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Annual Meeting 2022, Indiana Society of Anesthesiologists
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Browsing Annual Meeting 2022, Indiana Society of Anesthesiologists by Author "Boyer, Tanna J."
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Item A Simulation Case of Cricothyrotomy in an Acute Upper GI Bleed(2022-09-17) Yu, Corinna J.; Rigueiro, Frank; Backfish-White, Kevin; Boyer, Tanna J.Item Career Mentors & 5-Year Data on the IUSM Anesthesiology Match(2022-09-17) Yu, Corinna J.; Ye, Jian; Boyer, Tanna J.; Mitchell, Sally A.Item Interdisciplinary Surgery-Anesthesia Education as a Valuable Component of Surgical Pre-Internship Training(2022-09-17) Xu, Karen K.; Stanton-Maxey, Katie J.; Mitchell, Sally A.; Yu, Corinna J.; Dunlap, Julie D.; Boyer, Tanna J.Background/Objective: Research has shown that skills-based workshops for medical students entering a surgical internship can improve learner self-confidence and provide opportunities for competency assessment.1,2 The ACS/APDS/ASE Resident Prep Curriculum is used nationally to prepare medical students for entrance into a surgical internship. This curriculum includes workshops traditionally taught by surgical faculty, teaching emergency procedures such as cricothyroidotomy without first-line airway interventions.3 We propose widespread adoption of an interdisciplinary airway and line workshop taught by anesthesia faculty as an educational intervention for pre-internship surgeons. Interdisciplinary medical education has been shown to improve perceptions of interdisciplinary collegiality and attitudes.4 This is the first known addition of anesthesiologists as teaching faculty in workshops designed to prepare medical students for a surgical internship. Methods: A half-day workshop for medical students entering surgical internships was designed as part of the MS4 preparation for internship rotation at IUSM beginning in Spring of 2017. The workshop consists of four stations and two discussions, all taught by anesthesia faculty. Prior to the workshop, learners receive access to presentations and videos for each procedure via an online learning management system (Canvas). The day begins with a discussion of difficult airway characteristics and facial morphologies that may necessitate an airway discussion prior to anesthesia. Learners then begin rotating through a total of four stations. Skills taught at these stations include IV and arterial line placement with and without ultrasound, basic airway management skills, management of difficult airways, and emergency airway access. Learners also complete a simulation exercise covering noninvasive respiratory support options in a patient with increasing respiratory distress. At the end of the workshop, learners participate in a debriefing session and discussion of how to avoid future anesthesia cancellations. They also complete a post-workshop evaluation before leaving. Results: The post-workshop evaluation was completed by 20 students in 2019 and 23 students in 2022. All learners agreed or strongly agreed that faculty from non-surgical specialties had important knowledge and wisdom for surgical trainees. Nearly all learners agreed or strongly agreed that the workshop was useful (41/43, 95%), boosted their clinical self-confidence in airway management (39/43, 91%), and that the skills and knowledge learned would be useful to them as interns and residents (42/43, 98%). Most learners (39/43, 91%) agreed or strongly agreed that this workshop should be mandatory for all students preparing for a surgical internship. Conclusions: This interdisciplinary surgery-anesthesia workshop was valuable to learners. The success of this workshop highlights the role of anesthesia providers in interdisciplinary education to prepare medical students for a surgical internship. We also highlight the worthiness of anesthesia faculty time in the education of future surgical colleagues; discussions on when to consult anesthesia for difficult airways and other issues may improve collegiality and camaraderie between disciplines and decrease same-day surgery cancellations. References: 1. Peyre SE, Peyre CG, Sullivan ME, Towfigh S. A surgical skills elective can improve student confidence prior to internship. J Surg Res. 2006;133(1):11-15. doi:10.1016/j.jss.2006.02.022 2. Brunt LM, Halpin VJ, Klingensmith ME, et al. Accelerated skills preparation and assessment for senior medical students entering surgical internship. J Am Coll Surg. 2008;206(5):897-907. doi:10.1016/j.jamcollsurg.2007.12.018 3. ACS/APDS/ASE Resident Prep Curriculum. ACS. https://www.facs.org/for-medical-professionals/education/programs/acs-apds-ase-resident-prep-curriculum/. Accessed June 13, 2022. 4. Bullard MJ, Fox SM, Wares CM, Heffner AC, Stephens C, Rossi L. Simulation-based interdisciplinary education improves intern attitudes and outlook toward colleagues in other disciplines. BMC Med Educ. 2019;19(1):276. Published 2019 Jul 24. doi:10.1186/s12909-019-1700-1Item Intraoperative Accidental Extubation During Thyroidectomy in a Known Difficult Airway Patient: An Adult Simulation Case for Anesthesia Residents(2022-09-17) Perez Toledo, Javier A.; Okano, David R.; Mitchell, Sally A.; Cartwright, Johnny F.; Moore, Christopher; Boyer, Tanna J.Background: Intraoperative accidental extubation on a known difficult airway patient requires prompt attention. The incidence of accidental extubation is not very well known for the OR setting, however studies conducted in the ICU have ranges that vary widely from 0.5 to 35.8% in adults and even more so in the neonatal population with a range of 1% to 80.8%.[1-4] The accidental removal of an ETT can lead to injury of the vocal cords if the tracheal cube is still inflated. If the patient has a large amount of secretions it can lead to aspiration and ultimately aspiration pneumonia. If gone unnoticed it can lead to inadequate ventilation leading to hypoxemia and potential hypotension, brain damage, cardiac arrest, and death.[5-7] A good understanding of the steps to re-establish the airway is critical especially when the patient is known as a difficult airway. In regard to difficult airways, the incidence of different factors varies, for example the incidence of a difficult oro-tracheal intubation is around 7.4% [8] while the incidence of a difficult mask ventilation is 7.8%.[9] The situation becomes even more complicated if the case has been taken over by another anesthesiologist during the surgery, and specific and detailed information may not have been conveyed.[10] Methods: This scenario is a staple in our simulation curriculum, placed later in the CA-1/PGY-2 year. It is performed with a high-fidelity mannikin, with simulation environment set up as a true operating room. This simulation is primarily designed to train first-year clinical anesthesia (CA-1, PGY-2) residents. It is designed as a 50-minute encounter and focuses on the management of unintentional loss of an airway during a thyroidectomy on a known difficult airway patient. The endotracheal tube dislodgement is simulated by deliberate tube manipulation through the cervical access window of the mannequin. Following the conclusion of the simulation, residents learn via debriefing with good intention where they discuss learning objectives and receive formative feedback Results: Residents are given formative feedback and ungraded. The majority of the resident participants met the designed educational objectives. The learners were asked to provide feedback of their experience in the form of an online survey and 17/25 (68%) residents responded. Discussion: This simulation scenario achieves the educational objective of development of intraoperative emergency airway management skills for anesthesia residents. With simulation, we can accomplish this in a psychologically safe environment with no harm to actual patients. This simulation is also able to foster communication skills among anesthesiologists and the surgery team. Time constraints limit the number of residents who can sit in the "hot seat" but all participants learned from the scenario. Our feedback shows the airway structure of the mannequin limits the adequate insertion and positioning of supraglottic airway devices. Sources: 1. da Silva PS, Fonseca MC. Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg. 2012 May;114(5):1003-14.. https://doi.org/10.1213/ANE.0b013e31824b0296 2. da Silva PS, de Carvalho WB. Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations. Pediatr Crit Care Med. 2010;11:287–294. https://doi.org/10.1097/PCC.0b013e3181b80951 3. Kapadia FN, Bajan KB, Raje KV. Airway accidents in intubated intensive care unit patients: an epidemiological study. Crit Care Med. 2000;28:659–664. https://doi.org/10.1097/00003246-200003000-00010 4. McNett M, Kerber K. Unplanned Extubations in the ICU: risk factors and strategies for reducing adverse events. J Clin Outcomes Manag. 2015;22:303–311. 5. Chao CM, Sung MI, Cheng KC, Lai CC, Chan KS, Cheng AC, Hsing SC, Chen CM. Prognostic factors and outcomes of unplanned extubation. Sci Rep. 2017 Aug 17;7(1):8636. https://doi.org/10.1038/s41598-017-08867-1 6. de Lassence A, Alberti C, Azoulay É, et al. Impact of unplanned extubation and reintubation after weaning on nosocomial pneu-monia risk in the intensive care unit. A prospective multicenter study. Anesthesiology. 2002;97(1):148-156 https://doi.org/10.1097/00000542-200207000-00021 7. Kapadia F. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med. 2001; 163(7): 1755-1756 https://doi.org/10.1164/ajrccm.161.6.9908068 8. Combes X, Jabre P, Jbeili C, Leroux B, Bastuji-Garin S, Margenet A, Adnet F, Dhonneur G. Prehospital standardization of medical airway management: incidence and risk factors of difficult airway. Acad Emerg Med. 2006 Aug;13(8):828-34. https://doi.org/10.1197/j.aem.2006.02.016 9. Yildiz TS, Solak M, Toker K. The incidence and risk factors of difficult mask ventilation. J Anesth. 2005;19(1):7-11. doi: 10.1007/s00540-004-0275-z. PMID: 15674508. https://doi.org/10.1007/s00540-004-0275-z 10. Solet, Darrell J., et al. "Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs." Academic Medicine 80.12 (2005): 1094-1099.Item Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents(2022-09-17) Chen, Andy W.; Okano, David R.; Mitchell, Sally A.; Cartwright, Johnny F.; Moore, Christopher; Boyer, Tanna J.Introduction: Anesthesiologists may encounter multiple obstacles in communication when attempting to collect information for emergency surgeries. Occult tension pneumothorax that was asymptomatic in the Emergency Department (ED) could become apparent upon positive pressure ventilation and pose a critical threat to the patient intraoperatively. Methods: This simulation is primarily designed to train first-year of clinical anesthesia (CA-1) residents. It is designed as a 50-minute encounter consisting of 2 scenes. The first scene focuses on information collection and communication with a non-cooperative patient with multiple distractors. The second scene focuses on the early diagnosis of tension pneumothorax and the treatment. Results: This scenario has been developed as one of the regular simulation trainings at our facility. We tried to keep the simulation environment as realistic as possible. We did not grade the learners based on their performance, although most of the residents met the educational objectives. Commonly missed critical actions included misdiagnosing the tension pneumothorax as mainstem intubation, bronchospasm, pulmonary thromboembolism, or anaphylaxis. All residents learned from this scenario, as they rated the feedback and debriefing as “extremely useful” or “very useful.” Discussion: Our simulation program helps anesthesia residents develop crisis management skills for perioperative incidents in a safe environment, as well as to foster excellent communication skills. Time constraints limit the number of the residents who can sit in the “hot seat.” The structure of the mannequin often limits the ability to diagnose pneumothorax by auscultation. The scenarios can be also employed to educate student anesthesia assistants in the future.Item Local Anesthetic Systemic Toxicity: A Pediatric Simulation Case for Anesthesiology Residents(2022-09-17) Hunter, Isaac; Egan, Brian; Abbasi, Rania; Cossu, Anne; Acquaviva, Michael; Boyer, Tanna J.INTRODUCTION: Local anesthetic systemic toxicity (LAST) is a rare but potentially lethal complication of anesthesia. It is therefore crucial for providers to be prepared when cases arise. Simulations allow providers and trainees to practice rare events with potentially severe consequences with a narrow margin for error in a controlled environment. OBJECTIVE: The objective for this article is to describe the successful implementation of a LAST simulation scenario in order to assist other institutions in organizing similar simulations, as well as to describe the importance of this particular simulation. METHODS: This simulation requires access to a simulation mannequin and OR setup. It involves a 2-year-old male undergoing a hypospadias repair who experiences LAST. Residents are expected to diagnose LAST and manage the patient using pediatric advanced life support (PALS) and intralipid. We conducted the simulation yearly for CA1 residents in 1-hour sessions with three to five learners at a time. Evaluation was done using the Anesthetists’ Non-Technical Skills (ANTS) assessment tool, as well as direct observation during the simulation and debriefing session and a follow-up survey sent to participants. RESULTS: Five cohorts of 25-28 anesthesiology residents have completed this simulation. Common areas for improvement include delayed recognition of LAST and not using the ASRA LAST checklist. Most participants were knowledgeable about the treatment of LAST and knew the pediatric dosing, but still reported finding the simulation valuable for both their skills and confidence. CONCUSIONS: Teaching about LAST is critical for all anesthesiology residents, as this is a rare but can’t-miss diagnosis. This simulation scenario is a useful and broadly applicable resource to allow residents to practice this critical learning, and residents consistently provide positive feedback about their experience.Item Managing ARDS in the Operating Room: A Timely Simulation for Anesthesiology Residents(2022-09-17) Daly, Christine A.; Eddy, Christopher; Boyer, Tanna J.; Mitchell, Sally A.; Sturm, Julie F.; Webb, Timothy T.Introduction: Acute respiratory distress syndrome (ARDS) is a serious medical condition with high morbidity and mortality that frequently requires management in the intensive care unit (ICU). As critical care training is a vital component of anesthesiology residency and critically ill patients often require procedures necessitating anesthesia, understanding the presentation, management, and treatment of ARDS is essential to perioperative patient care. Educational Objectives: By the end of this simulation case, learners will be able to: identify and define ARDS; describe and apply ventilator strategies for patients with ARDS; and discuss strategies to improve oxygenation in patients with ARDS in addition to adjusting ventilator settings. Methods: This simulation involved a 66-year-old man with inhalational burn injuries undergoing debridement and homografting of burns in the operating room. During the case, the patient’s oxygenation and lung compliance demonstrated changes consistent with worsening ARDS. We conducted this simulation yearly for clinical anesthesia year 2 residents (CA2/PGY3; n=26) in 1-hour sessions with three to four learners at a time. The simulation covered five Anesthesiology Milestones related to ARDS as outlined in the Anesthesiology Milestones Project. Results: At the time of submission, 130 anesthesia residents completed the simulation. Commonly missed critical actions include failure to: recognize the need to adjust ventilator settings prior to inducing anesthesia; investigate causes of acute hypoxemia during the procedure; provide appropriate ventilator changes to improve the patient’s acute hypoxemia; and recognize the need to cancel the procedure. Most participants appropriately diagnosed and managed hypoxemia, and all agreed the simulation was a valuable learning experience. Conclusions: Simulation presents trainees with an effective opportunity to further their learning with regard to the recognition, management, and treatment of ARDS. This simulation provides an opportunity to discuss the currently evolving management of ARDS.Item Perioperative Anesthetic Considerations for Anti-NMDA Receptor Encephalitis Patients: A Case Report(2022-09-17) Chen, Andy W.; Axe, Michelle R.; Boyer, Tanna J.Introduction: Anti-NDMA receptor (anti-NMDA-R) encephalitis is a neurologic autoimmune disease that presents with characteristic psychiatric, neurological, and constitutional symptoms. It is caused by production of anti-NMDA-R antibodies, which in turn cause downregulation of NMDA receptors on central neurons. Detection of anti-NMDA-R antibodies in the serum or cerebrospinal fluid (CSF) confirms the diagnosis. The disease is often associated with an underlying tumor, most commonly an ovarian teratoma. Perioperative anesthetic management of patients with anti-NMDA-R encephalitis is a subject of interest to anesthesiologists because many anesthetic agents interact with the NMDA receptor, and therefore pose a risk of worsening the patient’s encephalitis, especially if surgical removal of the underlying teratoma is required for treatment. Case Description: A 15-year-old male diagnosed with anti-NMDA-R encephalitis in April 2022 was taken to the operating room (OR) for G-tube placement under general anesthesia in June 2022. The procedure followed a month-long hospitalization in the ICU and a month-long stay in the inpatient rehabilitation unit, all at Riley Children’s Hospital in Indianapolis, IN. The procedure was performed with total intravenous (IV) anesthesia with midazolam, dexmedetomidine, and remifentanil. Other medications the patient received during the procedure include cefazolin, dexamethasone, ondansetron, and ketorolac. Neither propofol nor volatile anesthetics were administered during the case. The patient remained hemodynamically stable intraoperatively with an uneventful postoperative course. Discussion: There is currently no definitive consensus on the optimal anesthetic regimen for patients with anti-NMDA-R encephalitis. In the available literature on this subject, both ketamine and nitrous oxide (N2O) have been routinely avoided because they are well-known for their direct NMDA-R antagonist activity. Commonly used agents include propofol, volatile anesthetics (e.g. sevoflurane), opioids, nondepolarizing paralytics, dexmedetomidine, and benzodiazepines (e.g. midazolam). Notably, volatile anesthetics (e.g. sevoflurane) and propofol are known to have some inhibitory activity on NMDA receptors, with volatile anesthetics demonstrating this moreso than propofol. Furthermore, there is some data to suggest that use of volatile anesthetics in these patients is associated with higher rates of postoperative adverse events, namely hypoventilation (potentially requiring reintubation) as well as pneumonia (e.g. aspiration pneumonia and ventilator-associated pneumonia). However, other studies and reviews have also reported no postoperative adverse events in the setting of volatile anesthetic use. A number of authors advocate for the use of midazolam, dexmedetomidine, and opioids, as these agents do not interact with NMDA receptors. Although there are no known reports of IV opioid-induced hypoventilation postoperatively in anti-NMDA-R encephalitis patients (to our knowledge), opioids still ought to be used judiciously in these patients, as they are at elevated risk of hypoventilation due to involvement of the brainstem respiratory center by the primary disease process.