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TEMPLATE DESIGN © com Comparison Of Manikin models versus Live Sheep in Can’t Intubate Can’t Ventilate training A.P.M. Moran 1, J. Dinsmore 2, D.A. Lacquiere 3, A.M.B. Heard 2. Departments of Anaesthesia: 1. Guys and St Thomas Hospital 2. Royal Perth Hospital, Australia 3. Taunton and Somerset NHS foundation Trust Background Discussion Further Information From our results a live sheep model appears to be a better training tool than a manikin model for all forms of cricothyroidotomy training. This is because there is greater similarity to human anatomy and the use of a live sheep model produces a more realistic scenario. There is not only time pressure and a sense of personal responsibility (as the sheep becomes hypoxic), but also movement of skin over the cricothyroid membrane, blood and vomitus. Of interest the cricothyroid membrane was more easily identifiable in the manikin. This highlights a possible flaw in manikin training that the landmarks are too easily found. Can’t intubate can’t ventilate (CICV) situations are rare but are associated with high rates of morbidity and mortality. At Royal Perth Hospital a structured training program is in place to ensure all anaesthetic staff are prepared to deal with the CICV scenario 1. On a weekly basis participants undergo training that takes the form of ‘dry lab’ manikin based teaching followed by a ‘wet lab’ session during which participants undertake CICV rescue techniques on anaesthetised sheep. Attendees at the training who have subsequently faced CICV scenarios have stated that in retrospect the ‘wet lab’ session was significantly more realistic than the manikin based session. We therefore conducted a prospective survey to compare the perceived realism of the live sheep model to that of the manikin. Method Both animal and human ethics approval were obtained. Participants performed cannula cricothyroidotomy, Melker airway insertion and the “scalpel bougie” technique on a manikin (Portex TOT100 Tracheostomy trainer and case) and then on live anaesthetised sheep. They were then asked to assess the realism of landmark recognition, the skin, and the overall realism of each procedure using a visual analogue scale (VAS) of Finally participants were asked to state their overall preference for performing each procedure on either the sheep or the manikin. As the VAS scores were not normally distributed, the results were analysed using the Wilcoxon paired-rank test. Insertion of Melker Airway technique Cannula Cricothyrodotomy technique Stabilise airway with non-dominant hand. Insert the tip of the needle through the skin advancing whilst aspirating. The end point of successful cannulation is the aspiration of air into the syringe. Secure the trochar with dominant hand, whilst the cannula is advanced over the needle into the airway. Perform a check aspiration. Following confirmation of position, attach the cannula to a jet ventilation source and begin ventilation. Videos of each technique can be found at: AMBHeardAirway Insert wire through the cannula. Withdraw the cannula over the wire. Insert scalpel blade making a stab incision along the wire. Ensure that the dilator is completely and fully seated inside the airway and that your grip prevents the dilator from moving backwards as the device is advanced. Advance combined unit in a caudal direction. Remove introducer and wire as one, inflate cuff and ventilate If desaturation occurs prior to successful Melker insertion the cannula can be carefully passed back over the wire and jet ventilation restarted Results 29 participants were included in this study The median Visual Analogue Score (VAS) for landmark recognition was significantly higher in the manikin than the sheep (median 9.5 (interquartile range ) vs 8 ( ), p=0.0009). The median VAS for skin realism was significantly higher in the sheep compared to the manikin (8.2 ( ) vs 5 ( ), p<0.0001). The VAS for realism of each procedure (cannula cricothyroidotomy, Melker insertion and scalpel bougie) was found to be significantly higher in the sheep compared to the manikin (9 (8- 9.5) vs 5.2 (4-6.5), 8.9 (8-9.3) vs 5.6 ( ), 9 (8-9.4) vs 5.3 (2.8-6) all p values <0.0001). All participants stated a preference for learning each procedure on the live sheep model compared to a manikin. Reference 1. Heard AMB, Green RJ, Eakins P. The formulation and introduction of a ‘can’t intubate, can’t ventilate’ algorithm into clinical practice. Anaesthesia 2009; 64: 601–608 Scalpel bougie technique Identify cricothyroid membrane and stabilise with non-dominant hand (ND). Make horizontal stab incision through cricothyroid membrane. Rotate blade through 90 so that the blade points caudally. Pull scalpel towards you, maintain the perpendicular alignment – this produces a triangular hole. ND hand now stabilises the scalpel. With the bougie pointing away and parallel to the floor, insert tip into trachea using the blade as a guide. Rotate and align bougie to allow insertion along the line of the trachea. Remove blade and insert feeling for tracheal rings and/or “hold up”. Re-oxygenate via bougie with jet ventilator. Railroad lubricated 6.0 ETT Scalpel bougie technique contd.
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