General Anesthesia for a Posttonsillectomy and Adenoidectomy Bleed

Cody C Breinholt; Clark J Obr

doi:10.15766/mep_2374-8265.10476

Abstract Introduction: Providers at all levels should have some understanding of the pathophysiology and be able to manage such a patient in the operating room. In addition, any anesthetists providing pediatric care should be able to identify and understand the importance of other comorbid conditions in these patients. This simulation on posttonsillectomy and adenoidectomy hemorrhage in the pediatric patient presents a challenging case usually encountered in some form by most anesthesia residents during training. This simulation's objective is to challenge and further reinforce the knowledge of anesthesiology resident physicians who have completed 1 year of clinical anesthesia and at least 1 month of pediatric anesthesia. Methods: The simulation can be delivered in a single session of 1 hour or less. Materials in this simulation include a case template designed to provide facilitators with a general overview, a checklist of critical actions each learner should perform during the scenario, a brief summary to be provided to the learner to reinforce knowledge gained through the activity, and an evaluation form to assess the learner's view of the activity's educational value. Results: Learner comments were almost unanimously positive. All learners who returned surveys answered the questions “This simulation enhanced my understanding of how to manage critically ill patients in the perioperative period” and “The content was current and relevant to my practice” with either agree or strongly agree. Discussion: The module offers various points to practice troubleshooting skills in the management of difficult IV line placement as well as difficult airway management. In reality, this case could be modified in multiple ways, including management of a more severe hemorrhage with a much more hypovolemic patient. ------------------------------- Educational Objectives By the end of this simulation, the learner will be able to: 1. Discuss the diagnosis and perioperative management of posttonsillectomy hemorrhage. 2. Identify primary versus secondary posttonsillectomy hemorrhage. 3. Identify expected laboratory abnormalities in an actively bleeding patient. 4. Analyze laboratory data, patient vital signs, and physical exam to diagnose volume status. 5. Propose goals of resuscitation, including correcting hypovolemia through administration of normal saline or lactated ringers solution, albumin, and/or the need for blood transfusion. 6. Discuss and manage comorbid conditions and their perioperative implications. 7. Identify a patient who has a full stomach and is at high risk for pulmonary aspiration and complications. 8. Identify and be prepared to manage a difficult airway. 9. Request appropriate consultation and aid from professional colleagues, such as making sure an ear, nose, and throat surgeon is present on induction. 10. Discuss and demonstrate preparation for emergent surgery in a non-NPO bleeding pediatric patient without an IV who is a difficult IV placement. 11. Identify the need for IV or intraosseous (IO) access prior to induction of anesthesia. 12. Describe special pharmacologic considerations for analgesia or light sedation to facilitate IV/IO placement. 13. Select and demonstrate proper use of necessary equipment, including ultrasound for IV access, IO kit, and proper airway equipment. 14. Discuss and demonstrate performing a rapid sequence induction along with a working knowledge of the American Society of Anesthesiologists' (ASA's) difficult airway algorithm. 15. Perform an airway exam in the emergent setting. 16. Demonstrate familiarity with and appropriate use of difficult intubation equipment and the ASA's difficult airway algorithm. 17. Discuss areas of strength and areas for improvement discovered during the simulation. --------------------------------------- Includes simulation case, supplemental data, critical actions checklist, debriefing summary, evaluation form

General Anesthesia for a Posttonsillectomy and Adenoidectomy Bleed

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