Mental practice: a simple tool to enhance team-based trauma resuscitation.

INTRODUCTION: Effective trauma resuscitation requires the coordinated efforts of an interdisciplinary team. Mental practice (MP) is defined as the mental rehearsal of activity in the absence of gross muscular movements and has been demonstrated to enhance acquiring technical and procedural skills. The role of MP to promote nontechnical, team-based skills for trauma has yet to be investigated. METHODS: We randomized anaesthesiology, emergency medicine, and surgery residents to two-member teams randomly assigned to either an MP or control group. The MP group engaged in 20 minutes of MP, and the control group received 20 minutes of Advanced Trauma Life Support (ATLS) training. All teams then participated in a high-fidelity simulated adult trauma resuscitation and received debriefing on communication, leadership, and teamwork. Two blinded raters independently scored video recordings of the simulated resuscitations using the Mayo High Performance Teamwork Scale (MHPTS), a validated team-based behavioural rating scale. The Mann-Whitney U-test was used to assess for between-group differences. RESULTS: Seventy-eight residents provided informed written consent and were recruited. The MP group outperformed the control group with significant effect on teamwork behaviour as assessed using the MHPTS: r=0.67, p<0.01. CONCLUSIONS: MP leads to improvement in team-based skills compared to traditional simulation-based trauma instruction. We feel that MP may be a useful and inexpensive tool for improving nontechnical skills instruction effectiveness for team-based trauma care.

Massive transfusion in the trauma patient: Continuing Professional Development.

PURPOSE: Massive transfusion has recently been given a dynamic definition, namely, the replacement of more than four red cell concentrates within an hour. The purpose of this continuing professional development module is to review the pathophysiology of hemorrhagic shock in the trauma patient and the current management strategies of the massively bleeding trauma patient. PRINCIPAL FINDINGS: The massively bleeding trauma patient requires concurrent hemorrhage control and blood replacement therapy. Although there are many complications of massive transfusions, such as acid-base disturbances, electrolyte abnormalities, and hypothermia, perhaps the most difficult aspect to manage is acute trauma coagulopathy. Historically, coagulopathy was attributed to dilution of coagulation factors; however, recent accumulated evidence indicates that it is a multifactorial process associated with hypoperfusion, factor consumption, and hyperfibrinolysis. In an attempt to minimize acute trauma coagulopathy, massive transfusion protocols with equal ratios of red cell concentrates, frozen plasma, and platelets have been proposed. This type of hemostatic resuscitation, with near equal ratios of blood and blood products, has improved survival, but it is not without risk. In addition to the rapid and effective restoration of blood volume, the specific goal of transfusion management should be to maintain the patient's oxygen carrying capacity, hemostasis, and biochemistry. CONCLUSION: The current literature does not permit firm conclusions to be drawn regarding optimal transfusion ratios. It remains appropriate, however, to devise a massive transfusion protocol at the institutional level that provides treating physicians with rapid delivery of a reasonable initial ratio of products. This would permit patient-centred management with an emphasis on surgical control of bleeding, maintenance of normothermia, avoidance of electrolyte abnormalities, acid-base balance, and the timely delivery of blood products. OBJECTIVES: After reading this module, the reader should be able to: 1. Enumerate the complications associated with massive transfusion in the trauma context; 2. Understand how the coagulopathy present in the trauma patient differs from that seen in the elective setting; 3. Identify the modifications suggested by the recent literature for the management of massive transfusion in the trauma setting; 4. Appreciate the evidence for the institution of massive transfusion protocols.

Validation of the Imperial College Surgical Assessment Device (ICSAD) for labour epidural placement.

PURPOSE: Technical proficiency in anesthesia has historically been determined subjectively. The purpose of this study was to establish the construct validity for the Imperial College Surgical Assessment Device (ICSAD), a measure of hand motion efficiency, as an objective assessment tool for technical skill performance, by examining its ability to distinguish between operators of different levels of experience performing a labour epidural. Concurrent validity for the ICSAD was investigated by comparison to a validated task specific checklist (CL) and global rating scale (GRS). METHODS: A single blinded, prospective, controlled study design compared three groups of subjects: novice residents (<30 epidurals), experienced residents (>100 epidurals), and staff anesthesiologists (>500 epidurals). Performance was measured using the ICSAD (number of movements, path length, time) and scores from a CL and GRS graded by examiners blinded to the level of training. Data were analyzed by multivariate analysis of variance (MANOVA). RESULTS: Twenty-nine subjects were recruited. Novice residents had longer path lengths compared to experienced residents (P = 0.031) and staff anesthesiologists (P = 0.0004), made more movements (P = 0.012) and took more time than staff (P = 0.009). Novice residents scored significantly worse on the GRS compared to experienced residents (P = 0.029) and staff (P = 0.01) and had significantly lower CL scores compared to staff (P = 0.003). CONCLUSIONS: Construct and concurrent validity for the ICSAD was established for a regional anesthesia technique by demonstrating that it can distinguish between operators of different levels of experience and by comparing it to the current standards of technical skill assessment.

Perceived sleepiness in Canadian anesthesia residents: a national survey.

PURPOSE: To compare the self-perceived sleepiness of Canadian anesthesia residents providing modified on-call duties (12-16 h) vs. traditional on-call duties (24 h). METHODS: A 25-item online survey was distributed to all Canadian anesthesia residents who, at that time, were on anesthesia rotations. The survey assessed resident demographics, perceived work patterns, and sleepiness, as well as their opinions on resident work hour reform. Self-perceived sleepiness was quantified using the validated Epworth sleepiness scale (ESS). RESULTS: Three hundred eight of 400 (77%) eligible Canadian anesthesia residents completed the survey. Forty-three percent of residents who worked traditional on-call (duration 24.1 +/- 0.5 h) shifts and 48% of residents who worked modified on-call (duration 15.5 +/- 1.8 h) shifts met ESS criteria for excessive daytime sleepiness. Overall mean ESS scores did not differ significantly between the traditional (9.1 +/- 4.9) and the modified call groups (9.5 +/- 4.8). Residents with an on-call frequency of >or=1:4 days or those who slept

Variations in early and intermediate neonatal outcomes for inborn infants admitted to a Canadian NICU and born of hypertensive pregnancies.

OBJECTIVE: To determine whether neonatal intensive care unit (NICU) outcomes vary by centre for inborn neonates of hypertensive pregnancies and, if so, whether that variation might be related to between-centre variations in obstetric practice. METHODS: The study comprised a prospective cohort of 13 505 singleton neonates admitted to 17 Canadian NICUs. Adjusting for potential confounders, we used multivariate regression to analyze the relation between centre of delivery and 6 dependent variables: (1) Apgar score < 7 at 5 minutes; (2) Score of Neonatal Acute Physiology-II (SNAP-II) score > or = 10; (3) neonatal death; (4) neonatal death or morbidity (owing to bronchopulmonary dysplasia [BPD], intraventricular hemorrhage [IVH], necrotizing enterocolitis [NEC], persistent ductus arteriosus [PDA], or periventricular leukomalacia [PVL]); (5) BPD alone; and (6) major neonatal morbidity (that is, at least one of IVH, PVL, NEC, or PDA). NICU practices known to influence these outcomes were included in the modelling for neonatal death and neonatal morbidity. In a sensitivity analysis for practice variation, antenatal steroid exposure was both included and excluded in each regression. RESULTS: For 5 of the 6 dependent variables, we identified between-centre variation that was not explained solely by variation in antenatal corticosteroid use. Adjusted odds ratios varied from 0.11 to 5.6 (the reference centre was the median rate of the adverse outcome). CONCLUSIONS: In the pregnancy hypertension setting, between-centre variations in practice are associated with variations in neonatal physiology and survival. For infants admitted to NICU, the obstetric management of hypertensive pregnancies appears to have an effect on both short- and medium-term neonatal outcomes, even after correction for NICU management.