Introduction Compared to the GlideRite® rigid stylet used with the GlideScope® and its hyperangulated blade, the Flex-it® stylet permits a dynamic orientation of the endotracheal tube toward the glottic aperture. Our study compared the GlideRite stylet and Flex-it stylet on GlideScope intubation durations in patients wearing a semi-rigid cervical collar, simulating conditions of cervical instability. Methods Our institutional research ethics board approved the study protocol (Hôpital Maisonneuve-Rosemont IRB#14013) for this single-centre randomized controlled trial on 12/05/2014. Eighty patients between 18 and 70 years old were randomized into one of two interventions: intubation with GlideScope + GlideRite stylet (GlideRite) or intubation with GlideScope + Flex-it stylet (Flex-it). We used a hyperangulated blade, size 4. All included patients provided written consent, had American Society of Anesthesiologists (ASA) physical status I or II, and did not exhibit any difficult intubation criteria or known cervical spine anomaly. Following induction of anesthesia, a Philadelphia® semi-rigid cervical collar was installed to simulate conditions associated with cervical instability. One of the three anesthesiologists participating in the study performed the intubation. The primary endpoint was intubation duration in seconds, from the beginning of the laryngoscopy until detection of expired CO2. Secondary outcomes were endotracheal tube handling duration in seconds, intubation failure, Intubation Difficulty Score, and ease of stylet removal. Variations in blood pressure, heart rate, O2 saturation during intubation, postoperative hoarseness, and sore throat intensity were also compared between the interventions. Results Intubation was longer when using Flex-it vs. GlideRite (sec, Median [quartiles]), 71 [50-84] vs. 48 [39-60], P = .006). Kaplan-Meier curves showed that at 1 min, 20% of Flex-it patients were intubated vs. only 20% of GlideRite patients. The endotracheal tube (ETT) handling duration (sec, Median [quartiles]) was longer with Flex-it than with GlideRite, with 48 [33-66] vs. 34 [25-39], P = .007. The percent of failures was significantly higher with Flex-it (13/38, 32.5%) compared to GlideRite (1/38, 2.5%), P< .001. The Intubation Difficulty Scale score was significantly higher for Flex-it, with median [quartiles] of 6[5-7], compared to 2[2-5] for GlideRite, P< .001. There were no blood stains on the ETT or desaturations in either intervention. Ease of stylet removal, hoarseness, sore throat, blood pressure and heart rate measurements, and O2 saturation after intubation were not different between the interventions. Conclusion Videolaryngoscopy intubation using the Flex-it stylet was slower, more difficult, and had more failures than the GlideRite stylet in patients with simulated cervical instability wearing a semi-rigid cervical collar.

In North America, telehealth increased by 40% between 2019 and 2020 and stabilized at 40% in 2021. As telehealth becomes more common, it is essential to ensure that healthcare providers have the required skills to overcome the challenges and barriers of this new modality of care. While the COVID-19 pandemic has accelerated the design and implementation of telehealth curricula in healthcare education programs, its general adoption is still a major gap and an important barrier to ensuring scaling up and sustainability of the telesshealth practice. Lack of experienced faculty and limited curricular time are two of the most common barriers to expanding telehealth education. Overcoming the barriers of telehealth curricula implementation may require moving away from the classic expert model of learning in which novices learn from experts. As the adoption of telehealth curricula is still in its early stages, institutions may need to plan for faculty development and trainee education at the same time. Questions regarding the timing and content of telehealth education, the interprofessional development of curricula, and the identification of optimal pedagogical methods remain open and crucial. This article reflects on these questions and presents telesimulation as an ideal instructional method for the training of telehealth competencies. Telesimulation can provide opportunities for practical training across a range of telehealth competencies, fostering not only technical proficiency but also communication skills and interprofessional collaboration.

Non-anaesthetists commonly administer procedural sedation worldwide, posing the risk of respiratory events that can lead to severe complications. This study aimed to evaluate whether simulation-based learning could lead to enhancements in the clinical proficiency of non-anaesthesiology residents in managing sedation and related respiratory complications. Following the evaluation of baseline clinical performance through a pre-test simulation, 34 residents were randomly allocated to either participate in an innovative simulation-based learning module (intervention group) or view a brief self-learning video (control group). After a one-month period, their clinical performance was assessed again in a post-test simulation involving respiratory arrest during procedural sedation. Two independent assessors rated each resident's performance using video recordings and a scoring tool with scores ranging from 0 to 19/19. The two assessments were averaged for each performance, and the pre- to post-test change was calculated for each resident. While baseline clinical performance was similar, mean (SD) increase in clinical performance was significantly greater in the intervention group than in the control group (+2.4 (1.6) points versus +0.8 (1.3) points, respectively; p = 0.002). Our simulation-based learning sedation module resulted in the enhanced management of sedation-related complications compared to baseline and minimal self-learning. Simulation-based medical education may offer an effective approach for equipping non-anaesthesiology residents with essential skills to mitigate risks associated with sedation. (ClinicalTrials.gov identifier: NCT02722226).

This article provides a road map, along with recommendations, for the adoption and implementation of telesimulation at a large scale. We provide tools for translating an in-presence simulation curriculum into a telesimulation curriculum using a combination off-the-shelf telecommunication platform. We also describe the roles and tasks that emerged within the simulation team when planning and delivering a telesimulation curriculum.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a treatment option for peritoneal metastases (PM) but is associated with significant postoperative morbidity. The aim of this study was to determine the prognostic value of computed tomographic (CT)-measured sarcopenia on postoperative outcomes and survival in patients undergoing CRS-HIPEC for PM from various origins. A retrospective cohort study was conducted between 2012 and 2020. Three-hundred and twelve patients (mean age 57.6 ± 10.3, 34.3% male) were included, of which 88 (28.2%) were sarcopenic. PM from a colorectal origin was the most common in both groups. The proportion of major postoperative complications (Clavien-Dindo ≥ III) was not higher in the sarcopenic group (15.9% in sarcopenic patients vs. 23.2% in nonsarcopenic patients, p = 0.17). The mean Comprehensive Complication Index scores, HIPEC-related toxicities, length of hospital stay, and duration of parenteral nutrition were comparable regardless of sarcopenia status. In the multivariate logistic regression analysis of severe complications, only peritoneal carcinomatosis index reached statistical significance (OR, 1.05; 95% CI, 1.01 to 1.08, p = 0.007). Sarcopenia did not impact origin-specific overall survival on Cox regression analysis. Sarcopenia was not associated with worse rates of postoperative severe complications or worse survival rates. Future prospective studies are required before considering sarcopenia as part of preoperative risk assessment.

Abstract Background With their demanding schedules, surgical residents have limited time to practice techniques. The aim is to evaluate the pedagogic model of self-directed learning using video in surgery residents. Methods Informed consent was obtained from all the participants. A randomized controlled trial was conducted in 2018 at Hôpital Maisonneuve-Rosemont (University of Montreal). Participants were general surgery residents. There were 27 eligible residents; 22 completed the study. They were filmed performing an intestinal anastomosis on cadaveric pig bowel. The self-directed learning by video (SDL-V) group was given an expert video, which demonstrated the technique performed by an experienced surgeon. The control group continued with their regular duties. Three weeks later, participants performed a second filmed anastomosis. Two attending surgeons evaluated the residents’ filmed anastomosis using the Objective Structured Assessment of Technical Skills scale. After their second anastomosis, all participants had access to the expert video and completed a survey. Results Score did not differ significantly between groups during the first (control: 23.6 (4.5) vs. SDL-V: 23.9 (4.5), p = 0.99, presented as mean (SD)) or second filmed anastomosis procedure (control: 27.1 (3.9) vs. SDL-V: 29.6 (3.4) p = 0.28). Both groups improved significantly from pre- to post-intervention (mean difference between the two anastomosis procedure with 95% CI for control: 3.5, [1.1; 5.9] and for SDL-V: 5.8, [3.4: 8.2]). Correlation between the evaluators for score was moderate (r = 0.6, 95% CI: [0.3: 0.8]). The pass/fail global evaluation exhibited poor inter-rater reliability (Kappa: 0.105, 95% CI: [− 0.2:0.4]). On the survey, all participants wanted more expert-made videos of specific surgical techniques. Conclusions Despite a higher final OSATS score for the intervention group, self-directed learning by video failed to produce a statistically significant difference on the overall OSATS scores between the two groups in this small cohort.

Hypotension is common following spinal anesthesia (SA) during elective Cesarean delivery (CD). Although common practice is to alleviate inferior vena cava (IVC) compression, limited evidence supports a 15° tilt for CD. We measured collapsibility of the IVC in supine and 15° left lateral tilt positions with ultrasound before and after SA and phenylephrine infusion in term parturients. Twenty term parturients scheduled for CD were recruited for this prospective study. Ultrasound measurements of the IVC were taken 1) supine before SA, 2) tilted 15° before SA, 3) supine after SA, and 4) tilted 15° after SA. A phenylephrine infusion was begun after injection of SA. The primary outcome was to evaluate the impact of position on the IVC collapsibility index (IVCCI): a measure of the difference between the maximum and minimum IVC diameter with respiration. The mean (standard deviation) IVCCI (%) before SA was higher in the supine 19.5 (8.0) than in the tilted 15.0 (6.4) position (mean difference, 4.5; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). After SA, there was no significant difference between IVCCI (%) in the supine 17.8 (8.3) and tilted 14.2 (6.9) position (mean difference, 3.5; 95% CI, -0.9 to 7.9; P = 0.13). There was no correlation between the pre-spinal IVVCI measurements and the quantity of phenylephrine used during the surgery. The IVCCI was lower in the 15° tilt position than in the supine position, but not after SA with a phenylephrine infusion. Ultrasound imaging can help identify IVC compression. www.clinicaltrials.gov (NCT03410199); registered 18 January 2018.

Introduction: We used eye-tracking technology to explore the visual perception of clinicians during a high-fidelity simulation scenario. We hypothesized that physicians who were able to successfully manage a critical situation would have a different visual focus compared to those who failed. Methods: A convenience sample of 18 first-year emergency medicine residents were enrolled voluntarily to participate in a high-fidelity scenario involving a patient in shock with a 3rd degree atrioventricular block. Their performance was rated as pass or fail and depended on the proper use of the pacing unit. Participants were wearing pre-calibrated eye-tracking glasses throughout the 9-min scenario and infrared (IR) markers installed in the simulator were used to define various Areas of Interest (AOI). Total View Duration (TVD) and Time to First Fixation (TFF) by the participants were recorded for each AOI and the results were used to produce heat maps. Results: Twelve residents succeeded while six failed the scenario. The TVD for the AOI containing the pacing unit was significantly shorter (median [quartile]) for those who succeeded compared to the ones who failed (42 [31–52] sec vs. 70 [61–90] sec, p = 0.0097). The TFF for the AOI containing the ECG and vital signs monitor was also shorter for the participants who succeeded than for those who failed (22 [6–28] sec vs. 30 [27–77] sec, p = 0.0182). Discussion: There seemed to be a connection between the gaze pattern of residents in a high-fidelity bradycardia simulation and their performance. The participants who succeeded looked at the monitor earlier (diagnosis). They also spent less time fixating the pacing unit, using it promptly to address the bradycardia. This study suggests that eye-tracking technology could be used to explore how visual perception, a key information-gathering element, is tied to decision-making and clinical performance.

PURPOSE:The effect of direct laryngoscopy using a Macintosh blade (MAC) vs GlideScope™ videolaryngoscopy using a Spectrum LoPro blade (GVL) on nociceptive stimulation has not been quantitatively studied. This study used the new nociception level (NOL) index to compare the nociceptive response induced by GVL or MAC during laryngoscopy with or without intubation.METHODS:Patients underwent two laryngoscopies at four-minute intervals (L1, L2), one with GVL and the other with MAC (first randomization). A third laryngoscopy (L3) followed by tracheal intubation was performed four minutes after L2 (GVL or MAC, second randomization). Nociception was quantitatively assessed by NOL and standard hemodynamic parameters (heart rate [HR] and mean arterial pressure). For the crossover design, blade comparisons accounted for sequence and blade type. A possible carryover effect between laryngoscopies was assessed.RESULTS:In the 50 patients randomized, there was no carryover effect from one laryngoscopy to the next for all analyzed parameters. Nociception level index peak values were higher with MAC than GVL. Analysis of ΔNOL showed a lower nociceptive response with GVL for L1+L2 combined. Mean peak NOL values were significantly higher after L3+intubation than after L1+L2, for both GVL and MAC groups. Analysis of ΔHR values did not show a significant difference between GVL and MAC for any laryngoscopy.CONCLUSION:Laryngoscopy alone with GVL induces less nociception than with MAC. The NOL was more sensitive than HR at detecting nociceptive responses to MAC vs GVL. Additionally, and irrespective of which technique/blade was used, the combination of laryngoscopy + tracheal intubation produced a much greater nociceptive response than the laryngoscopy alone.TRIAL REGISTRATION:www.clinicaltrials.gov (NCT03277872); registered 29 August 2017.

It is the patient who consults, often at the last minute, the one you sigh over when you see his or her name on your list, the one who makes you feel powerless, and whom you would like to refer to a colleague. Every practicing physician has experienced being involved in a dialog of the deaf, with a patient refusing physicians’ recommendations, in a therapeutic dead end. Faced with such patients, the physician tries to convey scientific evidence to untangle the situation. When it does not work, he looks for other arguments, raises his voice, and avoids looking the patient in the eyes. When he is out of resources, trying to sound professional, he uses a sentence such as “I understand and respect your beliefs, but I am telling you what I learned in medical school!”. At the same time, his non-verbal behavior betrays more than a hint of irritation. Far from being caricatures, such situations generally result in the physician diagnosing or labeling the patient as “difficult.” This label is affixed on more than one patient in ten, and for all sorts of reasons. How, then, do you re-establish a relationship of trust? Or, even better, how do you avoid such labeling?

During the perioperative period, nociception control is certainly one of the anesthesiologist's main objectives when assuming care of a patient. There exists some literature demonstrating that the nociceptive stimuli experienced during surgery are responsible for peripheral and central sensitization phenomena, which can in turn lead to persistent postsurgical pain. An individualized approach to the evaluation and treatment of perioperative nociception is beneficial in order to avoid the sensitization phenomena that leads to prolonged postoperative pain and to minimize the consumption of opiates and their adverse effects. In terms of sensitivity, specificity, and positive/negative predictive values when compared to heart rate (HR) and mean arterial pressure (MAP), recent literature has shown that the NOL variation (ΔNOL) is the best index to distinguish noxious from non-noxious stimuli. Chronic treatment with β1-adrenergic antagonists may constitute a limitation to the use of the NOL index. β1-adrenergic antagonists induce a depressive action on the heart rate, which results in a limitation of its variability after a noxious stimulus. Since heart rate and heart rate variability are two parameters integrated into the NOL index, the validity of the NOL index in a population of patients receiving β1-adrenergic antagonists has not yet been determined. Our study sought to explore the NOL index, the BIS, and the heart rate variation in a group of patients under chronic treatment with β1-adrenergic antagonists submitted to standardized noxious stimulus under general anesthesia. We then compared those results to a control group of patients from our previous study (CJA group) that received no β1-adrenergic antagonist chronic treatment. The patients in this study were subjected to a standardized anesthetic protocol from induction up to 3 min after a standardized tetanic stimulus to the ulnar nerve at a frequency of 100 Hz and an amperage of 70 mA, for a duration of 30 s. Data were electronically recorded to obtain NOL, BIS, and heart rate values every 5 s for the duration of the protocol. The NOL maximal mean value reached after noxious stimulation was not different between our two cohorts (CJA: 30(14) versus BETANOL: 36(14) (p = 0.12)). There was no statistically significant difference between our cohorts in regards of the NOL AUC representing the variation of the NOL over a 180 s period (CJA: 595(356) versus BETANOL: 634(301) (p = 0.30)). However, a repeated measurement ANCOVA identified slight statistically significant differences between our cohorts in the peak of variation of the NOL index between 20 and 65 s after noxious stimulation, the NOL index of the cohort of beta-blocked patients being higher than the CJA patients. Moreover, the time to reach the maximum value was not different (CJA: 73(37) versus BETANOL: 63(41) (p = 0.35)). NOL sensitivity and specificity to detect a noxious stimulus under general anesthesia were similar in patients taking beta-blockers or not, and were better than those of heart rate and Bispectral index (AUC NOL 0.97, CI(0.92–1), versus AUC BIS 0.78, CI(0.64–0.89) and AUC HR 0.66, CI(0.5–0.8)). In conclusion, the NOL index is a reliable monitor to assess nociception in a population of patients under chronic beta-blocker therapy. Patients under such therapy achieve similar maximal NOL values over a 180 s period after a standardized noxious stimulus and the NOL variation over time, represented by the AUC is not significantly different from a cohort of non-beta-blocked patients. Whether the patient takes beta-blockers or not, sensitivity of the NOL index is greater than that seen for BIS index or heart rate to detect an experimental noxious stimulus under general anesthesia.

BACKGROUNDNitrous oxide (N2O) has been used since the 19th century for its analgesic, antinociceptive and anxiolytic effects during surgical procedures in awake and anaesthetised patients. However, quantification of noxious stimuli that occur under general anaesthesia is a constant challenge for anaesthesiologists, and recently two new indices have been developed to assess intra-operative nociception.OBJECTIVEThe aim of this study was to quantify with new indices as well as with more classical clinical parameters the antinociceptive effect of N2O during general anaesthesia.DESIGNProspective, open label, patient-blinded, observational and descriptive trial.SETTINGSingle-centre academic hospital.PARTICIPANTSForty American Society of Anesthesiologists' physical status 1 to 3 patients undergoing general anaesthesia for elective abdominal surgery via laparotomy were recruited.MAIN OUTCOMES MEASURESIntra-operative pain was assessed using a standardised electrical stimulation of the forearm (tetanic stimulation at 70 mA, 100 Hz for 30 s), at 0, 25 and 50% inhaled N2O/O2. Heart rate (HR), mean arterial blood pressure, bispectral index, the analgesia nociception index and the nociception level (NOL) index were used to evaluate intra-operative nociception before and after each standardised tetanic stimulation.RESULTSThere was a 16% reduction of the analgesia nociception index reaction, a 31% reduction of the NOL reaction and a 51% reduction of the HR reaction to a standardised electrical tetanic nociceptive stimulation during administration of 50% N2O. Administration of 50 or 25% inhaled N2O produced the same quality of antinociception based on HR and NOL index analyses. HR and the NOL index were the best parameters to identify the antinociceptive effect of intra-operatively administered N2O.CONCLUSIONIn anaesthetised patients, our study demonstrated clinically significant antinociceptive properties of N2O. Our results showed that low concentrations of N2O (25%) are as effective as higher concentrations (50%) to achieve a significant antinociceptive effect. These findings may help decrease negative effects of using higher concentrations of N2O, including its side effects and its environmental pollution.TRIAL REGISTRATIONClinicalTrials.gov registration identifier: NCT02701478.

This article describes a high-fidelity (Hi-Fi) simulation-based innovative educational strategy intended to introduce anesthesiology residents to key ethical considerations and how they apply to their practice. Three Hi-Fi simulation scenarios involving situations with various ethical issues are described with their debriefing objectives and the trainees' subjective feedback. Three high-fidelity simulation scenarios are described: (a) teaching critical incident disclosure, (b) disclosing and discussing patient awareness during general anesthesia, and (c) would physicians override a do-not-resuscitate (DNR) order if the cause of a cardiac arrest is iatrogenic? We used Hi-Fi simulation in an innovative way to teach these principles of ethics. Simulation, through carefully crafted debriefing, can contribute to the acquisition of essential non-technical ethical skills. How best to integrate simulation in an existent ethics curriculum and how it compares with more traditional teaching methods are questions that need to be addressed.

Department of Anesthesiology, Centre d’apprentissage des Attitudes et Habiletés Cliniques (CAAHC), Université de Montréal, Faculty of Medicine, Montreal, Quebec, Canada Abstract: This article describes a high-fidelity (Hi-Fi) simulation-based innovative educational strategy intended to introduce anesthesiology residents to key ethical considerations and how they apply to their practice. Three Hi-Fi simulation scenarios involving situations with various ethical issues are described with their debriefing objectives and the trainees’ subjective feedback. Three high-fidelity simulation scenarios are described: (a) teaching critical incident disclosure, (b) disclosing and discussing patient awareness during general anesthesia, and (c) would physicians override a do-not-resuscitate (DNR) order if the cause of a cardiac arrest is iatrogenic? We used Hi-Fi simulation in an innovative way to teach these principles of ethics. Simulation, through carefully crafted debriefing, can contribute to the acquisition of essential non-technical ethical skills. How best to integrate simulation in an existent ethics curriculum and how it compares with more traditional teaching methods are questions that need to be addressed.

Alveolar flooding and airway obstruction are present in the acute respiratory distress syndrome. The impact of positive end-expiratory pressure on regional airway aeration has not been described.To assess bronchial and lung recruitment and distension during an incremental positive end-expiratory pressure trial in patients with acute respiratory distress syndrome.Six patients underwent lung and airway imaging at four positive end-expiratory pressure levels in a cohort trial. Images were post-processed by means of Functional Respiratory Imaging. This technique offers 3-dimensional visualisation and quantification of patients’ airway and lung geometry on a regional level.With increasing positive end-expiratory pressure from 0 to 20 cmH2O, the median bronchial recruitment was 151% and the median bronchial distension 43%. Non-aerated lower lobes bronchi had more bronchial volume increase at high positive end-expiratory pressure than partially aerated upper lobes bronchi. Lung recruitment tended to be higher in patients with non-focal acute respiratory distress syndrome. In two patients, bronchial volume increase at high positive end-expiratory pressure largely exceeded bronchial volume increase observed in matched healthy control subjects at total lung capacity, suggesting severe bronchial over-distension.In early acute respiratory distress syndrome, Functional Respiratory Imaging gives an innovative insight into the relationship between positive end-expiratory pressure-induced bronchial distension and recruitment, positive end-expiratory pressure-induced lung recruitment and hyperinflation and lung morphology.

OBJECTIVE:To compare the effect of exteriorized with in situ uterine repair on intraoperative nausea and vomiting during elective cesarean delivery under spinal anesthesia using a phenylephrine infusion.METHODS:This study was a randomized double-blinded controlled trial of 180 women undergoing elective cesarean delivery using a standardized anesthetic protocol. Patients were randomized to exteriorization (n=90) or in situ uterine repair (n=90). The spinal anesthetic, phenylephrine infusion, and blood pressure management were all standardized. The primary outcome was postdelivery intraoperative nausea and vomiting using a 4-point scale (0-3). A sample size of 80 patients per group was needed to demonstrate a 50% reduction in intraoperative nausea and vomiting with in situ repair.RESULTS:From November 2015 through July 2018, 180 patients were enrolled. Incidence of postdelivery intraoperative nausea and vomiting was 39% in the exteriorization group compared with 22% in the in situ group (P=.01). Incidence of hypotension (80% vs 50%; P<.001) and tachycardia (33% vs 17%; P=.02) was significantly higher in the exteriorization group, and more phenylephrine boluses were administered to this group (median 4 boluses [first and third quartiles 1.25-7] vs 2 [0-4]; P<.001). The duration of surgery, blood loss, and postoperative hemoglobin decline were similar between groups.CONCLUSION:In situ uterine repair for elective cesarean delivery under spinal anesthesia with a phenylephrine infusion is associated with less postdelivery intraoperative nausea and vomiting.CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT02587013.

INTRODUCTION:Experiential learning, followed by debriefing, is at the heart of Simulation-Based Medical Education (SBME) and has been proven effective to help master several medical skills. We investigated the impact of an educational intervention, based on high-fidelity SBME, on the debriefing competence of novice simulation instructors.METHODS:This is a prospective, randomized, quasi-experimental, pre- and post-test study. Sixty physicians without prior formal debriefing expertise attended a 5-day SBME seminar targeted on debriefing. Prior to the start of the seminar, 15 randomly chosen participants had to debrief a spaghetti and tape team exercise. Thereafter, the members of each team assessed their debriefer's performance using the Debriefing Assessment for Simulation in Healthcare (DASH)© score. The debriefing seminar that followed (intervention) consisted of 5 days of teaching that included theoretical and simulation training. Each scenario was followed by a Debriefing of the Debriefing (DOD) session conducted by the expert instructor. At the end of the course, 15 randomly chosen debriefers had to debrief a second tower building exercise and were re-evaluated with the DASH score by their respective team members. The Wilcoxon signed-rank test was used to compare pre- and post-test scores. Statistical tests were performed using GraphPad Prism 6.0c for Mac.RESULTS:A significant improvement in all items of the DASH score was noted following the seminar. The debriefers significantly improved their performance with regard to "maintaining an engaging learning environment" (Median [IQR]) (4[3-5] after the pre-test vs. 5.5[5-6] after the post-test, p<0.001); "structuring the debriefing in an organized way" (5[4-5] after the pre-test vs. 5[5-6] after the post-test, p=0.002); "provoking engaging discussion" (4[3-5.75] after the pre-test vs. 6[5-6] after the post-test, p<0.001); "identifying and exploring performance gaps" (5[4-6] after the pre-test vs. 6[5-6] after the post-test, p=0.014); and "helping trainees to achieve and sustain good future performance" (4[3-5] after the pre-test vs. 6[5-6] after the post-test, p<0.001).CONCLUSION:A simulation-based debriefing course, based mainly on DOD sessions, allowed novice simulation instructors to improve their overall debriefing skills including, more specifically, the ability to foster engagement in discussions and maintain an engaging learning environment.

The Pain Monitoring Device (PMD) monitor (Medasense Biometrics Ltd., Ramat Gan, Israel) uses the Nociception Level (NOL) index, a multiple parameter-derived index that has recently shown a good sensitivity and specificity to detect noxious stimuli. The aim of this study was to assess the latest version of the device (PMD200TM) on variations of the NOL response after standardized tetanic stimuli to study the correlation between remifentanil doses and NOL. Data from 26 patients undergoing midline laparotomy and receiving a desflurane-remifentanil-based anesthetic coupled with low thoracic epidural analgesia were analyzed. A standardized tetanic stimulus was applied to the forearm of the patients at different remifentanil infusion rates. The primary aim was to evaluate the correlation between post-tetanic stimulation NOL values from the PMD200 and remifentanil doses. The NOL index variations after experimental and clinical stimuli were also compared with heart rate (HR), mean arterial pressure (MAP), and Bispectral Index™ (BIS). A correlation between post-tetanic stimulation NOL values and remifentanil doses was found (r = −0.56; 95% confidence interval [CI], −0.70 to −0.44; P < 0.001). The NOL discriminated noxious from non-noxious states with the maximal Youden’s index value of the NOL receiver operating characteristic (ROC) curve showing a specificity of 88% (95% CI, 69.0 to 100) and sensitivity of 79.1% (95% CI, 56.2 to 95.5). The area under the NOL ROC curve (AUC, 0.9; 95% CI, 0.84 to 0.95) was significantly different from the other variables (P < 0.001 vs HR; P < 0.001 vs MAP; P < 0.001 vs BIS). The NOL value after noxious stimulus decreased with incremental remifentanil doses, showing a significant inverse correlation between the NOL index and opioid doses. The sensitivity and specificity of NOL to discriminate between noxious and non-noxious stimuli suggests its interesting potential as a monitor of nociception intensity during anesthesia. www.clinicaltrials.gov (NCT 02884778); 27 July, 2016.

Introduction: Transcutaneous cardiac pacing (TCP) is recommended for the treatment of symptomatic bradycardia, a life-threatening condition. Although TCP is taught in ACLS (advanced cardiac life support) courses, it is a difficult skill to master for junior residents. The main objective of this study is to measure the impact of having access to a checklist on successful TCP implementation. Our hypothesis was that the availability of a CL would improve performance of junior residents in the management of symptomatic bradycardia by facilitating TCP. Methods: We conducted a prospective, randomized, single-site study. First-year residents entering postgraduate programs and taking a mandatory ACLS course were enrolled. Students had didactic sessions on the management of symptomatic bradycardia followed by hands-on teaching on a low-fidelity manikin (ALS® simulator, Laerdal) using a CL conceived for this project as a teaching tool. Study participants were then assessed with a simulation scenario requiring TCP. Participants were randomly assigned to groups with and without CL accessibility. Performances were graded on six critical tasks. The primary outcome was the successful use of TCP, defined as having completed all tasks. Participants then completed a post-test questionnaire. Sample size estimation was based on a previous project (Ranger et al., 2018). Accepting an alpha error of 0.05 and a power of 80%, 45 participants in each group would permit the detection of 26.5% in performance gain. Results: Of 250 residents completing the ACLS course in 2017, 85 voluntary participants were randomized to a control group (no CL available during testing, n = 42) or an experimental group (CL available during testing, n = 43). Six participants in the experimental group adequately used TCP compared to five participants in the control group (p = 0.81, chi-squared test). Out of the 43 participants who had access to the CL, only 2 (5%) used it. Reasons why the CL was infrequently used were stated as the following: 24 participants (56%) mentioned not realizing it was available, 8 (19%) considered it was of little to no utility and 5 (19%) forgot a CL existed. Conclusion: Availability of a checklist previously used during simulation teaching did not increase junior residents’ capacity to correctly apply TCP. Non-recognition of CL availability and decreased perceived need for it were the main reasons for marginal use. Our results suggest that there are many limiting factors to CL effectiveness.