Team planning discussion and clinical performance: a prospective, randomised, controlled simulation trial.

Planning held before emergency management of a critical situation might be an invaluable asset for optimising team preparation. The purpose of this study was to investigate whether a brief planning discussion improved team performance in a simulated critical care situation. Forty-four pairs of trainees in anaesthesia and intensive care were randomly allocated to either an intervention or control group before participating in a standardised simulated scenario. Twelve different scenarios were utilised. Groups were stratified by postgraduate year and simulated scenario, and a facilitator was embedded in the scenario. In the intervention group, the pairs had an oral briefing followed by a 4-min planning discussion before starting the simulation. The primary end-point was clinical performance, as rated by two independent blinded assessors on a score of 0-100 using video records and pre-established scenario-specific checklists. Crisis resource management and stress response (cognitive appraisal ratio) were also assessed. Two pairs were excluded for technical reasons. Clinical performance scores were higher in the intervention group; mean (SD) 51 (9) points vs. 46 (9) in the control group, p = 0.039. The planning discussion was also associated with higher crisis resource management scores and lower cognitive appraisal ratios, reflecting a positive response. A 4-min planning discussion before a simulated critical care situation improved clinical team performance and cognitive appraisal ratios. Team planning should be integrated into medical education and clinical practice.

Use of a hand-held digital cognitive aid in simulated crises: the MAX randomized controlled trial.

BACKGROUND: Cognitive aids improve the technical performance of individuals and teams dealing with high-stakes crises. Hand-held electronic cognitive aids have rarely been investigated. A randomized controlled trial was conducted to investigate the effects of a smartphone application, named MAX (for Medical Assistance eXpert), on the technical and non-technical performance of anaesthesia residents dealing with simulated crises. METHODS: This single-centre randomized, controlled, unblinded trial was conducted in the simulation centre at Lyon, France. Participants were anaesthesia residents with >1 yr of clinical experience. Each participant had to deal with two different simulated crises with and without the help of a digital cognitive aid. The primary outcome was technical performance, evaluated as adherence to guidelines. Two independent observers remotely assessed performance on video recordings. RESULTS: Fifty-two residents were included between July 2015 and February 2016. Six participants were excluded for technical issues; 46 participants were confronted with a total of 92 high-fidelity simulation scenarios (46 with MAX and 46 without). Mean (sd) age was 27 (1.8) yr and clinical experience 3.2 (1.0) yr. Inter-rater agreement was 0.89 (95% confidence interval 0.85-0.92). Mean technical scores were higher when residents used MAX [82 (11.9) vs 59 (10.8)%; P<0.001]. CONCLUSION: The use of a hand-held cognitive aid was associated with better technical performance of residents dealing with simulated crises. These findings could help digital cognitive aids to find their way into daily medical practice and improve the quality of health care when dealing with high-stakes crises. CLINICAL TRIAL REGISTRATION: NCT02678819.

Resuscitation with lipid, epinephrine, or both in levobupivacaine-induced cardiac toxicity in newborn piglets.

BACKGROUND: The optimal dosing regimens of lipid emulsion, epinephrine, or both are not yet determined in neonates in cases of local anaesthetic systemic toxicity (LAST). METHODS: Newborn piglets received levobupivacaine until cardiovascular collapse occurred. Standard cardiopulmonary resuscitation was started and electrocardiogram (ECG) was monitored for ventricular tachycardia, fibrillation, or QRS prolongation. Piglets were then randomly allocated to four groups: control (saline), Intralipid(®) alone, epinephrine alone, or a combination of Intralipd plus epinephrine. Resuscitation continued for 30 min or until there was a return of spontaneous circulation (ROSC) accompanied by a mean arterial pressure at or superior to the baseline pressure and normal sinus rhythm for a period of 30 min. RESULTS: ROSC was achieved in only one of the control piglets compared with most of the treated piglets. Mortality was not significantly different between the three treatment groups, but was significantly lower in all the treatment groups compared with control. The number of ECG abnormalities was zero in the Intralipid only group, but 14 and 17, respectively, in the epinephrine and epinephrine plus lipid groups (P<0.05). CONCLUSIONS: Lipid emulsion with or without epinephrine, or epinephrine alone were equally effective in achieving a return to spontaneous circulation in this model of LAST. Epinephrine alone or in combination with lipid was associated with an increased number of ECG abnormalities compared with lipid emulsion alone.

Assessment of cardiovascular autonomic control by the empirical mode decomposition.

OBJECTIVES: Heart-rate variability (HRV) is an interesting tool for assessing cardiac autonomic system control, but nonstationarities raise problematic issues. The objective of this paper is to show that adapted signal processing tools may cope with nonstationary situations and improve the analysis of HRV. METHODS: We propose to use the recent method of Empirical Mode Decomposition (EMD), so as to analyze the cardiac sympatho-vagal balance on automatically extracted modes. The method, which is fully data-adaptive, consists in an iterative decomposition based on the idea that any signal can be locally represented as an oscillation superimposed to a more regular trend. When a signal is composed of distinct nonstationary components, EMD therefore achieves a time-varying filtering which effectively separates them. RESULTS: The method has been applied to situations where postural changes occur, provoking instantaneous changes in heart rate as a result of autonomic modifications. In the considered application where the sympatho-vagal balance is quantified by comparing the low-frequency (LF) and high-frequency (HF) components of RR intervals, EMD automatically achieves a separation of these components upon which further processing can be carried. Visualizing the decomposition in the time-frequency plane, we can identify local events due to the postural changes, and we can assess a (time-varying) HF vs. LF discrimination without resorting to some fixed high-pass/low-pass filtering. CONCLUSION: Assessing cardiovascular autonomic control by resorting to LF/HF measurements may prove difficult in nonstationary situations where the use of a priori fixed filters can be questioned. Because it is both local and fully data-adaptive, EMD appears as an appealing and versatile pre-processing technique for overcoming some of the limitations that conventional spectral methods are faced with in nonstationary situations.

Activation of calcium influx by ATP and store depletion in primary cultures of renal proximal cells.

Cytoplasmic calcium changes and calcium influx evoked by adenosine triphosphate (ATP) were investigated in primary cultures of rabbit proximal convoluted tubule cells. Extracellular ATP (50 microM) induced a biphasic increase of [Ca2+]i measured with the calcium probe fura-2. In the early phase, the mobilization of intracellular pools resulted in a transient increase of [Ca2+]i from 106 +/- 11 nM (n = 36) to 1059 +/- 115% (n = 29) of the resting level within 10 s. In the presence of external calcium, [Ca2+]i then decreased within 3 min to a sustained level (398 +/- 38%, n = 8). Measurements of fura-2 quenching by external manganese revealed that this phase was the result of an increased Ca2+ uptake, blocked by lanthanum (10 microM) and verapamil (100 microM) but not by the nifedipin (25 microM). Internal calcium store depletion by ATP induced an increased calcium influx through lanthanum- and verapamil-sensitive, nifedipin-insensitive calcium channels, located on the apical membrane of the cells. As indicated by 86Rb+ efflux measurements, ATP activated a potassium efflux that was blocked by barium and Leiurus quinquestriatus hebraeus (LQH) venom (containing charybdotoxin) indicating the involvement of Ca(2+)-sensitive K+ channels. Moreover, in the presence of the LQH venom, the internal calcium stores were not replenished after being depleted by ATP. Our results indicate that an ATP-evoked hyperpolarization of the plasma membrane leads to increased Ca2+ influx, which facilitates the replenishment of the internal stores.

Nucleotides mobilize intracellular calcium stores of renal proximal cells in primary culture: existence of a suramin-sensitive mechanism.

Changes of intracellular calcium concentrations [Ca2+]i were measured in primary cultured rabbit proximal convoluted tubules (PCT). A dual-excitation, digital-imaging inverted microscope was used to monitor the fura-2 fluorescence. The basal calcium level was 106 +/- 11 nM (n = 36). The stimulatory effects of adenosine triphosphate (ATP), adenosine diphosphate (ADP) and adenosine were studied. ATP and ADP induced transient increases of [Ca2+]i (1059 +/- 115% of the resting level (n = 29), and 659 +/- 134% (n = 10), respectively) by releasing calcium from cytoplasmic stores. Adenosine had less effect (279 +/- 48% of the resting level, n = 3). In the same conditions the ATP antagonist suramin (100 microM) inhibited the action of ATP and ADP to 231 +/- 52% (n = 3), and 308 +/- 29% (n = 4) of the resting level, respectively, but did not modify that of adenosine (281 +/- 72%, n = 3). A pretreatment (500 ng/ml for 2 h at 37 degrees C) of the culture with the toxin of Bordetella pertussis completely blocked the ATP response. Our results are evidence for the presence of a functional suramin-sensitive ATP and ADP puriceptor in cultured renal proximal cells. A pertussis-toxin-sensitive G protein is linked to the transduction mechanism. This receptor is distinct from an adenosine puriceptor also found in the proximal monolayer.