Despite equal blood loss from chest drains, both colloids interfered with blood coagulation and produced greater haemodilution, which was associated with more transfusion of blood products compared with crystalloid use only.

No abstract

Background:Training in transesophageal echocardiography (TEE) is based on hands-on training in the operating room, which is time consuming and therefore limits its experience among anesthesiologists. Medical simulations have been successfully used for training of invasive procedures in many areas.This paper compares the difference in effectiveness of teaching the 11 basic TEE views using either e-learning, simulation based training or hands-on training in the operating room in 3 groups of residents.Methods:We included 51 anesthesia and intensive care residents of all training levels but no prior training in echocardiography in this prospective randomized single-center study.Residents received a tutorial about theoretical knowledge followed by 2 practical study sessions either by e-learning using an online simulator (www.pie.med.utoronto.ca/TEE), with the simulation mannequin (CAE Vimedix Simulator) or in the operating room. Both, a theoretical multiple choice test (0–50 points) and a practical exam test (0–110 points) on the simulation mannequin had to be completed.The primary endpoint was the post-training scores in the practical and theoretical exams after all training sessions.Results:Residents received significantly higher test scores in both practical and theoretical examinations after training with the simulation mannequin (108.41 ± 2.09, 40.6 ± 5.23, n = 17) compared with e-learning (106.88 ± 4.53, 36 ± 4.76, n = 17) or hands-on training (106.82 ± 2.01, 34.94 ± 4.72, n = 17).Conclusions:Simulation based TEE training provides more effective training than other teaching methods. It is therefore especially suitable for the initial stages of TEE training to acquire psychomotor skills and knowledge of echo-anatomy.

No abstract

T he optimal perioperative fluid management regimen for patients having major surgery is still being debated. Crystalloids (eg, Ringer's lactate [RL]), and colloids such as hydroxyethyl starch (HES) and 5% human serum albumin (HA) are used for intraoperative fluid management in patients undergoing cardiac surgery. The latter 2 expand circulating volume to a greater extent than crystalloids and could be used for a restrictive fluid therapy regimen. Human serum albumin and HES, however, can affect blood coagulation and contribute to increased transfusion requirements. This randomized, double-blind, single-center study was performed over 4 years to compare external blood loss from chest drains among groups receiving 5% HA, 6% HES 130/0.4, or RL as the main infusion during cardiac surgery.Eighty patients each were randomized to receive 50 mL/kg per day of either HA, HES, or RL 50 mL/kg per day, with additional RL given as required. Fluid administration was started with 250 to 500 mL of the study solution during anesthesia induction. Intraoperative fluid therapy with the study solution was restricted to two-thirds of the maximally allowed daily dose (33.3 mL/kg). The last 16.7 mL/kg was kept for initial volume replacement in the intensive care unit (ICU). Rotation thromboelastometry ex vivo coagulation variables were examined. The primary outcome was clinical bleeding based on chest tube drainage during the first 24 hours. Blood transfusion, thromboelastometry variables, perioperative fluid balance, renal function, mortality, and ICU and hospital stays were also evaluated.The final cohort included 76, 81, and 79 patients in the HA, HES, and RL groups, respectively. Median chest tube drainage over 24 hours postoperatively did not differ among the groups (HA, 835 mL; HES, 700 mL; RL, 670 mL; P = 0.0850). The groups differed, however, in the quantity of blood transfusion (packed red blood cells [PRBCs] for HA and HES 300 mL, 0 for RL; P < 0.0004). Most units of PRBCs were given perioperatively during the first 24 hours. No intergroup differences were apparent for transfused FFP and platelets. Fibrinogen was required in 12%, 16%, and 4% of patients in the HA, HES, and RL groups, respectively (P = 0.0383). No differences were found in the 3 groups for the amount of coagulation factor concentrates given. Packed red blood cells were given to 58%, 61%, and 24% of patients in the HA, HES, and RL groups, respectively (P = 0.0013) and any blood product to 62%, 64%, and 35%, respectively (P = 0.0003). During surgery, hemoglobin (Hb) values declined from baseline in all groups, but those in the RL group showed the least decline during surgery and at arrival in the ICU (P < 0.0001 for both). At 24 hours postoperatively, HA patients had the lowest Hb values compared with HES and RL groups (P < 0.0001 for both). The Hb values did not differ among the 3 groups on postoperative day (POD) 6. Maximal clot firmness decreased in all groups during surgery but stayed in the reference range in the HA and RL groups; the lowest value was seen ...