Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care

Critically ill patients are frequently prescribed sedatives and analgesics to ensure patient safety, to relieve pain and anxiety, to reduce stress and oxygen consumption, and to prevent patient ventilator dysynchrony. Recent studies have revealed that these medications themselves contribute to worsening clinical outcomes. An evidence-based organizational approach referred to as the ABCDE bundle (Awakening and Breathing Coordination of daily sedation and ventilator removal trials; Choice of sedative or analgesic exposure; Delirium monitoring and management; and Early mobility and Exercise) is presented in this commentary

Use of a Portable Functional Near-Infrared Spectroscopy (fNIRS) System to Examine Team Experience During Crisis Event Management in Clinical Simulations

Objective: The aim of this study was to investigate the utilization of a portable functional near-infrared spectroscopy (fNIRS) system, the fNIRS PioneerTM, to examine team experience in high-fidelity simulation-based crisis event management (CEM) training for anesthesiologists in operating rooms.Background: Effective evaluation of team performance and experience in CEM simulations is essential for healthcare training and research. Neurophysiological measures with wearable devices can provide useful indicators of team experience to compliment traditional self-report, observer ratings, and behavioral performance measures. fNIRS measured brain blood oxygenation levels and neural synchrony can be used as indicators of workload and team engagement, which is vital for optimal team performance.Methods: Thirty-three anesthesiologists, who were attending CEM training in two-person teams, participated in this study. The participants varied in their expertise level and the simulation scenarios varied in difficulty level. The oxygenated and de-oxygenated hemoglobin (HbO and HbR) levels in the participants’ prefrontal cortex were derived from data recorded by a portable one-channel fNIRS system worn by all participants throughout CEM training. Team neural synchrony was measured by HbO/HbR wavelet transformation coherence (WTC). Observer-rated workload and self-reported workload and mood were also collected.Results: At the individual level, the pattern of HbR level corresponded to changes of workload for the individuals in different roles during different phases of a scenario; but this was not the case for HbO level. Thus, HbR level may be a better indicator for individual workload in the studied setting. However, HbR level was insensitive to differences in scenario difficulty and did not correlate with observer-rated or self-reported workload. At the team level, high levels of HbO and HbR WTC were observed during active teamwork. Furthermore, HbO WTC was sensitive to levels of scenario difficulty.Conclusion: This study showed that it was feasible to use a portable fNIRS system to study workload and team engagement in high-fidelity clinical simulations. However, more work is needed to establish the sensitivity, reliability, and validity of fNIRS measures as indicators of team experience

A simulation-based curriculum to introduce key teamwork principles to entering medical students

Abstract Background Failures of teamwork and interpersonal communication have been cited as a major patient safety issue. Although healthcare is increasingly being provided in interdisciplinary teams, medical school curricula have traditionally not explicitly included the specific knowledge, skills, attitudes, and behaviors required to function effectively as part of such teams. Methods As part of a new “Foundations” core course for beginning medical students that provided a two-week introduction to the most important themes in modern healthcare, a multidisciplinary team, in collaboration with the Center for Experiential Learning and Assessment, was asked to create an experiential introduction to teamwork and interpersonal communication. We designed and implemented a novel, all-day course to teach second-week medical students basic teamwork and interpersonal principles and skills using immersive simulation methods. Students’ anonymous comprehensive course evaluations were collected at the end of the day. Through four years of iterative refinement based on students’ course evaluations, faculty reflection, and debriefing, the course changed and matured. Results Four hundred twenty evaluations were collected. Course evaluations were positive with almost all questions having means and medians greater than 5 out of 7 across all 4 years. Sequential year comparisons were of greatest interest for examining the effects of year-to-year curricular improvements. Differences were not detected among any of the course evaluation questions between 2007 and 2008 except that more students in 2008 felt that the course further developed their “Decision Making Abilities” (OR 1.69, 95% CI 1.07–2.67). With extensive changes to the syllabus and debriefer selection/assignment, concomitant improvements were observed in these aspects between 2008 and 2009 (OR = 2.11, 95% CI: 1.28–3.50). Substantive improvements in specific exercises also yielded significant improvements in the evaluations of those exercises. Conclusions This curriculum could be valuable to other medical schools seeking to inculcate teamwork foundations in their medical school’s preclinical curricula. Moreover, this curriculum can be used to facilitate teamwork principles important to inter-disciplinary, as well as uni-disciplinary, collaboration

Additional file 1: Table S1. of A simulation-based curriculum to introduce key teamwork principles to entering medical students

Exercises Used in Teamwork Day 2007 and 2008. (PDF 203 kb

Additional file 3: Table S3. of A simulation-based curriculum to introduce key teamwork principles to entering medical students

Yearly Comparison of Exercises (P values). (PDF 277 kb

In Response

McEvoy MD, Thies K-C, Einav S, et al. In Response. Anesthesia & Analgesia. 2018;127(4):e70-e71

Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1

Cardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure. In this setting, there can be formulation of a differential diagnosis and a directed intervention that treats the likely underlying cause(s) of the crisis while concurrently managing the crisis itself. Management of cardiac arrest of the perioperative patient is predicated on expert opinion, physiologic rationale, and an understanding of the context in which these events occur. Resuscitation algorithms should consider the evaluation and management of these causes of crisis in the perioperative setting