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ISIS CURRICULUM

Team Training: Unanticipated

DifficultAirway

Created: July 1, 2006Modified: May 19, 20238

Contact Information

Description of Curriculum

Target Trainees

Prerequisite Knowledge and Skills

Goals and Objectives

Instructor Notes

Common Errors & Prevention Strategies

Cognitive Training

Skill Training

Equipment Setup

Assessment Methods

Appendices

Team Training: Unanticipated Difficult Airway 2

CURRICULUM OUTLINE

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1. Contact Information

Stefan Lombaard, MDAssistant Professor

Department of AnesthesiologyBox 356540, School of Medicine

University of Washington1959 NE Pacific Street

Seattle, WA 98195Email: [email protected]

Pager: 206-559-1673

Brian K. Ross, PhD, MDProfessor




Pager: 206-998-1060

Julia Metzner, MDAssistant Professor




Pager: 206-541-4938

Megan ShermanProgram Coordinator

Institute for Surgical and Interventional SimulationBox 356410, School of Medicine



Phone: 206-598-7779

Sara Kim, PhDAssociate Director, Education and Curriculum

Institute for Surgical and Interventional SimulationBox 357240, School of Medicine

1959 NE Pacific StreetSeattle, WA 98195

Email: [email protected]: 206-616-0597


2. Description of Curriculum

Course Overview:

This course is designed to teach learner(s) to recognize and manage an airway emergency which occurs in the setting of a failed spinal anesthetic.

The patient experiences pain after the surgery has started due to the tourniquet and, as result of injudicious sedation, becomes apnoeic and starts to desaturate. The patient simulator is placed in a state where it is impossible to be ventilated or intubated. The resident should recognize the seriousness of the situation and call for help. The ‘attending anesthesiologist’ should proceed according to American Society of Anesthesiologists (ASA) unanticipated difficult intubation guidelines, and eventually perform a cricothyroidotomy.

The secondary goal will be for the more junior resident (R2) to be able to perform intrathecal anesthesia. This includes reviewing the patient history and physical examination, especially an airway examination and discussing informed consent regarding the potential benefits and risks of a spinal anesthetic including the potential for a failed regional which may require general anesthesia. They should also be able to set up and perform the procedure using the appropriate monitoring.

Educational Rationale on How the Course Generalizes to Real-Life Circumstances: A “cannot intubate and cannot ventilate” event is a rare but serious situation which can arise due to the administration of anesthetic drugs. An anesthesiologist should be able to do a thorough preoperative airway examination in order to assess the likelihood of both difficult ventilation & difficult intubation. If the situation does arise unexpectedly however, the learner should be able to deal with it appropriately.

The goal of this course is to provide the learner with an opportunity to manage a life threatening airway emergency which plays out in real time, where the correct steps need to be taken in a limited period of time. Key elements include: 1) evaluating the preoperative airway, even though the procedure is performed under a regional anesthetic (note that the difficult airway will be unrecognized), 2) recognizing the need to call for assistance early in an event, 3) being able to use various alternative techniques for airway management, and 4) optimizing resource management skills.

Duration of Training Session: 2 hours.

Frequency of Course: 6 to 10 times per year.

Number of Trainees per Session: 3-5


3. Target Trainees

Primary: Anesthesia Junior and Senior Residents

Secondary: N/A


4. Prerequisite Knowledge and Skills

Required background knowledge:

Anatomy related to placing spinal anesthesia

Drugs used for spinal anesthesia

Indications and contraindications for rapid sequence induction

Drugs used for rapid sequence induction

ASA Difficult airway algorithm

ASA Guidelines for basic monitoring

Required background skills expected in trainees prior to receiving training in the target course:

Ability to do spinal anesthesia

Airway assessment

Rapid sequence induction

Emergency airway management

Bag mask ventilation: ensure proper technique

Proper use of oral & nasal airway

Placing LMA

Performing laryngoscopy

Performing cricothyroidotomy


5. Goals and Objectives

Goal 1: Proficiency in Intrathecal AnesthesiaThe learner will gain proficiency in performing intrathecal anesthesia in a safe and professional manner. (ACGME Competencies: Medical Knowledge1, Patient Care2, Interpersonal and Communication Skills3, Professionalism4, System-based Practice5, Practice-based Learning6)

Objective 1a- Patient Assessment prior to surgery [1,2,3,4]

The learner will be expected to identify 3-5 key features that he/she would look for in a preoperative history & physical examination of a patient presenting for semi-urgent surgery. (For example: associated injuries, cardio respiratory disease, airway examination, identify risk factors for aspiration, previous anesthetic history, current medications, allergies)

Objective 1b - Informed consent [2,3,4]

The learner will list relevant risks & benefits of doing spinal anesthesia.

Objective 1c– Appropriate monitoring [1,2]

The learner should be able to describe the ASA standards for basic anesthetic monitoring requirements.

Objective 1d- Equipment setup [2]

The learner should be able to set up the equipment required to perform an intrathecal block observing aseptic technique. He/she should be able to prepare the appropriate drugs in the appropriate amount which will be used. He /she is expected to demonstrate knowledge regarding the choice of spinal needle appropriate for each situation.

Objective 1e-Demonstrate understanding of the relevant anatomy [1]

The learner should be able to delineate the landmarks for spinal anesthesia. It should be placed at L3/4 or lower.

Objective 1f-Technical skills [2]

The learner will demonstrate competence in the technique of placing a spinal anesthetic including the use of specific spinal needle. He/she should be able to place the spinal needle in a controlled way and identify the intrathecal space before injecting the anesthetic drugs.



Goal 2: Management of conscious sedationThe learner will be able to provide sedation in a safe and professional manner. (ACGME Competencies: Medical Knowledge1, Patient Care2, Interpersonal and Communication Skills3, Professionalism4, System-based Practice5)

Objective 2a- Appropriate sedation [1,2,3,4,5]

The learner will be expected to provide sedation with continuous assessment of the effects of the sedative medications on the level of consciousness and on cardiac and respiratory function.They should be prepared to convert to general anesthesia if required.

Objective 2b- Recognition of over sedation [1,2,3,4,5]

The learner should anticipate that using more sedatives and intravenous analgesia could result in progressing beyond “conscious sedation”. The patient’s level of consciousness and respiratory rate should be continually re-assessed. They should recognize when the patient becomes unresponsive to voice and eventually physical stimulation. Airway support should be started when the patient becomes apneic.



Goal 3: Dealing with an perioperative airway emergencyThe learner will become proficient in dealing with an emergency situation, which plays out in real time where the patient is rapidly desaturating and cannot be ventilated or intubated due to upper airway obstruction. (ACGME Competencies: Medical Knowledge1, Patient Care2, Interpersonal and Communication Skills3, Professionalism4, System-based Practice5, Practice-based Learning6)

Objective 3a - Airway assessment [1,2,5]

The learner will identify potential risks for a difficult ventilation and intubation.

Objective 3b – Recognize problem & call for help [3,5,6]

The learner should recognize the seriousness of the situation and call for help early.

Objective 3c – Go through the appropriate steps of the ASA difficult airway algorithm [1,5,6]

The learner should become skilled at different methods of attempting to provide ventilation. They should be able to list alternative options when a given technique fails.

Objective 3d – CricothyroidotomyThe learner should be able to demonstrate competency in performing a cricothyroidotomy in an emergency situation.

Goal 4: Familiarity with equipment available to manage an unanticipated difficult airway (Competencies: Medical Knowledge1, Patient Care2, Interpersonal and Communication Skills3, Professionalism4, System-based Practice5, Practice=based-Learning6)

Objective 4a - Bag mask ventilation[1,2]

The learner should attempt bag mask ventilation with one hand then use a two handed technique while asking an assistant to do the ventilation.

Objective 4b - Supraglottic airway devices[1,2]

The learner should be able to place oral or nasopharyngeal airway devices to facilitate bag mask ventilation.

Objective 4b - LaryngoscopyThe learner should be able to use a laryngoscope and additional devices such as a stylette, appropriately.



Goal 5: ExtubationAfter stabilizing the patient with a surgical airway, the learner should present a plan for further management of the patient. The learner should be able to discuss what they would do postoperatively when the patient is ready to be extubated. (ACGME Competencies: Medical Knowledge1, Patient Care2, Interpersonal and Communication Skills3, System-based Practice5, Practice-based Learning6)

Objective 5a – Criteria for extubation [1,5]

The learner will describe the process of assessment to ensure a successful extubation.

Objective 5b – Management of the extubation [1,2,3]

The learner should explain how he/she would safely extubate the patient including steps that would facilitate re-intubation if the patient is not able to maintain an airway or adequate ventilation.

Goal 6: Team Training and Communication SkillsThe learner will become skilled in leadership and the management of operating personnel including nurses and anesthesia technicians. (Competencies: Interpersonal and Communication Skills3, Professionalism4, System-based Practice5, Practice-based Learning6)

Objective 6a – Team Training and Communication SkillsGiven a full-scale high-fidelity simulation using a human patient simulator in which the learners are faced with an inability to maintain or secure an airway, the learner will direct available resources to manage the crisis situation prioritizing patient safety.

Goal 7: Record KeepingThe learner should be able to demonstrate the importance of accurate recording keeping during an intra-operative critical event (Competencies: Patient Care2, Professionalism4, System-based Practice5)

Objective 7a– Record Keeping Given a full-scale high-fidelity simulation using a human patient simulator in which they have to deal with an airway emergency, the learner should be able to accurately document records during the event.

1. Ensure simulation room is correctly prepared Ensure the room is set up exactly the same as the hospital setting that

the learners are used to. All routinely used equipment should be in an expected location.

Additional items, such as the code cart or difficult airway cart, should not be visible. If needed, the participants should specifically request these items.

Standard monitoring may be attached prior to the simulation session in order to save time. With junior residents, monitoring may be left unconnected to ensure proper knowledge of appropriate monitoring required for spinal anesthesia.

2. Briefing prior to simulation session Discuss capabilities of simulator: where pulses can be felt, where to

listen for breath sounds. The instructor should ensure that learners can use the monitoring

correctly (For instance, the learner should be able to start the automatic blood pressure cuff and set it to repeat the blood pressure measurement at the appropriate interval).

The instructor should discuss resources available (i.e. asking anesthesia technician for equipment, location of telephone to call for help, etc.).

The instructor should discuss any deviations from the situation they would expect in the operating room. For instance: the inhalation agent vaporizer does not have an anesthetic agent present. What is set on the vaporizer dial will reflect the depth of anesthesia.

The learner should not assume that there is a problem with the simulator if something unexpected happens. They should act as they would if this were a real patient. Everything happens in real time (i.e. a chest X-ray will not be available, instantaneously).

The instructor will establish a safe environment. Emphasizing the focus of the course is to improve their ability to deal with a crisis situation.

Discuss principles of team management, including what is expected of the team leader and team members.

Instruct learners to call out drug names and dosages, so that this can be entered in the simulation.

Trainees should sign a consent form, agreeing not to discuss performance of team members outside of the simulation environment.

We also mention that the session is recorded on video as an aid during the debriefing. We ask them to sign a consent for archiving the video. If any one of the participants is not agreeable for the video to be archived, it is destroyed at the end of the day.


6. Instructor’s Notes

3. Additional notes during session The “patient” should insist on having a spinal, citing a friend (no familial

relationship) has had complications related to general anesthesia. The spinal simulator is brought into the room when the learners are

ready to proceed with a spinal. The simulator should be in clear view of the video camera used to record the session.

We have found that some learners will persist in doing oral intubation to the extent of breaking teeth on the manikin. We have changed to using rubber teeth. The “surgeon” should watch for persistent attempts at intubation, and point out how repeated intubation attempts may traumatize the airway, making subsequent attempts more difficult.

The “patient” should respond to actions by the anesthetic team (i.e. “The mask makes me feel claustrophobic” when a mask is placed on his face, or “Ouch!” when the spinal is done). This will add to the realism of the scenario and consequently, the degree of engagement by learners.

When the learners call for a surgical airway, we bring in a cricothyroidotomy simulator. Once the surgical airway has been established, the vital signs improve and the simulation is stopped.

4. Debriefing Please refer to section B for detailed debriefing notes. Participants are accompanied to the debriefing room. A video recording

is available to review key parts of the simulation. Key points for the debriefing:

Facilitate the discussion rather than giving a lecture, Learners should discuss why they chose certain courses of action

and discuss the consequences. Ask what they would do the same or differently if they did the same scenario again,

Engage everyone in the discussion particularly quiet team members. Key topics for discussion should include:

Sedation in a patient with a full stomach, Spinal anesthesia, Doing a rapid sequence induction, Management of a "Cannot intubate, cannot ventilate" emergency.

Briefly review the ASA guidelines for managing a difficult airway. Every participant receives a copy of the current guidelines.


6. Instructor’s Notes Cont’d


7. Common Errors & Prevention Strategies

Common errors observed in trainees and strategies for helping address the errors include:

1. Failure to anticipate a potential full stomach.Review factors which can delay gastric emptying (i.e., pain drugs) Discuss the potentially catastrophic consequences of dealing with a difficult airway in the setting of aspiration.

2. Persistence of sedation when the regional is not adequate.Review the potential risks for apnea, airway obstruction & aspiration, when sedation is used to cover pain from surgery or the tourniquet, in a situation where the spinal anesthesia is clearly not adequate.

3. Fixation error: failure to advance to a different approach if one method of ventilation is not effective.The instructor will discuss the potential for causing trauma, as well as the consequences of delaying definitive management of hypoxia. Learners should be able to explain reasons why a particular technique was not successful, and then try a different approach, circumventing the problem.

4. Failure to call for help earlyThe instructor should emphasize the importance of calling for help before the problem becomes life threatening.

5. Inefficient communication & teamworka. Lack of leadership

b. Unclear or ambiguous messages

The instructor should discuss the importance of clear communication and leadership during the management of an emergent airway management scenario.

General strategies to solve the problems Increase knowledge base through assigned reading and lectures.

Keep debriefing focused to re-evaluate critical thinking and structure planning of actions.

Utilize areas for improvement as teaching points.

Promote regular simulation training as an opportunity to correct previous mistakes.


8. Cognitive Training

Key methods for delivering cognitive training include the following:

ASA Practice Guidelines for Management of the Difficult Airway (This can be accessed via:http://ww.asahq.org/publicationsAndServices/Difficult%20Airway.pdf

Instructor led overview of managing a difficult airway during the debriefing. (See Appendix B)


9. Skill Training

Participants:

Doctor #1: Attending anesthesiologist (this is usually the most senior resident – R4)

Doctor #2: Anesthesia Resident (Junior resident)Doctor #3: Available attending (This is generally the R3 resident)

Doctor #4 / Nurse #1: Circulating nurseInstructor 1: Attending anesthesiologistInstructor 2: Surgeon

Briefings:

1. The course will include a brief introduction to the simulator. Learners are asked to not disclose the details of the scenario to other residents, and also to refrain from discussing each other’s performance outside of the simulation environment.

2. Review capabilities of simulator: Breath sounds - where to listen, make them listen Heart sounds Blood pressure - can take manual BP, how to start NIBP Pulse - where to feel Voice Emphasize that when a drug is administered, the person giving it should

clearly state the name & dose of the drug. Do not assume that something is wrong with the simulator if a problem occurs.

3. Review equipment in room: Set the scene – the patient has been pre-assessed and is in the operating

room. Emphasize everything that occurs is actually happening. Address any questions?

4. Doctor #2 will be asked to wait in the lounge.

6. The patient should be anxious and complain about pain as the learners enter the room. The patient should request more sedation.

7. The surgeon should prep & drape the field after the spinal block is established, and then proceed with mock surgery. He or she will be unable to perform surgical airway if requested but may be of assistance for any other tasks.


9. Skill Training-Continued

The Case:

Act #1: Simulation room: Handover

Instructor #1 will be the attending anesthesiologist originally assigned to anesthetize the patient. He/she has already pre-assessed the patient and has discussed performing a spinal anesthetic with the patient.

Instructor #1 will hand over care of the patient to all participants, except Doctor #2. Doctor #1 (“Attending”) & Doctor 2 (“Resident”) will need to introduce themselves to the patient and confirm the pre-assessment by completing a focused history & examination including airway assessment. The two will need to discuss how they would go about performing spinal anesthesia including IV access, monitoring equipment, emergency drugs & emergency equipment, etc.

Act #2: Simulation room: Spinal

Rhythm: sinusHR: 83 bpmBP: 150/90Sat: 96%RR: 20/min

This will be done using the spinal simulator. The learner should describe the steps he/she will complete, as if this were a real patient. He/she should set up a spinal tray and then perform a spinal. The learner should be able to describe pertinent anatomy.(If the residents are junior, the instructor would go through the correct procedure for setting up the tray.)

The trainee will identify: What drugs Combinations of drugs Dosage


Act #3: Sedation

Rhythm: sinus O2 Sat98%HR: 60 bpm RR 18/minBP: 110/60 ETCO2 21mmHg (Connected to O2 mask)

IV line in situECG, Pulse oximeter & NIBP in situO2 Mask on face with ETCO2 sample line attached

The “Patient”

Awake, anxious, requesting sedation (Is this going to hurt, what is happening, what are you giving me etc.)

Block level is to T12, unable to move legs.

The surgeon places a tourniquet, preps & drapes field & (eventually) starts operating.

After a period the patient starts complaining of pain in his leg related to the tourniquet and requests more sedation until he becomes unresponsive and apnoeic.

The events should be the same if the resident does a rapid sequence intubation.

Trigger for Act 4 is sedation / rapid sequence inductionArbitrary cutoff: midazolam > 5mg, fentanyl > 200mcg, propofol > 100mg or propofol infusion




START TIMER

Act #4: Time 0-4 minutes: Can’t intubate / can’t ventilate

Rhythm sinusHR 80 ramp up to 120 bpmBP 150/95 ramp up to 170/100O2 Sat 95% ramp to 90% over 3 min

then down to 80% over 1 minRR apneaETCO2 0 mmHg

Airway Inflate tongue & larynx

If the resident calls for help bring in Doctor #3.

If requested: the surgeon is unable to do a tracheotomy.

The difficult airway cart is available on request.

Attempts to manually ventilate & intubate should be unsuccessful.

When a cricothyroidotomy is in place and the patient is being ventilated, proceed to Act #8

Act #5: Time 4-6 minutes: Deteriorating oxygenation

Rhythm sinusHR 120 bpm ramp down to 30bpm + ventricular ectopic beatsBP 170/100 ramp down to 64/35O2 Sat 90% ramp down to 60%RR apneaETCO2 0 mmHg


Act #6: Time6+ minutes: Catastrophic deterioration

Rhythm sinus with runs of VTHR 30 bpmBP 64/35O2 Sat 60%RR 0/minETCO2 0 mmHg

Act #7: Cricothyroidotomy

Rhythm sinusHR ramp to 90 bpmBP ramp to 140/95O2 Sat ramp up to 95% over 3 minutesRR 15/minETCO2 70 mmHg

Act #8: Further management questions

Would you continue the case?How would you manage extubation?


Room Set-Up:

The simulation room is prepared to simulate a real operating room environment, which has been prepared by an anesthesia technician:

SimMan on OR table, awake & breathing spontaneously Anesthesia machine at head end of bed and turned on Anesthesia circuit connected with mask Anesthesia cart with airway equipment, drugs and patient history &

physicalStandard monitoring connected: ECG, Pulse oximeter & blood pressure cuff

IV line in situ

Equipment: Spinal Simulator Spinal tray with drugs Surgery equipment incl. drapes, tourniquet Patient History and Physical Sheet on Clip Board Anesthesia Machine Code cart (hidden or outside OR) Difficult Airway Kit (hidden or outside OR)

Please refer to Appendix D for detailed list of items required.


10. Equipment Setup


11. Assessment Methods

Type(s) of Assessment Methods Used in This Course

Pre-test Only Team Evaluation

Pre-test + Post-test Team Debriefing Evaluation

Post-test Only Instructor Evaluation Form

Performance Checklist Simulation Experience Evaluation Form

Appendix A Admissions History and Physical

Appendix B Debriefing questions

Appendix C Suggested clinical questions

Appendix D Equipment set-up

Appendix E Performance checklistAppendix F Team evaluation formAppendix G Simulation evaluation form

Appendix H Content and Instructor evaluation formAppendix I ReferencesAppendix J Scenario flowchart


12. Appendices


History: 55yr old male. Slipped & fell on his way to work. He has a fractured R ankle requiring open reduction & internal fixation. He has had 10mg of IV morphine in the ER for analgesia. They have also applied a temporary splint. Last meal 07:00, Accident happened @ 09:00

PMH:DM – diet controlledHypertension (controlled on Rx)High cholesterolAnxietyOccasional reflux after meals

Medications:Clonazepam 0.5mg nocteFelodipineRanitidine 150mg bd

Social:Occasional alcoholEx smoker. 30 pack year history.

No allergies.

No prior surgery. No family history of anesthesia related complications. However a close friend has died under general anesthesia.

Examination:

VITAL SIGNS: Pulse 90 bpm, BP 155/95, oxygen saturation 96% on room air. He weighs 94 kg and is 175cm tall.

GENERAL: He is a fit looking male, uncomfortable from pain in his leg, but otherwise in no distress.

CARDIOVASCULAR: S1, S2 regular with no murmur.

LUNGS: Clear to auscultation all fields.

ABDOMEN: Soft, nontender, nondistended. Bowel sounds present. No hepato- or splenomegaly.

AIRWAY: Malampati III, Thyromental distance 6 cm. Good mouth opening. Cx spine: full range of motion. Normal teeth.

The patient is extremely anxious. He has heard that general anesthesia is dangerous and insists on the procedure being performed under spinal anesthetic.

Appendix A: Admission History and Physical


Debriefing Questions. General points:The Basic Assumption for the debriefing is:We believe that everyone participating in the simulation scenario is intelligent, well-trained, cares about doing their best, and wants to improve.

Critique the performance, not the individual Ask open ended questions – avoid yes/no questions

Framework for debriefing:A. Reactions

Clear the air and set the stage for discussion Facts

1) What happened? Participants often want to know "the answer" Stick to the facts

2) How did you feel about that? Accept expressions of feelings

- Acknowledge is not the same as agree - Try to mirror feelings rather then evaluate them - Don't tell participants "that's OK" when it may not be

Give perspective if participant feelings are hurt. e.g.:- I've seen this a dozen times and that happens nearly every time ... or- I've made the same mistake ... or- We all make mistakes and this is a good place to learn from them or ...- Remind them of the Basic Assumption and say that we’ll work together

to figure out what happened ... or ...

B. UnderstandingRemember to use Advocacy-Inquiry: be curious!

Exploring Applying Generalizing

1) Exploring What were you thinking at the time? It looked to me like …..

(Use this to discuss some error you observed and would like to find out why the student chose a particular course of action)

How do you account for that? Why did that happen? What led to it? What next?

2) Applying What drug or procedure or behavior might be best? Have you ever done this clinically? How might this be reflected in your clinical practice?

3) Generalizing Have you ever seen anything similar to this in your practice? Are there analogies to the clinical world? What can be done in analogous situations?

Appendix B: Debriefing Questions


C. Summary Review what was learned and ensure the single scenario is put into a larger context.1) Relate this experience to higher level principles, e.g., principles of

teamwork, circulation and respiration, patient safety, etc. 2) What did you do well? 3) What would you do differently?

Specific crew resource management topics to discuss using this template:

1. Team leader’s performance: Was a team leader clearly identified? Were team members assigned to do specific tasks assigned

appropriately? Did he/she maintain awareness of the big picture? i.e. not

sidetracked Did the most life threatening issues get dealt with first?

A B C Did he/she allow team members to participate in the decision

making process? Were there any communication problems? i.e. not addressing

specific person, no parroting, miscommunication Did he/she use other resources appropriately i.e. non anesthesia

personnel?2. Team members:

Did he/she clearly communicate critical information to the team leader & other team members?

Did he/she request assistance if unable to complete task/during task overload?

Good communication: closed loop communication/parrot back, clarify instructions, verbalize activities

3. Group performance: Was everyone involved in the crises? Were there any fixation errors? Were there any conflicts? If so, was it resolved? Did the team address new emergent events effectively? What communication problems did we see?

- Get person’s attention- Make eye contact- Use names if possible- Parrot requests and responses- Use cross-checks and ‘call-outs’

Handover:- S – Situation:

I need you NOW for an airway emergency- B – Background:

55yr old male; failed spinal for ankle surgery; rapid sequence induction

- A – Assessment:can’t intubate can’t ventilate

- R – Recommendationneed help with airway management

Appendix B: Debriefing Questions (cont.)


Specific clinical management topics (i.e. issues from checklist which were missed):

1. Any issues doing spinal?2. Escalating sedation requirements3. Option for dealing with a failed regional technique4. Was a rapid sequence induction done due to full stomach?5. Discuss contraindications for a rapid sequence induction such as a known

difficult airway. (In this scenarion, there is nothing to suggest a difficult airway.)6. Any deviations from the difficult airway algorithm?7. Was someone assigned to record events during the crises? This person can

watch for repeated intubation attempts. Attempts should not last longer than 30 seconds and the recorder can help by notifying the anesthesiologist when the intubation time exceeds 30 seconds.The recorder is particularly useful in this scenario however it is often forgotten even it there is suffient personnel available.

8. Were there any fixation errors i.e. persisting with intubation / placing LMA?9. Was a surgical airway established in a timely fashion?

Additional topics:

1. What would your further management of the patient have been? i.e. talk to family, ICU care, extubation, etc.

2. Did it feel real? How can we improve this scenario?

3. Review importance of accurate record keeping, review the record – lapses in vital signs, drugs administered.

Appendix B: Debriefing Questions (cont.)


Anesthesia Knowledge

a. Review definition of difficult: Ventilation Intubation Laryngoscopy

b. How would you assess the potential for: Difficult bag mask ventilation? Difficult intubation?

c. How would either of these influence what you do?

d. Review ASA difficult airway algorithm

e. Discuss what equipment is useful or not useful in this particular situation

f. Review closed claims recommendation – don’t delay proceeding to surgicalairway if all else fails, have plan B [Management of the Difficult Airway - A Closed Claims Analysis: Anesthesiology 2005; 103:33–9]

Anesthesia Skills

a. Spinal anesthesia – techniqueb. Rapid sequence inductionc. Bag mask ventilation: ensure proper techniqued. Proper use of oral & nasal airwaye. LMAf. Laryngoscopyg. Cricothyroidotomy

Case Hand-Over

Essential elements of an adequate case hand-over

Intra-operative Communication

a. Essential elements of routine intra-operative communication:- Eye-contact, parroting responses, conveying urgency

b. Essential elements of intra-operative critical event communication – with nurses, surgeons, ancillary help

- Eye-contact, parroting responses, conveying urgency

Appendix C: Suggested Clinical Questions


Spinal Simulator LP simulator set up with water

Spinal needles: 22G, 24G, 25G, 27G

Introducer needle

Regional tray (unopened)

Chlorhexidine solution

Gloves

Drugs Bupivacaine

(2cc 0.75% with dextrose, 20cc 0.5% plain, 20cc 0.25% plain)

Lidocaine (30cc 1% plain, 5cc 2% plain)

Setup the spinal simulator in the room with SimMan

Anesthesia Machine SimMan in hospital gown, on OR bed (head on ‘donut’)

Voice

IV pole

IV line in situ

Monitoring: NIBP, EKG, Oxygen saturation probe

Gas analysis: End tidal CO2 monitoring

Propofol syringe pump

Full oxygen cylinder on machine

Ambu bag-mask system

Gloves

O2 Mask

Suction

Temperature probe

Emergency drugs

Antibiotics

ECG dots

Routine OR monitors

APPENDIX D: Equipment Set Up


Anesthesia Machine (continued)

IV in arm with fluid line attached

Suction canister with Yanker tip

Propofol infusion line

Full oxygen cylinder with flow meter

Surgery Drapes

Tourniquet

Patient History and Physical Sheet on Clip Board

Drugs Anesthesia cart fully supplied

Propofol (10 mg/ml) 20 ml syringe X 2

Fentanyl (50 mcg/ml) 5ml syringe X 3

Midazolam (1 mg/ml) 2 ml syringe X 1

Etomidate (2mg/ml) 10 ml syringe X 2

Ketamine (10mg/ml) 20ml syringe X 1

Succinylcholine (20mg/ml) 10ml in 20ml syringe X 2

Rocuronium (10mg/ml) 5ml syringe X 2

Kefzol (1 gm/250 ml) syringe X 1

Ephedrine (5mg/ml) 5ml in 10ml syringe X 1

Phenylephrine (200mcg/ml) 10 ml syringe

Atropine (0.4mg/ml) 2.5ml in a 5 ml syringe

Code cart – in operating room, fully stocked

Vasopressin / Epinephrine Amiodarone / Lidocaine Adenosine – 5 ml syringes (2 mg/ml) X 2 Ambubag Gloves

APPENDIX D: Equipment Set Up (cont.)


Difficult Airway Kit

Combitube (This may not be available)

LMA’s sizes 3, 4 & 5

Intubating LMAs sizes 3, 4 & 5

Endotracheal tubes size 6.5, 7.0 7.5, 8.0

Different laryngoscope blades

Macintosh 3 & 4

Miller 2 & 3

Fiber optic scope

Oral airways (green, yellow, red)

Nasal airways (28, 32, 34)

Introducer / stylet

Eschmann Stylet / Gum elastic bougie

Cricothyroidotomy kit

Retrograde kit

Jet ventilation system

Lighted stylet

Lubricant

APPENDIX D: Equipment Set Up (cont.)


APPENDIX E: Performance Checklist

Pre-Op Assessment, Anesthesia Planning & Spinal

_____Confirm Id: Patient’s name

_____Patient’s procedure

_____Patient’s allergies

_____Patient’s medications – emphasis on anticoagulation meds

_____Patient’s medical problems incl. bleeding tendencies

_____Assess potential for full stomach

pain / opioids / time between last meal & accident

_____Other injuries

_____Airway examination*

_____Verify consent

_____Ensure adequate IV

_____Prepare equipment for spinal

_____Appropriate monitoring

_____Appropriate emergency equipment & drugs

_____Use iliac crest to identify L4

_____Appropriate skill in placing spinal

_____Appropriate dose of local anesthetic for level of surgery

Sedation

_____No escalation of sedation – full stomach

_____Stop surgery / release tourniquet

_____Proceed to RSI*

_____Proper RSI technique


APPENDIX E: Performance Checklist (cont.)

Upper airway obstruction

_____100% O2*

_____Call for help*_____Brief description of problem

_____Attempt bag mask ventilation* – one person

_____Attempt bag mask ventilation – two person

_____Use oral / nasal airway

_____Attempt LMA

_____Attempt intubation not more than 2 X

_____Do not repeat failed technique* – change something ie different blade,

optimize position

_____Call for difficult airway cart*

_____Proceed to surgical airway*

_____Review plan for end of case (i.e. to PACU or ICU, extubation)

_____Appropriate use of resources ie can surgeon perform surgical airway

Upper airway obstruction

_____100% O2*

_____Call for help*_____Brief description of problem

_____Attempt bag mask ventilation* – one person

_____Attempt bag mask ventilation – two person

_____Use oral / nasal airway

_____Attempt LMA

_____Attempt intubation not more than 2 X

_____Do not repeat failed technique* – change something ie different blade,

* Bold items are critical steps


APPENDIX F: Team Evaluation Form

Date: Team MembersTime: Evaluator:

RatingStrongly Disagree / Strongly Agree 1-5N/A: n/a

Team leader:

1. Command authority / leader clearly recognized by team members. 1 2 3 4 5 n/a2. Maintains situational awareness – do not get

side tracked, reassess situation. 1 2 3 4 5 n/a3. Assign team members appropriately 1 2 3 4 5 n/a4. Prioritize appropriately 1 2 3 4 5 n/a5. Engage team members in decisions 1 2 3 4 5 n/a6. Good communication i.e. address specific persons

when requesting info or assigning tasks. 1 2 3 4 5 n/a7. Monitors actions of team members 1 2 3 4 5 n/a8. Balance team workload 1 2 3 4 5 n/a9. Resource management i.e. use non anesthesia

personnel. 1 2 3 4 5 n/a10. Appropriate handover / description of problem to new attending. 1 2 3 4 5 n/a

Team member:1. Clear understanding of his/her role. 1 2 3 4 5 n/a2. Verbalize observations/errors/critical info. 1 2 3 4 5 n/a3. Ask for assistance if unable to complete

task/during task overload. 1 2 3 4 5 n/a4. Good communication: closed loop

communication/parrot back, clarify instructions,verbalize activities. 1 2 3 4 5 n/a


Group:1. Everyone involved in crises. 1 2 3 4 5 n/a2. Avoid fixation errors. 1 2 3 4 5 n/a3. Resolves conflicts/disagreements. 1 2 3 4 5 n/a4. Roles are shifted to address urgent or

emergent events, when appropriate. 1 2 3 4 5 n/a

Overall assessment for each participant:

This person functioned as an effective team leader or team member : 1 2 3 4 5 n/a

APPENDIX F: Team Evaluation Form


APPENDIX G: Simulation Experience Evaluation Form

Rating:Strongly disagree strongly agree 1-5NA 0

Simulation Evaluation

1) Learners should spend more time working in the simulator 1 2 3 4 5 n/a

2) The course enhanced my understanding of how to handle critical incidents situations and crisis 1 2 3 4 5 n/a

3) The simulation was an effective educational tool1 2 3 4 5 n/a

4) The simulation experience provides a realistic model of working in a clinical setting 1 2 3 4 5 n/a

5) The debriefing session was an important learning opportunity1 2 3 4 5 n/a

6) What issue(s) would you like addressed in future simulation sessions?__________________________________________________________________________________________________________________________

7) Comments:_____________________________________________________________


Rating:Strongly disagree strongly agree 1-5NA 0

Content Evaluation1) The content was:

a) Current 1 2 3 4 5 n/ab) Best practice 1 2 3 4 5 n/ac) Free of bias 1 2 3 4 5 n/ad) Relevant to my practice 1 2 3 4 5 n/a

2) I will change my practice based on the i) information presented 1 2 3 4 5 n/a

3) The educational level of this activityi) was appropriate 1 2 3 4 5 n/a

4) The most important concept learned during this session that may contribute to a change in patient care is:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Instructor Evaluation

1) The instructor had a good command of the content 1 2 3 4 5 n/a2) The instructor’s presentation was clear & concise 1 2 3 4 5 n/a3) The instructor clearly demonstrated the required

skills 1 2 3 4 5 n/a4) The instructor created a safe environment for

the debriefing 1 2 3 4 5 n/a5) The instructor was an effective facilitator 1 2 3 4 5 n/a6) The instructor feedback was helpful 1 2 3 4 5 n/a 7) Overall, the instructor contributed to my learning 1 2 3 4 5 n/a8) Comments:

__________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________

APPENDIX H: Content and Instructor Evaluation Form


1. Practice Guidelines for Management of the Difficult Airway: Anesthesiology 2003; 98:1269–77http:// www.asahq.org/publicationsAndServices/Difficult%20Airway.pdf

2. Miller, CG: Management of the Difficult Intubation in Closed Malpractice Claims. ASA Newsletter 64(6):13-16 & 19, 2000

3. Management of the Difficult Airway - A Closed Claims Analysis: Anesthesiology 2005; 103:33–9

4. Standards for Basic Anesthetic Monitoring (Approved by ASA House of Delegates 10/21/86 and last amended 10/27/04)

5. ASA Guidelines for Regional Anesthesia in Obstetrics (Approved by the ASA House of Delegates on October 12, 1988, last amended on October 18, 2000)

6. Malec JF, Torsher LC, Dunn WF, Wiegmann DA, Arnold JJ, Brown DA, Phatak V: The Mayo High Performance Teamwork Scale: Reliability and Validity for Evaluating Key Crew Resource Management Skills. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2(1):4-10, Spring 2007.

APPENDIX I: References


Appendix J: Scenario flow sheet (1)


Appendix J: Scenario flow sheet (2)

ISIS Curriculum Outline · Web viewAnatomy related to placing spinal anesthesia Drugs used for...

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