T. Kyle Harrison

Use of cognitive aids in a simulated anesthetic crisis.

We evaluated empirically the extent to which the use of a cognitive aid during a high-fidelity simulation of a malignant hyperthermia (MH) event facilitated the correct and prompt treatment of MH. We reviewed the management of 48 simulated adult MH scenarios; 24 involving CA 1 and 24 involving CA 2 residents. In the CA 1 group, 19 of the 24 teams (79%) used a cognitive aid, but only 8 of the 19 teams used it frequently or extensively. In the CA 2 group, 18 of the 23 teams (78%) used a cognitive aid but only 6 of them used it frequently or extensively. The frequency of cognitive aid use correlated significantly with the MH treatment score for the CA 1 group (Spearman r = 0.59, P < 0.01) and CA 2 group (Spearman r = 0.68, P < 0.001). The teams that performed the best in treating MH used a cognitive aid extensively throughout the simulation. Although the effect was less pronounced in the more experienced CA 2 cohort, there was still a strong correlation between performance and cognitive aid use. We were able to show a strong correlation between the use of a cognitive aid and the correct treatment of MH.

Single lung ventilation in children using a new paediatric bronchial blocker

As video‐assisted thoracoscopic surgery has become more common in paediatric patients, the use of single lung ventilation in children has also increased. Single lung ventilation in young children is performed by either advancing a tracheal tube into the mainstem bronchus opposite the side of surgery or by positioning a bronchial blocker into the mainstem bronchus on the operative side. Techniques for placing a variety of bronchial blockers outside the tracheal tube have been described. We describe a technique for placement of a new bronchial blocker through an indwelling tracheal tube using a multiport adaptor and a fibreoptic bronchoscope.

A Randomized Comparison of Long-and Short-Axis Imaging for In-Plane Ultrasound-Guided Femoral Perineural Catheter Insertion

Continuous femoral nerve blocks provide effective analgesia after knee arthroplasty, and infusion effects depend on reliable catheter location. Ultrasound‐guided perineural catheter insertion using a short‐axis in‐plane technique has been validated, but the optimal catheter location relative to target nerve and placement orientation remain unknown. We hypothesized that a long‐axis in‐plane technique for femoral perineural catheter insertion results in faster onset of sensory anesthesia compared to a short‐axis in‐plane technique.

An In Vitro Study to Evaluate the Utility of the “Air Test” to Infer Perineural Catheter Tip Location

Injection of air under ultrasound guidance via a perineural catheter after insertion (“air test”) has been described as a means to infer placement accuracy, yet this test has never been rigorously evaluated. We tested the hypothesis that the air test predicts accurate catheter location greater than chance and determined the tests sensitivity, specificity, and positive and negative predictive values using a porcine‐bovine model and blinded expert in ultrasound‐guided regional anesthesia. The air test improved the expert clinicians assessment of catheter tip position compared to chance, but there was no difference when compared to direct visualization of the catheter without air injection.

A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty.

Proximal and distal (mid‐thigh) ultrasound‐guided continuous adductor canal block techniques have been described but not yet compared, and infusion benefits or side effects may be determined by catheter location. We hypothesized that proximal placement will result in faster onset of saphenous nerve anesthesia, without additional motor block, compared to a distal technique.

Supporting crisis response with dynamic procedure aids

Checklist usage can increase performance in complex, high-risk domains. While paper checklists are valuable, they are static, slow to access, and show both too much and too little information. We introduce Dynamic Procedure Aids to address four key problems in checklist usage: ready access to aids, rapid assimilation of content, professional acceptance, and limited attention. To understand their efficacy for crisis response, we created the dpAid software system. Its design arose through a multi-year participation in medical crisis response training featuring realistic team simulations. A study comparing Dynamic Procedure Aids, paper, and no aid, found that participants with Dynamic Procedure Aids performed significantly better than with paper or no aid. This study introduces the narrative simulation paradigm for comparatively assessing expert procedural performance through a score-and-correct approach.

Design and Implementation of a Perioperative Surgical Home at a Veterans Affairs Hospital

The innovative Perioperative Surgical Home model aims to optimize the outcomes of surgical patients by leveraging the expertise and leadership of physician anesthesiologists, but there is a paucity of practical examples to follow. Veterans Affairs health care, the largest integrated system in the United States, may be the ideal environment in which to explore this model. We present our experience implementing Perioperative Surgical Home at one tertiary care university-affiliated Veterans Affairs hospital. This process involved initiating consistent postoperative patient follow-up beyond the postanesthesia care unit, a focus on improving in-hospital acute pain management, creation of an accessible database to track outcomes, developing new clinical pathways, and recruiting additional staff. Today, our Perioperative Surgical Home facilitates communication between various services involved in the care of surgical patients, monitoring of patient outcomes, and continuous process improvement.

Preliminary Study of Ergonomic Behavior During Simulated Ultrasound-Guided Regional Anesthesia Using a Head-Mounted Display

A head‐mounted display provides continuous real‐time imaging within the practitioners visual field. We evaluated the feasibility of using head‐mounted display technology to improve ergonomics in ultrasound‐guided regional anesthesia in a simulated environment. Two anesthesiologists performed an equal number of ultrasound‐guided popliteal‐sciatic nerve blocks using the head‐mounted display on a porcine hindquarter, and an independent observer assessed each practitioners ergonomics (eg, head turning, arching, eye movements, and needle manipulation) and the overall block quality based on the injectate spread around the target nerve for each procedure. Both practitioners performed their procedures without directly viewing the ultrasound monitor, and neither practitioner showed poor ergonomic behavior. Head‐mounted display technology may offer potential advantages during ultrasound‐guided regional anesthesia.

Feasibility of eye-tracking technology to quantify expertise in ultrasound-guided regional anesthesia

Ultrasound-guided regional anesthesia (UGRA) requires an advanced procedural skill set that incorporates both sonographic knowledge of relevant anatomy as well as technical proficiency in needle manipulation in order to achieve a successful outcome. Understanding how to differentiate a novice from an expert in UGRA using a quantifiable tool may be useful for comparing educational interventions that could improve the rate at which one develops expertise. Exploring the gaze pattern of individuals performing a task has been used to evaluate expertise in many different disciplines, including medicine. However, the use of eye-tracking technology has not been previously applied to UGRA. The purpose of this preliminary study is to establish the feasibility of applying such technology as a measurement tool for comparing procedural expertise in UGRA. eye-tracking data were collected from one expert and one novice utilizing Tobii Glasses 2 while performing a simulated ultrasound-guided thoracic paravertebral block in a gel phantom model. Area of interest fixations were recorded and heat maps of gaze fixations were created. Results suggest a potential application of eye-tracking technology in the assessment of UGRA learning and performance.

Evaluation of a Standardized Program for Training Practicing Anesthesiologists in Ultrasound-Guided Regional Anesthesia Skills

Practicing anesthesiologists have generally not received formal training in ultrasound‐guided perineural catheter insertion. We designed this study to determine the efficacy of a standardized teaching program in this population.