Appendix 44. Simulation Training for Pediatric Emergencies. 44A.1 Required Skills for Anesthetic Management of Children and Infants

Transcription

1 Appendix 44 Simulation Training for Pediatric Emergencies Chris Chin 44A.1 Required Skills for Anesthetic Management of Children and Infants 1 44A.2 Timetable for Pediatric Emergencies Anesthesia Training with Simulation 1 44A.3 Sudden Infant Death Syndrome (SIDS)/Ventricular Fibrillation 2 44A.3.1 Scenario Summary 44A.3.2 Key Treatment Points 44A.3.3 Configuration Instructions 44A.3.4 Console Instructions 44A.3.5 Console Progression 44A.3.6 Debriefing Summary 44A.3.7 Observer Information 44A.3.8 Role-play Instructions 44A.4 Laryngeal Spasm 2 44A.4.1 Scenario Summary 44A.4.2 Key Treatment Points 44A.4.3 Console Instructions 44A.4.4 Progression 44A.4.5 Further Progression 44A.4.6 Configuration Instructions 44A.4.7 Debriefing Summary 44A.4.8 Candidate Information 44A.4.9 Observer Information 44A.4.10 Role-play Instructions 44A.5 Pre- and Postcourse Questionnaires 4 44A.1 Required Skills for Anesthetic Management of Children and Infants Resuscitation Basic life support (BLS) and advanced life support (ALS) at all ages. Preoperative assessment and preparation. Techniques of induction, maintenance, and monitoring for elective and emergency anesthesia. Selection, management, and monitoring of children for diagnostic and therapeutic procedures carried out under sedation. Maintenance of physiology: glucose, fluids, temperature. Strategies and practice for the management of anesthetic emergencies in children: loss of airway, laryngospasm, failed venous access, suxamethonium apnea, and anaphylaxis including latex allergy. Postoperative pain management including the use of local and regional anesthetic techniques, simple analgesics, nonsteroidal antiinflammatory drugs, and use of opioids (including infusions and Patient Controlled Analgesia). Communication with pediatric patients and their family. Ref: CCST in Anaesthesia III: Competency Based Specialist Registrar Years 1 and 2 Training and Assessment. A manual for trainees and trainers (Second Edition April 2003) A.2 Timetable for Pediatric Emergencies Anesthesia Training with Simulation 08:30 START Precourse questionnaire Introductory lecture Familiarization Change into blues 09:15 1st scenario then feedback and discussion 10:00 2nd scenario then feedback and discussion 10:45 3rd scenario then feedback and discussion 11:30 4th scenario then feedback and discussion 12:15 5th scenario then feedback and discussion 13:00 LUNCH 1

2 2 Simulation Training for Pediatric Emergencies 14:00 6th scenario then feedback and discussion 14:45 7th scenario then feedback and discussion 15:30 8th scenario then feedback and discussion 16:15 Concluding remarks Postcourse questionnaire Certificates 16:30 FINISH 44A.3.5 Console Progression The child remains in VF until treated with five defibrillation shocks. A slow sinus rhythm with a faint brachial pulse then develops. This becomes a sinus tachycardia with a good output after 1 or 2 minutes. 44A.3.6 Debriefing Summary 44A.3 Sudden Infant Death Syndrome (SIDS)/Ventricular Fibrillation 44A.3.1 Scenario Summary A 4-week-old baby girl is brought in, having been found in her mother s bed, apneic, and blue. She had been sleeping beside her mother, and her mother could not be certain for how long she had been like that. The paramedics found that she was in ventricular fibrillation and delivered one shock of 2 J/kg, which led to asystole. On arrival, she was receiving basic life support and bag-valve-mask ventilation. 44A.3.2 Key Treatment Points See key treatment points. 44A.3.7 Observer Information The candidate has received a pediatric crash call to the Accident and Emergency department. 44A.3.8 Role-play Instructions Parent Anxious, you went up to feed her and found her like that. Keep asking questions, but allow yourself to be led out of the room if asked to wait in the family room. Airway Establish airway patency Breathing Bag and mask with added O 2 Intubation and ventilation with O 2 Circulation Ventricular fibrillation protocol General therapy Continuous Basic Life Support with Advanced Life Support Accident and Emergency Fellow You re competent but have minimal pediatric experience and don t know the recent Pediatric Advanced Life Support guidelines. You know the guidelines changed (in 2005). Nurse Diagnosis Ventricular fibrillation. Possible Sudden Infant Death Syndrome/asphyxia You will do what is asked, but not competently. You have very little pediatric training. Pediatrician 44A.3.3 Configuration Instructions Accident and Emergency The child is on a trolley, and is being ventilated with an Ambu bag and face mask connected to oxygen 10 L/min. 44A.3.4 Console Instructions Ventricular fibrillation (VF). Not breathing. It s your first year as a Senior House Officer (as a Resident). You ve only just started and don t know what to do. 44A.4 Laryngeal Spasm 44A.4.1 Scenario Summary A 3-year old child has been anesthetized for an inguinal hernia repair. A laryngeal mask airway has been used. A caudal has

3 Simulation Training for Pediatric Emergencies 3 been attempted, but the consultant (staff) anesthetist is not sure if it will work. He has some fentanyl available just in case. The patient is lying supine, the surgical drapes are on, and the surgeon is ready to start operating. The consultant (staff) anesthetist has to leave for an emergency elsewhere in the hospital. At the start of surgery, the patient becomes tachycardic and starts to cough, then will develop laryngeal spasm. The patient will desaturate very quickly and become bradycardic. The airway will only improve with intubation. The surgeon will be cooperative but will continue to operate unless asked to stop. IV drip in situ and iv fluids (Hartmann s 100 mls in burette) attached. Surgical drapes in place. Surgical tray for inguinal hernia repair. Intubation trolley in anesthetic room. Face mask on anesthetic machine. Ayre s T-piece available in theater. Anesthetic drugs: Propofol in 4 mls left in 10 ml syringe. Fentanyl in 1 ml syringe. Atropine and suxamethonium not drawn up but available. 44A.4.2 Key Treatment Points Management of depth of anesthesia. Assessment and management of airway and breathing. Assessment and management of bradycardia. Management of the surgical team. 44A.4.7 Debriefing Summary Management of depth of anesthesia. Assessment and management of airway and breathing. Assessment and management of bradycardia. Management of the surgical team. 44A.4.3 Console Instructions Spontaneous breathing RR 22/min. Normal breathing pattern. O 2 35%/N 2 O 65%/Iso 1.5%. HR 90/min. BP 105/50 mm Hg. 99%. 44A.4.4 Progression Coughing sound at start of surgery. RR increases to 35/min. Paradoxical respiratory pattern. Reduced lung compliance/laryngeal spasm on. HR increases to 150/min. BP increases to 140/70 mm Hg. falls to 80% and then to 60% if not intubated. HR will fall to 55/min if not intubated or during intubation. 44A.4.5 Further Progression Laryngeal spasm will resolve with muscle relaxation only. will improve following intubation and ventilation. HR will respond to an appropriate dose of atropine. 44A.4.6 Configuration Instructions Theater setup. Baby with laryngeal mask airway breathing spontaneously on circle system. 44A.4.8 Candidate Information You are taking over whilst the consultant goes to an emergency aortic aneurysm in another theater. 44A.4.9 Observer Information The candidate has been asked to take over this case whilst the consultant goes to deal with a ruptured aortic aneurysm in another theater. The patient is a 3-year-old child having an inguinal hernia repair. 44A.4.10 Role-play Instructions Surgeon You re in a hurry to proceed and to finish as you have tickets for a concert/show and the list is running late. Operating department practitioner Be helpful but anxious. You have just finished your pediatric training. Nurse Be passive. Only help when specifically asked, but do not be obstructive. Outgoing anesthetist Be concise with your handover, you have to rush down to an emergency aortic aneurysm in another theater.

4 4 Simulation Training for Pediatric Emergencies 44A.5 Pre- and Postcourse Questionnaires BARTS AND THE LONDON MEDICAL SIMULATION CENTRE Pediatric Emergencies Anesthesia Training in the Simulation Course Precourse questionnaire This evaluation questionnaire will contribute to research into the effectiveness of simulator-based training. You may remain anonymous if you wish, but please use a pseudonym! (how do you make use of a pseudonym??) Name... Date... Consultant or Specialist Registrar Year: (circle as appropriate) How many 3/6/12 months Pediatric training blocks have you done? 3/12 6/12 1 year What Simulator courses have you previously attended? How confident are you in your own ability to manage the following: (1 = not at all confident, 10 = very confident) Pediatric cardiac arrest Pediatric trauma Critically ill/septic child Preparing for retrieval Difficult pediatric airway Pediatric burns Fitting child Anaphylaxis

5 Simulation Training for Pediatric Emergencies 5 BARTS AND THE LONDON MEDICAL SIMULATION CENTRE CONFIDENTIAL Pediatric Emergencies Anesthesia Training in the Simulation Course Postcourse questionnaire This evaluation questionnaire will contribute to research into the effectiveness of simulator-based training. You may remain anonymous if you wish, but please use the same pseudonym. Name... Date... Consultant or Specialist Registrar Year: (circle as appropriate) How confident are you in your ability to manage the following? (1 = not at all confident, 10 = very confident) Pediatric cardiac arrest Pediatric trauma Critically ill/septic child Preparing for retrieval Difficult pediatric airway Pediatric burns Fitting child Anaphylaxis What was the best part of the day, and why? Do you have any constructive comments to improve this course in the future? Will today s course assist you in your daily practice? (1 = not at all, 10 = very much)