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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
LETTER TO EDITOR  
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 539-541
Role of simulation in hemodynamic monitoring in cardiac surgery


1 Deparment of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India
2 Deparment of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana, India

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Date of Web Publication6-Jul-2016
 

How to cite this article:
Singh A, Mehta Y. Role of simulation in hemodynamic monitoring in cardiac surgery. Ann Card Anaesth 2016;19:539-41

How to cite this URL:
Singh A, Mehta Y. Role of simulation in hemodynamic monitoring in cardiac surgery. Ann Card Anaesth [serial online] 2016 [cited 2019 Nov 12];19:539-41. Available from: http://www.annals.in/text.asp?2016/19/3/539/185559


The Editor,

Simulation-based health-care education has expanded tremendously over the past few years, as witnessed by the creation and growth of the Society for Simulation in Healthcare. [1] By definition, simulation is a technology to replace, or amplify real patient experiences with guided experiences, artificially contrived which evokes or replicates substantial aspects of the real world in a fully interactive manner. [2]
Simulation-based learning can be helpful to develop health-care professional's knowledge, skills, and attitudes while protecting patients from unnecessary risks. Health-care simulators offer four main purposes - education, assessment, research, and health system integration in facilitating patient safety. Commonly used medical simulators are of virtual reality [Figure 1], screen-based [Figure 2], and mannequin-based/or realistic types, and they are quite varied in characteristics and fidelity (accuracy). [3]
Figure 1: Virtual reality simulator

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Figure 2: EV1000 screen-based simulator

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Since cardiovascular disease is intimately linked to cardiovascular hemodynamics, accurate assessment of the patient's hemodynamic state is critical for the diagnosis and treatment of heart disease. Unfortunately, while a variety of invasive and noninvasive approaches for measuring cardiac hemodynamics is in widespread use, they still only provide an incomplete picture of the hemodynamic state of a patient. In this context, computational modeling of cardiac hemodynamics presents as a powerful noninvasive modality that can fill this information gap and significantly impact the diagnosis as well as the treatment of cardiac disease.

Simulations allow us to practice virtual hemodynamic stabilization of a patient in both a surgical and Intensive Care Unit environment. After undergoing a successful cardiac surgical repair, the patient may have complications of depressed myocardial contractility, bleeding, or hypotension in addition to many other complications. Simulators provide us with the option of choosing one of the three shock case scenarios: Cardiogenic shock, hypovolemic shock, and septic shock. One may use a combination of fluid/diuretics and inotropes/vasodilators to ensure that all vital signs (heart rate, blood pressure, and cardiac index) are maintained within acceptable limits.

Diagnostic information

The chest drain will provide a visual indication of blood loss. The fluid balance sheet indicates the fluid intake and output including the hematocrit. Poor urine output may be a sign of low cardiac index. Cold extremities indicate peripheral vasoconstriction, which may also be a sign of low cardiac index. This clinical sign is shown in the simulation by the limbs becoming progressively pale and blue. If the myocardial perfusion pressure (diastolic pressure - left atrial pressure) becomes <20 mmHg, the myocardium will become ischemic, causing further depression of contractility and the electrocardiogram will display elevated ST segments. The cardiac index can be measured, and a Starling curve plotted to illustrate the relationship between myocardial filling, contractility, and stroke volume index. A chest X-ray may be ordered if tamponade is suspected. Interventions include a variety of fluids and drugs, options of temperature control, cardiac pacing, or return to operating room if bleeding is excessive or tamponade is suspected.

Pulmonary artery catheter simulator is a screen-based program that allows users to insert the catheter, advance the catheter, and inflate the balloon to obtain a wedge pressure. Transesophageal/transthoracic echocardiography simulator allows the user to insert, advance, withdraw, flex, or rotate the probe to obtain multiple views transecting the heart in various planes. [6],[7] The ultrasound image on the screen is adjusted on real time to match the probe's position. The mannequin simulator package is also available, and it can create stepwise learning process from basic information to advanced clinical application.

Simulation-based training has also been shown to enhance physician's performances during weaning from cardiopulmonary bypass. [4] Immersive training focusing on nontechnical skills are believed to be superior to passive discussion in traditional interactive teaching seminars. By providing a surrounding mimicking both the standardized process and dynamic crisis, high-fidelity simulation improves active memorization and enhances appropriate behaviors in real life while sparing patients from potential harm. [8]

In addition, the hemodynamic data obtained from the flow simulation can be directly used to investigate the flow patterns as well as clinically important variables such as pressure gradients, wall shear stresses, and vortex propagation. [5] To conclude, the proliferation of three/four-dimensional imaging technologies, increasing computational speeds, improved simulation algorithms, and the widespread availability of powerful computing platforms is enabling simulations of cardiac hemodynamics with unprecedented speed and fidelity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Issenberg SB. The scope of simulation-based healthcare education. Simul Healthc 2006;1:203-8.  Back to cited text no. 1
[PUBMED]    
2.
Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004;13 Suppl 1:i2-10.  Back to cited text no. 2
    
3.
Mehta Y, Jain R, Shastri N. Simulation in hemodynamic monitoring. In: Kapoor PM, editor. Clinical Simulation in Medicine. New Delhi: Jaypee Brothers Medical Publishers; 2016. p. 211-5.  Back to cited text no. 3
    
4.
Bruppacher HR, Alam SK, LeBlanc VR, Latter D, Naik VN, Savoldelli GL, et al. Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. Anesthesiology 2010;112:985-92.  Back to cited text no. 4
    
5.
Mittal R, Seo JH, Vedula V, Choi YJ, Liu H, Huang H, et al. Computational modeling of cardiac hemodynamics: Current status and future outlook. J Comput Phys 2016;305:1065-82.  Back to cited text no. 5
    
6.
Tempe DK, Batra UB, Datt V, Tomar AS, Virmani S. Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation. Annals of Cardiac Anaesthesia 2015;18:491-4.  Back to cited text no. 6
    
7.
Hakata S, Ota C, Kato Y, Fujino Y, Kamibayashi T, Hayashi Y. An analysis of the factors influencing pulmonary artery catheter placement in anesthetized patients. Annals of Cardiac Anaesthesia 2015;18:474-8.  Back to cited text no. 7
    
8.
Morozowich ST, Ramakrishna H. Pharmacologic agents for acute hemodynamic instability: Recent advances in the management of perioperative shock - A systematic review. Annals of Cardiac Anaesthesia 2015;18:543-54.  Back to cited text no. 8
    

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Correspondence Address:
Ajmer Singh
Deparment of Critical Care and Anaesthesiology, Medanta - The Medicity, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.185559

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