Browsing by Author "Perez Toledo, Javier A."

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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.