Protocol for a randomized controlled trial to reduce pediatric anesthesia emergence delirium by titration of sevoflurane anesthesia using brain function monitoring.

BACKGROUND: Emergence agitation or emergence delirium is a common complication of unknown etiology in pediatric anesthesia. Pediatric anesthesia emergence delirium (PAED) has been reported most commonly in younger children and may occur in about 30% of children up to 5-6 years old. Exposure to anesthetic agents may contribute to PAED, and we hypothesized that a management strategy to minimize exposure to volatile anesthetics may reduce PAED. Electroencephalography (EEG) signatures captured and displayed by brain function monitors during anesthesia change with concentration of sevoflurane and level of unconsciousness, and these EEG signatures may be used to inform titration of anesthetics. METHODS: A single-center, parallel-group, two-arm, superiority trial with a 1:1 allocation ratio will be performed to compare the incidence of PAED following standard sevoflurane anesthesia (maintained at 1.0MAC) and EEG-guided anesthesia (minimum concentration to sustain surgical anesthesia as determined by monitoring of EEG signatures). Participants between 1 and 6 years of age undergoing surgical procedures involving minimal postoperative pain will be randomly assigned to receive standard (n = 90) or EEG-guided (n = 90) anesthesia. PAED score will be assessed by a blinded observer in the PACU on arrival and after 5, 10, 15, and 30 min. DISCUSSION: Anesthesia management with proactive use of brain function monitoring is expected to reduce exposure to sevoflurane without compromising surgical anesthesia. We expect this reduced exposure should help prevent PAED. Routinely administering what may be considered standard levels of anesthetic such as 1.0 MAC sevoflurane may be excessive and potentially associated with unfavorable sequelae such as PAED. TRIAL REGISTRATION: Japan Registry of Clinical Trials (jRCT) jRCTs032210248. Prospectively registered on 17 August 2021.

Drowsiness following ondansetron given the day after general anesthesia for postoperative nausea: a pediatric case report.

BACKGROUND: Ondansetron is an antiemetic drug that is useful not only for prevention but also for the treatment of postoperative nausea and vomiting (PONV). We report a rare case of drowsiness in a child after using ondansetron for nausea on the day after general anesthesia. CASE PRESENTATION: A 5-year-old boy underwent circumcision under general anesthesia and suffered from postoperative nausea and vomiting. He was administered 0.1mg/kg of ondansetron in the PACU and 23 h later on the day after surgery. After the second dose, he acutely exhibited drowsiness which resolved in 3 h. He was discharged to home later on the same day. He was not given any other drugs at the time, and the drowsiness was thought to be directly attributable to ondansetron, though the exact mechanism was unknown. CONCLUSIONS: When drowsiness or other cognitive symptoms are observed after administration of ondansetron, it must be considered and managed as a possible side effect.

Audible capnometric cues with end-tidal carbon dioxide improve the quality of patient monitoring.

The importance of capnometry and end-tidal carbon dioxide (ETCO2) has been underscored in recent years by guidelines as a method to continuously monitor adequacy of ventilation during sedation and anesthesia. Guidelines for cardiopulmonary resuscitation (CPR) recommend attempts to improve CPR quality if ETCO2 is lower than 10 mmHg. ETCO2 is thus a time-critical parameter that may benefit from being delivered in real time to health care providers. We performed a pilot study to investigate whether the addition of audible capnometric cues after each breath enhanced providers' ability to maintain appropriate ventilation over conventional capnography. The addition of audible cues was confirmed to enhance control of ETCO2 during manual ventilation. We subsequently developed five distinct audible capnometric cues corresponding to different levels of ETCO2. We performed a study using ten random simulated test cases to confirm whether changes between levels as well as the direction of change could be distinguished using these audible cues. Audible cues were found to be easily distinguishable. 16 evaluators correctly identified presence and direction of change in ETCO2 with an average pass rate of 89%. It is anticipated that this "ETCO2 Audible Cue" feature will be able to improve the quality of patient monitoring, as well help improve the quality of CPR.

A Simulation Curriculum for Management of Trauma and Surgical Critical Care Patients.

BACKGROUND: Expectations continue to rise for residency programs to provide integrated simulation training to address clinical competence. How to implement such training sustainably remains a challenge. We developed a compact module for first-year surgery residents integrating theory with practice in high-fidelity simulations, to reinforce the preparedness and confidence of junior residents in their ability to manage common emergent patient care scenarios in trauma and critical care surgery. METHODS: The 3-day module features a combination of simulated patient encounters using standardized patients and electronic manikins, didactic sessions, and hands-on training. Manikin-based scenarios developed in-house were used to teach trauma and critical care management concepts and skills. Separate scenarios in collaboration with the regional organ donation program addressed communication in difficult situations such as brain death. Didactic material based on contemporary evidence, as well as skills stations, was developed to complement the scenarios. Residents were surveyed before and after training on their confidence in meeting the 14 learning objectives of the curriculum on a 5-point Likert scale. RESULTS: Data from 15 residents who underwent this training show an overall improvement in confidence across all learning objectives defined for the module, with confidence scores before to after training improving significantly from 2.8 (σ = 0.85, median = 3) to 3.9 (σ = 0.87, median = 4) of 5, p < 0.001. Although female residents reported higher posttraining confidence scores compared with male residents (average 4.2 female vs 3.8 male, p = 0.002), there were no other significant differences in confidence scores or changes to scores owing to resident sex or program status (categorical or preliminary). CONCLUSION: We successfully implemented a multimodal simulation-based curriculum that provides skills training integrated with the clinical context of managing trauma and critical care patients, simultaneously addressing a range of clinical competencies. Results to date show consistent improvement in residents' confidence in meeting learning objectives. Development of the curriculum continues for sustainability, as well as measures to embed objective evaluations of resident competence.

Development and implementation of a clinical pathway approach to simulation-based training for foregut surgery.

INTRODUCTION: Contemporary demands on resident education call for integration of simulation. We designed and implemented a simulation-based curriculum for Post Graduate Year 1 surgery residents to teach technical and nontechnical skills within a clinical pathway approach for a foregut surgery patient, from outpatient visit through surgery and postoperative follow-up. METHODS: The 3-day curriculum for groups of 6 residents comprises a combination of standardized patient encounters, didactic sessions, and hands-on training. The curriculum is underpinned by a summative simulation "pathway" repeated on days 1 and 3. The "pathway" is a series of simulated preoperative, intraoperative, and postoperative encounters in following up a single patient through a disease process. The resident sees a standardized patient in the clinic presenting with distal gastric cancer and then enters an operating room to perform a gastrojejunostomy on a porcine tissue model. Finally, the resident engages in a simulated postoperative visit. All encounters are rated by faculty members and the residents themselves, using standardized assessment forms endorsed by the American Board of Surgery. RESULTS: A total of 18 first-year residents underwent this curriculum. Faculty ratings of overall operative performance significantly improved following the 3-day module. Ratings of preoperative and postoperative performance were not significantly changed in 3 days. Resident self-ratings significantly improved for all encounters assessed, as did reported confidence in meeting the defined learning objectives. CONCLUSIONS: Conventional surgical simulation training focuses on technical skills in isolation. Our novel "pathway" curriculum targets an important gap in training methodologies by placing both technical and nontechnical skills in their clinical context as part of managing a surgical patient. Results indicate consistent improvements in assessments of performance as well as confidence and support its continued usage to educate surgery residents in foregut surgery.

Design, development and implementation of a surgical simulation pathway curriculum for biliary disease.

BACKGROUND: The initial focus of simulation in surgical education was to provide instruction in procedural tasks and technical skills. Recently, the importance of instruction in nontechnical areas, such as communication and teamwork, was realized. On rotation, the surgical resident requires proficiency in both technical and non-technical skills through the entire patient care pathway, i.e., pre-, intra- and postoperatively. METHODS: The focus was upon implementation of a biliary disease-based surgical simulation curriculum. The cornerstones of this module were clinical care pathway simulation sessions, at the commencement and conclusion of the 3 days. Each resident completed a simulated outpatient encounter with a standardized patient (SP) presenting with biliary colic, performed a laparoscopic cholecystectomy on a porcine model in a simulated operating room and completed an uncomplicated follow-up visit with the same SP. Assessments of resident performance were collected for every pathway scenario using standardized assessment forms approved by the American Board of Surgery. Additional formative sessions included hands-on, didactic and SP encounter sessions. RESULTS: The biliary surgical simulation pathway curriculum was successful implemented over the course of a 3-day, immersive module. The curriculum was delivered within the Penn Medicine Clinical Simulation Center and accommodated six junior surgical resident learners. The curriculum was divided into 4-h sessions, each led by a department faculty member. The cost of the implementation approximated $17,500 (USD). CONCLUSION: It is imperative that surgical residents undergo simulation training directly linked to their hospital responsibilities so as to provide immediate performance improvement and reduce errors in the clinical environment. This pathway curriculum has successfully shown the feasibility to implement this novel approach to surgical simulation for junior resident training at an academic medical center. Such a patient-focused approach to surgical simulation should lead to higher-quality training for residents and supports the use of this pathway curriculum in the future.

Direct effect of Pa(CO2) on respiratory sinus arrhythmia in conscious humans.

Respiratory sinus arrhythmia (RSA) may improve the efficiency of pulmonary gas exchange by matching the pulmonary blood flow to lung volume during each respiratory cycle. If so, an increased demand for pulmonary gas exchange may enhance RSA magnitude. We therefore tested the hypothesis that CO2 directly affects RSA in conscious humans even when changes in tidal volume (V(T)) and breathing frequency (F(B)), which indirectly affect RSA, are prevented. In seven healthy subjects, we adjusted end-tidal PCO2 (PET(CO2)) to 30, 40, or 50 mmHg in random order at constant V(T) and F(B). The mean amplitude of the high-frequency component of R-R interval variation was used as a quantitative assessment of RSA magnitude. RSA magnitude increased progressively with PET(CO2) (P < 0.001). Mean R-R interval did not differ at PET(CO2) of 40 and 50 mmHg but was less at 30 mmHg (P < 0.05). Because V(T) and F(B) were constant, these results support our hypothesis that increased CO2 directly increases RSA magnitude, probably via a direct effect on medullary mechanisms generating RSA.