Editorials
Fisher grade with high ICP support previous studies suggesting that high ICP can worsen vasospasm, and that ICP reduction, in particular osmotic diuresis, may reverse vasospasm development and clinical signs of delayed ischemia (8,9). American Heart Association guidelines recommend that aSAH-associated acute symptomatic hydrocephalus should be managed by CSF diversion (10). The role of ICP monitoring in the absence of hydrocephalus has not been established for this condition. Results of this and previous studies would indi cate that poor-grade patients with aSAH should receive ICP monitoring during the acute phase either with an external ven tricular drain with careful CSF drainage or with an intraparenchymal ICP monitoring device. Although good-grade patients were less represented in this study, the presence of high Fisher grade may also be a reasonable indication for ICP monitoring. This report adds to a limited number of studies assessing the course of ICP, predictive factors, and affect outcomes in patients with aSAH. The results are generalizable to high-grade aSAH and patients treated with endovascular coiling mainly. Although cases of truly refractory ICP may have limited options, improv ing cerebral perfusion by lowering increased ICP remains a reasonable treatment against delayed cerebral ischemia consid ering the inadequacy of our medical management thus far.
2. Lin N, Cahill KS, Frerichs KU, et al: Treatment o f ruptured and unrup tured cerebral aneurysms in the U SA: A paradigm shift. J Neurointerv Surg 2 0 1 2 ; 4 :1 8 2 - 1 8 9 3. M ura J, Rojas-Zalazar D, Ruiz A, et al: Im proved outcom e in highgrade aneurysmal subarachnoid hem orrhage by enhancem ent of endogenous clearance of cisternal blood clots: A prospective study that dem onstrates the role o f lamina te rm in a ls fenestration com bined w ith m odern m icrosurgical cisternal blood evacuation. Minim Invasive Neurosurg 2 0 0 7 ; 5 0 :3 5 5 - 3 6 2 4. Zoerle T, Lom bardo A, C olom bo A, et al: Intracranial Pressure After Subarachnoid H em orrhage. Crit Care M ed 2 0 1 5 ; 4 3 :1 6 8 - 1 7 6 5. H euer G G , Sm ith MJ, Elliott JP, et al: Relationship betw een intracra nial pressure and other clinical variables in patients w ith aneurysmal subarachnoid hemorrhage. J Neurosurg 2 0 0 4 ; 1 0 1 :4 0 8 - 4 1 6 6. Cahill J, Calvert JW, Zhang JH: M echanism s of early brain injury after subarachnoid hemorrhage. J Cereb Blood Flow Metab 2 0 0 6 ; 2 6 :1 3 4 1 - 1 3 5 3 7. Voldby B, Enevoldsen EM: Intracranial pressure changes follow ing aneurysm rupture. Part 1: C linical and angiographic correlations. J Neurosurg 1 9 8 2 ; 5 6 :1 8 6 - 1 9 6 8. Fukuhara T, Douville C M , Eliott JP, et al: Relationship betw een intra cranial pressure and the developm ent o f vasospasm after aneurys mal subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 1 9 9 8 ; 3 8 :7 1 0 -7 1 5 9. G am bardella G, De Blasi F, C aruso G, et al: Intracranial pressure, cerebral perfusion pressure, and S P E C T in the m anagem ent of patients w ith S A H H unt and H ess grades l-ll. Acta Neurochir Suppl 1 9 9 8 ; 7 1 :2 1 5 - 2 1 8 10.
REFERENCES 1.
Foltz EL, W ard A A Jr: C om m unicating hydrocephalus from subarach noid bleeding. J Neurosurg 1 9 5 6 ; 1 3 :5 4 6 - 5 6 6
C o n n o lly ES Jr, R abinstein AA , C arhuapom a JR, et al: G u id e lin e s fo r the m anagem ent o f aneurysm al subara ch n o id hem orrhage: A g u id e lin e fo r h e althcare p ro fe ssio n a ls from th e A m erican H eart A sso cia tio n /a m e rica n S tro ke A sso cia tio n . Stroke 2 0 1 2 ; 4 3 :1 7 1 1 - 1 7 3 7
Simulation: Why Not, When It Feels So Good?* S. Patrick Bender, MD Mark Hamlin, MD, MS Department of Anesthesiology University of Vermont College of Medicine/ University of Vermont Medical Center Burlington, VT
ith simulation-based education becoming ever more pervasive in medical school and in gradu ate medical education, the natural tendency is for it to spread into continuing medical education as well.
W
*S e e a ls o p. 186. K ey W o rd s : acute care physician; continuing m edical education; independent practitioner; m aintenance o f certification; sim ulation This w o rk w as perform ed at University o f V erm ont C ollege o f M edicine. Dr. Bender is employed by the University of Vermont Medical Center and the University of Vermont College of M edicine and received support for travel from the Society of Critical Care M edicine (S C C M ) (Ultrasound C ourse fac ulty). Dr. Hamlin is employed by the University o f Vermont Medical Center and the University of Vermont College o f Medicine, provided expert testimony (expert on case in Vermont), and lectured for the S C C M (Ultrasound faculty). C o p yrigh t © 2 0 1 4 by the S o cie ty o f C ritical C are M edicine and Lip p in co tt W illiam s & W ilkins D O I: 1 0 .1 0 9 7 /C C M .0 0 0 0 0 0 0 0 0 0 0 0 0 6 9 9
254
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Appropriately, or perhaps cynically, many physicians ques tion the benefit of simulation in terms of patient outcome. However, this has not stopped incorporation of a simulation requirement into some certification and maintenance of cer tification (MOC) processes (1). Being mandated to participate in an activity without proven effectiveness can be a difficult pill to swallow, especially when it is associated with increased cost and time required by the practitioner. In this issue of Critical Care Medicine, Khanduja et al (2) have systematically reviewed the literature regarding the effec tiveness of simulation for certified acute care physicians who are already in practice and have not been exposed to simula tion during graduate medical training. Despite an abundance of simulation literature, only 39 studies met these authors’ objective of evaluating either the validity or the effectiveness of simulation-based education for the acute care physician. The major findings of their review was that practitioners invariably perceived simulation as a positive learning experience, but it remains unclear whether practitioners retain the learned skills long term. No studies showed any benefit to patient safety. Not surprisingly, the significant majority of these studies (73%) incorporated anesthesiologists as the learners. Anes thesiology has a history of early adoption of simulation. It January 2 0 1 5 • Volume 4 3 • N um ber 1
Editorials
allows both a safe-learning environment for procedures and for simulation of very infrequent but life-threatening events, such as malignant hyperthermia, one of the most dreaded complications of anesthesia. Malignant hyperthermia occurs in 1:100,000 surgeries in adults and 1:30,000 surgical proce dures in children (3). This incidence is so low that it is likely that most trainees will go through their entire residency with out managing a case personally, or even having one occur in their hospital, making it necessary to simulate the experience. It is not surprising that a field with early adoption and plentiful experience with simulation-based education has a high degree of perceived benefit from the simulation process. If the other specialties involved in acute and critical care were proportion ally represented in the simulation literature, a difference in “buy-in” might have been seen. Two of the studies investigated long-term retention. Improvement in advanced airway procedure skills were retained after 1-year in one study. However, another study showed improved communication skills after simulation were not retained after 6 months. Despite the unclear duration of retention of skills learned via simulation described in this study, we should not totally disregard simulation as not benefi cial to the quality of patient care. Simulation-based education has been shown to improve patient care during Advanced Car diac Life Support events and has been implemented effectively for many years (4). Of great importance would be a discussion at the board certification level about the appropriate frequency of simulation-based education, and an understanding that dif ferent skills will be retained for different durations. Despite the lack of literature proving patient benefit from simulation-based education in acute care physician continuing education, we feel that this should not be an obstacle toward its widespread use. We do many things in medicine and critical care without obviously proven benefit. An appropriate analogy is the famous, or infamous, parachute discussion. There are no randomized controlled trials describing the benefit of jumping from an airplane with or without a parachute, but some things just make sense. As Smith and Pell state “Only two options exist. The first is that we accept that, under exceptional circum stances, common sense might be applied when considering the potential risks and benefits of interventions. The second is that
Critical Care Medicine
we continue our quest for the holy grail of exclusively evidence based interventions and preclude parachute use outside the context of a properly conducted trial” (5). Inconsistency is another concern here. We as anesthesiolo gists have different maintenance of certification requirements (1) than our medical and surgical colleagues (6) who staff the same ICUs at our hospital. We believe that all physicians would benefit from improved communication and procedural skills as can be learned via simulation. However, our MOC process is the only one to have an ongoing simulation requirement. Taking it another level deeper, because one of the authors was certified before time-limited board certification, the two of us have different MOC and simulation requirements (1). This sends an inconsistent message about the quality and effective ness of the varying types of continuing medical education we expect our colleagues to obtain. It seems unlikely that a landmark article will come for ward proving that simulation, when done properly, will lead to improved patient outcomes. But, with a focus on consis tent requirements across specialties, and evaluations of opti mal frequency, let us trust our physician colleagues who have invariably reported this to be a positive learning experience. So although the data may be a bit cloudy, we say grab your para chute, and jump right in to the wide open world of simulation.
REFERENCES 1. Maintenance of Certification in Anesthesiology, Component 4: Practice Performance Assessment and Improvement, Simulation. Available at: http://www.theaba.org/Home/anesthesiology_maintenance. Accessed September 3, 2014 2. Khanduja PK, Bould MD, Naik V, et al: The Role of Simulation in Continuing Medical Education for Acute Care Physicians: A Systematic Review. C rit Care M ed 2015; 43:186-193 3. Malignant Hyperthermia Association of America. Available at http:// www.mhaus.org/faq/about-mh. Accessed September 3, 2014 4. Wayne DB, Didwania A, Feinglass J, et al: Simulation-based educa tion improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study. Chest 2008; 133:56-61 5. Smith GC, Pell JP: Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of randomised controlled trials. BMJ 2003; 327:1459-1461 6. Levine Al, Schwartz AD, Bryson EO, et al: Role of simulation in U.S. physician licensure and certification. M t Sinai J Med 2012; 79:140-153
w w w .c c m jo u r n a l.o r g
255
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Fisher grade with high ICP support previous studies suggesting that high ICP can worsen vasospasm, and that ICP reduction, in particular osmotic diuresis, may reverse vasospasm development and clinical signs of delayed ischemia (8,9). American Heart Association guidelines recommend that aSAH-associated acute symptomatic hydrocephalus should be managed by CSF diversion (10). The role of ICP monitoring in the absence of hydrocephalus has not been established for this condition. Results of this and previous studies would indi cate that poor-grade patients with aSAH should receive ICP monitoring during the acute phase either with an external ven tricular drain with careful CSF drainage or with an intraparenchymal ICP monitoring device. Although good-grade patients were less represented in this study, the presence of high Fisher grade may also be a reasonable indication for ICP monitoring. This report adds to a limited number of studies assessing the course of ICP, predictive factors, and affect outcomes in patients with aSAH. The results are generalizable to high-grade aSAH and patients treated with endovascular coiling mainly. Although cases of truly refractory ICP may have limited options, improv ing cerebral perfusion by lowering increased ICP remains a reasonable treatment against delayed cerebral ischemia consid ering the inadequacy of our medical management thus far.
2. Lin N, Cahill KS, Frerichs KU, et al: Treatment o f ruptured and unrup tured cerebral aneurysms in the U SA: A paradigm shift. J Neurointerv Surg 2 0 1 2 ; 4 :1 8 2 - 1 8 9 3. M ura J, Rojas-Zalazar D, Ruiz A, et al: Im proved outcom e in highgrade aneurysmal subarachnoid hem orrhage by enhancem ent of endogenous clearance of cisternal blood clots: A prospective study that dem onstrates the role o f lamina te rm in a ls fenestration com bined w ith m odern m icrosurgical cisternal blood evacuation. Minim Invasive Neurosurg 2 0 0 7 ; 5 0 :3 5 5 - 3 6 2 4. Zoerle T, Lom bardo A, C olom bo A, et al: Intracranial Pressure After Subarachnoid H em orrhage. Crit Care M ed 2 0 1 5 ; 4 3 :1 6 8 - 1 7 6 5. H euer G G , Sm ith MJ, Elliott JP, et al: Relationship betw een intracra nial pressure and other clinical variables in patients w ith aneurysmal subarachnoid hemorrhage. J Neurosurg 2 0 0 4 ; 1 0 1 :4 0 8 - 4 1 6 6. Cahill J, Calvert JW, Zhang JH: M echanism s of early brain injury after subarachnoid hemorrhage. J Cereb Blood Flow Metab 2 0 0 6 ; 2 6 :1 3 4 1 - 1 3 5 3 7. Voldby B, Enevoldsen EM: Intracranial pressure changes follow ing aneurysm rupture. Part 1: C linical and angiographic correlations. J Neurosurg 1 9 8 2 ; 5 6 :1 8 6 - 1 9 6 8. Fukuhara T, Douville C M , Eliott JP, et al: Relationship betw een intra cranial pressure and the developm ent o f vasospasm after aneurys mal subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 1 9 9 8 ; 3 8 :7 1 0 -7 1 5 9. G am bardella G, De Blasi F, C aruso G, et al: Intracranial pressure, cerebral perfusion pressure, and S P E C T in the m anagem ent of patients w ith S A H H unt and H ess grades l-ll. Acta Neurochir Suppl 1 9 9 8 ; 7 1 :2 1 5 - 2 1 8 10.
REFERENCES 1.
Foltz EL, W ard A A Jr: C om m unicating hydrocephalus from subarach noid bleeding. J Neurosurg 1 9 5 6 ; 1 3 :5 4 6 - 5 6 6
C o n n o lly ES Jr, R abinstein AA , C arhuapom a JR, et al: G u id e lin e s fo r the m anagem ent o f aneurysm al subara ch n o id hem orrhage: A g u id e lin e fo r h e althcare p ro fe ssio n a ls from th e A m erican H eart A sso cia tio n /a m e rica n S tro ke A sso cia tio n . Stroke 2 0 1 2 ; 4 3 :1 7 1 1 - 1 7 3 7
Simulation: Why Not, When It Feels So Good?* S. Patrick Bender, MD Mark Hamlin, MD, MS Department of Anesthesiology University of Vermont College of Medicine/ University of Vermont Medical Center Burlington, VT
ith simulation-based education becoming ever more pervasive in medical school and in gradu ate medical education, the natural tendency is for it to spread into continuing medical education as well.
W
*S e e a ls o p. 186. K ey W o rd s : acute care physician; continuing m edical education; independent practitioner; m aintenance o f certification; sim ulation This w o rk w as perform ed at University o f V erm ont C ollege o f M edicine. Dr. Bender is employed by the University of Vermont Medical Center and the University of Vermont College of M edicine and received support for travel from the Society of Critical Care M edicine (S C C M ) (Ultrasound C ourse fac ulty). Dr. Hamlin is employed by the University o f Vermont Medical Center and the University of Vermont College o f Medicine, provided expert testimony (expert on case in Vermont), and lectured for the S C C M (Ultrasound faculty). C o p yrigh t © 2 0 1 4 by the S o cie ty o f C ritical C are M edicine and Lip p in co tt W illiam s & W ilkins D O I: 1 0 .1 0 9 7 /C C M .0 0 0 0 0 0 0 0 0 0 0 0 0 6 9 9
254
w w w .c c m jo u rn a l.o rg
Appropriately, or perhaps cynically, many physicians ques tion the benefit of simulation in terms of patient outcome. However, this has not stopped incorporation of a simulation requirement into some certification and maintenance of cer tification (MOC) processes (1). Being mandated to participate in an activity without proven effectiveness can be a difficult pill to swallow, especially when it is associated with increased cost and time required by the practitioner. In this issue of Critical Care Medicine, Khanduja et al (2) have systematically reviewed the literature regarding the effec tiveness of simulation for certified acute care physicians who are already in practice and have not been exposed to simula tion during graduate medical training. Despite an abundance of simulation literature, only 39 studies met these authors’ objective of evaluating either the validity or the effectiveness of simulation-based education for the acute care physician. The major findings of their review was that practitioners invariably perceived simulation as a positive learning experience, but it remains unclear whether practitioners retain the learned skills long term. No studies showed any benefit to patient safety. Not surprisingly, the significant majority of these studies (73%) incorporated anesthesiologists as the learners. Anes thesiology has a history of early adoption of simulation. It January 2 0 1 5 • Volume 4 3 • N um ber 1
Editorials
allows both a safe-learning environment for procedures and for simulation of very infrequent but life-threatening events, such as malignant hyperthermia, one of the most dreaded complications of anesthesia. Malignant hyperthermia occurs in 1:100,000 surgeries in adults and 1:30,000 surgical proce dures in children (3). This incidence is so low that it is likely that most trainees will go through their entire residency with out managing a case personally, or even having one occur in their hospital, making it necessary to simulate the experience. It is not surprising that a field with early adoption and plentiful experience with simulation-based education has a high degree of perceived benefit from the simulation process. If the other specialties involved in acute and critical care were proportion ally represented in the simulation literature, a difference in “buy-in” might have been seen. Two of the studies investigated long-term retention. Improvement in advanced airway procedure skills were retained after 1-year in one study. However, another study showed improved communication skills after simulation were not retained after 6 months. Despite the unclear duration of retention of skills learned via simulation described in this study, we should not totally disregard simulation as not benefi cial to the quality of patient care. Simulation-based education has been shown to improve patient care during Advanced Car diac Life Support events and has been implemented effectively for many years (4). Of great importance would be a discussion at the board certification level about the appropriate frequency of simulation-based education, and an understanding that dif ferent skills will be retained for different durations. Despite the lack of literature proving patient benefit from simulation-based education in acute care physician continuing education, we feel that this should not be an obstacle toward its widespread use. We do many things in medicine and critical care without obviously proven benefit. An appropriate analogy is the famous, or infamous, parachute discussion. There are no randomized controlled trials describing the benefit of jumping from an airplane with or without a parachute, but some things just make sense. As Smith and Pell state “Only two options exist. The first is that we accept that, under exceptional circum stances, common sense might be applied when considering the potential risks and benefits of interventions. The second is that
Critical Care Medicine
we continue our quest for the holy grail of exclusively evidence based interventions and preclude parachute use outside the context of a properly conducted trial” (5). Inconsistency is another concern here. We as anesthesiolo gists have different maintenance of certification requirements (1) than our medical and surgical colleagues (6) who staff the same ICUs at our hospital. We believe that all physicians would benefit from improved communication and procedural skills as can be learned via simulation. However, our MOC process is the only one to have an ongoing simulation requirement. Taking it another level deeper, because one of the authors was certified before time-limited board certification, the two of us have different MOC and simulation requirements (1). This sends an inconsistent message about the quality and effective ness of the varying types of continuing medical education we expect our colleagues to obtain. It seems unlikely that a landmark article will come for ward proving that simulation, when done properly, will lead to improved patient outcomes. But, with a focus on consis tent requirements across specialties, and evaluations of opti mal frequency, let us trust our physician colleagues who have invariably reported this to be a positive learning experience. So although the data may be a bit cloudy, we say grab your para chute, and jump right in to the wide open world of simulation.
REFERENCES 1. Maintenance of Certification in Anesthesiology, Component 4: Practice Performance Assessment and Improvement, Simulation. Available at: http://www.theaba.org/Home/anesthesiology_maintenance. Accessed September 3, 2014 2. Khanduja PK, Bould MD, Naik V, et al: The Role of Simulation in Continuing Medical Education for Acute Care Physicians: A Systematic Review. C rit Care M ed 2015; 43:186-193 3. Malignant Hyperthermia Association of America. Available at http:// www.mhaus.org/faq/about-mh. Accessed September 3, 2014 4. Wayne DB, Didwania A, Feinglass J, et al: Simulation-based educa tion improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study. Chest 2008; 133:56-61 5. Smith GC, Pell JP: Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of randomised controlled trials. BMJ 2003; 327:1459-1461 6. Levine Al, Schwartz AD, Bryson EO, et al: Role of simulation in U.S. physician licensure and certification. M t Sinai J Med 2012; 79:140-153
w w w .c c m jo u r n a l.o r g
255
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
