Achieving Lumbar Epidural Block Competency in Inexperienced Trainees after a Structured Epidural Teaching Model: A Randomized, Single Blind, Prospective Comparison of CUSUM Learning Curves.

Aim: The aim of this randomized, prospective study was to investigate whether the use of the structured epidural teaching model (SETM) may affect the learning curve for lumbar epidural block in novice trainees when compared with a standard teaching module. Introduction: There is a paucity of literature regarding the efficacy of teaching epidural blocks and comparisons between the different educational approaches. Method: Forty-four PGY3 anesthesia trainees were randomized to receive (study group) or to not receive (control group) the SDM (structured didactic model) before the beginning of their 6 months clinical practice rotation in labor and delivery suites. A CUSUM learning curve was built for every trainee. The scores were assigned by the staff instructor, who was unaware of the group to which the trainee belonged. Results: The number of subjects who achieved an improvement in performance was 8 trainees from the control group and 14 from the study group. The probability of achieving an improvement was higher (p < 05) in the study group than in the control group, with an aOR of 3.25 (CI: 1.01; 12.1). The proportion of subjects in the study group who completed the epidural without help was 1.21 (1.05-1.41) times the proportion of subjects who completed the epidural without help in the control group. The probability of completing the epidural block without any assistance was 21% higher in the study group than in the control group (p < 05). Conclusion: We have demonstrated that the use of the structured epidural teaching model (SETM) may improve the learning curve (CUSUM) for lumbar epidural block in novice, entirely inexperienced, anesthesia trainees.

Performance of the Hypotension Prediction Index With Noninvasive Arterial Pressure Waveforms in Awake Cesarean Delivery Patients Under Spinal Anesthesia.

BACKGROUND: Arterial hypotension is common after spinal anesthesia (SA) for cesarean delivery (CD), and to date, there is no definitive method to predict it. The hypotension prediction index (HPI) is an algorithm that uses the arterial waveform to predict early phases of intraoperative hypotension. The aims of this study were to assess the diagnostic ability of HPI working with arterial waveforms detected by ClearSight system in predicting impending hypotension in awake patients, and the agreement of pressure values recorded by ClearSight with conventional noninvasive blood pressure (NIBP) monitoring in patients undergoing CD under SA. METHODS: In this retrospective analysis of pregnant patients scheduled for elective CD under SA, continuous hemodynamic data measured with the ClearSight monitor until delivery were downloaded from an Edwards Lifesciences HemoSphere platform and analyzed. Receiver operating characteristic (ROC) curves were constructed to evaluate the performance of HPI algorithm working on the ClearSight pressure waveform in predicting hypotensive events, defined as mean arterial pressure (MAP) <65 mm Hg for >1 minute. The sensitivity, specificity, positive predictive value, and negative predictive value were computed at the optimal cutpoint, selected as the value that minimizes the difference between sensitivity and specificity. ClearSight MAP values were compared to NIBP MAP values by linear regression and Bland-Altman analysis corrected for repeated measurements. RESULTS: Fifty patients undergoing CD were included in the analysis. Hypotension occurred in 23 patients (48%). Among patients experiencing hypotension, the HPI disclosed 71 alerts. The HPI predicted hypotensive events with a sensitivity of 83% (95% confidence interval [CI], 69-97) and specificity of 83% (95% CI, 70-95) at 3 minutes before the event (area under the curve [AUC] 0.913 [95% CI, 0.837-0.99]); with a sensitivity of 97% (95% CI, 92-100) and specificity of 97% (95% CI, 92-100) at 2 minutes before the event (AUC 0.995 [95% CI, 0.979-1.0]); and with a sensitivity of 100% (95% CI, 100-100) and specificity 100% (95% CI, 100-100) 1 minute before the event (AUC 1.0 [95% CI, 1.0-1.0]). A total of 2280 paired NIBP MAP and ClearSight MAP values were assessed. The mean of the differences between the ClearSight and NIBP assessed using Bland-Altman analysis (±standard deviation [SD]; 95% limits of agreement with respective 95% CI) was -0.97 mm Hg (±4.8; -10.5 [-10.8 to -10.1] to 8.5 [8.1-8.8]). CONCLUSIONS: HPI provides an accurate real time and continuous prediction of impending intraoperative hypotension before its occurrence in awake patients under SA. We found acceptable agreement between ClearSight MAP and NIBP MAP.

Anesthesia management of pediatric dentistry patients with cardiofaciocutaneous syndrome: a case report.

Cardiofaciocutaneous syndrome is a rare syndrome characterized by particular craniofacial features, cardiac abnormalities, and multiple organ diseases. Patients present with pulmonary stenosis, hypertrophic cardiomyopathy, short neck, micrognathia, laryngomalacia, and tracheomalacia. These conditions may strongly influence patient perioperative outcomes. We describe a 15-year-old child with cardiofaciocutaneous syndrome presenting for a dentistry procedure. She had an uneventful perioperative and postoperative course except for difficult airway management.

"Please mind the gap": successful use of ultrasound-assisted spinal anesthesia for urgent cesarean section in a patient with implanted spinal cord stimulation system for giant chest wall arteriovenous malformation - a case report.

BACKGROUND: The use of Spinal Cord Stimulation (SCS) system to treat medically refractory neuropathic pain is increasing. Severe neuropathic pain can be found in giant chest wall arteriovenous malformations (AVMs), exceedingly rare and debilitating abnormalities, rarely reported during pregnancy. CASE PRESENTATION: We present a report of a pregnant patient with implanted Spinal Cord Stimulation (SCS) system because of painful thoracic AVM scheduled for an urgent cesarean section in which we used lumbar ultrasound (US) to rule out the possibility to damage SCS electrodes and to find a safe site to perform spinal anesthesia. CONCLUSIONS: The use of lumbar US to find a safe site for a lumbar puncture in presence of SCS system in a patient affected by painful thoracic AVM makes this case a particularly unique operative challenge and offers a new possible use of ultrasound to detect a safe space in patients with SCS implant.

Molecular signatures of mouse TRPV1-lineage neurons revealed by RNA-Seq transcriptome analysis.

UNLABELLED: Disorders of pain neural systems are frequently chronic and, when recalcitrant to treatment, can severely degrade the quality of life. The pain pathway begins with sensory neurons in dorsal root or trigeminal ganglia, and the neuronal subpopulations that express the transient receptor potential cation channel, subfamily V, member 1 (TRPV1) ion channel transduce sensations of painful heat and inflammation and play a fundamental role in clinical pain arising from cancer and arthritis. In the present study, we elucidate the complete transcriptomes of neurons from the TRPV1 lineage and a non-TRPV1 neuroglial population in sensory ganglia through the combined application of next-gen deep RNA-Seq, genetic neuronal labeling with fluorescence-activated cell sorting, or neuron-selective chemoablation. RNA-Seq accurately quantitates gene expression, a difficult parameter to determine with most other methods, especially for very low and very high expressed genes. Differentially expressed genes are present at every level of cellular function from the nucleus to the plasma membrane. We identified many ligand receptor pairs in the TRPV1 population, suggesting that autonomous presynaptic regulation may be a major regulatory mechanism in nociceptive neurons. The data define, in a quantitative, cell population-specific fashion, the molecular signature of a distinct and clinically important group of pain-sensing neurons and provide an overall framework for understanding the transcriptome of TRPV1 nociceptive neurons. PERSPECTIVE: Next-gen RNA-Seq, combined with molecular genetics, provides a comprehensive and quantitative measurement of transcripts in TRPV1 lineage neurons and a contrasting transcriptome from non-TRPV1 neurons and cells. The transcriptome highlights previously unrecognized protein families, identifies multiple molecular circuits for excitatory or inhibitory autocrine and paracrine signaling, and suggests new combinatorial approaches to pain control.

Resiniferatoxin for Pain Treatment: An Interventional Approach to Personalized Pain Medicine.

This review examines existing preclinical and clinical studies related to resiniferatoxin (RTX) and its potential uses in pain treatment. Like capsaicin, RTX is a vanilloid receptor (TRPV1) agonist, only more potent. This increased potency confers both quantitative and qualitative advantages in terms of drug action on the TRPV1 containing nerve terminal, which result in an increased efficacy and a long duration of action. RTX can be delivered by a central route of administration through injection into the subarachnoid space around the lumbosacral spinal cord. It can also be administered peripherally into a region of skin or deep tissue where primary afferents nerves terminate, or directly into a nerve trunk or a dorsal root ganglion. The central route is currently being evaluated as a treatment for intractable pain in patients with advanced cancer. Peripheral administration offers the possibility to treat a wide diversity of pain problems because of the ability to bring the treatment to the site of the pain (the peripheral generator). While not all pain disorders are appropriate for RTX, tailoring treatment to an individual patient's needs via a selective and local intervention that chemically targets a specific population of nerve terminals provides a new capability for pain therapy and a simplified and effective approach to personalized pain medicine.

Which factors predict candidate outcome in advanced life support courses? A preliminary observational study.

PURPOSE: To identify factors associated with candidate outcome in the European Resuscitation Council (ERC) advanced life support (ALS) provider courses. METHODS: Medical doctors participating as candidates to consecutive ALS courses organised by an ERC training centre in Italy were enrolled in this prospective cohort study. The association between the ALS course outcome and candidate demographics, professional background and pre-course knowledge measured by using the pre-course multiple choice quiz (MCQ) was investigated by using logistic regression. RESULTS: A total of 283 candidates, median age 31 years, were evaluated. Among them, 269 (95.1%) passed the final evaluation and 14 (4.9%) failed. Candidates who passed were younger (median age 31 vs. 37.5 years; p = 0.006) and attained a higher pre-course MCQ score (median 84 vs. 72.5%; p < 0.0001). On multivariate analysis, a higher pre-course MCQ score (OR 1.18 [95%CI 1.09-1.28]) and a basic life support (BLS) certification (OR 5.00 [95%CI 1.12-22.42]) were independent predictors of candidate success, while older age was associated with a significantly higher risk of failing (OR 0.90 [95%CI 0.83-0.97]). Female candidates had higher pass rates (97.2 vs. 91.2%; p = 0.048); however, after correction for confounders gender was not significantly associated with candidate outcome. Neither candidate specialty nor site of work was a predictor of candidate success. CONCLUSIONS: On ALS courses, younger age and a higher level of specific pre-course knowledge, as measured by both the pre-course MCQ and the presence of BLS certification, are the most important predictors of success. Candidate gender and professional background did not show a significant correlation with course outcome.