How to train thoracic anesthesia for residents and consultants?

PURPOSE OF REVIEW: The training of anesthesiologists in thoracic surgery is a significant challenge. International professional societies usually provide only a case number-based or time-based training concept. There are only a few concepts of simulation trainings in thoracic anesthesia and interprofessional debriefings on a daily basis are rarely applied. In this review, we will show how professional curricula should aim for competence rather than number of cases and why simulation-based training and debriefing should be implemented. RECENT FINDINGS: Recent curricula recommend so-called entrustable professional activities (EPAs)as a way out of the dilemma between the number of cases vs. competence. With these EPAs, competence can be mapped and prerequisites defined.Training concepts from simulation in healthcare have so far not explicitly reached anesthesia for thoracic surgery. In addition to mere technical training, combined technical-behavioral training forms have proven to be an effective training targeting the entire team in the context of the actual working environment in the operating theatre. SUMMARY: Interdisciplinary and interprofessional learning can take place in simulation trainings and on a daily basis through postevent debriefings. When these debriefings are conducted in a structured way, an improvement in the performance of the entire team can be the result. The basis for these debriefings - as well as for other training approaches - is psychological safety, which should be established and maintained together with all professions involved.

Continuous elastomeric pump-based ropivacaine wound instillation after open abdominal aortic surgery: how reliable is the technique?

INTRODUCTION: We aimed at quantifying the impact of continuous wound infusion with ropivacaine 0.33% on morphine administration and subjective pain relief in patients after open abdominal aortic repair in a double-blind, placebo-controlled study. METHODS: Before closing the abdominal wound, 2 multihole ON-Q® Soaker Catheters™ (I-Flow Corporation, Lake Forest, California, USA) were placed pre-peritoneally in opposite directions. Either ropivacaine 0.33% or saline 0.9% was delivered by an elastomeric pump at a rate of 2 mL/h for 72 hours in each of the catheters. Postoperative pain and morphine administration were assessed using the numerical rating scale (NRS) in 4-hour intervals. Total plasma concentrations of ropivacaine, unbound ropivacaine, and α1-acid glycoprotein (AAG) were measured daily. Mean arterial pressure, pulse rate, oxygen saturation, total amount of morphine administration, ventilation time, and length of stay in the intensive care unit (ICU) were recorded. At the end of the study period, the wound site and the condition of the catheters were assessed. RESULTS: The study was terminated prematurely due to a malfunction of the elastomeric balloon pump resulting in toxic serum levels of total ropivacaine in 2 patients (11.4 µmol/L and 10.0 µmol/L, respectively) on the second postoperative day. Six patients had been allocated to the ropivacaine group, and 9 patients had been allocated to the control group. Demographic and surgical data were similar in both groups. During the first 3 postoperative days, no difference between the ropivacaine and the control group was found in NRS (P = .15, P = .46, and P = .88, respectively) and morphine administration (P = .48). Concentrations of unbound serum ropivacaine (0.11 ± 0.08 µmol/L) were below toxic level in all patients. CONCLUSION: Continuous wound infusion of ropivacaine 0.33% 2 mL/h using an elastomeric system was not reliable and did not improve postoperative pain control in patients after open abdominal aortic surgery.