COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought

The world is facing a massive burden from the coronavirus disease 2019 (COVID-19) pandemic. Governments took the extraordinary step of locking down their own countries to curb the spread of the coronavirus. After weeks of severe restrictions, countries have begun to relax their strict lockdown measures. However, reopening will not be back to normal. Simulation facilities (SF) are training spaces that enable health professionals and students to learn skills and procedures in a safe and protected environment. Today's clinicians and students have an expectation that simulation laboratories are part of lifelong healthcare education. There is great uncertainty about how COVID-19 will impact future training in SF. In particular, the delivery of training activities will benefit of adequate safety measures implemented for all individuals involved. This paper discusses how to safely reopen SF in the post-lockdown phase

A year in review in Minerva Anestesiologica 2014

Year in revie

Astroglial excitability and gliotransmission: an appraisal of Ca2+ as a signalling route

Astroglial cells, due to their passive electrical properties, were long considered subservient to neurons and to merely provide the framework and metabolic support of the brain. Although astrocytes do play such structural and housekeeping roles in the brain, these glial cells also contribute to the brain's computational power and behavioural output. These more active functions are endowed by the Ca2+-based excitability displayed by astrocytes. An increase in cytosolic Ca2+ levels in astrocytes can lead to the release of signalling molecules, a process termed gliotransmission, via the process of regulated exocytosis. Dynamic components of astrocytic exocytosis include the vesicular-plasma membrane secretory machinery, as well as the vesicular traffic, which is governed not only by general cytoskeletal elements but also by astrocyte-specific IFs (intermediate filaments). Gliotransmitters released into the ECS (extracellular space) can exert their actions on neighbouring neurons, to modulate synaptic transmission and plasticity, and to affect behaviour by modulating the sleep homoeostat. Besides these novel physiological roles, astrocytic Ca2+ dynamics, Ca2+-dependent gliotransmission and astrocyte–neuron signalling have been also implicated in brain disorders, such as epilepsy. The aim of this review is to highlight the newer findings concerning Ca2+ signalling in astrocytes and exocytotic gliotransmission. For this we report on Ca2+ sources and sinks that are necessary and sufficient for regulating the exocytotic release of gliotransmitters and discuss secretory machinery, secretory vesicles and vesicle mobility regulation. Finally, we consider the exocytotic gliotransmission in the modulation of synaptic transmission and plasticity, as well as the astrocytic contribution to sleep behaviour and epilepsy

Lego® bricks assisted training of the novice debriefers [version 1; peer review: 2 approved, 1 approved with reservations]

Lego® Serious Play® is a guided workshop in which participants construct Lego creations to represent symbolic and metaphorical ideas in response to assignments. How to encourage inexperienced debriefers to concentrate on dialogue and communications strategies rather than engage in an unstructured debate on technical or behavioral abilities is one of the main challenges in training people to debrief a high-fidelity simulation session. We explore the use of Lego bricks in this study to build straightforward, standardised situations that debriefers in training can use to practice leading discussion. With this method, the different debriefing methodologies may be practiced focusing exclusively on method and dialogue, without getting involved or having to concentrate on the technical aspects

Objective Evaluation of a New Epidural Simulator by the CompuFlo® Epidural Instrument

Background. In this study, we describe a custom-made new epidural simulator, created by modifying the inner structure of a commercially available one, in the attempt to make it adequately realistic. To validate and evaluate the realism of our device, we used the Computerized Epidural Instrument CompuFlo. Method. The Compuflo CompuFlo curves obtained from 64 experiments on the epidural simulator were compared to 64 curves obtained from a previous human study, from consecutive laboring parturients requesting epidural analgesia. Results. Epidural simulator and human pressure curves were very similar. There was a significant difference between the drop of pressure due to false and true loss of resistance (LOR) in both the groups. Discussion. Our simulator can realistically reproduce the anatomical layers the needle must pass as demonstrated by the similarity between the simulator and human pressure curves and the small differences of pressure values recorded. CompuFlo may be used as an objective tool to create and assess and compare objectively the epidural task trainers

Maintaining Neonatal Normothermia during WHO Recommended Skin-to-Skin Contact in the Setting of Cesarean Section under Regional Anesthesia

ABSTRACT This study compared mothers' and newborns' temperatures (T) when the WHO recommended skin-to-skin contact (SSC) was practiced during cesarean section under regional anesthesia. 139 neonates were randomized to be left in their mothers' arms warmed by a forced air warmer (SSC-FAW) or put in an incubator. Maternal and newborn rectal T was recorded immediately after birth, at 5, 10 and 15 minute intervals. Maternal and neonatal T was comparable between the groups. FAW is as effective as an incubator in preventing neonatal hypothermia while the mother is undergoing surgery in the operating room, while favouring SSC

Mantaining neonatal normothermia during WHO recommended skin-to-skin contact in the setting of cesarean section under regional anesthesia

ABSTRACT This study compared mothers' and newborns' temperatures (T) when the WHO recommended skin-to-skin contact (SSC) was practiced during cesarean section under regional anesthesia. 139 neonates were randomized to be left in their mothers' arms warmed by a forced air warmer (SSC-FAW) or put in an incubator. Maternal and newborn rectal T was recorded immediately after birth, at 5, 10 and 15 minute intervals. Maternal and neonatal T was comparable between the groups. FAW is as effective as an incubator in preventing neonatal hypothermia while the mother is undergoing surgery in the operating room, while favouring SSC

Programmed Intermittent Epidural Bolus Versus Continuous Epidural Infusion for Labor Analgesia: The Effects on Maternal Motor Function and Labor Outcome. A Randomized Double-Blind Study in Nulliparous Women

BACKGROUND: Programmed intermittent epidural anesthetic bolus (PIEB) technique may result in reduced total local anesthetic consumption, fewer manual boluses, and greater patient satisfaction compared with continuous epidural infusion (CEI). In this randomized, double-blind study, we compared the incidence of motor block and labor outcome in women who received PIEB or CEI for maintenance of labor analgesia. The primary outcome variable was maternal motor function and the secondary outcome was mode of delivery. METHODS: Nulliparous, term women with spontaneous labor and cervical dilation <4 cm were eligible to participate in the study. Epidural analgesia was initiated and maintained with a solution of levobupivacaine 0.0625% with sufentanil 0.5 μg/mL. After an initial epidural loading dose of 20 mL, patients were randomly assigned to receive PIEB (10 mL every hour beginning 60 minutes after the initial dose) or CEI (10 mL/h, beginning immediately after the initial dose) for the maintenance of analgesia. Patient-controlled epidural analgesia (PCEA) using a second infusion pump with levobupivacaine 0.125% was used to treat breakthrough pain. The degree of motor block was assessed in both lower extremities using the modified Bromage score at regular intervals throughout labor; the end point was any motor block in either limb. We also evaluated PCEA bolus doses and total analgesic solution consumption. RESULTS: We studied 145 subjects (PIEB = 75; CEI = 70). Motor block was reported in 37% in the CEI group and in 2.7% in the PIEB group (P < 0.001; odds ratio = 21.2; 95% CI: 4.9-129.3); it occurred earlier (P = 0.008) (hazard ratio = 7.8; 95% CI: 1.9-30.8; P = 0.003) and was more frequent at full cervical dilation in the CEI group (P < 0.001). The incidence of instrumental delivery was 20% for the CEI group and 7% for the PIEB group (P = 0.03). Total levobupivacaine consumption, number of patients requiring additional PCEA boluses, and mean number of PCEA boluses per patient were lower in the PIEB group (P < 0.001). No differences in pain scores and duration of labor analgesia were observed. CONCLUSIONS: Maintenance of epidural analgesia with PIEB compared with CEI resulted in a lower incidence of maternal motor block and instrumental vaginal delivery

Differentiating False Loss of Resistance from True Loss of Resistance While Performing the Epidural Block with the CompuFlo® Epidural Instrument

Background. The occurrence of false losses of resistance may be one of the reasons for inadequate or failed epidural block. A CompuFlo® epidural instrument has been introduced to measure the pressure of human tissues in real time at the orifice of a needle and has been used as a tool to identify the epidural space. The aim of this study was to investigate the sensitivity and the specificity of the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance encountered during the epidural space identification procedure. Method. We performed epidural block with the CompuFlo® epidural instrument in 120 healthy women who requested labor epidural analgesia. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase in the pitch of the audible tone) was followed by a sudden and sustained drop in pressure for more than 5 seconds accompanied by a sudden decrease in the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau. We evaluate the sensitivity, specificity, and positive and negative predictive values of the ability of CompuFlo® recordings to correctly identify the true LOR from the false LOR. Results. The drop in pressure associated with the epidural space identification was significantly greater than that recorded after the false loss of resistance (73% vs 33%) (P=0.000001). The sensitivity was 0.83, and the AUC was 0.82. Discussion. We have confirmed the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance and established its specificity and sensitivity. Conclusion. An easier identification of dubious losses of resistance during the epidural procedure is essential to reduce the number of epidural attempts and/or needle reinsertions with the potential of a reduced risk of accidental dural puncture especially in difficult cases or when the procedure is performed by trainees