Comparison of nontechnical skills grading rubrics for OR in situ simulation for general surgery and Obstetrician/Gynecologist residents

BACKGROUND

This study utilized the Team Strategies and Tools to Enhance Performance and Patient Safety and the Nontechnical Skills for Surgeons grading systems to evaluate the nontechnical skills of general surgery and obstetrician/gynecologist residents to see if these grading systems were concordant. These simulations were also intended to teach about crisis resources available at our institution.

METHODS

Nineteen teams were created consisting of either one general surgery resident or 2 Obstetrician/Gynecologist residents plus 2 Anesthesia residents and 2 to 4 nurses. Each team was given a short briefing on Team Strategies and Tools to Enhance Performance and Patient Safety, then performed 2 simulated operating room crises. All exercises were graded by 2 independent observers with experience in the operating room and in using the Team Strategies and Tools to Enhance Performance and Patient Safety and Nontechnical Skills for Surgeons grading systems.

RESULTS

Averaged general surgery Team Strategies and Tools To Enhance Performance and Patient Safety score increased between scenarios (14.3-17; P ≤ .01), as did obstetrician/gynecologist Team Strategies and Tools to Enhance Performance and Patient Safety score (14.9-19.2; P ≤ .01). Averaged general surgery Nontechnical Skills for Surgeons score increased between scenarios (10.3-12.2; P ≤ .02), as did obstetrician/gynecologist Nontechnical Skills for Surgeons score (10.2-14.3; P ≤ .01). Surgery Team Strategies and Tools to Enhance Performance and Patient Safety scores demonstrated a strong correlation of movement with Nontechnical Skills for Surgeons scores (r = 0.83), as did obstetrician/gynecologist (r = 0.91). On average both general surgery (11%-100%; P ≤ .01) and obstetrician/gynecologist (50%-90%; P ≤ .01) saw a statistically significant increase in their awareness of the crisis checklist.

CONCLUSION

Team Strategies and Tools to Enhance and Patient Safety scores and Nontechnical Skills for Surgeons are effective and concordant tools for gauging general surgery and obstetrician/gynecologist resident nontechnical skills. In situ simulations are an effective way to teach general surgery and obstetrician/gynecologist residents about available crisis resources.

Pumpless arteriovenous extracorporeal membrane oxygenation: A novel mode of respiratory support in a lamb model of congenital diaphragmatic hernia

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is commonly required in neonates with congenital diaphragmatic hernia (CDH) complicated by pulmonary hypertension (PH). ECMO carries significant risk, and is contraindicated in the setting of extreme prematurity or intracranial hemorrhage. Pumpless arteriovenous ECMO (P-ECMO) may represent an alternative for respiratory support. The present study summarizes our initial experience with P-ECMO in a lamb model of CDH.

STUDY DESIGN

Surgical creation of CDH was performed at 65-75days' gestation. At term (135-145days), lambs were delivered into the P-ECMO circuit. Three animals were maintained on a low-heparin infusion protocol (target ACT 160-180) and three animals were maintained with no systemic heparinization.

RESULTS

Animals were supported by the circuit for 380.7 +/- 145.6h (range, 102-504h). Circuit flow rates ranged from 97 to 208ml/kg/min, with adequacy of organ perfusion demonstrated by stable serum lactate levels (3.0 +/- 1.7) and pH (7.4 +/- 0.3). Necropsy demonstrated no evidence of thrombogenic complications.

CONCLUSION

Pumpless extracorporeal membrane oxygenation achieved support of CDH model lambs for up to three weeks. This therapy has the potential to bridge neonates with decompensated respiratory failure to CDH repair with no requirement for systemic anticoagulation, and may be applicable to patients currently precluded from conventional ECMO support.

Mammalian cardiac regeneration after fetal myocardial infarction requires cardiac progenitor cell recruitment

BACKGROUND

In contrast to the adult, fetal sheep consistently regenerate functional myocardium after myocardial infarction. We hypothesize that this regeneration is due to the recruitment of cardiac progenitor cells to the infarct by stromal-derived factor-1α (SDF-1α) and that its competitive inhibition will block the regenerative fetal response.

METHODS

A 20% apical infarct was created in adult and fetal sheep by selective permanent coronary artery ligation. Lentiviral overexpression of mutant SDF-1α competitively inhibited SDF-1α in fetal infarcts. Echocardiography was performed to assess left ventricular function and infarct size. Cardiac progenitor cell recruitment and proliferation was assessed in fetal infarcts at 1 month by immunohistochemistry for nkx2.5 and 5-bromo-2-deoxyuridine.

RESULTS

Competitive inhibition of SDF-1α converted the regenerative fetal response into a reparative response, similar to the adult. SDF-inhibited fetal infarcts demonstrated significant infarct expansion by echocardiography (p < 0.001) and a significant decrease in the number of nkx2.5+ cells repopulating the infarct (p < 0.001).

CONCLUSIONS

The fetal regenerative response to myocardial infarction requires the recruitment of cardiac progenitor cells and is dependent on SDF1α. This novel model of mammalian cardiac regeneration after myocardial infarction provides a powerful tool to better understand cardiac progenitor cell biology and to develop strategies to cardiac regeneration in the adult.