ABSTRACT
BACKGROUND: There is increasing emphasis on performance-based assessment of clinical competence. The High Fidelity Patient Simulator (HPS) may be useful for assessment of clinical practice in anaesthesia, but needs formal evaluation of validity, reliability, feasibility and effect on learning. We set out to assess the reliability of a global rating scale for scoring simulator performance in crisis management. METHODS: Using a global rating scale, three judges independently rated videotapes of anaesthetists in simulated crises in the operating theatre. Five anaesthetists then independently rated subsets of these videotapes. RESULTS: There was good agreement between raters for medical management, behavioural attributes and overall performance. Agreement was high for both the initial judges and the five additional raters. CONCLUSIONS: Using a global scale to assess simulator performance, we found good inter-rater reliability for scoring performance in a crisis. We estimate that two judges should provide a reliable assessment. High fidelity simulation should be studied further for assessing clinical performance.
Subject(s)
Anesthesia/standards , Anesthesiology/standards , Clinical Competence/standards , Computer Simulation , Videotape Recording/instrumentation , Anesthesia/methods , Humans , Reproducibility of ResultsABSTRACT
The electrically driven Novacor implantable left ventricular assist device has been implanted in six patients (four men and two women) since Sept. 7, 1984. In four of the six patients (67%) the device was a successful bridge to cardiac transplantation. One patient died of multiple organ failure and Candida sepsis after 16 days of support with the device. One patient died in the operating room of uncontrollable hemorrhage and biventricular failure caused by severe cardiac rejection. Three patients are alive with cardiac transplants 38, 17, and 10 months after transplantation. One patient died after cardiac transplantation of presumed sepsis. The Novacor left ventricular assist device performed in all cases without mechanical or electrical failure. Excluding the intraoperative death, assist duration ranged from 2 to 16 days. The cardiac index (synonymous with device output) ranged from 2.4 to 3.4 L/min/m2. No embolic events (cerebrovascular or systemic) occurred during assistance with the device. Minimal red cell hemolysis was documented during the period of support. The Novacor left ventricular assist device is a safe and effective bridge to cardiac transplantation in patients with refractory cardiogenic shock.
Subject(s)
Assisted Circulation , Heart Transplantation , Heart-Assist Devices , Adult , Cardiac Output , Cardiomyopathies/therapy , Coronary Disease/therapy , Equipment Design , Female , Graft Rejection , Humans , Male , Middle AgedABSTRACT
The recently developed technology of Doppler echocardiography was used to evaluate a pregnancy complicated by aortic stenosis. Given the lack of established norms for this test during pregnancy and the known cardiovascular changes during pregnancy, it is difficult to interpret this test. However, in the case presented, this test suggested the need for more conservative management, a plan that was justified postpartum.
Subject(s)
Aortic Valve Stenosis/physiopathology , Blood Pressure , Echocardiography , Pregnancy Complications, Cardiovascular/physiopathology , Adult , Female , Humans , Pregnancy , SystoleABSTRACT
The anaesthetic records of 261 heart transplant recipients were reviewed. Data collected included demographic characteristics, physical status, results of preoperative cardiac catheterization studies, anaesthetics agents and incidences of complications which may have been related to anaesthetic management. Forty-five patients received a volatile agent (methoxyflurane 31, enflurane 10, halothane 4) and 216 patients were anaesthetized with a high-dose narcotic technique (morphine 122, fentanyl 71, hydromorphone 14, meperidine 9). Hypotension and arrhythmias were correlated with use of volatile and narcotic anaesthetics, respectively. No mortality was associated with anaesthetic management.
Subject(s)
Anesthesia, General , Heart Transplantation , Adolescent , Adult , Analgesics, Opioid , Anesthesia, General/mortality , Anesthesia, Inhalation , Arrhythmias, Cardiac/etiology , Child , Humans , Hypotension/etiology , Intraoperative Complications/etiology , Middle Aged , Postoperative Complications/mortality , Retrospective StudiesABSTRACT
This study was designed to ascertain whether gastric volume in early pregnancy is unduly large, and to determine whether preanesthetic administration of metoclopramide decreases this volume. Gastric pH and volume were measured following induction of general anesthetics in 20 nonpregnant surgical patients; 62 patients undergoing therapeutic abortion (mean gestational age, 15 +/- 3 weeks); and in 31 patients undergoing therapeutic abortions who received 10 mg metoclopramide intravenously, 15 to 30 min before anesthesia. Gastric volume was the same in the pregnant and nonpregnant control patients; in this former group, volume was not related to gestational age. In the nonpregnant control group, mean pH was lower, and there were more patients with a pH less than 2.5 than in the other groups; metoclopramide had no effect on pH. Treatment with metoclopramide resulted in significantly lower mean gastric volume (15 vs. 28 ml) and in significantly fewer patients with a gastric volume exceeding 25 ml (13% vs. 51%). Early pregnancy (less than 20 weeks gestation) confers no additional anesthetic hazard due to large gastric volume or low pH. Our data suggest that preanesthetic administration of metoclopramide may be beneficial in decreasing the risk of aspiration pneumonitis.
