Intraoperative hypotension in neonates: when and how should we intervene?

PURPOSE OF REVIEW: Organ hypoperfusion remains an important cause of postoperative morbidity in neonates. Blood pressure (BP) is frequently mistakenly used as a surrogate of organ perfusion and the predictive value of BP for outcome is unclear. The current article will focus on the role of BP in the optimization of organ perfusion during anaesthesia in neonates. RECENT FINDINGS: Population studies show a range of normal values for BP in neonates and there is no consensus on the definition of hypotension in neonates undergoing anaesthesia. The relationship between BP and outcome is unclear. Unnecessary treatment of low BP in neonates can be harmful. A theoretical approach to the definition of hypotension and increasing knowledge of neonatal cardiovascular pathophysiology can give insights to improve anaesthetic management. Near-infrared spectroscopy as a measure of organ perfusion can help to determine the need for treatment. SUMMARY: Anaesthetic management should focus on optimizing organ perfusion and not merely on maintaining a particular BP. A collaborative approach is recommended. The carbon dioxide tension is crucial to perfusion in the presence of cardiovascular shunts.

Use of unannounced spaced telephone testing to improve retention of knowledge after life-support courses.

BACKGROUND: Life-support courses improve knowledge and skills but attrition of factual knowledge is considerable. There is evidence that retention can be improved by spaced testing. AIM: To investigate the effect of spaced testing on retention of knowledge after a life-support course. METHOD: In a prospective-controlled trial using stratified randomization, 19 final-year medical students followed a half-day life-support course involving an identical written pre-test and end-of-course test consisting of a factual and a clinical case-based test (CCT). They were subsequently assigned to an intervention and a control group matched for the end-of-course test scores. The intervention group was given four unannounced spaced CCTs intermediate tests over 2 months. The control group took one intermediate test at 6 weeks. All students took a final retention test identical to the pre-test at 2 months. RESULTS: Test performance improved equally in both groups immediately after the course. Students in the intervention group retained factual information significantly better than those in the control group. There was no difference in performance on the CCTs. CONCLUSION: Unannounced spaced testing seems to have a positive effect on retention of factual knowledge after life-support courses. There was no evidence of an effect on clinical problem-solving ability.

The effect of the APLS-course on self-efficacy and its relationship to behavioural decisions in paediatric resuscitation.

AIMS: Self-efficacy may predict performance following life-support training but may be negatively influenced by experiences during training. To investigate both this and the use of self-efficacy in self-assessment we investigated the relationship between self-efficacy and measured performance during a simulated resuscitation, and the effect of death of a simulated patient on self-efficacy. MATERIALS AND METHODS: Consultant and trainee paediatricians and anaesthesiologists scored their self-efficacy for paediatric resuscitation skills before taking an unannounced simulated resuscitation test and objective structured clinical examination (OSCE)-tests of chest compressions and bag- and mask-ventilation. Performance in the simulation was scored by three independent expert observers and the OSCE's using a modified Berden and ventilation penalty scores. RESULTS: Self-efficacy for the relevant skill was significantly higher in doctors choosing to give chest compressions, to intubate or insert an intraosseous device and in those who decided to intubate early. Self-efficacy correlated moderately with the quality of global performance on the simulation but not with the OSCE scores, nor was quality of individual skills during the simulation related to self-efficacy. Self-efficacy was higher in doctors who had taken the Advanced Paediatric Life Support (APLS)-course. Death of the simulated patient had a negative effect on self-efficacy. CONCLUSION: Self-efficacy seems to be predictive of certain actions during a simulated resuscitation but does not correlate with quality of performance of resuscitation skills. Self-efficacy might therefore be useful as a predictor of the application of learning, but cannot be recommended for self-assessment. There is evidence to support the unwritten rule during simulation training the patient should not be allowed to die.

A practical approach to paediatric emergencies in the radiology department.

Acute life-threatening events involving children in the radiology department are rare. Nonetheless, radiologists should be competent in the relatively simple procedures required to maintain or restore vital functions in paediatric patients, particularly if their practice involves seriously ill or sedated children. This article gives a practical overview of the immediate management of paediatric emergencies that the radiologist is likely to encounter, using a structured (ABCD) approach. Emphasis is given to the early recognition of respiratory embarrassment and shock, and early intervention to prevent deterioration towards circulatory arrest. The management of cardiorespiratory arrest, anaphylaxis and convulsions in children is also addressed.

Continuing medical education in pediatric anesthesia--a theoretical overview.

The importance of continuing medical education (CME) as a method of improving the quality of care of children undergoing anesthesia is universally recognized. This article, which is based on a presentation at the FEAPA European Conference on Paediatric Anaesthesia in September 2007 in Amsterdam, gives a theoretical overview of continuing education and introduces some generic educational concepts, such as the CRISIS-criteria and Kirkpatrick's evaluation model, which are as relevant to pediatric anesthesia as to other areas of medical practice. The terms CME and continuing professional develop are described. Some consideration is given to how anesthesiologists can assess the potential worth of an educational activity for their practice. No attempt will be made to judge particular educational activities, as the choice of the most appropriate activity rests primarily with the individual.

The effect of the Advanced Paediatric Life Support course on perceived self-efficacy and use of resuscitation skills.

BACKGROUND: Perceived self-efficacy is a predictor of behaviour and therefore an important dimension of resuscitation training which may have consequences for patient care. The Advanced Paediatric Life Support (APLS) course makes use of techniques which would be expected to increase self-efficacy. We examined the effect of this course on perceived self-efficacy in respect of resuscitation skills and on the use of these skills. DESIGN: A prospective descriptive study using a questionnaire. METHODS: Questionnaires were sent to all doctor candidates following the course in the Netherlands over a period of 15 months and to a matched control group. Perceived self-efficacy in respect of paediatric resuscitation as a whole and six of its component skills was measured on a visual analogue scale. Questionnaires were sent out before the course and 3 and 6 months afterwards. FINDINGS: The candidate and control groups were not significantly different in terms of sex, specialty, grade or experience with children. Perceived self-efficacy increased significantly (p<0.01) in candidates following the course for all skills and remained increased for at least 6 months. There was no significant change in perceived self-efficacy in the control group. There was no change in the use of skills or in the number of critically ill children seen, in either group. CONCLUSIONS: The APLS course does have an important effect on perceived self-efficacy but this is not related to an increase in the frequency of use of the skills learned on the course, partly because the opportunity for increased use is lacking. Further work is needed to determine whether the quality of those skills is improved by the course.