Ruma Bose

Continuous perioperative insulin infusion decreases major cardiovascular events in patients undergoing vascular surgery: a prospective, randomized trial.

Background:A growing body of evidence suggests that hyperglycemia is an independent predictor of increased cardiovascular risk. Aggressive glycemic control in the intensive care decreases mortality. The benefit of glycemic control in noncardiac surgery is unknown. Methods:In a single-center, prospective, unblinded, active-control study, 236 patients were randomly assigned to continuous insulin infusion (target glucose 100–150 mg/dl) or to a standard intermittent insulin bolus (treat glucose > 150 mg/dl) in patients undergoing peripheral vascular bypass, abdominal aortic aneurysm repair, or below- or above-knee amputation. The treatments began at the start of surgery and continued for 48 h. The primary endpoint was a composite of all-cause death, myocardial infarction, and acute congestive heart failure. The secondary endpoints were blood glucose concentrations, rates of hypoglycemia (< 60 mg/dl) and hyperglycemia (> 150 mg/dl), graft failure or reintervention, wound infection, acute renal insufficiency, and duration of stay. Results:The groups were well balanced for baseline characteristics, except for older age in the intervention group. There was a significant reduction in primary endpoint (3.5%) in the intervention group compared with the control group (12.3%) (relative risk, 0.29; 95% confidence interval, 0.10–0.83; P = 0.013). The secondary endpoints were similar. Hypoglycemia occurred in 8.8% of the intervention group compared with 4.1% of the control group (P = 0.14). Multivariate analysis demonstrated that continuous insulin infusion was a negative independent predictor (odds ratio, 0.28; 95% confidence interval, 0.09–0.87; P = 0.027), whereas previous coronary artery disease was a positive predictor of adverse events. Conclusion:Continuous insulin infusion reduces perioperative myocardial infarction after vascular surgery.

Utility of a transesophageal echocardiographic simulator as a teaching tool.

OBJECTIVE This study was designed to test the hypothesis that simulator-based transesophageal echocardiographic training was a more effective method of training anesthesia residents with no prior experience in echocardiography as compared with conventional methods of training (books, articles, and web-based resources). STUDY DESIGN A prospective randomized study. SETTING An academic medical center (teaching hospital). PARTICIPANTS The participants consisted of first-year anesthesia residents. INTERVENTION The study design was composed of 2 groups: a control group (group 1, conventional group) and a study group (group 2, simulator group). The residents belonging to group 2 (simulator group) received a 90-minute simulator-based teaching session moderated by a faculty experienced in transesophageal echocardiography. Residents belonging to group 1 (conventional group) were asked to review the guidelines of the comprehensive intraoperative transesophageal echocardiographic examination published by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. They also were encouraged to use other learning resources (eg, textbooks, electronic media, and web-based resources) to understand the underlying concepts of echocardiography. Written pre- and post-test was administered to both groups. MEASUREMENTS AND MAIN RESULTS The groups were compared for the pretest scores by the nonparametric Mann-Whitney U test. Pre- and post-test scores were compared with a Wilcoxon paired test in the individual groups. The results showed a statistically significant difference between the scores of the 2 groups with better scores in the simulation group in the post-training test. CONCLUSION The simulator-based teaching model for transesophageal echocardiography is a better method of teaching the basic concepts of transesophageal echocardiography like anatomic correlation, structure identification, and image acquisition.

Transesophageal Echocardiography Simulator: A New Learning Tool

RANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)is a minimally invasive monitoring modality. The initialuse of TEE was limited to the acquisition of images in patientswith suboptimal echo windows during transthoracic echocar-diography. Its role has exponentially expanded to become al-most a standard of care during cardiac surgery and a valuableprocedural adjunct.

Transthoracic echocardiographic simulator: normal and the abnormal.

Despite anesthesiologists’ use of transesophageal echocardio-graphy (TEE) and familiarity with cardiovascular imaging,TTE has not been as widely used perioperatively. With therecent availability of relatively inexpensive and portable ultra-sound systems, there has been a resurgence of interest in usingthis modality to its full potential. Another possible reason for itsunderutilization could be the lack of structured training programsfor anesthesiologists. The National Board of Echocardiographymandates a minimum of 150 TTE examinations to be per-formed by operators, with 300 interpretations under appropriatesupervision, as requirements for certification. However, a short-age of trained personnel and staffing-related issues are two ofthe reasons for a comprehensive TTE examination either notbeing performed routinely or not in a timely fashion, particu-larly for preoperative risk stratification.TTE is a modality that requires considerable skill in imageacquisition and supervised training for interpretation. Tradi-tionally, cardiologists have employed the services of trainedechocardiography technicians for image acquisition, whereasemergency room and critical care physicians have to acquireand interpret transthoracic images themselves. Major nationalprofessional societies (eg, the American Society of Anesthesi-ologists, the Society of Cardiovascular Anesthesiologists, andthe Society of Critical Care Medicine) have taken the initiativeto educate their members about the benefits and applications ofechocardiography in routine practice. However, currently thereare no formal TTE image-acquisition training opportunitiesavailable for anesthesiologists.As a result, an increasing demand for this clinical skill isfurther exacerbated by a paucity of training opportunities, ne-cessitating the employment of alternate training methods totrain physicians in TTE. Therefore, the use of simulation tech-nology provides a unique opportunity to create a virtual train-ing environment to offset the initial learning curve and shortenthe eventual training duration.

Simulator-based Transesophageal Echocardiographic Training with Motion Analysis: A Curriculum-based Approach

Background:Transesophageal echocardiography (TEE) is a complex endeavor involving both motor and cognitive skills. Current training requires extended time in the clinical setting. Application of an integrated approach for TEE training including simulation could facilitate acquisition of skills and knowledge. Methods:Echo-naive nonattending anesthesia physicians were offered Web-based echo didactics and biweekly hands-on sessions with a TEE simulator for 4 weeks. Manual skills were assessed weekly with kinematic analysis of TEE probe motion and compared with that of experts. Simulator-acquired skills were assessed clinically with the performance of intraoperative TEE examinations after training. Data were presented as median (interquartile range). Results:The manual skills of 18 trainees were evaluated with kinematic analysis. Peak movements and path length were found to be independent predictors of proficiency (P < 0.01) by multiple regression analysis. Week 1 trainees had longer path length (637 mm [312 to 1,210]) than that of experts (349 mm [179 to 516]); P < 0.01. Week 1 trainees also had more peak movements (17 [9 to 29]) than that of experts (8 [2 to 12]); P < 0.01. Skills acquired from simulator training were assessed clinically with eight additional trainees during intraoperative TEE examinations. Compared with the experts, novice trainees required more time (199 s [193 to 208] vs. 87 s [83 to 16]; P = 0.002) and performed more transitions throughout the examination (43 [36 to 53] vs. 21 [20 to 23]; P = 0.004). Conclusions:A simulation-based TEE curriculum can teach knowledge and technical skills to echo-naive learners. Kinematic measures can objectively evaluate the progression of manual TEE skills.

Novel, Multimodal Approach for Basic Transesophageal Echocardiographic Teaching

OBJECTIVES Web and simulation technology may help in creating a transesophageal echocardiography (TEE) curriculum. The authors discuss the educational principles applied to developing and implementing a multimodal TEE curriculum. DESIGN AND SETTING The authors modified a pilot course based on principles for effective simulation-based education. Key curricular elements were consistent with principles for effective simulation-based education: (1) clear goals and carefully structured objectives, (2) conveniently accessed, graduated, longitudinal instruction, (3) a protected and optimal learning environment, (4) repetition of concepts and technical skills, (5) progressive expectations for understanding and skill development, (6) introduction of abnormalities after understanding of normal anatomy and probe manipulation is achieved, (7) live learning sessions that are customizable to meet learner needs and individualized proctoring in skill sessions, (8) use of multiple approaches to teaching, (9) regular and relevant feedback, and (10) application of performance and compliance measures. PARTICIPANTS Fifty-five learners participated in a curriculum with web-based modules, live teaching, and simulation practice between August 2011 and May 2013. CONCLUSION It is possible to develop and implement an integrated, multimodal TEE curriculum supported by educational theory. The authors will explore the transferability of this approach to intraoperative TEE on live patients.

Anesthetic management of supratentorial tumors.

The overall annual incidence of primary central nervous system (CNS) tumors was reported by the Central Brain Tumor Registry of the United States as 21.03 per 100,000 during the period between 2006 and 2010. Of the 326,711 reported tumors, the majority (>80%) were supratentorial. Craniotomies for supratentorial tumors (STT) provide unique challenges to both the surgeon and anesthesiologist. The main goals for anesthetic management include the optimization of intracranial pressure (ICP) and maintenance of cerebral perfusion pressure (CPP) to ensure adequate oxygen delivery to the cerebral tissues and avoid secondary insults to the brain. In this review, we will discuss the current literature and key points of intraoperative management.

Imaging skills for transthoracic echocardiography in cardiology fellows: The value of motion metrics

Background: Proficiency in transthoracic echocardiography (TTE) requires an integration of cognitive knowledge and psychomotor skills. Whereas cognitive knowledge can be quantified, psychomotor skills are implied after repetitive task performance. We applied motion analyses to evaluate psychomotor skill acquisition during simulator-based TTE training. Methods and Results: During the first month of their fellowship training, 16 cardiology fellows underwent a multimodal TTE training program for 4 weeks (8 sessions). The program consisted of online and live didactics as well as simulator training. Kinematic metrics (path length, time, probe accelerations) were obtained at the start and end of the course for 8 standard TTE views using a simulator. At the end of the course TTE image acquisition skills were tested on human models. After completion of the training program the trainees reported improved self-perceived comfort with TTE imaging. There was also an increase of 8.7% in post-test knowledge scores. There was a reduction in the number of probe accelerations [median decrease 49.5, 95% CI = 29-73, adjusted P < 0.01], total time [median decrease 10.6 s, 95% CI = 6.6-15.5, adjusted P < 0.01] and path length [median decrease 8.8 cm, 95% CI = 2.2-17.7, adjusted P < 0.01] from the start to the end of the course. During evaluation on human models, the trainees were able to obtain all the required TTE views without instructor assistance. Conclusion: Simulator-derived motion analyses can be used to objectively quantify acquisition of psychomotor skills during TTE training. Such an approach could be used to assess readiness for clinical practice of TTE.

Evaluation of the quality of transesophageal echocardiography images and verification of proficiency

Various metrics have been used in curriculum-based TEE training programs to evaluate acquisition of proficiency. However, the quality of task completion, i.e. the final image quality, was subjectively evaluated in these studies. Ideally, the end point metric should be an objective comparison of the trainee-acquired image with a reference ideal image. Therefore, we developed a simulator-based methodology of pre-clinical verification of proficiency (VOP) in trainees by tracking objective evaluation of the final acquired images. We utilized geometric data from the simulator probes to compare image acquisition of anesthesia residents who participated in our structured longitudinal simulator-based TEE educational program in versus ideal image planes determined froma panel of experts. Thirty-three participants completed the study (15 experts, 7 PGY-1, and 11PGY-4). The results of our study demonstrated a significant difference in image capture success rates between learners and experts (X2=14.716, df=2, p<0.001) with the difference between learners (PGY-1 and PGY-4) not being statistically significant (X2=0, df=1, p=1.000). Therefore, our results suggest that novices (i.e. PGY-1 residents) are capable of attaining a level of proficiency comparable to those with modest training (i.e. PGY-4 residents) after completion of a simulation-based training curriculum. However, professionals with years of clinical training (i.e. attending physicians) exhibit a superior mastery of such skills. It is hence feasible to develop a simulator-based VOP program in performance of TEE for junior anesthesia residents.Various metrics have been used in curriculum-based transesophageal echocardiography (TEE) training programs to evaluate acquisition of proficiency. However, the quality of task completion, that is the final image quality, was subjectively evaluated in these studies. Ideally, the endpoint metric should be an objective comparison of the trainee-acquired image with a reference ideal image. Therefore, we developed a simulator-based methodology of preclinical verification of proficiency (VOP) in trainees by tracking objective evaluation of the final acquired images. We utilized geometric data from the simulator probes to compare image acquisition of anesthesia residents who participated in our structured longitudinal simulator-based TEE educational program vs ideal image planes determined from a panel of experts. Thirty-three participants completed the study (15 experts, 7 postgraduate year (PGY)-1 and 11 PGY-4). The results of our study demonstrated a significant difference in image capture success rates between learners and experts (χ2 = 14.716, df = 2, P < 0.001) with the difference between learners (PGY-1 and PGY-4) not being statistically significant (χ2 = 0, df = 1, P = 1.000). Therefore, our results suggest that novices (i.e. PGY-1 residents) are capable of attaining a level of proficiency comparable to those with modest training (i.e. PGY-4 residents) after completion of a simulation-based training curriculum. However, professionals with years of clinical training (i.e. attending physicians) exhibit a superior mastery of such skills. It is hence feasible to develop a simulator-based VOP program in performance of TEE for junior anesthesia residents.

Preoperative Assessment of the Elderly Patient

Aging is an inevitable process producing changes in the structure and function of tissues and organ systems. The term “elderly” is generally reserved for individuals 65 years and older; this definition includes a heterogenous group of people with a wide range of physical and mental abilities. In contrast, “age-related illnesses” are conditions that occur with increasing frequency in the aged individual but are not inevitable or proportional to chronological aging. One of the main preoperative issues encountered by anesthesiologists is distinguishing the impact of age vs. the effect of disease processes on organ function. The challenge includes performing an accurate estimate of the functional reserve of organ systems, providing a realistic risk assessment associated with the procedure and making appropriate recommendations regarding optimization of the patient’s condition.