Christopher J. Gallagher

A randomized, controlled trial on dexmedetomidine for providing adequate sedation and hemodynamic control for awake, diagnostic transesophageal echocardiography

OBJECTIVE Transesophageal echocardiography (TEE) has become established as a sensitive and accurate diagnostic method for the rapid assessment of myocardial function. It was theorized that dexmedetomidine (Precedex; Hospira, Inc, Lake Forest, IL) might prove to be useful for sedating patients while undergoing TEE. DESIGN A prospective, randomized trial was designed comparing dexmedetomidine versus standard therapy (eg, midazolam and opioids) for sedation. SETTING This trial was performed in a tertiary care, single-institution university hospital. PARTICIPANTS Males and females, American Society of Anesthesiologists I to IV, ages 18 to 65 years, requiring diagnostic TEE. Patients were excluded if pregnant, if they had taken benzodiazepines or opioids within 24 hours, or if they were deemed to be too unstable to receive any kind of sedation. INTERVENTIONS Patients were randomized to standard therapy or dexmedetomidine infusion groups. Sedation was assessed at 6 time points. Pulse oximetry, electrocardiogram, heart rate, noninvasive blood pressure, and respiratory rate were monitored. Additional variables measured were the amount of each drug given, the time of the TEE procedure, and the time to recovery. MEASUREMENTS AND MAIN RESULTS A survey about the quality of sedation, the level of comfort, and whether or not they would accept this type of sedation again was administered after recovery from sedation. Demographic data and patient questionnaire responses were reported as means and standard errors or percents and were analyzed with the t test and chi-square test. Twenty-two patients were enrolled. Hemodynamics were statistically different between the two groups at several time points. Both systolic and diastolic blood pressures (BP) were elevated in the standard therapy group, whereas the dexmedetomidine group had a lower BP. Heart rate was elevated significantly in the standard therapy group compared with the dexmedetomidine group. There was no statistical or clinical difference between the groups in terms of oxygenation or respiratory rate. CONCLUSIONS The authors concluded that dexmedetomidine appears equivalent in achieving adequate levels of sedation without increasing the rate of respiratory depression or decreasing oxygen saturation compared with standard therapy, and it may be better in achieving desired hemodynamic results.

The current status of simulation in the maintenance of certification in anesthesia.

Over the past 20 years, simulation in anesthesia education and training has grown significantly. There are currently approximately 60 to 70 anesthesia simulation centers in the United States that are actively being used for training anesthesia residents, medical students, and for continuing medical education activities. Although simulation training for the next generation of anesthesiologists proves to be an expensive, time-consuming, and labor-intensive endeavor, simulation is here to stay. Anesthesia simulation has now achieved enough status that it will be formally incorporated into the Maintenance of Certification in Anesthesia (MOCA). Owing to the growing importance, simulation will now play with all current and future anesthesiologists it is important for all to understand 3 major points regarding simulation: (1) Where did simulation come from that it now plays a role in MOCA?; (2) Why is simulation included in MOCA? (3) Where will simulation go now that it is a part of MOCA? Using the next few pages we will address these important questions through a historic look at simulation in anesthesia, the progression of policy changes leading to simulation being incorporated into MOCA, and compare the state of anesthesia simulation with how our surgical

Lipid rescue for bupivacaine toxicity during cardiovascular procedures

Bupivacaine toxicity is a recognized complication of procedures done under local anesthetic infiltration. While local anesthetic toxicity is rare, it is potentially catastrophic and life-threatening.1 A 20% lipid emulsion has been used to resuscitate patients after bupivacaine overdose or inadvertent intravascular injection.2–7 While the use of lipid emulsion for local anesthetic toxicity has been reported extensively in the anesthesia literature,8 it has not yet been reported in the cardiology literature. We report a case of local anesthetic toxicity resulting in pulseless electrical activity during an electrophysiology procedure that was successfully treated by infusion of 20% lipid emulsion.

A case of intra-operative ventricular fibrillation: Electro-cauterization, undiagnosed Takotsubo cardiomyopathy or long QT syndrome?

INTRODUCTION Cardiac arrest in the perioperative setting is an extremely serious event that is estimated to occur between 4.6 and 19.7 per 10,000 anesthetics.(1-5) While risk factors for cardiac complications can be identified pre- operatively, in many cases workup of risk factors are not indicated by standard pre-operative testing guidelines. PRESENTATION OF CASE We present a case of a 47-year-old female undergoing an elective bilateral mastectomy who suddenly converted to ventricular fibrillation. While ventricular fibrillation is not a unique finding, our search for its etiology revealed two previously undiagnosed cardiac conditions, and possible electro- cautery induced ventricular fibrillation. DISCUSSION In this case study, we discuss the possible etiology of ventricular fibrillation in our patient and highlight the importance pre-operative patient investigation and history provide. CONCLUSION Searching for the potential causes that may have contributed to the cardiac arrest is an extremely useful exercise as it allows us to better prepare patients pre-operatively, improve intra-operative care, and prevent future cardiac events.

Board 159 - Program Innovations Abstract Branch Office for In-Situ Simulation (Submission #990)

Introduction/Background One of the biggest headaches in simulation education is getting people to actually do the simulations! One of the simplest and most effective measures (in these busy days where pulling people from clinical activities is difficult), is to “bring simulation closer to the learners”. We found that by setting up a simulation area within earshot of the operating rooms, we were much more successful in getting both learners and teachers to participate in more simulation exercises. Additional advantages include: 1) ease of returning to the OR in case of emergency; 2) being able to set up in an empty OR when one became available; 3) ability to borrow equipment (eg Glidescope®s) since we could quickly return it. We detailed how we did it, how we overcame problems and how we used this method to greatly expand our teaching efforts. Methods In-situ simulation presents a host of advantages. We took advantage of a “nearby piece of real estate” to set up an in-situ simulation “branch office” to aid in teaching simulation to anesthesia residents. We created a list of 30 emergencies that an anesthesiologist might face, then brought in CA-1 residents in a program we named “Drill Baby Drill”, with the thought being that if you drill the common things and drill them over and over again until the residents could respond quickly and accurately to common situations. Here are the emergencies we made them react to: can’t intubate, can’t mask ventilate, can’t intubate or ventilate, saturation drops, laryngospasm, bronchospasm, problems with the endotracheal tube, problems with intravenous lines, equipment problems, chaos from the cath lab, hypertension, hyopotension, increased and decreased heart rate with both hyper and hypotension, Cushing’s triad ST segment elevation consistent with an MI, decreased and increased end-tidal CO2, bucking during the case, vomiting on induction, rhythm disturbances, problems during a TURP, low hematocrit, thyroid storm, malignant hyperthermia, urine output too low or too high, anaphylaxis, local anesthetic toxicity, pneumothorax after central line placement. Given the busy OR schedule, “pulling people and going all the way to the Sim Center” was just not an option. So we set up our local “shop”, pulled the residents when the opportunity presented itself (usually in the early afternoon) and proceeded to “Drill Baby Drill” our CA-1’s. The response from both residents training and attendings who them worked with these residents was overwhelmingly positive. Results: Conclusion In-situ simulation provides a great opportunity to educate residents on a regular basis. With a little ingenuity and close attention to “possibilities that open up during the day”, you can give your residents a meaningful and regular exposure to simulation education right on your front doorstep. References 1. Miller K, Riley W, Davis S, Hansen H, In situ simulation: a method of experiential learning to promote safety and team behavior. J Perinat Neonat Nurs 2008; 22:105-13. 2. Boulet J, Murray D, Simulation-based assessment in anesthesiology. Anestthesiology 2010; 112:1041-52. 3. Okuda Y, Bryson E, DeMaria S et al. The utility of simulation in medical education: what is the evidence. Mt Sinai J of Med, 2009; 76:330-343. Disclosures None.

Core clinical competencies in anesthesiology: A case-based approach

The goal of this book is to prepare anesthesiology residents for their specialty examinations in the United States. The Accreditation Council for Graduate Medical Education (ACGME) is the body responsible for the accreditation of postgraduate medical training programs in the United States. The examinations evaluate residents on six core competencies of a competent physician as listed by the ACGME, namely, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The ACGME competencies are similar to the CanMEDS competencies used in Canada and other countries, specifically, medical expert, manager, collaborator, communicator, professional, scholar, and health advocate. The authors begin their book by providing a didactic and concise description of the six core ACGME competencies in medicine as a whole, followed by a short description within the context of anesthesiology. The book includes 77 clinical cases, and the authors advance either some or all of the six core ACGME competencies related to each specific case. The cases are gathered into six sections (Parts 1 to 6) according to the institutions of the contributing authors, many of whom are anesthesiology residents. The choice of gathering cases into sections according to the affiliation of the authors may be somewhat surprising, since, in my view, it would have been more logical to group the cases according to their main core competencies or even their main clinical focus. Each case study begins with a catchy title and continues with a case description written in a ‘‘humorous’’ and colloquial style. Whereas this style can be engaging and entertaining, the reader may often perceive this approach as being unusual at best, especially in this book which aims to advocate clinical core competencies, including professionalism. For example, Case 10 ‘‘Flame on!’’, a case regarding a conscious patient with 100% burns, starts with ‘‘A smell like barbeque fills the entire emergency room. ‘Funny,’ you think, ‘no one told me there was a picnic.’ You note that the smell is coming from the trauma bay...’’. Under the competency ‘‘Patient care’’ and the subcategory ‘‘Perform competently all medical and invasive procedures considered essential for the area of practice’’, the authors write, ‘‘As long as I didn’t stick the morphine syringe into the mattress by mistake, I was performing competently.’’ This style may appear to be counterproductive to teaching the core competencies that are being discussed. The hidden curriculum includes learning which is not visible and explicit in an educational program. For example, when medical students participate in an anesthesiology rotation, they learn technical skills, such as drug administration and tracheal intubation, and they also learn about professional relationships with other healthcare providers and the sociology of anesthesiologists, learning points which are often not explicit in their curriculum. I am concerned about the contribution this book, with its sarcastic style, may have on the hidden curriculum, i.e., in shaping the professional identity of residents and potentially contributing to cynical attitudes instead of encouraging compassion and empathy toward the patient. In each case, the description of the clinical core competencies is clear and well structured with a repetitive format to assist trainees in preparing for their examinations. The amount of redundancy is one drawback which is potentially irritating for the reader; in addition, this 472 page paperback book is rather large (9.6 9 7.4 9 1.1 inches and 1.9 pounds). The interest in this book lies within S. Boet, MD (&) The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada e-mail: sboet@toh.on.ca

On the Road with the Simulator

The staff of Jackson Memorial Hospital Patient Safety Center at the University of Miami in Miami Florida, USA, did a road trip. They drove from downtown Miami to Miami Beach (10 minutes, even with traffic). But it was still unforgettable for them. This chapter attempts to draw some lessons out of this journey. Planning is most important. Before embarking on your own simulator road trip, you have to decide what the thing is, i.e., what are your goals and objectives. Why are you doing this simulation? Who is your audience? What is your audience expecting to take away from the simulation? Then next step is, as the chapter demonstrates, to create a scenario that fits into the road trip. The staff narrate in their own words, “We need thinking, instructing, sentient creatures to make the simulation scene come to life. So we plucked the best and brightest from our attending staff. We produced the simulations on a Saturday and Sunday. Each day, we had three attendings. These attendings were familiar with simulation scenarios, the computer that ran the simulators, ‘faking it’ when glitches happened so that the ‘audience’ never perceive the glitches (this is the attribute most essential to any simulator instructor), and debriefing people after the scenario. Each of these instructors had worked with these simulators before and had worked with residents or medical students in a simulator setting. Experience counts.”

Board 160 - Program Innovations Abstract Using Root Cause Analysis Case for System-Wide Simulation Education (Submission #1045)

Introduction/Background Using root cause analysis as a springboard for system-wide simulation education holds significant potential. Root cause analysis (RCA) is a method of exploring an adverse clinical event in an attempt to discover the contributing factors. To improve patient safety, the RCA ideally uncovers system flaws which can be improved and corrected We used an RCA as basis for a three tiered approach to educating residents system wide. Methods A root cause analysis case (a retained wire after central line placement) was analyzed for educational points. Five significant lessons were evident from analysis of the events leading to the retained wire. A three tiered approach to getting these educational lessons out to the residents of an institution was employed, a survey to raise awareness, a video to illustrate the lessons and in-situ, small group simulation sessions to reinforce the lessons. A total of 53 residents completed the initial survey. A total of 42 viewed the video. In-situ teaching was done with the Emergency Medicine department (20 residents participated), Internal Medicine (22 residents), Surgery (15), Pathology (15), Pediatrics (15) and Anesthesiology (30). Teaching was either done in small groups (Emergency Medicine), during dedicated teaching time (Anesthesiology, done one Clinical Anesthesia class at a time) or during didactic time with the entire residency present (Surgery, Pathology, Pediatrics). The method of teaching the in-situ class varied depending on what worked most easily for the different specialties. Results: Conclusion The three tiered approach to spreading the lessons learned from a root cause analysis case was well received by the residents. By a multifaceted approach (survey, video, in-situ) and adapting to different schedules we were able to disseminate the lessons learned from the root cause analysis. Root cause analysis is a common method of exploring medical errors and close calls. Simulation education is a widespread educational method. Joining root cause analysis with a three-tiered educational approach is a novel method of disseminating the lessons learned from the root cause analysis. Single institution study may limit generalizability. No rigorous before/after measure of knowledge may limit interpretation. Not all institutions will be able to generate a teaching video so quickly and may lack the resources to conduct in-situ educational sessions. Getting the word out after a root cause analysis is important. Rather than keep the lessons learned “under wraps”, it is better to employ an aggressive approach to “getting the lessons out there”. References 1. Fischer MA, Mazor KM, Baril J, et al. Learning from mistakes: factors that influence how students and residents learn from medical errors. J Gen Intern Med. 2006 May; 21(5):419-23. 2. Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004 Dec; 13(6):417-21. 3. Dawson D, Chapman J, & Thomas MJW. Fatigue-proofing: A new approach to reducing fatigue related risk using the principles of error management. Sleep Med Rev. 2012 Apr; 16(2):167-75). 4. Carroll J, Rudolph J, & Hatakenaka S. Lessons learned from non-medical industries: Root cause analysis as culture change at a chemical plant. Qual Saf Health Care. 2002 September; 11(3):266-269. Disclosures None.

Board 529 - Technology Innovations Abstract A Cost-Effective Wireless Gadget for Simulation of Partial Seizures in a Child (Submission #1463)

Introduction/Background Seizures are the most common neurologic disorder in children, with up to 6% of all children having at least one episode by the age of 16.1 The annual incidence of CSE is reported to be ten to 73 episodes/100,000 children and the mortality reported to be between 2.7% and 8% with an overall morbidity between 10 and 20%.2 Therefore, early recognition of CSE is paramount to timely intervention, which often requires a coordinated effort of the resuscitating team and is amenable to high-fidelity simulation.3,4 Study Objective: Current high-fidelity pediatric mannequins provide multiple functionalities; however, a cost-effective, wireless mechanism simulating a partial seizure for a child-sized mannequin has not been described. Our goal was to build an inexpensive, wireless partial seizure mechanism for our pediatric status epilepticus simulation scenario to move either a leg or arm of a child-sized high-fidelity manikin. Methods A sufficient motorized device was found in an infant toy available for approximately 30 dollars (US). The toy’s internal motor, which drove an eccentric gear transmission causing a vibration effect, was disconnected from the wiring to the toy circuit rewired to the receiver circuit. The transmitter and receiver components of the gadget were found in a remote-controlled toy car for approximately ten dollars (US). The transmitter unit was powered by two AA batteries supplying 3.0 volts DC to a circuit with a 49 MHz radio frequency (RF) transmitter. The movement of either thumb knob controllers switches caused an RF transmission which activated two different channels (forward/backward, right/left) on the receiver circuit. The receiver embedded in the car was powered by two AAA batteries, supplying 3.0 volts DC to the circuit, housing a power switch. With the receiver power switch in the ‘on’ position, and the transmitter thumb knobs moved, the motor was powered and activated, causing the vibratory effect desired. A small 4 x 2 inch compartment was cut into the foam cushion of the gurney where the manikin calf and heel region would rest. The seizure gadget was placed inside with the extension of the motor compartment right side up. The leg was placed on top of the motor and secured with Velcro® straps to the gurney to avoid displacement. The leg was draped with a hospital sheet which accentuated the movement of the limb. This device was incorporated into the Pediatric Simulation Program at our institution for the status epilepticus scenario in an eight year old boy with severe pneumonia and hyponatremia. During the simulation, the facilitator could discretely control the duration and frequency of vibration of the leg from up to 15 feet away without interference from other electronic devices. To date, we have used the seizure gadget in three simulations in the high-fidelity suite as well as one in-situ simulation in the general pediatric ward. In each session, the gadget was able to achieve the intended effect of simulating seizure activity and the participants acknowledged the movement as such in each simulation. Results: Conclusion The literature shows high simulator validity is crucial to enhance the realism of a simulation session and subsequently education for participants, improving their skills and responses to critical events.5 We have demonstrated that an inexpensive and compact wireless seizure gadget can be constructed from commercial toy parts and incorporated into a simulation scenario depicting partial complex seizures in a child-sized manikin. References 1. Fleisher GR. Textbook of Pediatric Emergency Medicine. 6 ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. 2. Sofou K, Kristjansdottir R, Papachatzakis NE, Ahmadzadeh A, Uvebrant P. Management of prolonged seizures and status epilepticus in childhood: a systematic review. Journal of child neurology. Aug 2009;24(8):918-926. 3. Daniels K, Parness AJ. Development and use of mechanical devices for simulation of seizure and hemorrhage in obstetrical team training. Simulation in healthcare : journal of the Society for Simulation in Healthcare. Spring 2008;3(1):42-46. 4. Lemke D, Feux D, Doughty C. A novel mechanism for simulation of partial seizures in an infant. Simulation in healthcare : journal of the Society for Simulation in Healthcare. Dec 2012;7(6):359-361. 5. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical teacher. Jan 2005;27(1):10-28. Disclosures None.

The Use of Humor to Enrich the Simulated Environment

Humor in simulation is no laughing matter, as this chapter explains. That’s right; this chapter is more about “reining in” your humor than anything else. Humor is best served in small portions, like Godiva truffles, so pick your “insert humor here” moments carefully. We examine three questions—“Should you include humor?” (Yes.) “Should you study humor?” (Yes.) And finally, “Do you always deliver the punch line while answering the third question?” (Take my mannequin, please!) We will actually look at the literature on humor (talk about a laugh a minute!) and see how humor aids the educational process. And we’ll do all this in side-splitting fashion; who knew learning could be so much fun?