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Initial healthcare delivery after warfront injury is unpredictably challenging for military forces. As preparatory training, healthcare providers use simulation to improve their performance in stressful critical situations. This study investigated whether a digital CA held by the team leader improved performance in simulated combat casualty care.This randomized controlled trial was performed during a combat casualty training course for military physicians and nurses in France. Each pair of care providers completed 2 scenarios randomized to be undertaken either with or without a digital CA. The primary end point was the technical performance evaluated from a video recording by 2 independent raters using a pre-established score grid (up to 100%) according to military protocols. The secondary end point was the nontechnical performance (TEAM scale, maximum: 54 points).Thirty-six pairs of participants were included. Use of the digital CA improved both technical (74% vs 53%, P0.001) and nontechnical (42 vs 32, P0.001) performance.The digital CA improved technical and nontechnical performance during training of medical care for military combat casualties. Use of a dedicated digital CA might improve care in a combat environment.This study is a randomized controlled trial.

Introduction High-fidelity simulation is widely used in the ongoing education of caregivers. However, the complex high-stakes simulated crisis environment affects memorization. This study investigated whether participants would remember more key training messages 3 months after a simulated complex emergency situation if they had used a digital cognitive aid (CA) during the simulations. Materials and Methods This randomized controlled trial was performed during a combat casualty training course for military physicians and nurses. Each pair of care providers completed two scenarios randomized to be undertaken either with or without a digital CA. At the end of each debriefing, instructors gave five scenario-specific key messages aloud. Three months later, learners were asked to recall the messages from their two scenarios and were scored for each scenario. The primary endpoint was the number of key messages recalled. The secondary endpoints were the influence on the results of the profession and the scenario block and age of the leader. Results Thirty-six pairs of participants were included. Due to operational constraints, only 34 completed the study. The use of the digital CA was associated with a positive effect on memorization at 3 months (F = 82.2, P Conclusions The digital CA allowed learners to remember twice as many key elements 3 months after simulated training of medical care for military combat casualties. A dedicated digital CA might be an asset for better care in a combat environment and for learning and memorizing critical care procedures following complex emergency situations.

Background High-fidelity simulation is known to improve participant learning and behavioral performance. Simulation scenarios generate stress that affects memory retention and may impact future performance. The authors hypothesized that more participants would recall three or more critical key messages at three months when a relaxation break was performed before debriefing of critical event scenarios. Methods Each resident actively participated in one scenario and observed another. Residents were randomized in two parallel-arms. The intervention was a 5-min standardized relaxation break immediately before debriefing; controls had no break before debriefing. Five scenario-specific messages were read aloud by instructors during debriefings. Residents were asked by telephone three months later to recall the five messages from their two scenarios, and were scored for each scenario by blinded investigators. The primary endpoint was the number of residents participating actively who recalled three or more messages. Secondary endpoints included: number of residents observing who recalled three or more messages, anxiety level, and debriefing quality. Results In total, 149 residents were randomized and included. There were 52 of 73 (71%) residents participating actively who recalled three or more messages at three months in the intervention group versus 35 of 76 (46%) among controls (difference: 25% [95% CI, 10 to 40%], P = 0.004). No significant difference was found between groups for observers, anxiety or debriefing quality. Conclusions There was an additional 25% of active participants who recalled the critical messages at three months when a relaxation break was performed before debriefing of scenarios. Benefits of relaxation to enhance learning should be considered for medical education.

Background Cognitive aids improve the technical performance of individuals and teams dealing with high-stakes crises. Hand-held electronic cognitive aids have rarely been investigated. A randomized controlled trial was conducted to investigate the effects of a smartphone application, named MAX (for Medical Assistance eXpert), on the technical and non-technical performance of anaesthesia residents dealing with simulated crises. Methods This single-centre randomized, controlled, unblinded trial was conducted in the simulation centre at Lyon, France. Participants were anaesthesia residents with >1 yr of clinical experience. Each participant had to deal with two different simulated crises with and without the help of a digital cognitive aid. The primary outcome was technical performance, evaluated as adherence to guidelines. Two independent observers remotely assessed performance on video recordings. Results Fifty-two residents were included between July 2015 and February 2016. Six participants were excluded for technical issues; 46 participants were confronted with a total of 92 high-fidelity simulation scenarios (46 with MAX and 46 without). Mean ( sd ) age was 27 (1.8) yr and clinical experience 3.2 (1.0) yr. Inter-rater agreement was 0.89 (95% confidence interval 0.85–0.92). Mean technical scores were higher when residents used MAX [82 (11.9) vs 59 (10.8)%; P Conclusion The use of a hand-held cognitive aid was associated with better technical performance of residents dealing with simulated crises. These findings could help digital cognitive aids to find their way into daily medical practice and improve the quality of health care when dealing with high-stakes crises. Clinical trial registration NCT02678819.

Planning held before emergency management of a critical situation might be an invaluable asset for optimising team preparation. The purpose of this study was to investigate whether a brief planning discussion improved team performance in a simulated critical care situation. Forty-four pairs of trainees in anaesthesia and intensive care were randomly allocated to either an intervention or control group before participating in a standardised simulated scenario. Twelve different scenarios were utilised. Groups were stratified by postgraduate year and simulated scenario, and a facilitator was embedded in the scenario. In the intervention group, the pairs had an oral briefing followed by a 4-min planning discussion before starting the simulation. The primary end-point was clinical performance, as rated by two independent blinded assessors on a score of 0-100 using video records and pre-established scenario-specific checklists. Crisis resource management and stress response (cognitive appraisal ratio) were also assessed. Two pairs were excluded for technical reasons. Clinical performance scores were higher in the intervention group; mean (SD) 51 (9) points vs. 46 (9) in the control group, p = 0.039. The planning discussion was also associated with higher crisis resource management scores and lower cognitive appraisal ratios, reflecting a positive response. A 4-min planning discussion before a simulated critical care situation improved clinical team performance and cognitive appraisal ratios. Team planning should be integrated into medical education and clinical practice.

SummaryObjective/Aim To assess the impact of sevoflurane and anesthesia-induced hypotension on cerebral blood flow (CBF) in children younger than 2 years. Background Inhalational induction with sevoflurane is the most commonly used technique in young children. However, the effect of sevoflurane on cerebral perfusion has been only studied in adults and children older than 1 year. The purpose of this study is to assess the impact of sevoflurane anesthesia on CBF in neonates and infants, using transcranial Doppler (TCD) sonography. Methods Children younger than 2 years, ASA I or II, for abdominal or orthopedic surgery were included. Induction of anesthesia was started by sevoflurane 6% and maintained with an expired fraction of sevoflurane 3%. Mechanical ventilation was controlled to maintain an end tidal CO2 around 39 mmHg. CBF was assessed by measuring the velocities (systolic velocity SVmca, diastolic velocity DVmca and mean velocity MVmca) in the proximal segment of the middle cerebral artery (mca) in children awake and then 15 min after induction. Mean arterial pressure (MAP) variation was noted. Results One hundred and thirteen children were included. We observed a significant decrease in MAP (−30%). DVmca decreased and pulsatility index increased significantly after induction. Subgroup analysis according to age showed that in infants older than 6 months, despite a significant reduction in MAP, there was no change in CBF velocity (CBFV) as measured by TCD sonography, until MAP dropped below 40% of baseline. In infants younger than 6 months, a significant decrease in MAP was observed which was associated with a significant variation in CBFV. In this population, when CBFV start to decrease, MAP under sevoflurane anesthesia was 38 mmHg or −20% from baseline value. Conclusion Our results are in favor of a reduction in CBF after induction with sevoflurane in children younger than 6 months. This population is more sensitive to MAP decrease than older children because of a lower limit of cerebral autoregulation, and this limit may be 38 mmHg with sevoflurane anesthesia.

Resume La survie du greffon est moins bonne chez les receveurs de moins de cinq ans du fait d’un plus grand risque de thrombose vasculaire. Ces thromboses sont prevenues par le choix du donneur, la technique chirurgicale, une optimisation hemodynamique peri-operatoire et une anticoagulation preventive. La normalite de la croissance est un objectif majeur de la prise en charge des enfants transplantes. La taille finale moyenne a augmente au cours des 20 dernieres annees pour se situer entre −1,63 et −0,92 SDS selon l’âge et la periode de transplantation.

High-fidelity simulation (HFS) calls heavily upon cognitive capacities and generates stress and anxiety. The objectives of this prospective, observational study were to assess trait anxiety and fear of negative evaluation (FNE) in anaesthesiology and critical care residents and appraise their state anxiety levels and cardiovascular responses during HFS training sessions.First-year anaesthesiology and critical care residents completed the French-Canadian adaptation of the State-Trait Anxiety Inventory (IASTA Y-1: state anxiety, IASTA Y-2: trait anxiety) and the French adaptation of the Fear of Negative Evaluation Scale (FNE). Their heart rate (HR) and blood pressure (BP) were assessed before and after the training session.Twenty-three residents (8 women, 15 men) were included in the study. IASTA Y-1 and Y-2 scores were low (respectively 40.2±9.9 and 39.7±8) and FNE scores were moderate (16.7±5.5). HR measurements before and after the training sessions were significantly higher than at rest (respectively 78±19, 80±17 and 63±9b/min; P0.001). BP measurements before and after the HFS sessions were not significantly different. The IASTA Y-2 and FNE scores of female residents were significantly higher than those of male residents (respectively P=0.004 and P=0.049).First-year anaesthesiology and critical care residents had low trait anxiety and FNE. HFS training increased their HR but not their BP. Their state anxiety also remained low. Several differences between individuals were noted, particularly between men and women.

Summary Background Pupillary diameter (PD) monitoring and Analgesia Nociception Index (ANI) (Metrodoloris, Lille, France), an online wavelet transform-based heart rate variability index, have been used in the assessment of pain. Objective The aim of this study was to evaluate the capacity of pupillary reflex dilatation and ANI to provide early assessment of regional anesthesia (RA) success following skin incision in children anesthetised with sevoflurane. Methods A total of 58 children, eligible for RA, were included after sevoflurane induction. The sevoflurane concentration was adjusted to maintain a MAC of 1.3 in oxygen and nitrous oxide, and a RA was performed. Pupillary diameter and ANI were recorded just prior to skin incision and then every 30 s for a period of 2 min. Regional anesthesia failure was defined by an increase in heart rate ≥ 10% occurring during the first 2 mins following incision. Results Thirty-nine and 19 subjects presented RA success and failure, respectively. In the RA failure group, skin incision induced both changes in PD (P

Graft survival is worse in recipient aged less than 5 years due to the greater risk of vascular thrombosis. Thrombosis may be prevented by the choice of the donor, method of surgery, perioperative hemodynamic optimisation and preventive anti-coagulation. Normal growth is a major objective of the management of transplanted children. The mean final height increased during the 20 last years to be between -1.63 and -0.92 SDS depending on age and period of the transplantation.

Introduction Au cours d’une simulation haute-fidelite (SHF), l’etudiant doit mettre en application ses connaissances sous le regard de ses pairs et des instructeurs. La peur de l’evaluation negative est correlee positivement au caractere anxieux de l’apprenant. Elle peut etre mesuree a l’aide d’une echelle developpee par Watson et Friend, traduite en francais et validee par Musa et al. l’echelle de peur de l’evaluation negative(PEN) [1] . L’objectif de notre etude etait de mesurer chez des internes en anesthesie-reanimation beneficiant d’un programme d’enseignement par SHF, le niveau de peur de l’evaluation negative et de verifier les hypotheses que les sujets les plus anxieux avaient des scores de PEN plus eleves et que les femmes avaient des scores de PEN superieurs aux hommes. Materiel et methodes L’echelle de PEN est un outil d’auto-evaluation qui comporte 30 items. Le resultat s’obtient en additionnant les notes obtenues a chaque item. Plus le score est eleve (au maximum 30), plus la peur de l’evaluation negative est grande. Le trait d’anxiete etait evalue a l’aide du questionnaire IASTA-Y2 (Inventaire d’Anxiete Situationnelle et de Trait d’Anxiete) [2] . Les scores varient de 20 (degre le plus faible d’anxiete) a 80 (degre le plus fort). Les formulaires PEN et IASTA-Y2 etaient renseignes quelques semaines apres la SHF. Notre etude porte sur 25 etudiants (9 femmes, 16 hommes). Les variables quantitatives ont ete comparees en utilisant le test de Mann–Whitney–Wilcoxon. Resultats Deux etudiants ont ete exclus en raison de donnees manquantes. En choisissant comme valeur discriminative la valeur moyenne du score IASTA-Y2 soit 40, nous avons constitue un groupe « moins anxieux » ( n = 13) et un groupe « plus anxieux » ( n = 10). Les moyennes des scores de PEN dans le groupe « plus anxieux » etaient significativement plus elevees que dans le groupe « moins anxieux » ( p = 0,012). Les femmes avaient un score moyen de PEN significativement superieur a celui des hommes ( p = 0,049). Les resultats figurent dans le Tableau 1 . Discussion La correlation positive entre la peur de l’evaluation negative et le trait d’anxiete se verifie dans notre etude. Il existe une difference selon le genre pour la peur de l’evaluation negative. Le stress et l’anxiete sont des facteurs psychologiques qui jouent des roles importants dans les fonctions cognitives en general et dans l’apprentissage et la retention des informations en particulier [3] . L’application de tests psychometriques comme le PEN et le IASTA-Y2 pourrait permettre aux enseignants de reperer les etudiants les plus vulnerables et d’adapter les seances de SHF.

Cytoplasmic calcium changes and calcium influx evoked by adenosine triphosphate (ATP) were investigated in primary cultures of rabbit proximal convoluted tubule cells. Extracellular ATP (50 microM) induced a biphasic increase of [Ca2+]i measured with the calcium probe fura-2. In the early phase, the mobilization of intracellular pools resulted in a transient increase of [Ca2+]i from 106 +/- 11 nM (n = 36) to 1059 +/- 115% (n = 29) of the resting level within 10 s. In the presence of external calcium, [Ca2+]i then decreased within 3 min to a sustained level (398 +/- 38%, n = 8). Measurements of fura-2 quenching by external manganese revealed that this phase was the result of an increased Ca2+ uptake, blocked by lanthanum (10 microM) and verapamil (100 microM) but not by the nifedipin (25 microM). Internal calcium store depletion by ATP induced an increased calcium influx through lanthanum- and verapamil-sensitive, nifedipin-insensitive calcium channels, located on the apical membrane of the cells. As indicated by 86Rb+ efflux measurements, ATP activated a potassium efflux that was blocked by barium and Leiurus quinquestriatus hebraeus (LQH) venom (containing charybdotoxin) indicating the involvement of Ca(2+)-sensitive K+ channels. Moreover, in the presence of the LQH venom, the internal calcium stores were not replenished after being depleted by ATP. Our results indicate that an ATP-evoked hyperpolarization of the plasma membrane leads to increased Ca2+ influx, which facilitates the replenishment of the internal stores.

Changes of intracellular calcium concentrations [Ca2+]i were measured in primary cultured rabbit proximal convoluted tubules (PCT). A dual-excitation, digital-imaging inverted microscope was used to monitor the fura-2 fluorescence. The basal calcium level was 106 ± 11 nM (n = 36) . The stimulatory effects of adenosine triphosphate (ATP), adenosine diphosphate (ADP) and adenosine were studied. ATP and ADP induced transient increases of [Ca2+]i ( 1059 ± 115% of the resting level ( n = 29 ), and 659 ± 134% (n = 10) , respectively) by releasing calcium from cytoplasmic stores. Adenosine had less effect ( 279 ± 48% of the resting level, n = 3 ). In the same conditions the ATP antagonist suramin (100 μM) inhibited the action of ATP and ADP to 231 ± 52% (n = 3) , and 308 ± 29% (n = 4) of the resting level, respectively, but did not modify that of adenosine ( 281 ± 72%, n = 3) . A pretreatment (500 ng/ml for 2 h at 37°C) of the culture with the toxin of Bordetella pertussis completely blocked the ATP response. Our results are evidence for the presence of a functional suramin-sensitive ATP and ADP puriceptor in cultured renal proximal cells. A pertussis-toxin-sensitive G protein is linked to the transduction mechanism. This receptor is distinct from an adenosine puriceptor also found in the proximal monolayer.

Background Although multiple individual immune parameters have been demonstrated to predict the occurrence of secondary infection after critical illness, significant questions remain with regards to the selection, timing and clinical utility of such immune monitoring tests. Research question As a sub-study of the REALISM study, the REALIST score was developed as a pragmatic approach to help clinicians better identify and stratify patients at high risk for secondary infection, using a simple set of relatively available and technically robust biomarkers. Study design and methods This is a sub-study of a single-centre prospective cohort study of immune profiling in critically ill adults admitted after severe trauma, major surgery or sepsis/septic shock. For the REALIST score, five immune parameters were pre-emptively selected based on their clinical applicability and technical robustness. Predictive power of different parameters and combinations of parameters was assessed. The main outcome of interest was the occurrence of secondary infection within 30 days. Results After excluding statistically redundant and poorly predictive parameters, three parameters remained in the REALIST score: mHLA-DR, percentage of immature (CD10− CD16−) neutrophils and serum IL-10 level. In the cohort of interest (n = 189), incidence of secondary infection at day 30 increased from 8% for patients with REALIST score of 0 to 46% in patients with a score of 3 abnormal parameters, measured ad D5–7. When adjusted for a priori identified clinical risk factors for secondary infection (SOFA score and invasive mechanical ventilation at D5–7), a higher REALIST score was independently associated with increased risk of secondary infection (42 events (22.2%), adjusted HR 3.22 (1.09–9.50), p = 0.034) and mortality (10 events (5.3%), p = 0.001). Interpretation We derived and presented the REALIST score, a simple and pragmatic stratification strategy which provides clinicians with a clear assessment of the immune status of their patients. This new tool could help optimize care of these individuals and could contribute in designing future trials of immune stimulation strategies. Graphical Abstract