Sylvain Boet

Virtual simulation training for fibreoptic intubation

Thereare few opportunities for anesthesiology residents to learnthis skill in a clinical setting with patients with ‘‘true’’difficult airways, and learning FOI with patients withnormal airways raises ethical considerations. Conse-quently, anesthesiology residents may be challenged togain sufficient FOI experience during the course of theirpostgraduate training. Computer virtual reality simulationmay optimize learning opportunities in the clinical settingby providing an ethical and cost-effective modality todevelop the basic skills of airway bronchoscopy.

Setting standards for simulation in anesthesia: the role of safety criteria in accreditation standards.

PurposeIn this article, we describe a critical event which occurred in a simulation centre, and we also review possible safety issues for participants and staff involved in medical simulation training.Principal findingsThe authors report an incident with the potential of harming trainees and staff which occurred during a full-scale simulation. The episode raised the question of training safety in simulation centres. In this instance, the computer program controlling the mannequin enabled a continuous and non-regulated outflow of carbon dioxide which led to an intense reaction in the soda lime canister. The absorbent canister became too hot to be touched (a temperature probe, later placed in the centre of the front canister, measured 53°C). All activities involving the mannequin and anesthesia machine were stopped immediately.ConclusionsSimulation in healthcare is a valuable educational tool to train for a variety of clinical encounters in a safe environment without harming a patient. Due to technological progress and the use of authentic equipment recreating near real environments, simulation training has become exceedingly realistic. The Society for Simulation in Healthcare (SSH) has published revised accreditation standards for simulation centres which incorporate training safety sub-criteria to address and manage. By highlighting recommendations of other high-risk industries on this issue, SSH proposes a possible approach to enhance safety in medical simulation.RésuméObjectifDans cet article, nous décrivons un événement critique survenu dans un centre de simulation et passons en revue des questions de sécurité potentielles pour les participants et le personnel prenant part à la formation en simulation médicale.Constatations principalesLes auteurs rapportent un incident survenu pendant une simulation à grande échelle qui aurait pu potentiellement blesser les personnes en formation et le personnel. Cet épisode a soulevé la question de la sécurité de la formation dans les centres de simulation. Dans le cas présenté ici, le programme informatique contrôlant le mannequin a permis le débit continu et non régulé de dioxyde de carbone, ce qui a entraîné une réaction intense dans le réservoir de chaux sodée. Le réservoir absorbant est devenu trop chaud pour pouvoir être manipulé (par la suite, un thermomètre placé au centre du réservoir frontal a mesuré une température de 53°C). Toutes les activités impliquant le mannequin et la machine d’anesthésie ont été immédiatement interrompues.ConclusionLa simulation est un outil éducatif précieux en soins de santé; il permet de former le personnel à plusieurs situations cliniques dans un environnement sécuritaire et sans mettre en péril un patient. En raison des progrès technologiques et de l’utilisation d’équipement authentique recréant des environnements quasi réels, la formation en simulation est devenue très réaliste. La Société pour la simulation en soins de santé (Society for Simulation in Healthcare – SSH) a publié des normes d’agrément révisées destinées aux centres de simulation; ces normes intègrent des sous-critères de sécurité de la formation qui doivent être pris en compte. En mettant en exergue les recommandations d’autres industries à haut risque concernant cette question, la SSH propose une approche possible afin d’améliorer la sécurité en simulation médicale.

Evolving challenges and opportunities for difficult airway management guidelines

Airway management is a key competency for every anesthesiologist. In 1990, Caplan et al. reported that 34% of anesthesia-related claims were related to airway management. Since that time, several national airway management guidelines have been published with the aim to establish and promote safer airway management practice. Since the publication of those guidelines, studies have shown a decrease in anesthesia complications related to airway management. Of course, it is not possible to determine causality, and there have been other significant changes in practice over this time, e.g., supraglottic airways are now used in more than half the patients in the United Kingdom (UK). Unfortunately, despite these advances in both protocols and technology, airway complications in anesthesia still occur, and they are often associated with severe complications, i.e., brain damage or death. Herein, we consider the contents of future airway management guidelines that might create a further impact on patient safety, while bearing in mind the known problematic adherence to airway management guidelines, the role of medical education, and the rapid evolution of new airway management technology and skills. When we consider the history of major developments in airway management, we observe a recent acceleration of the development of technology and skills in this area. The Macintosh and Miller blades, designed in the 1940s when curare was introduced into anesthesia, are still in common use. Major incremental steps in airway management occurred with the development of fibreoptic intubation in the early 1970s, and again in the 1980s, with the invention of the laryngeal mask airway (LMA) and the rigid fibreoptic laryngoscopes (e.g., Bullard). Other major advances were made in the 1990s with the intubating laryngeal mask airway (ILMA), devices for transillumination (e.g., Trachlight), and videolaryngoscopy. During the last decade, anesthesiologists have used combinations of these new techniques to produce even further airway management possibilities, e.g., the combination of the LMA or the ILMA with fibreoptic bronchoscopy. The recent availability of sugammadex may change airway management practice and should be considered in new airway management guidelines. In addition to these ‘‘quantum leaps’’, there has also been a rapid increase in the number of new versions of very similar airway management devices, in part because of the ‘‘me too device’’ phenomenon. This increase in technology provides both advantages and disadvantages to anesthesiologists. Although we have more options for managing difficult intubation, it can be difficult to know the appropriate airway tool to use for a given purpose, especially considering the logistic challenges of conducting controlled trials on patients with difficult airways. A key tension for future guidelines is to reconcile the increasing number of new airway management options with Attributable to: Department of Anesthesiology, St. Michael’s Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada.

Teaching hemodynamics via horticulture

To the Editor, Hemodynamics is a core subject learned by all medical students and health care providers. Various analogies can be used when teaching the interaction between cardiac output, venous return, arterial pressure, and oxygen delivery. However, students may still be confused when they try to integrate these analogies into a single comprehensive mental model. Herein, we propose an ‘‘advance organizer’’, namely, gardening to teach hemodynamics to medical students. An advance organizer is an analogy-based educational tool that draws on information that is present prior to learning, typically intuitive knowledge or information with which all learners are familiar without any specific teaching. For example, everyone old enough to be a medical student should be familiar with watering flowers. Given this basic background information, the learner can organize and interpret new information – related to hemodynamic physiology – and integrate the new knowledge into the old information schema. Hemodynamics is like gardening. The garden (human body) is composed of blades of grass (cells) that need water (oxygenated blood). The gardener must operate a hand pump (heart) with a unidirectional valve (heart valves) that will water the whole lawn through a hose (vascular system). When the pump is operated, a jet of water is emitted from the pipe (systole) and reaches the most distant areas of the garden. When the pressure on the pump is released, the water is emitted from the hose at lower pressure (diastole). The gardener pumps at a certain frequency (heart rate) with a developed force (inotropy). The pressure of the jet of water also depends on the resistance of the pipe. The jet of water is characterized by flow and pressure. Pressure depends on both flow and resistance from the nozzle of the hose (pressure = flow 9 resistance). The gardener must provide enough water pressure to reach all blades of grass in the lawn and must deliver sufficient flow to provide ample water to the whole lawn. Tissue oxygenation is represented by water (oxygenated blood) reaching the blades of grass (cells). The change in the color of the grass (lactatemia) is a very late test of the quality of irrigation. Any good gardener wants to make sure that the grass is watered sufficiently by testing the humidity in the soil (venous oxygen saturation – SvO2) to prevent the grass from turning yellow (hyperlactatemia). If the soil is dry (low SvO2), the grass will soon turn yellow (hyperlactatemia). If the grass is already yellow, watering is necessary, but watering too much can be more harmful than beneficial (ischemia-reperfusion phenomenon). This advance organizer can be refined. A water pipe and arm pump activated by the gardener results in a pulsatile cardiac output, and excess water not absorbed by the grass returns to the pump, corresponding to venous return This work should be attributed to Pole Anesthesie, Reanimation Chirurgicale, SAMU, Hopitaux Universitaires de Strasbourg, Strasbourg, France.