Visuospatial ability as a predictor of novice performance in ultrasound–guided regional anesthesia

Background: Visuospatial ability correlates positively with novice performance of simple laparoscopic tasks. The aims of this study were to identify if visuospatial ability could predict technical performance of an ultrasound–guided needle task by novice operators, and to describe how emotional state, intelligence and fear of failure impact on this. Methods: Sixty medical student volunteers enrolled in this observational study. We used an instructional video to standardize training for ultrasound-guided needle advancement in a turkey breast model and assessed volunteers’ performance independently by two assessors using composite error score (CES) and global rating scale (GRS). We assessed their ‘visuospatial ability’ with mental rotation test (MRT), group embedded figures test (GEFT) and Alice Heim group ability (AH4) test. ‘Emotional state’ was judged with UWIST mood adjective checklist (UMACL) and fear of failure, and ‘general cognitive ability’ with numerical reasoning test (NRT-20). Results: High CES scores (high error rate) were associated with low MRT scores (= −0.54; P<0.001). Better GRS scores were associated with better MRT scores (= 0.47; P<0.001). Regarding emotions, GRS scores were low when anxiety levels were high (= −0.35; P= 0.005) and CES scores (errors) were low when individuals reported feeling vigorous and active (= −0.30; P= 0.01). Conclusions: MRT predicts novice performance of an ultrasound-guided needling task on a turkey model, and as a trait measure could be used as a tool to focus training resources on less able individuals. Anxiety adversely affects performance. Both may therefore prove useful in directing targeted training in USGRA

Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomized controlled trial

Objective Fractured neck of femur is a severely painful condition with significant mortality and morbidity. We investigated whether early and continuous use of femoral nerve block can improve pain on movement and mobility after surgery in older participants with fragility neck of femur fracture. Design Prospective single centre, randomised controlled pragmatic trial. Setting Secondary care, acute NHS Trust, UK. Participants Participants admitted with a history and examination suggesting fractured neck of femur. Intervention Immediate continuous femoral nerve block via catheter or standard analgesia. Results One hundred and forty one participants were recruited, with 23 excluded. No significant difference was detected between cumulative dynamic pain scores (standard care (n = 56) vs 4 intervention (n = 55) 20 (IQR 15-24) vs 20 (15-23) p=0.51) or cumulated ambulation scores (standard care vs intervention 6 (5-9) vs 7 (5-10) p=0.76). There were no statistically different differences in secondary outcomes except cumulative pain at rest: 5 (0.5-6.5) in the standard care group and 2 (0-5) in the intervention group (p=0.043). Conclusions Early application of continuous femoral nerve block compared with standard systemic analgesia did not result in improved dynamic pain scores or superior post-operative ambulation. This technique may provide superior pain relief at rest. Continuous femoral nerve block did not delay initial control of pain, or mobilisation after surgery

Early cerebral perfusion pressure augmentation with phenylephrine after traumatic brain injury may be neuroprotective in a pediatric swine model*

Objective: Cerebral perfusion pressureage, and current guidelines recommend maintaining cerebral perfusion pressure between 40 mm Hg–60 mm Hg. Although adult traumatic brain injury studies have observed an increased risk of complications associated with targeting a cerebral perfusion pressure \u3e70, we hypothesize that targeting a cerebral perfusion pressure of 70 mm Hg with the use of phenylephrine early after injury in the immature brain will be neuroprotective. Design: Animals were randomly assigned to injury with a cerebral perfusion pressure of 70 mm Hg or 40 mm Hg. Diffuse traumatic brain injury was produced by a single rapid rotation of the head in the axial plane. Cerebral microdialysis, brain tissue oxygen, intracranial pressure, and cerebral blood flow were measured 30 min–6 hrs postinjury. One hour after injury, cerebral perfusion pressure was manipulated with the vasoconstrictor phenylephrine. Animals were euthanized 6 hrs posttraumatic brain injury, brains fixed, and stained to assess regions of cell injury and axonal dysfunction. Setting: University center. Subject: Twenty-one 4-wk-old female swine. Measurements and Main Results: Augmentation of cerebral perfusion pressure to 70 mm Hg resulted in no change in axonal dysfunction, but significantly smaller cell injury volumes at 6 hrs postinjury compared to cerebral perfusion pressure 40 (1.1% vs. 7.4%, p \u3c .05). Microdialysis lactate/pyruvate ratios were improved at cerebral perfusion pressure 70 compared to cerebral perfusion pressure 40. Cerebral blood flow was higher in the cerebral perfusion pressure 70 group but did not reach statistical significance. Phenylephrine was well tolerated and there were no observed increases in serum lactate or intracranial pressure in either group. Conclusions: Targeting a cerebral perfusion pressure of 70 mm Hg resulted in a greater reduction in metabolic crisis and cell injury volumes compared to a cerebral perfusion pressure of 40 mm Hg in an immature swine model. Early aggressive cerebral perfusion pressure augmentation to a cerebral perfusion pressure of 70 mm Hg in pediatric traumatic brain injury before severe intracranial hypertension has the potential to be neuroprotective, and further investigations are needed

The impact of video games on ultrasound-guided regional anesthesia skills

Background: There is an association between video game practice and laparoscopic expertise in trainee surgeons. Ultrasound-guided regional anesthesia has many parallels with laparoscopic surgery. The aim of this study was to explore whether video game experience is associated with enhanced performance in a simulated ultrasound-guided task in novice operators.Methods: In this prospective observational study, 60 medical student volunteers were recruited. Following characterization of video game experience, they underwent an assessment of visuospatial abilities. Following standardized teaching, the recruits’ technical performance of an ultrasound-guided needle task was assessed for overall quality by global rating scale [GRS].Results: Out of a total possible GRS score of 35, gamers compared to non-gamers demonstrated 5.2 (95% CI 1.9, 8.4) units of better performance. Gamers also performed better in mental rotation test (MRT) scores (Difference 4.1, 95% CI 1.2, 7.0) .Conclusion: Video game practice is associated with increased mental rotation ability and enhanced technical performance in a simulated ultrasound-guided task

Cerebral haemodynamic changes during propofol-remifentanil or sevoflurane anaesthesia: transcranial Doppler study under bispectral index monitoring.

INTRODUCTION: Transcranial Doppler (TCD) can detect the cerebral circulation arrest (CCA) in brain death. TCD is highly specific, but less sensitive because of false-negatives accounting for up to 10%. The aim of the study was to explore the diagnostic accuracy of TCD and to determine whether it can be augmented by strategies such as the insonation of the extracranial internal carotid artery (ICA) and sequential examinations. METHODS: Data of 184 patients, who met clinical criteria of brain death, observed from 1998 through 2006, were retrospectively reviewed. The study of cerebral arteries was performed through the transtemporal approach, suboccipital insonation of the vertebro-basilar system, transorbital insonation of the ICA and ophthalmic artery, and transcervical insonation of the extracranial ICA. Repeated exams were performed in cases of persistent diastolic flow. RESULTS: The specificity of the testing was 100%, no false-positive cases were recorded. The sensitivity of conventional TCD examination was 82.1%. The insonation of the extracranial ICA increased sensitivity to 88% allowing the detection of CCA in those patients lacking temporal windows; serial examinations further increased sensitivity to 95.6%. CONCLUSIONS: The addition of insonation of the cervical ICA and of the siphon increased sensitivity of TCD. Nevertheless, a CCA flow patterns may appear later on those segments. Serial examinations, may be needed in those cases

Patient-maintained propofol sedation for adult patients undergoing surgical or medical procedures: a scoping review of current evidence and technology

Patient-maintained propofol sedation (PMPS) is the delivery of procedural propofol sedation by target-controlled infusion with the patient exerting an element of control over their target-site propofol concentration. This scoping review aims to establish the extent and nature of current knowledge regarding PMPS from both a clinical and technological perspective, thereby identifying knowledge gaps to guide future research. We searched MEDLINE, EMBASE, and OpenGrey databases, identifying 17 clinical studies for analysis. PMPS is described in the context of healthy volunteers and in orthopaedic, general surgical, dental, and endoscopic clinical settings. All studies used modifications to existing commercially-available infusion devices to achieve prototype systems capable of PMPS. The current literature precludes rigorous generalisable conclusions regarding the safety or comparative clinical effectiveness of PMPS, however cautious acknowledgement of efficacy in specific clinical settings is appropriate. Based on the existing literature, together with new standardised outcome reporting recommendations for sedation research and frameworks designed to assess novel health technologies research, we have made recommendations for future pharmacological, clinical, behavioural, and health economic research on PMPS. We conclude that high-quality experimental clinical trials with relevant comparator groups assessing the impact of PMPS on standardised patient-orientated outcome measures are urgently required

A prototype patient-maintained propofol sedation system using target controlled infusion for primary lower-limb arthroplasty

Each year, many operations in the UK are performed with the patient awake, without the use of general anaesthesia. These include joint replacement procedures, and in order to reduce patient anxiety, the supervising anaesthetist delivers the sedative propofol intravenously using a target-controlled infusion (TCI) device. However, it is clinically challenging to judge the required effect-site concentration of sedative for an individual patient, resulting in patient care issues related to over or under-sedation. To improve the process, patient-maintained propofol sedation (PMPS), where the patient can request an increase in concentration through a hand-held button, has been considered as an alternative. However, due to the proprietary nature of modern TCI pumps, the majority of PMPS research has been conducted using prototypes in research studies. In this work, a PMPS system is presented that effectively converts a standard infusion pump into a TCI device using a laptop with TCI software. Functionally, the system delivers sedation analogous to a modern TCI pump, with the differences in propofol consumption and dosage within the tolerance of clinically approved devices. Therefore, the Medicines and Healthcare products Regulatory Agency (MHRA) has approved the system as a safe alternative to anaesthetist-controlled TCI procedures. It represents a step forward in the consideration of PMPS as a sedation method as viable alternative, allowing further assessment in clinical trials

Erector spinae plane blocks for the early analgesia of rib fractures in trauma (ESPEAR): Protocol for a multicentre pilot randomised controlled trial with feasibility and embedded qualitative assessment

INTRODUCTION: Patients with rib fractures commonly experience significant acute pain and are at risk of hypoxia, retained secretions, respiratory failure and death. Effective analgesia improves these outcomes. There is widespread variation in analgesic treatments given to patients including oral, intravenous and epidural routes of administration. Erector spinae plane (ESP) blockade, a novel regional analgesic technique, may be effective, but high-quality evidence is lacking. METHODS AND ANALYSIS: To determine if a definitive trial of ESP blockade in rib fractures is possible, we are conducting a multicentre, randomised controlled pilot study with feasibility and qualitative assessment. Fifty adult patients with rib fractures will be randomised in a 1:1 ratio to ESP blockade with multimodal analgesia or placebo ESP blockade with multimodal analgesia. Participants and outcome assessors will be blinded. The primary feasibility outcomes are recruitment rate, retention rate and trial acceptability assessed by interview. ETHICS AND DISSEMINATION: The study was approved by the Oxford B Research Ethics Committee on 22 February 2022 (REC reference: 22/SC/0005). All participants will provide written consent. Trial results will be reported via peer review and to grant funders. TRIAL REGISTRATION NUMBER: ISRCTN49307616. Copyright © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.https://doi.org/10.1136/bmjopen-2022-06293

Validity and reliability of an objective structured assessment tool for performance of ultrasound-guided regional anaesthesia

Background: We aimed to examine the validity and reliability of previously developed criterion-referenced assessment checklist (AC) and global rating scale (GRS) to assess performance in ultrasound-guided regional anaesthesia (UGRA). Methods: Twenty-one anaesthetists’ single, real-time, UGRA procedures (total: 21 blocks) were assessed using 22-item AC and 9-item GRS scored on a 3-point and 5-point Likert scales respectively. We used one-way ANOVA to compare assessment scores between 3 groups (group I: ≤30 blocks in the preceding year; group II: 31–100; group III: >100). Concurrent validity was evaluated using Pearson’s correlation (r). We calculated type-A intra- class correlation coefficient (ICC) using an absolute agreement definition in two-way random effects model, and inter-rater reliability (IRR) using absolute agreement between raters. The inter-item consistency was assessed by Cronbach’s alpha (α). Results: Greater UGRA experience in the preceding year was associated with better AC [F (2,18) 12.01; p <0.001] and GRS [F (2,18) 7.44; p =0.004] scores. There was strong correlation between mean AC and GRS scores [r=0.73 (p <0.001)] and strong inter-item consistency for AC (α = 0.94) and GRS (α = 0.83). The ICC (95% CI) and IRR (95% CI) for AC was 0.96 (0.95 – 0.96) and 0.91 (0.88 – 0.95) respectively and 0.93 (0.90 – 0.94) and 0.80 (0.74 – 0.86) for GRS. Conclusions: Both assessments differentiated between individuals who have performed fewer (≤30) and many (>100) blocks in the preceding year, supporting construct validity. It also established concurrent validity and overall reliability. We recommend both tools may be used in UGRA assessment