Publications

The ability to apply perioperative ultrasound techniques is a desirable skill for clinicians. We implemented a multimodal 13-day basic ultrasound course for 6 anesthesia interns. Their scores on a knowledge test increased after the course and were sustained and similar to those of 6 senior residents 90 days later. The interns acquired images of the heart in volunteers with little assistance after the course. They maintained their ability to acquire echocardiographic images on a simulator 90 days later with kinematic measures superior to the same seniors. Through this course, interns gained knowledge and skills equal to or greater than seniors.

OBJECTIVE: To investigate whether a transesophageal echocardiography (TEE) simulator with motion analysis can be used to impart proficiency in TEE in an integrated curriculum-based model.

DESIGN: A prospective cohort study.

SETTING: A tertiary-care university hospital.

PARTICIPANTS: TEE-naïve cardiology fellows.

INTERVENTIONS: Participants underwent an 8-session multimodal TEE training program. Manual skills were assessed at the end of sessions 2 and 8 using motion analysis of the TEE simulator's probe. At the end of the course, participants performed an intraoperative TEE; their examinations were video captured, and a blinded investigator evaluated the total time and image transitions needed for each view. Results are reported as mean±standard deviation, or median (interquartile range) where appropriate.

MEASUREMENTS AND MAIN RESULTS: Eleven fellows completed the knowledge and kinematic portions of the study. Five participants were excluded from the evaluation in the clinical setting because of interim exposure to TEE or having participated in a TEE rotation after the training course. An increase of 12.95% in post-test knowledge scores was observed. From the start to the end of the course, there was a significant reduction (p<0.001 for all) in the number of probe. During clinical performance evaluation, trainees were able to obtain all the required echocardiographic views unassisted but required a longer time and had more probe transitions when compared with an expert.

CONCLUSION: A curriculum-based approach to TEE training for cardiology fellows can be complemented with kinematic analyses to objectify acquisition of manual skills during simulator-based training.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the effects of preemptive ultrasound-guided thoracic paravertebral block versus intercostal block on postoperative respiratory function and pain control in patients undergoing video-assisted thoracoscopic surgery.

SUBJECTS: 50 consecutive patients undergoing video-assisted thoracoscopic surgery.

METHOD: A prospective cohort of patients who received either ultrasound-guided thoracic paravertebral block immediately before the procedure or intercostal block placed by the surgeon at the end of the procedure were studied. Pulmonary function was assessed before surgery and 4 h postoperatively. Pain was assessed with the visual analog scale at 2 and 4 h after surgery both at rest and on coughing.

RESULTS: 30 patients on the paravertebral block group and 20 on the intercostal block group were studied. Forced vital capacity (p < 0.001), forced expiratory volume at 1 s (p < 0.001) and forced expiratory flow 25-75% (p = 0.001) were significantly higher at 4 h with paravertebral block compared to the intercostal block group. The visual analog score for pain was significantly improved with paravertebral block at rest (p < 0.05) and with cough (p = 0.00). Perioperative narcotic use was significantly reduced with paravertebral block in comparison to intercostal block (p = 0.04).

CONCLUSIONS: When compared to intercostal blocks, ultrasound-guided thoracic paravertebral block appears to preserve lung function and provide better pain control in the immediate postoperative period after video-assisted thoracoscopic surgery.

OBJECTIVES: Teaching transesophageal echocardiography (TEE) remains challenging. The authors hypothesized that using online modules with live teaching in an echo training course would be feasible and result in superior knowledge acquisition to live teaching only.

DESIGN: In this prospective cohort study, the authors implemented a TEE course with online modules and live teaching and compared it to a live-teaching-only version.

SETTING: The online-and-live-teaching version of the course consisted of online modules and live sessions at Beth Israel Deaconess Medical Center (BIDMC), an academic medical center. The live-teaching-only version consisted of live sessions at BIDMC.

PARTICIPANTS: Course participants included anesthesia trainees at BIDMC.

INTERVENTIONS: Trainees taking the online-and-live-teaching version viewed online modules before live review lectures and simulation. Trainees taking the live-teaching-only version viewed live lectures before simulation.

MEASUREMENTS AND MAIN RESULTS: Twenty-seven trainees completed the online-and-live-teaching version; six completed the live-teaching-only version. Trainees took a course exam after the first and last live sessions. For the online-and-live-teaching version, average pretest and posttest scores were 62.0%±13.7% and 77.5%±8.1%, respectively; pretest and posttest passing (≥70%) rates were 29.6% and 85.2%, respectively. Compared to the live-teaching-only version, the average pretest score was not significantly different (p=0.17), but the average posttest score was significantly higher (p=0.01). Trainee comfort with, and knowledge of, TEE increased after both versions. Trainees rated the utility of the live lectures and online modules similarly.

CONCLUSIONS: A multimodal TEE curriculum increased trainees' knowledge of TEE concepts and had a positive reception from trainees.

Intraoperative echocardiography of the mitral valve has evolved from a qualitative assessment of flow-dependent variables to quantitative geometric analyses before and after repair. In addition, 3-dimensional echocardiographic data now allow for a precise assessment of mitral valve apparatus. Complex structures, such as the mitral annulus, can be interrogated comprehensively without geometric assumptions. Quantitative analyses of mitral valve apparatus are particularly valuable for identifying indices of left ventricular and mitral remodeling to establish the chronicity and severity of mitral regurgitation. This can help identify patients who may be unsuitable candidates for repair as the result of irreversible remodeling of the mitral valve apparatus. Principles of geometric analyses also have been extended to the assessment of repaired mitral valves. Changes in mitral annular shape and size determine the stress exerted on the mitral leaflets and, therefore, the durability of repair. Given this context, echocardiographers may be expected to diagnose and quantify valvular dysfunction, assess suitability for repair, assist in annuloplasty ring sizing, and determine the success and failure of the repair procedure. As a result, anesthesiologists have progressed from being mere service providers to participants in the decision-making process. It is therefore prudent for them to acquaint themselves with the principles of intraoperative quantitative mitral valve analysis to assist in rational and objective decision making.

OBJECTIVES: Teaching transesophageal echocardiography (TEE) remains challenging. The authors hypothesized that using online modules with live teaching in an echo training course would be feasible and result in superior knowledge acquisition to live teaching only.

DESIGN: In this prospective cohort study, the authors implemented a TEE course with online modules and live teaching and compared it to a live-teaching-only version.

SETTING: The online-and-live-teaching version of the course consisted of online modules and live sessions at Beth Israel Deaconess Medical Center (BIDMC), an academic medical center. The live-teaching-only version consisted of live sessions at BIDMC.

PARTICIPANTS: Course participants included anesthesia trainees at BIDMC.

INTERVENTIONS: Trainees taking the online-and-live-teaching version viewed online modules before live review lectures and simulation. Trainees taking the live-teaching-only version viewed live lectures before simulation.

MEASUREMENTS AND MAIN RESULTS: Twenty-seven trainees completed the online-and-live-teaching version; six completed the live-teaching-only version. Trainees took a course exam after the first and last live sessions. For the online-and-live-teaching version, average pretest and posttest scores were 62.0%±13.7% and 77.5%±8.1%, respectively; pretest and posttest passing (≥70%) rates were 29.6% and 85.2%, respectively. Compared to the live-teaching-only version, the average pretest score was not significantly different (p=0.17), but the average posttest score was significantly higher (p=0.01). Trainee comfort with, and knowledge of, TEE increased after both versions. Trainees rated the utility of the live lectures and online modules similarly.

CONCLUSIONS: A multimodal TEE curriculum increased trainees' knowledge of TEE concepts and had a positive reception from trainees.