniers peuvent être utilisés pour déterminer l’effet d’interventions éducationnelles sur la performance.