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This study compares surgical residents' knowledge acquisition of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) between in-person and online procedural training cohorts before receiving independent in-person Dynamic Haptic Robotic Simulation training.Three surgical residency procedural training cohorts, two in-person (N = 26) and one online (N = 14), were compared based on their performance on a 24-item US-IJCVC evaluation checklist completed by an expert physician completed after training. Pre- and post-training US-IJCVC knowledge was also compared for the online cohort.No significant change in the pass rates on the US-IJCVC checklist was found between in-person and online cohorts (p = 0.208). There were differences in the Economy of Time and Motion between in-person and online cohorts (p 0.005). The online cohort had significant increases in US-IJCVC knowledge pre-to post-training (p 0.008).Online training with independent simulation practice was as effective as in-person training for US-IJCVC.

The Dynamic Haptic Robotic Trainer (DHRT) was developed to minimize the up to 39% of adverse effects experienced by patients during Central Venous Catheterization (CVC) by standardizing CVC training, and provide automated assessments of performance. Specifically, this system was developed to replace manikin trainers that only simulate one patient anatomy and require a trained preceptor to evaluate the trainees’ performance. While the DHRT system provides automated feedback, the utility of this system with real-world scenarios and expertise has yet to be thoroughly investigated. Thus, the current study was developed to determine the validity of the current objective assessment metrics incorporated in the DHRT system through expert interviews. The main findings from this study are that experts do agree on perceptions of patient case difficulty, and that characterizations of patient case difficulty is based on anatomical characteristics, multiple needle insertions, and prior catheterization.

Background Simulation-based training is a clinical skill learning method that can replicate real-life situations in an interactive manner. In our study, we compared a novel hybrid learning method with conventional simulation learning in the teaching of endotracheal intubation. Methods One hundred medical students and residents were randomly divided into two groups and were taught endotracheal intubation. The first group of subjects (control group) studied in the conventional way via lectures and classic simulation-based training sessions. The second group (experimental group) used the hybrid learning method where the teaching process consisted of distance learning and small group peer-to-peer simulation training sessions with remote supervision by the instructors. After the teaching process, endotracheal intubation (ETI) procedures were performed on real patients under the supervision of an anesthesiologist in an operating theater. Each step of the procedure was evaluated by a standardized assessment form (checklist) for both groups. Results Thirty-four subjects constituted the control group and 43 were in the experimental group. The hybrid group (88%) showed significantly better ETI performance in the operating theater compared with the control group (52%). Further, all hybrid group subjects (100%) followed the correct sequence of actions, while in the control group only 32% followed proper sequencing. Conclusions We conclude that our novel algorithm-driven hybrid simulation learning method improves acquisition of endotracheal intubation with a high degree of acceptability and satisfaction by the learners’ as compared with classic simulation-based training.

We report on data and debriefing observations in the context of an immersive simulation conducted to (a) train clinicians and (b) test new protocols and kits, developed in table-top exercises without prior clinical experience to fit anticipated clinical encounters in the setting of the rapidly expanding COVID-19 pandemic. We simulated scenarios with particular relevance for anesthesiology, perioperative and critical care, including (1) cardiac arrest, (2) emergency airway management, (3) tele-instruction for remote guidance and supervision, and (4) transporting an intubated patient. Using a grounded theory approach, three authors (MHA, DLR, EHS) developed emergent themes. First alone and then together, we sought consensus in uncovering overarching themes and constructs from the debriefings. We thus performed an informal qualitative thematic analysis based in a critical realist epistemological position - the understanding that our findings, while real, are affected by situational variables and the observer's perspective[ 1 , 2 ]. We compared data from videos and triangulated the data by member checking. All participants and course instructors volunteered to participate in this educational project and contributed as co-authors to this manuscript. During debriefing, we applied crisis resource management concepts including situation awareness, prioritization of tasks, and clear communication practices, conducting the debriefing with emphasis on current TeamStepps 2.0 terminology and concepts. [ 3 , 4 ] In addition, we re-evaluated formerly familiar processes, as shortcomings of protocols, kits, and interdisciplinary cooperation became apparent. The data provide detailed observations on how immersive simulation and debriefing among peers mitigated the unfamiliarity of individual clinicians and the organization at large with the demands of an unprecedented healthcare crisis. We also observed and report on the anxiety caused by resource constraints, risk to clinicians in the face of limited personal equipment, and the overall uncertainty surrounding COVID-19. We began to summarize, interpret, critique, and discuss our data and debriefing observations in a rapid co-publication in the Journal of Clinical Anesthesia. [Healthcare Simulation to Prepare for the COVID-19 Pandemic] [5]

Introduction Even physicians who routinely work in complex, dynamic practices may be unprepared to optimally manage challenging critical events. High-fidelity simulation can realistically mimic critical clinically relevant events, however the reliability and validity of simulation-based assessment scores for practicing physicians has not been established. Methods Standardised complex simulation scenarios were developed and administered to board-certified, practicing anesthesiologists who volunteered to participate in an assessment study during formative maintenance of certification activities. A subset of the study population agreed to participate as the primary responder in a second scenario for this study. The physicians were assessed independently by trained raters on both teamwork/behavioural and technical performance measures. Analysis using Generalisability and Decision studies were completed for the two scenarios with two raters. Results The behavioural score was not more reliable than the technical score. With two raters > 20 scenarios would be required to achieve a reliability estimate of 0.7. Increasing the number of raters for a given scenario would have little effect on reliability. Conclusions The performance of practicing physicians on simulated critical events may be highly context-specific. Realistic simulation-based assessment for practicing physicians is resource-intensive and may be best-suited for individualized formative feedback. More importantly, aggregate data from a population of participants may have an even higher impact if used to identify skill or knowledge gaps to be addressed by training programs and inform continuing education improvements across the profession.

Highlights • COVID-19 challenged providers and organization with unfamiliar and unprecedented scenarios. • We simulated anticipated airborne contagion scenarios to familiarize providers with safe practices. • COVID-19 procedures were safely examined in realistic situations and modified based on participant debriefings. • Simulation promoted interdisciplinary integration of our organizational response to COVID-19.

Background We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. Methods A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Results Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Conclusions Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Acute adrenal insufficiency is a rare but potentially life-threatening event during the perioperative period. The usual manifestations of an acute adrenal crisis can mimic common postoperative complications and a high index of suspicion is required for the diagnosis. Early diagnosis and prompt treatment can be lifesaving. We present the case of a 65-year-old man who, after a partial nephrectomy, developed acute adrenal insufficiency, which remained undiagnosed in the postoperative period, eventually leading to cardiac arrest. This case highlights the need for perioperative physicians to have a watchful eye for diagnosing and treating this uncommon yet lethal condition.

Pediatric anesthesiology as a subspecialty has benefitted greatly from the introduction of simulation technology, ranging from the instruction of residents rotating through pediatric anesthesiology for the first time to the development of refresher course scenarios for seasoned attending pediatric anesthesiologists. Part task trainers as well as high-fidelity in situ simulation have been utilized to enhance procedural skills; assess competencies such as communication, medical knowledge, and patient care; and strengthen team training and crisis resource management. Several methods of assessment exist for the evaluation of performance in the high- and low-fidelity simulation environment. Simulation has been shown to be efficacious in the development of multidisciplinary teamwork skills, which are crucial in preparing hospital teams for pediatric emergencies. Lastly, simulation may be integrated into a residency curriculum and assist in the assessment of many of the competency-based milestones set forth by accrediting bodies. Given these advantages, the use of simulation technology in the field of pediatric anesthesiology is continually evolving, and a bright future lies ahead with growing collaboration within the field both nationally and internationally.

Introduction We developed a taxonomy of simulation delivery and documentation deviations noted during a multicenter, high-fidelity simulation trial that was conducted to assess practicing physicians' performance. Eight simulation centers sought to implement standardized scenarios over 2 years. Rules, guidelines, and detailed scenario scripts were established to facilitate reproducible scenario delivery; however, pilot trials revealed deviations from those rubrics. A taxonomy with hierarchically arranged terms that define a lack of standardization of simulation scenario delivery was then created to aid educators and researchers in assessing and describing their ability to reproducibly conduct simulations. Methods Thirty-six types of delivery or documentation deviations were identified from the scenario scripts and study rules. Using a Delphi technique and open card sorting, simulation experts formulated a taxonomy of high-fidelity simulation execution and documentation deviations. The taxonomy was iteratively refined and then tested by 2 investigators not involved with its development. Results The taxonomy has 2 main classes, simulation center deviation and participant deviation, which are further subdivided into as many as 6 subclasses. Inter-rater classification agreement using the taxonomy was 74% or greater for each of the 7 levels of its hierarchy. Cohen kappa calculations confirmed substantial agreement beyond that expected by chance. All deviations were classified within the taxonomy. Conclusions This is a useful taxonomy that standardizes terms for simulation delivery and documentation deviations, facilitates quality assurance in scenario delivery, and enables quantification of the impact of deviations upon simulation-based performance assessment.

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Background Laryngeal tubes (LT) are often used as rescue airway devices. Among prehospital medical personnel, the success rates are high and significantly faster compared to an endotracheal tube (ETT). Therefore, LTs are increasingly used in the prehospital setting. The exchange of an LT for an ETT may often be desirable. Two fiberoptic bronchoscope–facilitated techniques have been described to exchange an LT for an ETT: an intraluminal technique using an Aintree intubating catheter and an extraluminal technique using a nasal route alongside the LT. In this randomized cross-over mannequin study, we compared the intraluminal with the extraluminal exchange technique. The primary outcome was time to achieve an effective airway through an ETT. We hypothesized that the intraluminal technique would be significantly faster. Methods Thirty anesthesia providers were recruited to the study. Each participant attempted both techniques in an intubation simulation model. The tube exchange time was recorded from picking up the fiberoptic bronchoscope until confirmation of ventilation with the ETT. Results Four participants in each group had a failed attempt at intubation. Time to establish an endotracheal intubation was significantly shorter with the intraluminal technique vs the extraluminal technique (77.5 vs 140 seconds; P = .03). Conclusion Based on the results of our study, we suggest that the intraluminal technique may be a suitable alternative for a fiberoptic-guided rapid exchange of an LT for an ETT to establish an effective airway in a challenging situation.

Background Observations of cardiopulmonary arrests (CPAs) reveal concerning patterns when clinicians identify a problem, (e.g. loss of pulse) but do not immediately initiate appropriate therapy (e.g. compressions) resulting in delays in life saving therapy. Methods We hypothesized that when individuals utilized specific, short, easy-to-state action phrases stating an observation followed by an associated intervention, there would be a higher likelihood that appropriate action would immediately occur. Phase I: A retrospective analysis of residents in simulated CPAs measured what proportion verbalized “There's no pulse”, statements and/or actions that followed and whether “Action-Linked Phrases” were associated with faster initiation of compressions. Phase II: Two prospective, quasi-experimental studies evaluated if teaching three Action-Linked Phrases for Basic Life Support (BLS) courses or six Action-Linked Phrases for Advanced Cardiovascular Life Support (ACLS) courses was associated with increased use of these phrases. Results Phase I: 62% (42/68) of residents verbalized “there's no pulse” during initial assessment of a pulseless patient, and only 16/42 (38%) followed that by stating “start compressions”. Residents verbalizing this Action-Linked Phrase started compressions sooner than others: (30 s [IQR:19–42] vs. 150 [IQR:51-242], p

Simulation-based medical education is growing in use and popularity in various settings and specialties. A literature review yields scant information about the use of simulation-based medical education in neurology, however. The specialty of neurology presents an interesting challenge to the field of simulation-based medical education because of the inability of even the most advanced mannequins to mimic a focal neurologic deficit. The authors present simulator protocols for status epilepticus and acute stroke that use a high-fidelity mannequin despite its inability to mimic a focal neurologic deficit. These protocols are used in the training of third- and fourth-year medical students during their neurology clerkship at Penn State College of Medicine. The authors also provide a review of the pertinent literature.

Purpose To demonstrate that a nonbiologic strabismus surgery simulator is not inferior to a biologic wet lab for teaching the key steps of strabismus surgery. Methods A total of 41 medical students were randomly assigned to one of two groups: biologic wet lab or nonbiologic simulator. The students trained according to the group's protocol then participated in a recorded final assessment using a realistic strabismus surgery model. Two independent reviewers, masked to training method, graded the video recordings using three scoring systems: the International Council of Ophthalmology Approved-Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery (ICO-OSCAR), the Global Rating Scale of Objective Structured Assessment of Technical Skills (OSATS), and the Alphabetic Summary Scale (ASS). Results The primary endpoint, total ICO-OSCAR score, was 36.7 ± 2.2 for the wet lab group and 36.0 ± 2.7 for the nonbiologic group (difference in means, −0.7; one-sided 95% CI, −2.0, ∞). The lower bound of the one-sided 95% confidence interval for the difference in mean scores was −2.0, which was greater than the a priori noninferiority margin of −5.0 points. The secondary outcome measure, mean total OSATS score and ASS score, revealed no statistical significant differences between training methods (P = 0.73 and P = 0.44, resp.). Conclusions The simple, nonbiologic strabismus surgery simulator is not inferior to the biologic wet lab with respect to total ICO-OSCAR score. It is a portable, inexpensive, and effective training tool for novice surgeons.

In November 2006, a Simulation Summit was convened in Chicago, IL by the Society for Simulation in Healthcare. The purpose of this gathering was to bring together stakeholders from the widest possible range of societies, organizations, and regulatory agencies with an interest in healthcare simulation. Thirty-three organizations were represented by over 50 participants. Through structured small and large group discussions, eight major themes emerged for the advancement of simulation into the mainstream of healthcare education. Four of these were unanimously agreed upon, and four were widely accepted by the group. This paper summarizes the results of this Summit including future plans to advance the integration of simulation into the mainstream of healthcare.

Introduction: Prompting devices for chest compressions have been advocated as a means of improving CPR quality in previous AHA guidelines. Studies have shown overall CPR quality improves with the use of these devices. Hypothesis: This study compared the impact of prompting devices on providers with varying levels of experience and proficiency. Methods: A convenience sample of 53 subjects with varying degrees of CPR experience, ranging from zero to frequent opportunities to perform CPR, were enrolled. Using a skills recording CPR manikin, data on each subject’s chest compression performance was obtained. All subjects performed an initial one-minute cycle of continuous chest compressions with no prompting device. After a brief rest, subjects were randomized to use one of two CPR prompting devices (Philips MRX with Q-CPR or Laerdal Medical CPRmeter). An additional one minute of CPR was conducted with the first device. Subjects were then crossed over to use the other prompting device after another brief rest. Results: Across the entire group, nearly all parameters significantly improved with the prompting devices, confirming previous studies on the efficacy of CPR prompting devices. However, when subjects’ results were examined by breaking the group into three performance levels (high, medium and low) based on the Overall CPR Score generated by the manikin software, there were differences in performance. Paired t -tests were conducted on the low and high performance groups. The low-level group significantly improved across 7 of 8 variables with both devices. The high-level group had only minor changes from baseline (both positive and negative) in most variables, but had significant or near significant decrease in proficiency in one variable - percent correctly released compressions ( p = 0.011 for Philips device; p = 0.052 for the Laerdal device). Conclusions: CPR prompting devices improve the overall quality of chest compressions. Individuals with existing high performance CPR skills could be distracted by the device, reducing the quality of compressions compared to using no device. When a CPR prompting device is introduced into a health care system, all providers, especially high performers, require practice with the device in order to acclimate to its use.

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

Cardiac arrest is a major public health issue, with more than 500 000 deaths of children and adults per year in the United States.1–3 Despite significant scientific advances in the care of cardiac arrest victims, there remain striking disparities in survival rates for both out-of-hospital and in-hospital cardiac arrest. Survival can vary among geographic regions by as much as 6-fold for victims in the prehospital setting.4,5 Significant variability in survival outcomes also exists for cardiac arrest victims in the hospital setting, particularly when the time of day or the location of the cardiac arrest is considered.6 Inconsistencies in performance of both healthcare professionals and the systems in which they work likely contribute to these differences in outcome.7 For out-of-hospital cardiac arrest victims, the key determinants of survival are the timely performance of bystander cardiopulmonary resuscitation (CPR) and defibrillation for those in ventricular fibrillation or pulseless ventricular tachycardia. Only a minority of cardiac arrest victims receive potentially lifesaving bystander CPR, thus indicating room for improvement from a systems and educational point of view. For in-hospital cardiac arrest, the important provider-dependent determinants of survival are early defibrillation for shockable rhythms and high-quality CPR, along with recognition and response to deteriorating patients before an arrest. Defining the optimal means of delivering resuscitation education to address these critical determinants of survival may help to improve outcomes from cardiac arrest. Resuscitation education is primarily focused on ensuring widespread and uniform implementation of the science of resuscitation (eg, the Scientific Statements and Guidelines) into practice by lay and healthcare CPR providers. It aims to close the gap between actual and desired performance by providing lay providers with CPR skills and the self-efficacy to use them; supplementing training with in-the-moment support, such as dispatch-assisted CPR; improving healthcare professionals’ ability …

Simulation has been used for medical teaching and testing for at least four decades in some form, such as that used for cardiopulmonary resuscitation training; however, new technology applied to medical and procedural training has recently led to a marked increase in the use of simulation-based instruction. Educational theory has further supported simulation for medical education and procedural training. Simulation-based testing to demonstrate competence with new procedures is already required by the US Food and Drug Administration for one angiographicallyplaced device, and it is likely that simulationbased credentialing for procedures will be increasingly prevalent. Anesthesiologists, like other physicians, may be credentialed or certified based on their performance in a simulated environment in the future. This review describes some of the current simulation-based education techniques related to cardiovascular and thoracic anesthesiology. Additional discussion covers some of the applicable educational theory and the expected future uses of simulation modalities in healthcare education, testing, and practice.

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.

Given in clinically relevant large doses to rats, mu-opioids produce limbic system hypermetabolism and histopathology. This investigation extends these observations, in both rats and humans, for the short-acting drug remifentanil, which allows more precise control and assessment of the effects of duration of opioid exposure. We performed two series of experiments: one in rats for neuropathologic effects and the second in humans for neurometabolic effects. Fifty mechanically ventilated rats received saline solution or remifentanil 20-160 microg x kg(-1) x min(-1) for 3 h, followed by neuropathologic evaluation 7 days later. Four volunteers underwent induction of anesthesia and endotracheal intubation with propofol and rocuronium administration followed by remifentanil infusion at 1-3 microg x kg(-1) x min(-1) with positron emission tomography evaluation of cerebral metabolic rate for glucose. In rats, dose-related electroencephalogram activation was evident and 19 of 40 remifentanil-treated rats showed brain damage, primarily in the limbic system (P0.01). In humans, cerebral metabolic rate for glucose in the temporal lobe increased from 6.29 +/- 0.32 to 7.68 +/- 1.05 mg x 100 g(-1) x min(-1) (P0.05). These data indicate that prolonged large-dose remifentanil infusion is neurotoxic in rats with congruent metabolic effects with brief infusion in humans and suggest that some adverse effects reported in rats may be clinically relevant.This study demonstrates dose-related remifentanil neurotoxicity in physiologically controlled rats with congruent brain metabolic effects in four humans undergoing positron emission tomography evaluation during brief large-dose remifentanil anesthesia. These data suggest that some adverse effects reported in rats may be clinically relevant.

The mission of the Penn State Hershey Clinical Simulation Center is to improve patient outcomes with effective programs that promote and enhance practitioner skills, clinical competence, teamwork, and interdisciplinary collaboration. To advance the field of health care simulation, the Center conducts innovative research into simulation theory, practice, and technology. To support the Center’s mission, the latest equipment and proven methodologies are incorporated into curricula (Figs. 1-3). Staff work with faculty to develop and validate new educational tools and tests in an ongoing development process. In addition to its American College of Surgeons accreditation as a Comprehensive Education Institute, the Center is also accredited by the Society for Simulation in Healthcare and is endorsed by the American Society of Anesthesiologists.

Study Objectives: To evaluate the cerebral vascular effects of cis-atracurium and rocuronium given after thiopental induction of anesthesia. Design: Randomized, single-blinded study. Setting: University-affiliated hospital Patients: 39 adult ASA physical status I and II patients undergoing nonintracranial procedures. Interventions: Patients received intravenously (IV), either saline placebo, cis-atracurium, or rocuronium after induction of general anesthesia with thiopental sodium. Measurements: The right middle cerebral artery was insonated using a pulsed-wave range-gated transcranial Doppler, and data were recorded at preinduction, immediately postinduction, at injection of the study drug, and at 15-second intervals for 3 minutes thereafter. The variables recorded for each subject included the systolic, diastolic, and mean flow velocity, as well as pulsality index, systolic, diastolic, and mean arterial blood pressure (MAP), and end-tidal carbon dioxide concentration. Main Results: No significant differences between the groups were present in the postanesthetic induction maximal or minimal mean flow velocity. Conclusions: cis-Atracurium and rocuronium, administered after thiopental, do not produce clinically relevant changes in cerebral blood flow velocity.

Intraosseous vascular access is a time-tested procedure that is reemerging in popularity. This is primarily a result of the emphasis on intraosseous access in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Advanced Cardiac Life Support. Modern intraosseous insertion devices are easy to learn and use, suggesting the possibility of use beyond the resuscitation setting. We present a case series of recent intraosseous insertions for a variety of indications by anesthesiologists at our institution to demonstrate the potential utility of this alternative access technique.

Purpose The purpose of this study was to assess the effectiveness of high-fidelity simulation for teaching root cause analysis (RCA) in graduate medical education. Methods Thirty clinical anesthesiology-1 through clinical anesthesiology-3 residents were randomly assigned to 2 groups: group A participants received a 10-minute lecture on RCA and participated in a simulation exercise where a medical error occurs, and group B participants received the 10-minute lecture on RCA only. Participants completed baseline, postintervention, and 6-month follow-up assessments, and they were evaluated on their attitude toward as well as understanding of RCA and “systems-based” care. Results All 30 residents completed the surveys. Baseline attitudes and knowledge scores were similar between groups. Postintervention knowledge scores were also similar between groups; however, group B was significantly more skeptical (P Conclusion High-fidelity simulation in conjunction with focused didactics is an effective strategy for teaching RCA and systems theory in graduate medical education. Our findings also suggest that there is greater retention of knowledge and increased positive attitude toward systems improvement when focused didactics are coupled with a high-fidelity simulation exercise.

Patients with tracheotomies are managed by a wide variety of healthcare professionals. As a result, information regarding best practice is scattered throughout the medical literature and can be difficult to identify and implement in the clinical setting. Tracheotomy Management: A Multidisciplinary Approach is a practical review of all tracheotomy procedures and acute and chronic tracheotomy care. It combines evidence-based practice and expert opinion to create an invaluable hands-on guide for any healthcare provider managing patients with tracheotomies. Each chapter is authored by at least two different subspecialists, contains case studies with real-life examples of problematic clinical scenarios, and is enhanced by high quality images. The rationale for different approaches is discussed to guide the decision-making process. Written and edited by tracheotomy experts from a wide variety of disciplines, Tracheotomy Management: A Multidisciplinary Approach is essential reading for anesthesiologists, nurse anesthetists and critical care and emergency physicians.

This section of the 2010 AHA Guidelines for CPR and ECC addresses cardiac arrest in situations that require special treatments or procedures beyond those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). We have included 15 specific cardiac arrest situations. The first several sections discuss cardiac arrest associated with internal physiological or metabolic conditions, such as asthma (12.1), anaphylaxis (12.2), pregnancy (12.3), morbid obesity (12.4), pulmonary embolism (PE) (12.5), and electrolyte imbalance (12.6). The next several sections relate to resuscitation and treatment of cardiac arrest associated with external or environmentally related circumstances, such as ingestion of toxic substances (12.7), trauma (12.8), accidental hypothermia (12.9), avalanche (12.10), drowning (12.11), and electric shock/lightning strikes (12.12). The last 3 sections review management of cardiac arrest that may occur during special situations affecting the heart, including percutaneous coronary intervention (PCI) (12.13), cardiac tamponade (12.14), and cardiac surgery (12.15). Asthma is responsible for more than 2 million visits to the emergency department (ED) in the United States each year, with 1 in 4 patients requiring admission to a hospital.1 Annually there are 5,000 to 6,000 asthma-related deaths in the United States, many occurring in the prehospital setting.2 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.3 This section focuses on the evaluation and treatment of patients with near-fatal asthma. Several consensus groups have developed excellent guidelines for the management of asthma that are available on the World Wide Web: ### Pathophysiology The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with …

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

Optimizing the links in the Chain of Survival improves outcomes and saves lives. The use of evidence-based education and implementation strategies will allow organizations and communities to strengthen these links in the most effective and efficient manner.

Historically, basic medical, nursing, and other healthcare training started with the mastery of a specified body of didactic material demonstrated by successful completion of written, often multiple choice, tests in each subject area. Next, basic patient evaluation and treatment in a clinical setting with expert guidance and feedback provided by experienced clinicians was coupled with directed reading and/or lectures. Evaluation consisted of more written exams, and perhaps a clinical grade that encompassed the faculty’s overall impression of the student’s clinical performance. If successful, the student would progress to specialty training with a focused apprenticeship in the area of interest. Board exams were viewed as an end-point designating competency for future practice. Ongoing education was largely left up to the initiative of the individual, or perhaps to the local requirements of the workplace, and measured in hours of continuing education.

Crisis resource management (CRM) is a team-training program that teaches nontechnical skills such as: collaboration, communication, task management, teamwork, and leadership. The purpose of this study was to evaluate improvement in the nontechnical skills of a multidisciplinary team of pediatric residents, anesthesiology residents and pediatric nurses following participation in the CRM educational program. Self-efficacy theory guided the teaching method used in the CRM program. The Collaboration and Satisfaction about Care Decisions instrument and the Anesthetists' Nontechnical Skills System served as outcome measures. Seven multidisciplinary groups were studied with a total of 40 subjects. A significant increase was found in posttest scores for perceived collaboration and satisfaction with care and in numerical ratings of observed team skills following the CRM program. The results suggest multidisciplinary team participation in the CRM program increased perceived team collaboration, satisfaction with care, and observed teamwork skills.

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.