Cricothyrotomy training increases adherence to the ASA difficult airway algorithm in a simulated crisis: a randomized controlled trial.

PURPOSE: Non-adherence to airway guidelines in a 'cannot intubate-cannot oxygenate' (CICO) crisis situation is associated with adverse patient outcomes. This study investigated the effects of hands-on training in cricothyrotomy on adherence to the American Society of Anesthesiologists difficult airway algorithm (ASA-DAA) during a simulated CICO scenario. METHODS: A total of 21 postgraduate second-year anesthesia residents completed a pre-test teaching session during which they reviewed the ASA-DAA, became familiarized with the Melker cricothyrotomy kit, and watched a video on cricothyrotomy. Participants were randomized to either the intervention 'Trained' group (n = 10) (taught and practiced cricothyrotomy) or the control 'Non-Trained' group (n = 11) (no extra training). After two to three weeks, performances of the groups were assessed in a simulated CICO scenario. The primary outcome measure was major deviation from the ASA-DAA. Secondary outcome measures were (1) performance of the four categories of non-technical behaviours using the validated Anaesthetists' Non-Technical Skills scale (ANTS) and (2) time to perform specific tasks. RESULTS: Significantly more non-trained than trained participants (6/11 vs 0/10, P = 0.012) committed at least one major ASA-DAA deviation, including failure to insert an oral airway, failure to call for help, bypassing the laryngeal mask airway, and attempting fibreoptic intubation. ANTS scores for all four categories of behaviours, however, were similar between the groups. Trained participants called for help faster [26 (2) vs 63 (48) sec, P = 0.012] but delayed opening of the cricothyrotomy kit [130 (50) vs 74 (36) sec, P = 0.014]. CONCLUSION: Hands-on training in cricothyrotomy resulted in fewer major ASA-DAA deviations in a simulated CICO scenario. Training in cricothyrotomy may play an important role in complying with the ASA-DAA in a CICO situation but does not appear to affect non-technical behaviours such as decision-making.

Setting standards for simulation in anesthesia: the role of safety criteria in accreditation standards.

PURPOSE: In this article, we describe a critical event which occurred in a simulation centre, and we also review possible safety issues for participants and staff involved in medical simulation training. PRINCIPAL FINDINGS: The authors report an incident with the potential of harming trainees and staff which occurred during a full-scale simulation. The episode raised the question of training safety in simulation centres. In this instance, the computer program controlling the mannequin enabled a continuous and non-regulated outflow of carbon dioxide which led to an intense reaction in the soda lime canister. The absorbent canister became too hot to be touched (a temperature probe, later placed in the centre of the front canister, measured 53°C). All activities involving the mannequin and anesthesia machine were stopped immediately. CONCLUSIONS: Simulation in healthcare is a valuable educational tool to train for a variety of clinical encounters in a safe environment without harming a patient. Due to technological progress and the use of authentic equipment recreating near real environments, simulation training has become exceedingly realistic. The Society for Simulation in Healthcare (SSH) has published revised accreditation standards for simulation centres which incorporate training safety sub-criteria to address and manage. By highlighting recommendations of other high-risk industries on this issue, SSH proposes a possible approach to enhance safety in medical simulation.

High-fidelity simulation demonstrates the influence of anesthesiologists' age and years from residency on emergency cricothyroidotomy skills.

BACKGROUND: Age-related deterioration in both cognitive function and the capacity to control fine motor movements has been demonstrated in numerous studies. However, this decline has not been described with respect to complex clinical anesthesia skills. Cricothyroidotomy is an example of a complex, lifesaving procedure that requires competency in the domains of both cognitive processing and fine motor control. Proficiency in this skill is vital to minimize time to reestablish oxygenation during a "cannot intubate, cannot ventilate" scenario. In this prospective, controlled, single-blinded study, we tested the hypothesis that age affects the learning and performance of emergency percutaneous cricothyroidotomy in a high-fidelity simulated cannot intubate/cannot ventilate scenario. METHODS: Thirty-six staff anesthesiologists (19 aged younger than 45 years and 17 older than 45 years) managed a high-fidelity cannot intubate/cannot ventilate scenario in a high-fidelity simulator before and after a 1-hour standardized training session. The group division cutoff age of 45 years was based on the median age of our sample subject population before enrollment. The scenarios required the insertion of an emergency percutaneous cricothyroidotomy. We compared cricothyroidotomy skills in the older group with those in the younger group using procedural time, 5-point task-specific checklist score, and global rating scale score. Correlation based on age, years from residency, weekly clinical hours worked, previous continuing medical education in airway management, and previous simulation experience was also performed. RESULTS: In both prestandardization and poststandardization, age and years from residency correlated with procedural time, checklist scores, and global rating scores. Baseline, prestandardization variables were all better for the younger group, with a mean age of 37 years, compared with the older group, with a mean age of 58 years. Procedural time was 100 (72-128) seconds versus 152 (120-261) seconds. Checklist scores were 7.0 (6.1-8.0) versus 6.0 (4.8-8.0). Global rating scale scores were 22.0 (17.8-29.8) versus 17.5 (10.4-20.6). After the 1-hour standardized training session, the younger group continued to perform better than the older group with procedural time of 75 (66-91) seconds versus 87 (78-123) seconds, checklist scores of 10.0 (9.1-10.0) versus 9.0 (8.0-10.0), and global rating scale scores of 35.0 (32.1-35.0) versus 32.0 (29.0-33.8). Regression analysis was performed on the poststandardization data. Both age and years from residency independently affected procedural time, checklist scores, and global rating scale scores (all P < 0.05). CONCLUSIONS: Baseline proficiency with simulated emergency cricothyroidotomy is associated with age and years from residency. Despite standardized training, operator age and years from residency were associated with decreased proficiency. Further research should explore the potential of using age and years from residency as factors for implementing periodic continuing medical education.

Incomplete adherence to the ASA difficult airway algorithm is unchanged after a high-fidelity simulation session.

PURPOSE: Although guidelines for difficult airway management have been published, the extent to which consultant anesthesiologists follow these guidelines has not been determined. The purpose of this study is to observe how consultant anesthesiologists manage a "cannot intubate, cannot ventilate" (CICV) scenario in a high-fidelity simulator and to evaluate whether a simulation teaching session improves their adherence to the American Society of Anesthesiologists (ASA) difficult airway algorithm. METHODS: With Ethics Board approval and informed consent, all staff anesthesiologists in a single tertiary care institution were invited to enrol in this study where they managed a simulated unanticipated CICV scenario in a high-fidelity simulator. The scenario involved a patient with a difficult airway whose trachea could not be intubated and where it was impossible to ventilate the patient's lungs. Airway management options, including laryngeal mask airway, a fibreoptic bronchoscope, and a Glidescope were available for use but scripted to fail. A percutaneous cricothyroidotomy was required to re-establish adequate ventilation. Following the scenario, there was a personalized one-hour video-assisted expert debriefing focusing on the ASA difficult airway guidelines and "hands-on" cricothyroidotomy teaching. The second scenario followed immediately with an identical CICV scenario. The content to either scenario was not revealed beforehand. Outcome measures included: 1) major deviations from the ASA difficult airway guidelines; 2) time to start cricothyroidotomy; and 3) time to achieve ventilation. RESULTS: Thirty-eight anesthesiologists agreed to participate. The number of major deviations from the ASA algorithm was similar in the first and second sessions. These deviations included: multiple laryngoscopies (0 vs 2 pre-post; P = 0.49), use of fibreoptic bronchoscope (8 vs 7 pre-post; P = 1.0), bypass of laryngeal mask airway attempt (7 vs 13 pre-post; P = 0.19), and failure to call for anesthetic help (12 vs 8 pre-post; P = 0.43). However, more participants failed to call for surgical help in the second session (7 vs 16; P = 0.04). The times to start cricothyroidotomy and the times to achieve ventilation were significantly shorter in the second session (205.5 +/- 61.3 sec vs 179.7 +/- 65.1 sec; P = 0.01 and 356.9 +/- 117.2 sec vs 269.4 +/- 77.43 sec; P = 0.0002, respectively). CONCLUSION: No substantial changes in airway management in a CICV scenario were observed after an intense one-hour personalized video-assisted airway-focused simulation debriefing session with an expert. It appears that multiple factors other than airway algorithms come into play in emergency airway decision-making processes, including one's personal clinical experience with the many available airway devices.