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1796415-48977900Simulation Case: Cardiac Arrest After Carbon Dioxide EmbolismDepartment of Anesthesiology CurriculumLoma Linda University Medical Simulation CenterCreated March 2015Table of ContentsInstructor discussion guide3Target audience and learning objectives6Simulation lab set-up instructions8Case narrative9Instructor notes10 Debriefing plan11Guided study questions and answers13Appendix 1: Simulation instructions16Appendix 2: Faculty evaluation of learner19Appendix 3: Learner evaluation of simulation20References21INSTRUCTOR DISCUSSION GUIDESimulation Case: Cardiac Arrest Following Carbon Dioxide EmbolismIntended Use of Case: Education of anesthesiologists in practice, anesthesiology residents and fellows, senior medical students, certified registered nurse anesthetists (CRNA), certified registered nurse anesthetist students (SRNA). This scenario may also be used for interdepartmental training with surgeons in practice, surgery residents, and operating room nurses. Purpose: In this simulation exercise, the learner manages cardiac arrest secondary to carbon dioxide (CO2) embolism after the surgeon inadvertently places a Veress needle into the inferior vena cava (IVC) and begins CO2 insufflation. This simulation provides an opportunity for the learner to formulate a differential diagnosis, communicate and effectively implement a treatment plan, and mobilize additional resources during a crisis situation.Educational Objectives:Identify potential causes of an acute drop of end-tidal CO2 leading to cardiac arrest and prioritize the differential diagnosis including: Carbon dioxide (CO2) embolism; pulmonary thromboembolism; incorrect placement of endotracheal tube (including kinked or obstructed endotracheal tube or breathing circuit); pneumothorax; acute coronary syndrome; cardiogenic shock.Implement treatment strategies for cardiac arrest including: Calling for help; notifying surgeon of drop in end-tidal CO2 and the suspected cause; changing patient position to left lateral decubitus; auscultating for a mill-wheel precordial murmur; detecting CO2 embolism via transesophageal echocardiography, precordial Doppler, or transesophageal Doppler; establishing additional intravenous access; placing invasive monitors; administering fluids and vasopressors; investigating alternative causes of cardiac arrest if data do not support initial suspicions.Initiate and correctly execute the Advanced Cardiac Life Support pulseless electrical activity algorithm.Evaluate for secondary injury such as inferior vena cava injury or cardiac injury resulting from hypotension. Collaborate with surgeon to determine whether immediate surgical intervention is required (ex. repair of inferior vena cava injury), or whether further surgical intervention will be deferred. Discuss appropriate patient disposition (Intensive Care Unit, step-down unit, etc.) and goals for post-operating room care with surgeon. Determine whether cardiology consultation is indicated given the patient’s age and post-cardiac arrest status. Determine whether the patient may be discharged to home if she is extubated at the end of anesthetic, returns to her baseline neurologic status, has stable vital signs, and the period of cardiac arrest was extremely plete comprehensive post-event debriefing to enable the learner to internalize the debriefing process and assimilate the experience into clinical practice.Attached Case Files:Please review files in the order listed in this instructor guide.Simulation Case: Cardiac Arrest During Carbon Dioxide EmbolismIncludes list of materials required in simulated operating room Lab results – to be presented verbally or to be distributed in hard copy as requested by the learnerAppendix 1 - Simulation Instructions Includes instructions for sample simulation programDesigned for adult manikin (ex. Laerdal SimMan?)Cardiac rhythm included with each simulation stateAppendix 2 – Evaluation FormTo be completed by faculty running simulation scenarioIncorporates primary and secondary learning objectivesConceptual Background:This simulation was created as part of our core Anesthesiology Simulation Curriculum. Carbon dioxide (CO2) embolism is a rare, but potentially life-threatening complication of laparoscopic surgery. The clinical presentation is variable, ranging from asymptomatic to cardiovascular collapse or death, and depends on the rate and volume of carbon dioxide entrapment within major vascular structures. This simulation requires the participant to quickly formulate a differential diagnosis, recognize a CO2 embolism, initiate treatment including Advanced Cardiac Life Support, and determine appropriate post-event patient disposition. Implementation:Set-up15 MINPreparation10 MINSimulation15-20 MINDebrief20 MINTwo confederates are needed to serve as the surgeon and the circulating nurse. Faculty assistance with debriefing is described as highly beneficial by participants.Limitations:While we provide a learner evaluation tool, it has not been formally validated for resident evaluation. Rather, the tool provides faculty members with information regarding overall knowledge gaps that should be highlighted during simulation debriefing. Our simulation program provides various physiologic “states” as the patient’s condition worsens. Learner actions may deviate from the expected sequence of events, requiring faculty members to quickly alter the simulation program. As a result, the faculty or technician controlling the manikin must have knowledge of how to control a simulation manikin. Making the manikin respond to the learner’s management decisions provides a more realistic learning experience.Future Directions:We aim to run this case as an inter-disciplinary exercise involving general surgeons and operating room staff (nurses, technicians, etc.) as well as anesthesia providers. This will allow us to assess team dynamics and crisis resource management skills among health care providers who work together clinically. An inter-disciplinary debriefing will allow learners to better understand the concerns and priorities of different care providers during a crisis situation.INSTRUCTOR’S GUIDESIMULATION CASE: CARDIAC ARREST AFTER CARBON DIOXIDE (CO2) EMBOLISMTarget Audience:Anesthesiologists in practiceAnesthesiology residents and fellows (PGY 2 - PGY 5)Interdepartmental residents completing a rotation in anesthesiaMedical students (third and fourth year)Certified registered nurse anesthetistsStudent registered nurse anesthetistsOperating room nursing staffSurgeons in practiceSurgery residentsLearning ObjectivesPrimary ObjectivesIdentify potential causes of an acute intraoperative decrease in end-tidal carbon dioxide (ETCO2) leading to cardiac arrest and prioritize the differential diagnosis including: Carbon dioxide (CO2) embolism; pulmonary thromboembolism; incorrect placement of endotracheal tube (including kinked or obstructed endotracheal tube or breathing circuit); pneumothorax; acute coronary syndrome; cardiogenic shock.Identify potential sources of CO2 embolism including: Inadvertent Veress needle placement into the uterine wall, the hepatic vasculature, the aorta, or the inferior vena cava. Implement treatment strategies for severe intraoperative hypotension secondary to acute CO2 embolism including: Calling for help; notifying surgeon of drop in end-tidal CO2 and the suspected cause; changing patient position to left lateral decubitus/Trendelenburg; auscultating for a mill-wheel precordial murmur; detecting CO2 embolism via transesophageal echocardiography, precordial Doppler, or transesophageal Doppler; establishing additional intravenous access; placing invasive monitors; administering fluids and vasopressors; investigating alternative causes of cardiac arrest if data do not support initial suspicions.Initiate and correctly execute the Advanced Cardiac Life Support (ACLS) (1) pulseless electrical activity (PEA) algorithm.Evaluate for secondary injury such as inferior vena cava injury or cardiac injury resulting from hypotension. Collaborate with surgeon to determine whether immediate surgical intervention is required (ex. repair of inferior vena cava injury), or whether further surgical intervention will be deferred. Discuss appropriate patient disposition (Intensive Care Unit, step-down unit, basic floor, home, etc.) and goals for post-operating room care with surgeon. Determine whether cardiology consultation is indicated given the patient’s age and post-cardiac arrest status. Determine whether the patient may be discharged to home if she is extubated at the end of anesthetic, returns to her baseline neurologic status, has stable vital signs, and the period of cardiac arrest was extremely brief. Complete thorough debriefing to enable the learner to internalize the debriefing process and assimilate the experience into clinical practice.Secondary ObjectivesRecognize the causes of and correctly diagnose PEA. Effectively communicate patient's rapidly deteriorating clinical status to surgeon; prioritize actions needed to address clinical condition.Engage other health care providers to assist in patient care.Call for help. Appropriately delegate responsibilities to responders.Maintain effective closed-loop communication with surgical team during crisis situation.Demonstrate appropriate professional composure during ACLS and within communication with other team members.Critical Actions ChecklistComplete pre-anesthetic evaluation, including focused history and physical examinationPerform intravenous induction of general anesthesiaPerform endotracheal intubationRecognize acute decrease in ETCO2Confirm endotracheal tube positioningCommunicate need to stop CO2 insufflationChange patient position to left lateral decubitus/Trendelenburg Check for pulseInitiate ACLS pulseless electrical activity algorithmDiscuss need for continued surgical intervention in setting of inferior vena cava injury with surgeonDiscuss appropriate patient disposition and goals for post-operating room care with surgeon Determine whether patient may be discharged to home if the period of cardiac arrest was extremely brief and she has returned to her neurologic and hemodynamic baselineEnvironmentLab Set Up – Operating RoomManikin Set Up:Adult manikin in supine positionOne peripherally inserted central catheter (PICC) attached to crystalloid fluidFluids available in OR: Crystalloid (attached to PICC), one bottle simulated albuminMonitors Required:Non-invasive blood pressure cuffFive-lead electrocardiogramPulse oximeterCapnograph (end-tidal CO2 detector)Temperature probeOther Equipment Required:Laparoscopic video monitorCO2 insufflatorVeress needleEndotracheal tube LaryngoscopeOral airwaysAnesthesia machine with oxygen sourceSuction StethoscopeBag-valve-maskLabeled syringesIntravenous fluids and linesInfusion pumpsDefibrillator ActorsAnesthesia providerPlayed by learnerManages anestheticCirculating nursePlayed by confederateReceives directives from anesthesia providerAssists with ACLS as directed by learnerPrompts anesthesia provider for post-operative patient dispositionSurgeonPlayed by confederatePlaces Veress needle and initiates CO2 insufflation of abdomen Assists with ACLS as directed by learnerCase NarrativePatient History: Samantha Bond is a 68-year-old woman (weight: 55 kg, height: 62 in) with chronic abdominal pain and decreased PO intake on total parenteral nutrition thought to be secondary to adhesions from four prior abdominal surgeries. She is scheduled for laparoscopic versus open lysis of abdominal adhesions. The patient is in the operating room awaiting induction of general anesthesia.Case status (upon request): Intravenous access: PICC line in left upper extremityInvasive monitors: NoneReview of Systems:CNS: NegativeCardiovascular: Hypercholesterolemia, otherwise negativePulmonary: Active tobacco use (30 pack-year smoking history); uses albuterol inhaler as needed for wheezing Renal / Hepatic: NegativeEndocrine: NegativeHeme/Coag: NegativeCurrent Medications and Allergies:Home medications: Simvastatin, albuterol inhaler as neededAllergies: No known drug allergiesPhysical Examination:General: Alert and oriented x 3; no apparent distressWeight, Height: 55 kg, 62 inVital Signs: Temp - 36.6° C; BP - 163/68; HR - 82; RR - 20; O2 sat - 96% room airAirway: Mallampati II, thyromental distance 2.5 cm, no loose teeth Lungs:Clear to auscultation bilaterallyHeart:Regular rate and rhythm, no murmursAbdomen: Soft, mildly-tender, and non-distendedExtremities: No cyanosis or edemaLaboratory, Radiology, and Other Relevant Studies:Provided (pre-operative values):Hemoglobin 15.8 g/dL; platelets 158 x 109/LSodium 138 mEq/L; potassium 4.3 mEq/L; creatinine 0.6 mg/dL, glucose 112 mg/dLBaseline Simulator State: Vitals: HR- 90; BP- 148/58; RR- 20; O2 Sat 96%; Neurologic: Awake and conversantRespiratory: Lungs clear to auscultation bilaterally.Cardiovascular: NSRGastrointestinal: WNLGenitourinary: WNLMetabolic: WNLEnvironmental: Normothermia, 36.8°CBranch pointsSurgeon places Veress needle and begins CO2 insufflation of abdomen: Acute CO2 embolus resulting in decreased ETCO2, hypotension, and hypoxia. Hypotension is refractory to vasopressors and crystalloid administration: Patient in PEA and ACLS initiated.Third dose of epinephrine administered during ACLS: Return of spontaneous circulation, though remains hypotensive.Continued fluid and vasopressor administration: Patient stable and normotensive.Instructor NotesThis scenario was developed to provide participants with a simulated experience involving a severe complication of laparoscopic surgery. The patient, Samantha Bond, is a 68-year-old woman with chronic abdominal pain who is scheduled to undergo a laparoscopic versus open lysis of abdominal adhesions. The patient is awake and conversant in the operating room, awaiting the induction of general anesthesia.The learner is given the opportunity to conduct a pre-anesthetic evaluation, including a focused history and physical examination. Induction of general anesthesia and endotracheal tube placement are uneventful. The patient is prepped and draped for surgery. The surgeon introduces a Veress needle into the patient's abdomen and begins CO2 insufflation to create pneumoperitoneum. Unbeknownst to the learner, the surgeon has inadvertently placed the Veress needle within the inferior vena cava. CO2 insufflation results in a CO2 embolism manifesting as decreased ETCO2, hypoxia, and hypotension. Blood pressure does not improve despite IV fluid or vasopressor administration. Eventually, the patient experiences cardiac arrest, with cardiac rhythm analysis revealing PEA. Successful learners will develop a differential diagnosis for intraoperative decrease in ETCO2, diagnose acute CO2 embolism, communicate the patient's change in status to the operating room team, call for help, consider turning the patient to the left lateral decubitus/Trendelenburg position if it does not interfere with ACLS, and activate the ACLS algorithm for pulseless electrical activity. Assuming ACLS guidelines are followed, return of spontaneous circulation will occur after two doses of epinephrine. Please refer to Appendix 1 for sample Simulation Instructions. A discussion between the learner and the surgeon should occur regarding immediate post-arrest management. Specifically, this conversation should address whether immediate care of the patient’s inferior vena cava injury and/or lysis of adhesions should be undertaken, or whether further operative management should be deferred. The learner should discuss appropriate post-operating room disposition with the surgeon (Intensive Care Unit, step-down unit, basic floor, home, etc.). Collaboratively, they should determine whether the patient may be discharged to home if she is extubated at the end of anesthetic, returns to her baseline neurologic status, has stable vital signs, and the period of cardiac arrest was extremely brief. They should also determine whether cardiology consultation is indicated given the patient’s age and post-cardiac arrest status. Limitations to this case include facility manpower to run the simulation, requiring a minimum of two confederates (surgeon and circulating nurse) to play appropriate roles. The reproducibility and replication of the scenario is dependent on the familiarity of the trainee with the surgical procedure, causes of decreased intraoperative ETCO2, treatment of acute CO2 embolism, and ACLS. Anticipation of learner skill level by faculty may be beneficial in guiding desired learner actions to prevent early termination of the case.Debriefing PlanCarbon dioxide (CO2) embolism is a rare, but potentially life-threatening complication of laparoscopic surgery. The clinical presentation is variable, ranging from asymptomatic to cardiovascular collapse or death, and depends on the rate and volume of carbon dioxide entrapment within major vascular structures. Most cases of serious carbon dioxide embolism occur at the beginning of laparoscopic procedures, due to inadvertent placement of the Veress needle into a large vein, artery, or solid organ during establishment of pneumoperitoneum. Potential sites of CO2 entrapment include the uterine wall, the hepatic vasculature, the aorta, and the inferior vena cava. CO2 is the gas of choice for pneumoperitoneum because it is chemically inert, colorless, inexpensive, and less combustible than air. It is highly soluble in blood and is rapidly absorbed across the peritoneum.Two conditions are necessary for a CO2 embolism to occur: 1) communication between a source of CO2 and the patient’s vasculature, and 2) a pressure gradient between the two sources (2). Although similar to a venous air embolism (VAE), a CO2 embolism results from active administration of pressurized carbon dioxide gas via surgical equipment, whereas a VAE is caused by passive entrainment of atmospheric air, classically occurring during surgery in the sitting position. In the case of VAE, the operative field is above the level of the heart, creating a negative pressure gradient and drawing air into the low-pressure venous system. In either case, once gas enters the right ventricle it may cause a physical blockage of outflow into the pulmonary artery, leading to cardiovascular collapse. If the gas enters the pulmonary vasculature it may cause severe vasoconstriction, bronchoconstriction, and worsening right heart strain. Both the volume of gas delivered and the speed at which it is delivered are important factors. If a small amount of air is present (0.5 ml/kg), signs would include wheezing, altered mental status, and decreased ETCO2. In some cases, a sudden transient increase in ETCO2 may be seen at this time (3). Once the volume of gas reaches 0.5-2.0 ml/kg, signs including hypotension, pulmonary hypertension with right heart strain, myocardial ischemia, and cerebral ischemia may be present. At these gas volumes, ETCO2 is expected to decrease due to a lack of perfusion within the pulmonary vasculature. A massive embolism with a gas volume >2 ml/kg results in complete cardiovascular collapse (4). The most sensitive monitor for gas embolism is echocardiography, which is able to detect as little as 0.02 ml/kg of gas. Although not as sensitive, a noninvasive precordial Doppler Ultrasound is also very good at detecting emboli down to 0.05 ml/kg of air. Other monitors by which an embolus may be diagnosed include end-tidal CO2 monitor, end-tidal N2 monitor (to differentiate between air and CO2 etiologies) and the pulmonary artery catheter (2). Auscultation of the heart may reveal a mill-wheel precordial murmur. Treatment centers on reducing the insoluble gas volume within the heart. The surgeon should immediately be informed of suspected CO2 embolus, and CO2 insufflation discontinued. Therapies include administration of 100% FiO2 and avoidance of nitrous oxide, which may further expand the intra-cardiac gas bubble. Steep Trendelenburg and left lateral position (Durant’s position) is classically employed to allow gas bubbles to rise to the apex of the right atrium and away from the pulmonary vessels, but there is no human data on its efficacy (4). Hyperventilation speeds the removal of CO2 from the vascular system (5). Intravenous fluids should be administered to maintain adequate central venous pressure. Relevant ACLS algorithms should be initiated if the patient is in cardiac arrest. If a central venous catheter is present, its distal port may be used to aspirate the attempt aspiration of intracardiac CO2 (4,6).Overall prognosis is dependent on the volume and rate of CO2 entrained (3). Discharge to home may be entertained if only a small amount CO2 is entrained, there are no prolonged hemodynamic or electrocardiographic changes, and the patient remains at baseline neurologic status. If an intraoperative cardiac arrest has occurred, the patient’s disposition requires further assessment. Therapy is largely supportive. Inpatient observation and targeted therapies must be initiated if there is concern for end-organ damage. Suspected myocardial damage should be investigated with an electrocardiogram, cardiac enzymes, and possibly an echocardiogram. If there is concern for neurologic injury, imaging should be obtained and the initiation of therapeutic hypothermia should be considered. Though exact temperature goals has been debated, avoidance of hyperthermia is important for neuroprotection (7, 8). Hyperbaric oxygenation therapy has also been used after a CO2 embolism to reduce the size of CO2 bubbles in the vasculature (5). Reust et al. administered hyperbaric oxygenation therapy after a CO2 embolism at 2.8 atm for 90 minutes; the patient recovered with no adverse sequelae (9). a. Individual or group debriefing, with or without video playbackUtilize self and/or peer rating of performanceIdentify and discuss anesthetics issues, psychological impact, patient issues, and surgical issuesIdentify the impact of the experience, clarify facts and concepts used in the simulation, and defuse the emotional experience of the learner to facilitate achieving the learning objectives of the simulationApply the simulator experience to the real clinical world and evaluate behaviors that emerged in the scenarioGuided Study Questions:What is the expected change in ETCO2 during insufflation of the abdomen for a laparoscopic procedure?Answer: The ETCO2 should increase due to absorption of exogenous CO2 from the pneumoperitoneum. Additionally, increased intra-abdominal pressure may impair ventilation leading to a further increase (10).What is the differential diagnosis for a sudden increase in end-tidal CO2 during establishment of pneumoperitoneum?Answer: small CO2 embolism, hypoventilation, normal CO2 absorption, increased muscular activity, malignant hyperthermia, bicarbonate infusion.What is the differential diagnosis for a sudden drop in end-tidal CO2?Answer: There are two broad categories which can cause this: decreased lung perfusion and ventilation issues. Decreased lung perfusion examples include: hypotension caused by carbon dioxide (CO2) embolism, thromboembolism, hemorrhage, tension pneumothorax, anesthetic overdose, venous obstruction, acidosis, cardiac arrhythmias, cardiac tamponade, anaphylaxis, accidental intravenous injection of local anesthetic. Ventilation examples include: incorrect placement of endotracheal tube, kinked or obstructed endotracheal tube or breathing circuit, or hyperventilation.How can a CO2 embolism be differentiated from a venous air embolism?Answer: The signs and symptoms are the same with the exception of end-tidal N2, which would increase for VAE and decrease for CO2 embolism.What is the expected PaCO2 following a CO2 embolus?Answer: The PaCO2 will increase due to impaired ventilation and the presence of exogenous CO2 (4, 5).What is the treatment for a CO2 embolism?Answer: The treatment depends on the volume of air entrained. If the vitals are stable, then stopping the entrainment of CO2 and ventilation with 100% FiO2 may be adequate. If, however, the patient is unstable, supportive care through ACLS protocol, hyperventilation with 100% FiO2, and placement in left lateral decubitus position may be necessary (5). One may also consider hyperbaric O2 therapy. Hyperthermia should be avoided if neurologic injury is suspected (7,9).What pathophysiologic changes occur during CO2 embolism?Answer: The most devastating change with a CO2 embolism is right ventricle outflow or pulmonary artery obstruction, leading to right heart failure and cardiovascular collapse. Also seen are pulmonary hypertension, systemic hypotension, arrhythmia, tachycardia, bradycardia or asystole, decrease in PaO2, and respiratory acidosis secondary to an increase in PaCO2 (4, 5).If you suspected a CO2 embolism, what monitors would you place and why?Answer: Besides American Society of Anesthesiologists standard monitors, one could consider obtaining central venous access for administration of vasopressors, and possible aspiration of intra-cardiac gas. The insertion of a central venous catheters carries its own risk of VAE.(11) An arterial line would also be of benefit for blood pressure monitoring and blood gas sampling.What position should you consider putting the patient in if you suspect a CO2 embolism?Answer: Left lateral decubitus position theoretically would reduce right ventricular and pulmonary artery obstruction while Trendelenburg positioning would prevent embolic spread to the brain. We would consider this position if it did not interfere with other therapies such as ACLS. Data for the use of this position is only available in dogs; there are no human studies to date (12).Can air be aspirated through a PICC line if CO2 embolism is suspected?Answer: Not likely. The PICC has a high resistance due to its long length and small lumen. Additionally, the catheter tip of a properly positioned PICC is located outside the right atrium in the superior vena cava (SVC), which leaves it unable to aspirate intra-cardiac air. It is worth attempting but will not likely yield results. What are the causes of pulseless electrical activity?Answer: Hypoxia, acidosis, severe hypovolemia, thromboembolism, gas embolism, tension pneumothorax, coronary occlusion, electrolyte abnormalities, toxins, tamponade (1).When do you consider therapeutic hypothermia on a patient and what temperature is appropriate?Answer: Unconscious adults with spontaneous circulation after cardiac arrest. Temperature goals remain controversial, but hyperthermia should be avoided (7).Why is hyperbaric oxygenation therapy thought to help improve patient outcomes after CO2 air embolism?Answer: Hyperbaric oxygenation is thought to reduce the size of intravascular CO2 bubbles (9). Pilot Testing and RevisionsA. Number of participants: this scenario was tested on 3 residentsB. Anticipated management mistakes: Depending on your hospital’s requirements, trainees participating in this exercise may not have completed ACLS certification through the American Heart Association. We recommend having copies of ACLS algorithms available as cognitive aids to learners (1). Learners may be slow to change patient position during resuscitation. The circulating nurse or surgeon may need to prompt the learner to do so. C. Faculty evaluation of learner: please refer to Appendix 2D. Evaluation form for participants: please refer to Appendix 3 AuthorsBryan Halverson, M.D. (Corresponding Author)Assistant Professor of AnesthesiologyDepartment of Anesthesiology, Loma Linda University School of MedicineDepartment of AnesthesiologyLoma Linda University Medical Center11234 Anderson Street, Room 2532Loma Linda, CA 92354Phone: 909-558-4475 Fax: 909-558-4143 Email: bhalverson@llu.eduMathew R. Malkin, M.D.Assistant Professor of AnesthesiologyDepartment of Anesthesiology, Loma Linda University School of MedicineJohn Lenart, M.D.Assistant Professor of AnesthesiologyDepartment of Anesthesiology, Loma Linda University School of MedicineMarissa G. Vadi, M.D., M.P.H. Assistant Professor of AnesthesiologyDepartment of Anesthesiology, Loma Linda University School of Medicine Please attribute work to the Department of Anesthesiology at the Loma Linda University School of Medicine.APPENDIX 1: SIMULATION INSTRUCTIONS (13)StatePatient StatusStudent learning outcomes or actions desired and trigger to move to next state1. BASELINE(0:00)Awake HR 84BP 164/63RR 14SpO2 98%Temp 36.8°COn room airLearner Actions: Interview patientConfirm history of present illness and past medical historyPerform focused physical examination including airway examinationOperator: Read case stem to learnerAnswer learner’s questions using voice of patientTeaching Points: Pre-anesthetic history and physical Trigger: Learner induces general anesthesia 2. Induction (3:00)AnesthetizedHR 106BP 82/44RR 10SpO2 96%Temp 36.4°CETCO2: 36Learner Actions: Induce general anesthesiaConfirm satisfactory endotracheal tube position Notify surgeon when anesthetic induction complete Operator: Phenylephrine increases BP to 106/55, decreases HR to 75Confederate: Nurse: apply sterile prep to patient’s abdomenSurgeon: apply sterile drapes; ask learner when surgical procedure may begin; place Veress needle and begin CO2 insufflationTeaching Points:Confirmation of endotracheal tube placementTrigger: Surgeon places Veress needle and begins CO2 insufflation3. CO2 embolism(6:00)AnesthetizedHR 49BP 52/25RR 14SpO2 74%Temp 36.2°CETCO2: 6Learner Actions: Identify acute decrease in ETCO2Re-confirm satisfactory endotracheal tube positionInstruct surgeon to discontinue CO2 insufflationChange patient position to left lateral decubitus with steep TrendelenburgCall for help100% oxygenTurn off volatile anesthetic Administer IV fluids and vasopressorsOperator: Vasopressor and IV fluids do not improve hypotensionProceed to “4. Pulseless Electrical Activity” regardless of intervention.Operator: Surgeon: "What do you think is going on?” Teaching Points: When to call for assistanceEffective communication of changes in patient's status with surgeon and nurseDifferential diagnosis for acute intraoperative decrease in ETCO2 Trigger: No trigger4. PULSELESS ELECTRICAL ACTIVITY (PEA)(8:00)AnesthetizedHR 55BP noneRR 14SpO2 noneTemp 35.7°CETCO2: 0Learner Actions: Identify pulseless electrical activity and notify surgeon of critical change in patient's conditionContinue 100% oxygenPlace defibrillator padsInitiate ACLSOperator: Patient remains in PEA until 2nd round of epinephrine givenConfederate: Nurse: “Doctor, how are we going to do chest compressions with the patient in the lateral position?”Teaching Points: Differential diagnosis for PEA (5 H’s & T’s)CPR is less effective when not in the supine positionTrigger: 2nd round of epinephrine given5. RETURN OF SPONTANEOUS CIRCULATION (12:00)HR 134 (sinus)BP 75/35RR 14SpO2 92%Temp 35.1°CETCO2: 75ABG: 7.14/82/283/14Base Def -12 Hgb 13.2Lactate 8.2Na 138K 4.9, ionized Ca 1.12Learner Actions: Place arterial lineCheck ABG, electrolytesConsider administration of amnestic agentConsult critical care specialist for possible therapeutic hypothermia after cardiac arrestOperator: BP improves over 1 min to 96/48 with return of circulationConfederate:Surgeon: “What do we do now? Can I do the case?”Teaching Points: Inclusion/exclusion criteria for therapeutic hypothermia after cardiac arrestTrigger: No trigger6. stable normotensive (15:00)HR 95BP 100/65RR 14SpO2 100%Temp 35.6°CETCO2: 40Learner Actions: Determine appropriate postoperative setting for patient (PACU, ICU, etc.)Determine what studies need to be done to evaluate end organ damageOperator:Maintain patient's hemodynamic statusConfederate:Nurse: “Where will the patient be going after he leaves the OR?”Surgeon: “Can we extubate? The patient is stable.”Teaching Points: Extubation criteriaAppropriate patient disposition after critical intraoperative eventAPPENDIX 2: FACULTY EVALUATION OF LEARNER Learner’s Name: _______________________ Yes No N/AIdentifies potential causes of acute hypotension/hypocarbia and prioritizes the differential diagnosis.ACGME Core Competencies: Patient Care, Medical KnowledgeConfirms endotracheal tube is in correct position.ACGME Core Competencies: Patient Care, Medical KnowledgeEffectively communicates patient’s deteriorating clinical status to surgeon and circulating nurse.ACGME Core Competencies: Patient Care, Interpersonal and Communication Skills, ProfessionalismCalls for help. Appropriately delegates responsibilities to responders.ACGME Core Competencies: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Systems Based PracticePlaces patient into left lateral decubitus/Trendelenberg position.ACGME Core Competencies: Patient Care, Medical KnowledgeInitiates and correctly executes the ACLS pulseless electrical activity algorithm.ACGME Core Competencies: Patient Care, Medical KnowledgeMaintains effective closed-loop communication with other health care providers during crisis situation.ACGME Core Competencies: Patient Care, Interpersonal and Communication Skills, ProfessionalismDemonstrates appropriate professional composure during ACLS. ACGME Core Competencies: Patient Care, Interpersonal and Communication Skills, ProfessionalismConsiders need for post-arrest cardiology consultation.ACGME Core Competencies: Patient Care, Medical KnowledgeArranges for appropriate patient disposition (ICU).ACGME Core Competencies: Patient Care, Medical Knowledge, Systems Based PracticeIdentifies personal strengths, deficiencies, and knowledge limitations during debriefing. ACGME Core Competencies: Practice-Based Learning and Improvement APPENDIX 3: LEARNER EVALUATION OF SIMULATIONSimulation goals and objectives were stated clearly. Simulation goals and objectives were met.The simulation was educational and I learned something from it.What I learned in simulation will change/improve my practice.The instructors communicated well with participants and were effective leaders in this scenario.The instructors created a positive learning environment.The feedback I received during the simulation debriefing was beneficial. I would recommend this simulation to a colleague.Additional Comments:Please rate each statement: Agree = 1; Disagree = 2; Neutral = 3REFERENCESNeumar RW, Otto CW, Link MD, et al. Part 8 adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;123(6):e480.O'Dowd LC and Kelley MA. Air embolism. Available at: . Accessed August 7, 2015.Sollazzi L, Perilli V, Punzo G, et al. Suspect carbon dioxide embolism during retroperitoneoscopic adrenalectomy. Eur Rev Med Pharmacol Sci 2011;15(12):1478-1482.Mirski MA, Lele AV, Fitzsimmons L, et al. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007;106:164-177. Park E, Kwon J, Kim K. Carbon dioxide embolism during laparoscopic surgery. Yonsei Med J 2012;53(3):459-466.Shaikh N and Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock 2009;2:180-185.Kaneko T and Kasaoka S. Effectiveness of lower target temperature therapeutic hypothermia in post-cardiac arrest syndrome patients with a resuscitation interval of <30min. J Intensive Care 2015;3:28.Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33° C versus 36° C after cardiac arrest. N Engl J Med 2013;369:2197-2206.Reust RS, Diener BC, Stroup JS, et al. Hyperbaric treatment of arterial CO2 embolism occurring after laparoscopic surgery: a case report. Undersea Hyperb Med 2006;33:317-320.Perrin M, Fletcher A. Laparoscopic abdominal surgery. Contin Educ Anaesth Crit Care Pain. 2004;4(4):107-110.Vesely TM. Air embolism during insertion of central venous catheters. J Vasc Interv Radiol. 2001;12(11):1291-5.Mehlhorn U, Burke EJ, Butler BD, Davis KL, Katz J, Melamed E, et al. Body position doesn't affect hemodynamic respond to venous air embolism in dogs. Anesth Analg. 1994;79:734–9.Taekman J. Template for simulation Patient Design. Creative Commons License. Available at: . 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