Ultrasound-guided regional anesthesia (UGRA) requires knowledge of anatomy, hand–eye coordination, and safe needling techniques. Extended reality (XR), including augmented reality, virtual reality (VR), and mixed reality, is an emerging simulation modality for UGRA training. We sought to conduct a systematic review to evaluate the current evidence on the effectiveness of XR for UGRA training. We searched MEDLINE, Embase®, the Cochrane Library, Web of Science®, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to 15 November 2024. We included randomized controlled trials, observational studies, and case series. We categorized outcomes by Kirkpatrick levels and assessed risk of bias. From 1,703 articles, we included seven studies (N = 137 participants). Four studies reported participant reactions. One trial (n = 29) found higher self-confidence in anatomical landmark identification and procedural performance (P < 0.001). One study assessed knowledge, reporting a score increase (P < 0.001). Augmented reality head-mounted display studies found shorter procedure times (10 vs 7 sec; P = 0.03 and 18 vs 12 sec; P = 0.002), higher needle visibility (34 CRD42023424194 ); first submitted 18 May 2023.

INTRODUCTION:Manikin-based high-fidelity simulation (HFS) is critical in anesthesia for teaching crisis resource management skills in a safe environment. However, HFS is known to result in significant stress, potentially affecting learning. Virtual reality (VR) has emerged as a promising alternative to HFS, but the impact on stress remains unknown. This study compares perceived and physiological stress in anesthesia trainees during VR and HFS, and in high- and low-performing subjects after HFS. METHODS:This secondary analysis from a prospective, sequential, randomized controlled trial compares anesthesia trainee volunteers who undergo either VR or HFS scenarios. Perceived stress was measured using the State-Trait Anxiety Inventory (STAI), the Medical Emotion Scale (MES), and the NASA Task Load Index (NASA-TLX). Physiological stress was assessed via heart rate variability standard deviation between successive N-N intervals (SDNN) and the low-frequency/high-frequency (LF/HF) ratio. Trainees' performance was assessed with the Ottawa Global Rating Scale. RESULTS:Among the 34 volunteers enrolled, both the VR and HFS groups demonstrated similar STAI, MES, and NASA-TLX scores following the scenarios. However, VR elicited lower SDNN values (mean difference, -12, 95% CI, -23 to -1.0, P=0.034), but not the LF/HF ratio. No difference was observed in stress indicators between high-performing and low-performing trainees. CONCLUSIONS:Anesthesia trainees experience comparable levels of perceived stress in the form of anxiety, emotional responses, and task load in VR and HFS scenarios. A lower heart rate variability during VR scenarios may indicate greater physiological stress. The relevance and implications of these findings in simulation require further clarification. STUDY REGISTRATION:ClinicalTrials.gov (NCT05041049).

Virtual reality (VR) may offer training advantages over mannequin-based high-fidelity simulation (HFS), but data are lacking. We sought to investigate whether VR is noninferior to HFS in teaching nontechnical skills to anesthesiology trainees. We conducted a sequential randomized controlled noninferiority trial to compare two simulation crisis management scenarios in 31 anesthesiology trainees. Scenario #1 was delivered either as a VR or as HFS. After 3 weeks, all participants underwent scenario #2, delivered only as HFS. We set a noninferiority margin of 0.6 for the overall improvement on the Ottawa Global Rating Scale (O-GRS), a crisis resource management scale, in scenario #2 between the two groups. As secondary outcomes, we compared changes in the Anaesthetists’ Non-technical Skills (ANTS) scale and the Managing Emergencies in Paediatric Anaesthesia Global Rating Scale (MEPA-GRS) between the two groups. We also evaluated the VR module using the VR Sickness Questionnaire (VRSQ), the System Usability Scale (SUS), the Technology Acceptance Model, and a feedback survey. During scenario #2, VR was noninferior to HFS regarding the overall O-GRS improvement (mean difference [upper bound 97.5 NCT05041049 ); first submitted 10 September 2021.

Ultrasound-guided regional anesthesia (UGRA) is an essential skill in anesthesiology, yet non-regional anesthesia fellowship-trained anesthesiologists often have limited opportunities to perform it. Using the Theoretical Domains Framework(TDF), we aimed to explore the barriers to and facilitators of anesthesiologists’ performing UGRA without fellowship training in Canada. We conducted a qualitative study following ethics approval, using semistructured interviews with 15 Canadian staff anesthesiologists who did not complete a regional anesthesia fellowship. Interviews were audio-recorded, transcribed, and analyzed using NVivo 12 (QSR International, Burlington, MA, USA) with a deductive coding approach based on the TDF. We used predefined criteria to identify relevant TDF domains that influence the performance of ultrasound-guided regional anesthesia. We achieved data saturation by the 15th interview. Eight TDFdomains were identified as most relevant to performing UGRA. Key facilitators were institutional support and dedicated resources, training and practice opportunities, mentorship and teamwork, and confidence. Major barriers were lack of resources/staff/time, surgeon resistance, fear of complications/workflow disruption and provider anxiety, low confidence, and insufficient training/practice. Ultrasound-guided regional anesthesia adoption by non-regional anesthesia fellowship-trained anesthesiologists is influenced by a complex interplay of individual, social, and environmental factors. These findings highlight clear targets for implementation strategies, including more training, resource allocation, and strengthened interdisciplinary collaboration across departments such as anesthesia, surgery, and emergency medicine. Addressing these barriers and leveraging enablers through theory-informed interventions may increase UGRA uptake and ultimately lead to better perioperative patient care.

INTRODUCTION:Ultrasound-guided regional anaesthesia enhances pain control, patient outcomes and lowers healthcare costs. However, teaching this skill effectively presents challenges with current training methods. Simulation-based medical education offers advantages over traditional methods. However, the use of instructional design features in ultrasound-guided regional anaesthesia simulation training has not been defined. This systematic review aimed to identify and evaluate the prevalence of various instructional design features in ultrasound-guided regional anaesthesia simulation training and their correlation with learning outcomes using a modified Kirkpatrick model. METHODS:A comprehensive literature search was conducted including studies from inception to August 2024. Eligibility criteria included randomised controlled trials; controlled before-and-after studies; and other experimental designs focusing on ultrasound-guided regional anaesthesia simulation training. Data extraction included study characteristics; simulation modalities; instructional design features; and outcomes. RESULTS:Of the 2023 articles identified, 62 met inclusion criteria. Common simulation modalities included live-model scanning and gel phantom models. Instructional design features such as the presence of expert instructors, repetitive practice and multiple learning strategies were prevalent, showing significant improvements across multiple outcome levels. However, fewer studies assessed behaviour (Kirkpatrick level 3) and patient outcomes (Kirkpatrick level 4). DISCUSSION:Ultrasound-guided regional anaesthesia simulation training incorporating specific instructional design features enhances educational outcome; this was particularly evident at lower Kirkpatrick levels. Optimal combinations of instructional design features for higher-level outcomes (Kirkpatrick levels 3 and 4) remain unclear. Future research should standardise outcome measurements and isolate individual instructional design features to better understand their impact on clinical practice and patient safety.

Peripheral nerve blocks (PNBs) in older adult patients with a hip fracture improve morbidity and mortality, reduce health care costs, and improve quality of care. Despite the benefits, PNB use rates remain low. We aimed to use the Theoretical Domains Framework to investigate the barriers and facilitators to PNB use in patients with a hip fracture from the perspective of Canadian anesthesiologists. We created an online survey that collected both quantitative and qualitative responses. After research ethics board approval, the survey was distributed among all Canadian Anesthesiologists’ Society (CAS) members. We present five-point Likert responses as medians and interquartile ranges [IQRs], conducted thematic analysis on the narrative feedback, and performed cluster analysis to explore patterns associated with survey responses. We obtained responses from 256/2,498 (10.2

Purpose Simulation-based medical education (SBME) is provided by all anesthesiology residency programs in Canada. The purpose of this study was to characterize SBME in Canadian anesthesiology residency training programs. Methods We administered a 21-question survey to the simulation director/coordinator for all 17 Canadian academic departments of anesthesiology from October 2019 to January 2020. The survey consisted of questions pertaining to the characteristics of the simulation centres, their faculty, learners, curriculum, and assessment processes. Results All 17 residency training programs participated in the survey and reported large variability in the number and formal training of simulation faculty and in content delivery. Five programs (29%) did not provide faculty recognition for curriculum design and running simulation sessions. Most programs offered one to four simulation sessions per academic year for each year of residency. All programs offered mannequin-based and part-task trainers for teaching technical and nontechnical skills. Fourteen programs (82%) offered interprofessional and interdisciplinary simulation sessions, and ten programs (59%) did not include in situ simulation training. Commonly reported barriers to faculty involvement were lack of protected time (12 programs, 71%), lack of financial compensation (ten programs, 59%), and lack of appreciation for SBME (seven programs, 41%). Conclusion Large variability exists in the delivery of SBME in Canadian anesthesiology residency simulation programs, in part because of differences in financial/human resources and educational content. Future studies should explore whether training and patient outcomes differ between SBME programs and, if so, whether additional standardization is warranted.

Simulation-based education in ultrasound-guided regional anesthesia (UGRA) improves knowledge, skills, and patient outcomes. Nevertheless, it is not known how simulation-based UGRA education is used across Canada. We aimed to characterize the current use of simulation-based UGRA education in Canadian anesthesiology residency training programs. We developed and distributed a structured national survey to simulation leads of all 17 Canadian anesthesiology residency training programs. The survey inquired about program demographics, simulation modalities, facilitators and barriers to simulation use, use for assessment, and beliefs around simulation-based UGRA education. We gathered data from August to November 2023 and summarized our findings descriptively. Fifteen programs (88

According to the Canadian Anesthesiologists' Society Guidelines to the Practice of Anesthesia, ''The anesthesiologist must remain constantly vigilant, understanding that brief interruption in continuous monitoring may be unavoidable and there are certain circumstances in which a monitor may fail.'' 1 We challenge this statement by asking to what extent is constant vigilance a realistic expectation for anesthesiologists?Humans have well-described limits to perception and attention at the best of times, even without common contextual factors such as fatigue, boredom, distractions, and cognitive overload.In this issue of the Journal, Mizubuti et al. highlight the importance of inattentional blindness (IB) in anesthesiology, which is defined as a ''phenomenon in which people fail to notice stimuli appearing in front of their eyes when they are preoccupied with an attentionally demanding task.'' 2 A wellknown example of IB, winning the 2004 Ig Nobel Prize for Psychology, is of an ''invisible gorilla'' that walks through a group of people passing a ball back and forth. 3As the authors point out, IB not only applies to people in gorilla suits but there are also many examples of IB in health care that can result in potentially life-threatening medical errors.How can an improved understanding of this phenomenon improve patient safety?Mizubuti et al.'s study was a multicentre, international observational study of 280 staff anesthesiologists.Participants watched a four-minute video of a simulated patient who undergoes an emergency laparotomy and encounters unexpected intraoperative hemorrhage.Participants were asked to identify any abnormality, which was classified as either common (hypotension, tachycardia, hypoxia, and hypothermia) or uncommon (the patient turning his head while anesthetized and a loosely connected central line leading to a continuous trickling of blood).They found that anesthesiologists across all age groups were less likely to identify the rare abnormalities compared with the common ones.They also found that the perception of being fatigued (or not) did not influence IB.The authors conclude that IB is present in anesthesiologists in a wide range of age groups and that efforts should be put toward mitigating IB to prevent future medical errors.Nontechnical skills (NTS), including leadership, communication, and situational awareness (SA) are core competencies required for all anesthesiologists, and poor NTS is often a root cause of many intraoperative errors that can result in significant adverse patient outcomes. 4ituational awareness is a foundational NTS for other cognitively ''downstream'' crisis resource management skills such as decision-making, leadership, and communication.Situational awareness is divided into three levels.Level 1 is the perception of the patient's

BACKGROUND:Physiological changes associated with ageing could negatively impact the crisis resource management skills of acute care physicians. This study was designed to determine whether physician age impacts crisis resource management skills, and crisis resource management skills learning and retention using full-body manikin simulation training in acute care physicians.METHODS:Acute care physicians at two Canadian universities participated in three 8-min simulated crisis (pulseless electrical activity) scenarios. An initial crisis scenario (pre-test) was followed by debriefing with a trained facilitator and a second crisis scenario (immediate post-test). Participants returned for a third crisis scenario 3-6 months later (retention post-test).RESULTS:For the 48 participants included in the final analysis, age negatively correlated with baseline Global Rating Scale (GRS; r=-0.30, P<0.05) and technical checklist scores (r=-0.44, P<0.01). However, only years in practice and prior simulation experience, but not age, were significant in a subsequent stepwise regression analysis. Learning from simulation-based education was shown with a mean difference in scores from pre-test to immediate post-test of 2.28 for GRS score (P<0.001) and 1.69 for technical checklist correct score (P<0.001); learning was retained for 3-6 months. Only prior simulation experience was significantly correlated with a decreased change in learning (r=-0.30, P<0.05).CONCLUSIONS:A reduced amount of prior simulation training and increased years in practice, but not age on its own, were significant predictors of low baseline crisis resource management performance. Simulation-based education leads to crisis resource management learning that is well retained for 3-6 months, regardless of age or years in practice.

Introduction The proportion of older acute care physicians (ACPs) has been steadily increasing. Ageing is associated with physiological changes and prospective research investigating how such age-related physiological changes affect clinical performance, including crisis resource management (CRM) skills, is lacking. There is a gap in the literature on whether physician’s age influences baseline CRM performance and also learning from simulation. We aim to investigate whether ageing is associated with baseline CRM skills of ACPs (emergency, critical care and anaesthesia) using simulated crisis scenarios and to assess whether ageing influences learning from simulation-based education. Methods and analysis This is a prospective cohort multicentre study recruiting ACPs from the Universities of Toronto and Ottawa, Canada. Each participant will manage an advanced cardiovascular life support crisis-simulated scenario (pretest) and then be debriefed on their CRM skills. They will then manage another simulated crisis scenario (immediate post-test). Three months after, participants will return to manage a third simulated crisis scenario (retention post-test). The relationship between biological age and chronological age will be assessed by measuring the participants CRM skills and their ability to learn from high-fidelity simulation. Ethics and dissemination This protocol was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB Number 140–2015) and the Ottawa Health Science Network Research Ethics Board (#20150173–01H). The results will be disseminated in a peer-reviewed journal and at scientific meetings. Trial registration number NCT02683447 .

As simulator fidelity (i.e., realism) increases from low to high, the simulator more closely resembles the real environment, but it also becomes more expensive. It is generally assumed that the use of high-fidelity simulators results in better learning; however, the effect of fidelity on learning non-technical skills (NTS) is unknown. This was a non-inferiority trial comparing the efficacy of high- vs low-fidelity simulators on learning NTS.

INTRODUCTION:During video laryngoscopy (VL) with angulated or hyper-curved blades, it is sometimes difficult to complete tracheal intubation despite a full view of the larynx. When using indirect VL, it has been suggested that it may be preferable to obtain a deliberately restricted view of the larynx to facilitate passage of the endotracheal tube. We used the GlideScope® GVL video laryngoscope (GVL) to test whether deliberately obtaining a restricted view would result in faster and easier tracheal intubation than with a full view of the larynx.METHODS:We recruited 163 elective surgical patients and randomly allocated the participants to one of two groups: Group F, where a full view of the larynx was obtained and held during GVL-facilitated tracheal intubation, and Group R, with a restricted view of the larynx (< 50% of glottic opening visible). Study investigators experienced in indirect VL performed the intubations. The intubations were recorded and the video recordings were subsequently assessed for total time to intubation, ease of intubation using a visual analogue scale (VAS; where 0 = easy and 100 = difficult), first-attempt success rate, and oxygen saturation after intubation. Complications were also assessed.RESULTS:The median [interquartile range (IQR)] time to intubation was faster in Group R than in Group F (27 [22-36] sec vs 36 [27-48] sec, respectively; median difference, 9 sec; 95% confidence interval [CI], 5 to 13; P < 0.001). The median [IQR] VAS rating for ease of intubation was also better in Group R than in Group F (14 [6-42) mm vs 50 mm [17-65], respectively; median difference, 20 mm; 95% CI, 10 to 31; P < 0.001). There was no difference between groups regarding the first-attempt success rate, oxygen saturation immediately after intubation, or complications.CONCLUSIONS:Using the GVL with a deliberately restricted view of the larynx resulted in faster and easier tracheal intubation than with a full view and with no additional complications. Our study suggests that obtaining a full or Cormack-Lehane grade 1 view may not be desirable when using the GVL. This trial was registered at ClinicalTrials.gov: NCT02144207.