Intraoperative Emergencies Research Articles

3-D Brain Reconstruction by Hierarchical Shape-Perception Network From a Single Incomplete Image.

3-D shape reconstruction is essential in the navigation of minimally invasive and auto robot-guided surgeries whose operating environments are indirect and narrow, and there have been some works that focused on reconstructing the 3-D shape of the surgical organ through limited 2-D information available. However, the lack and incompleteness of such information caused by intraoperative emergencies (such as bleeding) and risk control conditions have not been considered. In this article, a novel hierarchical shape-perception network (HSPN) is proposed to reconstruct the 3-D point clouds (PCs) of specific brains from one single incomplete image with low latency. A branching predictor and several hierarchical attention pipelines are constructed to generate PCs that accurately describe the incomplete images and then complete these PCs with high quality. Meanwhile, attention gate blocks (AGBs) are designed to efficiently aggregate geometric local features of incomplete PCs transmitted by hierarchical attention pipelines and internal features of reconstructing PCs. With the proposed HSPN, 3-D shape perception and completion can be achieved spontaneously. Comprehensive results measured by Chamfer distance (CD) and PC-to-PC error demonstrate that the performance of the proposed HSPN outperforms other competitive methods in terms of qualitative displays, quantitative experiment, and classification evaluation.

Tracheostomy-Assisted Foreign Body Removal: Insights From a Case Series and Literature Review.

Foreign body aspiration into the trachea is a common occurrence in children. While most foreign bodies in the airways can be removed using rigid tracheoscopy, there are instances where tracheostomy or tracheotomy is needed. This article presents a series of cases in which tracheostomy was necessary to remove foreign bodies, and summarizes the relevant experiences and lessons learned. We reviewed a total of 7 cases in which tracheostomy and rigid tracheoscopy were combined for foreign body removal out of a larger cohort of 1559 cases at Shenzhen Children's Hospital in Guangdong, China over a 20-year period. The combined use of tracheostomy and rigid tracheoscopy resulted in successful removal of foreign bodies in all 7 patients reviewed in this study. Six patients developed complications of tracheotomy, mainly including mediastinal emphysema (5/7), subcutaneous emphysema (3/7), and pneumothorax (1/7). Tracheotomy was temporary in all patients. In cases where a foreign body in the trachea is too large or has irregular, sharp edges, is embedded in submucosal tissues with edema, cannot be passed smoothly through the vocal cords, or local endoscopic facilities are inadequate, a tracheotomy may be necessary. However, this approach should be used with caution, and close collaboration with anesthesiologists and careful management of intraoperative emergencies are crucial for improving the success rate of the procedure. Additionally, the complications should be noted, paying particular attention to early complications such as pneumothorax, pneumomediastinum, and bleeding.

Current practices in organization of anesthesia drug tray

Background: The risk of medication error is high in the operating room, since the anesthesiologist prepares, stores, and administers the medication. Poor labeling practices and cluttered drug trays increase the risk of syringe swap and medication error. Well-organized drug tray can reduce the incidence of erroneous drug administration and decrease the response time during intraoperative emergencies. Aims and Objectives: The aim of the study was to determine the attitude and practices of anesthesiologists in organizing drug trays. Materials and Methods: In the first part of the study, 30 drug trays with 209 syringes were observed before and after the procedure for 14 parameters. At the end of the procedure, a questionnaire was given to the anesthesiologists involved about their knowledge of labeling and organizing drug tray. Results: All the labels were handwritten with 139 (74.7%) syringes labeled circumferentially, and 47 (25.2%) syringes labeled vertically. Unlabeled syringes found were 23 (11.0%). Labels were legible in 168 (90.3%) syringes. Syringes were not found to be replaced in their designated place according to the template at the end of surgery in 7 (23.3%) trays. About 66.7% of anesthesiologists had experienced incorrect pickup of the syringe and 40.0% of anesthesiologists reported that they rely on other pointers apart from the label to identify the drug. Conclusion: This study identifies the variation of practices in labeling, organizing, and maintaining drug tray among anesthesiologists. Adherence to institutional protocol, eternal vigilance, and improvement in error reporting practice would minimize the incidence of medication error.

Modified Branch-first Open Repair of Thoracoabdominal Aortic Aneurysm- A Technical Description

The current conventional open TAAA repairs are performed by select centers around the world with good outcomes. However, lesser experienced centers often encounter difficulties in replicating similar results of open TAAA surgeries. The modified branch-first open repair of TAAA has shown to be effective in minimizing visceral and renal complications by providing continuous visceral blood flow throughout the procedure. By debranching the visceral vessels first, we can perform this complex aortic procedure in a more controlled manner as compared to the traditional clamp and sew technique which requires speed, precision and experience. The entire repair can be performed on beating heart by deriving native blood flow via a closed circuit or a modification of the left heart bypass and continuously perfusing the abdominal viscera, thus avoiding cardiopulmonary bypass or deep hypothermic circulatory arrest which helps minimize bleeding and overall morbidity associated with extensive TAA surgeries. Adequate pre-operative planning is imperative to prevent spinal cord complications and intra-operative emergencies.

Diagnosis and treatment strategies for intraoperative pulmonary embolism caused by renal tumor thrombus shedding

To provide an overview of techniques for prevention, immediate diagnosis, and treatment strategies of intraoperative pulmonary embolism caused by renal tumor thrombus shedding. A total of 290 patients admitted into our medical center from March 2015 to May 2021 were retrospectively analyzed. All patients underwent radical nephrectomy with tumor thrombectomy. Six patients were diagnosed as pulmonary embolism during the perioperative period, of which two patients had tumor thrombus shedding. One patient underwent thoracotomy and thrombectomy, one patient underwent interventional thrombectomy, and four patients underwent conservative treatment. All patients have gone through our diagnosis and strategy flow chart. Demographic data, tumor characteristics, tumor thrombus characteristics, and follow-up data were collected. In the preoperative risk factor assessment, of the 253 patients who entered the follow-up, 163 were women, 48 were older than 60 years old, and 83 had a duration of more than 2 months. In addition, 27 patients had tumor thrombus with bland thrombus, and 43 patients had floating tumor thrombus. 78 patients underwent postoperative anticoagulation after evaluation. The average follow-up time was 23.3 8.6 months (range, 7-31 months). All patients were alive during the follow-up period. For acute pulmonary embolism during nephrectomy and tumor thrombectomy, management strategies can be used to deal with intraoperative emergencies and provide reference.

Use of In-Situ Simulation Based Clinical Systems Test of Thoracic Robotic Surgery Emergencies.

With the advancement of robotic surgery, some thoracic surgeons have been slow to adopt to this new operative approach, in part because they are un-scrubbed and away from the patient while operating. Aiming to allay surgeon concerns of intra-operative emergencies, an insitu simulation-based clinical system's test (SbCST) can be completed to test the current clinical system, and to practice low-frequency, high-stakes clinical scenarios with the entire operating room (OR) team. Six different OR teams completed an insitu SbCST of an intra-operative pulmonary artery injury during a robot-assisted thoracic surgery at a single tertiary care center. The OR team consisted of an attending thoracic surgeon, surgery resident, anesthesia attending, anesthesia resident, circulating nurse, and a scrub technician. This test was conducted with an entire OR team along with study observers and simulation center staff. Outcomes included the identified latent safety threats (LSTs) and possible solutions for each LST, culminating in a complete failure mode and effects analysis (FMEA). A Risk Priority Number (RPN) was determined for each LST identified. Pre- and post-simulation surveys using Likert scales were also collected. The six FMEAs identified 28 potential LSTs in four categories. Of these 28 LSTs, nine were considered high priority based on their Risk Priority Number (RPN) with seven of the nine being repeated multiple times. Pre- and post-simulation survey responses were similar, with the majority of participants (94%) agreeing that high fidelity simulation of intra-operative emergencies is helpful and provides an opportunity to train for high-stakes, low-frequency events. After completing the SbCST, more participants felt confident that they knew their role during an intra-operative emergency than their pre-simulation survey responses. All participants agreed that simulation is an important part of continuing education and is helpful for learning skills that are infrequently used. Following the SbCST, more participants agreed that they knew how to safely undock the da Vinci robot during an emergency. SbCSTs provide an opportunity to test the current clinical system with a low-frequency, high-stakes event and allow medical personnels to practice their skills and teamwork. By completing multiple SbCSTs, we were able to identify multiple LSTs within different OR teams, allowing for a broader review of the current clinical systems in place. The use of these SbCSTs in conjunction with debriefing sessions and FMEA completion allows for the most significant potential improvement of the current system. This study shows that SbCST with FMEA completion can be used to test current systems and create better systems for patient safety.

Physicians' perspectives and attitudes toward surgical bailout in transcatheter aortic valve replacement

ObjectivesThe incidence of surgical bailout during transcatheter aortic valve replacement (TAVR) is ∼1%, with an associated 50% in-hospital mortality. We performed an exploratory qualitative study of TAVR team perceptions regarding routine surgical bailout planning with patients. MethodsWe developed a semistructed interview guide to explore clinician perspectives on the TAVR consent process, managing intraoperative emergencies, and involving patients in surgical contingency planning. We interviewed surgeons, cardiologists, and anesthesiologists involved with TAVR in 4 hospitals. We performed qualitative thematic analysis via independent coding of salient quotations from the transcribed texts. Codes were categorized based on shared meaning and the final themes were derived by identifying key content, and examining its relational nature. ResultsThirteen interviews were conducted, identifying 4 major themes. Participants agreed that eliciting patient preference for bailout is crucial, particularly when surgical outcome is ambiguous. In those cases, participants offered criteria for determining which patients should be engaged in a more nuanced discussion. The ethos of specialty clinicians impacted anticipation and response to procedural emergencies. Finally, physician attitudes reflected strong emotional responses to patient death/morbidity, particularly in iatrogenic injury. Participants expressed anxiety with performing TAVR without surgical backup, while also demonstrating willingness to respect patients' wishes. ConclusionsThe TAVR team supports engaging patients regarding potential surgical bailout and honoring their preferences in the event of complication. However, clinical judgment about the expected outcome of bailout would frame that discussion. Participants described the emotional weight of not pursuing bailout if indicated and the importance of good coping mechanisms.

Intraoperative Fluoroscopy for Central Venous Catheter Tip Position- "Use It When U Have It Modality"

Central venous catheters (CVC) are a vital part of an anaesthetist's armamentarium for resuscitation during intraoperative emergencies and they carry an inherent risk associated with tip malposition. Various sources recommend catheter tip position at the distant one-third of superior venecava (SVC) as ideal. Our principle concern is to place the tip above the pericardial reflection of SVC to avoid vascular erosion and consequent pericardial tamponade. There are multiple ways of ensuring that the catheter tip is in safe zone.

Protective and therapeutic experience of perioperative safety in extremely elderly patients with biliary diseases.

To explore the protective and therapeutic measures of improving perioperative safety in extremely elderly patients with biliary diseases, so as to improve the therapeutic efficacy of surgery.A retrospective case–control study of 412 elderly patients with biliary diseases was carried out from July 2013 to July 2019. Seventy eight cases were divided into the high age (HA) group (≥80 years) and 334 into the middle–low age (MLA) group (60–79 years).In the HA compared with MLA group, 1.Preoperative coexisting diseases: the occurrence of coexisting coronary heart disease (CHD), hypertension, chronic bronchitis with emphysema, hypoproteinemia, and anemia were significantly increased;2.Laboratory examinations: function of liver, kidneys, heart, lungs, and blood coagulation significantly declined;3.Surgical procedures: open cholecystectomy with transcystic common bile duct (CBD) exploration significantly higher, while laparoscopic cholecystectomy significantly lower;4.Operative effects: intraoperative blood loss, operation time, postoperative hospital stay, and length of hospitalization significantly increased or prolonged;5.Postoperative complications: postoperative respiratory failure, pulmonary infection, anemia and electrolyte disorder significantly increased;6.Therapeutic outcomes: no significant difference in the therapeutic effects.Although the surgical risk was significantly increased, there was no significant difference in the therapeutic efficacy in the HA compared with MLA group, suggesting that surgical treatment in extremely elderly patients with biliary diseases is safe and feasible. The key is to actively treat preoperative coexisting diseases, strictly adhere to surgical indications, reasonably select surgical procedures, precisely perform the operation, closely monitor and control intraoperative emergencies, timely prevent and treat postoperative complications, so as to improve the perioperative safety of extremely elderly patients with biliary diseases.

Intraoperative consultation of vascular surgeons is increasing at a major American trauma center

ObjectiveVascular surgeons are often called to aid other surgical specialties for complex exposure, hemorrhage control, or revascularization. The evolving role of the vascular surgeon in the management of intraoperative emergencies involving trauma patients remains undefined. The primary aims of this study included determining the prevalence of intraoperative vascular consultation in trauma, describing how these interactions have changed over time, and characterizing the outcomes achieved by vascular surgeons in these settings. We hypothesized that growing endovascular capabilities of vascular surgeons have resulted in an increased involvement of vascular surgery faculty in the management of the trauma patient over time. MethodsA retrospective review of all operative cases at a single level I trauma center where a vascular surgeon was involved, but not listed as the primary surgeon, between 2002 and 2017 was performed. Cases were abstracted using Horizon Surgical Manager, a documentation system used in our operating room to track staff present, the type of case, and use. All elective cases were excluded. ResultsOf the 256 patients initially identified, 22 were excluded owing to the elective or joint nature of the procedure, leaving 234 emergent operative vascular consultations. Over the 15-year study period, a 529% increase in the number of vascular surgery consultations was seen, with 65% (n = 152) being intraoperative consultations requiring an immediate response. Trauma surgery (n = 103 [44%]) and orthopedic surgery (n = 94 [40%]) were the most common consulting specialties, with both demonstrating a trend of increasing consultations over time (general surgery, 1400%; orthopedic surgery, 220%). Indications for consultation were extremity malperfusion, hemorrhage, and concern for arterial injury. The average operative time for the vascular component of the procedures was 2.4 hours. Of patients presenting with ischemia, revascularization was successful in 94% (n = 116). Hemorrhage was controlled in 99% (n = 122). In-hospital mortality was relatively low at 7% (n = 17). Overall, despite the increase in intraoperative vascular consultations over time, a concomitant increase in the proportion of procedures done using endovascular techniques was not seen. ConclusionsVascular surgeons are essential team members at a level I trauma center. Vascular consultation in this setting is often unplanned and often requires immediate intervention. The number of intraoperative vascular consultations is increasing and cannot be attributed solely to an increase in endovascular hemorrhage control, and instead may reflect the declining experience of trauma surgeons with vascular trauma. When consulted, vascular surgeons are effective in quickly gaining control of the situation to provide exposure, hemorrhage control, or revascularization.

Code Blue in the Operating Room—pharmacy is on the way!

BackgroundPharmacists have become an integrated part of the cardiac arrest (Code Blue) response team in the emergency department and inpatient settings. However, the attendance of pharmacists at intraoperative codes is less established. ObjectiveThe purpose of this paper was to describe the creation of the Perioperative Pharmacy Attendance for Intraoperative Codes Safety Initiative, report the impact it had on the intraoperative emergency code team, and discuss the limitations and difficulties experienced by the pharmacy department so that other institutions may have a foundation on which to build similar programs. Practice descriptionA large academic medical center successfully incorporated pharmacists into the intraoperative emergency code team. Practice innovationWe began by obtaining collaborative leadership support by using a quality assurance and improvement focus. In an organized manner, we methodically developed workflow protocols, educational programming, and promotional material to ensure that our initiative was able to be effectively used by the institution. Evaluation methodsA year after the implementation, clinicians evaluated the program and reported its impact on team performance. An evaluation regarding the difficulties experienced with the initiation of the program was also performed. ResultsMost clinicians stated that having pharmacists at intraoperative emergencies improved patient care as well as the code team’s performance. The difficulties experienced during the development of this program included workflow disruptions and the need for a continued effort to effectively advertise it to clinicians. ConclusionOur institution was able to create the successful Perioperative Pharmacy Attendance for Intraoperative Codes Safety Initiative. This paper describes the steps taken to create and implement this successful program as well as the integration of pharmacists into the intraoperative emergency setting.

Systems-focused simulation to prepare for COVID-19 intraoperative emergencies.

Although intraoperative emergencies are uncommon,1 we need to develop evidence-informed and contextualized guidance for intraoperative emergencies involving patients with COVID-19. At our academic pediatric hospital, we assembled a multi-disciplinary team to examine and adapt intraoperative emergency workflows to ensure safety for patients with suspected COVID-19 infection, and limit exposure for healthcare providers, with a focus on system improvement (rather than individual performance).

Perioperative Hyperoxyphobia: Justified or Not? Benefits and Harms of Hyperoxia during Surgery

The use of an inspiratory oxygen fraction of 0.80 during surgery is a topic of ongoing debate. Opponents claim that increased oxidative stress, atelectasis, and impaired oxygen delivery due to hyperoxic vasoconstriction are detrimental. Proponents point to the beneficial effects on the incidence of surgical site infections and postoperative nausea and vomiting. Also, hyperoxygenation is thought to extend the safety margin in case of acute intraoperative emergencies. This review provides a comprehensive risk-benefit analysis for the use of perioperative hyperoxia in noncritically ill adults based on clinical evidence and supported by physiological deduction where needed. Data from the field of hyperbaric medicine, as a model of extreme hyperoxygenation, are extrapolated to the perioperative setting. We ultimately conclude that current evidence is in favour of hyperoxia in noncritically ill intubated adult surgical patients.

A Digital Cognitive Aid for Anesthesia to Support Intraoperative Crisis Management: Results of the User-Centered Design Process.

BackgroundStressful situations during intraoperative emergencies have negative impact on human cognitive functions. Consequently, task performance may decrease and patient safety may be compromised. Cognitive aids can counteract these effects and support anesthesiologists in their crisis management. The Professional Association of German Anesthesiologists set up a project to develop a comprehensive set of digital cognitive aids for intraoperative emergencies. A parallel development for several software platforms and stationary and mobile devices will accommodate the inhomogeneity of the information technology infrastructure within German anesthesia departments.ObjectiveThis paper aimed to provide a detailed overview of how the task of developing a digital cognitive aid for intraoperative crisis management in anesthesia was addressed that meets user requirements and is highly user-friendly.MethodsA user-centered design (UCD) process was conducted to identify, specify, and supplement the requirements for a digital cognitive aid. The study covered 4 aspects: analysis of the context of use, specification of user requirements, development of design solutions, and evaluation of design solutions. Three prototypes were developed and evaluated by end users of the application. Following each evaluation, the new requirements were prioritized and used for redesign. For the first and third prototype, the System Usability Scale (SUS) score was determined. The second prototype was evaluated with an extensive Web-based questionnaire. The evaluation of the third prototype included a think-aloud protocol.ResultsThe chosen methods enabled a comprehensive collection of requirements and helped to improve the design of the application. The first prototype achieved an average SUS score of 74 (SD 12), indicating good usability. The second prototype included the following main revisions: 2-column layout, initial selection of patient type (infant, adult, or parturient), 4 offered search options, and the option to check off completed action steps. Its evaluation identified the following major revision points: add quick selection for resuscitation checklists, design the top bar and tabs slightly larger, and add more pictograms to the text. The third prototype achieved an average SUS score of 77 (SD 15). The evaluation of the think-aloud protocol revealed a good intuitiveness of the application and identified a missing home button as the main issue.ConclusionsAnesthesiology—as an acute medical field—is particularly characterized by its high demands on decision making and action in dynamic, or time-critical situations. The integration of usability aspects is essential for everyday and emergency suitability. The UCD process allowed us to develop a prototypical digital cognitive aid, exhibiting high usability and user satisfaction in the demanding environment of anesthesiological emergencies. Both aspects are essential to increase the acceptance of the application in later stages. The study approach, combining different methods for determining user requirements, may be useful for other implementation projects in a highly demanding environment.

Cognitive Support to Promote Shared Mental Models during Safety-Critical Situations in Cardiac Surgery (Late Breaking Report).

To address the, currently unmet, need for intra-operative safety-critical cognitive support in cardiac surgery, we have developed, validated, and implemented a series of customized checklists to address intra-operative emergencies, using a simulated operative setting. These crisis checklists are designed to provide cognitive and communication support to the operative team to reduce the likelihood of adverse events and improve adherence to best-practice guidelines. We recruited a number of content specialists including members of the hospital safety network and intraoperative cardiac surgery team members, and utilized a Delphi consensus method to develop procedure-specific guidelines for select intraoperative crises. Cardiac surgery team members were subsequently trained on utilizing the developed checklists, performed operative simulations, and were surveyed to determine checklist facility and effectiveness. We developed and validated five checklists for the following cardiac surgery crisis scenarios: (a) Cardiopulmonary Bypass Failure; (b) Systemic Air Embolism; (c) Venous Air Lock; (d) Protamine Reaction; Heparin Resistance. Upon initiation of the crisis management, a crew resource management approach was triggered. A member of the operative team was designated as the "reader" for each scenario to guide the team through the process. After training, 89% of operative team members surveyed indicated that they would like the crisis checklist to be used if they had one of these events occurring to them. Crisis management challenges members of the cardiac surgery team in reasoning accurately and according to best practice during periods of high cognitive workload and psychological stress. These crisis checklists were developed, validated, and simulated with the goal of supporting human performance and shared mental models in the clinical setting.

Malignant Hyperthermia Versus Thyroid Storm in a Patient With Symptomatic Graves Disease: A Case Report.

Malignant hyperthermia and thyroid storm are intraoperative emergencies with overlapping symptoms but different treatment protocols. We faced this diagnostic dilemma in a 25-year-old patient with symptomatic hyperthyroidism, elevated free T3 and free T4, and low thyroid-stimulating hormone from Graves disease despite treatment with propranolol 80 mg daily and methimazole 40 mg every 8 hours. During thyroidectomy, he developed hyperthermia and hypercarbia without tachycardia. When the rate of rise of PaCO2 and temperature accelerated, we treated the patient for malignant hyperthermia, a diagnosis subsequently confirmed by genetic testing.

Development of a Surgical Safety Training Program and Checklist for Conversion during Robotic Partial Nephrectomies

To evaluate the impact of standardized training and institutional checklists on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy (RAPN). Participants to a surgical team safety training program were randomly divided into 2 groups. A total of 20 emergencies were simulated: group 1 performed simulations followed by a 4-hour theoretical training; group 2 underwent 4-hour training first and then performed simulations. All simulations were recorded and scored by 2 independent physicians. Time to conversion (TC) and procedural errors were analyzed and compared between the 2 groups. A correlation analysis between the number of previous conversion simulations, total errors number, and TC was performed for each group. Group 1 showed a higher TC than group 2 (116.5 vs 86.5 seconds, P = .0.53). As the number of simulation increased, the numbers of errors declined in both groups. The 2 groups tend to converge toward 0 errors after 9 simulations; however, the linear correlation was more pronounced in group 1 (R2 = 0.75). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R2 = 0.7 and group 2, R2 = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1. OC is a rare but potentially dramatic event in the setting of RAPN, and every robotic team should be prepared to manage intraoperative emergencies. Training protocols can effectively improve teamwork and facilitate timely conversions to open surgery in the event of intraoperative emergencies during RAPN. Further studies are needed to confirm if such protocols may translate into an actual safety improvement in clinical settings.

Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion.

Video assisted thoracic surgery (VATS) has become a routinely utilized approach to complex procedures of the chest, such as pulmonary resection. It has been associated with decreased postoperative pain, shorter length of stay and lower incidence of complications such as pneumonia. Limitations to this modality may include limited exposure, lack of tactile feedback, and a two-dimensional view of the surgical field. Furthermore, the lack of an open incision may incur technical challenges in preventing and controlling operative misadventures leading to major hemorrhage or other intraoperative emergencies. While these events may occur in the best of circumstances, prevention strategies are the primary means of avoiding these injuries. Unplanned conversions for major intraoperative bleeding or airway injury during general thoracic surgical procedures are relatively rare and often can be avoided with careful preoperative planning, review of relevant imaging, and meticulous surgical technique. When these events occur, a pre-planned, methodical response with initial control of bleeding, assessment of injury, and appropriate repair and/or salvage procedures are necessary to maximize outcomes. The surgeon should be well versed in injury-specific incisions and approaches to maximize adequate exposure and when feasible, allow completion of the index operation. Decisions to continue with a minimally invasive approach should consider the comfort and experience level of the surgeon with these techniques, and the relative benefit gained against the risk incurred to the patient. These algorithms may be expected to shift in the future with increasing sophistication and capabilities of minimally invasive technologies and approaches.

Pediatric anaphylaxis in the operating room for anesthesia residents: a simulation study.

Pediatric intraoperative emergencies are rare but it is crucial for an anesthesia resident to be proficient in their management. Even the more common emergencies like anaphylaxis may not happen frequently for this proficiency to occur. Simulation increases exposure to these rare events in a safe learning environment to improve skills and build confidence while standardizing curriculum. Anesthesia residents participated in a simulated case of intraoperative pediatric anaphylaxis to evaluate knowledge and performance gaps. The study also sought to determine whether a difference exists between second- (CA2) and third-year (CA3) anesthesia residents when managing pediatric anaphylaxis and cardiopulmonary arrest. Anesthesia residents completed a standardized programmed simulation of intraoperative anaphylaxis in a 5-year old undergoing tonsillectomy and adenoidectomy. Anaphylaxis presented and progressed to bradycardia and pulseless electrical activity if anaphylaxis went unnoticed or untreated. Key time points were recorded. A scripted debriefing and written evaluation followed. Average time to diagnose anaphylaxis was 7.6min, and time to give epinephrine was 6.5min. Thirty-five percent of residents started epinephrine infusion following initial bolus. Average time calling for help between CA3 and CA2 residents was 2.5min vs 5min (P=0.01). CA3 residents verbalized a broader differential, including malignant hyperthermia and pneumothorax. Progression to pulseless electrical activity occurred in 65% of sessions prior to epinephrine being administered. No resident initiated chest compressions for bradycardia. Important performance deficits were seen in senior anesthesia residents during a simulated case of pediatric intraoperative anaphylaxis. Although CA3 performed better, deficits still existed. Anesthesia residents and training programs should partner in developing additional training recognizing anaphylaxis, pulseless electrical activity, and indication for chest compressions in a child.

Development of a rapid response plan for intraoperative emergencies: the Circulate, Scrub, and Technical Assistance Team

BackgroundUnplanned intraoperative events are inevitable and cause stress and inefficiency among staff. We believe that developing a technical rapid response team with explicitly defined, narrow roles would reduce the amount of chaos during such emergencies. This article provides a detailed description of the development and implementation of such a program. MethodsIn-situ simulation of an intraoperative emergency was used for a formal assessment of the current practice. Debriefing sessions identified areas of improvement and solicited solutions. A multidisciplinary working group then developed and implemented the technical rapid response team based on the needs assessment. The program was designed to create a Circulating, Scrubbing, and Technical Assistance Team that helps with equipment, supplies, anesthesia, and communication. ResultsWe anticipate the program will foster a culture of safety, and promote positive relationships and attitudes of the entire multidisciplinary team. ConclusionsIn the future, research regarding patient outcomes and staff satisfaction and safety attitudes may help provide objective evidence of the benefits of the program.