Design of an interface for teaching cardiovascular physiology to anesthesia clinicians with a patient simulator connected to a minimally invasive cardiac output monitor (LiDCO rapid®).

Cardiovascular physiology can be simulated in patient simulators but is limited to the simulator monitor curves and parameters, missing some important data that today is known as essential to fluid management and therapeutic decision in critical ill and high-risk surgical patients. Our main objective was to project and implement a unidirectional communication channel between a pre-existing patient simulator and a minimally invasive cardiac output monitor (LiDCO rapid®); a monitor that connects to real patients and interprets the arterial wave. To connect the patient simulator to the hemodynamic monitor, firstly, we had to assess both systems and design a communication channel between them. LiDCO monitor accepts as an input an analog voltage varying between 0 V and 5 V and that every volt is directly proportional to a blood pressure (mmHg) value ranging from 0 mmHg (0 V) to 500 mmHg (5 V). A Raspberry Pi 0 (Rpi0) with a WIFI chip integrated was needed and added to a digital analogue converter connected to the board. We designed a system that allowed us to collect, interpret and modify data, and feed it to the LiDCO rapid® monitor. We had developed a Python® script with three independent threads and a circular buffer to handle the data transmission between both systems. The LiDCO hemodynamic monitor successfully received data sent from our setup like a real patient arterial wave pulse and interpreted it to estimate several hemodynamic parameters, as cardiac output, stroke volume, systemic vascular resistance, pulse pressure variation, and stroke volume variation. The connection between the patient simulator and the LiDCO monitor is being used to create arterial curves and other hemodynamic parameters for clinical scenarios where residents and anesthesiologists can simulate a variety of unstable hemodynamic conditions, preparing them to face similar situations with real patients in a safe environment and with their own monitors.

Non-technical skills in nursing education: effectiveness of a high-fidelity simulation-based course / Competências não-instrumentais no ensino de estudantes de enfermagem: eficácia de um programa em contexto de simulação de alta-fidelidade

Literature refers that patients are commonly affected by preventable adverse events associated with non-technical skills failures. Non-technical skills training programs address to prepare for, respond to, and mitigate adverse events in healthcare. This study took place at Center for Clinical Simulation of Aveiro University. Third year prelicensure nursing students were included in two groups: control group (N=27), and experimental group (N=20, who participated in the training course developed, focusing on non-technical skills and crisis resource management acting principles). The study was divided in two different moments, before the implementation of the course, and after the implementation of the course. The course was then divided in three sessions: one four-hour theoretical session; and two three-hour practical sessions, each including two high-fidelity simulation-based different scenarios, four in total.Regarding non-technical skills, we found significant differences in the experimental group in eleven items after intervention. As per participants' self-confidence levels, those who participated seem to have significantly increased confidence in their skills. Regarding social-demographic variables, it seems that students from primary healthcare tend to present better non-technical skills than students from maternal health specialty. Overall these results seem to suggest that the course developed was effective in increasing students' knowledge and awareness on non-technical skills. It was demonstrated that the development and application of the structured course is feasible and positive changes in behavior can be measured through the instru-ments developed. Then, consideration must be given in integrating non-technical skills training into nursing education

No disponible

Propofol TCI Reductions Do Not Attenuate Significant Falls in Cardiac Output Associated With Anesthesia Induction and Knee-Chest Positioning in Spinal Surgery.

BACKGROUND: Induction of anesthesia and the knee-chest position are associated with hemodynamic changes that may impact patient outcomes. The aim of this study was to assess whether planned reductions in target-controlled infusion propofol concentrations attenuate the hemodynamic changes associated with anesthesia induction and knee-chest position. MATERILAS AND METHODS: A total of 20 patients scheduled for elective lumbar spinal surgery in the knee-chest position were included. In addition to standard anesthesia monitoring, bispectral index and noninvasive cardiac output (CO) monitoring were undertaken. The study was carried out in 2 parts. In phase 1, target-controlled infusion propofol anesthesia was adjusted to maintain BIS 40 to 60. In phase 2, there were 2 planned reductions in propofol target concentration: (1) immediately after loss of consciousness-reduction calculated using a predefined formula, and (2) before positioning-reduction equal to the average percentage decrease in CO after knee-chest position in phase 1. Changes from baseline in CO and other hemodynamic variables following induction of anesthesia and knee-chest positioning were compared. RESULTS: Induction of anesthesia led to decreases of 25.6% and 19.8% in CO from baseline in phases 1 and 2, respectively (P<0.01). Knee-chest positioning resulted in a further decrease such that the total in CO reduction from baseline to 10 minutes after positioning was 38.4% and 46.9% in phases 1 and 2, respectively (P<0.01). There was no difference in CO changes between phases 1 and 2, despite the planned reductions in propofol during phase 2. There was no significant correlation between changes in CO and mean arterial pressure. CONCLUSIONS: Planned reductions in propofol concentration do not attenuate anesthesia induction and knee-chest position-related decreases in CO. The knee-chest position is an independent risk factor for decrease in CO. Minimally invasive CO monitors may aid in the detection of clinically relevant hemodynamic changes and guide management in anesthetized patients in the knee-chest position.

Effect of Hemodynamic Changes in Plasma Propofol Concentrations Associated with Knee-Chest Position in Spinal Surgery: A Prospective Study.

BACKGROUND: Anesthesia induction and maintenance with propofol can be guided by target-controlled infusion (TCI) systems using pharmacokinetic (Pk) models. Physiological variables, such as changes in cardiac output (CO), can influence propofol pharmacokinetics. Knee-chest (KC) surgical positioning can result in CO changes. OBJECTIVES: This study aimed to evaluate the relationship between propofol plasma concentration prediction and CO changes after induction and KC positioning. METHODS: This two-phase prospective cohort study included 20 patients scheduled for spinal surgery. Two different TCI anesthesia protocols were administered after induction. In phase I (n = 9), the loss of consciousness (LOC) concentration was set as the propofol target concentration and CO changes following induction and KC positioning were quantified. In phase II (n = 11), based on data from phase I, two reductions in the propofol target concentration on the pump were applied after LOC and before KC positioning. Propofol plasma concentrations were measured at different moments in both phases: after induction and after KC positioning. RESULTS: Schnider Pk model showed a good performance in predicting propofol concentration after induction; however, after KC positioning, when a significant drop in CO occurred, the measured propofol concentrations were markedly underestimated. Intended reductions in the propofol target concentration did not attenuate HD changes. In the KC position, there was no correlation between the propofol concentration estimated by the Pk model and the measured concentration in plasma, as the latter was much higher (P = 0.013) while CO and BIS decreased significantly (P < 0.001 and P = 0.004, respectively). CONCLUSIONS: Our study showed that the measured propofol plasma concentrations during the KC position were significantly underestimated by the Schnider Pk model and were associated with significant CO decrease. When placing patients in the KC position, anesthesiologists must be aware of pharmacokinetic changes and, in addition to standard monitoring, the use of depth of anesthesia and cardiac output monitors may be considered in high-risk patients.

Non-technical skills assessment scale in nursing: construction, development and validation1.

OBJECTIVES: The introduction of non-technical skills during nursing education is crucial to prepare nurses for the clinical context and increase patient safety. We found no instrument developed for this purpose. to construct, develop and validate a non-technical skills assessment scale in nursing. METHOD: methodological research. Based on the literature review and experience of researchers on non-technical skills in healthcare and the knowledge of the principles of crisis resource management, a list of 63 items with a five-point Likert scale was constructed. The scale was applied to 177 nursing undergraduate students. Descriptive statistics, correlations, internal consistency analysis and exploratory factor analysis were performed to evaluate the psychometric properties of the scale. RESULTS: scale items presented similar values for mean and median. The maximum and the minimum values presented a good distribution amongst all response options. Most items presented a significant and positive relationship. Cronbach alpha presented a good value (0.94), and most correlations were significant and positive. Exploratory factor analysis using the Kaiser-Meyer-Olkin test showed a value of 0.849, and the Bartlett's test showed adequate sphericity values (χ2=6483.998; p=0.000). One-factor model explained 26% of the total variance. CONCLUSION: non-technical skills training and its measurement could be included in undergraduate or postgraduate courses in healthcare professions, or even be used to ascertain needs and improvements in healthcare contexts.

Non-technical skills assessment scale in nursing: construction, development and validation / Escala de avaliação de habilidades não técnicas em enfermagem: construção, desenvolvimento e validação / Escala de evaluación de habilidades no técnicas en enfermería: construcción, desarrollo y validación

ABSTRACT The introduction of non-technical skills during nursing education is crucial to prepare nurses for the clinical context and increase patient safety. We found no instrument developed for this purpose. Objectives: to construct, develop and validate a non-technical skills assessment scale in nursing. Method: methodological research. Based on the literature review and experience of researchers on non-technical skills in healthcare and the knowledge of the principles of crisis resource management, a list of 63 items with a five-point Likert scale was constructed. The scale was applied to 177 nursing undergraduate students. Descriptive statistics, correlations, internal consistency analysis and exploratory factor analysis were performed to evaluate the psychometric properties of the scale. Results: scale items presented similar values for mean and median. The maximum and the minimum values presented a good distribution amongst all response options. Most items presented a significant and positive relationship. Cronbach alpha presented a good value (0.94), and most correlations were significant and positive. Exploratory factor analysis using the Kaiser-Meyer-Olkin test showed a value of 0.849, and the Bartlett's test showed adequate sphericity values (χ2=6483.998; p=0.000). One-factor model explained 26% of the total variance. Conclusion: non-technical skills training and its measurement could be included in undergraduate or postgraduate courses in healthcare professions, or even be used to ascertain needs and improvements in healthcare contexts.

RESUMO A introdução de habilidades não técnicas durante o ensino de enfermagem é fundamental para preparar os enfermeiros para o contexto clínico e aumentar a segurança do paciente. Não foram encontrados quaisquer instrumentos desenvolvidos para essa finalidade. Objetivos: construir, desenvolver e validar uma escala de avaliação de habilidades não técnicas em enfermagem. Método: pesquisa metodológica. Com base na revisão da literatura e na experiência dos pesquisadores em habilidades não técnicas em saúde, e no conhecimento dos princípios do gerenciamento de recursos em crises, foi construída uma lista de 63 itens e com uma escala Likert de cinco pontos. A escala foi aplicada em 177 estudantes de graduação em enfermagem. Estatística descritiva, correlações, análises de consistência interna e análise fatorial exploratória foram realizadas para avaliar as propriedades psicométricas da escala. Resultados: os itens da escala apresentaram valores semelhantes para média e mediana. Os valores máximo e mínimo mostraram uma boa distribuição em todas as opções de resposta. A maioria dos itens apresentou uma relação significativa e positiva. O alfa de Cronbach apresentou um bom valor (0,94) e a maioria das correlações foi significativa e positiva. A análise fatorial exploratória através do teste de Kaiser-Meyer-Olkin apresentou um valor de 0,849, e o teste de Bartlett apresentou valores de esfericidade adequados (χ2=6483.998; p=0.000). O modelo de um fator explicou 26% da variância total. Conclusão: a formação em habilidades não técnicas e sua mensuração poderiam ser incluídos nos programas de graduação ou pós-graduação de profissões da saúde, ou até mesmo serem utilizadas para avaliar as necessidades e melhorias nos contextos de cuidados de saúde.

RESUMEN La introducción de habilidades no técnicas durante la educación de enfermería es fundamental para preparar a los enfermeros para el contexto clínico y aumentar la seguridad del paciente. No se encontraron instrumentos desarrollados para este propósito. Objetivos: construir, desarrollar y validar una escala de evaluación de habilidades no técnicas en enfermería. Método: investigación metodológica. Con base en la revisión de la literatura y la experiencia de los investigadores en habilidades no técnicas en el cuidado de la salud y el conocimiento de los principios del manejo de recursos en crisis, se construyó una lista de 63 ítems y con una escala Likert de cinco puntos. Se aplicó la escala a 177 estudiantes de pregrado en enfermería. Se realizaron estadísticas descriptivas, correlaciones, análisis de consistencia interna y análisis factorial exploratorio para evaluar las propiedades psicométricas de la escala. Resultados: los ítems de la escala presentaron valores similares para la media y la mediana. Los valores máximo y mínimo mostraron una buena distribución en todas las opciones de respuesta. La mayoría de los ítems presentaron una relación significativa y positiva. El alfa de Cronbach presentó un buen valor (0,94), y la mayoría de las correlaciones fueron significativas y positivas. El análisis factorial exploratorio mediante la prueba Kaiser-Meyer-Olkin mostró un valor de 0,849, y la prueba de Bartlett mostró valores de esfericidad adecuados (χ2=6483.998; p=0,000). El modelo de un factor explicó el 26% de la varianza total. Conclusión: la capacitación en habilidades no técnicas y su medición podrían incluirse en programas de grado y posgrado en profesiones de la salud, o incluso utilizarse para evaluar las necesidades y mejoras en los contextos de atención médica.

Non-technical skills assessment for prelicensure nursing students: An integrative review.

BACKGROUND: In nursing, non-technical skills are recognized as playing an important role to increase patient safety and successful clinical outcomes (Pearson and McLafferty, 2011). Non-technical skills are cognitive and social resource skills that complement technical skills and contribute to safe and efficient task performance (Flin et al., 2008). In order to effectively provide non-technical skills training, it is essential to have an instrument to measure these skills. METHODOLOGY: An online search was conducted. Articles were selected if they referred to and/or described instruments assessing non-technical skills for nurses and/or prelicensure nursing students in educational, clinical and/or simulated settings with validation evidence (inclusion criteria). RESULTS: Of the 53 articles located, 26 met the inclusion criteria. Those referred to and/or described 16 instruments with validation evidence developed to assess non-technical skills in multidisciplinary teams including nurses. CONCLUSION: Although articles have shown 16 valid and reliable instruments, to our knowledge, no instrument has been published or developed and validated for the assessment of non-technical skills of only nurses in general, relevant for use in high-fidelity simulation-based training for prelicensure nursing students. Therefore, there is a need for the development of such an instrument.

Paratracheal cyst rupture: a differential diagnosis for tracheal rupture / Ruptura de cisto paratraqueal: um diagnóstico diferencial para ruptura traqueal

Abstract Tracheobronchial rupture is a rare but potentially life-threatening complication commonly caused by neck and chest trauma. Iatrogenic tracheobronchial rupture can be caused by intubation, tracheostomy, bronchoscopy but also linked to pre-existing primary diseases. Paratracheal air cysts, infrequently described in literature, seem to be associated with obstructive lung disease and weaknesses in right posterior lateral wall of the trachea. We report a case of a paratracheal air cyst rupture in a previous healthy patient.

Resumo A ruptura traqueobrônquica (RTB) é uma complicação rara, mas potencialmente fatal, comumente causada por trauma de pescoço e tórax. A RTB iatrogênica pode ser causada por intubação, traqueostomia, broncoscopia, mas também pode estar relacionada a doenças primárias preexistentes. Os cistos aéreos paratraqueais, raramente descritos na literatura, parecem estar associados à doença pulmonar obstrutiva e fraqueza da parede posterolateral direita da traqueia. Relatamos o caso de uma ruptura de cisto aéreo paratraqueal em paciente previamente saudável.

Paratracheal cyst rupture: a differential diagnosis for tracheal rupture.

Tracheobronchial rupture is a rare but potentially life-threatening complication commonly caused by neck and chest trauma. Iatrogenic tracheobronchial rupture can be caused by intubation, tracheostomy, bronchoscopy but also linked to pre-existing primary diseases. Paratracheal air cysts, infrequently described in literature, seem to be associated with obstructive lung disease and weaknesses in right posterior lateral wall of the trachea. We report a case of a paratracheal air cyst rupture in a previous healthy patient.

[Paratracheal cyst rupture: a differential diagnosis for tracheal rupture]. / Ruptura de cisto paratraqueal: um diagnóstico diferencial para ruptura traqueal.

Tracheobronchial rupture is a rare but potentially life-threatening complication commonly caused by neck and chest trauma. Iatrogenic tracheobronchial rupture can be caused by intubation, tracheostomy, bronchoscopy but also linked to pre-existing primary diseases. Paratracheal air cysts, infrequently described in literature, seem to be associated with obstructive lung disease and weaknesses in right posterior lateral wall of the trachea. We report a case of a paratracheal air cyst rupture in a previous healthy patient.

[Does rurality affect the outcome of trauma patients?]. / O doente politraumatizado grave: implicações da ruralidade na mortalidade, incapacidade e qualidade de vida.

OBJECTIVES: To determine the impact of rurality in epidemiology, injury severity, health care facilities, length of stay, mortality, functional outcome and quality of life in severe trauma patients. METHODS: All trauma patients admitted in our Emergency Room between 2001 and 2007. Data was collected from the prospective Trauma Registry and Follow-Up Registry 6 months after the accident. Patients were divided in three groups according to residence area: R (rural), SU (semi-urban) and U (urban). Sex, age, type of injury, length of stay in hospital and intensive care, anatomic severity (AIS), politrauma severity (ISS), physiologic severity (RTS), surveillance probability (TRISS index), pre-hospital care, previous admission in other hospital, intensive care admission, Euroqol and Extended Glasgow Outcome scale and mortality were studied in order to find a relation with rurality. RESULTS: 1150 patients were analyzed (214 rural, 219 semi-urban, 717 urban). We found a statistical significant relation between rurality and pre-hospital care with rural patients having less medical approach in pre-hospital (R group: 12,2%; SU group: 17,7%; U group: 70,1%, p < 0,001), previous admission in other hospital with rural patients being more often admitted in another hospital before transfer to the trauma centre (R group: 89,2%; SU group: 85,8%; U group: 61,9%, p < 0,001) and intensive care admission (R group: 82,2%; SU group: 78,5%; U group: 72,4%, com p < 0,006). We did not find any significant relation between other variables studied namely severity and early or late outcome. CONCLUSIONS: Living in rural areas does not seam to give more burden of disease to severe trauma patients. Rural patients are similar to those that live in urban areas concerning epidemiology, injury severity and outcome. Despite lack of medical pre-hospital care and higher previous admission in other hospital in rural patients, mortality between groups didn't differ in our trauma centre.