Publications by authors named "George Shorten"

82 Publications

Distinguishing cerebral salt wasting syndrome and syndrome of inappropriate ADH in a patient with traumatic brain injury.

BMJ Case Rep 2021 Mar 10;14(3). Epub 2021 Mar 10.

Department of Anaesthesia and Intensive Care, University College Cork, Cork, Ireland.

A previously healthy 48-year-old woman was referred to our intensive care unit (ICU) from a neurosurgical ward due to deterioration of her conscious level. She had a road traffic accident 6 days earlier. On admission to the hospital, a brain CT demonstrated subarachnoid haemorrhage which was considered not amenable to surgical intervention. A second CT brain performed shortly after admission to ICU showed no change in comparison to the initial CT. Serum sodium level on ICU admission was 108 mEq/L; serum and urine osmolalities were 223 mOsm/kg and 438 mOsm/kg, respectively. Her hyponatraemia was initially attributed to syndrome of inappropriate antidiuretic hormone. However, a clinical impression of low volume status raised the suspicion of cerebral salt wasting syndrome. She was managed by infusion of hypertonic saline and fluids for 5 days and discharged from ICU after improvement of her conscious level and normalisation of serum sodium.
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http://dx.doi.org/10.1136/bcr-2020-237027DOI Listing
March 2021

Anaesthetic management of a patient with eosinophilic granulomatosis with polyangiitis for internal fixation of a fractured femur.

BMJ Case Rep 2021 Jan 8;14(1). Epub 2021 Jan 8.

Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease with an estimated annual incidence of 0.5-6.8 per million. It is characterised by necrotising vasculitis with multiorgan eosinophilic infiltration. Pulmonary manifestations are the most common presentation of EGPA, and cardiac complications are the most common cause of death. Anaesthetic management of EGPA is challenging due to perioperative pulmonary complications, multiorgan involvement and greater risk of cholinesterase enzyme deficiency. We are reporting the anaesthetic management of a 58-year-old woman, diagnosed with EGPA 3 years ago, who underwent urgent intramedullary nail insertion for a femur fracture. The anaesthetic technique comprised femoral nerve block and spinal anaesthesia, thereby avoiding (1) the need for upper airway manipulation, (2) potential adverse effects of anticholinesterase drugs (for reversal of neuromuscular blockade) and (3) histamine release associated with morphine administration perioperatively. Surgery and anaesthesia were uneventful.
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http://dx.doi.org/10.1136/bcr-2020-239052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798413PMC
January 2021

Personal protective equipment during the COVID-19 pandemic (Letter #1).

Authors:
George D Shorten

Can J Anaesth 2020 11 7;67(11):1647-1648. Epub 2020 Aug 7.

Department of Anaesthesia, University College Cork, Cork, Ireland.

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http://dx.doi.org/10.1007/s12630-020-01784-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413642PMC
November 2020

European Section/Board of Anaesthesiology/European Society of Anaesthesiology consensus statement on competency-based education and training in anaesthesiology.

Eur J Anaesthesiol 2020 06;37(6):421-434

From the University College Cork, Cork, Ireland (GDS), Section of Anaesthesia, Analgesia and Intensive Care Department of Surgical and Biomedical Sciences University of Perugia, Italy (EDR), Faculty of Medicine, Technion Institute of Technology, Chair of Anaesthesiology, Intensive Care and Pain Therapy Division, Carmel Medical Centre, Haifa, Israel (ZG), Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland (LNM), Department of Anaesthesiology and Intensive Care Medicine, Riga Stradiņš University, Riga, Latvia (OS).

: The change from time-based to competency-based medical education has been driven by society's requirement for greater accountability of medical practitioners and those who train them. The European Society of Anaesthesiology and European Section/Board of Anaesthesiology (Anaesthesiology Section of the European Union Medical Specialists) endorse the general principles of competency-based medical education and training (CBMET) outlined by the international competency-based medical education collaborators. A CBMET curriculum is built on unambiguously defined learning objectives, each of which offers a measurable outcome, amenable to assessment using valid and reliable tools. The European training requirements laid out by the European Board of Anaesthesiology define four 'Generic Competences', namely expert clinician, professional leader, academic scholar and inspired humanitarian. A CBMET programme should clearly document core competencies, defined end-points, proficiency standards, practical descriptions of teaching and assessment practices and an assessment plan. The assessment plan should balance the need to provide regular, multidimensional formative feedback to the trainee with the need to inform high stakes decisions. A trainee who has not achieved a proficiency standard should be provided with an individualised training plan to address specific competencies or deficits. Programme formats will inevitably differ given the constraints of scale and resource that apply in different settings. The resources necessary to develop and maintain a CBMET programme in anaesthesiology include human capital, access to clinical learning opportunities, information technology and physical infrastructure dedicated to training and education. Simulation facilities and faculty development require specific attention. Reflective practice is an important programme element that supports wellbeing, resilience and achievement of professional goals. CBMET programmes should enable establishment of a culture of lifelong learning for the anaesthesiology community.
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http://dx.doi.org/10.1097/EJA.0000000000001201DOI Listing
June 2020

Pulmonary embolism occurring early after major trauma.

BMJ Case Rep 2019 Sep 20;12(9). Epub 2019 Sep 20.

Radiology, HSE South, Cork, Ireland.

Pulmonary embolism (PE) secondary to trauma is the third most common cause of death in trauma patients who have survived 24 hours following injury. We describe a case of PE diagnosed within 3 hours of a major trauma in a previously well adolescent female. The early occurrence of PE in this case is at odds with what is generally reported (3-5 days) after major trauma. General consensus is that patients who suffer major trauma move from an initial hypocoaguable state, with increased risk of bleeding, to normocoagulable or hypercoaguable state, with a subsequent increased risk of venothromboembolism. However, Sumislawski recently demonstrated that a marginally greater proportion of trauma patients were in fact hypercoaguable rather than hypocoaguable on arrival to hospital and that trauma-induced coagulopathy tended to resolve within 24 hours; such data cause us to re-evaluate when to commence thromboprophylaxis for major trauma patients.
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http://dx.doi.org/10.1136/bcr-2018-228783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768327PMC
September 2019

Artificial Intelligence and Training Physicians to Perform Technical Procedures.

Authors:
George Shorten

JAMA Netw Open 2019 08 2;2(8):e198375. Epub 2019 Aug 2.

Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, University College Cork, Cork, Ireland.

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http://dx.doi.org/10.1001/jamanetworkopen.2019.8375DOI Listing
August 2019

Delirium after hip fracture surgery.

J Clin Anesth 2019 12 5;58:119-120. Epub 2019 Jul 5.

Department of Anaesthesia, Cork University Hospital, Wilton Rd, Cork, Ireland; School of Medicine, Brookfield Health Sciences Centre, University College Cork, College Rd, Cork, Ireland. Electronic address:

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http://dx.doi.org/10.1016/j.jclinane.2019.06.034DOI Listing
December 2019

A comparison of the analgesic efficacy of local infiltration analgesia vs. intrathecal morphine after total knee replacement: A randomised controlled trial.

Eur J Anaesthesiol 2019 04;36(4):264-271

From the Department of Anaesthesiology, Cork University Hospital and University College Cork, Cork, Ireland (DM, JM, JG, FL, GS, GI).

Background: Local infiltration analgesia (LIA) is an effective pain management technique following total knee arthroplasty (TKA).

Objective: To investigate if LIA provides better analgesia for patients undergoing unilateral TKA than intrathecal morphine.

Design: Randomised controlled trial.

Setting: Single tertiary referral centre.

Patients: Consecutive American Society of Anesthesiologists Physical Status I to III patients scheduled to undergo unilateral TKA were randomised to two groups.

Intervention: The control group received spinal anaesthesia with intrathecal bupivacaine and preservative-free morphine 0.3 mg. The intervention group received opioid-free spinal anaesthesia with bupivacaine, followed by intra-operative infiltration of the knee with levobupivacaine 2 mg kg and adrenaline 0.5 mg diluted to a volume of 100 ml with 0.9% saline. An intra-articular catheter was placed during surgery and used to give a bolus of 15 ml of levobupivacaine 0.5% on the morning of the first postoperative day.

Main Outcome Measures: Visual analogue scale (VAS) scores for pain were assessed repeatedly for 48 h postoperatively, at rest and on passive knee flexion to 30°. The primary outcome was VAS scores for pain at rest and on movement at 24 postoperative hours. Secondary outcomes were VAS scores at rest and on movement at 2, 6, 12 and 48 postoperative hours, opioid consumption, degree of active flexion of operative knee achieved in the first 48 h and the incidence of opioid-related side effects.

Results: Forty three patients completed the study. Mean (± SD) VAS scores for pain at 24 h were lower in the intervention group than the control group at rest; 16.43 (± 20.3) vs. 37.2 (± 33.6), (P = 0.029). VAS scores for pain at 24 h on movement were also lower in the intervention group vs. the control group; 39.1 (± 22.8) vs. 57.0 (± 30.9), (P = 0.037). VAS scores were also lower on movement; 25.9 (± 16.8) vs. 40.5 (± 24.0), (P = 0.028) at 48 h.

Conclusion: We conclude that LIA conferred superior analgesia compared with intrathecal morphine 0.3 mg at 24 and 48 h following TKA.

Trial Registration: Clinicaltrials.gov identifier: NCT01312415.
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http://dx.doi.org/10.1097/EJA.0000000000000943DOI Listing
April 2019

Efficacy of axillary versus infraclavicular brachial plexus block in preventing tourniquet pain: A randomised trial.

Eur J Anaesthesiol 2019 01;36(1):48-54

From the Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital and University College Cork, Cork, Ireland (DB, GI, PM, GS).

Background: Axillary and infraclavicular brachial plexus blocks are commonly used for upper limb surgery. Clinicians require information on the relative benefits of each to make a rational selection for specific patients and procedures.

Objectives: The main objective of the study was to compare axillary and infraclavicular brachial plexus block in terms of the incidence and severity of tourniquet pain.

Design: Single blinded, randomised trial.

Setting: University affiliated hospital, level-1 trauma centre.

Patients: Age more than 18 years, ASAI-III patients undergoing orthopaedic surgery distal to the elbow, with an anticipated tourniquet duration of more than 45 min were recruited.

Interventions: Patients underwent either ultrasound guided axillary brachial plexus block or infraclavicular block (ICB).

Main Outcome Measures: Incidence of tourniquet pain (onset, severity, associated haemodynamic changes) and block characteristics (block performance/onset times, distribution, incidence of adverse events, patient satisfaction) were recorded.

Results: Eighty two patients (40 in the axillary block and 42 in the ICB group) were recruited. The incidence (5/36 and 3/35; P = 0.71), onset time (73.0 ± 14.8 and 86.6 ± 5.7 min; P = 0.18) and severity (mild/moderate; 4/1 and 1/2; P = 0.51) of tourniquet pain were similar in the two groups. The incidence of paraesthesia during block performance, and block performance time were greater in the axillary block group (P = 0.0054 and 0.012, respectively). The volume of local anaesthetic administered was greater in the ICB group (P < 0.01). ICB was associated with a greater degree of sensory block in the distributions of both the axillary nerve and the medial cutaneous brachial nerve (P < 0.01). Overall patient satisfaction and incidence of inadvertent vascular puncture were similar in the two groups.

Conclusion: For surgical procedures which are of moderate duration, infraclavicular and axillary blocks are associated with similar incidences of tourniquet pain. Other factors appear to differentiate between these two blocks, namely block performance time, incidence of paraesthesia and dose of local anaesthetic.

Trial Registration: ClinicalTrials.gov ID: NCT02714738.
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http://dx.doi.org/10.1097/EJA.0000000000000928DOI Listing
January 2019

Proficiency-based progression training: an 'end to end' model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study.

BMJ Open 2018 10 15;8(10):e020099. Epub 2018 Oct 15.

The ASSERT Centre, University College Cork, Cork, Ireland.

Background: Training procedural skills using proficiency-based progression (PBP) methodology has consistently resulted in error reduction. We hypothesised that implementation of metric-based PBP training and a valid assessment tool would decrease the failure rate of epidural analgesia during labour when compared to standard simulation-based training.

Methods: Detailed, procedure-specific metrics for labour epidural catheter placement were developed based on carefully elicited expert input. Proficiency was defined using criteria derived from clinical performance of experienced practitioners. A PBP curriculum was developed to train medical personnel on these specific metrics and to eliminate errors in a simulation environment.Seventeen novice anaesthetic trainees were randomly allocated to undergo PBP training (Group P) or simulation only training (Group S). Following training, data from the first 10 labour epidurals performed by each participant were recorded. The primary outcome measure was epidural failure rate.

Results: A total of 74 metrics were developed and validated. The inter-rater reliability (IRR) of the derived assessment tool was 0.88. Of 17 trainees recruited, eight were randomly allocated to group S and six to group P (three trainees did not complete the study). Data from 140 clinical procedures were collected. The incidence of epidural failure was reduced by 54% with PBP training (28.7% in Group S vs 13.3% in Group P, absolute risk reduction 15.4% with 95% CI 2% to 28.8%, p=0.04).

Conclusion: Procedure-specific metrics developed for labour epidural catheter placement discriminated the performance of experts and novices with an IRR of 0.88. Proficiency-based progression training resulted in a lower incidence of epidural failure compared to simulation only training.

Trial Registration Number: NCT02179879. NCT02185079; Post-results.
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http://dx.doi.org/10.1136/bmjopen-2017-020099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194403PMC
October 2018

Datafication of medical device use for training and device design.

Authors:
George Shorten

Lancet 2018 09;392(10151):914-915

Department of Anaesthesia and Intensive Care Medicine, University College Cork, Cork T12 AK54, Ireland. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(18)31820-8DOI Listing
September 2018

Deliberate practice using validated metrics improves skill acquisition in performance of ultrasound-guided peripheral nerve block in a simulated setting.

J Clin Anesth 2018 Aug 1;48:22-27. Epub 2018 May 1.

Department of Anaesthesia and Intensive Care, Cork University Hospital and University College Cork, Cork, Ireland.

Study Objectives: The aim of this study was to compare the effects of deliberate vs. self-guided practices (both using validated metrics) on the acquisition of needling skills by novice learners.

Design: Randomized Controlled Study.

Setting: Simulation lab, Department of Anesthesia, St.Vincent's Hospital, Dublin.

Subjects: Eighteen medical students.

Interventions: Students were assigned to either (i) deliberate practice (n = 10) or (ii) self-guided practice (n = 8) groups. After completion of a 'learning phase', subjects attempted to perform a predefined task, which entailed advancing a needle towards a target on a phantom gel under ultrasound guidance. Subsequently, all subjects practiced this task using predefined metrics. Only subjects in the deliberate practice group had an expert anesthesiologist during practice. Immediately after completing 'practice phase', all subjects attempted to perform the same task, and, on the following day, made two further attempts in succession. Two trained consultant anesthesiologists assessed a video of each performance independently using the pre-defined metrics.

Measurements: Number of procedural steps completed and number of errors made.

Main Results: Compared with novices who self-guided their practice using metrics, those who undertook expert-supervised deliberate practice using metrics completed more steps (performance metrics) immediately after practice (median [range], 14.5 [12-15] vs. 3 [1-10], p < 0.0001) and 24 h later (15 [12-15] vs. 4.5 [1-11], p < 0.0001 and 15 [11-15] vs. 4 [2-14], p < 0.0001). They also made fewer errors immediately after practice (median [range], 0 [0-0] vs. 5 [3-8], p < 0.0001) and 24 h later, (0 [0-3] vs. 6.5 [3-8], p < 0.0001 and 0 [0-3] vs. 4 [2-7], p < 0.0001).

Conclusion: Combining deliberate practice with metrics improved acquisition of needling skills.
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http://dx.doi.org/10.1016/j.jclinane.2018.04.015DOI Listing
August 2018

An evaluation of operating room throughput in a stand-alone soft-tissue trauma operating theatre.

Rom J Anaesth Intensive Care 2017 Apr;24(1):13-20

Department of Anaesthesia, Cork University Hospital, and University College Cork, Ireland.

Background: Operating room time is a limited, expensive commodity in acute hospitals. Strategies aimed at reduction of non-operative time improve operating room throughput and capacity. We conducted a prospective study to evaluate and augment operating room throughput and capacity using context-specific work practice changes.

Methods: Following institutional and ethical approval, an interdisciplinary group designed and introduced a series of work practice changes specific to a stand-alone soft tissue trauma theatre, comprising modifications to patient processing, staff behaviours and additional anaesthesiologist hours. Time intervals relating to each patient were measured during a 16 week period before and after implementing work practice changes. The primary outcome measure was non-operative time, with daily caseload and cancellations amongst secondary outcome measures.

Results: 251 procedures were included over 58 working days (8 to 17 Monday to Friday). Non-operative time [55.6 (31.1) vs 52.3 (9.8) minutes, p = 0.48], daily caseload [4 [1-9] vs 4 [2-7], p = 0.56], and the number of daily cancellations [3 [0-11] vs 5 [0-8], p = 0.38], did not differ between baseline and study phases. Regional anaesthesia for upper limb surgery increased during the study phase [26/59 (44.0%) vs 10/63 (15.9%), p = 0.014] with resultant decrease in mean duration of recovery room stay [20.7 (17.7) vs 30 (20.5) minutes, p = 0.0001] and increased recovery room bypass [26/116 (22.4%) vs 6/135 (4.4%), p = 0.0002]. Avoidable delays accounted for 124.8 (72.2) minutes of theatre time lost each day.

Conclusion: In conclusion, additional attending anaesthesiologist hours combined with work practice changes did not impact on measures of theatre throughput and capacity. The study identified important variables that contribute to avoidable delays, and points the way for future research.
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http://dx.doi.org/10.21454/rjaic.7518.241.walDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5555422PMC
April 2017

Development of performance and error metrics for ultrasound-guided axillary brachial plexus block.

Adv Med Educ Pract 2017 5;8:257-263. Epub 2017 Apr 5.

Department of Anaesthesia and Intensive Care, University College Cork and Cork University Hospital.

Purpose: Change in the landscape of medical education coupled with a paradigm shift toward outcome-based training mandates the trainee to demonstrate specific predefined performance benchmarks in order to progress through training. A valid and reliable assessment tool is a prerequisite for this process. The objective of this study was to characterize ultrasound-guided axillary brachial plexus block to develop performance and error metrics and to verify face and content validity using a modified Delphi method.

Methods: A metric group (MG) was established, which comprised three expert regional anesthesiologists, an experimental psychologist and a trained facilitator. The MG deconstructed ultrasound-guided axillary brachial plexus block to identify and define performance and error metrics. Experts reviewed five video recordings of the procedure performed by anesthesiologists with different levels of expertise to aid task deconstruction. Subsequently, the MG subjected the metrics to "stress testing", a process to ascertain the extent to which the performance and error metrics could be scored objectively, either occurring or not occurring with a high degree of reliability. Ten experienced regional anesthesiologists used a modified Delphi method to reach consensus on the metrics.

Results: Fifty-four performance metrics, organized in six procedural phases and characterizing ultrasound-guided axillary brachial plexus block and 32 error metrics (nine categorized as critical) were identified and defined. Based on the Delphi panel consensus, one performance metric was modified, six deleted and three added.

Conclusion: In this study, we characterized ultrasound-guided axillary brachial plexus block to develop performance and error metrics as a prerequisite for outcome-based training and assessment. Delphi consensus verified face and content validity.
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http://dx.doi.org/10.2147/AMEP.S128963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388285PMC
April 2017

Wearable Recording Devices for Surgical Training.

JAMA Surg 2017 05;152(5):507-508

Department of Anesthesia, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland.

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http://dx.doi.org/10.1001/jamasurg.2016.5657DOI Listing
May 2017

Further considerations on competence by design: when opportunity stops knocking.

Can J Anaesth 2017 04 9;64(4):430. Epub 2016 Dec 9.

Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1007/s12630-016-0786-8DOI Listing
April 2017

Postoperative analgesic effect, of preoperatively administered dexamethasone, after operative fixation of fractured neck of femur: randomised, double blinded controlled study.

BMC Anesthesiol 2016 Sep 22;16(1):79. Epub 2016 Sep 22.

Department of Anaesthesia, Intensive Care and Pain Medicine/University College Cork, Cork University Hospital, Wilton, Cork, Ireland.

Background: Fractured neck of femur is a common cause of hospital admission in the elderly and usually requires operative fixation. In a variety of clinical settings, preoperative glucocorticoid administration has improved analgesia and decreased opioid consumption. Our objective was to define the postoperative analgesic efficacy of single dose of dexamethasone administered preoperatively in patients undergoing operative fixation of fractured neck of femur.

Methods: Institutional ethical approval was granted and written informed consent was obtained from each patient. Patients awaiting for surgery at Cork University Hospital were recruited between July 2009 and August 2012. Participating patients, scheduled for surgery were randomly allocated to one of two groups (Dexamethasone or Placebo). Patients in the dexamethasone group received a single dose of intravenous dexamethasone 0.1 mg kg immediately preoperatively. Patients in the placebo group received the same volume of normal saline. Patients underwent operative fixation of fractured neck of femur using standardised spinal anaesthesia and surgical techniques. The primary outcome was pain scores at rest 6 h after the surgery.

Results: Thirty seven patients were recruited and data from thirty patients were analysed. The groups were similar in terms of patient characteristics. Pain scores at rest 6 h after the surgery (the principal outcome) were lesser in the dexamethasone group compared with the placebo group [0.8(1.3) vs. 3.9(2.9), mean(SD) p = 0.0004]. Cumulative morphine consumption 24 h after the surgery was also lesser in the dexamethasone group [7.7(8.3) vs. 15.1(9.4), mean(SD) mg, p = 0.04].

Conclusions: A single dose of intravenous dexamethasone 0.1 mg kg administered before operative fixation of fractured neck of femur improve significantly the early postoperative analgesia.

Trial Registration: ClinicalTrials.gov identifier: NCT01550146 , date of registration: 07/03/2012.
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http://dx.doi.org/10.1186/s12871-016-0247-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5034605PMC
September 2016

Competency-based medical education: Its time has arrived.

Can J Anaesth 2016 Jul 30;63(7):802-6. Epub 2016 Mar 30.

Department of Anaesthesia and Intensive Care Medicine, University College Cork, Cork, Ireland.

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http://dx.doi.org/10.1007/s12630-016-0638-6DOI Listing
July 2016

Re: Adductor Canal Blockade Following Total Knee Arthroplasty-Continuous or Single-Shot Technique?

J Arthroplasty 2016 Feb 30;31(2):555-6. Epub 2015 Sep 30.

Cork University Hospital and University College Cork, Cork, Ireland.

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http://dx.doi.org/10.1016/j.arth.2015.09.022DOI Listing
February 2016

New assessment tool for remote simulation-based ultrasound-guided regional anesthesia: a call for further refinement.

Reg Anesth Pain Med 2015 May-Jun;40(3):290-1

Cork University Hospital Cork, Ireland Cork University Hospital Cork, Ireland Department of Anaesthesia University College Cork Cork, Ireland.

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http://dx.doi.org/10.1097/AAP.0000000000000222DOI Listing
May 2016

Determination of the minimum initial intrathecal dose of isobaric 0.5% bupivacaine for the surgical repair of a proximal femoral fracture: A prospective, observational trial.

Eur J Anaesthesiol 2015 Nov;32(11):759-63

From the Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital/University College Cork, Cork, Ireland.

Background: Femoral neck fractures usually require operative fixation. Spinal anaesthesia is the preferred technique for many anaesthetists, although single-shot spinal anaesthesia may have severe haemodynamic side-effects.

Objective: To determine the initial minimum intrathecal dose of 0.5% isobaric bupivacaine required in order to achieve surgical anaesthesia within 15 min.

Design: Prospective controlled trial using the Dixon and Massey up-and-down method.

Setting: Patients awaiting surgery for proximal femoral fractures at Cork University Hospital were recruited between September 2012 and December 2012.

Patients: With institutional ethics approval and having obtained written informed consent from each, American Society of Anesthesiologists' physical status I to III patients aged more than 60 years were recruited. Twenty-three patients were recruited to the study, of which 22 were managed as per protocol. One patient was excluded because of the inability to insert an intrathecal catheter.

Intervention: A 22-guage spinal catheter was inserted between the L3 and L5 vertebral levels. An initial dose of 1 ml 0.5% isobaric bupivacaine was arbitrarily chosen as a starting point. The dose in subsequent patients was determined by the outcome of the preceding spinal block and adjusted by 0.1 ml until data on six independent pairs of patients with successful block/failed block were acquired.

Main Outcome Measures: The minimum effective local anaesthetic dose of intrathecal 0.5% isobaric bupivacaine to achieve surgical anaesthesia was defined as the primary outcome.

Results: The minimum effective local anaesthetic dose of 0.5% bupivacaine was 0.24 ml (95% confidence interval 0.18 to 0.68).

Conclusion: Our findings may influence clinicians' initial dose selection for spinal anaesthesia when a spinal catheter is used. The dose may be less than previously thought.

Trial Registration: Clinicaltrials.gov identifier: NCT01680120.
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http://dx.doi.org/10.1097/EJA.0000000000000235DOI Listing
November 2015

The medical procedure pathway: creating a global standard methodology to benefit patients.

Eur J Anaesthesiol 2015 Feb;32(2):79-82

From the ASSERT for Health Centre, University College Cork, Cork, Ireland (GDS, AGG), and Department of Surgery, University of Washington Medical Center, Seattle, Washington, USA (RMS).

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http://dx.doi.org/10.1097/EJA.0000000000000170DOI Listing
February 2015

Defining a competency map for a practical skill.

Clin Teach 2014 Dec;11(7):531-6

Department of Anaesthesia and Intensive Care, Cork University Hospital, Ireland.

Background: In recent years there has been a move towards a competency-based model for assessing the performance of practical procedures in clinical medicine rather than the traditional assumption that competency is achieved with increasing experience. For such an assessment to be valid, the necessary competencies comprising that skill must be identified. Our aim was to map the individual competencies necessary to perform a given procedural skill using spinal anaesthesia as the example, and to explore the relationship of individual competencies with each other.

Methods: In the first part of the study an extensive hierarchical task analysis (HTA) was undertaken to determine the competencies necessary for the performance of spinal anaesthesia. Secondly, the concept of competency-based knowledge space theory (CbKST) was applied to the map. CbKST is based on the principle that acquisition of a specific skill is usually preceded by a number of dependent or prerequisite skills. Our aim was to map the individual competencies necessary to perform a given procedural skill

Results: The analysis yielded a comprehensive HTA of the skills necessary to perform spinal anaesthesia, comprising 509 individual competencies. Applying the concept of CbKST yielded 194 key competences with at least one dependent or prerequisite skill.

Discussion: We have defined a comprehensive HTA or competency map for use in the assessment of the performance of spinal anaesthesia. This CbKST approach will provide clinicians who undertake medical procedures to better understand their own performance, and to improve over time.
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http://dx.doi.org/10.1111/tct.12194DOI Listing
December 2014

Improving clinical performance using rehearsal or warm-up: an advanced literature review of randomized and observational studies.

Acad Med 2014 Oct;89(10):1416-22

Dr. O'Leary is assistant professor, Department of Anesthesia, University of Toronto, and staff anesthesiologist, Hospital for Sick Children, Toronto, Ontario, Canada. Dr. O'Sullivan is research fellow, Department of Anesthesia, University College Cork, Cork, Ireland. Dr. Barach is anesthesiologist and visiting professor, University College Cork, Cork, Ireland. Professor Shorten is professor of anesthesia and dean, School of Medicine, University College Cork, Cork, Ireland.

Purpose: To determine whether rehearsal (the deliberate practice of skills specific to a procedure) or warm-up (the act or process of warming up by light exercise or practice) prior to performing complex clinical procedures on patients can improve the task performance of operators and operating teams.

Method: The authors performed an advanced literature search for clinical studies published between 1975 and October 2012 using MEDLINE, EMBASE, the Cochrane Controlled Trials Register, ISI Web of Knowledge, and clinicaltrials.gov. They identified randomized controlled trials and observational studies that evaluated the effects of physical rehearsal or warm-up prior to performing complex clinical procedures. Two reviewers independently reviewed titles and abstracts and then full texts before abstracting data using a standardized form. They resolved disagreements by consensus.

Results: The authors identified 1,886 potential articles and included 7 in their review (2 randomized controlled trials and 5 observational studies). All reported that rehearsal or warm-up by operators or operating teams is feasible. Only two clinical studies objectively demonstrated that warm-up can improve overall technical performance. Other objective evidence supporting the positive effects of rehearsal or warm-up for other team or nontechnical outcomes was limited.

Conclusions: The potential benefits of and optimal techniques for performing physical rehearsal and warm-up have not been established. Preliminary findings suggest that preoperative rehearsal or warm-up can improve the performance of operators or operating teams, but there is a paucity of objective evidence and comparative clinical studies in the existing literature to support their routine use.
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http://dx.doi.org/10.1097/ACM.0000000000000391DOI Listing
October 2014

A comparison of three techniques (local anesthetic deposited circumferential to vs. above vs. below the nerve) for ultrasound guided femoral nerve block.

BMC Anesthesiol 2014 Jan 25;14. Epub 2014 Jan 25.

Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital and University College Cork, Cork, Ireland.

Background: Fractured neck of femur generally requires operative fixation and is a common cause of admission to hospital. The combination of femoral nerve block and spinal anesthesia is a common anesthetic technique used to facilitate the surgical procedure. The optimal disposition of local anesthetic (LA) relative the femoral nerve (FN) has not been defined. Our hypothesis was: that the deposition of LA relative to the FN influences the quality of analgesia for positioning of the patient for performance of spinal anesthesia. The primary outcome was verbal rating (VRS) pain scores 0-10 assessed immediately after positioning the patient to perform spinal anesthesia.

Methods: With Institutional ethical approval and having obtained written informed consent from each, 52 patients were studied. The study was registered with ClinicalTrials.gov (NCT01527812). Patients were randomly allocated to undergo to one of three groups namely: intention to deposit lidocaine 2% (15 ml) i. above (Group A), ii. below (Group B), iii. circumferential (Group C) to the FN. A blinded observer assessed i. the sensory nerve block (cold) in the areas of the terminal branches of the FN and ii. VRS pain scores on passive movement from block completion at 5 minutes intervals for 30 minutes. Immediately after positioning the patient for spinal anesthesia, VRS pain scores were recorded.

Results: Pain VRS scores during positioning were similar in the three groups [Above group/Below group/Circumferential group: 2(0-9)/0(0-10)/3(0-10), median(range), p:0.32]. The block was deemed to have failed in 20%, 47% and 12% in the Above group, Below group and Circumferential group respectively. The median number of needle passes was greater in the Circumferential group compared with the Above group (p:0.009). Patient satisfaction was greatest in the Circumferential group [mean satisfaction scores were 83.5(19.8)/88.1(20.5)/93.8(12.3), [mean(SD), p=0.04] in the Above, Below and Circumferential groups respectively.

Conclusions: We conclude that there is no clinical advantage to attempting to deposit LA circumferential to the femoral nerve (relative to depositing LA either above or below the nerve), during femoral nerve block in this setting.
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http://dx.doi.org/10.1186/1471-2253-14-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3933203PMC
January 2014

Convergence and translation: attitudes to inter-professional learning and teaching of creative problem-solving among medical and engineering students and staff.

BMC Med Educ 2014 Jan 22;14:14. Epub 2014 Jan 22.

School of Medicine, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland.

Background: Healthcare worldwide needs translation of basic ideas from engineering into the clinic. Consequently, there is increasing demand for graduates equipped with the knowledge and skills to apply interdisciplinary medicine/engineering approaches to the development of novel solutions for healthcare. The literature provides little guidance regarding barriers to, and facilitators of, effective interdisciplinary learning for engineering and medical students in a team-based project context.

Methods: A quantitative survey was distributed to engineering and medical students and staff in two universities, one in Ireland and one in Belgium, to chart knowledge and practice in interdisciplinary learning and teaching, and of the teaching of innovation.

Results: We report important differences for staff and students between the disciplines regarding attitudes towards, and perceptions of, the relevance of interdisciplinary learning opportunities, and the role of creativity and innovation. There was agreement across groups concerning preferred learning, instructional styles, and module content. Medical students showed greater resistance to the use of structured creativity tools and interdisciplinary teams.

Conclusions: The results of this international survey will help to define the optimal learning conditions under which undergraduate engineering and medicine students can learn to consider the diverse factors which determine the success or failure of a healthcare engineering solution.
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http://dx.doi.org/10.1186/1472-6920-14-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3996181PMC
January 2014

The effect of simulation-based training on initial performance of ultrasound-guided axillary brachial plexus blockade in a clinical setting - a pilot study.

BMC Anesthesiol 2014 26;14:110. Epub 2014 Nov 26.

Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Wilton, Cork Ireland ; Department of Anaesthesia and Intensive Care Medicine, University College Cork, Cork, Ireland ; ASSERT for Health Centre, University College Cork, Cork, Ireland.

Background: In preparing novice anesthesiologists to perform their first ultrasound-guided axillary brachial plexus blockade, we hypothesized that virtual reality simulation-based training offers an additional learning benefit over standard training. We carried out pilot testing of this hypothesis using a prospective, single blind, randomized controlled trial.

Methods: We planned to recruit 20 anesthesiologists who had no experience of performing ultrasound-guided regional anesthesia. Initial standardized training, reflecting current best available practice was provided to all participating trainees. Trainees were randomized into one of two groups; (i) to undertake additional simulation-based training or (ii) no further training. On completion of their assigned training, trainees attempted their first ultrasound-guided axillary brachial plexus blockade. Two experts, blinded to the trainees' group allocation, assessed the performance of trainees using validated tools.

Results: This study was discontinued following a planned interim analysis, having recruited 10 trainees. This occurred because it became clear that the functionality of the available simulator was insufficient to meet our training requirements. There were no statistically significant difference in clinical performance, as assessed using the sum of a Global Rating Score and a checklist score, between simulation-based training [mean 32.9 (standard deviation 11.1)] and control trainees [31.5 (4.2)] (p = 0.885).

Conclusions: We have described a methodology for assessing the effectiveness of a simulator, during its development, by means of a randomized controlled trial. We believe that the learning acquired will be useful if performing future trials on learning efficacy associated with simulation based training in procedural skills.

Trial Registration: ClinicalTrials.gov identifier: NCT01965314. Registered October 17th 2013.
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http://dx.doi.org/10.1186/1471-2253-14-110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384236PMC
October 2015

Use of a group concept mapping approach to define learning outcomes for an interdisciplinary module in medicine.

Perspect Med Educ 2014 Jun;3(3):245-53

Centre for Learning Sciences and Technologies, Open Universiteit Nederland, Valkenburgerweg 177, 6419 AT, Heerlen, the Netherlands.

Learning outcomes are typically developed using standard group-based consensus methods. Two main constraints with standard techniques such as the Delphi method or expert working group processes are: (1) the ability to generate a comprehensive set of outcomes and (2) the capacity to reach agreement on them. We describe the first application of Group Concept Mapping (GCM) to the development of learning outcomes for an interdisciplinary module in medicine and engineering. The biomedical design module facilitates undergraduate participation in clinician-mentored team-based projects that prepare students for a multidisciplinary work environment. GCM attempts to mitigate the weaknesses of other consensus methods by excluding pre-determined classification schemes and inter-coder discussion, and by requiring just one round of data structuring. Academic members from medicine and engineering schools at three EU higher education institutions participated in this study. Data analysis, which included multidimensional scaling and hierarchical cluster analysis, identified two main categories of outcomes: technical skills (new advancement in design process with special attention to users, commercialization and standardization) and transversal skills such as working effectively in teams and creative problem solving. The study emphasizes the need to address the highest order of learning taxonomy (analysis, synthesis, problem solving, creativity) when defining learning outcomes.
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http://dx.doi.org/10.1007/s40037-013-0095-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4078057PMC
June 2014

Simulators for training in ultrasound guided procedures.

Med Ultrason 2013 Jun;15(2):125-31

Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital and University College Cork, Ireland.

The four major categories of skill sets associated with proficiency in ultrasound guided regional anaesthesia are 1) understanding device operations, 2) image optimization, 3) image interpretation and 4) visualization of needle insertion and injection of the local anesthetic solution. Of these, visualization of needle insertion and injection of local anaesthetic solution can be practiced using simulators and phantoms. This survey of existing simulators summarizes advantages and disadvantages of each. Current deficits pertain to the validation process.
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http://dx.doi.org/10.11152/mu.2013.2066.152.sfs1gs2DOI Listing
June 2013