Perioperative Critical Events Research Articles

Crisis checklist for critical event debriefings: Findings from a mixed-methods study

BackgroundPerioperative critical events (e.g., anaphylaxis, cardiac arrest) are common life-threatening emergencies across health systems but may be infrequent at the level of the individual clinician. Proximal debriefing shortly after such events has been promoted in the medical literature and via simulation, however the gap between principle and practice is poorly understood. We sought to study the patterns and components of these debriefs based on real-life events. MethodsIn this observational mixed-methods study, anesthesia providers in perioperative care areas and intensive care units from an academic medical center who recently experienced a perioperative critical event were queried regarding patterns of critical event debriefing and invited to participate in a semi-structured interview. We measured the types and location of critical events, rate of debriefing, and supporting themes surrounding the event. ResultsOver a six-month period, 81 critical events were queried, of which 28 (35 %) were debriefed. Common events included significant/prolonged hypotension and/or hypoxemia (33 %), cardiac arrest (27 %), and massive hemorrhage (21 %). Common event locations included operating room (70 %), nonoperating room anesthesia (10 %), and intensive care unit (7 %). Of the events queried, 51 events had a semi-structured interview. The themes for an ideal debriefing aligned with the themes of performing a Welfare check, assessing Acute corrections, soliciting Team reactions, allowing for medical Education, and providing supportive Resources. ConclusionOne-third of perioperative critical events were proximally debriefed. Themes from involved anesthesiology personnel revealed desirable components of a practical and brief real-time proximal debriefing. A checklist encompassing a review of the literature, multidisciplinary expertise, and lessons from this mixed-methods work has the potential to improve the quantity and quality of debriefing that is often absent in the aftermath of a perioperative critical event.

End organ perfusion and pediatric microcirculation assessment.

Cardiovascular instability and reduced oxygenation are regular perioperative critical events associated with anesthesia requiring intervention in neonates and young infants. This review article addresses the current modalities of assessing this population's adequate end-organ perfusion in the perioperative period. Assuring adequate tissue oxygenation in critically ill infants is based on parameters that measure acceptable macrocirculatory hemodynamic parameters such as vital signs (mean arterial blood pressure, heart rate, urinary output) and chemical parameters (lactic acidosis, mixed venous oxygen saturation, base deficit). Microcirculation assessment represents a promising candidate for assessing and improving hemodynamic management strategies in perioperative and critically ill populations. Evaluation of the functional state of the microcirculation can parallel improvement in tissue perfusion, a term coined as "hemodynamic coherence". Less information is available to assess microcirculatory disturbances related to higher mortality risk in critically ill adults and pediatric patients with septic shock. Techniques for measuring microcirculation have substantially improved in the past decade and have evolved from methods that are limited in scope, such as velocity-based laser Doppler and near-infrared spectroscopy, to handheld vital microscopy (HVM), also referred to as videomicroscopy. Available technologies to assess microcirculation include sublingual incident dark field (IDF) and sublingual sidestream dark field (SDF) devices. This chapter addresses (1) the physiological basis of microcirculation and its relevance to the neonatal and pediatric populations, (2) the pathophysiology associated with altered microcirculation and endothelium, and (3) the current literature reviewing modalities to detect and quantify the presence of microcirculatory alterations.

A Prospective Randomized Controlled Pilot Simulation Study to Investigate the Effect of Audiovisual Decision Support on Diagnosis and Therapeutic Interventions.

Combining audiovisual decision support during perioperative critical events might enhance provider diagnostic and therapeutic accuracy and efficiency. This study is a prospective, randomized controlled pilot trial studying the impact of audiovisual decision support on anesthesia professional performance at NorthShore University HealthSystem's high fidelity simulation center. Twenty anesthesia professionals (>2 years of clinical experience in the current role) were randomized to 2 groups (current care model vs. audiovisual assistance) and underwent 3 periprocedural simulation scenarios, where patient deterioration occurs: anaphylaxis, amniotic fluid embolism, and cardiac arrest during dental case. Overall, there was a statistically significant decrease in the mean and median pooled times to diagnosis in both the amniotic fluid embolism and pediatric dental scenarios. There was a statistically significant increase in the number of participants in the intervention group who made diagnosis 3 before the end of the scene (P = 0.03) in the amniotic fluid embolism case. In the pediatric dental case, there was a statistically significant reduction in the median time to diagnosis 1 and diagnosis 3 in the intervention group versus control (P = 0.01 and P = 0.0002). A significant increase in the number of participants in the intervention group versus control made the correct diagnosis 2 before vital sign change 3 (P = 0.03), and more participants in the intervention group made the correct diagnosis 3 before the end of the scene when compared with control (P = 0.001). The median time to start intervention 2 during the dental case was statistically significantly greater in the intervention group versus the control (P = 0.05). All other endpoints were not statistically significant among the 3 simulation scenarios. Six questions were answered by all participants upon immediate completion of the simulation scenarios and revealed that 19 of 20 participants had delivered anesthesia care to patients similar to the 3 simulation scenarios and 18 of 20 participants reported that they would prefer audiovisual assistance to detect abnormalities in vital signs that subsequently provides appropriate diagnostic and therapeutic options. This pilot study suggested some significant improvement in anesthesia professional time to correct diagnosis and completion of identification of the correct diagnosis before the next vital change in the audiovisual cue group versus control, particularly in the outpatient dental case. In addition, the mean and median pooled times to diagnosis were significantly reduced by approximately 1 minute in both evaluated simulation scenarios. The postsimulation survey responses also suggest the desirability of an audiovisual decision support tool among the current anesthesia professional participants. However, overall, there were no significant differences in the time to intervention between groups in all simulation scenarios.

PHARMACOGENETIC ASPECTS OF THE USE OF PERIOPERATIVE DRUGS IN PEDIATRICS. Review

Relevance. It is known that in children the frequency of perioperative critical events due to the introduction of drugs is more than 5%. For example fentanyl, which is used as an adjunct to surgical anesthesia, is a major factor in increasing the number of deaths from opioid overdoses. Among the areas of reducing the frequency of severe adverse reactions to perioperative drugs - taking into account the pharmacogenetic variations of the patient.
 Objective is to consider current data on pharmacogenetic aspects of pharmacokinetics and pharmacodynamics of perioperative drugs.
 Methods. Analysis of the data presented in PubMed by keywords "pharmacogenetics", "general anesthetics", "analgesics", "muscle relaxants", "children". Search depth – 7 years (2014-2020), with a retrospective deepening of some positions until 2002.
 Results. The pharmacogenetic aspects of the pharmacokinetics of perioperative drugs are related to the genes of the enzymes that metabolize them and their transporters. Current data on the prevalence of polymorphic alleles of CYP2C9 genes (provides metabolism of nonsteroidal anti-inflammatory and anticonvulsant drugs) and CYP2D6 (metabolizes opioids, antidepressants, antiemetics) in Europe and, in particular, in Ukraine were presented. Thus, the inactive allele CYP2C19 * 2 was found in 13%, while the allele of increased activity CYP2C19 * 17 - in 25% of the population of Ukraine; allele with lost CYP2D6 function (CYP2D6 * 4) - in 18.6% of Ukrainians. Homozygotes with CYP2C9 * 3 polymorphism metabolize nonsteroidal anti-inflammatory drugs much more slowly than wild-type carriers, which may lead to their accumulation and side effects. The analgesic effect of codeine occurs only after it is metabolized in the liver by CYP2D6 to morphine. Respiratory depression, apnea and death may occur in patients with excessive metabolic rate even after a single dose of codeine; however, was noted the ineffectiveness of ondansetron due to a decrease in its concentration in the blood in thesepatients. Concomitant use of midazolam and fentanyl may prolong the effect of fentanyl by competing metabolism of midazolam by the hepatic enzyme CYP3A4, especially in patients with low metabolism. Plasma butyrylcholinesterase deficiency reduces succinylcholine inactivation in 1 in 1,500 people. Changing the genotype of uridine diphosphate glycosyltransferase causes increased glucuronidation of morphine, which may lead to a decrease in its effectiveness. As an example of pharmacogenetic changes in pharmacodynamics can be considered malignant hyperthermia, which occurs due to exposure to volatile anesthetics and depolarizing muscle relaxants in mutations in the RYR1 gene. Carriers of the minor allele (G) of the 5HT2A rs6313 gene require less propofol and 40% less time to start induction of anesthesia.
 Conclusions. The efficacy and safety of perioperative drugs are largely related to the pharmacogenetic aspects of their pharmacokinetics, especially mutations in genes of enzymes of the metabolism. Mutations in the genes of volatile anesthetic receptors and depolarizing muscle relaxants when their used cause a risk of malignant hyperthermia. The application of pharmacogenetics is the need to titrate drugs that have significant variability of action depending on the genotype. It is advisable to avoid the use of drugs with a high risk of pharmacogenetic reactions, if other alternative drugs are available.

Use of a High-Fidelity Patient Simulator to Introduce an Evidence-Based Emergency Manual into Certified Registered Nurse Anesthetist Practice

Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia care to thousands of patients each year. Despite increased anesthetic safety, low-frequency, high-risk perioperative critical events still occur. Although CRNAs have been expected to rely on memory alone to manage the spectrum of these critical events, the use of an emergency manual (EM) may improve CRNA performance. At one Army community hospital, recent experiences with similar critical events led to the development of the following question: Will the use of high-fidelity simulation training with the staff CRNAs on the use of EMs produce both increased performance in key tasks and positive satisfaction scores related to the use of the emergency manual during critical events now and in the future? Twenty staff CRNAs participated in high-fidelity simulated scenarios involving low-frequency, high-risk critical events before and after training on the use of an EM based on a change strategy developed by Goldhaber-Fiebert and Howard in 2012. Changes in performance after training were evaluated using a tool designed by Arriaga et al. Before EM training, CRNAs completed 46.05% of key tasks in the simulated scenario. After EM training, CRNAs completed up to 94.02% of key tasks in simulated scenarios. The observed increase in the completion of key tasks by CRNAs during simulated critical events after EM training and increase in satisfaction scores demonstrates how a well-constructed training program facilitates the implementation of an evidence-based EM into practice and can improve the quality and consistency of CRNA performance during low-frequency, high-risk perioperative events.

Perioperative critical events and morbidity associated with anesthesia in early life: Subgroup analysis of United Kingdom participation in the NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective multicenter observational study.

BackgroundThe NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective observational study reported critical events requiring intervention during 35.2% of 6542 anesthetic episodes in 5609 infants up to 60 weeks postmenstrual age. The United Kingdom (UK) was one of 31 participating countries.MethodsSubgroup analysis of UK NECTARINE cases (12.8% of cohort) to identify perioperative critical events that triggered medical interventions. Secondary aims were to describe UK practice, identify factors more commonly associated with critical events, and compare 30‐day morbidity and mortality between participating UK and nonUK centers.ResultsSeventeen UK centers recruited 722 patients (68.7% male, 36.1% born preterm, and 48.1% congenital anomalies) undergoing anesthesia for 876 surgical or diagnostic procedures at 25–60 weeks postmenstrual age. Repeat anesthesia/surgery was common: 17.6% patients prior to and 14.4% during the recruitment period. Perioperative critical events triggered interventions in 300/876 (34.3%) cases. Cardiovascular instability (16.9% of cases) and/or reduced oxygenation (11.4%) were more common in younger patients and those with co‐morbidities or requiring preoperative intensive support. A higher proportion of UK than nonUK cases were graded as ASA‐Physical Status scores >2 or requiring urgent or emergency procedures, and 39% required postoperative intensive care. Thirty‐day morbidity (complications in 17.2%) and mortality (8/715, 1.1%) did not differ from nonUK participants.ConclusionsPerioperative critical events and co‐morbidities are common in neonates and young infants. Thirty‐day morbidity and mortality data did not demonstrate national differences in outcome. Identifying factors associated with increased risk informs preoperative assessment, resource allocation, and discussions between clinicians and families.

Contextualizing the Content of Clinical Communications: A Learning Point

Suboptimal communication or inadequate exchange of important clinical information can be peculiarly perilous in subspecialties like cardiac anesthesia that are characterized by a highly predisposed working environment.[1] [2] [3] While the fraternity acknowledges an effective communication to be at the cornerstone of minimizing the susceptibility to avoidable perioperative critical events, as George Bernard Shaw aptly puts it: the major problem with communication is precisely the illusion that it has taken place.[1] [4]

Critical event debriefing: a checklist for the aftermath.

Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal critical event debriefing. Evidence-based key processes to consider for proximal critical event debriefing can be summarized by the WATER mnemonic: Welfare check (assessing team members' emotional and physical wellbeing to continue providing care); Acute/short-term corrections (matters to be addressed before the next case); Team reactions and reflections (summarizing case; listening to team member reactions; plus/delta conversation); Education (lessons learned from the event and debriefing); Resource awareness and longer term needs [follow-up (e.g. safety/quality improvement report), local peer-support and employee assistance resources]. A cognitive aid to accompany this mnemonic is provided with the publication. There is growing literature on how to conduct proximal perioperative critical event debriefing. Evidence-based best practices, as well as a cognitive aid to apply them, may help bridge the gap between theory and clinical practice. In this era of increased attention to burnout and wellness, the consideration of interventions to improve the quality and frequency of critical event debriefing is paramount.

Anesthesia for children with complete trisomy 18 (Edwards syndrome): A cohort review of 84 anesthesia encounters in nine patients.

Trisomy 18 or Edwards syndrome is the second most common aneuploidy with a prevalence between 1/3000 and 1/10000 live births. The syndrome encompasses malformations of the central nervous, cardiac, respiratory, gastrointestinal, and genitourinary systems. Trisomy 18 carries a poor prognosis with 90% of patients not surviving beyond 1year of age; however, the current trend toward more aggressive supportive care may prolong survival. The limited anesthesia literature highlights the abnormal airway anatomy but generally describes uneventful airway management and perioperative course. Our goal was to review all anesthesia encounters recorded for eleven trisomy 18 patients treated at Children's Wisconsin during the study period to explore the frequency of anesthesia encounters and to improve our understanding of the perioperative risks. We performed a retrospective chart review of all patients with trisomy 18 who were treated at our institution between 2012 and 2017. Records were screened for anesthesia encounters, perioperative critical events and complications, enrollment in palliative care, code status, and time of death. Eleven children were identified. Children were born between 2001 and 2016. Two children never required anesthesia care. Nine patients had a total of 84 anesthesia encounters for 121 surgical or diagnostic procedures or emergent intubations. Critical events and perioperative complications included difficult mask ventilation (n=7), difficult intubation (n=15), and mechanical or pharmacological cardiopulmonary resuscitation (n=6). Five patients presented with difficult peripheral intravenous access. One patient died in the immediate postoperative period. On five occasions, patients required emergent intubation outside of the operating room. Difficult airway management and respiratory compromise were critical concerns during the perioperative period in our patient population, and the inability to ventilate could lead to cardiorespiratory arrest. This case series provides a comprehensive, longitudinal view of complete trisomy 18 patients in the perioperative period and adds information for counseling families and care providers.

Critical Event Debriefing

Safety Tip of the Month| August 2020 Critical Event Debriefing ASA Monitor August 2020, Vol. 84, 13. https://doi.org/10.1097/01.M99.0000695128.46328.c6 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Critical Event Debriefing. ASA Monitor 2020; 84:13 doi: https://doi.org/10.1097/01.M99.0000695128.46328.c6 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: debriefing Critical event debriefing is valued in medicine for its role in education and learning (JAMA 2014;312:2333-4; Anesthesiology 2014;120:160-171; Circulation 2018;138:e82-e122; Arch Intern Med 2008;168:1063-9), quality assurance (Qual Saf Health Care 2005;14:e25), multidisciplinary team training (Ann Surg 2014;259:403-10), and many other domains. It has also been embraced by other high-stakes industries (Cureus 6: e174). Perioperative critical events (such as massive hemorrhage, anaphylaxis, or cardiac arrest) can be both rare to the individual provider and common (in aggregate) across large health systems (N Engl J Med 2013;368:246-53). This combination only adds to the potential impact these events can have on perioperative teams. A growing body of research suggests that only a fraction of actual perioperative critical events are followed by any form of debriefing (Anesthesiology 2019;130:1039-48). While the barriers to debriefing can vary (e.g., production pressure, limited... You do not currently have access to this content.

Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application.

When life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists-the Pedi Crisis 2.0 application-as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above "excellent" overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology.

Incidence of peri-operative paediatric cardiac arrest and the influence of a specialised paediatric anaesthesia team: Retrospective cohort study.

Peri-operative critical events are still a major problem in paediatric anaesthesia care. Access to more experienced healthcare teams might reduce the adverse event rate and improve outcomes. The current study analysed incidences of peri-operative paediatric cardiac arrest before and after implementation of a specialised paediatric anaesthesia team and training programme. Retrospective cohort study with before-and-after analysis. Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany. A total of 36 243 paediatric anaesthetics (0 to 18 years) were administered between 2008 and 2016. Implementation of a specialised paediatric anaesthesia team and training programme occurred in 2014 This included hands-on supervised training in all fields of paediatric anaesthesia, double staffing for critical paediatric cases and a 24/7 emergency team. A logistic regression analysis with risk factors (age, ASA physical status, emergency) was used to evaluate the impact of implementation of the specialised paediatric anaesthesia team. Incidences of peri-operative paediatric cardiac arrest and anaesthesia-attributable cardiac arrest before and after the intervention. Twelve of 25 paediatric cardiac arrests were classified as anaesthesia-attributable. The incidence of overall peri-operative paediatric cardiac arrest was 8.1/10 000 (95% CI 5.2 to 12.7) in the period 2008 to 2013 and decreased to 4.6/10 000 (95% CI 2.1 to 10.2) in 2014 to 2016. Likewise, the incidence of anaesthesia-attributable cardiac arrest was lower after 2013 [1.6/10 000 (95% CI 0.3 to 5.7) vs. 4.3/10 000 (95% CI 2.3 to 7.9)]. Using logistic regression, children anaesthetised after 2013 had nearly a 70% lower probability of anaesthesia-attributable cardiac arrest (odds ratio 0.306, 95% CI 0.067 to 1.397; P = 0.1263). For anaesthesia-attributable cardiac arrest, young age was the most contributory risk factor, whereas in overall paediatric cardiac arrest, ASA physical statuses 3 to 5 played a more important role. In this study on incidences of peri-operative paediatric cardiac arrest from a European tertiary care university hospital, implementation of a specialised paediatric anaesthesia team and training programme was associated with lower incidences of peri-operative paediatric cardiac arrest and a reduced probability of anaesthesia-attributable cardiac arrest.

Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study).

The anaesthesia practice in children observational trial of 31,127 patients in 261 European hospitals revealed a high (5.2%) incidence of severe critical events in the peri-operative period and wide variability in practice. A sub-analysis of the UK data was undertaken to investigate differences compared with the non-UK cohort in the incidence and nature of peri-operative severe critical events and to attempt to identify areas for quality improvement. In the UK cohort of 7040 paediatric patients from 43 hospitals, the overall incidence of peri-operative severe critical events was lower than in the non-UK cohort (3.3%, 95%CI: 2.9-3.8 vs. 5.8%, 95%CI: 5.5-6.1, RR 0.57, p<0.001). There was a lower rate of bronchospasm (RR 0.22, 95%CI: 0.14-0.33; p<0.001), stridor (RR 0.42, 95%CI: 0.28-0.65; p<0.001) and cardiovascular instability (RR 0.69, 95%CI: 0.55-0.86; p=0.001) than in the non-UK cohort. The proportion of sicker patients where less experienced teams were managing care was lower in the UK than in the non-UK cohort (10.4% vs. 20.4% of the ASA physical status 3 and 9% vs. 12.9% of the ASA physical status 4 patients). Differences in work-load between centres did not affect the incidence and outcomes of severe critical events when stratified for age and ASA physical status. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk patients in the UK. Areas for quality improvement include: standardisation of serious critical event definitions; increased reporting; development of evidence-based protocols for management of serious critical events; development and rational use of paediatric peri-operative risk assessment scores; implementation of current best practice in provision of competent paediatric anaesthesia services in Europe; development of specific training in the management of severe peri-operative critical events; and implementation of systems for ensuring maintenance of skills.

The effect of an electronic cognitive aid on the management of ST-elevation myocardial infarction during caesarean section: a prospective randomised simulation study

BackgroundCognitive aids have come to be viewed as promising tools in the management of perioperative critical events. The majority of published simulation studies have focussed on perioperative crises that are characterised by time pressure, rare occurrence, or complex management steps (e.g., cardiac arrest emergencies, management of the difficult airway). At present, there is limited information on the usefulness of cognitive aids in critical situations with moderate time pressure and complexity. Intraoperative myocardial infarction may be an emergency to which these limitations apply.MethodsAnaesthetic teams were allocated to control (no cognitive aid; n = 10) or intervention (cognitive aid provided; n = 10) groups. The primary aim of this study was to compare cognitive aid versus memory for intraoperative ST-elevation myocardial infarction (STEMI) management in a simulation of caesarean delivery under spinal anaesthesia. We identified nine evidence-based metrics of essential care from current guidelines and subdivided them into mandatory (high level of evidence; no interference with surgery) and optional (lower class of recommendation; possible impact on surgery) tasks. Six clinically relevant tasks were added by consensus. Implementation of these steps was measured by scoring task items in a binary fashion (yes/no). The interval between the diagnosis of STEMI and the first contact with the cardiac catheterisation lab was measured. To determine whether or not the cognitive aid had prompted an action, participants from the cognitive aid group were interviewed during debriefing on every single treatment step. At the end of the simulation, session participants were asked to complete a survey.ResultsThe presence of the cognitive aid did not shorten the time interval until the cardiac catheterisation lab was contacted. The availability of the cognitive aid improved task performance in the tasks identified from the guidelines (93% vs. 69%; p < 0.001) as well as overall task performance (87.5% vs. 59%; p < 0.001). The observed difference in performance can be attributed to the use of the cognitive aid, as performance from memory alone would have been comparable across both groups. Trainees appeared to derive greater benefit from the cognitive aid than did consultants and nurses.ConclusionsThe management of intraoperative ST-elevation myocardial infarction can be improved if teams use a cognitive aid. Trainees appeared to derive greater benefit from the cognitive aid than did consultants and nurses.

Assessment Tools for Use During Anesthesia-Centric Pediatric Advanced Life Support Training and Evaluation

BackgroundPediatric perioperative cardiac arrests are rare events that require rapid, skilled and coordinated efforts to optimize outcomes. We developed an assessment tool for assessing clinician performance during perioperative critical events termed Anesthesia-centric Pediatric Advanced Life Support (A-PALS). Here, we describe the development and evaluation of the A-PALS scoring instrument. MethodsA group of raters scored videos of a perioperative team managing simulated events representing a range of scenarios and competency. We assessed agreement with the reference standard grading, as well as interrater and intrarater reliability. ResultsOverall, raters agreed with the reference standard 86.2% of the time. Rater scores concerning scenarios that depicted highly competent performance correlated better with the reference standard than scores from scenarios that depicted low clinical competence (P < 0.0001). Agreement with the reference standard was significantly (P < 0.0001) associated with scenario type, item category, level of competency displayed in the scenario, correct versus incorrect actions and whether the action was performed versus not performed. Kappa values were significantly (P < 0.0001) higher for highly competent performances as compared to lesser competent performances (good: mean = 0.83 [standard deviation = 0.07] versus poor: mean = 0.61 [standard deviation = 0.14]). The intraclass correlation coefficient (interrater reliability) was 0.97 for the raters’ composite scores on correct actions and 0.98 for their composite scores on incorrect actions. ConclusionsThis study provides evidence for the validity of the A-PALS scoring instrument and demonstrates that the scoring instrument can provide reliable scores, although clinician performance affects reliability.

Critical Event Checklists to Manage Perioperative Critical Events Using High-Fidelity Simulation

Abstract This resource contains eight high-fidelity simulation scenarios designed for operating room teams to manage critical events. These scenarios were developed to simulate one of eight critica...

Board 193 - Program Innovations Abstract Implementation of a Perioperative Emergency Manual with In-Situ Simulation Training (Submission #438)

Introduction/Background Critical events in the operating room are stressful and demanding even for highly trained physicians and staff. Emergency manuals and other cognitive aids, such as checklists, can help deliver best practices to patients during critical events. The Stanford Emergency Manuala was developed by the Stanford Anesthesia Cognitive Aid Group (SACAG)b as a resource for perioperative critical events. Simulation-based studies have shown that accessibility of and familiarity with relevant cognitive aids are vital to their effective use.1,2 Additionally, roles such as "readers" (staff who elect to read sections of an emergency manual aloud) have been shown to improve team performance in simulated crisis situations.3 As part of a hospital quality improvement project, we implemented an in situ mannequin-based simulation training curriculum in our hospital operating rooms, along with embedding two Emergency Manuals in all operating rooms (ORs). We hypothesized that these training sessions would lead to a significant improvement in OR staff familiarity with and intended usage of Emergency Manuals. Methods Members of the OR staff were identified by a nurse educator to participate in a scheduled simulation session, grouped according to specialty group and OR shift. We ran a total of nine single-session training modules over five months. In total, 126 staff participated in the training curriculum, including 64 nurses (51%), 30 surgical technicians (24%), 15 operating room assistants (12%), 12 anesthesia technicians (9%), and 5 staff members from other operating room roles (4%). During each 50 minute session we introduced why and how to use the Emergency Manual, along with principles of Crisis Resource Management (CRM)4 in the context of in-situ simulations portraying intraoperative critical events. Scenarios were designed to represent rare, refractory and complex events. They consisted of two to three live actors playing supporting roles and a low fidelity manikin. We used equipment available in the OR as well as a simulated display of vital signs (Laerdal SimMan 2G) controlled by a simulation technician.c Active participants in the simulation scenarios were assigned predetermined roles while other trainees observed and took notes about Emergency Manual use and CRM behaviors. All participants subsequently actively contributed during the group debrief. Following each session, participants completed a standardized evaluation form and a retrospective post-intervention Likert scale-based self-assessment to evaluate awareness of, familiarity with and willingness to use the Emergency Manual during clinical situations. Following the training sessions, familiarity with the existence and format of the Emergency Manual increased significantly (p<0.001). Participants reported more willingness to use the Emergency Manual for pre-crisis educational review and as a resource for debriefing (p<0.001). Additionally, participants reported a significant increase in willingness to suggest the Emergency Manual for use during rare, refractory and complex events, including willingness to act as a "reader" (p<0.001). Participant satisfaction with the sessions was high, with many qualitative responses expressing desire for more trainings of this type. Results: Conclusion Successful clinical implementation of emergency manuals depends upon accurate content that is presented in a usable format, as well as accessibility, familiarity and clinical culture. We show that even brief in-situ simulation is an effective training model to promote OR staff familiarity with why and how to use a novel cognitive aid - in this case the Stanford Emergency Manual - and to increase planned behavior regarding its future use. Future goals will include further integration at the individual, team and systems levels, interdisciplinary in-situ trainings, as well as the assessment of real time usage of the Emergency Manual during critical events.

Anesthesia Core Skill Simulation Package for Anesthesia Newbies

Abstract Introduction Perioperative critical events remain a leading cause of adverse patient outcomes. The ability to recognize complications, make decisions about resources needed, and treat quic...

Endoscopic and stereotactic neurosurgery

Review of the anesthetic considerations for neuroendoscopy and stereotactic procedures. Minimally invasive procedures are increasingly applied in novel ways in the diagnosis and treatment of neurological pathologies. Endoscopic third ventriculostomy, endoscopic shunt revisions and drainage of intraventricular hematoma using a neuroendoscope have become routine neurosurgical procedures. Stereotaxis has expanded its scope from simple brain biopsy to functional neurosurgery and psychiatry. While these procedures are 'minimally invasive', perioperative critical events may still occur. Vigilance in preoperative assessment and intraoperative monitoring is essential in minimizing perioperative morbidity and mortality in patients undergoing neuroendoscopic and stereotactic procedures.

Endovascular repair of aortic aneurysms: Critical events and adjunctive procedures

Objective: We sought to define the learning curve relative to the incidence and range of intraoperative problems and to establish guidelines for troubleshooting during the endovascular repair of infrarenal aortic aneurysms. Methods: We prospectively evaluated our first 75 consecutive cases over a 12-month period and focused on perioperative critical events and adjunctive procedures as categorical outcome measures collected during the operation. Patients were separated into three groups on the basis of the date of their operation, such that group 1 consisted of our first 25 cases, group 2 our next 25 cases, and group 3 our last 25 cases. Results: At least one critical event and adjunctive procedure marked 67 (89%) of 75 cases. In 51%, there were at least two critical events and adjunctive procedures. There were no immediate open conversions or intraoperative deaths. Access problems occurred in 28% of the 75 cases and were addressed by use of brachial-femoral artery access (30%), iliac artery/aortic bifurcation balloon angioplasty (8%), and iliofemoral conduits (4%). Graft foreshortening was the most common deployment event (44%), necessitating distal covered extensions. Iliac graft limb twists and kinks occurred in 12% of cases and were managed with balloon angioplasty and uncovered stents. General incidents included balloon ruptures (10%), arterial dissections (6%), iliac artery rupture (2.6%), and lower extremity ischemia (4%). The two cases of iliac artery rupture were managed with distal covered extensions, and there were no cases of atheroemboli. Intraoperative endoleaks were encountered in 44% of the cases and included proximal attachment sites (15%), distal attachment sites (9%), type 2 sources, and “blushes.” Management of intraoperative endoleaks included proximal/distal covered extensions and re-ballooning. Our 30-day endoleak rate was 20%. The incidence of critical events did not decrease in the latter one third compared with the first two thirds of cases. Conclusions: Critical events occur frequently during endovascular repair of aortic aneurysms. The intraoperative problems range from the common endoleaks, access and deployment issues, and balloon ruptures, to rare but life-threatening complications such as iliac artery rupture. A toolbox of accessories that includes wires, catheters, large balloons, covered proximal and distal extensions, and uncovered stents is essential given the frequency of adjunctive procedures. Successful aortic endografting requires more than mere familiarity with basic endovascular techniques. (J Vasc Surg 2001;33:1226-32.)