Journal of Pediatric Intensive Care, Table of Contents

J Pediatr Intensive Care
DOI: 10.1055/s-0042-1758453

Original Article

Emergent Bedside Resternotomy: An Innovative Simulation Model for Training Pediatric Cardiac Intensive Care Teams

Toluwani Akinpelu

¹Department of Anesthesiology and Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, Texas, United States

²Rio Grande Valley School of Medicine, University of Texas, Edinburg, Texas, United States

,

Nikhil R. Shah

³Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States

,

Mohammed Alhendy

⁴Division of Pediatric Critical Care, The Children's Hospital of San Antonio, San Antonio, Texas, United States

,

Malarvizhi Thangavelu

⁴Division of Pediatric Critical Care, The Children's Hospital of San Antonio, San Antonio, Texas, United States

,

Karen Weaver

⁴Division of Pediatric Critical Care, The Children's Hospital of San Antonio, San Antonio, Texas, United States

,

Nicole Muller

⁴Division of Pediatric Critical Care, The Children's Hospital of San Antonio, San Antonio, Texas, United States

,

James McElroy

⁴Division of Pediatric Critical Care, The Children's Hospital of San Antonio, San Antonio, Texas, United States

,

Utpal S. Bhalala

¹Department of Anesthesiology and Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, Texas, United States

³Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States

⁵Department of Critical Care, Texas A & M University, College Station, Texas, United States

› Author Affiliations

Abstract

Cardiac tamponade after cardiac surgery is a life-threatening event that requires simultaneous resuscitation and emergent resternotomy by the intensive care team. A simulated scenario using an innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the validity of this mannequin to investigate the confidence level and crisis resource management skills of the team during bedside resternotomy to manage postoperative cardiac tamponade. The simulation scenario was developed using the sternotomy mannequin for a pediatric cardiac intensive care unit (CICU) team. The case involved a 3-year-old male, intubated, and mechanically ventilated after surgical repair of congenital heart disease, progressing to cardiac arrest due to cardiac tamponade. We conducted a formative learner assessment before and after each scenario as well as a structured, video debriefing following each encounter. The simulation was repeated in a 6-month interval to assess knowledge retention and improvement in clinical workflow. The data were analyzed using student t-test and chi-square test, when appropriate. Of the 72 CICU providers, a significant proportion of providers (p < 0.0001) showed improved confidence in assessing and managing cardiac arrest associated with postoperative cardiac tamponade. All providers scored ≥3 for the impact of the scenario on practice, teamwork, communication, assessment skills, improvement in cardiopulmonary resuscitation, and opening the chest and their confidence in attending similar clinical situations in future. Most (96–100%) scored ≥3 for the perception on the realism of mannequin, the scenario, reopening the sternotomy, and level of stress. Time to diagnosis of cardiac tamponade (p = 0.004), time to the first dose of epinephrine (p = 0.045), and median number of interruptions to chest compressions (p = 0.006) all significantly decreased between the two sessions. Time to completion of resternotomy improved by 81.4 seconds; however, this decrease was not statistically significant. Implementation of a high-fidelity mannequin for postoperative cardiac tamponade simulation can achieve a realistic and reproducible training model with positive impacts on multidisciplinary team education.

Keywords

Keywords

resternotomy - simulation - cardiac tamponade - mannequin - cardiopulmonary arrest - PICU

References
1 Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002; 39 (12) 1890-1900
2 Reller MD, Strickland MJ, Riehle-Colarusso T, Mahle WT, Correa A. Prevalence of congenital heart defects in metropolitan Atlanta, 1998-2005. J Pediatr 2008; 153 (06) 807-813
3 Lüscher TF. Outcome of congenital heart disease with modern cardiac care. Eur Heart J 2018; 39 (12) 969-971
4 Ball L, Costantino F, Pelosi P. Postoperative complications of patients undergoing cardiac surgery. Curr Opin Crit Care 2016; 22 (04) 386-392
5 Spodick DH. Acute cardiac tamponade. N Engl J Med 2003; 349 (07) 684-690
6 Shaath GA, Jijeh AMZ, Ismail SR. et al. Predictors of reopening the sternum in children after cardiac surgery. Pediatr Crit Care Med 2020; 21 (03) 235-239
7 Galante GJ, Schantz DI, Myers KA, Pockett CR, Rebeyka IM, Mackie AS. Echocardiographic screening for postoperative pericardial effusion in children. Pediatr Cardiol 2021; 42 (07) 1531-1538
8 Aggarwal R, Darzi A. Technical-skills training in the 21st century. N Engl J Med 2006; 355 (25) 2695-2696
9 Jakimowicz JJ, Cuschieri A. Time for evidence-based minimal access surgery training–simulate or sink. Surg Endosc 2005; 19 (12) 1521-1522
10 Dunning J, Fabbri A, Kolh PH. et al; EACTS Clinical Guidelines Committee. Guideline for resuscitation in cardiac arrest after cardiac surgery. Eur J Cardiothorac Surg 2009; 36 (01) 3-28
11 Weinstock PH, Kappus LJ, Kleinman ME, Grenier B, Hickey P, Burns JP. Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program. Pediatr Crit Care Med 2005; 6 (06) 635-641
12 Donaldson L. Safer medical practice: machines, manikins and polo mints, 150 Years of the Annual Report of the Chief Medical Officer: On the State of the Public Health 2008. Department of Health; 2009: 49-55
13 Shetty R, Thyagarajan S. Simulation in pediatrics: Is it about time?. Ann Card Anaesth 2016; 19 (03) 505-510
14 Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest 2008; 133 (01) 56-61
15 Hunt EA, Walker AR, Shaffner DH, Miller MR, Pronovost PJ. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. Pediatrics 2008; 121 (01) e34-e43
16 Langhan TS, Rigby IJ, Walker IW, Howes D, Donnon T, Lord JA. Simulation-based training in critical resuscitation procedures improves residents' competence. CJEM 2009; 11 (06) 535-539
17 Abella BS, Alvarado JP, Myklebust H. et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005; 293 (03) 305-310
18 Marsch SC, Müller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation 2004; 60 (01) 51-56
19 Hunziker S, Bühlmann C, Tschan F. et al. Brief leadership instructions improve cardiopulmonary resuscitation in a high-fidelity simulation: a randomized controlled trial. Crit Care Med 2010; 38 (04) 1086-1091 Erratum in: Crit Care Med. 2010 Jun;38(6):1510
20 Hunziker S, Tschan F, Semmer NK. et al. Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial. BMC Emerg Med 2009; 9: 3
21 Stocker M, Allen M, Pool N. et al. Impact of an embedded simulation team training programme in a paediatric intensive care unit: a prospective, single-centre, longitudinal study. Intensive Care Med 2012; 38 (01) 99-104
22 Augenstein JA, Deen J, Thomas A. et al. Pediatric emergency medicine simulation curriculum: cardiac tamponade. MedEdPORTAL 2018; 14: 10758
23 Alkhalifah M, McLean M, Koshak A. Acute cardiac tamponade: an adult simulation case for residents. MedEdPORTAL 2016; 12: 10466
24 Lo TY, Morrison R, Atkins K, Reynolds F. Effective performance of a new post-operative cardiac resuscitation simulation training scheme in the Paediatric Intensive Care Unit. Intensive Care Med 2009; 35 (04) 725-729
25 Deters DR, Hunninghake J, Ruiz J, Marquez DJ, Ramirez DJ, Coffman RV. Increase intensive care staff comfort and proficiency with emergent re-sternotomy in the post-open-heart patient by using SynDaver® simulation. Cureus 2022; 14 (01) e20875
26 Guenther TM, Chen SA, Gustafson JD, Wozniak CJ, Kiaii B. Development of a porcine model of emergency resternotomy at a low-volume cardiac surgery centre. Interact Cardiovasc Thorac Surg 2020; 31 (06) 803-805
27 Allan CK, Thiagarajan RR, Beke D. et al. Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams. J Thorac Cardiovasc Surg 2010; 140 (03) 646-652
28 Kane J, Pye S, Jones A. Effectiveness of a simulation-based educational program in a pediatric cardiac intensive care unit. J Pediatr Nurs 2011; 26 (04) 287-2944