Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy

BACKGROUND

Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared perioperative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped).

METHOD

We conducted a multicentre, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals.

RESULTS

We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs, and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 (2-14) days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher intensive care unit (ICU) admission rate and longer hospital LOS.

CONCLUSION

Disease severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs.

Use of backboards in cardiopulmonary resuscitation: a systematic review and meta-analysis

To achieve optimal chest compression depth, victims of cardiac arrest should be placed on a firm surface. Backboards are usually placed between the mattress and the back of a patient in the attempt to increase cardiopulmonary resuscitation (CPR) quality, but their effectiveness remains controversial. A systematic search was performed to include studies on humans and simulation manikins assessing CPR quality with or without backboards. The primary outcome of the meta-analysis was the difference in chest compression depth between these two conditions. Out of 557 records, 16 studies were included in the review and all were performed on manikins. The meta-analysis, performed on 15 articles, showed that the use of backboards during CPR increases chest compression depth by 1.46 mm in manikins. Despite statistically significant, this increase could have a limited clinical impact on CPR, due to the substantial heterogeneity of experimental conditions and the scarcity of other CPR quality indicators.

Assessing anaesthesiology and intensive care specialty physicians: An Italian language multisource feedback system

BACKGROUND

Physician professionalism, including anaesthesiologists and intensive care doctors, should be continuously assessed during training and subsequent clinical practice. Multi-source feedback (MSF) is an assessment system in which healthcare professionals are assessed on several constructs (e.g., communication, professionalism, etc.) by multiple people (medical colleagues, coworkers, patients, self) in their sphere of influence. MSF has gained widespread acceptance for both formative and summative assessment of professionalism for reflecting on how to improve clinical practice.

METHODS

Instrument development and psychometric analysis (feasibility, reliability, construct validity via exploratory factor analysis) for MSF questionnaires in a postgraduate specialty training in Anaesthesiology and intensive care in Italy. Sixty-four residents at the Università del Piemonte Orientale (Italy) Anesthesiology Residency Program. Main outcomes assessed were: development and psychometric testing of 4 questionnaires: self, medical colleague, coworker and patient assessment.

RESULTS

Overall 605 medical colleague questionnaires (mean of 9.3 ±1.9) and 543 coworker surveys (mean 8.4 ±1.4) were collected providing high mean ratings for all items (> 4.0 /5.0). The self-assessment item mean score ranged from 3.1 to 4.3. Patient questionnaires (n = 308) were returned from 31 residents (40%; mean 9.9 ± 6.2). Three items had high percentages of "unable to assess" (> 15%) in coworker questionnaires. Factor analyses resulted in a two-factor solution: clinical management with leadership and accountability accounting for at least 75% of the total variance for the medical colleague and coworker's survey with high internal consistency reliability (Cronbach's α > 0.9). Patient's questionnaires had a low return rate, a limited exploratory analysis was performed.

CONCLUSIONS

We provide a feasible and reliable Italian language MSF instrument with evidence of construct validity for the self, coworkers and medical colleague. Patient feedback was difficult to collect in our setting.

Potential harm caused by physicians' a-priori beliefs in the clinical effectiveness of hydroxychloroquine and its impact on clinical and economic outcome - A simulation approach

Despite growing controversies around Hydroxychloroquine's effectiveness, the drug is still widely prescribed by clinicians to treat COVID19 patients. Therapeutic judgment under uncertainty and imperfect information may be influenced by personal preference, whereby individuals, to confirm a-priori beliefs, may propose drugs without knowing the clinical benefit. To estimate this disconnect between available evidence and prescribing behavior, we created a Bayesian model analyzing a-priori optimistic belief of physicians in Hydroxychloroquine's effectiveness. Methodology: We created a Bayesian model to simulate the impact of different a-priori beliefs related to Hydroxychloroquine's effectiveness on clinical and economic outcome. Results: Our hypothetical results indicate no significant difference in treatment effect (combined survival benefit and harm) up to a presumed drug's effectiveness level of 20%, with younger individuals being negatively affected by the treatment (RR 0.82, 0.55–1.2; (0.95 (1.1) % expected adverse events versus 0.05 (0.98) % expected death prevented). Simulated cost data indicate overall hospital cost (medicine, hospital stay, complication) of 18.361,41€ per hospitalized patient receiving Hydroxychloroquine treatment. Conclusion: Off-label use of Hydroxychloroquine needs a rational, objective and datadriven evaluation, as personal preferences may be flawed and cause harm to patients and to society.

Augmented Reality Learning Environment for Basic Life Support and Defibrillation Training: Usability Study

Background

Basic life support (BLS) is crucial in the emergency response system, as sudden cardiac arrest is still a major cause of death worldwide. Unfortunately, only a minority of victims receive cardiopulmonary resuscitation (CPR) from bystanders. In this context, training could be helpful to save more lives, and technology-enhanced BLS simulation is one possible solution.

Objective

The aim of this study is to assess the feasibility and acceptability of our augmented reality (AR) prototype as a tool for BLS training.

Methods

Holo-BLSD is an AR self-instruction training system, in which a standard CPR manikin is “augmented” with an interactive virtual environment that reproduces realistic scenarios. Learners can use natural gestures, body movements, and spoken commands to perform their tasks, with virtual 3D objects anchored to the manikin and the environment. During the experience, users were trained to use the device while being guided through an emergency simulation and, at the end, were asked to complete a survey to assess the feasibility and acceptability of the proposed tool (5-point Likert scale; 1=Strongly Disagree, 5=Strongly Agree).

Results

The system was rated easy to use (mean 4.00, SD 0.94), and the trainees stated that most people would learn to use it very quickly (mean 4.00, SD 0.89). Voice (mean 4.48, SD 0.87), gaze (mean 4.12, SD 0.97), and gesture interaction (mean 3.84, SD 1.14) were judged positively, although some hand gesture recognition errors reduced the feeling of having the right level of control over the system (mean 3.40, SD 1.04).

Conclusions

We found the Holo-BLSD system to be a feasible and acceptable tool for AR BLS training.

Cognitive appraisals and team performance under stress: A simulation study

OBJECTIVES

The present study explored how challenge and threat responses to stress relate to performance, anxiety, confidence, team identity and team characteristics (time spent in training and postgraduate experience) in a medical simulation-based team competition.

METHODS

The study was conducted during a national simulation-based training event for residents, the SIMCUP Italia 2018. The SIMCUP is a simulation competition in which teams of four compete in simulated medical emergency scenarios. Cross-sectional data were collected prior to the 3 days of the competition. Subjects included 95 participants on 24 teams. Before the competition on each day, participants completed brief self-report measures that assessed demands and resources (which underpin challenge and threat responses to stress), cognitive and somatic anxiety, self-confidence and team identification. Participants also reported time (hours) spent practising as a team and years of postgraduate experience. A team of referees judged each scenario for performance and assigned a score. A linear mixed model using demands and resources was built to model performance.

RESULTS

The data showed that both demands and resources have positive effects on performance (31 [11-50.3] [P < .01] and 54 [25-83.3] [P < .01] percentage points increase for unitary increases in demands and resources, respectively); however, this is balanced by a negative interaction between the two (demands * resources interaction coefficient = -10 [-16 to -4.2]). A high level of resources is associated with better performance until demands become very high. Cognitive and somatic anxieties were found to be correlated with demands (Pearson's r = .51 [P < .01] and Pearson's r = .48 [P < .01], respectively). Time spent training was associated with greater perceptions of resources (Pearson's r = .36 [P < .01]).

CONCLUSIONS

We describe a model of challenge and threat that allows for the estimation of performance according to perceived demands and resources, and the interaction between the two. Higher levels of resources and lower demands were associated with better performance.

Current and potential treatment options for hyperphosphatemia

INTRODUCTION

Hyperphosphatemia is common in late stages of chronic kidney disease and is often associated with elevated parathormone levels, abnormal bone mineralization, extra-osseous calcification, and increased risk of cardiovascular events and death. Several classes of oral phosphate binders are available to help control plasma phosphorus levels. Although effective at lowering serum phosphorus, they all have safety, tolerability, and compliance issues that need to be considered when selecting which one to use.

AREAS COVERED

This paper reviews the most established treatment options for hyperphosphatemia, in patients with chronic kidney disease, focusing on the new inhibitors of active phosphate absorption.

EXPERT OPINION

The prevention and the treatment of hyperphosphatemia is today far to be satisfactory. Nonetheless, an extending range of phosphate binders are now available. Aluminum has potentially serious toxic risks. Calcium-based binders are very effective but can lead to hypercalcemia and/or positive calcium balance and progression of cardiovascular calcification. No long-term data are available for the new calcium acetate/magnesium combination product. Lanthanum is an effective phosphate binder, and long-term effects of tissue deposition seem clinically irrelevant. Sevelamer, appear to have profiles that would lead to pleiotropic effects and reduced progression of vascular calcification, and the main adverse events seen with these agents are gastrointestinal. Iron has a powerful capability of binding phosphate, thus numerous preparations are available, both with and without significant systemic absorption of the iron component. The inhibitors of active intestinal phosphate transport, with their very selective mechanism of action and low pill burden seem the most interesting approach; however, do not seem at present to be effective alone, in reducing serum phosphorus levels.

Assessment of intradialysis calcium mass balance by a single pool variable-volume calcium kinetic model

INTRODUCTION

A reliable method of intradialysis calcium mass balance quantification is far from been established. We herein investigated the use of a single-pool variable-volume Calcium kinetic model to assess calcium mass balance in chronic and stable dialysis patients.

METHODS

Thirty-four patients on thrice-weekly HD were studied during 240 dialysis sessions. All patients were dialyzed with a nominal total calcium concentration of 1.50 mmol/L. The main assumption of the model is that the calcium distribution volume is equal to the extracellular volume during dialysis. This hypothesis is assumed valid if measured and predicted end dialysis plasma water ionized calcium concentrations are equal. A difference between predicted and measured end-dialysis ionized plasma water calcium concentration is a deviation on our main hypothesis, meaning that a substantial amount of calcium is exchanged between the extracellular volume and a nonmodeled compartment.

FINDINGS

The difference between predicted and measured values was 0.02 mmol/L (range -0.08:0.16 mmol/L). With a mean ionized dialysate calcium concentration of 1.25 mmol/L, calcium mass balance was on average negative (mean ± SD -0.84 ± 1.33 mmol, range -5.42:2.75). Predialysis ionized plasma water concentration and total ultrafiltrate were the most important predictors of calcium mass balance. A significant mobilization of calcium from the extracellular pool to a nonmodeled pool was calculated in a group of patients.

DISCUSSION

The proposed single pool variable-volume Calcium kinetic model is adequate for prediction and quantification of intradialysis calcium mass balance, it can evaluate the eventual calcium transfer outside the extracellular pool in clinical practice.