ABSTRACT
Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform reliably compared with an awake subarachnoid block in skilled hands.1 While local anaesthetic systemic toxicity is a rare complication of caudal anaesthesia, this case illustrates the potential for caudal anaesthesia done awake in enhancing patient safety through early recognition of local anaesthetic systemic toxicity.
Subject(s)
Anesthesia, Caudal/adverse effects , Bupivacaine/toxicity , Herniorrhaphy , Intraoperative Complications/chemically induced , Neurotoxicity Syndromes/diagnosis , Seizures/chemically induced , Adenosine/administration & dosage , Adjuvants, Anesthesia/administration & dosage , Anti-Arrhythmia Agents/administration & dosage , Bupivacaine/administration & dosage , Fat Emulsions, Intravenous/administration & dosage , Herniorrhaphy/methods , Humans , Infant , Intraoperative Complications/drug therapy , Midazolam/administration & dosage , Monitoring, Intraoperative , Neurotoxicity Syndromes/drug therapy , Neurotoxicity Syndromes/physiopathology , Oxygen/administration & dosage , Patient Safety , Respiration, Artificial , Seizures/drug therapy , Seizures/physiopathology , Treatment OutcomeABSTRACT
BACKGROUND: Active 'hands-on' participation in the 'hot-seat' during immersive simulation-based training (SBT) induces stress for participants, which is believed to be necessary to improve performance. We hypothesized that observers of SBT can subsequently achieve an equivalent level of non-technical performance as 'hot-seat' participants despite experiencing lower stress. METHODS: We randomized 37 anaesthesia trainees into two groups to undergo three consecutive SBT scenarios. Eighteen 'hot-seat' trainees actively participated in all three scenarios, and 19 'observer' trainees were directed to observe the first two scenarios and participated in the 'hot-seat' only in scenario 3. Salivary cortisol (SC) was measured at four time points during each scenario. Primary endpoint for stress response was the change in SC (ΔSC) from baseline. Performance was measured using the Anaesthetist's Non-Technical Skills (ANTS) Score. RESULTS: Mean SC increased in all participants whenever they were in the 'hot-seat' role, but not when in the observer role. Hot-seat ΔSC (mcg/dL) for scenarios 1, 2, and 3 were 0.122 (p = 0.001), 0.074 (p = 0.047), and 0.085 (p = 0.023), respectively. Observers ΔSC (mcg/dL) for scenarios 1, 2, and 3 were -0.062 (p = 0.091), 0.010 (p = 0.780), and 0.144 (p = 0.001), respectively. Mean ANTS scores were equivalent between the 'hot-seat' (40.0) and 'observer' (39.4) groups in scenario 3 (p = 0.733). CONCLUSIONS: Observers of SBT achieved an equivalent level of non-technical performance, while experiencing lower stress than trainees repeatedly trained in the 'hot-seat'. Our findings suggest that directed observers may benefit from immersive SBT even without repeated 'hands-on' experience and stress in the hot-seat. The directed observer role may offer a less stressful, practical alternative to the traditional 'hot-seat' role, potentially rendering SBT accessible to a wider audience. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02211378, registered August 5, 2014, retrospectively registered.
