Biomedical subjects

Randolph H Steadman

Publications and source records attributed to Randolph H Steadman.

7 recordsLinked to original sources

PubMed2006

Preoperative characteristics and intraoperative transfusion and vasopressor requirements in patients with low vs. high MELD scores.

Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation.

Adult↗

PubMed2006

Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills.

OBJECTIVE: To determine whether full-scale simulation (SIM) is superior to interactive problem-based learning (PBL) for teaching medical students acute care assessment and management skills. DESIGN: Randomized controlled trial. SETTING: Simulation center at a U.S. medical school. SUBJECTS: Thirty-one fourth-year medical students in a week-long acute care course. INTERVENTIONS: After institutional review board approval and informed consent, eligible students were randomized to either the SIM or PBL group. On day 1, all subjects underwent a simulator-based initial assessment designed to evaluate their critical care skills. Two blinded investigators assessed each student using a standardized checklist. Subsequently, the PBL group learned about dyspnea in a standard PBL format. The SIM group learned about dyspnea using the simulator. To equalize simulator education time, the PBL group learned about acute abdominal pain on the simulator, whereas the SIM group used the PBL format. On day 5, each student was tested on a unique dyspnea scenario. MEASUREMENTS AND MAIN RESULTS: Mean initial assessment and final assessment checklist scores and their change for the SIM and PBL groups were compared using the Student's t-test. A p < .05 was considered significant. The SIM and PBL groups had similar mean (PBL 0.44, SIM 0.47, p = .64) initial assessment scores (earned score divided by maximum score) and were deemed equivalent. The SIM group performed better than the PBL group on the final assessment (mean, PBL 0.53, SIM 0.72, p < .0001). When each student's change in score (percent correct on final assessment minus percent correct on the initial assessment) was compared, SIM group students performed better (mean improvement, SIM 25 percentage points vs. PBL 8 percentage points, p < .04) CONCLUSIONS: For fourth-year medical students, simulation-based learning was superior to problem-based learning for the acquisition of critical assessment and management skills.

Adult↗

PubMed2006

An advanced specialty training program in anesthesiology: a special educational fellowship designed to return community anesthesiologists to clinical practice.

We describe a program for community anesthesiologists designed to evaluate clinical skills and provide additional training in the latest technologies in anesthesiology. This educational program was established for previously trained anesthesiologists who require additional training for either remedial purposes or because of a prolonged absence from practice. All enrollees had an active, unrestricted California medical license and malpractice insurance. Approximately half of the participants had been in active practice at the time of enrollment; the remainder had been away from practice from 1 to 9 yr. The first 24 graduates of the fellowship spent an average of 9 wk (range, 3-24 wk) in the program to meet their individualized goals. Graduates were surveyed an average of 15 mo after completion of the fellowship. All respondents indicated that they would enroll in the program again; 80% indicated they learned new technical skills, 73% stated that the fellowship introduced them to a greater variety of drugs, and 50% indicated that the fellowship changed their approach to patient care. This program may serve as a model for any discipline of medicine and is particularly relevant for those with a substantial component of technical skills expected of its practitioners.

Adult↗

PubMed2006

Intraoperative hypokalemia in pediatric liver transplantation: incidence and risk factors.

In this retrospective study of 268 children undergoing liver transplantation, we investigated the incidence of intraoperative potassium (K+) disturbances and the risk factors for hypokalemia in the preperfusion and postreperfusion periods. Overall, hypokalemia was the predominant disturbance, occurring in 72.0% of pediatric patients during liver transplantation. Hypokalemia was more common during the postreperfusion period than the prereperfusion period. Hyperkalemia, though a commonly cited complication, was infrequent during pediatric liver transplantation. Using multivariate logistic regression analysis, baseline serum K+ < or =3.5 mmol/L, base excess >5 mmol/L, and creatinine < or =0.5 mg/dL were found to be predictors for hypokalemia in the prereperfusion period; and body weight < or =15 kg, K+ < or =3.5 mmol/L, fresh-frozen plasma transfusion >90 mL/kg, and absence of ascites at surgery were independent predictors for hypokalemia in the postreperfusion period. These findings support the use of K+ replacement to maintain normokalemia and avoid the potential complications related to hypokalemia in pediatric liver transplantation, especially in children with the risk factors for hypokalemia.

Adolescent↗

PubMed2005

Antifibrinolytics in orthotopic liver transplantation: current status and controversies.

This article reviews the current status and controversies of the 3 commonly used antifibrinolytics-epsilon-aminocaproic acid, tranexamic acid and aprotinin-during liver transplantation. There is no general consensus on how, when or which antifibrinolytics should be used in liver transplantation. Although these drugs appear to reduce blood loss and decrease transfusion requirements during liver transplantation, their use is not supported uniformly in clinical trials. Aprotinin has been studied more extensively in clinical trials and appear to offer more advantages compared to two other antifibrinolytics. Because of the diverse population of liver transplant recipients and the potential adverse effects of antifibrinolytics, especially life-threatening thromboembolism, careful patient selection and close monitoring is prudent. Further studies addressing the risks and benefits of antifibrinolytics in the setting of liver transplantation are warranted.

Aminocaproic Acid↗

PubMed2004

Anesthesia for liver transplant surgery.

Liver transplantation offers patients with liver disease an optimal chance for long-term survival. Current indications, preoperative assessment, patient selection, intraoperative anesthetic management and outcomes are described. The management of special situations, including retransplantation, pediatric transplantation, and fulminant hepatic failure are also reviewed. The success of liver transplantation has led to increased demand. This demand, coupled with a nonexpanding supply of deceased donor organs, has resulted in a shortage of grafts and prolonged waiting times. Novel solutions using segmental liver grafts from living donors, and the challenges associated with this approach, are discussed.

Anesthesia↗

PubMed2002

Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study.

BACKGROUND: Anesthesia simulators can generate reproducible, standardized clinical scenarios for instruction and evaluation purposes. Valid and reliable simulated scenarios and grading systems must be developed to use simulation for evaluation of anesthesia residents. METHODS: After obtaining Human Subjects approval at each of the 10 participating institutions, 99 anesthesia residents consented to be videotaped during their management of four simulated scenarios on MedSim or METI mannequin-based anesthesia simulators. Using two different grading forms, two evaluators at each department independently reviewed the videotapes of the subjects from their institution to score the residents' performance. A third evaluator, at an outside institution, reviewed the videotape again. Statistical analysis was performed for construct- and criterion-related validity, internal consistency, interrater reliability, and intersimulator reliability. A single evaluator reviewed all videotapes a fourth time to determine the frequency of certain management errors. RESULTS: Even advanced anesthesia residents nearing completion of their training made numerous management errors; however, construct-related validity of mannequin-based simulator assessment was supported by an overall improvement in simulator scores from CB and CA-1 to CA-2 and CA-3 levels of training. Subjects rated the simulator scenarios as realistic (3.47 out of possible 4), further supporting construct-related validity. Criterion-related validity was supported by moderate correlation of simulator scores with departmental faculty evaluations (0.37-0.41, P < 0.01), ABA written in-training scores (0.44-0.49, < 0.01), and departmental mock oral board scores (0.44-0.47, P < 0.01). Reliability of the simulator assessment was demonstrated by very good internal consistency (alpha = 0.71-0.76) and excellent interrater reliability (correlation = 0.94-0.96; P < 0.01; kappa = 0.81-0.90). There was no significant difference in METI versus MedSim scores for residents in the same year of training. CONCLUSIONS: Numerous management errors were identified in this study of anesthesia residents from 10 institutions. Further attention to these problems may benefit residency training since advanced residents continued to make these errors. Evaluation of anesthesia residents using mannequin-based simulators shows promise, adding a new dimension to current assessment methods. Further improvements are necessary in the simulation scenarios and grading criteria before mannequin-based simulation is used for accreditation purposes.

Anaphylaxis↗