Role of simulators in anesthesia practice

Speaker- Dr. Sangeeta

Moderator- Dr. Surendra Kumar

• Simulation refers to the artificial replication of sufficient elements of a real-world domain to achieve a stated goal

Goals

1. understanding the domain better.

2.training personnel to deal with the domain.

3. testing the capacity of personnel to work in the domain.

Fidelity

• refers to how closely it replicates the domain.

• It is determined by the number of elements that are replicated and the discrepancy between each element and the real world.

• Preparation for warfare had helped in development of simulation technologies, especially for aviation, shipping, and the operation of armored vehicles . Commercial aviation has also contributed

History

• The first anaesthesia simulator, SIM1, was described in 1969 by Denson and Abrahamson.

• Developed as a an aid in learning to intubate and to induce anesthesia

• Consist of mannequin with intubatable airway, upper torso and arms

• In mid 1980’s computer based simulator were developed like “SLEEPER AND BODY”.

• In 1986 Gaba and DeAnda, developed a full-scale simulator called the Comprehensive Anesthesia Simulation Environment (CASE) to study the decision-making processes of anaesthetists during critical events.

• Gaba, Fish and Howard refined CASE to be used in the development of the Anesthesia Crisis Resource Management (ACRM) course.

• Drs Michael Good and JS Gravenstein developed the Gainesville Anesthesia Simulator (GAS), which later became the prototype for the Medical Education Teachnologies Inc (METI) simulator.

• Team Oriented Medical Simulation (TOMS), developed in 1994 by Helmreich, Schaefer and colleagues at the University of Basel

Applications

• Education

• Training

• Research

• Risk management and public relations

• Performance assessment

CLASSIFICATION OF PATIENT SIMULATORS

1. mannequin-based simulators(full-scale simulator, hands-on simulator, realistic simulator,high-fidelity simulator)

2. screen-only or screen-based simulator ("microsimulator").

3. virtual reality simulator

Components of a Patient Simulator

• A set of outputs make up a representation of the patient, the clinical environment, and diagnostic and therapeutic equipment.

• control logic- changes in the simulated patient's condition can be generated, controlled, and sent to the appropriate output of the representation.

Types • 1. software as a fixed sequence of events.• 2. manual control logic allows scripting of combinations of

changes in control input .• 3. mathematical differential equations model a patient's

physiology and pharmacology to provide the bulk of the control logic.

• 4. finite-state models- instructor initiation of abnormal events, and even manual modulation of modeled parameters

• instructor/operator's station (IOS) --allows the instructor to create specific patients, select and implement abnormal events and faults, and monitor the progress of the simulation session.

Prototypic example of a simulation center

Mannequin-Based Simulators (Realistic, Full-Scale, High-Fidelity "Macro" Simulators)

• In 1986, Gaba and DeAnda began developing the Comprehensive Anesthesia Simulation Environment (CASE) with a primary goal of conducting research into decision making by anesthetists

• CASE used a commercially available mannequin modified to enable occlusion of the left main stem bronchus, infusion of CO2 insertion of intravenous lines.

This mannequin allowed mask ventilation, intubation, and auscultation of breath sounds,but it did not have palpable pulses or spontaneous ventilation and lack physiologic and pharmacologic models

• CASE extensively used in anesthesia crisis resource management (ACRM) training program

High-fidelity patient simulator system (MedSim Eagle Patient Simulator). The mannequin is in middle and is the interface of trainees with the simulation. from left to right: opened simulator

chest with fully functional lungs, pneumatic systems, sensors, and electronics cables; eyes with movable lids andreactive controllable pupils; and interface cart with gas analyzer and servo control boards. Lower pictures from left to

right: interface cart with built-in network personal computer, umbilical cords from the interface cart to themannequin, clinical monitoring and the main simulation workstation, and interface cart with noninvasive blood

pressure simulator (NIBP) for oscillometric measurements.

• These high fidelity patient simulator is completely operated by physiologic, pharmacologic and finite-state models with detailed models of cardiovascular, pulmonary, fluid, acid-base-electrolyte,

and thermal physiology.

Gainesville Anesthesia Simulator (GAS)and METI Human Patient Simulator

• An interesting component of the Gainesville Anesthesia Simulator (GAS) was an anesthesia machine modified to incorporate a variety of mechanical faults that could be triggered electronically.

• Also featured a complex, quantitatively accurate physical simulation of multiple gas exchange.

• lung concentrations of O2 , N2 O, N2 , and one volatile anesthetic could be physically made to match the alveolar gas content predicted by a mathematical model of gas exchange and anesthetic uptake and distribution.

• GAS further developed by Medical Education Technologies, Inc. (METI, Sarasota, FL). Now called the Human Patient Simulator (HPS) it also uses full physiologic and pharmacologic mathematical models.

• METI offers a child-sized mannequin (PediaSim) that has the same functionality as the adult model

• can be controlled by the same base computer and IOS. Recently, METI released a more mobile and much less expensive simulator called "Emergency Care Simulator (ECS)."

The METI Human Patient Simulator. The mannequin rests on a standard ICU bed. Interface and linkagehardware is contained in a separate cart. A loudspeaker in the headrest provides the "patient's voice" to allow the

mannequin to act as a "standardized patient."

The METI instructor/operator's station (IOS) allows full control over the model-based physiology andpharmacology of the "patient." The numbers over the mannequin show the status of all physiologic

variables of themodel (e.g., blood gases, cardiocirculatory parameters). At the IOS more than one patient can be run

at a time and dynamically allocated to different mannequins.

Laerdal SimMan

• Laerdal (Stavanger, Norway) manufacturer of basic life support and advanced cardiac life support training devices ranging from cardiopulmonary resuscitation mannequins to mega-code training stations

• Introduced SimMan simulator in 2000 • it uses a virtual monitor rather than clinical monitoring

systems.• SimMan's control logic is provided by direct instructor

control of individual data values and settings• augmented by a script-based control logic (i.e., there are

no mathematical models)

The SimMan mannequin (Laerdal) during trauma resuscitation training. The mobility and advanced airway features with some manual task training possibilities (such as chest

tube placement, manual blood pressure measurements) make this type of simulator well suited for training sessions outside simulation centers.

Desirable features of future mannequin-based• Advanced skin signs such as Change in skin color to cyanotic or pale Diaphoresis Change in skin temperature (e.g., as a result of shock or fever) Rash, hives, or generalized edema• Regurgitation, vomiting, airway bleeding or secretions• Physical coughing (currently only sounds are simulated)• Convulsions• Purposeful movements of extremities• Support for spinal, epidural, or other regional anesthesia procedures• EEG signals (e.g., for BIS, AEP)• Intracranial pressure• Support for physical central venous cannulation• Fetal/maternal cardiotocogram (CTG)• A fully interactive simulator of a neonate or infant

Screen-Based Simulators

• SLEEPER and BODY• SLEEPER used complex transport model to deal with

gas exchange and drug distribution. Predict concentration of drugs in specific anatomic region (myocardium)

• Anesoft Anesthesia simulator- Anesthesia simulator consultant (ASC) - provides graphic representations of mock monitoring displays and clinical equipments, also photographs to display patient and actions taken on it.

-Uses pharmacokinetic and pharmacodynamic models.

Virtual Reality Simulators

• Virtual reality refers to a set of techniques in which one interacts with a synthetic ("virtual") environment that exists solely in the computer

• The actions of the user in the environment are translated directly from typical physical activities, not through manipulating a special pointing device

complete virtual reality patient simulator would be very complicated because it requires--

1. A complete computer model of the patient, the environment, and the function of every object in the environment that could be used (e.g., monitoring devices, carts)

2. A means of tracking visual, audio, and touch fields of the user to determine what is to be displayed and to identify what physical actions are being performed

3. Appropriate display hardware for every sensory modality and appropriate input hardware for each action pathway (e.g., touch, speech)

4. Hardware to compute all the models, to conduct the tracking, and to produce all the output to the display hardware in real time

virtual reality is still under development.

ANESTHESIA CRISIS RESOURCE MANAGEMENT (ACRM)

Key points in anesthesia crisis resource management (ACRM)• Know the environment• Anticipate and plan• Call for help early• Exercise leadership and followership• Distribute the workload• Mobilize all available resources• Communicate effectively• Use all available information• Prevent and manage fixation errors• Cross (double) check• Use cognitive aids• Re-evaluate repeatedly• Use good teamwork• Allocate attention wisely• Set priorities dynamically

The ACRM curriculum uses several teaching modalities to achieve these goals, including

1. A comprehensive textbook on anesthesia crisis management (Crisis Management in Anesthesiology)

2. A brief presentation reviewing the principles of ACRM and anesthesia safety.

3. Analysis of a videotape of an aviation accident. 4. Small group exercises analyzing a videotape of an

actual anesthetic mishap or analyzing written or video presentations about difficult cases.

5. Several hours of complex multifaceted realistic simulations in which training participants rotate through different roles, including primary anesthesiologist, first responder (called "cold" with no knowledge of the situation), and scrub nurse. Other personnel play the roles of surgeons, nurses, and technicians as in a real OR. Each situation is followed by a detailed debriefing with video feedback.

Use of Patient Simulation for Training Health Care Personnel outside Anesthesia

• The ICU

• The emergency department or trauma center

• The delivery room

• Cardiac arrest response teams

• Radiology• Field response by ambulance staff and combat casualty

care in the military• training for the management of chemical, biologic,

nuclear threats from accidents, weapons of mass destruction or terrorism.

Realistic patient simulation for studying the performance of medical rescue teams in full chemical protection gear. Teams wore normal uniforms or full protection suits while performing basic resuscitation

actions

In rescue situations with full protective gear, communication within the team and with the patient is

difficult.

USE OF PATIENT SIMULATION IN SUPPORT OF BIOMEDICAL INDUSTRIES

• Numerous centers offer training to executives and sales representatives of equipment and pharmaceutical manufacturers.

• simulator allows these individuals to gain some understanding of the clinician's task demands

during patient care and the situations in which their company's drugs or devices could be useful.

• Simulators used to train the manufacturer's representatives and clinicians in safe use of the drug.

• to conduct research on human factors issues in the development of new monitoring and therapeutic devices.

• It was possible to train anesthetists in the application of remifentanil with the simulator, even before remifentanil was approved by the Food and Drug Administration in the United States

OTHER USES• Some centers use simulators for conducting "outreach"

programs with high-school or college students interested in health care.

• Simulators used to produce educational videotapes on various patient safety issues.

• Used as adjuncts in medicolegal proceedings. • Can be used to illustrate typical perioperative situations

and the role of different monitors and therapeutic actions• Nontechnical skills assessment-

- Cognitive and mental skills, including decision making, planning, and situation awareness

- Social and interpersonal skills with aspects of team working, communication, and leadership

EFFECTIVENESS OF SIMULATION TRAINING

simulation has many advantages as a training tool.1. There is no risk to a patient.2. Exercises in routine procedures can be repeated intensively,

whereas situations and events involving uncommon, but serious problems can be presented at will.

3. Participants can learn to use actual complex devices (with a hands-on simulator).

4. The same situation can be presented independently to multiple subjects for evaluating individual or group performance.

5. Errors can be allowed to occur that in a clinical setting would require immediate intervention by a supervisor.

6. The simulation can be frozen to allow discussion of the situation and its management, and it can be restarted or begun anew to demonstrate alternative techniques.

7. Recording, replay, and critique of performance are facilitated because patient safety or confidentiality is not an issue.

Research issues that can be addressed by using anesthesia simulators

• Cognitive Science of Dynamic Decision Making• Human-Machine Interactions• Teaching Anesthesia in the Operating Room How much teaching can be accomplished in the operating room

without sacrificing the anesthesia crew's vigilance? How well can faculty detect and categorize the performance of

anesthesia trainees? What teaching styles are best integrated with case management in

the operating room?• Issues of Teamwork How does the anesthesia crew (attending plus resident or certified

registere nurse anesthetist pair) interact during case and crisis management?

How is workload distributed among individuals? How do crew members communicate with each other, and how do

they communicate with other members of the operating room team?

• Effects of Performance-Shaping Factors on Anesthetist Performance

How do sleep deprivation, fatigue, aging, or the carryover effects of over-the-counter medications, coffee, or alcohol affect the performance of anesthetists?

• Intelligent Decision Support

Can smart alarm systems or artificial intelligence provide correct and clinically meaningful decision support in the operating room or intensive care unit?

• Development of new devices and applications

• Research Regarding the Technique of Simulation Itself

FUTURE OF PATIENT SIMULATION IN ANESTHESIA

Patient simulators have emerged from their purely experimental phase to become an accepted, though still new component of research and training in health care.

It is highly likely that simulators will become a regular part of the initial and recurrent training of most anesthetists and many other clinicians.

The anesthesia community can be proud of its pioneering role in developing patient simulation technology and simulation-based training curricula.

As this process continues, it is also likely that anesthetists will continue to lead the rest of health care in the evolution of this technology and its educational, research, and evaluation applications

Refrences

Miller’s Anaesthesia, 6th ed. International Practice of Anaesthesia. Prys-Roberts.

Recent advances Chopra V, Gesink BJ, deJong J, Bovill JG, Spierdijk J, Brand R.

Does training on an anaesthesia simulator lead to improvement in performance? Br J Anaesth 1994; 73: 293-7.

Morgan PJ, Cleave-Hogg D, McIlroy J, Devitt JH. A comparison of experiential and visual learning for undergraduate medical students. Anesthesiology 2002; 96: 10-16.

Nyssen AS, Larbuisson R, Janssens M, Pendeville P, Mayne A. A

comparison of the training value of two types of anesthesia simulators: computer screen-based and mannequin-based simulators. Anesth Analg 2002; 94: 1560-5.

Yee B, Naik V, Joo HS et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology 2005; 103: 241-8.