In this month’s Regional Anesthesia and Pain Medicine, Neal et al., examine the use of the ASRA Checklist in trainee performance during a simulated episode of Local Anesthetic Systemic Toxicity (LAST). LAST is an extremely rare complication of regional anesthesia. Seizures being reported 0.02% of the time and cardiac arrest even more infrequently1. Primary therapy revolves around the timely initiation of IV lipid emulsion therapy and modification of ACLS protocol in the setting of LAST.
LAST, like many situations encountered in anesthesia, requires quick diagnosis and action. How do we best prepare a clinician for a rare, but life-threatening event? How do we streamline care to provide life-saving treatment in an efficient and consistent manner?
Dr. Neal and colleagues examined both of these questions. Using high definition simulation, they compared trainee performance in treating an episode of LAST with and without the ASRA LAST Checklist. Participants were presented with a 73 year old man who was consented for a femoral nerve block. Participants were then asked to describe how they would place the block. During this time, evaluators made special note of preventative measures included on the checklist. The simulated patient then began to exhibit signs of LAST. Participants were then required to diagnose and treat.
Participant’s performance was then evaluated on technical and nontechnical scales. Items such as appropriate therapy, timeliness of therapy as well as communication and case management were all graded. As expected, the group randomized to receive the ASRA checklist during the scenario implemented lipid therapy at correct dose more often. They also scored higher on situational awareness and decision making.
Is simulation an effective tool for training in these situations? Recent experience suggests it might be. In 2008, successful resuscitation of a patient with LAST was attributed to simulation training. The primary caregiver’s, attending faculty and anesthesia resident, both underwent simulation training 8 weeks prior to the event. Both attributed their prompt diagnosis and initiation of therapy to the simulator training2. Unfortunately, prospective clinical study on the effects of simulation training is difficult for such rare events.
Then consider the use of checklists. Most participants in Neal’s study felt that checklists were useful tools and used the ASRA checklist to manage their “patient” when it was provided. Yet two-thirds of the participants were neutral or agreed that they should be able to respond appropriately to an emergency situation from memory alone. It is interesting to note that all participants were given a copy of the ASRA checklist 2 weeks prior to the study. This was done unobtrusively and in an unrelated activity to the simulation.
In the “high stake” situations, decision making suffers when providers are stressed or fatigued. Does the use of a checklist provide that essential steps are not missed? Does it become a crutch? Does it become a substitute for clinical reasoning? How do we best use these tools to provide the safest care for our patients? How do we best season these tools for useful practice? Simulation may key be to testing clinical checklists and honing them to practical use in patient situations.
Find the original article here.