Clinical Fellow in Critical Care Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; Interim Executive Director, Center for Medical Simulation, Boston, MA, USA.
J Clin Anesth. 2023 Nov;90:111235. doi: 10.1016/j.jclinane.2023.111235. Epub 2023 Aug 24.
In a perioperative emergency, anesthesiologists must acknowledge the unfolding crisis promptly, call for timely assistance, and avert patient harm. We aimed to identify vital signs and qualitative factors prompting crisis acknowledgment and to compare responses between observers and participants in simulation.
Prospective, simulation-based, observational study.
An anesthesia crisis resource management course at a freestanding simulation center.
Sixty attending anesthesiologists from a variety of practice settings.
In each case, a primary anesthesiologist in charge (PAIC) managed a simulated patient undergoing a uniformly scripted sequence of perioperative anaphylaxis and called for help from another anesthesiologist when a crisis began. Anesthesiologist observers (AOs) viewed the case separately and recorded times of crisis onset.
Simulation footage was reviewed by investigators for patient vital signs and participant behaviors at times of crisis acknowledgment, with the call for help as an explicit proxy for PAIC crisis acknowledgment. These factors were categorized, and group-level data were compared.
Nineteen PAICs and 41 AOs were included. Clinicians acknowledged crises around a mean arterial pressure (MAP) of 65 mmHg and oxygen saturation of 94% as anaphylactic shock progressed. PAICs acknowledged crises at a higher respiratory rate than AOs (20 vs. 18 breaths/min, p = 0.038). Other vitals and timing of crisis acknowledgment did not differ between PAICs and AOs. Nearly half of all participants (45%) identified crises at MAP <65 mmHg. Timing of crisis acknowledgment varied widely (range: 421 s).
Despite overall heterogeneity in clinical performance, anesthesiologists acknowledged crises per standard definitions of hypotension. Thresholds for crisis acknowledgment did not significantly differ between PAICs and AOs, suggesting minimal effect from active care responsibility. Many indicated crises at MAP <65 mmHg or after significant deterioration, risking failure-to-rescue events. We suggest that crisis management instruction should address triggers for requesting help.
在围手术期紧急情况下，麻醉师必须迅速认识到危机的发生，及时寻求帮助，并避免患者受到伤害。我们旨在确定促使危机意识的生命体征和定性因素，并比较观察者和模拟参与者的反应。
前瞻性、基于模拟的观察性研究。
一个独立的模拟中心的麻醉危机资源管理课程。
来自各种实践环境的 60 名主治麻醉师。
在每种情况下，负责的主要麻醉师（PAIC）管理一名接受统一脚本围手术期过敏反应的模拟患者，并在危机开始时向另一名麻醉师寻求帮助。麻醉师观察员（AO）分别观察病例并记录危机开始的时间。
调查人员对模拟片段进行了审查，以确定患者生命体征和参与者在危机意识时刻的行为，将求助作为 PAIC 危机意识的明确代理。这些因素进行了分类，并比较了组级数据。
共纳入 19 名 PAIC 和 41 名 AO。随着过敏反应休克的进展，临床医生在平均动脉压（MAP）为 65mmHg 和氧饱和度为 94%时承认危机。PAIC 承认危机时的呼吸频率高于 AO（20 次/分钟比 18 次/分钟，p=0.038）。PAIC 和 AO 之间其他生命体征和危机意识的时间没有差异。近一半的参与者（45%）在 MAP<65mmHg 时识别出危机。危机意识的时间差异很大（范围：421s）。
尽管临床表现总体存在异质性，但麻醉师根据低血压的标准定义承认了危机。PAIC 和 AO 之间的危机意识阈值没有显著差异，这表明主动护理责任的影响很小。许多人表示在 MAP<65mmHg 或出现明显恶化后出现危机，有失败救援事件的风险。我们建议危机管理指导应解决寻求帮助的触发因素。
