Use of High Fidelity Simulation in Cardiac-specific Anesthesia Scenarios for Resident Education and Assessment
Use of High Fidelity Simulation in Cardiac-specific Anesthesia Scenarios for Resident Education and Assessment
High fidelity simulations provide a unique opportunity for teaching and evaluation of
 knowledge, clinical reasoning, decision making and teamwork. We have developed a series of
 novel cardiac based simulations that review difficult learning objectives of cardiac
 anesthesiology rotation. We hypothesized that residents who have completed a rotation in
 cardiac anesthesiology will perceive these simulations to be both mentally challenging and a
 useful tool in preparing them for their subsequent clinical experience and for their
 anesthesiology board. For the first time, we have used the NASA Task Load Index Scale in
 evaluating Neuro Cognitive Workload during Cardiac Anesthesia Based simulation scenarios
 .Residents who have completed the cardiac rotation at least once would be assigned the task
 in small groups either a group of 2 or group of 3.The module consists of 3 different
 scenarios. The scenarios include, weaning the patient off of cardio pulmonary bypass,
 management of severe protamine drug reaction and acute hypotension from malfunction of the
 coronary graft in a simulated operating room in real time.

 1. Setting up a Simulation Lab,almost similar to real cardiac operating rooms would have
 cardio-pulmonary bypass machine,transesophageal echocardiography images upon request,all
 emergency medications with various infusions pumps,defibrillator,real time monitors
 include EKG,SpO2,invasive arterial line,CVP,PAP,ETCO2,operating room surgical
 equipment,anesthesia machine with ventilator.

 2. Tasks Assigned to the residents

 3. Feed-back and Teaching Session

 4. At the end of each session residents are encouraged to reflect upon how they performed
 and learning gaps that they perceived and areas that they felt needed to improve upon.

 5. Feedback session would be followed by interactive teaching to reinforce the knowledge.

 6. Evaluation of Hypothesis using NASA TLX Scale. Immediately following the Simulation
 based training, residents would be given the paper based NASA TLX scale to assess the
 neurocognitive workload
The Ohio State University CSEAC Scenarios Content expert: Sujatha Bhandary MD The Ohio State
 University CSEAC 1st Scenario Development Form Scenario Name: Weaning from Cardiopulmonary
 Bypass Content expert: Sujatha Bhandary MD Date of Development: 8/29/14 Targeted Audience:
 CA-2, CA-3 anesthesia residents Simulation Platform: HPS

 Synopsis of Scenario:

 The purpose of this scenario is for the participant to take a thoughtful, systematic approach
 to weaning a patient off of cardiopulmonary bypass (CPB). Separation from cardiopulmonary
 bypass is a task which requires attention to multiple organ systems, communication with other
 members of the patient care team (i.e. surgeon, perfusionist), and a firm grasp of
 cardiopulmonary physiology. A small randomized controlled study of residents has previously
 demonstrated that simulation-based training in weaning from CPB has translated to improved
 clinical performance in the OR. While this task can at first be overwhelming for the trainee,
 high fidelity simulation provides an opportunity to practice this complex task in a safe
 environment.

 The scenario will begin with the patient under general anesthesia and on cardiopulmonary
 bypass. The surgeon will have just completed an uncomplicated triple vessel CABG on a 57 year
 old male with 45 minutes of bypass time. When the participant takes over the case the patient
 will have a junctional bradycardia (rate 40) with a MAP of 50 mmHg, a temperature of 35
 degrees celcius, and a SpO2 of 100%. The surgeon will announce that he is planning to remove
 the aortic cross clamp at which time the resident should call for their attending. The
 participant will be informed that their attending will not arrive and they will need to
 complete the task on their own. After removal of the cross clamp the patient will go into
 ventricular fibrillation. The participant will be responsible for recognizing the arrhythmia
 and treating the condition with lidocaine and defibrillation. After defibrillation the
 patient will go back into a junctional bradycardia which the participant will need to treat
 by pacing. At this point the participant will also need to begin ventilating the patient and
 treating underlying hyperkalemia (which will become evident upon obtaining an ABG). Failure
 to treat the hyperkalemia will result in refractory ventricular fibrillation. An
 echocardiogram (if requested) will reveal a normal appearing heart with good contractility.
 After pacing the patient, ventilating, and treating the underlying metabolic disturbances the
 patient can be successfully weaned off of CPB with a low dose epinephrine drip. At this point
 the scenario will end.

 Learning Objectives:

 1. Describe the conditions necessary before attempting to wean the patient from CPB

 2. Demonstrate the steps involved in weaning the patient from CPB.

 3. Communicate effectively with other members of the patient care team (i.e. perfusionist
 and surgeon) during weaning from CPB.

 4. Recognize and treat arrhythmias and metabolic disturbances prior to weaning from CPB.

 Scenario Intro (read to learner) Your patient is a 57 year old male who is undergoing a
 triple vessel CABG (LIMA to LAD, saphenous to RCA, and saphenous to OM). In addition to
 CAD the patient has a history of type 2 DM and HLD. The surgeon has just completed the
 last graft with a total bypass time of 45 minutes. The procedure has been uncomplicated
 to this point. The patient has an arterial line, a 16 g IV, and an introducer with a
 PAC. The patient is on no infusions and is receiving isoflurance via the bypass machine.
 The patient is currently paralyzed. There is a transesophageal echocardiogram available
 upon request. The surgeon has placed epicardial pacing wires. Your task will be to wean
 the patient off of CPB.

 Facilitator briefing/ Curricular information:

 Prior to receiving hand-off and beginning the scenario the participant will be handed a
 sheet with the patient's pre-op history and physical already completed. All labs and
 imaging will be provided. The resident will have the opportunity to ask additional
 questions to the departing provider. The confederates in the room will include the
 cardiac surgeon and a perfusionist. Echocardiography will be available upon request as
 will arterial blood gases. The following infusions will already be in-line but not yet
 started: epinephrine, nitroprusside, and insulin. Other cardiac drugs (lidocaine,
 amiodarone, nitroglycerine, norepinephrine, vasopressin) will be drawn up and available.
 Epicardial wires coming from the surgical field. These can be connected to a pacing box
 which will provided upon request.

 Educational Learning Model

 Prerequisites: Completion of cardiac anesthesiology rotation Didactics Needs: Powerpoint
 presentation, debriefing room Learning Method: Experiential Debriefing Method: Guided
 reflection with peer feedback. Didactic content. Preparation Supporting Files

 • Patient preoperative report

 • PowerPoint presentation Roles

 -  Cardiac Surgeon

 -  Perfusionist Setting

 -  OR

 -  Patient intubated, sedated, paralyzed, on CPB

 Monitors Available to Participant • Code Cart with pacing/defibrillation pads • EKG
 monitoring

 • Five-lead electrocardiogram

 • Pulse-oximetry

 • Temperature probe

 -  Capnography

 -  Arterial catheter

 -  Central venous catheter

 -  Pulmonary artery catheter

 -  Transesophageal Echocardiogram

 Other Equipment Required

 • Anesthesia machine that has passed the check out

 • Airway equipment on the cart including Macintosh 3 and Miller 2 blades, endotracheal
 tube sizes 6 and 7 with stylet and empty 10 mL syringe

 • Two prepared 1000 mL intravenous fluid bags on blood infusion lines

 • Pharmacologic agents available upon request: propofol, etomidate, ketamine,
 succinylcholine, vecuronium, midazolam, fentanyl, atropine, ephedrine, phenylephrine,
 epinephrine (in syringe and prepared in 100 mL saline bag), norepinephrine (in syringe
 and prepared in 100 mL saline bag), vasopressin, neostigmine, glycopyrrolate,
 metoprolol, esmolol,

 • Epinephrine, Nitroprusside, and Insulin drips connected to a manifold and in line with
 the patient's CVC

 • Yankauer suction

 • Record keeping material (computer record or paper)(IHIS)

 -  Foley catheter

 -  Video of echocardiogram of normal heart (transesophageal four chamber and
 transgastric short axis)

 -  Alaris pump for delivery for IV anesthetics (Epinephrine, Nitroprusside, and
 Insulin) Learner Information (Information given to learner during scenario)

 Scenario Introduction (give to learner in all 3 scenarios):

 Your patient is a 57 year old male who is undergoing a triple vessel CABG (LIMA to LAD,
 saphenous to RCA, and saphenous to OM). In addition to CAD the patient has a history of
 type 2 DM and HLD. The surgeon has completed the last graft with a total bypass time of
 45 minutes. The procedure has been uncomplicated to this point. The patient has an
 arterial line, a 16 g IV, and an introducer with a PAC. The patient is on no infusions
 and is receiving isoflurance via the bypass machine. The patient is currently paralyzed.
 There is transesophageal echocardiogram available. The surgeon has placed epicardial
 pacing wires. Your task will be to wean the patient off of CPB.

 General Information (SBAR):

 Name: Jerry Gergich Age: 57 Birth Date: 10/28/1957 Weight: 90 kg Height: 5'10'' Vital
 Signs: HR 65 (sinus), BP 122/80, RR 14, SpO2 98%

 Patient History:

 History of Present Illness: unstable angina x 1 month Allergies: NKDA Medications:
 carvedilol, glyburide, aspirin Past Medical / Surgical History: inguinal hernia repair
 (uneventful GA) Intake/outputs: n/a

 Symptoms:

 Events leading up to Illness: worsening chest pain Onset of symptoms: 1 month
 Provocation / provokes: exertion Severity of pain: 5/10 Review of Systems CNS: AAO x 3,
 no neurologic deficits Cardiovascular: chest discomfort with exertion, no syncope or
 dyspnea Pulmonary: normal; no wheezing, cough Abdominal: within normal limits

 Physical Exam:

 Airway: MP 2, good neck extention, normal TM distance, good oral opening Chest: RRR, no
 murmurs; lungs clear Abdominal: within normal limits Neuro: within normal limits

 Laboratory, Radiology, and Other Relevant Studies: Labs:

 -  Labs: Hct 39, platelets 360 on admission

 -  Chemistry: within normal limits

 -  Type and Cross: negative antibody screen; 4 units available

 -  PT, PTT, INR: within normal limits

 -  LHC: 90% stenosis of LCA, RCA and OM.

 -  Echo: Normal LV and RV size and function; LV EF 55%

 -  EKG: NSR, Inverted T waves in leads II and V5.

 Simulation Sequence

 1. On Bypass

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 40 50 100 n/a n/a 5 5/3 n/a 35

 EKG: junctional bradycardia Appearance/PE: intubated, sedated, paralyzed, on CPB
 Operator details: After receiving hand-off the surgeon will announce that he will soon
 be removing the aortic cross-clamp.

 Learner Objectives and Interventions: The participant should make sure he/she receives a
 thorough hand-off with a clear understanding of the patient's background and surgical
 course. The resident should call his/her attending physician in preparation for weaning
 from CPB.

 Transition Cue: Removal of Cross Calmp Go to state: Maintenance

 2. Ventricular Fibrillation

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp n/a 40 100% n/a n/a 4 5/2 n/a 35.3

 EKG: Ventricular fibrillation Appearance/PE: anesthetized, paralyzed, on CPB Operator
 details: Surgeon will continue to operate without noticing the rhythm. If the
 participant does not recognize the rhythm within 30 seconds the perfusionist will
 announce that he is giving 100 mg lidocaine via the bypass machine.

 Learner Objectives and Interventions: The participant should recognize the arrhythmia
 and direct the surgeon to administer shocks to the patient.

 Transition Cue: Defibrillation Go to state: Junctional Bradycardia

 3. Junctional Bradycardia

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 40 50 100 n/a n/a 4 5/2 n/a 35.3

 EKG: junctional bradycardia Appearance/PE: Anesthetized, paralyzed, on CPB Operator
 details: The surgeon will ask for the participant to begin ventilating the patient.

 Learner Objectives and Interventions: Participant should ventilate the patient with
 adequate tidal volumes/rate. Ask for pacer box and begin pacing the patient. If the
 participant does not ask for it, the perfusionist will simply bring the participant a
 pacing box (pre-set to 80; v-paced)

 Transition Cue: Pacing Go to state: Hyperkalemia

 4. Hyperkalemia

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 80 50 100 Vent 20 5 4/2 n/a 35.7

 EKG: V-paced Appearance/PE: Anesthetized, paralyzed, mechanically ventilated, on CPB Operator
 details: If the participant has not already asked for it at this point, the perfusionist will
 bring him/her the results for an ABG: (pH 7.4, paO2 350, paCO2 34, HCO3 22, K+ 6, Glu 250,
 Ca++ 4, Hct 24). The surgeon will ask if he can come off of bypass.

 Learner Objectives and Interventions: The participant should treat the underlying metabolic
 disturbance (mainly hyperkalemia and hyperglycemia) before allowing the surgeon to proceed
 with removal from bypass. If insulin is given the patient will progress to state: "wean off".
 If no insulin is given the patient will go back to state 2: "ventricular fibrillation".

 Transition Cue: Insulin Given Go to state: Wean Off

 Transition Cue: Insulin Not Given Go to state: Ventricular Fibrillation

 4. Wean Off

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 80 78/50 100 Vent 22 6 5/2 n/a 35.8

 EKG: V-paced Appearance/PE: Anesthetized, paralyzed, mechanically ventilated, on CPB Operator
 details: Surgeon will ask which drips the patient is on. Learner Objectives and
 Interventions: The participant should look at the echocardiogram (which will reveal a normal
 heart). The participant should provide inotropic support (low dose epinephrine drip) at which
 point the BP will increase to approximately 110/60 over 30 seconds. The scenario will then
 end.

 The Ohio State University CSEAC 2nd Scenario Development Form Scenario Name: Protamine
 Reaction Content expert: Sujatha Bhandary MD Date of Development: 8/29/14 Targeted Audience:
 CA-2, CA-3 anesthesia residents Simulation Platform: HPS

 *Synopsis of Scenario:

 The purpose of this scenario is to expose trainees to a severe type III protamine reaction
 after weaning off of cardiopulmonary bypass. Although the most severe reaction to
 administration of protamine (severe pulmonary vasoconstriction, RV failure, systemic
 hypotesnsion) is rare, the result can be catastrophic. High fidelity simulation provides an
 opportunity for trainees to get exposure to this entity in a safe, controlled environment.
 The scenario will be followed by both a debriefing session to allow the participants to
 reflect on their performance and a short didactic session on proper administration of
 protamine and the pathophysiology of protamine reactions.

 The scenario will begin after completion of the previous scenario: "Weaning from
 Cardiopulmonary Bypass". As before the patient is a 57 year old male who has just undergone
 an uncomplicated triple vessel CABG with 45 minutes of bypass time. The patient was
 successfully weaned off of CPB after treatment of hyperkalemia (see prior scenario). This
 scenario can begin either after debriefing the previous scenario or may begin without
 interruption. The surgeon will start the scenario by asking the participant to administer
 protamine. At this point the patient is hemodynamically stable (V-paced at 80, BP 110/60, PAP
 30/15, CO 5.2). The patient will start the scenario on an epinephrine drip at 0.02
 mcg/kg/min. The participant will be informed that the patient was given 30,000 unites of
 heparin in preparation for going on CPB. The last ACT was 468. The patient will not have any
 hemodynamic changes in response to a test dose of protamine, and the participant should
 continue to administer the appropriate dose. After 2 minutes without a change in vitals the
 patient will begin to undergo hemodynamic changes consistent with a type III protamine
 reaction over the course of 5 minutes (hypotesnsion, desaturation, decreased cardiac output,
 pulmonary hypertension). Upon recognizing the problem the participant should discontinue the
 protamine infusion, call for help, communicate with the surgeon, and provide supportive care
 for the patient. An echocardiogram (upon request) will demonstrate a dilated RV. Intervening
 to stop the protamine and administer vasopressors will stabilize the patient, however failure
 to act will result in cardiovascular collapse and necessitate going back on CPB.

 Learning Objectives:

 5.Demonstrate appropriate administration of protamine following cardiopulmonary bypass.

 6.Recognize the signs of an acute type III protamine reaction and respond appropriately.

 7.Describe the different types of protamine reactions, the pathophysiology of each, and the
 risk factors for developing them.

 Scenario Intro (read to learner) Your patient is a 57 year old male who is undergoing a
 triple vessel CABG (LIMA to LAD, saphenous to RCA, and saphenous to OM). In addition to CAD
 the patient has a history of type 2 DM and HLD. The procedure has been uncomplicated to this
 point. The patient has an arterial line, a 16 g IV, and an introducer with a PAC. The patient
 is currently paralyzed. There is a transesophageal echocardiogram available upon request. The
 patient as already been successfully weaned off of CPB and is hemodynamically stable on a low
 dose epinephrine drip.

 *Facilitator briefing/ Curricular information: Prior to receiving hand-off and beginning the
 scenario the participant will be handed a sheet with the patient's pre-op history and
 physical already completed. All labs and imaging will be provided. The resident will have the
 opportunity to ask additional questions to the departing provider. The confederates in the
 room will include the cardiac surgeon and a perfusionist. Echocardiography will be available
 upon request as will arterial blood gases. The patient will already be on an epinephrine
 infusion at 0.02 mcg/kg/min. Other cardiac drugs (lidocaine, amiodarone, nitroglycerine,
 norepinephrine, vasopressin) will be drawn up and available. Epicardial wires coming from the
 surgical field will be connected to a pacing box set at 80 (V-paced).

 Educational Learning Model

 Prerequisites: Completion of cardiac anesthesiology rotation Didactics Needs: Powerpoint
 presentation, debriefing room Learning Method: Experiential Debriefing Method: Guided
 reflection with peer feedback. Didactic content.

 Preparation Supporting Files

 -  Patient preoperative report

 -  PowerPoint presentation

 Roles

 -  Cardiac Surgeon

 -  Perfusionist

 Setting

 -  OR

 -  Patient intubated, sedated, paralyzed, on CPB

 Monitors Available to Participant • Code Cart with pacing/defibrillation pads

 -  EKG monitoring

 -  Five-lead electrocardiogram

 -  Pulse-oximetry

 -  Temperature probe

 -  Capnography

 -  Arterial catheter

 -  Central venous catheter

 -  Pulmonary artery catheter

 -  Transesophageal Echocardiogram

 Other Equipment Required

 • Anesthesia machine that has passed the check out

 -  Airway equipment on the cart including Macintosh 3 and Miller 2 blades, endotracheal
 tube sizes 6 and 7 with stylet and empty 10 mL syringe

 -  Two prepared 1000 mL intravenous fluid bags on blood infusion lines

 -  Pharmacologic agents available upon request: propofol, etomidate, ketamine,
 succinylcholine, vecuronium, midazolam, fentanyl, atropine, ephedrine, phenylephrine,
 epinephrine (in syringe and prepared in 100 mL saline bag), norepinephrine (in syringe
 and prepared in 100 mL saline bag), vasopressin, neostigmine, glycopyrrolate,
 metoprolol, esmolol,

 -  Epinephrine, Nitroprusside, and Insulin drips connected to a manifold and in line with
 the patient's CVC

 -  Yankauer suction

 -  Record keeping material (compurecord or paper)(IHIS)

 -  Foley catheter

 -  Video of echocardiogram of normal heart (transesophageal four chamber and transgastric
 short axis)

 -  Alaris pump for delivery for IV anesthetics (Epinephrine, Nitroprusside, and Insulin)

 -  Pacing Box Learner Information (Information given to learner during scenario)

 1. Initial Baseline

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 80 110/60 100 Vent (14) 30 12 30/15 5.4 36 EKG:
 V-paced Appearance/PE: intubated, sedated, paralyzed, on vent Operator details: Epi
 infusion running at 0.02 mcg/kg/min into patient's central line. This scenario
 state will take off directly after the final state of the prior scenario ("weaning
 off CPB"). The surgeon will ask for protamine to be given. If the participant asks
 the perfusionist will inform him/her that the total heparin dose was 30,000 units
 and the last ACT was 468. The test dose will be negative (no change in vital
 signs).

 ABG (if requested): pH 7.34, PaO2 350, PaCO2 35, HCO3 23, K+ 4.4, Ca++ 4, Glu 180,
 Hct 23) Learner Objectives and Interventions: Calculation of proper reversal dose
 of protamine. Administration of test dose of protamine and slow administration of
 full reversal dose with careful attention to potential hemodynamic changes.

 Transition Cue: Administration of Protamine Go to state: Protamine Reaction

 2. Protamine Reaction

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 80 70/35 92% Vent (14) 20 28 60/45 36 EKG:
 V-pace Appearance/PE: anesthetized, paralyzed, on vent Operator details: Changes in
 vital signs will occur slowly (over 5 minutes). Surgeon will continue to operate
 without noticing the changes in vital signs. An Echo (if requested) will show a
 dilated RV. Stopping the infusion and administration of vasopressors will result in
 stabilization. Failure to stop the infusion will lead to further deterioration.

 Learner Objectives and Interventions: Discontinue protamine infusion. Communicate
 with surgeon. Call for help. Provide supportive care for the patient
 (vasopressors).

 Transition Cue: Stop Infusion Go to state: Stabilization Transition Cue: Failure to
 Stop Infusion Go to state: Severe Reaction

 3. Stabilization

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 80 95/57 95 Vent (14) 30 16 40/20 36 EKG:
 V-paced Appearance/PE: intubated, sedated, paralyzed, on vent Operator details:
 Vitals will stabilize to current state over 2 minutes following discontinuation of
 protamine and administration of vasopressors. Surgeon will ask if the provider can
 restart the protamine now. After discussion with surgeon the scenario will end.

 Learner Objectives and Interventions: Discuss with surgeon options for reversal of
 heparin.

 4. Severe Reaction

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 80 45/20 89 Vent (14) 15 23 70/44 36

 EKG: V-paced Appearance/PE: intubated, sedated, paralyzed, on vent Operator details: Failure
 to stop the infusion will result in worsening of the patient's condition to the current
 state. Surgeon will now became aware of the hemodynamic changes and will insist on going
 emergently back on CPB. The scenario will end.

 The Ohio State University CSEAC 3rd Scenario Development Form Scenario Name: Coronary Air
 After Bypass Grafting Content expert: Sujatha Bhandary MD Date of Development: 8/29/14
 Targeted Audience: CA-2, CA-3 anesthesia residents Simulation Platform: HPS

 Synopsis of Scenario:

 The purpose of this scenario is for the participant to take a thoughtful, systematic approach
 to the sudden onset of ST changes and hypotension following completion of coronary artery
 bypass graft (CABG) surgery. Specifically this scenario will deal with intracoronary air,
 which if unrecognized can be fatal. Residual air has been reported to be present as in as
 much as 12% of patients undergoing CABG surgery.* This simulation will give residents the
 chance to treat this condition in a safe, constructive environment so that they will be more
 comfortable with diagnosing this rare but potentially devastating condition. The simulation
 is intended to rely on the residents' knowledge of cardiac physiology, and basic
 echocardiography interpretation.

 The scenario will start following the completion of the previous scenario (Protamine
 Reaction) at which the time patient has been successfully weaned off of bypass and the chest
 has just been closed. Immediately after beginning the scenario the surgeon will leave the
 room. At this time the fellow (confederate) will begin to suture the skin. Shortly thereafter
 the patient will have ST elevation in the inferior EKG leads. The fellow will ask if the
 echocardiogram looks okay. A mid-esophageal four-chamber view of the patient's heart will
 demonstrate air bubbles in the left ventricle. A trans-gastric short axis view of the heart
 (if requested) will show the inferior wall of the heart to be akinetic. The patient will
 become hypotensive with decreased cardiac index. The resident should simultaneously form a
 differential diagnosis and treat the symptoms while communicating to the surgeon his/her
 findings. Ultimately the resident should request that the surgeon reopen the patient's chest
 and purge the intra-cardiac air. Failing to do so will result in the patient going into
 cardiogenic shock and ventricular fibrillation.

 Learning Objectives:

 8. Form a differential for post CABG hypotension and EKG changes. 9. Diagnose intra-cardiac
 air and regional wall motion abnormalities on echocardiogram.

 10. Effectively treat cardiogenic shock with pharmacologic agents. 11. Communicate with the
 surgeon regarding the need for surgical intervention.

 Scenario Intro (read to learner) Your patient is a 57 year old male who is undergoing a
 triple vessel CABG (LIMA to LAD, saphenous to RCA, and saphenous to OM). In addition to CAD
 the patient has a history of type 2 DM and HLD. The surgeon completed the grafts with a total
 bypass time of 45 minutes. The patient has been weaned of cardiac bypass and successfully
 reversed with protamine. The chest has just been closed. The procedure has been uncomplicated
 to this point. The patient has an arterial line, a 16 g IV, and an introducer with a PAC. The
 patient is on a low dose epinephrine infusion (.0.02 mcg/kg/min). The patient is currently
 paralyzed. There is a transesophageal echocardiogram available upon request. The surgeon has
 placed epicardial pacing wires. You will be responsible for transitioning the patient to the
 cardiac ICU.

 Facilitator briefing/ Curricular information:

 Prior to receiving hand-off and beginning the scenario the participant will be handed a sheet
 with the patient's pre-op history and physical already completed. All labs and imaging will
 be provided. The resident will have the opportunity to ask additional questions to the
 departing provider. The confederates in the room will include the cardiac surgeon and a
 perfusionist. Echocardiography will be available upon request as will arterial blood gases.
 The patient is on a low dose epinephrine infusion (0.02 mcg/kg/min). Other cardiac drugs
 (lidocaine, amiodarone, nitroglycerine, norepinephrine, vasopressin) will be drawn up and
 available. Epicardial wires coming from the surgical field. These can be connected to a
 pacing box which will provided upon request.

 Educational Learning Model Prerequisites: Completion of cardiac anesthesiology rotation
 Didactics Needs: Powerpoint presentation, debriefing room Learning Method: Experiential
 Debriefing Method: Guided reflection with peer feedback. Didactic content. Preparation
 Supporting Files • Patient preoperative report

 -  PowerPoint presentation Roles

 -  Cardiac Surgeon

 -  Perfusionist Setting

 -  OR

 -  Patient intubated, sedated, paralyzed, on CPB

 Monitors Available to Participant • Code Cart with pacing/defibrillation pads • EKG
 monitoring • Five-lead electrocardiogram • Pulse-oximetry

 • Temperature probe

 -  Capnography

 -  Arterial catheter

 -  Central venous catheter

 -  Pulmonary artery catheter

 -  Transesophageal Echocardiogram

 Other Equipment Required • Anesthesia machine that has passed the check out

 • Airway equipment on the cart including Macintosh 3 and Miller 2 blades, endotracheal tube
 sizes 6 and 7 with stylet and empty 10 mL syringe

 • Two prepared 1000 mL intravenous fluid bags on blood infusion lines

 • Pharmacologic agents available upon request: propofol, etomidate, ketamine,
 succinylcholine, vecuronium, midazolam, fentanyl, atropine, ephedrine, phenylephrine,
 epinephrine (in syringe and prepared in 100 mL saline bag), norepinephrine (in syringe and
 prepared in 100 mL saline bag), vasopressin, neostigmine, glycopyrrolate, metoprolol,
 esmolol,

 -  Epinephrine, Nitroprusside, and Insulin drips connected to a manifold and in line with
 the patient's CVC

 -  Yankauer suction

 -  Record keeping material (compurecord or paper)(IHIS)

 -  Foley catheter

 -  Video of echocardiogram 2 views (transesophageal four chamber with intracardiac air in
 LV and transgastric short axis with akinetic inferior wall)

 -  Alaris pump for delivery for IV anesthetics (Epinephrine, Nitroprusside, and Insulin

 *Learner Information (Information given to learner during scenario)

 Simulation Sequence

 1. Chest Closed

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 70 110/60 100 14 (vent) 35 12 30/15 5 36.3

 EKG: normal sinus rhythm Appearance/PE: intubated, sedated, paralyzed; chest closed
 Operator details: The surgeon has just finished closing the chest at which time he/she
 will give a sign out and leave the room.

 Learner Objectives and Interventions: The participant should make sure he/she receives a
 thorough hand-off with a clear understanding of the patient's background and surgical
 course.

 Transition Cue: Surgeon leaves the room Go to state: ST elevation

 2. ST Changes

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 70 110/60 100% 14 (vent) 35 12 30/15 5 36.3

 EKG: Normal sinus rhythm; ST depression in AVF, II, III Appearance/PE: intubated,
 sedated, paralyzed; chest closed Operator details: Fellow will begin suturing the skin
 and will ask the participant what the cardiac index is. At this point the patient should
 experience ST depression in the inferior leads.

 Learner Objectives and Interventions: The participant should recognize the EKG changes
 and look to the echocardiogram for clinical correlation. He/She should communicate with
 the surgical team.

 Transition Cue: Learner looks at Echocardiogram Go to state: ST Elevation

 3. ST Elevation

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp 70 85/50 100 14 (vent) 27 10 40/25 1.5 36.3

 EKG: normal sinus rhythm; ST elevation in AVF, II, III Appearance/PE: Intubated,
 sedated, paralyzed; chest closed Operator details: TEE four chamber view will
 demonstrate air bubbles in the LV. Trans-gastric short axis will show akinetic inferior
 wall. Patient will get hypotensive over 2 minutes, but will responds to IV epinephrine.

 Learner Objectives and Interventions: Participant should form differential for
 hypotention with ST elevation, and treat pharmacologically with epinephrine. The
 participant should communicate with the surgeon regarding the need for re-opening at
 which point the scenario will end. If he/she does not communicate with the surgical team
 the patient will decompensate and go into VFib.

 Transition Cue: Failure to communicate with surgeon Go to state: VFib

 4. VFib

 Vital signs:

 HR BP SPO2 RR ETCO2 CVP PAP CO Temp n/a - - 14 (vent) 0 0 0 0 36.3

 EKG: V-fib Appearance/PE: Intubated, sedated, paralyzed; chest closed Operator details:
 Failure to communicate with the team regarding intracardiac air and need to re-open will
 result in worsening cardiogenic shock developing to ventricular fibrillation. Surgeon will
 re-enter room and ask what happened.

 Learner Objectives and Interventions: Recognize ventricular fibrillation and begin ACLS
 (epinephrine/defibrillation). Regonize intracoronary air as ca
Inclusion Criteria:

 -  Resident physicians who have completed at least one month of cardiac rotation are
 included.This high fidelity simulation lab course if offerred to every resident that
 meets the criteria.This is a part of their educational activity.At the beginning of
 the course they are given the option to participate in the survey.If they do not wish
 to participate in the survey it will not affect their education.Participitaion in the
 survey is purely voluntary.

 Exclusion Criteria:

 -  Resident physicians that did not wish to participate in filling out the survey or not
 able to fill out the survey.