Standardized, Interdepartmental, Simulation-Based Central Line Insertion Course Closes an Educational Gap and Improves Intern Comfort with the Procedure.

Central line placement is a common procedure, routinely performed by junior residents in medical and surgical departments. Before this project, no standardized instructional course on the insertion of central lines existed at our institution, and few interns had received formal ultrasound training. Interns from five departments participated in a simulation-based central line insertion course. Intern familiarity with the procedure and with ultrasound, as well as their prior experience with line placement and their level of comfort, was assessed. Of the 99 interns in participating departments, 45 per cent had been trained as of October 2015. Forty-one per cent were female. The majority (59.5%) had no prior formal ultrasound training, and 46.0 per cent had never placed a line as primary operator. Scores increased significantly, from a precourse score mean of 13.7 to a postcourse score mean of 16.1, P < 0.001. All three of the self-reported measures of comfort with ultrasound also improved significantly. All interns reported the course was "very much" helpful, and 100 per cent reported they felt "somewhat" or "much" more comfortable with the procedure after attendance. To our knowledge, this is the first hospital-wide, standardized, simulation-based central line insertion course in the United States. Preliminary results indicate overwhelming satisfaction with the course, better ultrasound preparedness, and improved comfort with central line insertion.

Comparison of Phenylephrine and Ephedrine in Treatment of Spinal-Induced Hypotension in High-Risk Pregnancies: A Narrative Review.

PURPOSE: To compare maternal and fetal effects of intravenous phenylephrine and ephedrine administration during spinal anesthesia for cesarean delivery in high-risk pregnancies. SOURCE: An extensive literature search was conducted using the US National Library of Medicine, MEDLINE search engine, Cochrane review, and Google Scholar using search terms "ephedrine and phenylephrine," "preterm and term and spinal hypotension," "preeclampsia and healthy parturients," or "multiple and singleton gestation and vasopressor." Society of Obstetric Anesthesia and Perinatology meeting abstracts for the past 4 years were also searched for relevant studies. PRINCIPLE FINDINGS: Both phenylephrine and ephedrine can be safely used to counteract hypotension after spinal anesthesia in patients with uteroplacental insufficiency, pregnancy-induced hypertension, and in non-elective cesarean deliveries. Vasopressor requirements before delivery in high-risk cesarean sections are reduced compared to healthy parturients. Among the articles reviewed, there were no statistically significant differences in umbilical arterial pH, umbilical venous pH, incidence of fetal acidosis, Apgar scores, or maternal hypotension when comparing maternal phenylephrine and ephedrine use. CONCLUSION: From the limited existing data, phenylephrine and ephedrine are both appropriate selections for treating or preventing hypotension induced by neuraxial blockade in high-risk pregnancies. There is no clear evidence that either medication is more effective at maintaining maternal blood pressure or has a superior safety profile in this setting. Further investigations are required to determine the efficacy, ideal dosing regimens, and overall safety of phenylephrine and ephedrine administration in high-risk obstetric patients, especially in the presence uteroplacental insufficiency.

From Bad to Worse: Paraganglioma Diagnosis during Induction of Labor for Coexisting Preeclampsia.

Pheochromocytomas and extra-adrenal paragangliomas are catecholamine-secreting tumors that rarely occur in pregnancy. The diagnosis of these tumors in pregnancy can be challenging given that many of the signs and symptoms are commonly attributed to preeclampsia or other more common diagnoses. Early diagnosis and appropriate management are essential in optimizing maternal and fetal outcomes. We report a rare case of a catecholamine-secreting tumor in which diagnosis occurring at the time labor was being induced for concomitant preeclampsia with severe features. Her initial presentation in hypertensive crisis with other symptoms led to diagnostic workup for secondary causes of hypertension and led to eventual diagnosis of paraganglioma. Obtaining this diagnosis prior to delivery was essential, as this led to prompt multidisciplinary care, changed the course of her clinical management, and ultimately enabled good maternal and fetal outcomes. This case highlights the importance of maintaining a high index of suspicion for secondary causes of hypertension and in obstetric patients and providing timely multidisciplinary care.

Age differences in inflammatory and hypermetabolic postburn responses.

OBJECTIVE: The aim of this study was to identify contributors to morbidity and death in severely burned patients <4 years of age. METHODS: A total of 188 severely burned pediatric patients were divided into 3 age groups (0-3.9 years, 4-9.9 years, and 10-18 years of age). Resting energy expenditure was measured through oxygen consumption, body composition through dual-energy x-ray absorptiometry, liver size and cardiac function through ultrasonography, and levels of inflammatory markers, hormones, and acute-phase proteins through laboratory chemistry assays. RESULTS: Resting energy expenditure was highest in the 10- to 18-year-old group, followed by the 4- to 9.9-year-old group, and was lowest in the 0- to 3.9-year-old group. Children 0 to 3.9 years of age maintained lean body mass and body weight during acute hospitalization, whereas children >4 years of age lost body weight and lean body mass. The inflammatory cytokine profile showed no differences between the 3 age groups, whereas liver size increased significantly in the 10- to 18-year-old group and was lowest in the 0- to 3.9-year-old group. Acute-phase protein and cortisol levels were significantly decreased in the toddler group, compared with the older children. Cardiac data indicated increased cardiac work and impaired function in the toddler group, compared with the other 2 age groups. CONCLUSIONS: Increased mortality rates for young children are associated with increased cardiac work and impaired cardiac function but not with the inflammatory and hypermetabolic responses.