Ten years of simulation‐based training in pediatric anesthesia: The inception,evolution, and dissemination of the Managing Emergencies in Pediatric Anesthesia (MEPA) course

2016 marked the 10‐year anniversary of the inception of the Managing Emergencies in Paediatric Anaesthesia (MEPA) course. This simulation‐based program was originally created to allow trainees in pediatric anesthesia to experience operating room emergencies which although infrequent, would be considered key competencies for any practicing anesthetist with responsibility for providing care to children. Since its original manifestation, the course has evolved in content, scope, and worldwide availability, such that it is now available at over 60 locations on five continents. The content has been modified for different learner groups and translated into several languages. This article describes the history, evolution, and dissemination of the MEPA course to share lessons learnt with educators considering the launch of similar initiatives in their field.     

Review article: Simulation in anesthesia: state of the science and looking forward

Purpose

Within the field of anesthesia, simulation has been used as a tool for training and assessment for over 30?years. The purpose of this review is to evaluate the state of the science in terms of its effectiveness as an approach to both training and assessment in anesthesia. Articles in the area of simulation and anesthesia published up to and including 2011 were reviewed for inclusion in this narrative review.

Principal findings

Simulation-based training is generally well received by participants, it can lead to improved performance in subsequent simulation events, and some transfer of learning to the clinical setting is evident. There is also some early evidence that well-designed performance assessments could have the required reliability and validity to support high-stakes examinations. However, further work is needed in order to set standards and establish the predictive validity to support such assessments.

Conclusion

For simulation to realize its potential impact, further research is needed to understand how to optimize this modality of learning more effectively, how to transfer knowledge of research findings to practice, and also how to broaden the simulation modalities used in anesthesia. In future, the optimal use of simulation will depend on a clear understanding of what can and cannot be accomplished with simulation and its various modalities.     

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and biliary drainage

Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, and endoscopic biliary drainage have dramatically changed the diagnosis and management of disorders of the pancreas and hepatobiliary tract. Endoscopic retrograde cholangiopancreatography will provide a high-resolution study that will define accurately the nature and location of the disease process involving the pancreas or bile ducts. Although sonography, CT, and, recently, MRI may provide clues to the diagnosis, it often remains for endoscopic retrograde cholangiopancreatography to establish the diagnosis with certainty. Endoscopic sphincterotomy has been invaluable in the management of common bile-duct stones. In patients who have had their gallbladders removed, sphincterotomy has avoided reoperation in the same field and the risk of general anesthesia. Sphincterotomy also is assuming an increasingly important role in the management of common-duct stones in patients with their gallbladders in situ who are poor operative candidates. In these patients, sphincterotomy likewise avoids the risk of general anesthesia and the surgical stress of opening a major body cavity. The technique has also proved to be helpful in the palliative treatment of ampullary and distal common bile-duct carcinomas in those patients who are poor operative candidates. Finally, sphincterotomy has found a role in the treatment of choledochal cysts and may provide relief of pain in those patients with the elusive diagnoses of postcholecystectomy syndromes, biliary dyskinesias, and sphincter of Oddi dysfunction. Endoscopic biliary drainage is becoming an increasingly popular option for the palliation of malignant biliary obstruction. In those patients who are poor operative candidates, the risk of general anesthesia and major surgery is avoided. In those patients with obviously incurable tumors, endoscopic drainage allows for a brief hospitalization without surgery in the face of a short life expectancy.     

Simulation in cardiothoracic and vascular anesthesia education: tool or toy?

The use of simulators in cardiothoracic and vascular anesthesia runs the gamut from standardized patients and part-task trainers to full-scale high-fidelity human patient simulators. The use of simulation to teach medical students, anesthesiology residents, board-certified anesthesiologists with subspecialty interests, hospital administrators, attorneys, and the lay public is still evolving as educational research evaluates the use of simulation and health professional educators struggle to define its role and value. This article provides a general overview of the field and attempts to critically evaluate what is and what is not scientifically determined about simulation and simulators.     

Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study

BACKGROUND: Anesthesia simulators can generate reproducible, standardized clinical scenarios for instruction and evaluation purposes. Valid and reliable simulated scenarios and grading systems must be developed to use simulation for evaluation of anesthesia residents. METHODS: After obtaining Human Subjects approval at each of the 10 participating institutions, 99 anesthesia residents consented to be videotaped during their management of four simulated scenarios on MedSim or METI mannequin-based anesthesia simulators. Using two different grading forms, two evaluators at each department independently reviewed the videotapes of the subjects from their institution to score the residents' performance. A third evaluator, at an outside institution, reviewed the videotape again. Statistical analysis was performed for construct- and criterion-related validity, internal consistency, interrater reliability, and intersimulator reliability. A single evaluator reviewed all videotapes a fourth time to determine the frequency of certain management errors. RESULTS: Even advanced anesthesia residents nearing completion of their training made numerous management errors; however, construct-related validity of mannequin-based simulator assessment was supported by an overall improvement in simulator scores from CB and CA-1 to CA-2 and CA-3 levels of training. Subjects rated the simulator scenarios as realistic (3.47 out of possible 4), further supporting construct-related validity. Criterion-related validity was supported by moderate correlation of simulator scores with departmental faculty evaluations (0.37-0.41, P < 0.01), ABA written in-training scores (0.44-0.49, < 0.01), and departmental mock oral board scores (0.44-0.47, P < 0.01). Reliability of the simulator assessment was demonstrated by very good internal consistency (alpha = 0.71-0.76) and excellent interrater reliability (correlation = 0.94-0.96; P < 0.01; kappa = 0.81-0.90). There was no significant difference in METI versus MedSim scores for residents in the same year of training. CONCLUSIONS: Numerous management errors were identified in this study of anesthesia residents from 10 institutions. Further attention to these problems may benefit residency training since advanced residents continued to make these errors. Evaluation of anesthesia residents using mannequin-based simulators shows promise, adding a new dimension to current assessment methods. Further improvements are necessary in the simulation scenarios and grading criteria before mannequin-based simulation is used for accreditation purposes.     

Other techniques for obstetric pain management: Caudal, paracervical, and pudendal blocks

The use of paracervical, pudendal, and caudal anesthesia in the obstetric population has declined over the past 30 years. However, each technique offers the unique advantage for regional anesthesia when central axial blockade is not possible or when obstetric anesthesia services are not available. Paracervical blockade inhibits pain arising from cervical dilation and uterine contractions; therefore, it is useful to relieve the pain of the first stage of labor or to provide anesthesia for postpartum dilation and curettage. The major limitation of this technique is the potential for fetal bradycardias after local anesthesia injection; therefore, it may be most useful when the fetus is not a consideration (eg, stillbirth in pregnancy). Pudendal nerve blockade provides anesthesia for the lower vagina and perineum, which is most commonly used during the second stage of labor. This block is useful for low-outlet, operative vaginal deliveries or for postpartum perineal trauma repairs. The caudal block provides epidural anesthesia of the sacral roots, although large local-anesthetic volumes anesthetize the thoracic and lumbar levels. Currently, the most favored technique of caudal anesthesia is a single-shot bolus of local anesthesia because it provides profound and expedient saddle block anesthesia/analgesia. Both anesthesiologists and delivering health care providers should be aware of these alternatives for their obstetric patients. Copyright © 2001 by W.B. Saunders Company     

The lower limits of flammability of halothane, enflurane, and isoflurane.

Halothane, enflurane, and isoflurane, generally regarded as nonflammable, can be ignited under laboratory conditions. Attainment of similar conditions during clinical anesthesia is most unlikely. Nevertheless, early in the course of anesthesia while the concentration of the agent is still high, electrosurgery is best avoided if nitrous oxide is part of the anesthetic mixture and the operative field is exposed directly to the inflowing gases (as during certain laryngeal procedures).     

Interaction between anesthesia,gender, and functional outcome task following diffuse traumatic brain injury in rats

A number of experimental and clinical studies have demonstrated that functional outcome following traumatic brain injury differs between males and females. Some studies report that females have a better outcome than males following trauma while others report the opposite. In experimental studies, some of the contradictory results may be due to the different experimental conditions, including type of anesthesia and the outcome measures employed. In the present study we have used three different anesthetic protocols and four different outcome measures to determine how these parameters interact and affect functional outcome following traumatic brain injury in male and female rats. Diffuse traumatic brain injury was induced in adult male and female animals using the impact-acceleration brain injury model. Mortality in female animals was no different than males when using halothane anesthesia, slightly better than males when using isoflurane anesthesia, but significantly worse than males under pentobarbital anesthesia. Female animals always performed better than males on rotarod tests of motor outcome, with this effect being unrelated to anesthetic effects. Conversely, in cognitive tests using the Barnes Maze, only isoflurane-anesthetized females performed better than their male counterparts. Similarly, in an open field activity task, females always performed better than males after trauma, with isoflurane-anesthetized females also performing significantly better than the halothane-anesthetized female group after injury. Our results suggest that female animals do better than males after diffuse traumatic brain injury, although this observation is dependent upon the type of anesthesia and the functional task employed. Isoflurane is particularly protective in females, pentobarbital is deleterious to female outcome, while halothane anesthesia has the least influence on gender-related outcome.     

Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education

BACKGROUND: Critical incident reporting and observational studies have identified nontechnical skills that are vital to successful anesthesia crisis management. Examples of such skills include task management, team working, situation awareness, and decision making. These skills are not necessarily acquired through clinical experience and may need to be specifically taught. This study uses a high-fidelity patient simulator to assess the effect of repeated exposure to simulated anesthesia crises on the nontechnical skills of anesthesia residents. METHODS: After institutional research board approval and informed consent, 20 anesthesia residents were recruited. Each resident was randomized to participate as the primary anesthesiologist in the management of three different simulated anesthesia crises using a high-fidelity patient simulator. After each session, videotaped footage was used to facilitate debriefing of their nontechnical skills. The videotapes were later reviewed by two expert blinded independent assessors who rated each resident's nontechnical skills by using a previously validated and reliable marking system. RESULTS:: A significant improvement in the nontechnical skills of residents was demonstrated from their first to second session and from their first to third session (both P < 0.005). However from their second to third session, no significant improvement was observed. Interrater reliability between assessors was modest (single rater intraclass correlation = 0.53). CONCLUSION: A single exposure to anesthesia crises using a high-fidelity patient simulator can improve the nontechnical skills of anesthesia residents. However, an additional simulation session may confer little or no additional benefit.     

Review article: Teaching, learning, and the pursuit of excellence in anesthesia education

Purpose

Excellence in anesthesia education has been advocated to meet the future needs and direction of the specialty. The purpose of this article is twofold: first, to review the current medical education literature and theory in order to inform teaching and learning in anesthesia; and second, to advocate for excellence in anesthesia education.

Source

This review considers the general education, educational psychology, and medical education literature based on a search of the MEDLINE and ERIC databases, educational Web sites, and library catalogues.

Principal findings

Excellent teaching is considered that which facilitates and maximizes learning. A conceptual framework of learning as a convergence of teacher, learner, assessment, and context is proposed. The contribution of each component to learning is examined in order to enable anesthesia teachers to choose and adapt the most appropriate educational approaches for their particular contexts. The relationship of excellent teaching, scholarly teaching, and the scholarship of teaching is explored. Strategies for promoting excellence in anesthesia education are suggested.

Conclusions

The call for excellence in anesthesia has become an important theme, particularly with respect to education. While excellent teaching is a goal to which all anesthesia faculty should aspire, scholarly teaching and scholarship in teaching should also be promoted in order to advance anesthesia education for the benefit of the profession and ultimately for patient care.     

Simulation: a teaching tool for liver transplantation anesthesiology

Anesthesia for liver transplantation (ALT) requires extensive preparation and rapid recognition of changing clinical conditions. Owing to the proliferation of transplant centers, greater number of anesthesia providers need training in specific skills required to treat these patients. These cases are no longer limited to few transplant centers; therefore, reduction of cases in individual centers has created a need for simulation training to prepare and supplement clinical experience. We have developed an ALT simulation course for senior anesthesia residents which combines didactic sessions with live-patient-based and mannequin-based simulation. Outcomes have been measured using pre- and post-simulation course quizzes as well as a survey given at the end of the month-long ALT rotation. Twenty-four senior anesthesiology residents (n = 24) have completed the ALT simulation course. Residents had an average score of 75% ± 10% on the pre-simulation quiz, which increased to 92% ± 6.5% on the post-simulation quiz (p < 0.001). Furthermore, survey scores indicated that residents noted that the course provided an improvement in their preparedness, confidence, anticipation, and understanding of the importance of communication skills in the care of this patient population. The ALT simulation course provided a standardized in-depth exposure to clinical issues involved in the perioperative care of liver transplant patients.     

Improved long-lasting postoperative analgesia,recovery function and patient satisfaction after inguinal hernia repair with inguinal field block compared with general anesthesia

BACKGROUND: Inguinal hernia repair is a common surgical procedure, and different types of anesthetic techniques are in use. We wanted to test if preoperative inguinal field block (IFB) with ropivacaine would provide benefits in the postoperative period compared with general anesthesia and wound infiltration. METHODS: Sixty patients scheduled for inguinal hernia repair were randomized to receive general anesthesia with wound infiltration postoperatively, or inguinal field block (IFB) before surgery, with no or only light sedation intraoperatively. General anesthesia was induced with midazolam, fentanyl and propofol, maintained with propofol and alfentanil, and supplemented with nitrous oxide in oxygen through a laryngeal mask. The IFB was performed by an anesthesiologist, with 50-60 ml ropivacaine and 5 mg/ml with a dedicated technique. RESULTS: All significant differences were in favor of the IFB group: less pain (visual analog scale, verbal pain score) postoperatively and until day 7, faster mobilization with less pain, lower analgesic consumption, and higher patient satisfaction. CONCLUSION: Preoperative inguinal field block for hernia repair provides benefits for patients in terms of faster recovery, less pain, better mobilization and higher satisfaction throughout the whole first postoperative week.     

Insertion of vagal nerve stimulator using local and regional anesthesia

BACKGROUND: Vagal nerve stimulation (VNS) is a valuable therapy for patients with intractable epilepsy. Placement of a vagal nerve stimulator typically requires general anesthesia, which frequently interrupts anticonvulsant therapy. Insertion of the stimulator using regional/local anesthesia may offer the advantages of continuity of anticonvulsant therapy and implantation in the outpatient setting. METHODS: We retrospectively compared the first 10 consecutive patients undergoing VNS implantation under general anesthesia with the first 12 consecutive patients undergoing VNS implantation under regional/local anesthesia. Patients for the regional/local anesthesia were selected on the basis of their ability to cooperate and follow commands. Regional anesthesia for implantation of the VNS leads was achieved by performing superficial and deep cervical plexus blocks. A local anesthetic field block of a small area of the posterior chest provided anesthesia for insertion of the generator. RESULTS: All of the patients undergoing regional/local anesthesia completed the procedure without difficulty and on an outpatient basis. None complained of discomfort, sedation, nausea, or vomiting and none had seizures in the perioperative period. These results contrasted with the group that underwent general anesthesia (n = 10), who had an 80% incidence of nausea and vomiting and a 30% incidence of postoperative seizures. CONCLUSION: VNS implantation under regional/local anesthesia is proficiently performed as an outpatient procedure with minimal postoperative side effects.     

P. Prithvi Raj, MD, FFARCS: regional anesthesia pioneer

At a time when regional anesthesia was a curious alternative, Dr. Raj developed techniques to improve the success of the blocks and make regional analgesia more acceptable to the average anesthesiologist. His abundant research and numerous articles, books, lectures and demonstrations on regional anesthesia and pain management have established him as a world leader in the field. He has described new blocks and new techniques of doing old blocks. He has described the mechanism of action of intravenous regional analgesia. He has improved education and training by opening pain centers across the country, each of which has offered pain fellowship opportunities. He has founded societies dedicated to research and education in regional analgesia and pain management. Regional anesthesia and pain management will forever be linked with the name of Dr. Prithvi Raj. University of Texas Southwestern Medical Center is proud to have been a part of his early development.     

Simulation-based training in obstetric anesthesia: an update

In this update we explore the current applications of simulation in obstetric anesthesia, describe what is known regarding its impacts on care and consider the different settings in which simulation programs are required. We will introduce practical strategies, such as cognitive aids and communication tools, that can be applied in the obstetric setting and share ways in which a program might apply these tools. Finally, we provide a list of common obstetric emergencies essential for a program’s curriculum and common teamwork pitfalls to address within a comprehensive obstetric anesthesia simulation program.     

Tutorial: context-sensitive decrement times for inhaled anesthetics

Context-sensitive decrement times for inhaled anesthetics connect two values: a) the duration of anesthesia (nominally at a constant alveolar concentration)-the "context" and b) the time to decrease the alveolar or vital tissue (e.g., brain, heart, kidney, and liver, collectively called the vessel-rich group of tissues) concentration by some fractional "decrement" of the starting concentration. Increasing duration of anesthesia increases the time to a given decrement in a nonlinear manner that may considerably delay recovery. In the present report we use a commercially available simulation program (Gas Man) to confirm and enlarge on these concepts. In this simulation, increasing duration of anesthesia can markedly delay complete awakening for isoflurane. Increasing anesthesia duration imposes considerably less delay in awakening from sevoflurane compared with isoflurane. For desflurane, only prolonged anesthesia or decrements of 95% and more should delay awakening from anesthesia. These changes are shown to be the result of the relative solubility of each anesthetic in blood and tissue. An increase in cardiac output is also shown to delay awakening.     

A survey of 800 patients' knowledge, attitudes, and concerns regarding anesthesia.

The present study was undertaken to assess patients' knowledge, attitudes, and concerns regarding anesthetic management. A survey of 34 items was developed and administered preoperatively to 800 consecutive patients. Included were 303 men and 497 women with a mean age 52 yr and a mean educational level of 12 yr. Patients were interviewed on their knowledge of the role and training of anesthesiologists and on their preferences regarding anesthetic management. Patients also rated the intensity of their concern on 20 written statements expressing potential anesthetic complications. Results indicated that patients' perceptions of the anesthesiologist's training and role were accurate. Most patients preferred (a) general to regional anesthesia and (b) not to select their own anesthesiologist. Most significant preoperative concerns regarding the anesthesiologist focused on experience, qualifications, and presence or absence during the anesthesia. Patient concerns also included the possibility of not waking up postoperatively, experiencing pain, and becoming paralyzed. Intensity of concern was inversely related to age and unrelated to educational level or occupation. Variables related to type of concern included patient's sex, type of anesthesia, and proposed surgical procedure. Issues of least concern included disclosure of personal matters during anesthesia, experiencing impaired judgment postoperatively, and being asleep or bedridden for a prolonged period of time. It is suggested that anesthesiologists address significant patient concerns during the preoperative visit to enhance their effectiveness in patient care. Efforts to educate the public on the anesthesiologist's role in perioperative care should improve patient confidence.     

Simulation devices in cardiothoracic and vascular anesthesia

The subspecialty of cardiothoracic and vascular anesthesia is becoming increasingly complex. Trainees must learn to manage difficult cases and be skilled in performing a variety of procedures. With work hour limitations and societal pressures working to reduce learning and practice opportunities for trainees, new training modalities must be utilized. Simulation is currently being used to increase training efficiency. It allows trainees to experience uncommon clinical situations and complications, repetitive practice opportunities, and can be done on a flexible schedule-all without risk to the patient. Additionally, feedback after a simulation can provide trainees with an assessment of their training progress. Many of the procedures and cases in cardiothoracic and vascular anesthesia can be simulated. Current devices can simulate bronchoscopy, vessel cannulation, complex case management, and cardiopulmonary bypass. They vary from the simple to the complex and from inexpensive homemade wooden devices to high-end computer-controlled virtual reality simulators. Although not all these simulators have been validated as to their educational efficacy, they offer a new avenue to improve training efficacy and efficiency. More research needs to be done to validate these devices and assess their role in anesthesia training.     

脑和脊髓微透析技术的理论、方法和应用

全麻和疼痛机制的研究是麻醉学的热点。了解全麻下中枢神经系统活动机制，必须对神经细胞间隙中的化学物质进行动态监测。脑和脊髓微透析技术是研究活体神经递质释放的重要先进技术，它能将活体神经递质的变化与行为学有机联系起来，在全麻和疼痛机制的研究中具有重要价值。文中综述了脑和脊髓微透析技术的主要理论，实施方法以及在麻醉学领域的应用。     

New drugs,new techniques,new indications in pediatric regional anesthesia

The use of regional anesthesia in children represents one of the most effective methods for perioperative analgesia and postoperative pain control. Things have been dramatically changed in the last two decades due to the appearance of new safer drugs and new tools; moreover new techniques were introduced showing their efficacy. In this paper we briefly describe the efficacy of new local anesthetics and adjuvants; we review the use of continuous peripheral blocks and other not very diffused techniques of regional anesthesia.