titrating to effect as needed) If they give the drug after they have been informed that the patient is SEIZING – they have to recognize the seizure and then treat it They have not recognized the seizure and they are using the drug as a sedative They are propofol to induce anesthesia and the seizures are controlled Requests surgeon to stop procedure ACCEPTABLE Asks the surgeon to stop the procedure so that they can get control of the situation. Asks the surgeon to stop the procedure because it is unsafe to proceed. Asks the surgeon to stop the procedure because the patient is unstable. UNACCEPTABLE Asks the surgeon to stop during initial handover to get control of the case Administers initially small doses of a vasopressor (e.g; phenylephrine ≤ 200mcg, ephedrine < 25mg, epinephrine < 50 mcg) ACCEPTABLE: Actually administers phenylephrine in a reasonable dose (<200 mcg per administration) Actually administers ephedrine in a reasonable dose (<10 mg per administration) Gives a reasonable alternative (e.g., 1–2 U of vasopressin). STANDARDIZATION NOTE: If they give a drug stating the drug name but do not verbalize the dose then the confederates should query or ask them for a dose then mark as present. for crash cart and/or defibrillator ACCEPTABLE: Verbally requests that the crash cart be brought into the room STANDARDIZATION NOTE: In some centers the crash cart is already present in the room, the participant will have to ask for the crash cart to be brought closer to the bedside Discusses clinical concerns with surgeon ACCEPTABLE: Talks to the surgeon about the diagnosis being LAST States that the problems or patient’s current condition is due to the local anesthetic getting into the blood stream UNACCEPTABLE: States that the problems are due to the (without being specific) … unless immediately asks for lipid emulsion States that the problem is due to the local anesthetic (without being specific as to how) … unless immediately asks for lipid emulsion.
UNACCEPTABLE: Using the AED mode of the defibrillator After diagnosis of LAST, adjusts ACLS management as recommended by ASRA (Reduced dose epinephrine of 200 mcg instead of 1 mg, avoid use of vasopressin, calcium channel and and local anesthetics) ACCEPTABLE: Verbalizes that they are adjusting medication doses due to the diagnosis of LAST. AND/OR Administers reduced of epinephrine (e.g., 200 mcg) AND Does not administer vasopressin, calcium channel blockers, or local anesthetics Endoscopic retrograde cholangiopancreatography with post-operative malignant hyperthermia CPE ACCEPTABLE/UNACCEPTABLE ACTIONS Assesses patient mental status (e.g., talks to the patient). ACCEPTABLE: to the patient and asks about ongoing problems Assesses patient physiological status (e.g., checks vital signs.) ACCEPTABLE: Observes and/or touches the monitors Cycles the blood pressure cuff or asks to cycle the blood pressure cuff Mentions relevant signs Examines patient [Observes patient as conversing with her; Places hands on patient; Listens to patient's lungs, asks what they're seeing] ACCEPTABLE: Observes patient as conversing with her Places on patient and speaks with her Listens to patient's lungs Asks what the bedside nurse what they're seeing Reviews patient's anesthesia record and preoperative history ACCEPTABLE: Observes and/or handles anesthesia record and pre-op records
NOTE: In some cases, the contents of several incompletely diluted vials of dantrolene may be administered. This may be acceptable. Asks to place a foley urinary catheter ACCEPTABLE: Participants asks the nurse for a foley catheter NOTE: Some centers have been hiding the out of sight and when the participants ask for the foley catheter the nurse shows the foley to them (which typically contains red urine). Checks the color of the urine and/or asks to send urine specimen to lab ACCEPTABLE: Verbally red colored urine Specifically asks that urine sample be sent to lab Small bowel obstruction with unstable atrial fibrillation followed by a myocardial infarction CPE ACCEPTABLE/UNACCEPTABLE ACTIONS Surveys anesthesia workspace ACCEPTABLE: Observes and/or touches at least two (three) of the following: monitors, patient, drugs, airway equipment, IVs, surgical field. Cycles the blood pressure cuff or asks to cycle the blood pressure cuff Checks the ventilator, makes adjustments Asks about IV’s and gauges Reviews patient's anesthesia record and preoperative history ACCEPTABLE: Observes and/or handles anesthesia record post-handover Actively participates during handover with the outgoing anesthesiologist using the pre-operative records UNACCEPTABLE: If checks anesthesia records for first time during handover to the First Responder
Announces that the rhythm is or could be atrial fibrillation ACCEPTABLE: Verbally states that it is atrial fibrillation or Afib. Verbally states that it is an “irregularly irregular” rhythm. Important to notice irregularity and sudden onset of event. UNACCEPTABLE: States that it is a supraventricular tachycardia without ever mentioning irregularity. States patient is “tachycardic” without clarifying the nature of tachycardia Announces that the rhythm is unstable or that is hypotension ACCEPTABLE: States out loud that the patient (or the hemodynamics) is unstable. States out loud that the blood pressure is low or the patient is hypotensive Treats the patient with pressors. Treats the patient with appropriate medications to slow the HR. (implication that it will improve the blood pressure) Administers vasoconstrictor of choice (phenylephrine - < 200mcg) ACCEPTABLE: Actually gives phenylephrine in a reasonable dose (< 200 mcg per administration) If they give an alternative – e.g. 1 – 2 U Vasopressin. If they give the drug but do not verbalize the dose and the confederates do not query / ask them for a dose – mark as present. (Standardization error) Administers IV fluid bolus ACCEPTABLE: States / verbalizes that they are giving a fluid bolus, IV bolus, or “volume” Opens up fully the IV roller clamp. Raises IV pole or squeezes IV bag Touches the roller clamp, stop cock, IV tubing and verbalizes need for fluid/volume Administers drugs to slow the heart rate ACCEPTABLE: Administers a beta-blocker, adenosine or amiodarone. If they give the drug but do not verbalize the dose and the confederates do not query / ask them for a dose – mark as present. (Standardization error) Notifies surgeon/team about clinical situation ACCEPTABLE:
Requests that cardiologist be contacted Discusses treatment options with cardiologist and/or surgeon including at two of the following: a. Transfer to cardiac catheterization laboratory, b. Heparin infusion in the OR, c. Additional hemodynamic support, d. Intraaortic ballon counter-pulsation, e. Amiodarone infusion in the OR, f. Use of TEE or TTE ACCEPTABLE: If they discuss at least two of the treatment options either with Surgeon Cardiologist Team (first responder and hot seat) If the Cardiologist suggests it – the team has to demonstrate behavior befitting a consultant and discuss the treatment option with the cardiologist UNACCEPTABLE: If the cardiologist or surgeon suggests it and the teams decides to follow orders