Anesthesiology national CME program and ASA activities in simulation

This article traces the history of anesthesiology's role in simulation from Resusci Anne and Sim One to the use of simulation today for introducing new products and techniques to otherwise fully trained, practicing physicians. The article also describes the latest efforts of the American Society of Anesthesiologists (ASA) to promote simulation-based instruction. The article focuses in particular on the activities of the ASA Committee on Simulation Education. Many predict that simulation-based teaching will generate the next revolution in health care education. The ASA is hoping to capitalize on anesthesiology's long involvement and leadership in simulation-based health care education to help bring about this revolution.     

Harmonization of vascular surgical training in Europe. A task for the European Board of Vascular Surgery (EBVS)

The competence of vascular surgeons defined as the level of skill, knowledge and experience necessary to safely perform vascular surgical procedures is determined to a high degree by the quality of the preceding training. In Europe, quality assurance of vascular surgical training, unlike in the USA, is not uniform and is not the responsibility of a centralized European authority, but is a matter in which the different countries have autonomous regulations. Consequently, different targets for duration, contents and general principles for training in vascular surgery have been set. Although in the past this may not have been a problem, the unification of countries in the European Community (EC), at present known as the European Union (EU), has changed this perspective because there is increasing impetus towards a mutual recognition of trade and education between member states. In 1975, EC directive 75/362 was adopted, which insured 'freedom of migration' for medical doctors along with many other professional trades (Publications of the European Communities no. L167, 30-6-1975, p. 1). This directive implicated that certificates, diplomas and other documents issued by the national competent authorities proving medical qualification allowed physicians to practice in any EU country. In order to make this law practical it seems essential that specialist training programmes throughout the EU should conform to certain agreed basic standards. The objective of this article is to present an overview on the current pattern of vascular surgical training in Europe. In addition, the structures that were established during the recent years to promote uniformly high standards of training in vascular surgery throughout the EU will be discussed.     

Current status of the treatment strategy for life-threatening hemorrhage in hospitals accredited by the Japanese Society of Anesthesiologists (JSA), and practical use of "Guidelines for Action Against Intraoperative Critical Hemorrhage"

The JSA and the Japanese Society of Blood Transfusion and Cell Therapy established "Guidelines for Action Against Intraoperative Critical Hemorrhage" in 2007. This guideline shows practical strategies for managing life-threatening hemorrhage. From 2007 to 2009, we conducted the annual survey with transfusion services of 384 hospitals accredited by the JSA. From the results of these surveys, we proposed some new strategies for managing life-threatening hemorrhage as follows: 1) It is necessary to establish a documentation of institutional procedures for urgent transfusion practices including an emergency code for blood requirement, according to "Guidelines for Action Against Intraoperative Critical Hemorrhage". 2) The simulation exercise according to the documentation of institutional emergency transfusion procedures should be held. 3) On the occurrence of a life-threatening hemorrhage, we should make an appropriate decision to use uncrossmatched ABO-matched blood components and/or ABO-mismatched compatible blood components, to save the patient's life. 4) Though it is well known that the post-transfusion graft versus host disease (PT-GVHD) has poor prognosis and irradiation of blood products is essential for avoiding the PT-GVHD, in some hospitals, non-irradiated blood components were used in situation of critical hemorrhage. We recommend that irradiated blood components should be used if possible in resuscitating a patient with critical hemorrhage.     

Guidelines for planning clinical trials.

This paper outlines the necessary steps involved in setting up and administering a clinical trial. The importance of adequate preparation, with careful definition of priorities and objectives, is emphasized. Guidelines for writing a clinical protocol are discussed in detail, as well as aids to deal with the running of the study, statistical planning, and presentation of results. The principle of different types of study, methods of patient assessment, and an overall plan of study, have already been introduced in the preceding paper.     

Hepatic resections by means of electrothermal bipolar vessel device (EBVS) LigaSure V: early experience

Background Many techniques and devices are available for performing liver resection, such as clamp crushing, Cavitron Ultrasonic Surgical Aspirator (CUSA), Hydrojet and dissecting sealer, ultrasonic shears, and, more recently, electrothermal bipolar vessel sealing system (EBVS). In this prospective trial we sought to evaluate the impact of EBVS on hepatic resections. Methods From March 2004 to December 2005, 24 patients from our consecutive liver resection series were enrolled in the present study. There were 17 males and 7 females with a mean age of 59.6 years (range = 41–80) who had colonic cancer metastases (18), hepatocarcinoma (3), angioma (2), and intrahepatic lithisasis (1). Patients were prospectively randomized to undergo liver resection via EBVS LigaSure V (12 patients, group A) or ultrasonic shears harmonic scalpel (HS) (12 patients, group B). Hepatic procedures did not differ significantly between the two groups and were as follows: right hepatectomy (2), left hepatectomy (1), bisegmentectomy (14), and segmentectomy (7). Results There was no mortality in either group. The mean operative time was 136.7 min (range = 90–210) in group A and 187.9 min (range = 130–360) in group B. The Pringle maneuver was done in five patients in group A [mean time = 11.4 min (range = 6–12)] and in four patients in group B [mean time = 16 min (range = 9–26)]. The mean blood loss, total bile salts, and hemoglobin concentration from drained fluid on the second postoperative day were 205.8 vs. 506.7 ml, 0.6 vs. 1.1 mmol/L, and 1.0 vs. 2.1 g/L (p < 0.05) for groups A and B, respectively. Mean postoperative hospital stay was 6.1 vs. 7.8 days. In group B a patient who underwent right hepatectomy for colon cancer metastases had transient hepatic failure. No patients received blood transfusions in group A, while two or more blood units were administered in two cases in group B. Conclusions In the present study EBVS proved to be safe and effective for liver resection. By means of this device, statistically significant benefits concerning blood loss, total bile salts, and hemoglobin postoperative leakage were found.     

Guidelines for designing resident rating forms.

A well-designed rating form provides one means to evaluate a resident's clinical performance. A clear perception of the program's goals is the foundation on which an original--or revised--design should rest. Suggestions for three different types of rating forms are presented here.     

Guidelines for surgical procedures after liver transplantation.

OBJECTIVE: The first purpose of this study is to identify the types and incidences of surgical procedures in patients who have previously undergone liver transplantation, with particular focus on the complication rates and the lengths of hospital stay. The second purpose is to present the management guidelines for patients with liver transplants at the preoperative, intraoperative, and postoperative stages of surgical procedure. SUMMARY BACKGROUND DATA: The surgical literature on this issue is scant, and with the growing liver transplant patient population it is not unlikey for any surgery specialist to have to operate on a patient who has undergone liver transplantation. METHODS: A sample of 409 patients with available hospital records, with a minimum of a 2-year follow-up, and with telephone access for interviews was chosen. Type of surgery, time from the liver transplant, hospital stay, immunosuppressive regimen, and complications were recorded. RESULTS: A large proportion of patients (24.2%) underwent some type of surgical procedure 2 to 10 years after liver transplantation. The authors demonstrate that most of the elective procedures can be safely carried out without an increased incidence of complication and without longer hospital stay than the general population. Conversely, emergent procedures are plagued by a greater incidence of complications that not only affect the function of the liver graft but may risk the life of the patient.     

Use of the electrothermal bipolar vessel system (EBVS) in laparoscopic adrenalectomy: a prospective study

Background Since laparoscopic adrenalectomy (LA) has been adopted as the gold standard for the treatment of adrenal diseases, the development of technology for vascular control and dissection manoeuvres, amongst other things, may play a pivotal role in its further improvement. We report our experience with the electrothermal bipolar vessel sealing (EBVS) device for LA. Methods From January 2004 to January 2006, 50 patients (pts) undergoing LA were selected and randomized for use of the EBVS (25 pts, group A) versus the UltraSonic Shears (USS) device (25 pts, group B). Age, sex, body mass index (BMI), previous surgery and associated diseases were similar between the two groups. The main surgical parameters collected for each patient (pt) concerned operative time, major and minor complications, conversion rate, blood loss, hospital stay and histology. Results There was no mortality in either group. The right adrenalectomy mean operative time (OpT) was 51.8 mins (range 40–90 mins) and 68.6 mins (range 50–130 mins) in group A and B, respectively (P not significant). The left adrenalectomy mean OpT was 72.2 mins (range 55–100 mins) and 94 mins (range 65–140 mins) for group A and B, respectively (P < 0.05). The mean blood loss was 83 ml (group A) and 210 ml (group B) (p < 0.05). Complications were not different for the two groups. The mean hospital stay was 2.9 and 3.1 days in group A and B, respectively (P not significant). Conclusions EBVS in LA may provide a significantly short operating time and blood loss.     

CME program. Tracheotomy and inhalation injury

Indications for tracheotomy in patients with respiratory burns have been unclear. Much of the literature is inconclusive or misleading. A thorough understanding of the pathogenesis, diagnosis, and therapy of inhalation injury is necessary to understand the role of tracheotomy. A critical review reveals relatively clearcut indications for the use of tracheotomy in inhalation injury, but many unanswered questions. Increased participation by otolaryngologists in burn management is recommended.