Your First Anesthesia Simulator Case
1. If you are an experienced anesthesia provider but want to learn how to use Anesthesia Simulator, continue with this section. If you are new to anesthesia, and would like more information about the steps involved in an intravenous anesthetic induction sequence, skip this section and scroll down to the section entitled Your First Anesthetic Induction below.
2. We suggest you run case 1 first. If you already opened a different case, click New Case and select case 1 to get started.
3. You can control a number of personalized settings for the application in the Settings menu. Many users enable or disable the pulse oximeter sound depending on your preference.
4. The simulator initially presents the patient in the operating room with the anesthesia machine. The patient already has a running IV and is connected to routine monitors including ECG, non-invasive blood pressure, and pulse oximeter.
5. The preop evaluation is presented. You can review the preop evaluation again anytime during the simulation by clicking the Preop button. Make note of the patient’s weight in the Physical Exam section of the preop evaluation since you will need that to calculate drug dosages.
6. Take a few minutes to familiarize yourself with the main simulator screen. The simulation clock is located in the upper left hand corner of the display. You can click on the clock to pause the simulation.
7. The Help menu provides suggestions about what to do next during the case scenario. Use the What Now help feature frequently to keep you on track. Learning objectives with a suggested management plan for each case are available. In addition a glossary of abbreviations used in the application, and normal values are also provided in the Help option.
8. Examine the patient with the Patient menu. You can also use the Patient menu to control the patient position and temperature.
9. Use the Monitor menu to control monitors for the case. Routine monitors, including ECG, non-invasive blood pressure (NBP), pulse oximeter are automatically placed. The airway gas monitor (AGM) will be activated when the patient is connected to the breathing circuit. You can also use invasive arterial pressure, a central venous line, a pulmonary artery catheter and a urimeter as required by the clinical situation.
10. The patient comes to the operating room with one IV running. You control the type of IV fluid and rate of administration with the Fluids menu. You can run up to two intravenous lines. Select the type of fluid in the content field and adjust the infusion rate. You can also administer a fluid bolus if desired.
11. Select the Airway options to place an anesthesia mask on the patient. Control the oxygen flow using the flowmeter on the anesthesia machine. You are now pre-oxygenating the patient. Notice that the capnogram is activated when the patient has a mask or tube in place.
12. Sedate the patient prior to intubation. If you can’t remember the patient’s weight, you will find it in the Physical Exam section of the Preop Evaluation.
13. Inject midazolam by selecting it from the Drugs list, then a bolus of 2 mg. Select Administer to give the drug.
14. Then administer fentanyl, lidocaine, propofol and rocuronium. You can review dosing and other information about the selected drug by clicking Display Drug Info after selecting the drug.
15. When the patient is apneic, control the ventilation by selecting Breathing, Bag Assist/Control, and set the desired tidal volume and respiratory rate.
16. Intubate the patient by selecting Airway, then Laryngoscopy and Place Tube. Resume ventilation with the Breathing menu and confirm correct placement of the endotracheal tube by listening to the breath sounds in the Patient menu, and observing the CO2 wave form.
17. For maintenance anesthesia you can use inhalation agents and/or continuous infusions. Select inhalation agents on the anesthesia machine in the lower section of the display or from the Drugs menu. Drug information for all medications, including inhalation agents, is available in the Drugs menu.
18. If you are ever unsure what to do next during the simulation, select Help > What Now for a brief synopsis of what to do next.
19. You just performed an anesthetic induction. In simulated cases that have a critical incident, the emergency is typically programmed to occur a few minutes after induction or incision.
20. After induction, tell the surgeon to prep the patient in the surgeon menu. After a few minutes the surgeon will request permission to make the incision.
21. Deepen the anesthetic to an adequate level and inform the surgeon when it is appropriate to make the incision.
22. In these simulations it is not necessary to have the surgeon complete the entire operation. A heart icon will appear when you have successfully completed the learning objectives for the simulated case. A ghost indicates the patient has died and you should try the case again. A broken heart means the patient survived but you could have managed the case better. It is not necessary to obtain a perfect score for the simulation. The heart icon indicates you managed the case well.
23. You can review the case record using the Case Log option. In addition to a record of the simulated patient’s condition and your management throughout the simulated scenario, you will receive a debriefing of your management. You can also Save the record to your account in the cloud.
24. Select New Case to start another simulation. Before you exit the current case, you may want to save the record of your case management.
25. You can review previously saved case logs in My Account > View My Cases.
Your First Anesthetic Induction
1. We suggest you run case 1 first. If you already opened a different case, click New Case in the upper right-hand corner, then select case 1 to get started.
2. The simulator initially presents the patient in the operating room with the anesthesia machine. The patient already has a running IV and is connected to routine monitors including ECG, non-invasive blood pressure, and pulse oximeter. At he start of this case the vital signs are stable.
3. You can control a number of personalized settings for the application in the Settings menu. Many users enable or disable the pulse oximeter sound depending on your preference.
4. The preop evaluation is presented. You can review the preop evaluation again anytime during the simulation by clicking the Preop button. Make note of the patient’s weight in the Physical Exam section of the preop evaluation since you will need that to calculate drug dosages. The patient in case 1 weighs 72 kg.
5. Take a few minutes to familiarize yourself with the main simulator screen. The simulation clock is located in the upper left hand corner of the display. You can click on the clock to pause the simulation.
6. Examine the patient with the Patient menu. At the start of this case the patient is awake and anxious. You can also use the Patient menu to control the patient position and temperature.
7. Use the Monitor menu to control monitors for the case. Routine monitors, including ECG, non-invasive blood pressure (NBP), pulse oximeter are automatically placed. The airway gas monitor (AGM) will be activated when the patient is connected to the breathing circuit. You can also use invasive arterial pressure, a central venous line, a pulmonary artery catheter and a urimeter as required by the clinical situation. Although you normally wouldn’t start an art-line for this case, you may want to start one for your first simulation so you can observe beat to beat blood pressure changes.
The Monitors menu also includes a nerve stimulator to check the current state of neuromuscular blockade during the simulated case scenario.
8. The patient comes to the operating room with one IV running. You control the type of IV fluid and rate of administration with the Fluids menu. You can run up to two intravenous lines. Select the type of fluid in the content field and adjust the infusion rate. You can also administer a fluid bolus if desired. The Fluid Status section displays the current fluid In’s and Out’s throughout the case simulation including the fluids administered before the patient came to the operating room.
9. At this point you should administer a medication to help relieve anxiety. Inject midazolam by selecting it from the Drugs list, then a bolus of 2 mg. Select Administer to give the drug.
10. Select the Airway options to place an anesthesia mask on the patient. Control the oxygen flow using the flowmeter on the anesthesia machine. You are now pre-oxygenating the patient. Notice that the AGM, AWP monitor, and spirometer are activated when the patient has a mask or tube in place.
Pre-oxygenation (or denitrogenation) is the process of administering oxygen to the patient prior to inducation of anesthesia. This improves safety since it will delay arterial oxygen desaturation when the patient becomes apneic during anesthetic induction. Continue administering oxygen by mask until the end-tidal O2 value is at least 90%.
11. The Help menu provides suggestions about what to do next during the case scenario. Use the What Now help feature frequently to keep you on track. Learning objectives with a suggested management plan for each case are available. In addition a glossary of abbreviations used in the application, and normal values are also provided in the Help option.
12. To continue the induction sequence, administer fentanyl 100 mcg. Fentanyl is a synthetic opioid. Administration of fentanyl prior to induction of anesthesia will cause the patient to become sleepier It will also depress the respiratory drive. Notice the respiratory rate on the spirometer slows to 10 breaths per minute. This amount of fentanyl will help to blunt tachycardia and hypertension associated with endotracheal intubation.
13. To further decrease the response to intubation, administer lidocaine 100 mg.
14. Administer propofol 2-2.5 mg/kg (140-160 mg) to induce anesthesia. You can review dosing and other information about the selected drug by clicking Display Drug Info after selecting the drug.
15. Notice that the patient quickly becomes apneic after the administration of propofol. You may want to ensure that you can ventilate the patient before administering a neuromuscular blocking agent. Control the ventilation by selecting Breathing > Bag Assist/Control, and set the desired tidal volume and respiratory rate. The presence of CO2 in the capnogram confirms that you are successffully performing bag/mask ventilation.
16. Now administer either rocuronium 0.6-1 mg/kg (60 mg) to produce muscle relaxation to facilitate endotracheal intubation. Alternatively, you could use succinylcholine or other muscle relaxant for this purpose.
17. If you want, you can follow the strength of the neuromuscular blockade by clicking Monitors > ‘Train of Four’.
18. Intubate the patient by selecting Airway, then Laryngoscopy and Place Tube. Resume ventilation with the Breathing menu. You may want to use the ventilator. Confirm correct placement of the endotracheal tube by listening to the breath sounds in the Patient menu, and observing the CO2 wave form in the capnogram.
19. Use an inhalation agent for maintenance anesthesia. Select the desired vaporizer in the anesthesia machine in the lower section of the display. Set the vaporizer to the desired concentration. Notice in the airway gas monitor that it takes some time to build up the anesthetic level in the circuit inspired gas(I) and even longer in the patient(E). Sevoflurane is initially set as the vaporizer. The Minimum Alveolar Concentration(MAC) for sevoflurane is about 2%. Set the vaporizer to 4% initially and watch closely as the end-tidal value builds up over the next few minutes. This method is called over-pressurization, which decreases the delay time to reach MAC. If you would like to read more about the inhalation agents, select the Drug menu, select your vaporizer, and study the Drug Information section.
20. If you are ever unsure what to do next during the simulation, select Help > What Now for a brief synopsis of what to do next.
21. You just performed an anesthetic induction. In simulated cases that have a critical incident, the emergency is typically programmed to occur a few minutes after induction or incision.
22. After induction, tell the surgeon to prep the patient in the surgeon menu. After a few minutes the surgeon will request permission to make the incision.
23. Deepen the anesthetic to an adequate level and inform the surgeon when it is appropriate to make the incision. Make sure you reset the vaporizer level closer to MAC when the patient reaches the desired depth of anesthesia.
24. In these simulations it is not necessary to have the surgeon complete the entire operation. A heart icon will appear when you have successfully completed the learning objectives for the simulated case. A ghost indicates the patient has died and you should try the case again. A broken heart means the patient survived but you could have managed the case better. It is not necessary to obtain a perfect score for the simulation. The heart icon indicates you managed the case well.
25. You can review the case record using the Case Log option. In addition to a record of the simulated patient’s condition and your management throughout the simulated scenario, you will receive a debriefing of your management. You can also Save the record to your account in the cloud.
26. Select New Case to start another simulation. Before you exit the current case, you may want to save the record of your case management.
27. You can review previously saved case logs in My Account > View My Cases.