Article Notes
- It is clinical outcomes that primarily matter, and;
- Simulation is uniquely positioned to address improvements in the many domains of teamwork.
Why is this important?
Although we have moved beyond routinely using high tidal volumes in favour of ’protective ventilation strategies’ the specifics of what is protective and what improves outcomes is controversial. Previous trials have struggled to demonstrate post-operative respiratory benefits from protective strategies.
What did they do?
In this small randomised controlled trial, Généreux et al. investigated whether intraoperative PEEP (7 cmH2O) and recruitment manoeuvres (RM) q30min would reduce atelectasis post-extubation. Using ultrasound to measure intraoperative and post-operative atelectasis gives their study greater flexibility than other studies using CT scanning, generally considered the gold standard for atelectasis measurement.
And they found...
Among 34-85 yo women undergoing open gynae-oncology surgery >2h duration, there was no post-extubation difference in atelectasis whether receiving PEEP/RM or zero PEEP.
Not so fast
There was however less intraoperative atelectasis among the protective ventilation group, supporting the common use of PEEP and RM to improve oxygenation during surgery. Additionally, they specifically excluded morbidly obese women (BMI > 40 kg/m2), an increasingly common demographic at risk of ventilation challenges.
Nonetheless this study adds to the evidence that current protective ventilation strategies do not actually reduce post-operative respiratory complications.
Be smart
One interesting observation was the large amount of inter-patient variability, the researchers noting:
“...this heterogeneity highlights the need to dynamically monitor lung aeration changes and personalise our delivery of mechanical ventilation in the perioperative setting.”
As with many perioperative interventions, the benefits may in fact lie in the personalisation of our care for each individual patient.
Daniel Jolley
Why is this important?
Most simulation research focuses on skills and knowledge (the easiest factors to measure), even though:
Brazil et al. applied a relational coordination (RC) framework to understand teamwork-aspects of simulation research, particularly as these impact wider institutional and healthcare system performance.
“The RC framework — shared knowledge, shared goals and mutual respect in the context of communication that is timely, accurate, frequent and problem-solving based — can provide a common language for simulation educators to design and debrief simulation exercises that aim to have a translational impact” (Brazil et al. 2019)
What did they do?
The researchers undertook a narrative survey of staff involved in early major trauma care at a university teaching hospital. Over half of the respondents had participated in the institution’s existing in situ trauma simulation program.
Survey responses were analysed using the RC framework, and found to be consistent with each RC domain. Most notably trauma simulation acted as an enabler of mutual respect and improved communication, along with enhancing the understanding of team roles and prioritising problem-solving focused communication.
The take-home
The impact of simulation needs to be understood in the context of the greater goal – healthcare system improvement – and that this occurs with pre-existing organisational cultures and relationships. Simulation outcomes goals are not exclusive to small teams or individual performance.
The various domains within the relational coordination framework provide an easy to use guide for understanding, communicating and deploying simulation benefits, drawing a path from the ‘here’ to the ‘there’ of improved outcomes.
“Simulation should be considered as a tool to build and strengthen relationships between practitioners across traditional boundaries.”
Daniel Jolley
This editorial accompanied the 2004 study from Ekman, the first published evidence showing a reduction in awareness when BIS monitoring is used to monitor depth of anaesthesia.
Ekman’s findings were shortly after confirmed by Myles et al. in their landmark 2004 B-Aware Trial.
This editorial and the two related studies are well worth reading to give historical context to the emergence of reliable depth-of-anaesthesia monitors.
Daniel Jolley