Telehealth Competencies: Training Physicians for a New Reality?

In North America, telehealth increased by 40% between 2019 and 2020 and stabilized at 40% in 2021. As telehealth becomes more common, it is essential to ensure that healthcare providers have the required skills to overcome the challenges and barriers of this new modality of care. While the COVID-19 pandemic has accelerated the design and implementation of telehealth curricula in healthcare education programs, its general adoption is still a major gap and an important barrier to ensuring scaling up and sustainability of the telesshealth practice. Lack of experienced faculty and limited curricular time are two of the most common barriers to expanding telehealth education. Overcoming the barriers of telehealth curricula implementation may require moving away from the classic expert model of learning in which novices learn from experts. As the adoption of telehealth curricula is still in its early stages, institutions may need to plan for faculty development and trainee education at the same time. Questions regarding the timing and content of telehealth education, the interprofessional development of curricula, and the identification of optimal pedagogical methods remain open and crucial. This article reflects on these questions and presents telesimulation as an ideal instructional method for the training of telehealth competencies. Telesimulation can provide opportunities for practical training across a range of telehealth competencies, fostering not only technical proficiency but also communication skills and interprofessional collaboration.

A practical guide for translating in-person simulation curriculum to telesimulation

This article provides a road map, along with recommendations, for the adoption and implementation of telesimulation at a large scale. We provide tools for translating an in-presence simulation curriculum into a telesimulation curriculum using a combination off-the-shelf telecommunication platform. We also describe the roles and tasks that emerged within the simulation team when planning and delivering a telesimulation curriculum.

Ultrasound evaluation of inferior vena cava compression in tilted and supine term parturients

PURPOSE

Hypotension is common following spinal anesthesia (SA) during elective Cesarean delivery (CD). Although common practice is to alleviate inferior vena cava (IVC) compression, limited evidence supports a 15° tilt for CD. We measured collapsibility of the IVC in supine and 15° left lateral tilt positions with ultrasound before and after SA and phenylephrine infusion in term parturients.

METHODS

Twenty term parturients scheduled for CD were recruited for this prospective study. Ultrasound measurements of the IVC were taken 1) supine before SA, 2) tilted 15° before SA, 3) supine after SA, and 4) tilted 15° after SA. A phenylephrine infusion was begun after injection of SA. The primary outcome was to evaluate the impact of position on the IVC collapsibility index (IVCCI): a measure of the difference between the maximum and minimum IVC diameter with respiration.

RESULTS

The mean (standard deviation) IVCCI (%) before SA was higher in the supine 19.5 (8.0) than in the tilted 15.0 (6.4) position (mean difference, 4.5; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). After SA, there was no significant difference between IVCCI (%) in the supine 17.8 (8.3) and tilted 14.2 (6.9) position (mean difference, 3.5; 95% CI, -0.9 to 7.9; P = 0.13). There was no correlation between the pre-spinal IVVCI measurements and the quantity of phenylephrine used during the surgery.

CONCLUSION

The IVCCI was lower in the 15° tilt position than in the supine position, but not after SA with a phenylephrine infusion. Ultrasound imaging can help identify IVC compression.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03410199); registered 18 January 2018.

A randomized controlled trial comparing nociception level (NOL) index, blood pressure, and heart rate responses to direct laryngoscopy versus videolaryngoscopy for intubation: the NOLint project

PURPOSE

The effect of direct laryngoscopy using a Macintosh blade (MAC) vs GlideScope™ videolaryngoscopy using a Spectrum LoPro blade (GVL) on nociceptive stimulation has not been quantitatively studied. This study used the new nociception level (NOL) index to compare the nociceptive response induced by GVL or MAC during laryngoscopy with or without intubation.

METHODS

Patients underwent two laryngoscopies at four-minute intervals (L1, L2), one with GVL and the other with MAC (first randomization). A third laryngoscopy (L3) followed by tracheal intubation was performed four minutes after L2 (GVL or MAC, second randomization). Nociception was quantitatively assessed by NOL and standard hemodynamic parameters (heart rate [HR] and mean arterial pressure). For the crossover design, blade comparisons accounted for sequence and blade type. A possible carryover effect between laryngoscopies was assessed.

RESULTS

In the 50 patients randomized, there was no carryover effect from one laryngoscopy to the next for all analyzed parameters. Nociception level index peak values were higher with MAC than GVL. Analysis of ΔNOL showed a lower nociceptive response with GVL for L1+L2 combined. Mean peak NOL values were significantly higher after L3+intubation than after L1+L2, for both GVL and MAC groups. Analysis of ΔHR values did not show a significant difference between GVL and MAC for any laryngoscopy.

CONCLUSION

Laryngoscopy alone with GVL induces less nociception than with MAC. The NOL was more sensitive than HR at detecting nociceptive responses to MAC vs GVL. Additionally, and irrespective of which technique/blade was used, the combination of laryngoscopy + tracheal intubation produced a much greater nociceptive response than the laryngoscopy alone.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03277872); registered 29 August 2017.

Assessing the antinociceptive effect of nitrous oxide to tetanic stimulation in anaesthetised patients with new intra-operative nociception monitors: An observational study

BACKGROUND

Nitrous oxide (N2O) has been used since the 19th century for its analgesic, antinociceptive and anxiolytic effects during surgical procedures in awake and anaesthetised patients. However, quantification of noxious stimuli that occur under general anaesthesia is a constant challenge for anaesthesiologists, and recently two new indices have been developed to assess intra-operative nociception.

OBJECTIVE

The aim of this study was to quantify with new indices as well as with more classical clinical parameters the antinociceptive effect of N2O during general anaesthesia.

DESIGN

Prospective, open label, patient-blinded, observational and descriptive trial.

SETTING

Single-centre academic hospital.

PARTICIPANTS

Forty American Society of Anesthesiologists' physical status 1 to 3 patients undergoing general anaesthesia for elective abdominal surgery via laparotomy were recruited.

MAIN OUTCOMES MEASURES

Intra-operative pain was assessed using a standardised electrical stimulation of the forearm (tetanic stimulation at 70 mA, 100 Hz for 30 s), at 0, 25 and 50% inhaled N2O/O2. Heart rate (HR), mean arterial blood pressure, bispectral index, the analgesia nociception index and the nociception level (NOL) index were used to evaluate intra-operative nociception before and after each standardised tetanic stimulation.

RESULTS

There was a 16% reduction of the analgesia nociception index reaction, a 31% reduction of the NOL reaction and a 51% reduction of the HR reaction to a standardised electrical tetanic nociceptive stimulation during administration of 50% N2O. Administration of 50 or 25% inhaled N2O produced the same quality of antinociception based on HR and NOL index analyses. HR and the NOL index were the best parameters to identify the antinociceptive effect of intra-operatively administered N2O.

CONCLUSION

In anaesthetised patients, our study demonstrated clinically significant antinociceptive properties of N2O. Our results showed that low concentrations of N2O (25%) are as effective as higher concentrations (50%) to achieve a significant antinociceptive effect. These findings may help decrease negative effects of using higher concentrations of N2O, including its side effects and its environmental pollution.

TRIAL REGISTRATION

ClinicalTrials.gov registration identifier: NCT02701478.

Self-directed learning by video as a means to improve technical skills in surgery residents: a randomized controlled trial

BACKGROUND

With their demanding schedules, surgical residents have limited time to practice techniques. The aim is to evaluate the pedagogic model of self-directed learning using video in surgery residents.

METHODS

Informed consent was obtained from all the participants. A randomized controlled trial was conducted in 2018 at Hôpital Maisonneuve-Rosemont (University of Montreal). Participants were general surgery residents. There were 27 eligible residents; 22 completed the study. They were filmed performing an intestinal anastomosis on cadaveric pig bowel. The self-directed learning by video (SDL-V) group was given an expert video, which demonstrated the technique performed by an experienced surgeon. The control group continued with their regular duties. Three weeks later, participants performed a second filmed anastomosis. Two attending surgeons evaluated the residents' filmed anastomosis using the Objective Structured Assessment of Technical Skills scale. After their second anastomosis, all participants had access to the expert video and completed a survey.

RESULTS

Score did not differ significantly between groups during the first (control: 23.6 (4.5) vs. SDL-V: 23.9 (4.5), p = 0.99, presented as mean (SD)) or second filmed anastomosis procedure (control: 27.1 (3.9) vs. SDL-V: 29.6 (3.4) p = 0.28). Both groups improved significantly from pre- to post-intervention (mean difference between the two anastomosis procedure with 95% CI for control: 3.5, [1.1; 5.9] and for SDL-V: 5.8, [3.4: 8.2]). Correlation between the evaluators for score was moderate (r = 0.6, 95% CI: [0.3: 0.8]). The pass/fail global evaluation exhibited poor inter-rater reliability (Kappa: 0.105, 95% CI: [- 0.2:0.4]). On the survey, all participants wanted more expert-made videos of specific surgical techniques.

CONCLUSIONS

Despite a higher final OSATS score for the intervention group, self-directed learning by video failed to produce a statistically significant difference on the overall OSATS scores between the two groups in this small cohort.

Using High-Fidelity Simulation to Teach Ethics Related Non-Technical Skills: Description of an Innovative Model

This article describes a high-fidelity (Hi-Fi) simulation-based innovative educational strategy intended to introduce anesthesiology residents to key ethical considerations and how they apply to their practice. Three Hi-Fi simulation scenarios involving situations with various ethical issues are described with their debriefing objectives and the trainees' subjective feedback. Three high-fidelity simulation scenarios are described: (a) teaching critical incident disclosure, (b) disclosing and discussing patient awareness during general anesthesia, and (c) would physicians override a do-not-resuscitate (DNR) order if the cause of a cardiac arrest is iatrogenic? We used Hi-Fi simulation in an innovative way to teach these principles of ethics. Simulation, through carefully crafted debriefing, can contribute to the acquisition of essential non-technical ethical skills. How best to integrate simulation in an existent ethics curriculum and how it compares with more traditional teaching methods are questions that need to be addressed.

The impact of a high fidelity simulation-based debriefing course on the Debriefing Assessment for Simulation in Healthcare (DASH)© score of novice instructors

INTRODUCTION

Experiential learning, followed by debriefing, is at the heart of Simulation-Based Medical Education (SBME) and has been proven effective to help master several medical skills. We investigated the impact of an educational intervention, based on high-fidelity SBME, on the debriefing competence of novice simulation instructors.

METHODS

This is a prospective, randomized, quasi-experimental, pre- and post-test study. Sixty physicians without prior formal debriefing expertise attended a 5-day SBME seminar targeted on debriefing. Prior to the start of the seminar, 15 randomly chosen participants had to debrief a spaghetti and tape team exercise. Thereafter, the members of each team assessed their debriefer's performance using the Debriefing Assessment for Simulation in Healthcare (DASH)© score. The debriefing seminar that followed (intervention) consisted of 5 days of teaching that included theoretical and simulation training. Each scenario was followed by a Debriefing of the Debriefing (DOD) session conducted by the expert instructor. At the end of the course, 15 randomly chosen debriefers had to debrief a second tower building exercise and were re-evaluated with the DASH score by their respective team members. The Wilcoxon signed-rank test was used to compare pre- and post-test scores. Statistical tests were performed using GraphPad Prism 6.0c for Mac.

RESULTS

A significant improvement in all items of the DASH score was noted following the seminar. The debriefers significantly improved their performance with regard to "maintaining an engaging learning environment" (Median [IQR]) (4[3-5] after the pre-test vs. 5.5[5-6] after the post-test, p<0.001); "structuring the debriefing in an organized way" (5[4-5] after the pre-test vs. 5[5-6] after the post-test, p=0.002); "provoking engaging discussion" (4[3-5.75] after the pre-test vs. 6[5-6] after the post-test, p<0.001); "identifying and exploring performance gaps" (5[4-6] after the pre-test vs. 6[5-6] after the post-test, p=0.014); and "helping trainees to achieve and sustain good future performance" (4[3-5] after the pre-test vs. 6[5-6] after the post-test, p<0.001).

CONCLUSION

A simulation-based debriefing course, based mainly on DOD sessions, allowed novice simulation instructors to improve their overall debriefing skills including, more specifically, the ability to foster engagement in discussions and maintain an engaging learning environment.

Transcutaneous cardiac pacing competency among junior residents undergoing an ACLS course: impact of a modified high fidelity manikin

BACKGROUND

Transcutaneous cardiac pacing (TCP) is recommended to treat unstable bradycardia. Simulation might improve familiarity with this low-frequency procedure. Current mannequins fail to reproduce key features of TCP, limiting their usefulness. The objective of this study was to measure the impact of a modified high-fidelity mannequin on the ability of junior residents to achieve six critical tasks for successful TCP.

METHODS

First-year residents from various postgraduate programs taking an advanced cardiovascular life support (ACLS) course were enrolled two consecutive years (2015 and 2016). Both cohorts received the same standardized course content. An ALS simulator® mannequin was used to demonstrate and practice TCP during the bradycardia workshop of the first cohort (control cohort, 2015) and a modified high-fidelity mannequin that reproduces key features of TCP was used for the second cohort (intervention cohort, 2016). Participants were tested after training with a simulation scenario requiring TCP. Performances were graded based on six critical tasks. The primary outcome was the successful use of TCP, defined as having completed all tasks.

RESULTS

Eighteen participants in the intervention cohort completed all tasks during the simulation scenario compared to none in the control cohort (36 vs 0%, p < 0.001). Participants in the intervention cohort were more likely to recognize when pacing was inefficient (86 vs 12%), obtain ventricular capture (48 vs 2%), and check for a pulse rate to confirm capture (48 vs 0%).

CONCLUSIONS

TCP is a difficult skill to master for junior residents. Training using a modified high-fidelity mannequin significantly improved their ability to establish TCP during a simulation scenario.

Rationale for the administration of systemic 5-FU in combination with heated intraperitonal oxaliplatin

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (OX) is the standard of care for selected patients with peritoneal carcinomatosis of colorectal origin. Because 5-FU is mandatory to improve efficacy of OX when used by systemic route, several teams now empirically combine intravenous (IV) 5-FU with HIPEC OX, but this practice has yet to be supported by preclinical data. Using a murine model, we studied the impact of IV 5-FU on peritoneal absorption of HIPEC OX.

METHODS

Under general anesthesia, 24 Sprague-Dawley rats were submitted to 4 different doses of IV 5-FU (0, 100, 400 and 800 mg/m²) and a fixed dose of HIPEC OX (460 mg/m²) perfused at 40 °C during 25 min. At 25 min, samples in different compartments were harvested (peritoneum, portal vein and systemic blood) and the concentrations of 5-FU and OX were measured by high performance liquid chromatography.

RESULTS

Peritoneal absorption of OX was significantly higher (17.0, 20.1, 34.9 and 38.1 nmol/g, p < 0.0001) with increasing doses of 5-FU (0, 100, 400 and 800 mg/m², respectively). Peritoneal absorption of OX reached a plateau between 400 and 800 mg/m² of IV 5-FU.

CONCLUSION

IV 5-FU enhances peritoneal absorption of HIPEC OX. The most efficient dose of IV 5-FU to be used in combination with HIPEC OX seems to be 400 mg/m².

Video Coaching as an Efficient Teaching Method for Surgical Residents-A Randomized Controlled Trial

BACKGROUND

As surgical training is evolving and operative exposure is decreasing, new, effective, and experiential learning methods are needed to ensure surgical competency and patient safety. Video coaching is an emerging concept in surgery that needs further investigation.

DESIGN

In this randomized controlled trial conducted at a single teaching hospital, participating residents were filmed performing a side-to-side intestinal anastomosis on cadaveric dog bowel for baseline assessment. The Surgical Video Coaching (SVC) group then participated in a one-on-one video playback coaching and debriefing session with a surgeon, during which constructive feedback was given. The control group went on with their normal clinical duties without coaching or debriefing. All participants were filmed making a second intestinal anastomosis. This was compared to their first anastomosis using a 7-category-validated technical skill global rating scale, the Objective Structured Assessment of Technical Skills. A single independent surgeon who did not participate in coaching or debriefing to the SVC group reviewed all videos. A satisfaction survey was then sent to the residents in the coaching group.

SETTING

Department of Surgery, HôpitalMaisonneuve-Rosemont, tertiary teaching hospital affiliated to the University of Montreal, Canada.

PARTICIPANTS

General surgery residents from University of Montreal were recruited to take part in this trial. A total of 28 residents were randomized and completed the study.

RESULTS

After intervention, the SVC group (n = 14) significantly increased their Objective Structured Assessment of Technical Skills score (mean of differences 3.36, [1.09-5.63], p = 0.007) when compared to the control group (n = 14) (mean of differences 0.29, p = 0.759). All residents agreed or strongly agreed that video coaching was a time-efficient teaching method.

CONCLUSIONS

Video coaching is an effective and efficient teaching intervention to improve surgical residents' technical skills.

Interference between surgical magnetic drapes and pacemakers: an observational study comparing commercially available devices and a new magnetically isolated drape

Background

Magnetic fields may potentially interfere with the function of cardiovascular implantable electronic devices. Sterile magnetic drapes used to hold surgical instruments are often placed on the patient’s thorax, and they are likely to interfere with the function of these devices.

Methods

Thirty patients were recruited to compare a new prototype surgical magnetic drape (LT10G™ by Menodys) made with bottom-isolated ferrite magnets to the Covidien magnetic drape we used in a previous study. Twenty additional patients were recruited to compare the prototype drape with four commercially available surgical magnetic drapes.

Results

Magnetic interference was found in 33 of the 50 total patients (70 %) when the Covidien drape was placed over the pacemaker. Of the 20 additional patients, 5 patients (25 %) displayed magnetic interference with a second type of surgical magnetic drape. A third magnetic drape caused interference in one patient (5 %), whereas a larger drape of the same model did not interfere in any patient. No patients demonstrated magnetic interference with the prototype drape.

Conclusion

Bottom isolation of magnets in the prototype magnetic drape (LT10G™) used during surgery prevents magnetic interference in all patients when placed over the pacemaker. Three of the four commercially available magnetic drapes tested demonstrated magnetic interference. Flipping the prototype drape is not recommended as it may expose non-isolated magnets to the cardiovascular implantable electronic device.

Electronic supplementary material

The online version of this article (doi:10.1186/s12938-016-0205-y) contains supplementary material, which is available to authorized users.

Electrocautery effect on intestinal vascularisation in a murine model

BACKGROUND

The use of electrocautery devices is associated with complications such as perforation or fistulisation when used near intestinal structures. This is likely due to its effect on vascularisation of the bowel wall. To test this hypothesis we established a murine model to quantify the effect of electrocautery injury on the intestinal microvascularisation.

METHODS

Sprague-Dawley rats were subjected to five electrocautery injuries on the small bowel in coagulation mode (30 W intensity) and in cut mode (40 W, 80 W and 200 W intensities) for durations of 1, 2 and 5 s. 5 mg/kg of fluorescein was injected intravenously, the injured bowel segments harvested and the rat sacrificed. The segments were analysed to measure the fluorescence of injured bowel compared to adjacent unharmed tissue.

RESULTS

A significant decrease in bowel wall microvascularisation occurred with increasing intensity (coag 30 W/cut 40 W versus cut 200 W 1 s: p < 0.05) and duration of electrocautery injury (cut 40 W 1/2 s versus 5 s: p < 0.05). There was a 40% perforation rate when decreased bowel wall microvascularisation was 25% or more. Despite similar electrocautery injury, a significantly greater microvascularisation decrease was observed in jejunum compared to ileum (p < 0.05).

CONCLUSION

We successfully established a murine model to quantify the decrease of bowel wall microvascularisation associated with electrocautery use. Unsurprisingly, the decrease in microvascularisation is greater with higher intensity and duration of electrocautery and is associated with more perforations in the experimental model. The jejunum seems more vulnerable to electrocautery injury than the ileum. These observations support caution when using electrocautery devices near intestinal structures.

Impact of electrocautery and hyperthermic intraperitoneal chemotherapy on intestinal microvasculature in a murine model

BACKGROUND

Electrocautery (EC) is used during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Using a murine model, we studied the effect of HIPEC on small bowel EC lesions and surrounding normal tissues.

METHODS

Thirty-two rats were divided into five groups: a control group with EC lesions; EC plus intraperitoneal heated 5% dextrose (D5W); EC plus oxaliplatin (OXA, 460 mg/m(2)); EC plus mitomycin C 10 mg/m(2) (MMC10); EC plus MMC 35 mg/m(2) (MMC35). EC lesions and surrounding tissue microvasculature were analysed after intravenous injection of fluorescein.

RESULTS

In the ileum OXA significantly reduced EC lesions microvasculature compared with the control group; MMC10 caused greater reduction than the control, D5W and MMC35 groups. Surrounding tissue microvasculature was significantly reduced by MMC35 exposure when compared to the control, OXA or MMC10 groups. In the jejunum EC injuries exposed to OXA or MMC10 had significantly reduced microvasculature compared to the control, heated D5W and MMC35 groups. Surrounding tissue microvasculature was significantly reduced by MMC35 exposure when compared to the OXA group. There was no significant microvasculature difference between the EC lesions made before or after HIPEC.

CONCLUSION

HIPEC with OXA and MMC10 potentiates small bowel wall EC injuries. MMC35 reduces surrounding unharmed tissue microvasculature. There was no effect of hyperthermia alone on microvasculature.

Effect of chemotherapy and heat on biomechanical properties of absorbable sutures

BACKGROUND

The quality of tissue repairs depends on tissue integrity, surgical technique, and material properties of the sutures used. Currently, there is no clear consensus on which is the best suture to use during cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy. The aim of this study was to evaluate the impact of heat and chemotherapy on sutures' biomechanical properties.

METHODS

Six different 3.0 absorbable sutures (Biosyn, Dexon II, Maxon, Monocryl, PDS II, and Vicryl Plus) were tested. All suture strands were incubated for a 24-h period in saline, mitomycin-c, and oxaliplatin at 37 and 45°C. Suture loops were then loaded to failure using a servohydraulic testing machine. Data for tensile breaking force (TBF) and elongation rate were collected for all samples.

RESULTS

Under basal condition, Maxon was the strongest of all sutures with a TBF of 59.6 ± 4.3 N (P < 0.01), and no significant difference in TBF was observed between other sutures. Heat alone had no impact on sutures' biomechanical parameters. Exposition to mitomycin-c at 45°C did not significantly affect sutures' basal tensile properties, with Maxon remaining the strongest suture. When incubated in oxaliplatin at 45°C, the six suture types had a similar TBF. In all experimental conditions, multifilament sutures had a significantly lower elongation rate than monofilament sutures, and no correlations were demonstrated between elongation rate and the TBF of sutures.

CONCLUSIONS

This study showed that exposition to heated chemotherapy did not significantly affect absorbable sutures biomechanical properties.

Replacing a double-lumen tube with a single-lumen tube or a laryngeal mask airway device to reduce coughing at emergence after thoracic surgery: a randomized controlled single-blind trial

BACKGROUND

Coughing episodes occur frequently at extubation after thoracic surgery, and this may be due in part to the double-lumen tube (DLT). In this study, the DLT was replaced with either a single-lumen endotracheal tube (ETT) or a laryngeal mask airway (LMA) device or left in place, and the incidence of coughing at emergence was compared between the three groups.

METHODS

Fifty-eight adults scheduled for thoracic surgery with a DLT were included. Exclusion criteria were an anticipated difficult airway, obesity, and contraindication to the use of an LMA ProSeal™ (LMA-P). After surgery but before emergence, patients were randomized to having the DLT (1) removed and replaced by an LMA-P (LMA-P Group), (2) removed and replaced by an ETT (ETT Group), or (3) left in place (DLT Group). The primary outcome was the number of coughing episodes at extubation.

RESULTS

Among 184 patients screened, 124 did not meet inclusion criteria, and two patients, both in the ETT Group, were excluded after randomization, leaving 20, 18, and 20 patients in the LMA-P, ETT, and DLT Groups, respectively. There were fewer coughing episodes (median [quartiles]) in the LMA-P Group than in the DLT Group (0[0-1] vs 2[1-3], respectively; P = 0.01). In the DLT Group, 90% of patients coughed at least once. This incidence was not significantly different in the ETT Group (83%; P = 0.222) but was significantly reduced in the LMA-P Group (35%; P < 0.001). No patient had oxygen desaturation during airway exchange or at extubation. The incidence and severity of hoarseness and sore throat were similar in all groups.

CONCLUSION

Coughing at extubation after thoracic surgery can be reduced if the DLT is replaced by an LMA-P before emergence. The number of patients in this trial was too small to evaluate the risks associated with exchanging the airway device. This trial was registered at ClinicalTrials.gov: NCT00925613.

[Hi-Fi simulation: Teaching crisis resource management to surgery residents]

BACKGROUND

High-fidelity (HiFi) simulation has shown its effectiveness for teaching crisis resource management (CRM) principles, and our institutional experience in this area is mainly with anesthesiology residents. We recently added to our postgraduate curriculum a new CRM course designed to cater to the specific needs of surgical residents.

AIM

This short communication describes the experience of the University of Montreal Simulation Centre (Centre d'Apprentissage des Attitudes et Habiletés Cliniques CAAHC) regarding HiFi simulationbased CRM and communication skills teaching for surgical residents.

METHODS

Thirty residents agreed to participate in a simulation course with pre-established scenarios and educational CRM objectives on a voluntary basis.

RESULTS

When surveyed immediately after the activity, all residents agreed that the educational objectives were well defined (80% "strongly agree" and 20% "agree"). The survey also showed that the course was well accepted by all participants (96% "strongly agree" and 4% "agree").

CONCLUSION

Further trials with randomized groups and more reliable assessment tools are needed to validate our results. Still, integrating HiFi simulation based CRM learning in the surgical residency curriculum seems like an interesting step.

Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents

BACKGROUND

Focused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents' proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone.

METHODS

Junior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions.

RESULTS

After the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher's exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher's exact test p = 0.0055).

CONCLUSIONS

Our study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Hyperthermic intraperitoneal chemotherapy with oxaliplatin as treatment for peritoneal carcinomatosis arising from the appendix and pseudomyxoma peritonei: a survival analysis

Background

Appendiceal peritoneal carcinomatosis (PC) is rare and its long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive treatment approach used in our institution for the last eight years.

Methods

Data from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted of complete surgical cytoreduction (CRS), followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460 mg/m²) at 43°C over 30 minutes. Ronnett’s histologic classification was used for tumor grading.

Results

Between February 2003 and April 2011, 78 patients underwent laparotomy with curative intent. The mean follow-up period was 33.7 months. A total of 58 patients received HIPEC, but 11 patients could not have CRS and received no HIPEC. Nine patients with a negative second-look surgery also received no HIPEC. The five-year overall survival for the entire cohort was 66.2%; 100% for the negative second-look patients, 77% for the HIPEC patients and 9% for the unresectable patients (P <0.0001). A total of 15 patients (25.9%) had isolated peritoneal recurrence, no patient had visceral recurrence only, and five patients (8.6%) had both. In regards to the five-year disease-free survival for the HIPEC patients, histologic grade (disseminated peritoneal adenomucinosis 100%, peritoneal mucinous carcinomatosis with intermediate features 40%, peritoneal mucinous carcinomatosis 20%; p =0.0016) and completeness of cytoreduction (CCR-0 56%, CCR-1 24%; P =0.0172) were prognostic factors. There was one postoperative mortality. The major complication rate for patients treated with HIPEC was 40%, including intra-abdominal abcess (17%), hemorrhage (12%) and anastomotic leak (10%). One patient in the HIPEC group experienced temporary grade II neuropathy and grade III thrombocytopenia.

Conclusions

This therapeutic approach seems both feasible and safe in selected patients. Recurrence is, however, frequent and represents a challenge.

The difficult airway with recommendations for management--part 2--the anticipated difficult airway

BACKGROUND

Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.

METHODS

To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.

PRINCIPAL FINDINGS

Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy.

CONCLUSIONS

With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy with oxaliplatin for peritoneal carcinomatosis arising from colorectal cancer

BACKGROUND

Peritoneal carcinomatosis (PC) from colorectal cancer is associated with a poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) have improved survival compared to systemic chemotherapy. We evaluate the results of this treatment in our institution.

METHODS

Treatment consisted of complete CRS followed by HIPEC with oxaliplatin (460 mg/m(2) ) in 2 L/m(2) of D5W at 42°C during 30 min.

RESULTS

From 2004 to 2011, 40 patients with PC from colorectal cancer were included and 25 CRS + HIPEC were performed. Six patients had a negative second-look surgery and nine had unresectable disease. Median follow-up was 22.8 months. Overall 3- and 5-year survival rates for the cohort were 56% and 33%. The 3- and 5-year overall survival rates were 61% and 36% for HIPEC group, 82% and 67% for patients with negative second-look, and 22% and 0% for the unresectable group (P = 0.0087). 3-year disease-free survival for HIPEC group was 22%. Major complication and mortality rate for HIPEC group were 20% and 4%. Peritoneal carcinomatosis index (P = 0.0374) and lymph node status (P = 0.027) were prognostic indicators.

CONCLUSIONS

CRS + HIPEC with oxaliplatin for PC from colorectal cancer is an effective treatment with encouraging survival results.

Periarticular injection in knee arthroplasty improves quadriceps function

BACKGROUND

The postoperative analgesic potential of periarticular anesthetic infiltration (PAI) after TKA is unclear as are the complications of continuous femoral nerve block on quadriceps function.

QUESTIONS/PURPOSES

We asked (1) whether PAI provides equal or improved postoperative pain control in comparison to a femoral nerve block in patients who have undergone TKA; and (2) if so, whether PAI improves early postoperative quadriceps control and facilitates rehabilitation.

METHODS

We randomized 60 patients to receive either PAI or femoral nerve block. During the first 5 days after TKA, we compared narcotic consumption, pain control, quadriceps function, walking distance, knee ROM, capacity to perform a straight leg raise, and active knee extension. Medication-related side effects, complications, operating room time, and hospitalization duration were compared.

RESULTS

Opioid consumption was lower in the PAI group during the first 8 postoperative hours (12.5 mg versus 18.7 mg morphine), as was reported pain at rest (1.7 versus 3.5 on a 10-point VAS). Thereafter, narcotic consumption and reported pain were similar up to 120 hours. More subjects in the femoral nerve block group experienced quadriceps motor block (37% versus 0% in the PAI group). On Days 1 to 3, subjects in the PAI group experienced better capacity to perform the straight leg raise, active knee extension, and had longer walking distances.

CONCLUSIONS

PAI provided pain control equivalent to that of a femoral nerve block while avoiding a motor block and its negative functional impacts. The data suggest it should be considered an alternative to a femoral nerve block.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Simultaneous percutaneous implantation of a microdialysis probe for monitoring perineural concentrations of local anaesthetics during peripheral nerve block in rabbits

OBJECTIVE

To develop a technique that allows simultaneous percutaneous implantation of both a microdialysis probe and injection catheter in order to monitor the perineural pharmacokinetics of local anaesthetics (LA) after a femoral block.

STUDY DESIGN

Prospective experimental study.

ANIMALS

Five anaesthetized male New Zealand rabbits with a mean ± SD weight of 3.2 ± 0.2 kg.

METHODS

After femoral nerve localization by electrostimulation, an injection catheter and a microdialysis probe were slowly and simultaneously inserted into a cannula left into place in the perineural region. Both were then secured into place, after removal of the cannula. At the end of the experiment, methylene blue was injected to confirm the distance from the femoral nerve during subsequent postmortem anatomical dissection of the injection site.

RESULTS

Staining was adequate and the catheter found to be located within 4 mm of the femoral nerve in three out of five rabbits.

CONCLUSIONS AND CLINICAL RELEVANCE

This procedure allows direct implantation of a microdialysis probe near the injection site of LA during a femoral nerve block without loosing nerve localization accuracy. This procedure has been used successfully to monitor the regional pharmacokinetics of LA after a peripheral nerve block.

Pharmacokinetics of intraperitoneal irinotecan in a pig model

Complete surgical cytoreduction of peritoneal implants and immediate intraperitoneal (lP) chemotherapy offers the greatest survival in selected patients with peritoneal carcinomatosis. This study was undertaken to describe the metabolism and pharmacokinetics of normothermic intraperitoneal CPT-11, free and glucuronized SN-38, in a pig model. Thirteen pigs were used for experimentation. Animals were grouped for IV and IP CPT-1 1 administration. Eleven pigs underwent laparotomy through a midline incision and instillation of 100, 200, and 400mg IP CPT-11. Systemic venous blood, portal blood and peritoneal fluid samples were taken at 5, 10, 20, 30, and 45 min, then every hour up to 8 hr for the 100 mg. For the three groups, peritoneal CPT-11 exposition was on average 4.9 times greater in the peritoneum than in the systemic venous or portal circulations and the systemic CPT-11 fraction absorbed from the peritoneum linearly increased with time. Free SN-38 was measurable in the earliest peritoneal samples taken. The initial instillation dose of CPT-11 did not impact on the SN-38 converted fraction, which remained stable at approximately 0.04% during the first 4 hour. Mean peritoneal SN-38: CPT-11 AUC ratio was 0.043. OPT-11 peritoneal conversion into SN-38 appeared slightly Inferior to the systemic conversion ratio. This norrnothermic IP OPT-11 pharmacokinetic study performed in a pig model confirms the possibility to achieve at least a 30 times higher peritoneal than systemic exposure. Peritoneal exposure to active SN-38 begins at the moment of CPT-11 peritoneal instillation. A fixed and small traction of less than 0.1% of CPT-11 is converted into SN-38, underlying the importance of a sufficient initial IP dose of CPT-11.

[Inspiratory support versus spontaneous breathing during preoxygenation in healthy subjects. A randomized, double blind, cross-over trial]

OBJECTIVE

Applying an inspiratory support (AI) and a positive end expiratory pressure (PEP) could increase the effectiveness of the preoxygenation.

STUDY DESIGN

This randomized double blinded controlled study compares the impact on the expiratory oxygen fraction (FEO(2)) of two levels of AI with PEP to a traditional preoxygenation.

PATIENTS AND METHODS

Twenty healthy volunteers were studied. The criteria of exclusion were a body mass index >30, the presence of beard or moustache and the claustrophobia. Each subject went through three modes of preoxygenation during 3 minutes each in a random order: 1-spontaneous ventilation (VS), 2-preoxygenation with AI with 4 cmH(2)O/PEP 4 cmH(2)O (AI-4/PEP-4), 3-preoxygenation with AI with 6 cmH(2)O/PEP 4 cmH(2)O (AI-6/PEP-4). Subject's tolerance and leaks were also noted.

RESULTS

The FEO(2) at the end of the 3 minutes of preoxygenation was higher (p<0,001) with AI-4/PEP-4 (94+/-3%) and AI-6/PEP-4 (94+/-4%) than with technique VS (89+/-6%). One hundred percent and 90% of the participants reached one FEO(2)=90% with AI-4/PEP-4 and AI-6/PEP-4 respectively vs 65% with VS (p=0.0013). The participants tolerated better the VS and the AI-4/PEP-4 than the AI-6/PEP-4. More leaks were noted with the AI-6/PEP-4 than with the VS and the AI-4/PEP-4.

CONCLUSION

This study shows applying AI plus PEP during preoxygenation improves its effectiveness in the healthy subjects. It also suggests that, in a population of healthy volunteers, combination AI-4/PEP-4 is preferable to AI-6/PEP-4 because so effective, but better tolerated.

Low-dose fentanyl-midazolam combination improves sevoflurane induction in adults

PURPOSE

We investigated the effects of a combination of low-dose fentanyl-midazolam premedication on the speed of inhaled induction with sevoflurane and ProSeal laryngeal mask airway (PLMA) insertion conditions.

METHODS

Eighty adult patients undergoing elective surgery were randomized in a double-blind fashion to receive either a normal saline placebo (Group PLAC) or a fentanyl 0.6 microg x kg(-1) and midazolam 9 microg x kg(-1) premedication (Group FM) 5 min before tidal volume sevoflurane 8%/O(2) induction. Anxiety levels, times to loss of eyelash reflex (LER) and PLMA insertion, and cardiorespiratory data were recorded.

RESULTS

Times to LER (Group PLAC: 66 +/- 34 sec vs Group FM: 47 +/- 18 sec, P = 0.0027, difference = 19 sec: 95% confidence interval [CI] 7-31 sec) and to PLMA insertion (Group PLAC: 186 +/- 80 sec vs Group FM: 119 +/- 44 sec, P < 0.0001, difference = 68 sec: 95% CI 39-97 sec) were shorter following FM. After PLMA insertion, end-tidal sevoflurane concentration (EtSevo) was lower and end-tidal CO(2) (EtCO(2)) was higher following FM. Respiratory rate (RR) was lower with FM, but there was no difference regarding tidal volume. Adverse events, such as movements and apnea, occurred more often in Group PLAC. Systolic blood pressure (SBP) and heart rate (HR) during induction were both lower with FM. Anxiety level after premedication was lower following FM administration. All participants remembered the face mask being applied in Group PLAC vs 69% in Group FM, P < 0.0001.

CONCLUSION

Administration of a low-dose fentanyl-midazolam combination prior to sevoflurane induction decreases time to LER and allows for more rapid and less eventful PLMA insertion. Both SBP and HR were lower when premedication was administered. Patients receiving premedication were less anxious and less likely to remember the face mask. However, premedication was associated with a lower RR and increased EtCO(2) values following PLMA insertion, in spite of lower EtSevo concentrations. (ClinicalTrials.gov ID NCT00723164).

Optimizing preoxygenation in adults

PURPOSE

Preoxygenation increases oxygen reserves and duration of apnea without desaturation (DAWD), thus it provides valuable additional time to secure the airway. The purpose of this Continuing Professional Development (CPD) module is to examine the various preoxygenation techniques that have been proposed and to assess their effectiveness in healthy adults and in obese, pregnant, and elderly patients.

PRINCIPAL FINDINGS

The effectiveness of preoxygenation techniques can be evaluated by measuring DAWD, i.e., the time for oxygen saturation to decrease to <90%. Clinically, preoxygenation is considered adequate when end-tidal oxygen fraction is >90%. This is usually achieved with a 3-min tidal volume breathing (TVB) technique. As a rule, asking the patient to take four deep breaths in 30 sec (4 DB 30 sec) yields poorer results. Eight deep breaths in 60 sec (8 DB 60 sec) is equivalent to TVB 3 min. The DAWD is decreased in obese patients, pregnant women, and patients with increased metabolism. Obese patients may benefit from the head-up position and positive pressure breathing. A TVB technique is preferable in the elderly. Failure to preoxygenate is often due to leaks, which commonly occur in edentulous or bearded patients. In cases of difficult preoxygenation, directly applying the circuit to the mouth might be a useful alternative. Supplying extra oxygen in the nasopharynx during apnea might increase DAWD.

CONCLUSION

Since ventilation and tracheal intubation difficulties are unpredictable, this CPD module recommends that all patients be preoxygenated. The TVB 3 min and the 8 DB 60 sec techniques are suitable for most patients; however, the 4 DB 30 sec is inadequate.

Surgical cytoreduction and intraperitoneal chemotherapy for peritoneal carcinomatosis arising from the appendix

BACKGROUND

Peritoneal carcinomatosis (PC) originating in the appendix is a rare disease for which the long-term prognosis is poor. The aim of our study was to evaluate the results of an aggressive treatment approach used in our institution in the last decade.

METHODS

We prospectively collected and analyzed data from all patients with PC. Treatment consisted of complete surgical cytoreduction of the tumour followed by intraperitoneal chemotherapy. Chemotherapy was either early postoperative intraperitoneal chemotherapy (EPIC) or hyperthermic intraperitoneal chemotherapy (HIPEC). We used Ronnett's classification for tumour grading (disseminated peritoneal adenomucinosis = grade 0, peritoneal mucinous carcinomatosis with intermediate features = grade 1 and peritoneal mucinous carcinomatosis = grade 2).

RESULTS

From September 1997 to June 2005, 37 patients underwent laparotomy with curative intent; 13 received EPIC and 11 HIPEC. Thirteen patients could not have complete cytoreductive surgery and received no intraperitoneal chemotherapy. The estimated 5-year overall survival was 56% (95% confidence interval [CI] 34%-77%) for all patients, 58% (95% CI 30%-86%) for patients who underwent EPIC and 60% (95% CI 10%-100%) for patients who underwent HIPEC (p = 0.97). Histologic grade was an important prognostic indicator as all patients with grade 0 tumours survived whereas no patients with grade 2 tumours survived (p < 0.001). Patients with grade 1 tumours had an estimated 87% (95% CI 64%-100%) 5-year overall survival. There was no mortality attributed to surgery. The overall complication rate was 36%, including fistulas (16%), intra-abdominal abscesses (12%) and hemorrhage (9%).

CONCLUSION

This therapeutic approach seems both feasible and safe in select patients. Patients with high-grade tumours are poor candidates for this treatment.