Evaluation einer aktuellen Handlungsempfehlung zur Narkoseeinleitung des nicht nüchternen Säuglings mithilfe eines neu entwickelten simulatorbasierten Modells

Abstract

„Evaluation of a new practice guideline for the induction of general anaesthesia of non-fasted infants using a novel simulation-based model“ Abstract In this study we evaluated a new clinical practice guideline for rapid sequence induction (RSI) of non-fasted infants as well as a new simulator-based model for the evaluation of clinical guidelines in acute medical care. Due to the absence of bag-valve mask ventilation after during the induction of anaesthesia classical RSI leads to an increased time pressure. This technique is associated with hypoxaemia in the patient and high levels of stress in the provider (Eich et al. 2009a). On the other hand stress is a potential trigger for the development of unsafe actions and critical incidences. Hence, in 2007, the Scientific Working Group for Paediatric Anaesthesia of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) published a new practice guideline for the induction of general anaesthesia of non-fasted infants (controlled RSI) (Schmidt et al. 2007; Schreiber 2007). Essential changes comprised of the planned use of gentle mask ventilation as well as the omissions of the muscle relaxant succinylcholine and the cricoid pressure. These measures were aimed to reduce time pressure and stress levels and consecutively the incidence of unsafe actions and critical incidences. For this study, we developed a simulator-based model to evaluate the new controlled RSI technique as compared to classic RSI. We combined observational methods with the measurement of stress levels and self-assessment of stress perception. Thirty male anaesthesiologists (specialists and trainees) participated in this controlled randomised study, randomly assigned to one of the two groups. Using the SimBaby® simulator each candidate completed a standardised induction of general anaesthesia in a 4-week-old infant with obstructive pyloric stenosis. The classic and controlled RSI techniques were performed by fifteen candidates each (Eich et al 2009a; Eich et al. 2009b). The scenario was programmed, including the vital signs and their progression (trends). During the course of the scenario, we observed and recorded unsafe actions and critical incidences such as hypoxaemia (SpO2 below 90%), forced mask ventilation as well as difficulties and complications of the endotracheal intubation. Additionally, the candidates‘ stress levels were measured using ergospirometry (heart and respiratory rate, respiratory minute volume, oxygen consumption, and carbon dioxide production), the analysis of cortisol and alpha-amylase in the saliva, and a self-assessment-questionnaire on subjective stress and safety perception (Eich et al. 2009A; Eich et al. 2009b). In all candidates, substantial and reproducible increases of all stress indicators were observed in the course of the scenario. During controlled RSI, measured objective stress indicators as well as the candidates’ individual perception of stress were lower as compared to classic RSI. During classic RSI, as opposed to controlled RSI, hypoxaemia occurred in all trials. The incidence of unsafe actions and critical incidences was relatively low in both techniques. In conclusion, our data show that a controlled RSI technique as compared to classic RSI, is capable to reduce stress levels in the provider and thereby to lower the incidence of unsafe actions and critical incidences (Eich et al. 2009a). The newly developed simulator-based model has shown to be a feasible and valid model for the evaluation of clinical guidelines in acute medical care (Eich et al. 2009b).