Browsing by Author "Moore, Christopher"

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    Cricothyrotomy in Acute Upper Gastrointestinal Bleed: A Difficult Airway Simulation Case for Anesthesiology Residents
    (Association of American Medical Colleges, 2024-01-16) Yu, Corinna J.; Rigueiro, Frank; Backfish-White, Kevin; Cartwright, Johnny; Moore, Christopher; Mitchell, Sally A.; Boyer, Tanna; Anesthesia, School of Medicine
    Introduction: Patients with acute upper gastrointestinal bleeding may have challenging airways. This simulation teaches anesthesiology residents the skill of cricothyrotomy as a surgical last resort while managing acute bleeding in the airway. Methods: The simulation involved a 55-year-old patient with history of alcohol abuse admitted to the ICU with hematemesis and acute blood loss for esophagogastroduodenoscopy in the ICU setting. The mannequin had tubing in the posterior oropharynx connected to a pressurized bag of simulated blood hidden from view. While conversing, the patient began to cough and gag, and the bag of fluid was opened, filling the posterior oropharynx with blood, which prompted immediate intubation attempts, designed to fail no matter what the learners attempted. When residents requested a surgical airway, they were provided with a cricothyrotomy kit and a task trainer to perform the procedure. Residents were evaluated using a behavior checklist, debriefed, then asked to complete a postsimulation survey. Results: Fifty-eight anesthesiology residents completed the simulation and provided feedback via a 5-point Likert scale of agreement. Most residents quickly recognized the need for emergency intubation. Eighty-eight percent of participants strongly agreed that the simulation was a valuable learning experience, with 99% stating it increased their confidence and clinical decision-making in handling similar scenarios in the future. Discussion: This simulation provides a chance to practice valuable airway management skills that increase resident confidence in cricothyrotomy. Future work may examine if these skills and confidence levels are sustainable over time and if they are applied in future patient encounters.
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    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.
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    Intraoperative Accidental Extubation during Thyroidectomy in a Known Difficult-Airway Patient: An Adult Simulation Case for Anesthesiology Residents
    (MDPI, 2022-10-12) Okano, David R.; Perez Toledo, Javier A.; Mitchell, Sally A.; Cartwright, Johnny F.; Moore, Christopher; Boyer, Tanna J.; Anesthesia, School of Medicine
    Intraoperative accidental extubation on a known difficult-airway patient requires prompt attention. A good understanding of the steps to re-establish the airway is critical, especially when the patient is known to have a difficult airway documented or discovered on induction or acquires a difficult airway secondary to intraoperative events. The situation becomes even more complicated if the case has been handed off to another anesthesiologist, where specific and detailed information may not have been conveyed. This simulation was designed to train first-year clinical anesthesia residents. It was a 50 min encounter that focused on the management of complete loss of an airway during a thyroidectomy on a known difficult-airway patient. The endotracheal tube dislodgement was simulated by deliberate tube manipulation through the cervical access window of the mannequin. Learners received a formative assessment of their performance during the debrief, and most of the residents met the educational objectives. Learners were asked to complete a survey of their experience, and the feedback was positive and constructive. The response rate was 68% (17/25). Our simulation program helped anesthesiology residents develop intraoperative emergency airway management skills in a safe environment, as well as foster communication skills among anesthesiologists and the surgery team.
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    Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents
    (MDPI, 2022-06-16) Okano, David Ryusuke; Chen, Andy W.; Mitchell, Sally A.; Cartwright, Johnny F.; Moore, Christopher; Anesthesia, School of Medicine
    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. Here, we describe a simulation exercise that was developed as a curriculum module for the Indiana University (IU) Anesthesiology residency program. It is primarily designed for first-year clinical anesthesia residents (CA-1/PGY-2). It is a 50 min encounter with two scenarios. The first scenario focuses on information collection and communication with a non-cooperative patient with multiple distractors. The second scenario focuses on the early diagnosis of tension pneumothorax and subsequent treatment. The residents were given formative feedback and met the educational objectives. Commonly missed critical actions included misdiagnosing the tension pneumothorax as mainstem intubation, bronchospasm, pulmonary thromboembolism, and anaphylaxis. Residents rated the feedback and debriefing as "extremely useful" or "very useful." Time constraints limit the number of residents who can sit in the "hot seat." The structure of the mannequin limits the ability to diagnose pneumothorax by auscultation and ultrasound. In the future, the scenarios may also be utilized to educate student anesthesiologist assistants and other non-physician anesthesia learners.
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    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.
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    Stunned Myocardium as a Sequela of Acute Severe Anemia: An Adult Simulation Case for Anesthesiology Residents
    (Association of American Medical Colleges, 2024-09-06) Okano, David Ryusuke; Ko, Bryan; Giuliano, Marelle; Mitchell, Sally; Cartwright, Johnny; Moore, Christopher; Boyer, Tanna; Anesthesia, School of Medicine
    Introduction: Anesthesiologists develop anesthetic plans according to the surgical procedure, patient's medical history, and physical exams. Patients with ischemic heart disease are predisposed to intraoperative cardiac complications from surgical blood loss. Unanticipated events can lead to intraoperative complications despite careful anesthesia planning. Methods: This anesthetic management simulation was developed for the anesthesiology residency curriculum during the first clinical anesthesia year (CA 1/PGY 2 residents). A total of 23 CA 1 residents participated. A 50-minute encounter focused on a 73-year-old male who presents for an elective total hip replacement and develops acute myocardial stunning in the setting of critical acute blood loss and a delay in the transportation of blood products. Results: One hundred percent of the residents felt the simulation was educationally valuable in the immediate postsimulation survey (Kirkpatrick level 1). The follow-up survey showed that 100% of residents felt the simulation increased their knowledge of managing acute cardiac ischemia (Kirkpatrick level 2), and 93% felt it increased awareness and confidence in similar real-life situations that positively affected patient outcomes (Kirkpatrick level 3). Discussion: Our simulation provides a psychologically safe environment for anesthesiology residents to develop management skills for acute critical anemia and cardiogenic shock and foster communication skills with a surgery team.