Emotionality and heightened anxiety during medical simulation encounters have been hypothesized to contribute to improved cognition and learning, but the overall stress "dose response curve" of experiential learning remains unclear. We sought to (1) identify the degree and time course of physiologic stress induced in physicians by simulation-based training (SBT), when compared with a traditional tutorial-based interactive-education training (IET) and (2) compare differences in stress responses to simulation activities among pediatric provider groups. Twenty-seven gastroenterology physicians were randomized among six crisis resource management courses taught by SBT versus IET. Eleven RNs and four technicians participated in the SBT exercises. Heart rate (HR) and salivary cortisol (SC) levels were measured in all participants at four time points before, during, and after participation in the SBT sessions and at two time points before and after the IET sessions. Physicians who underwent SBT (n = 13) demonstrated increased tachycardia at the end of the session (+17 beats/min), when compared with those in the IET group (n = 14) who demonstrated an overall negative response (-4 beats/min, P = 0.001). Similarly, physicians in the SBT group demonstrated increased SC (+0.140 μg/dL, 70% over baseline), when compared with physicians in the IET group who had a median decrease in SC (-0.015 μg/dL, 20% under baseline, P = 0.001). There were similar increases in HR in all participants after SBT, but technicians experienced a relatively smaller increase in SC compared with physicians and nurses. After high-fidelity SBT within the gastroenterology suite, clinicians independent of their role demonstrated increased physiologic stress levels-as measured by HR and SC levels-compared with traditional IET sessions. The study provides novel calibration data compared with a traditional baseline for future investigations aimed at further understanding the dose-response curve of simulation-based experiences to optimize emotionality, cognition, and learning.

Summary: Emergence delirium is a significant problem in children regaining consciousness following general anaesthesia. We compared the emergence characteristics of 120 patients randomly assigned to receive a single intravenous dose of dexmedetomidine 0.3 μg.kg ⁻¹ , propofol 1 mg.kg ⁻¹ , or 10 ml saline 0.9% before emerging from general anaesthesia following a magnetic resonance imaging scan. Emergence delirium was diagnosed as a score of 10 or more on the Paediatric Anaesthesia Emergence Delirium scale. The incidence of emergence delirium was 42.5% in the dexmedetomidine group, 33.3% in the propofol group and 41.5% in the saline group (p = 0.671). Three patients in the dexmedetomidine group, none in the propofol group and two in the saline group required pharmacological intervention for emergence delirium (p = 0.202). Administration of neither dexmedetomidine nor propofol significantly reduced the incidence, or severity, of emergence delirium. The only significant predictor for emergence delirium was the time taken to awaken from general anaesthesia, with every minute increase in wake‐up time reducing the odds of emergence delirium by 7%.

Active ‘hands-on’ participation in the ‘hot-seat’ during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as ‘hot-seat’ participants despite experiencing lower stress. We randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen ‘hot-seat’ trainees actively participated in all three scenarios, and 19 ‘observer’ trainees were directed to observe the first two scenarios and participated in the ‘hot-seat’ only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist’s Non-Technical Skills (ANTS) Score. Mean SC increased in all participants whenever they were in the ‘hot-seat’ role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were −0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the ‘hot-seat’ (40.0) and ‘observer’ (39.4) groups in scenario 3 (p = 0.733). Observers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the ‘hot-seat’. Our findings suggest that directed observers may benefit from immersive SBT even without repeated ‘hands-on’ experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional ‘hot-seat’ role, potentially rendering SBT accessible to a wider audience. ClinicalTrials.gov Identifier NCT02211378 , registered August 5, 2014, retrospectively registered.