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Electroconvulsive therapy (ECT) is an evidence-based treatment for severe depression and bipolar disorder in pregnant women. Electroconvulsive therapy involves induction of general anesthesia, muscle relaxation, and positive-pressure ventilation. Airway manipulation may lead to complications such as vocal cord injury, aspiration, inability to ventilate, and death. The purpose of this study was to determine whether there were differences in the incidence of airway complications in pregnant patients who underwent mask ventilation (MV) versus endotracheal intubation (ETI) compared with nonpregnant control subjects.We conducted a single-center retrospective chart review of all adult pregnant patients who underwent anesthesia for ECT from June 1, 2011, to June 30, 2020. Each ECT treatment delivered to a pregnant patient was matched with 2 ECT treatments delivered to a nonpregnant female control subject. Charts were queried for airway management (MV vs ETI), gestational age, and airway complications. Each ECT treatment was considered an independent event.Seventy-six ECT treatments from 11 pregnant patients were matched with 154 ECT treatments from 13 nonpregnant patients. In pregnant patients, airway management consisted of MV in 57 of the 76 treatments: 12 of 12 in the first trimester, 33 of 44 in the second trimester, and 12 of 20 in the third trimester. All 154 ECT treatments in the control group used MV. No airway complications were experienced in pregnant or nonpregnant patients with MV or ETI.No airway complications were observed in pregnant patients undergoing MV or ETI regardless of gestational age.

Oral carbohydrate consumption before surgery improves insulin sensitivity, cardiac output and well-being, and shortens hospital stays without adverse effects. No work has compared higher-dose carbohydrate beverages made for preoperative consumption to common, commercial oral rehydration solutions with lower carbohydrate concentrations. We recruited low-risk women undergoing scheduled cesarean deliveries with planned spinal anesthesia. Participants were randomized to one of three groups: those who consumed Clearfast® beverage, those who consumed Gatorade Thirst Quencher® beverage, or fasting control. Participants in the two beverage groups received 710 mL of the appropriate beverage the night before surgery and 355 mL 2 h before surgery. Participants in the control group fasted after midnight the night before surgery. Two hours before surgery, we recorded baseline patient well-being using visual analogue scales, followed by beverage consumption for subjects in the beverage groups. One hour later, we repeated the same assessment. Additional recorded measures included cord blood glucose level, intraoperative variables, breastfeeding success, and a quality of recovery assessment administered 1 day after surgery. Forty-seven patients were recruited: 15 received Clearfast®, 17 received Gatorade Thirst Quencher®, and 15 patients fasted after midnight. Group differences in change in patient well-being using visual analog scales were analyzed using linear regression. Both beverage-consuming groups showed significant improvements in patient well-being using visual analog scales while fasted patients showed no change. Either a common oral rehydration beverage or a higher-dose carbohydrate beverage consumed preoperatively resulted in superior well-being compared to fasting. No differences in other outcomes were noted. This study was registered on ClinicalTrials.gov with clinical trial registration number: NCT02684513.

Background It has been proposed that cricoid pressure can exacerbate an unstable cervical injury and lead to neurologic deterioration. Objective We sought to examine the amount of motion cricoid pressure could cause at an unstable subaxial cervical spine injury, and whether posterior manual support is of any benefit. Methods Five fresh, whole cadavers had complete segmental instability at C5–C6 surgically created by a fellowship-trained spine surgeon. Cricoid pressure was applied to the anterior cricoid by an attending anesthesiologist. In addition, the effect of posterior cervical support was tested during the trials. The amount of angular and linear motion between C5 and C6 was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). Results When cricoid pressure is applied, the largest angular motion was 3 degrees and occurred in flexion-extension at C5–C6. The largest linear displacement was 1.36 mm and was in anterior-posterior displacement of C5–C6. When manual posterior cervical support was applied, the flexion-extension was improved to less than half this value (1.43 degrees), and this reached statistical significance ( p = 0.001). No other differences were observed to be significant in the other planes of motion with the applications of support. Conclusions Based on the evidence presented, we believe that the application of cricoid pressure to a patient with a globally unstable subaxial cervical spine injury causes small displacements. There may be some benefit to the use of manual posterior cervical spine support for reducing motion at such an injured segment.

Uterine and placental pathology can be a major cause of morbidity and mortality in the parturient and infant. When presenting alone, placental abruption, uterine rupture, or placenta accreta can result in significant peripartum hemorrhage, requiring aggressive surgical and anesthetic management; however, the presence of multiple concurrent uterine and placental pathologies can result in significant morbidity and mortality. We present the anesthetic management of a parturient who underwent an urgent cesarean delivery for non-reassuring fetal tracing in the setting of chronic hypertension, preterm premature rupture of membranes, and chorioamnionitis who was subsequently found to have placental abruption, uterine rupture, and placenta accreta.

In this paper we present a study exploring whether the physical presence of another human changes how people perceive and behave with virtual teammates. We conducted a study (n = 69) in which nurses worked with a simulated health care team to prepare a patient for surgery. The agency of participants' teammates was varied between conditions; participants either worked with a virtual surgeon and a virtual anesthesiologist, a human confederate playing a surgeon and a virtual anesthesiologist, or a virtual surgeon and a human confederate playing an anesthesiologist. While participants perceived the human confederates to have more social presence ( p < 0.01), participants did not preferentially agree with their human team members. We also observed an interaction effect between agency and behavioral realism. Participants experienced less social presence from the virtual anesthesiologist, whose behavior was less in line with participants' expectations, when a human surgeon was present.

Researchers have created mixed-reality humans (MRHs) and applied them to critical team training. MRHs are embodied conversational agents with virtual and physical components that inhabit the user's space. In this research, MRHs role-played members of an operating-room team. Studies examined how MRH components affected social presence (the user's sense of "being there" with an embodied conversational agent) and the training of communication skills for medical teams.

In the past few years, advances have been made on how mixed reality humans (MRHs) can be used for interpersonal communication skills training for medical teams; however, little research has looked at how MRHs can influence communication skills during training. One way to influence communication skills is to leverage MRHs as models of communication behavior. We created a mixed reality medical team training exercise designed to impact communication behaviors that are critical for patient safety. We recruited anesthesia residents to go through an operating room training exercise with MRHs to assess and influence residents' closed loop communication behaviors during medication administration. We manipulated the behavior of the MRHs to determine if the MRHs could influence the residents' closed loop communication behavior. Our results showed that residents' closed loop communications behaviors were influenced by MRHs. Additionally, we found there was a statistically significant difference between groups based on which MRH behavior residents observed. Because the MRHs significantly impacted how residents communicated in simulation, this work expands the boundaries for how VR can be used and demonstrates that MRHs could be used as tools to address complex communication dynamics in a team setting.

Objective Neuraxial hematoma is a rare complication of spinal or epidural anesthesia. However, variable coagulation factor defects are relatively common in patients with Fontan circulation, and may predispose such patients to either increased risk of thrombosis or coagulopathy. These defects may indirectly increase their risk of neuraxial hematoma. Case Report We report a case of delayed neuraxial hematoma after the start of full-dose anticoagulation for pulmonary embolus on a postpartum patient with Fontan physiology who had continuous spinal anesthesia for cesarean delivery 4 days earlier. Conclusions Parturients with single ventricle physiology present numerous challenges to balance, including pregnancy-related physiologic alterations in blood volume, cardiac output, systemic vascular resistance, oxygen consumption, and coagulation. Although neuraxial anesthesia is common in this population, it is not without risks. We report the circumstances surrounding a parturient with single ventricle physiology who experienced neuraxial hematoma 4 days after continuous spinal anesthesia despite adherence to accepted guidelines. Eighteen months after undergoing a cesarean section, she had a full recovery and returned to her baseline medical status.

Despite research showing that team training can lead to strong improvements in team performance, logistical difficulties can prevent team training programs from being adopted on a large scale. A proposed solution to these difficulties is the use of virtual humans to replace missing teammates. Existing research evaluating the use of virtual humans for team training has been conducted in settings involving a single human trainee. However, in the real world, multiple human trainees would most likely train together. In this paper, we explore how the presence of a second human trainee can alter behavior during a medical team training program. Ninety-two nurses and surgical technicians participated in a medical training exercise, where they worked with a virtual surgeon and virtual anesthesiologist to prepare a simulated patient for surgery. The agency of the nurse and the surgical technician were varied between three conditions: human nurses and surgical technicians working together; human nurses working with a virtual surgical technician; and human surgical technicians working with a virtual nurse. Variations in agency did not produce statistically significant differences in the training outcomes, but several notable differences were observed in other aspects of the team’s behavior. Specifically, when working with a virtual nurse, human surgical technicians were more likely to assist with speaking up about patient safety issues that were outside of their normal responsibilities; human trainees spent less time searching for a missing item when working with a virtual partner, likely because the virtual partner was physically unable to move throughout the room and assist with the searching process; and more breaks in presence were observed when two human teammates were present. These results show that some behaviors may be influenced by the presence of multiple human trainees, though these behaviors may not impinge on core training goals. When developing virtual human-based training programs, designers should consider that the presence of other humans may reduce involvement during training moments perceived to be the responsibility of other trainees and also should consider that a virtual teammate’s limitations may cause human teammates to limit their own behaviors in corresponding ways (e.g., searching less).

Despite research showing that team training can lead to strong improvements in team performance, logistical difficulties can prevent team training programs from being adopted on a large scale. A proposed solution to these difficulties is the use of virtual humans to replace missing teammates. Existing research evaluating the use of virtual humans for team training has been conducted in settings involving a single human trainee. However, in the real world multiple human trainees would most likely train together. In this paper, we explore how the presence of a second human trainee can alter behavior during a medical team training program. Ninety-two nurses and surgical technicians participated in a medical training exercise, where they worked with a virtual surgeon and virtual anesthesiologist to prepare a simulated patient for surgery. The agency of the nurse and the surgical technician were varied between three conditions: human nurses and surgical technicians working together; human nurses working with a virtual surgical technician; and human surgical technicians working with a virtual nurse. Variations in agency did not produce statistically significant differences in the training outcomes, but several notable differences were observed in other aspects of the team's behavior. Specifically, when working with a virtual nurse, human surgical technicians were more likely to assist with speaking up about patient safety issues that were outside of their normal responsibilities; human trainees spent less time searching for a missing item when working with a virtual partner, likely because the virtual partner was physically unable to move throughout the room and assist with the searching process; and more breaks in presence were observed when two human teammates were present. These results show that some behaviors may be influenced by the presence of multiple human trainees, though these behaviors may not impinge on core training goals. When developing virtual human-based training programs, designers should consider that the presence of other humans may reduce involvement during training moments perceived to be the responsibility of other trainees, and should consider that a virtual teammate's limitations may cause human teammates to limit their own behaviors in corresponding ways (e.g. searching less).

As the prevalence of adults with palliated congenital heart disease continues to increase, so, too, does the number of these patients who will become pregnant. Practicing physicians need to be familiar with the impact that normal physiologic changes associated with pregnancy and delivery has on patients with palliated congenital heart disease. The physiologic impact of pregnancy on a patient with palliated cyanotic congenital heart disease and the management of her delivery are presented.

Medical educators often use standardized patient (SP) encounters to train and assess a novice’s ability to gather history, to perform physical examinations, and to synthesize data to form diagnoses. These types of encounters have even been incorporated into various high-stakes exams, such as the Medical Council of Canada’s Qualifying Examination Part II (since 1996), the Educational Commission for Foreign Medical Graduates’ Clinical Skills Assessment (from 1998 to 2004), and the United States Medical Licensing Exam Step 2 Clinical Skills Assessment (since 2004).1–3 Yet, we believe possible limitations exist with this method of training and assessment. While deficiencies in performance may be due to inexperience and lack of skill or knowledge on the part of the examinee, they may also be due to flaws inherent in human SPs. Various studies examining the use of SPs in trainee assessments have found predominantly promising results, suggesting that performance during clinical skills assessments with SPs during high-stakes exams not only has high validity, but also predicts performance on similar high-stakes exams. Further, these studies demonstrate that SP ethnicity, nationality, gender, and primary language have at most only a minor influence on the student’s performance.4–14 However, we found no study that has reported what influence abnormal physical findings have on the decision-making abilities of examinees during clinical skills assessments. SPs may not deliver a consistent history, especially over multiple repetitions, and they frequently cannot exhibit abnormal physical findings. They are typically healthy, ambulatory adults who have essentially no consistent physical findings, even though they are tasked with presenting many common diseases that are associated with significant abnormal physical findings. While real patients who are able to present actual disease states can and should participate in medical training, their inconsistent availability limits the uniform educational experiences of students. Some investigators have addressed these limitations with “augmented” SP encounters. Sun and colleagues used modified stethoscopes that could play abnormal auscultatory findings during physical exams of SPs.15 Sun further augmented SP encounters with virtual pathology echocardiograms that utilized tracking technology to display an abnormal exam when the echo probe was in an appropriate anatomic location over a patient’s thorax.16 While promising, these techniques can neither discern nor display disease conditions that affect the physical appearance of the patient. The Virtual Experiences Research Group (VERG; Gainesville, Florida) is exploring human-to-virtual human interactions with unique applications of virtual reality. VERG developed a highly immersive virtual human (VH) for this purpose. The VH enables the presentation of a consistent history and abnormal physical findings for multiple learners. Some medical educators have already used the VH to assess medical students and teach them communication skills.17 Moreover, VERG merged the VH with a mannequin to create a mixed reality simulation for breast exams.18 While the SP supply is limited, the VH offers the exciting possibility of creating an almost limitless repository of diverse and challenging virtual clinical scenarios that are difficult to consistently duplicate with authentic SPs. The purpose of this study was to determine if junior anesthesiology residents would more frequently suspect obstructive sleep apnea (OSA) during a preoperative exam of a VH as compared to an SP.

Background: The literature suggests that blood product transfusions have a negative impact on the survival of liver transplant patients. We investigated the impact of intraoperative blood product usage on the survival of liver transplantation patients being transplanted for hepatitis C-related end-stage liver disease. In addition, we analyzed a potentially more sensitive metric, namely disease recurrence and fibrosis progression, obtained from follow-up liver biopsies. Methods: We retrospectively studied 194 consecutive patients with hepatitis C virus (HCV) undergoing liver transplantation. To investigate the effect of red blood cell (RBC) or platelet transfusions on post-transplant HCV recurrence, hepatic biopsy data from 4 months and 1 year after transplantation were studied. In addition, survival data were analyzed. Results: There was no effect of intraoperative RBC or platelet transfusion on either 1- or 5-year patient survival following liver transplantation. There was no difference in HCV disease recurrence or progression of hepatic fibrosis at 4 months or 1 year attributable either to RBC or to platelet transfusion. Conclusion: This study was not able to confirm an effect on the survival of HCV-infected liver transplant patients related to intraoperative transfusion of RBCs or platelets. In addition, these transfusions had no effect on HCV recurrence or fibrosis progression. This is not to condone a liberal transfusion practice, but rather to reassure that when clinically indicated, transfusion does not have a significant impact on patient survival or disease recurrence in HCV-infected liver transplant patients.

In a group setting, it is possible for attributes of one group member to indirectly affect how other group members are perceived. In this paper, we explore whether one group member's agency (e.g. if they are real or virtual) can indirectly affect behavior with other group members. We also consider whether variations in the agency of a group member directly affects behavior with that group member. To do so, we examined gaze behavior during a team training exercise, in which sixty-nine nurses worked with a surgeon and an anesthesiologist to prepare a simulated patient for surgery. The agency of the surgeon and the anesthesiologist were varied between conditions. Nurses' gaze behavior was coded using videos of their interactions. Agency was observed to directly affect behavior, such that participants spent more time gazing at virtual teammates than human teammates. However, participants continued to obey polite gaze norms with virtual teammates. In contrast, agency was not observed to indirectly affect gaze behavior. The presence of a second human did not affect participants' gaze behavior with virtual teammates.

Introduction During critical incidents, teamwork failures can compromise patient safety. This study provides evidence that virtual humans can be used in simulated critical incidents to assess the learning needs of health professionals, and provide important information that can inform the development of continuing education programs in patient safety. We explored the effectiveness of information transfer during a devolving medical situation between postanesthesia care unit (PACU) nurses and a virtual attending physician. Methods We designed a three-stage scenario: tutorial, patient transfer, and critical incident. We developed 2 checklists to assess information transfer: Critical Patient Information and Interprofessional Communication Skills. All participants were videotaped; 2 raters reviewed all videos and assessed performance using the checklists. Results Participants (n = 43) who completed all 3 stages scored 62.3% correct on critical patient information transfer and 61.6% correct on interprofessional communication skills. Almost 87% missed a fatal drug error. The checklists measured each item on a 1/0 (done/not) calculation. Additionally, no relationship was found between years of nursing experience and performance on either checklist. Discussion The PACU nurses in this study did not consistently share critical information with an attending (virtual) physician during a critical incident, and most missed a fatal dosage error. These findings strongly suggest a crucial need for additional structured team training among practicing health care teams, and they demonstrate the utility of using virtual humans to simulate team members.

Due to logistical scheduling challenges, social training of conflict resolution skills with healthcare professionals is a difficult task. To overcome these challenges, we used virtual humans to fill in as surgical teammates and train conflict resolution skills in a surgical scenario. Surgical technologists were recruited at a United States teaching hospital to interact with a virtual nurse, virtual surgeon, and virtual anesthesiologist in a team training exercise. Leveraging social learning theory, the virtual nurse on the team modeled one of two conflict resolution strategies, either best practices or bad practices, during an important decision moment in the exercise. In a second important decision moment, we assessed if surgical technologists demonstrated the conflict resolution model they observed. We found human participants were successfully able to demonstrate the ideal conflict resolution strategy after observing the virtual nurse model best practices. While we found participants were positively influenced by the best practices model, we also found that conversely, the bad practices model negatively influenced participants’ conflict resolution behavior. If humans can be positively influenced by virtual humans, this form of social training could transform medical team training, empowering more healthcare professionals to speak up, and potentially decreasing the chances of patient morbidity or death in the OR.

This research explores the extent to which humans behave realistically during conflict with a virtual human occupying a position of authority. To this end, we created a virtual team to train nurses how to manage conflict in the operating room; the team’s virtual surgeon engages in reckless behavior that could endanger the safety of the team’s patient, requiring nurses to intervene and correct the virtual surgeon’s behavior. Results from post-hoc behavioral analysis and semi-structured interviews indicate that participants behaved realistically during conflict, as compared against existing behavioral frameworks. However, some participants reported perceiving their virtual teammates as strangers, which they felt may have caused them to behave differently than they would with their normal teammates.

The concepts of immersion and presence focus on the environment in a virtual environment. We instead focus on embodied conversational agents (ECAs). ECAs occupy the virtual environment as interactive partners. We propose that the ECA analogues of immersion and presence are physicality and social presence. We performed a study to determine the effect of an ECA's physicality on social presence and eliciting realistic behavior from the user. The results showed that increasing physicality can elicit realistic behavior and increase social presence but there was also an interaction effect with plausibility.

Study design Human cadaveric study using various intubation devices in a cervical spine instability model. Objective We sought to evaluate various intubation techniques and determine which device results in the least cervical motion in the setting of a global ligamentous instability model. Summary of background data Many patients presenting with a cervical spine injury have other injuries that may require rapid airway management with endotracheal intubation. Secondary neurologic injuries may occur in these patients because of further displacement at the level of injury, vascular insult, or systemic decrease in oxygen delivery. The most appropriate technique for achieving endotracheal intubation in the patient with a cervical spine injury remains controversial. Methods A global ligamentous instability at the C5-C6 vertebral level was created in lightly embalmed cadavers. An electromagnetic motion analysis device (Liberty; Polhemus, Colchester, VT) was used to assess the amount of angular and linear translation in 3 planes during intubation trials with each of 4 devices (Airtraq laryngoscope, lighted stylet, intubating LMA, and Macintosh laryngoscope). The angular motions measured were flexion-extension, axial rotation, and lateral bending. Linear translation was measured in the medial-lateral (ML), axial, and anteroposterior planes. Intubation was performed by either an emergency medical technician or by a board-certified attending anesthesiologist. Both time to intubate as well as failure to intubate (after 3 attempts) were recorded. Results There was no significant difference shown with regards to time to successfully intubate using the various devices. It was shown that the highest failure-to-intubate rate occurred with use of the intubating LMA (ILMA) (23%) versus 0% for the others. In flexion/extension, we were able to demonstrate that the Lightwand (P = 0.005) and Airtraq (P = 0.019) resulted in significantly less angular motion than the Macintosh blade. In anterior/posterior translation, the Lightwand (P = 0.005), Airtraq (P = 0.024), and ILMA (P = 0.021) all caused significantly less linear motion than the Macintosh blade. In axial rotation, the Lightwand (P = 0.017) and Airtraq (P = 0.022) resulted in significantly less angular motion than the Macintosh blade. In axial translation (P = 0.037) and lateral bending (P = 0.003), the Lightwand caused significantly less motion than the Macintosh blade. Conclusion In a cadaver model of C5-C6 instability, the greatest amount of motion was caused by the most commonly used intubation device, the Macintosh blade. Intubation with the Lightwand resulted in significantly less motion in all tested parameters (other than ML translation) as compared with the Macintosh blade. It should also be noted that the Airtraq caused less motion than the Macintoshblade in 3 of the 6 tested planes. There were no significant differences in failure rate or the amount of time it took to successfully intubate in comparing these techniques. We therefore recommend the use of the Lightwand, followed by the Airtraq, in the setting of a presumed unstable cervical spine injury over the Macintosh laryngoscope.

Intracranial hemorrhage in the pregnant patient is a rare cause of peripartum morbidity, and it presents a diagnostic and management dilemma. The case of a term parturient who presented with headache is presented. Clinical suspicion led to the diagnosis of ruptured cerebellar arteriovenous malformation. Optimal timing of interventions, both neurosurgical and obstetric, are discussed. We chose to pursue Cesarean section prior to definitive neurosurgical intervention in this term parturient. Delivery of the fetus before surgery eliminates concern for adverse pregnancy outcome when interventions for cerebral protection are used, such as hyperventilation, administration of mannitol, barbiturate coma, and induced hypertension or hypotension. Subsequent management options, including general, spinal, epidural, and combined-spinal epidural (CSE) anesthesia for Cesarean delivery, are discussed. We selected CSE anesthesia so as to provide a hemodynamically stable delivery followed by planned endovascular embolization.