Name: using simulation models to train clinicians in the use of point-of-care ultrasound
Uploaded: 2024-08-09T13:20:00.000+00:00
Duration: 5 min 4 s
Description: The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide ...

作者要感谢西澳大利亚州尼德兰兹市查尔斯盖尔德纳爵士医院的超声学家 James Rippey 博士，他为如何在实验中创建所使用的仿真模型提供了指导和说明。该项目没有得到任何机构财政支持。

这项研究得到了埃迪斯科文大学人类研究伦理委员会的批准，参考编号 REMS 2021-02489-STEINWANDEL。从研讨会参与者那里获得了知情同意，并提供了参与者信息表的副本。只有在 2021 年至 2022 年的交付期间参加过其中一个超声研讨会的研讨会参与者才被邀请参加并纳入本研究。2023 年和 2024 年的所有后续研讨会参与者均被排除在本研究之外。
1. 创建和准备仿真模型12
<ol><li>用锋利的菜刀水平切一块普通的生鸡胸肉，以允许插入三个或更多充满液体的人工血管，这将在本实验中模拟人体血管。</li>
	<li>人工血管的准备<ol><li>使用 260 mL 导管尖端注射器用冷玫瑰果茶或用红色食用色素制备的水填充造型气球（260Q 号）。用准备好的液体填充建模气球，并去除气球中多余的空气。</li>
		<li>将液体推入气球，同时通过反复将注射器推入和推出建模气球来去除任何气泡。当这个重复的过程完成后，气球必须没有气泡并略微加压。</li>
		<li>用一个结拧紧建模气球，以避免任何液体泄漏。</li>
	</ol></li>
	<li>将充满液体的造型气球放在鸡胸肉的下半部分。将另一块鸡胸肉对折（放在上面）。用透明薄膜包裹这个鸡胸肉模拟模型，并将其放在托盘上（图 1）。</li>
</ol><img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66905/66905fig01.jpg"> 图 1：仿真模型。 仿真模型由生鸡胸肉和充满液体的建模气球 （260Q） 创建。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/66905fig01large.jpg" target="_blank">请单击此处查看此图的较大版本。</a>
2. 模拟血管通路插管
<ol><li>将带有线性探头和探头盖的带电 POCUS 设备（便携式或固定式）放在步骤 1 中准备的患者组织的模拟模型上。</li>
	<li>将一些超声凝胶涂抹在仿真模型中的感兴趣区域。戴上一双未消毒的手套。</li>
</ol>3. 测量容器的深度和卡尺
<ol><li>在仿真模型中模拟血管的横向视图中，通过将超声探头放在仿真模型的顶部，并将血管视图居中在超声设备屏幕的中间，使模拟血管可视化并实现感兴趣血管的良好视野，在那里它将显示为黑色圆形结构。确保可以识别出合理尺寸的容器，至少占据屏幕的 1 /3。</li>
	<li>通过在仿真模型上移动超声探头，将该血管放置在 POCUS 设备屏幕的中央，以便可以看到整个血管结构。如果需要，调整超声设备上的图像大小和对比度设置，以获得血管和周围组织的最佳视野，以区分血管空间和周围组织。按超声设备上的 Freeze 功能按钮冻结图像。</li>
	<li>在冻结的图像上，放置数字标记，以指示血管中心的深度。放置数字标记以测量容器的直径（卡尺）（图 2）。 注意：此信息有助于观察者对所需套管的大小和长度做出关键决定，这可能适合可能到达该特定血管并实现成功插管。</li>
</ol><img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66905/66905fig02.jpg"> 图 2：容器测量。 在超声屏幕上测量模拟血管（横视图）。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/66905fig02large.jpg" target="_blank">请单击此处查看此图的较大版本。</a>
4. 观察船舶方向
<ol><li>将超声探头旋转 90° 以获得血管的纵向视图。该视图允许观察者对容器的方向和预期的插管做出决定，在实际插管的后续过程之前提供关键信息。</li>
	<li>观察血管与超声探头对齐的方向。一旦观察到血管方向，使用它来决定插管放置的方向可能有用并且对于插管的插入和放置也很成功，即使血管可能看起来更深并且可能无法触及或从外部看到（图 3）。</li>
</ol><img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66905/66905fig03.jpg"> 图 3：模拟船舶的纵视图。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/66905fig03large.jpg" target="_blank">请单击此处查看此图的较大版本。</a>
5. 深血管插管
注意：结合所有这些信息，在观察者的脑海中创建了一个该容器的虚拟画面;随后是血管插管的过程。
<ol><li>将线性探针置于血管的横向视图中。取下 PIVC 套管的保护针盖以开始插管程序。</li>
	<li>将血管的横视装置放在 POCUS 设备的屏幕上中央。在线性探针的中间以大约 40° 的角度缓慢小心地插管（垂直）模拟模型，并瞄准血管的顶部（上端）。</li>
	<li>将针尖推进到模拟模型的组织中并瞄准血管。尝试在 POCUS 设备穿过组织时通过同时推进针头但用超声探头跟随针尖来目视识别 POCUS 设备屏幕上的针尖（图 4）。</li>
	<li>使用 POCUS 最终放置套管<ol><li>进一步将针头穿过组织推向血管，然后缓慢跟随超声探头，针尖与针头推进同时进行相同的运动。 注意：通过这种方式，临床医生可以确保针尖在模拟模型组织内的所需解剖空间中始终可见，然后向血管内空间移动。</li>
		<li>可视化针尖进入血管内空间，然后将针头调平到较浅的角度，并进一步推进针头，最后将其放在模拟模型血管的中心（最终目的地）。</li>
		<li>使用 POCUS 设备验证针尖的位置，方法是通过改变超声探头的角度或以小 （mm） 的增量来来回移动超声，直到针尖在屏幕上视觉上消失/重新出现。</li>
		<li>观察 PIVC 的另一端是否有红色液体的一些证据，以确认放置正确。从 PIVC 中取出管心针（视频 1）。</li>
	</ol></li>
</ol><img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/66905/66905fig04.jpg"> 图 4：模拟船舶的横视图。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/66905fig04large.jpg" target="_blank">请点击此处查看此图的较大版本。</a>
视频 1：套管推进到血管中心。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/Video.zip" target="_blank">请点击此处下载此视频。</a>

使用仿真模型培训 POCUS 血管插管的新手

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E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+mastery+learning+improves+ultrasound-guided+peripheral+intravenous+catheter+insertion+skills+of+practicing+nurses.">Simulation-based mastery learning improves ultrasound-guided peripheral intravenous catheter insertion skills of practicing nurses.</a> Simulation in Healthcare. 17 (1), 7-14 (2022).</li><li>Bahl, A., Mielke, N., Diloreto, E., Gibson, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Operation+stick:+A+vascular+access+specialty+program+for+the+generalist+emergency+medicine+clinician.">Operation stick: A vascular access specialty program for the generalist emergency medicine clinician.</a> J Vasc Access. , (2024).</li><li>Oh, E. J., Lee, J. -. H., Kwon, E. J., Min, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+training+using+a+vessel+phantom+effectively+improved+first+attempt+success+and+dynamic+needle-tip+positioning+ability+for+ultrasound-guided+radial+artery+cannulation+in+real+patients:+An+assessor-blinded+randomized+controlled+study.">Simulation-based training using a vessel phantom effectively improved first attempt success and dynamic needle-tip positioning ability for ultrasound-guided radial artery cannulation in real patients: An assessor-blinded randomized controlled study.</a> PLoS One. 15 (6), e0234567 (2020).</li></ol>

作者声明不存在利益冲突。

困难静脉疾病的血管通路插管需要经验、手部灵活性以及在套管穿过人体组织进入血管内间隙时持续观察针尖位置的进展18。虽然超声在静脉通路困难的患者2 中的使用变得更加普遍，但初级临床医生和新手也有必要熟悉超声在血管通路空间中的使用，并接受足够的培训 17,19,20.在使用 POCUS 和 USGPIVC 的培训中，没有详细报道要教授、理解和实践哪些具体的基本要素。为了实现充分的培训，使用了12 提出的高保真模拟模型，并且有可能证明在参加之前出版物中的研讨会后，研讨会参与者使用超声与血管通路插管相关的信心水平有所提高8。因此，可以假设，当使用类似方法时，在执行这些培训和教育课程的仿真模型中使用超声的类似方法可能会在其他地方取得成功。
已经为超声在血管通路程序中的应用制定了几项临床指南21,22。同时，据报道，在过去几年中，临床领域可用的超声设备数量有所增加。初级医生在使用这项技术方面需要足够的实践教育，使用模拟模型的面对面教学可能是将专业知识传授给新手的最合适方法23.在当地机构举办的一系列为期半天的研讨会，每个研讨会持续 4 小时，已经表明，在对模拟模型进行充分培训并在经验丰富的辅导员的指导下，初学者可以在他们的临床领域成功应用这项技术8。这种方法表明，一旦这种方法用于患者，研讨会主持人在指导参与者完成 POCUS 引导插管期间的每一个观察步骤，所采用的循序渐进的方法可能是成功获得插管结果的关键因素。由于之前在多项研究中已描述高度复杂患者的困难血管通路条件 （DIVA） 普遍增加 24,25,26,27,28，因此使用 POCUS 和 USGPIVC 可能提供合适的解决方案来解决各种临床环境中首次尝试时插管失败的问题。
在研讨会期间，首先对这种循序渐进的方法进行了理论解释和讨论，然后向参与者进行了实际演示，然后他们在提供的仿真模型上单独练习相同的方法。这些教育课程以最多 15 名参与者的小组形式进行，每个参与者都获得了自己的个人模拟模型和 POCUS 设备，以多次练习该程序。每个仿真模型至少插入了三个仿真血管，这些血管既无法触及，也无法从外部看到。此功能允许每个单独的研讨会参与者进行多次插管尝试，以防第一次插管尝试导致模拟模型中的血管泄漏，因为只有重复使用 USGPIVC 才能增加对该技术用户的信心。在研讨会结束时，评估了参与者在仿真模型中识别血管、测量血管深度、卡尺和方向的能力，还评估了他们是否能够在横向（平面外）视图中插管血管。几乎所有参与者都能够在所有研讨会结束时展示这种能力，并声称这项练习对他们有用。
虽然该研讨会最初针对来自不同临床领域的广泛和普通临床医生，旨在提供对在建立血管通路空间中使用超声原理的基本理解，但将来可能有必要为特定临床领域创建更具体的教学方法。以前建议将 USGPIVC 培训纳入医学本科课程3，现在可能还必须考虑在各种临床环境中工作的临床医生实际教授的不同技能要求，并且他们需要不同的专业技能来使用超声插入插管。很明显，与在儿科环境中工作的麻醉师29 或护士30 相比，照顾慢性肾病患者的临床医生很可能会在直径较大的血管中使用大口径插管。在设计课程时需要考虑培训要求的这些不同方面，在设计用于培训的模拟模型时也需要考虑它们，因为较小的船只需要更加复杂，尽可能真实地进行模拟，并与临床现实进行比较。需要开发和设计量身定制的具体课程，旨在为各种环境中的临床医生建立良好的 USGPIVC 技能，以实现学习者的最佳结果，并最终改善临床结果。这最终可能导致在血管通路插管的最佳临床实践领域建立超声的使用。
研讨会参与者报告的方法表明，在一些临床领域，超声可用，但仅在插管之前用于可视化，而不是用于插管本身，这可能是对课程开发的有用建议。如果在未来的研讨会中将这种方法用作工作场所的初始教育计划，以在临床环境中考虑血管通路时增加超声的使用和采用，则可能会为更普遍地接受这种技术铺平道路，即 USGPIVC，作为长期最佳实践。这也可能包括并影响未来版本的输液治疗实践标准27。此外，基于模拟的掌握学习 （SBML） 并将 USGPIVC 包含在这些概念中可能有助于共享和分发这种方法的知识31,32。尽管已经开发了一些教育计划并在今天应用了33，但没有明确描述哪些特定要素对于学习 USGPIVC 成功至关重要。这是否与操作者有关血管深度和大小的关键信息有关？它是关于血管方向的信息吗？是关于操作员重复和熟练地执行这项任务的手动灵巧性吗？是视觉观察和手工灵巧的结合导致了 USGPIVC 的最终成功吗？很明显，这些要素需要进一步的研究以及明确的识别和描述，以指导该领域未来成功的教育方法，并为该领域的目标课程建立共同原则，这应该是全球通用的标准做法。临床医生采用并理解通过使用基于模拟的学习34 首次尝试插管被认为是最佳临床实践，这一点也很重要。这之前也已在系统评价中得到证实14。
这项研究也有一些局限性。首先，每个仿真模型的每个仿真模型都有不同数量的三个充满流体的建模气球。预计在第一次插管尝试后，每个球囊（血管）都会泄漏和放气，可能无法重复使用。因此，我们在每个模拟器中放置了三艘船，以便在不同的船只中进行多次尝试，为个人提供重复和相似的体验，并提高操作员的技能。
其次，充满液体的建模球囊（尺寸 260Q）可实现的最小血管尺寸为 0.6 厘米，这肯定不能反映临床医生在现实生活中可能遇到的情况，尤其是在儿科环境中，但这是在给定情况下在车间设置和可用材料中可以达到的最小血管尺寸。研讨会的主要教学目标是传授理论和实践知识以及使用超声对血管通路插管的基本理解，在插管过程中始终观察针尖，以避免意外的血管损伤、外渗或组织损伤。
研究结果可能仅限于西澳大利亚 （WA） 地理环境中的学习者和临床医生，因为全球其他地区可能有不同的教育方法或指南来实现类似的结果。此外，研究结果可能部分存在偏差，因为参与者是热衷于学习的人，并有意选择（自愿自行注册）参加研讨会，这可能有助于积极的学习成果。需要未来的研究来评估持续时间较长（一整天或几天）的研讨会是否提供更好的学习成果。调查 USGPIVC 研讨会的哪些教学要素对于实现预期的学习成果至关重要也可能特别有趣。此外，需要更多的研究来揭示高级临床医生对采用新型血管通路方法的态度，例如通过 USGIPVC，因为在这项研究中，只有初级临床医生参与（自我登记），没有高级临床医生自行登记。发生这种情况是因为高级临床医生已经具备 USGC 的技能吗？或者高级临床医生在日常实践中不需要这项任务？标志性插管方法在高级临床医生中是否更常见，由于他们的长期临床经验，他们是否总是成功地使用这种方法？此外，了解和更多地了解临床医生的批判性观点和考虑，即在使用 POCUS 观察个体的血管状况后，结合所需或计划的治疗干预措施，例如所需的静脉注射药物或较小或较大量的静脉输液（较大尺寸的插管，用于较大容量的液体）。
正如本研究所证明的那样，将插管练习与床旁超声 （POCUS） 指导相结合的模拟教学方法在研讨会期间提高了参与者的技能水平，并在之后保持了改进。一些参与者随后能够在他们的临床环境中应用这项技能。当患者出现静脉通路困难 （DIVA） 情况时，这项教育活动可能会促进临床医生采用这种新方法，因为一些研讨会参与者可能倾向于与同事分享他们的积极经验。初级医生占所有参与者的一半，这凸显了在一线医护人员在提供患者护理时遇到 DIVA 情况的情况下，显然有必要进行高级培训。此外，创建和整合专门针对使用 POCUS 进行血管通路的循证临床指南将非常有益。通过将能力途径和临床指南相结合，医疗机构可以在将 POCUS 用于血管通路程序时培养卓越文化、患者安全和改善结果。

大多数被紧急医院收治的患者至少接受一根外周静脉导管 （PIVC），目的是抽血、输液和/或给药以及诊断目的1。首次尝试插入失败是很常见的，据报道，高达 50% 的住院患者存在静脉通路困难 （DIVA）2。为了缓解这种情况，使用超声引导下 PIVC 插入 （USGPIVC） 已被证明可以提高插入成功率，并且已建议多个医疗保健专业进行培训和实践教育 3,4,5。如今，床边的床旁超声 （POCUS） 更频繁地用于建立血管通路。POCUS 也被描述为增强体格检查教学和学习的有用工具6。虽然有几项研究描述了 USGPIVC 的培训可能会提高临床医生的技能 7,8,9,10，但尚未详细描述该培训的哪些具体要素是在将 POCUS 应用于 USGPIVC 时实现预期结果的基本组成部分。为了实现这一目标，开发了 POCUS 和 USGPIVC 联合培训课程，涵盖了培训的基本方面，这些方面被认为是 USGPIVC 研讨会的基本方面和学习目标，包括理论背景和实践方面。
在血管通路插管之前和期间培训新手使用 POCUS 需要一个理想的模拟环境，以实现有效的学习成功，从而复制与人体解剖环境中类似的解剖条件11。因此，由鸡胸肉和充满液体的建模球囊创建的仿真模型被发现是理想的，可用于生成这样的仿真模型12。这种方法教会学习者观察技能，首先在安全的模拟环境中评估个体患者水平的血管状况，这有助于选择所需套管长度、评估血管深度和宽度以及个体患者的血管方向的整体决策过程。这允许对任何未来患者的个体解剖状况进行严格评估，临床医生可能希望随后决定计划的插管是否可能成功。为了获得这些信息，当 POCUS 获得的图像被正确解释时，通常会提供可靠和关键的信息元素，除了临床医生的经验和手动灵活性外，这些信息还可能导致插管成功。
在第二步中，学习者在这个模拟环境中被教导发展使用超声探头的手部灵巧性，同时在视觉下将套管插入模拟血管的手部技能，观察 POCUS 屏幕和插入部位。这种不断可视化模拟血管并在插入过程中仔细观察针尖的观察技能是该模拟活动总体学习目标中最重要的方面，直到针尖最终放置在感兴趣的解剖区域，在这种情况下位于模拟血管的中心。这个过程对于避免意外和不必要的血管损伤、组织、出血或外渗至关重要，因为该技术旨在随后由参与者在临床环境中用于患者。
一些作者之前曾建议使用低成本的模拟模型和小型教学小组13 将超声实施并整合到医学院课程中。其他人建议制定结构化的培训计划，然后在模拟环境中进行实践课程14。还描述说，使用超声有助于手术成功，并可能降低患者的风险15。其他人观察到，使用 POCUS 和 USGPIVC 培训急诊科 （ED） 的临床医生在短期内增加了这种方法的使用。尽管如此，血管通路的正式教育计划也可能缺乏一致性 7,16,17。相比之下，其他人描述说，正规的血管通路培训可以提高对 PIVC 插入最佳实践的依从性11。
这种教育方法的目的是为学习者模拟类似的视觉和灵巧体验，以便他们能够在临床环境和将来的患者中复制和应用这项技能。选择了一种观察性纵向混合方法研究方法，并使用电子调查来评估使用超声 （POCUS） 与外周静脉插管相关的研讨会参与者的信心水平。这些调查首先用于模拟模型，随后用于入院患者的研讨会参与者的临床专业。
研讨会分为三个部分。首先，向参与者介绍了在交互式学习环境中在血管通路插管空间使用超声的一些基本原理和理论。在第二种方法中，研讨会主持人使用模拟器演示了血管通路评估方法，并创建了模拟的人工血管，演示了通过横向和纵向视图以及使用 POCUS 进行观察来观察血管深度、大小和方向。随后通过研讨会主持人使用 POCUS 和模拟器进行了演示插管，然后邀请参与者在他们的个人模拟器上自己练习这项任务。在研讨会结束时，参与者在模拟器中使用横向和纵向视图识别和测量血管大小、深度和方向的技能进行了单独评估，然后对模拟血管进行超声引导插管。参加研讨会后，参与者被邀请在电子调查中评估他们对使用 USPIVC 的信心技能。在参加研讨会后 8 周，参与者再次被邀请在电子调查中回答他们是否在个人临床环境中应用了这项采用的技能。

<table><tbody><tr><td>BD Insyte Autogard BC Pro shielded IV catheter with blood control technology (PIVC)</td><td>BD</td><td>318054</td><td></td></tr><tr><td>Catheter tipped syringe 30 or 50 ml</td><td>BD Plastipak&amp;nbsp;</td><td>301229, 300865</td><td></td></tr><tr><td>Celeste Nitrile Powder Free Examination gloves sizes S/M/L (non-sterile)</td><td>Celeste</td><td>CLS121</td><td></td></tr><tr><td>Goliath Cling wrap</td><td>Goliath</td><td></td><td></td></tr><tr><td>modelling balloons 260 Q</td><td>Qualatex&amp;nbsp;</td><td>99321</td><td></td></tr><tr><td>Point-of care ultrasound device, eg. Philips Lumify or Vscan Air</td><td>Philips or GE Healthcare</td><td></td><td>https://www.usa.philips.com/healthcare/product/HC989605450382/lumify-c5-2-curved-array-transducer</td></tr><tr><td>probe cover for Philips lumify</td><td>Philips&amp;nbsp;&amp;nbsp;</td><td></td><td>https://www.usa.philips.com/healthcare/product/HC989605450382/lumify-c5-2-curved-array-transducer</td></tr><tr><td>raw chicken breast</td><td></td><td></td><td></td></tr><tr><td>Sunsonic Ultrasound Transmission Gel 250 ml</td><td>Sunsonic</td><td>LG250</td><td></td></tr><tr><td>Tasty Herbal Infusion Rosehip Tea</td><td>Tasty</td><td></td><td></td></tr><tr><td>Victorinox Fibrox Chef&#039;s Knife 20 cm</td><td>Victorinox</td><td>40520</td><td></td></tr></tbody></table>

using simulation models to train clinicians in the use of point-of-care ultrasound

临床医生使用床旁超声 （POCUS） 已被证明是一种有益的无创血管通路评估方法，它可以提供视觉和可测量信息的关键要素，这些信息被证明在血管通路插管的情况下是有用的，并结合临床医生的实践技能进行插管。然而，在这种情况下使用 POCUS 是为了实际训练和使使用该技术的新手能够熟练地随后以谨慎和成功的方式对患者执行这项任务。这些血管状况的模拟可能有助于帮助医疗保健专业人员学习、理解、应用和建立安全血管插管的实用技能，以达到预期的结果。该项目旨在通过参加为期半天的研讨会，建立将 POCUS 与仿真模型结合使用并执行特定任务的技能，使临床医生能够在临床实践中使用该方法为患者进行血管通路插管。采用混合方法纵向研究设计来评估床旁超声研讨会对外周静脉插管插入的效果，包括参与者在模拟模型上执行的特定任务。共有 81 人参加了 2021 年和 2022 年的 11 场半天研讨会。提供一个将仿真模型与各种 POCUS 设备结合使用的研讨会有助于在临床医生中建立这种新学到的技能，例如在插管前使用 POCUS 测量静脉的深度、卡尺和方向，为操作者提供基本的解剖学事实，这增加了插管首次成功的可能性。

2021 年至 2022 年期间，共有 81 人参加了 11 次为期半天的研讨会。大多数参与者是住院医务人员 （n=43， 53%），其次是员工发展/临床护士和临床护士顾问 （n=19， 25.3%），平均具有 8 年的临床经验。一半的参与者 （n=40， 49%） 只有 2 年或更短的临床经验。还有一些其他研讨会参与者，例如核医学技术专家、牙科镇静师和诊断放射科医生。近四分之一的参与者受雇于卫星血液透析 （HD） 诊所。几乎所有工作场所都有超声设备 （n=75， 92.6%）。大多数参与者 （n=55,67.9%） 是女性，平均年龄为 35.7 岁（表 1）。
研讨会参与者遵循研讨会主持人的指示，能够在一些理论指导和观察主持人在仿真模型中演示任务后，使用 POCUS 设备与所描述的仿真模型一起逐步成功执行相同的插管过程。
研讨会参与者被邀请在研讨会之前和研讨会结束时直接完成一项电子调查，表明他们对使用 POCUS for USGPIVC 的信心水平。这些调查包括 11 个封闭式问题和 3 个开放式问题，参与者能够使用超声对他们的个人技能进行评分，同时按照 10 分制评分量表进行评分，范围从 0 = 不太熟练到 10 = 非常熟练。研讨会结束八周后，参与者再次被邀请完成一项最终调查，以表明他们当前技能在临床实践中采用和使用新学到的技能的任何进展。在最后一项调查中，询问了 9 个封闭式问题和 2 个开放式问题，这些问题涉及他们自我评估的 USGPIVC 技能。使用 SPSS 统计进行数据分析。分析了在三个时间点使用三个不同电子调查得出的 POCUS 的个体自我评估插管技能，并使用应用了 Bonferroni 校正的 Wilcoxon 符号排名测试进行 Friedman 检验和事后分析。< 0.05 的 p 值被认为具有统计学意义，并对开放式问题的回答进行了内容分析（图 5，表 2）。
自我评估的插管技能在三个时间段内表现出具有统计学意义的变化 （p < 0.001）。事后分析揭示了研讨会前自我评估的插管熟练度的统计差异，与研讨会后立即 （p < 0.001） 和研讨会后 8 周 （p < 0.001） 形成鲜明对比。然而，在研讨会后立即和 8 周随访之间，未观察到使用 POCUS 进行自我评估的插管技能存在显着差异 （p=.722）。一些研讨会参与者报告了研讨会的结论，在他们的工作场所，管理层只允许在插管前使用超声，以帮助临床医生观察血管，并在尝试插管之前让操作者对特定的个体血管状况有更好的印象和理解。
大多数研讨会参与者声称，使用模拟模型参加研讨会提高了他们使用超声显着插管静脉血管的临床技能，并且在研讨会结束时他们对使用这项技术更有信心，在将这项技术应用于他们的临床环境后，该技术进一步进步。在研讨会结束后 8 周，参与者再次被邀请完成另一个电子版调查。大多数参与者随后能够在他们的临床环境中与患者一起练习这项新学到的技能，并且与他们的大多数临床机构一样，POCUS 设备可用（表 3; 表 4）。
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/66905/66905fig05.jpg"> 图 5：插管技能的自我评估。 参与者在研讨会之前、之后（结束时）和研讨会后 8 周提供的自我评估的插管技能水平。在研讨会之前，中位数为 1，IQR：0 到 3;研讨会结束后，中位数为 6，IQR：5 至 7;8 周后，中位数：6，IQR：4 至 8。n 数字是研讨会前 81 个，研讨会后 80 个，之后 8 周为 43。此数字已从8 修改。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/66905fig05large.jpg" target="_blank">请单击此处查看此图的较大版本。</a>
表 1：基线人口统计数据。 此表已从8 修改而来。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/Table%201_RE.xlsx" target="_blank">请点击此处下载此表格。</a>
表 2：插管技能的自我评估。 参与者在研讨会之前、之后和之后 8 周自我评估的插管技能的 p 值 n 值是研讨会前 81 分，研讨会后 80 分，讲习班后 8 周为 43。此数字已从8 修改。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/Table%202_RE.xlsx" target="_blank">请点击此处下载此表格。</a>
表 3：研讨会后评估。 此表已从8 修改而来。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/Table%203_%20RE.xlsx" target="_blank">请点击此处下载此表格。</a>
表 4：研讨会完成后 8 周的评估。 此数字已从8 修改。 <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66905/Table%204_RE.xlsx" target="_blank">请点击此处下载此表格。</a>

作者聚焦：通过模拟培训评估临床医生对超声引导下血管插管的采用情况

本方案描述了一种理想的解决方案，可以培训新手使用床旁超声设备，以掌握在患者使用床旁超声进行预期的静脉血管插管之前和期间目视评估不同个体解剖血管状况的实用临床技能。

使用仿真模型培训临床医生使用床旁超声 

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide ...

using-simulation-models-to-train-clinicians-use-point-care

Nanyang Technological University

Research

JoVE Journal

Medicine

Using Simulation Models to Train Clinicians in the Use of Point-of-Care Ultrasound

838 次观看.  Edith Cowan University. 该实验试图回答不熟悉超声用于血管插管的临床医生的问题，他们可能能够在模拟模型中学习和练习超声引导插管的技能，并随后能够将这项技能应用于临床环境。便携式超声设备在临床领域越来越普及，因为它们现在比过去更实惠，但临床医生需要接受有关如何成功使用它们的培训。当新手有机会在模拟模型上进行培训并在将相同技术应用于临床?...

视频: 作者聚焦：通过模拟培训评估临床医生对超声引导下血管插管的采用情况

Establishing a Multidisciplinary Cavernous Carotid Injury Simulation to Train Neurosurgical, Otolaryngology, and Anesthesia Residents

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for technique and algorithm development in resident learners. This study develops a realistic cadaveric model for the training of crisis resource management in the setting of cavernous carotid artery injury. An expanded endonasal approach and right cavernous carotid injury is performed on a cadaveric head. The cadaver&#39;s right common carotid artery is cannulated and connected to a perfusion pump delivering pressurized simulated blood. A simulation mannequin is incorporated into the model to allow for vital sign feedback. Surgical and anesthesia resident learners are tasked with obtaining vascular control with a muscle patch technique and medical management over the course of 3 clinical scenarios with increasing complexity. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the learners prior to beginning the simulation. An independent reviewer evaluated the learners on communication skills, crisis management algorithms, and implementation of appropriate skill sets. After each scenario, residents were debriefed on how to improve technique based on evaluation scores in areas of situational awareness, decision-making, communications and teamwork, and leadership. After the simulation, learners provided feedback on the simulation and this data was used to improve future simulations. The benefit of this cadaveric model is ease of set-up, cost-effectiveness, and reproducibility.

This protocol establishes a multidisciplinary model to train learners on management of cavernous carotid artery injury. Cadaveric heads undergo expanded endonasal approach and injury to the cavernous carotid artery, and perfusion pump simulates blood flow to the injury point. Learners are tasked with medical and surgical management over 3 scenarios.

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for ...

科研

医学

Creation of Patient-Specific Silicone Cardiac Models with Applications in Pre-surgical Plans and Hands-on Training

Three dimensional&#160;models can be a valuable tool for surgeons as they develop surgical plans and medical fellows as they learn about complex cases. In particular, 3D models can play an important role in the field of cardiology, where complex congenital heart diseases occur. While many 3D printers can provide anatomically correct and detailed models, existing 3D printing materials fail to replicate myocardial tissue properties and can be extremely costly. This protocol aims to develop a process for the creation of patient-specific models of complex congenital heart defects using a low-cost silicone that more closely matches cardiac muscle properties. With improved model fidelity, actual surgical procedural training could occur in advance of the procedure. Successful creation of cardiac models begins with the segmentation of radiologic images to generate a virtual blood pool (blood that fills the chambers of the heart) and myocardial tissue mold. The blood pool and myocardial mold are 3D printed in acrylonitrile butadiene styrene (ABS), a plastic dissolvable in acetone. The mold is assembled around the blood pool, creating a negative space simulating the myocardium. Silicone with a shore hardness of 2A is poured into the negative space and allowed to cure. The myocardial mold is removed, and the remaining silicone/blood pool model is submerged in acetone. The described process results in a physical model in which all cardiac features, including intra-cardiac defects, are represented with more realistic tissue properties and are more closely approximated than a direct 3D printing approach. The successful surgical correction of a model with a ventricular septal defect (VSD) using a GORE-TEX patch (standard surgical intervention for defect) demonstrates the utility of the method.

Patient-specific models improve surgeon and fellow confidence when developing or learning surgical plans. Three-dimensional (3D) printers generate adequate detail for surgical preparation, but fail to replicate tissue haptic fidelity. A protocol is presented detailing the creation of patient-specific, silicone cardiac models, combining 3D printing precision with simulated silicone tissue.

创建患者专用硅胶心脏模型，应用于术前计划和实践培训

Three dimensional&#160;models can be a valuable tool for surgeons as they develop surgical plans and medical fellows as they learn about complex cases. In ...

生物工程

Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome (TTTS), but is technically challenging and can lead to significant complications. Acquiring and maintaining the necessary surgical skills require consistent practice, a critical caseload, and time. Training on realistic surgical simulators can potentially shorten this steep learning curve and enables several proceduralists to acquire procedure-specific skills simultaneously. Here we describe realistic simulators designed to allow the user familiarity with the equipment and specific steps required in the surgical treatment of TTTS, including fetoscopic handling, approaches to anterior and posterior placenta, recognition of anastomoses, and efficient coagulation of vessels. We describe the skills that are especially important in conducting placental laser coagulation that the surgeon can practice on the model and apply in a clinical case. These models can be adapted easily depending on the availability of materials and require standard fetoscopy equipment. Such training systems are complementary to traditional surgical apprenticeships and can be useful aids for fetal medicine units that provide this clinical service.

Practicing the specific skills required for fetoscopic laser coagulation of monochorionic placental anastomoses on realistic models can aid less experienced surgeons in overcoming the steep learning curve associated with this procedure that is now regarded as the standard of care for twin-twin transfusion syndrome.

模型外科训练: 用逼真模拟器 Fetoscopic 激光光凝单绒毛膜 Diamniotic 双胎胎盘的技能习得

Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome ...

Creation of a High-Fidelity, Low-Cost, Intraosseous Line Placement Task Trainer via 3D Printing

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures in a safe environment before ultimately performing the procedure on a patient. Many procedural task trainers available to date suffer from several drawbacks, including unrealistic anatomy and the tendency to develop user-created &#39;landmarks&#39; after the trainer tissue undergoes repeated manipulations, potentially leading to inappropriate psychomotor skill development. To ameliorate these drawbacks, a process was created to produce a high-fidelity procedural task trainer, created from anatomy obtained from computed tomography (CT) scans, that utilize ubiquitous three-dimensional (3D) printing technology and off-the-shelf commodity supplies.
This method includes creating a 3D printed tissue mold capturing the tissue structure surrounding the skeletal element of interest to encase the bony skeletal structure suspended within the tissue, which is also 3D printed. A tissue medium mixture, which approximates tissue in both high-fidelity geometry and tissue density, is then poured into a mold and allowed to set. After a task trainer has been used to practice a procedure, such as intraosseous line placement, the tissue media, molds, and bones are reclaimable and may be reused to create a fresh task trainer, free of puncture sites and manipulation defects, for use in subsequent training sessions.

We describe a procedure to process computed tomography (CT) scans into high-fidelity, reclaimable, and low-cost procedural task trainers. The CT scan identification processes, export, segmentation, modeling, and 3D printing are all described, along with the issues and lessons learned in the process.

通过 3D 打印创建高保真、低成本、骨内线放置任务训练器

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures ...

Point-of-Care Lung Ultrasound in Adults: Image Acquisition

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally prevents direct visualization of the lung parenchyma. When showing the lung parenchyma, ultrasound typically generates a number of non-anatomic artifacts. However, over the past several decades, these artifacts have been studied by diagnostic point-of-care ultrasound (POCUS) practitioners, who have identified findings that have value in narrowing the differential diagnoses of cardiopulmonary dysfunction. For instance, in patients presenting with dyspnea, lung POCUS is superior to chest radiography (CXR) for the diagnosis of pneumothorax, pulmonary edema, lung consolidations, and pleural effusions. Despite its known diagnostic value, the utilization of lung POCUS in clinical medicine remains variable, in part because training in this modality across hospitals remains inconsistent. To address this educational gap, this narrative review describes lung POCUS image acquisition in adults, including patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

Point-of-care ultrasound (POCUS) of the lungs provides quick answers in rapidly changing clinical scenarios. We present an efficient and informative protocol for image acquisition for use in acute care settings.

成人床旁肺部超声:图像采集

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally ...

Point-of-Care Ultrasound: A Review of Ultrasound Parameters for Predicting Difficult Airways

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON method, which looks for and evaluates the Mallampati classification, signs of obstruction, and neck mobility. Clinical findings help predict a higher likelihood of difficult tracheal intubation, but no clinical result reliably excludes difficult intubation. Ultrasound as an adjunct to clinical examination can provide the clinician with a dynamic anatomical airway assessment, which is impossible with clinical examination alone. In the hands of anesthesiologists, ultrasound is becoming more popular in the perioperative period. This method is particularly applicable for identifying proper endotracheal tube positioning in specific patient populations, such as those who are morbidly obese and patients with head and neck cancer or trauma. The focus is on identifying the normal anatomy, correctly positioning the endotracheal tube, and refining the parameters that predict difficult intubation. Several ultrasound measurements are clinical indicators of difficult direct laryngoscopy in the literature. A meta-analysis revealed that the distance from the skin to the epiglottis (DSE) is most associated with a difficult laryngoscopy. An ultrasound of the airway could be applied in routine practice as an adjunct to the clinical examination. A full stomach, rapid sequence intubation, gross visual anatomical abnormalities, and restricted neck flexibility prevent using ultrasound to assess the airway. The airway evaluation is performed with a linear array transducer of 12-4 MHz, with the patient in the supine position, with no pillow, and with the head and neck in a neutral position. The central axis of the neck is where the ultrasound parameters are measured. These image acquisitions guide the standard ultrasound examination of the airway.

A point-of-care ultrasound (POCUS) is a simple, non-invasive, and portable tool that enables dynamic airway assessment. Several studies have attempted to determine the role of ultrasound parameters as an adjunct to clinical examination in predicting difficult laryngoscopies.

床旁超声:预测困难气道的超声参数综述

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON ...

Optic Nerve Sheath Point of Care Ultrasound: Image Acquisition

The goal of this protocol is to develop a standardized method for acquiring images of the optic nerve sheath and measuring the optic nerve sheath diameter (ONSD). Diagnostic ultrasound of the ONSD to detect intracranial hypertension has traditionally faced many problems because of methodologic discrepancies. Due to inconsistencies in the measuring techniques, the potential for ONSD to become a non-invasive bedside monitoring tool for ICP has been hampered. However, establishing a transparent, consistent methodology for measuring the ONSD would support its use as a valid and reliable method of identifying intracranial hypertension. This is important as it has both high sensitivity and specificity in acute care settings. This narrative review describes ONSD POCUS image acquisition, including patient positioning, transducer selection, probe placement, the acquisition sequence, and image optimization. Further, visual aids are provided to assist in real-time during image acquisition. This method should be considered for patients for whom there are concerns regarding intracranial hypertension but who do not have an intracranial monitor in place.

Point-of-care ultrasound (POCUS) of the optic nerve sheath diameter (ONSD) has been shown to be useful in identifying patients with increased intracranial pressure (ICP). However, the non-standardized technique for this POCUS has hampered its use. We present a standardized image acquisition protocol for use in the acute care setting.

视神经鞘床旁超声:图像采集

The goal of this protocol is to develop a standardized method for acquiring images of the optic nerve sheath and measuring the optic nerve sheath diameter ...

使用床旁超声对腹主动脉进行成像

An Approach to Point-Of-Care Ultrasound Evaluation of the Abdominal Aorta

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography (CT) is the current gold standard to image the abdominal aorta, the process of obtaining a CT may be time-consuming, requires the use of intravenous contrast dye, and involves exposure to ionizing radiation. Point-of-care Ultrasound (POCUS) can be performed at the bedside and has excellent sensitivity and specificity for the diagnosis of abdominal aortic aneurysm and excellent specificity for the diagnosis of abdominal aortic dissection. Additionally, POCUS is non-invasive, cost-effective, lacks ionizing radiation, requires no intravenous contrast dye, and can be performed without taking the patient from a critical care area. Screening for abdominal aortic aneurysm (AAA) can be done in primary care settings as well. 
This article will review the approach to POCUS of the abdominal aorta to evaluate such critical pathology. In this paper, we will review the sonographic anatomy of the abdominal aorta as well as the choice of the ultrasound probe, description of POCUS image acquisition, and some pearls and pitfalls of using POCUS to aid in the diagnosis of potentially life-threatening abdominal aortic pathology.

作者聚焦：使用床旁超声全面评估腹主动脉

This protocol reviews the steps to image the abdominal aorta with point-of-care ultrasound. We discuss image acquisition, troubleshooting imaging pitfalls and artifacts, and the recognition of life-threatening abdominal aortic pathology.

腹主动脉床旁超声评估方法

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography ...

使用仿真模型培训临床医生使用床旁超声

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此视频中的章节

Establishing a Multidisciplinary Cavernous Carotid Injury Simulation to Train Neurosurgical, Otolaryngology, and Anesthesia Residents

创建患者专用硅胶心脏模型，应用于术前计划和实践培训

模型外科训练: 用逼真模拟器 Fetoscopic 激光光凝单绒毛膜 Diamniotic 双胎胎盘的技能习得

通过 3D 打印创建高保真、低成本、骨内线放置任务训练器

成人床旁肺部超声:图像采集

床旁超声:预测困难气道的超声参数综述

视神经鞘床旁超声:图像采集

腹主动脉床旁超声评估方法

腹主动脉床旁超声评估方法

腹主动脉床旁超声评估方法