[Patient simulation for hand therapy in an anesthesiologist after an occupational injury: A case study]

We described the use of clinical simulation for hand therapy in an anesthesiologist that accidentally suffered from entrapment with the surgical table in the right thumb and underwent a partial toe-to-hand autograft. At week 14 after surgery, the patient practiced anesthetic tasks and clinical scenarios using a patient simulator instead undergoing a regular occupational therapy regimen. Quantifiable physical, functional and psychological measures improved during and after the simulation intervention, and there was no decline one month after the patient returned to work. The use of clinical simulation as part of the rehabilitation process of an anesthesiologist after hand injury contributed to improving the range of motion, strength, sensibility, and functional tests. Overall, it played an important role in determining the worker's potential to withstand the demands of anesthesia practice.

Role of 3D printing for the protection of surgical and critical care professionals in the COVID-19 pandemic

Antecedentes y objetivo

Durante la pandemia de COVID-19 se produce una reducción del material para la protección de los profesionales. La impresión 3D ofrece la posibilidad de compensar la escasez de algunos de los suministros. El objetivo es describir el papel de la impresión 3D en un servicio de salud durante la pandemia de COVID-19, con énfasis en proceso para desarrollar un producto final listo para ser implementado en el entorno clínico.

Materiales y métodos

Se formó un grupo de trabajo entre la administración sanitaria, clínicos y otras instituciones público-privadas de Cantabria coordinado en el Hospital virtual Valdecilla. El proceso incluyó la recepción de las propuestas de impresión, el conocimiento de los recursos de impresión en la región, la selección de los dispositivos, la creación de un equipo para cada proyecto, diseño de prototipos, evaluación y rediseño, fabricación montaje y distribución.

Resultados

Se producen 1) dispositivos que ayudan a prevenir el contagio de los profesionales: pantallas de protección facial (2.400 unidades), accesorios personalizados para fotóforos (20 unidades) y horquillas salvaorejas para mascarillas (1.200 unidades); 2) productos relacionados con la ventilación de pacientes infectados: conectores de sistemas de ventilación no invasiva entre tubuladura y mascarilla; y 3) hisopos oro y nasofaríngeos (7.500 unidades) para la identificación de portadoras del coronavirus con el objetivo de diseñar protocolos de actuación en las área clínicas.

Conclusiones

La impresión 3D es un recurso válido para la producción de material de protección de los profesionales cuyo suministro está reducido durante una pandemia.

[Simulation as a tool to facilitate change in healthcare organisations]

OBJECTIVE

To describe the use of simulation as a tool to support the strategic management of change in the Cantabrian Regional Health Service in Spain.

METHODS

A working group was created to: 1) define the strategic areas of innovation and change; 2) establish criteria for the selection of proposals that can be addressed with simulation; 3) analyse and select the proposals; 4) design and implement the simulation programs, and 5) evaluate results.

RESULTS

The constantly changing needs of the regional health system enabled 6 strategic areas to be identified during 2017-208: 1) efficient use of resources; 2) implementation of health plans of interest in the community; 3) patient safety improvement; 4) management of health personnel; 5) development of new professional skills, and 6) selection and implementation of new technology.

CONCLUSIONS

Clinical simulation is a useful tool to promote innovation strategies in healthcare, facilitating the adaptation of professionals and patients to change.

Emotional response to a high-fidelity trauma simulation: An observational study

INTRODUCTION

The emotional environment created during a simulation session can influence learning. Positive emotions improve perceptual processing and facilitate learning, while negative emotions can reduce working memory, resulting in poorer learning outcomes.

OBJECTIVES

The aim of this study was to investigate the impact of simulation training on emotions during all phases of a high-fidelity simulation using standard prebriefing and «good judgement debriefing » techniques.

METHODS

This was an observational study that included 74 anesthesiologists participating in a simulation-based training. A standardized prebriefing was followed by «good judgement debriefing». In order to assess emotions, we used the circumplex model of emotion, and asked participants to complete the affect grid scale before prebriefing (Stage 1), before starting the simulation (Stage 2), before debriefing (Stage 3) and following debriefing (Stage 4).

RESULTS

The affect grid scores obtained from 67 participants were analyzed. Following debriefing, the experience of the polytrauma patient simulation was significantly more pleasant compared to previous stages (P<0.01). In addition, participants perceived the activity as becoming increasingly active as it progressed (P<0.01).

CONCLUSIONS

High-fidelity trauma simulation creating a safe environment using a standardized prebriefing and «good judgement debriefing» is experienced as a pleasant and active activity at all stages of the simulation. Further investigation is needed to assess the impact of these results on learning.

Learning outcomes evaluation of a simulation-based introductory course to anaesthesia

OBJECTIVE

An increased number of errors and reduced patient safety have been reported during the incorporation of residents, as this period involves learning new skills. The objectives were to evaluate the learning outcomes of an immersive simulation boot-camp for incoming residents before starting the clinical rotations. Airway assessment, airway control with direct laryngoscopy, and epidural catheterization competencies were evaluated.

MATERIAL AND METHOD

Twelve first-year anaesthesiology residents participated. A prospective study to evaluate transfer of endotracheal intubation skills learned at the simulation centre to clinical practice (primary outcome) was conducted. A checklist of 28 skills and behaviours was used to assess the first supervised intubation performed during anaesthesia induction in ASA I/II patients. Secondary outcome was self-efficacy to perform epidural catheterization. A satisfaction survey was also performed.

RESULTS

Seventy-five percent of residents completed more than 21 out of 28 skills and behaviours to assess and control the airway during their first intubation in patients. Twelve items were performed by all residents and 5 by half of them. More than 83% of participants reported a high level of self-efficacy in placing an epidural catheter. All participants would recommend the course to their colleagues.

CONCLUSIONS

A focused intensive simulation-based boot-camp addressing key competencies required to begin anaesthesia residency was well received, and led to transfer of airway management skills learned to clinical settings when performing for first time on patients, and to increased self-reported efficacy in performing epidural catheterization.

The making of expert clinicians: reflective practice

Debriefing is a rigorous reflection process which helps trainees recognize and resolve clinical and behavioral dilemmas raised by a clinical case. This approach emphasizes eliciting trainees'assumptions about the situation and their reasons for performing as they did (mental models). It analyses their impact on actions, to understand if it is necessary to maintain them or construct new ones that may lead to better performance in the future. It blends evidence and theory from education research, the social and cognitive sciences, and experience drawn from conducting and teaching debriefing to clinicians worldwide, on how to improve professional effectiveness through "reflective practice".

[Bringing clinical simulation into anesthesiology and postoperative recovery care residency training]

This article describes the use of clinical simulations for training residents in anesthesiology and postoperative recovery care at Hospital Universitario Marqués de Valdecilla. A working group defined criteria for the competencies residents would acquire by means of simulation training, designed the scenarios to be used, and took responsibility for coordinating and funding the program. We used the platform of the Critical Events Training Center of the Marcelino Botin Foundation, now part of our center's virtual hospital. The simulation-based training modules include 4 activities in the residents' first year, 3 in each of the second and third years, and 4 in the fourth year; all center on acquisition of the identified competencies and take into consideration the time availability of residents and instructors and the budget. We have concluded that integrating clinical simulations into residency training is a challenge for educators, given that a large part of the benefit derived from this tool comes from complementing it with other instructional resources and adapting it to the syllabus. More studies are required to establish criteria to guide the integration of this tool into the curriculum in those areas of the specialty where it can work most efficiently; the effectiveness of the approach also needs to be assessed. Simulations facilitate training without putting patients at risk and provide residents with early exposure to situations that might otherwise be difficult to observe. This tool also encourages the practice of reflective clinical decision-making.

Electronic properties of polyoxometalates: a DFT study of alpha/beta-[XM(12)O(40)](n-) relative stability (M=W, Mo and X a main group element)

Keggin heteropolyanions [XM(12)O(40)](n-) have various isomeric structures, alpha and beta being the most common. Conventionally, the alpha structure appears to be the most stable, but calculations carried out at the DFT level for X = P(V), Si(IV), Al(III), As(V), Ge(IV), and Ga(III) and M = W(VI) and Mo(VI) show that this stability depends on several factors, particularly on the nature of the heteroatom (X) and the total charge of the cluster. In this paper, we apply the clathrate model to the Keggin molecule to carry out a fragment-interaction study to elucidate when and why the traditional relative stability of various isomers can be inverted. The fully oxidized anions that have inverted the traditional stability trend in this series are [AlW(12)O(40)](5-) and [GaW(12)O(40)](5-), both of which contain a third-group heteroatom and an overall charge of -5. beta-isomers are always more easily reduced than alpha-isomers. This experimental observation suggests that reduction favors the stability of beta-isomers and one of the most important results of this study is that the alpha/beta inversion is achieved in most cases after the second reduction. The alpha- and beta-isomers may have different properties because the energy of the LUMO, a symmetry-adapted d(xy)-metal orbital, is different.

Electronic and magnetic properties of alpha-Keggin anions: A DFT study of [XM12O40](n-), (M = W, Mo; X = Al(III), Si(IV), P(V), Fe(III), Co(II), Co(III)) and [SiM11VO40](m- (M = Mo and W)

Calculations based on density functional theory (DFT) have been carried out to investigate the electronic and magnetic properties of the alpha-Keggin anions mentioned in the title. The atomic populations and the distribution of the electron density computed for the studied clusters support the hypothesis that an oxidized Keggin anion is an XO(4)(n-) clathrate inside a neutral M(12)O(36) cage. The energy gap between the band of occupied orbitals, formally delocalized over the oxo ligands, and the unoccupied d-metal orbitals, delocalized over the addenda, has been found to be independent of the central ion. However, substitution of a W or a Mo by V modifies the relative energy of the LUMO and then induces important changes in the redox properties of the cluster. In agreement with the most recent X-ray determination of [Co(III)W(12)O(40)](5-) and with the simplicity of the (183)W NMR and (17)O NMR spectra observed for this anion the calculations suggest that [Co(III)W(12)O(40)](5-) has a slightly distorted T(d ) geometry. For the parent cluster [CoW(12)O(40)](6-) the quadruplet corresponding to the anion encapsulating a Co(II) was found to be approximately 1 eV more stable than the species formed by a Co(III) and 1 e delocalized over the sphere of tungstens. The one-electron reduction of [Co(II)W(12)O(40)](6-) and [Fe(III)W(12)O(40)](5-) leads to the formation of the 1 e blue species [Co(II)W(12)O(40)](7-) and [Fe(III)W(12)O(40)](6-). The blue-iron cluster is considerably antiferromagnetic, and in full agreement with this behavior the low-spin state computed via a Broken Symmetry approach is 196 cm(-1) lower than the high-spin solution. In contrast, the cobalt blue anion has a low ferromagnetic coupling with an S-T energy gap of +20 cm(-1). This blue species is more stable than the alternative reduction product [Co(I)W(12)O(40)](7-) by more than 0.7 eV.

[Ambulatory septoplasty]

The AA. admit that the septoplasty under general anaesthesia is a surgical procedure that can be realized ambulatory, without added risks to patient. With viewpoint they have done a retrospective survey of the whole group of septoplasties performed under general anaesthesia at Torrelavega Hospital (Santander) in two years, between April 1995 and August 1997. The total number of cases amounted 56 (49 men and 7 women), lasting the procedure, more or less, one hour; postanaesthesia recovery also about 86 minutes and the hospital permanence about six hours and a half. Readmitted were 14 cases, because vomiting (7), for laryngeal spasm (2), bleeding (1), retention of urine (1) and other because vertigo (1), fever (1) and headache (1).

[Major ambulatory surgery in otorhinolaryngology]

In the last years we have witnessed a great increase of major ambulatory surgery procedures in our specialty. Some of them are very common as adenoidectomies, tonsillectomies and also the insertion of transtympanic tubes. Nevertheless there is no agreement about which of the procedures should be realized through AMS. The aim of this work is to do a review on the most important features involved in AMS entlightening what kind of operations can be included i such programmes.

[Ambulatory laryngeal microsurgery]

OBJECTIVE

The aim of the present study was to determine if laryngeal microsurgery (LMS) under general anesthesia is a safe and convenient procedure when carried out on an outpatient basis in selected patients.

MATERIAL AND METHODS

Seventy-eight adult patients (60 men and 18 women) were scheduled for outpatient LMS under general anesthesia between February 1995 and December 1996.

RESULTS

Their age range was 19 to 77 years (mean 48 years). Forty-four (56.4%) were ASA I, 32 (41%) ASA II, and 2 (2.6%) ASA III. Laryngeal biopsy was performed in 40 cases (51.3%), polypectomy in 30 cases (38.5%), excision of Reinke's edema in 5 cases (6.4%), and cyst excision in 3 cases (3.8%). The mean stay in the Day Hospital was 7 hours (range 2.5-10 h). Seven patients (9%) had immediate postoperative complications. Three patients were admitted overnight. No patient had to be readmitted to the hospital after discharge.

CONCLUSIONS

Outpatient laryngeal microsurgery is an appropriate and safe alternative to inpatient surgery in carefully selected patients, who are kept under strict observation in the immediate postoperative period.

[Cerebrospinal fluid drainage to protect the spinal cord during surgical repair of thoracoabdominal aortic aneurysm]

Spinal cord injury is a serious complication of aortic cross-clamping during thoracoabdominal aortic surgery. We report the case of a 59-year-old man whose mycotic pseudoaneurysm in the thoracoabdominal aorta was repaired surgically. Cerebrospinal fluid pressure was monitored and the fluid was drained to protect the spinal cord while the aorta was clamped. A 19-G epidural catheter was inserted into the subarachnoid space using a paramedian approach form L2-L3. The aorta was clamped at the thoracic level in the descending distal portion and at the abdominal level above the kidney, for a period of 61 minutes. A total of 65 ml of cerebrospinal fluid was drained. The early postoperative period was uneventful and tubes were removed 40 hours after surgery. The results of neurological examination were normal. One week later the patient developed a respiratory infection, which was followed by multi-organ failure and died 22 days after the operation. We discuss the case and review the various alternatives available for protecting the spinal cord during surgery on the thoracoabdominal aorta.

Could the piggyback operation in liver transplantation be routinely used?

OBJECTIVE

To determine if orthotopic liver transplantation with inferior vena cava preservation, performed without using caval cross clamping or venovenous bypass, can minimize hemodynamic instability and low renal perfusion pressure.

DESIGN

A prospective case series of 44 consecutive adult orthotopic liver transplantations, with a maximum follow-up of 30 months.

SETTING

An institutional university referral center.

PATIENTS

Between November 1990 and May 1993, 39 consecutive adult liver transplant recipients underwent transplantation with the following primary diagnoses: alcoholic cirrhosis (n = 23), viral cirrhosis (n = 9), primary biliary cirrhosis (n = 2), Wilson's disease (n = 2), primary sclerosing cholangitis (n = 1), fulminant hepatic failure (n = 1), and secondary hepatic malignant neoplasm (n = 1); five had repeated orthotopic liver transplantation.

INTERVENTION

Orthotopic liver transplantations were performed using the piggyback technique, but with placement of the vascular clamp on the inferior vena cava laterally instead of across it so that it remained patent throughout the anhepatic stage. Favorable anatomic conditions in the recipients were not considered; venovenous bypass was not used.

MAIN OUTCOME MEASURES

Intraoperative hemodynamic profile, blood loss and replacement, surgical time and complications, and patient survival.

RESULTS

No significant hemodynamic changes with lateral clamping and no increases in surgical complications, rate of retransplantation, blood product requirements, or survival rate compared with the standard procedure.

CONCLUSION

The piggyback operation could be routinely used in orthotopic liver transplantation.

[Heart rupture following thoracic blunt trauma]

We describe a 39-year-old woman who suffered rupture of the left auricula as a result of a non-penetrating chest wound received in a traffic accident. Rupture of the heart chambers after trauma is not infrequent, but survival is extremely rare. The patient was released from care and has suffered no subsequent complications.

Enhancement of opiate analgesia by nimodipine in cancer patients chronically treated with morphine: a preliminary report

The ability of nimodipine, a calcium-channel blocker, to enhance morphine analgesia and/or modify the development of tolerance was studied in patients with cancer pain who had needed successive increments of morphine for periods ranging from 21 to 780 days. Assessment of daily morphine consumption was the primary effect parameter. Nimodipine succeeded in reducing the daily dose of morphine in 16 of 23 patients (oral, n = 13; intrathecal, n = 3), and failed to modify it in 2 patients. Total oral daily dose was reduced by nimodipine (120 mg/day) from 282.6 +/- 47.7 mg to 158.7 +/- 26.2 mg (n = 15, P < 0.001). Intrathecal morphine was also reduced by 1-5 mg/day. Nimodipine was withdrawn in 5 patients during the first week of treatment due to intolerance (n = 3) or aggravation of the disease (n = 2). These preliminary results support experimental findings showing that pharmacological interference with Ca(2+)-related events may modify chronic opioid effects, including the expression of tolerance.