Module: Acute Hypotension/Endotracheal Tube Change.
Scenario Name: Hypovolemia in an Adult Patient With History of Liver Transplantation.
Patient File Name: Kyaw Zin Kyi.
Simulation Developers: Cynthia Wang, MD; Christine C. Myo, MD; Kenneth Kuchta, MD; and Samuel H. Wald, MD.
Simulator: Laerdal SimMan.
Date of Development: July 2010 to September 2010.
Appropriate for following learning groups:
Residents: PGY 1–7
Specialties (for faculty and residents): Anesthesia, Radiology, and Surgery
Nurse Anesthesia Faculty
Nurse Anesthesia Student: Year 1–2
The average life expectancy and age of the US population has been steadily increasing which has been reflected in the type of patient presenting for anesthesia and surgery. Concomitant with increasing age, patients have a larger number of comorbidities which must be considered in anesthetic planning.1 For instance, data from the Centers for Disease Control show that the incidence of obesity and disability among Americans has increased over the past 5 to 6 years.2 As a result, medical professionals have had to adapt to the modern-day patient who is frequently more elderly and who presents with more comorbidities, both in number and in complexity.
Furthermore, medical advancements such as organ transplantation have allowed patients to survive longer but potentially with more complicated disease than in previous years. In fact, United Network for Organ Sharing data indicate that patients older than 50 years comprise a larger fraction of the organ transplantation waiting list than they did 10 years before, and patient and graft survival have also improved over the past 10 years.3 Increasingly, these patients are surviving longer than ever before, though not without experiencing residual sequelae from their organ dysfunction and diseases associated with having had a solid organ transplantation.
The patient who has undergone a liver transplant typically has had damage to multiple organ systems as part of the disease process. The renal, pulmonary, and cardiac systems may be affected even after correction of liver function by transplantation. Furthermore, patients who have undergone liver transplant surgery have been exposed to multiple blood product transfusions and are therefore prone to developing multiple antibodies. This leads to difficulty in crossmatching units of blood in the future. These patients require long-term use of immunosuppressants which predisposes them to opportunistic infections.4 Patients who have undergone liver transplantation surgery have even greater mortality rates if they are older, have diabetes, or have coexisting renal insufficiency.5
In this simulation exercise, the learner manages not only a patient who requires resuscitation but also the management which is complicated by the history of a liver transplant. Our objective is to not only have the learner address the issues surrounding acute hypovolemia and management of a difficult airway but also to do so in the setting of a complex patient. This serves as training for the future of medical practice.
At the conclusion of the simulation session, the participant will have an understanding of the following core competencies (learning domains are listed in parentheses).
Medical Knowledge (Cognitive)
- Describe etiologies for hypotension and prioritize the differential diagnosis.
- Identify the risks and benefits of using uncrossmatched blood in an immunosuppressed patient.
- Generate a plan and assemble appropriate equipment for airway management in a patient with a potentially difficult airway.
- Implement treatment strategies for hypotension secondary to hypovolemia, including obtaining adequate access, establishing appropriate monitoring, obtaining blood products, and calling for help to resuscitate the patient (psychomotor).
- Recognize the risk of not transfusing during ongoing blood loss (cognitive).
- Appreciate that an easy airway in the beginning of a case may have become more challenging by the end of the case (affective).
Interpersonal and Communications Skills
- Effectively recognize a rapidly worsening situation, prioritize actions that address critical issues, and engage other providers to assist in patient care (affective organization).
- Communicate with surgical team during crisis (cognitive and affective).
- Ask for help; use responder/delegate responsibility (cognitive, psychomotor).
- Recognize the need to call for additional support and equipment when faced with a difficult airway (cognitive).
Recognize the need for personnel and equipment for the management of airway complications when transferring care from the operating room (OR) to other hospital settings (affective responding to phenomenon).
Questions for Debriefing
- What are the common etiologies of unexpected hypotension during sinus surgery?
- What are the factors that you considered when you decided to use uncrossmatched blood?
- What are the concerns related to manipulating the airway in this patient?
- Did you effectively communicate with the surgical team? What could you have done differently?
- What technical or communication skills would you like to improve upon?
For details regarding assessment tools, see Appendix.
Non-invasive blood pressure cuff
Capnograph end-tidal CO2 detector
Other Equipment Required
Endotracheal tube (ETT) (oral Ring, Adair, and Elwyn [RAE] and standard ETT)
Laryngeal mask airway
Nasal and oral airways
Suction (Yankauer and endobronchial catheters)
Nasal canula and/or nonrebreather face mask
Intravenous fluids and lines
Tube exchange catheter (including Aintree catheter)
Transtracheal jet ventilator
Central venous catheter sets
Other Optional Equipment
Video recorder (video recording recommended for debriefing purposes).
Setup: 20 minutes.
Orientation: 15 minutes.
Simulation: 20 minutes.
Debriefing: 30 minutes.
CASE STEM FOR THE FACILITATOR
In this scenario, the case is already under way and the learner receives report from attending who the learner has to relieve for a lunch break.
The patient is a 68-year-old man with hepatitis C and end-stage liver disease, who had a liver transplant 10 months ago, who is now presenting with facial pain, diplopia, and epistaxis, and who is coming to the OR for endoscopic sinus surgery. A 20 g IV in the left arm is placed, and a smooth intravenous induction with propofol and succinylcholine was performed. Upon direct laryngoscopy, the patient was a grade I view. The patient was intubated atraumatically with a 7.0 oral RAE endotracheal tube (ETT), the ETT was secured with the natural bend of the oral RAE tube at the lower lip, and the head of the bed was turned 90 degrees without event. Cefazolin, fentanyl, and rocuronium were given just before incision. The patient is maintained on 2 L of oxygen and 5% of desflurane. The vitals are stable, the patient is normothermic, and a normal capnogram is noted. The attending will leave for his lunch break. Two minutes after the learner receives report, the surgeon starts suctioning, and a liter of blood is lost from the surgical site. The surgeon states that he may be losing some blood.
Facilitator/Coordinator’s Background and Briefing Information
Mucormycosis is a nonseptate fungal infection that can lead to a necrotising vasculitis in immunocompromised patients. The fungus invades vessel walls causing a secondary thrombosis of the vessel lumen. This results in infarction, necrosis, and a characteristic dark eschar. The sinuses and nasal cavity are typically the initial site of infection, but primary infections involving the lungs, soft tissue and skin, and gastrointestinal tract may also be seen. Orbital involvement can occur by contiguous spread from the sinus through arterioles penetrating the thin medial wall of the orbit.
Patients with rhino-orbital mucormycosis often have an associated systemic disease, most commonly poorly controlled diabetes mellitus. Other predisposing states include renal failure, hematologic and solid tumor cancers, patients on chemotherapy, cirrhosis, and organ transplantation with immunosuppressive therapy. The prognosis is often dismal with a high mortality rate. Once the diagnosis of mucormycosis is made through tissue biopsy rather than fungal culture, immediate treatment with liposomal amphotericin B and surgical debridement of necrotic tissue are vital.
During the scenario, the surgeon will unexpectedly biopsy the carotid during endoscopic sinus surgery, which causes unexpected bleeding. With a rapidly declining blood pressure (BP), the learner will have to prioritize his/her treatment strategy and quickly develop a plan to resuscitate the patient. The nurse and surgeon in the room will provide necessary support with invasive monitors and blood if the participant asks and delegates. If the participant places the patient in Trendelenburg position, the blood improves only minimally and the bleeding worsens, prompting the surgeon to insist that the patient be flattened. If crystalloids, non blood product colloid, or phenylephrine is given, only transient improvement occurs. If the participant initiates advanced cardiac life support measures such as chest compressions or epinephrine, transient hypertension for 2 minutes occurs, after which the patient will return to the previous decompensated state when advanced cardiac life support stops.
If the participant does not ask for blood, the nurse can state that there was a type and screen sent from the emergency department, which is standard procedure for the purposes of this scenario. After several minutes, the nurse can then notify the participant that the blood bank called to say that it will be several hours before there will be crossmatched blood available and asks if this is acceptable. The participant must then decide what type of blood product should be available for resuscitation, taking into consideration the possibility of transfusion reactions if uncrossmatched products are administered. The surgeon can start packing the nares, but the BP should only begin to stabilize if adequate monitoring and intravenous access is established and blood products are given for resuscitation. The participant should also request plasma, note the temperature, and administer calcium as part of the resuscitation, demonstrating his/her understanding of the physiological consequences of large-volume resuscitation.
An interventional radiologist, consulted for possible future embolization, images the head and neck region and informs the participant that the oral RAE tube initially inserted at the beginning of the case is dangerously high. Imaging accessed in the OR via the hospital information network reveals the tip of the ETT to be 5 cm above the carina. The nurse and surgeon encourage the participant to change the tube as quickly and carefully as possible. If necessary, the OR nurse who is giving report to the intensive care unit (ICU) nurse states that the ICU refuses to accept the patient with an oral RAE ETT at that location. The participant must devise a way to change the ETT. If the participant chooses to extubate and reintubate using traditional direct laryngoscopy, there will be poor visualization, the patient will desaturate, and a surgical airway will be required. If the participant calls for backup in preparation for a surgical airway and chooses to exchange the tube with a tube exchanger and possibly with the assistance of a video laryngoscope or Glidescope, a successful intubation will result. After the tube exchange occurs, the patient can then be transferred to the ICU (Table 1; Fig. 1).
PATIENT DATA BACKGROUND AND BASELINE STATE
History of Present Illness
The patient is a 68-year-old man with a complaint of diplopia secondary to fungal sinusitis/mucormycosis. The patient has had diplopia, epistaxis, and facial pain for 3 days.
Orthotopic liver transplant 10 months ago.
End-stage liver disease secondary to hepatitis C.
Review of Systems
Orthotopic liver transplant—normal airway during prior anesthetic.
Neutral Protamine Hagedorn (NPH)
No known drug allergies.
General: no acute distress, alert, and oriented × 3.
Weight: 58 kg.
Vital signs: heart rate: 69, BP: 148/82, respiratory rate: 18, and SaO2: 99% (room air).
Airway: grossly normal, Mallampati II, full range of motion, three finger breadth thryomental distance, poor dentition, and none loose.
Lungs: clear to auscultation.
Heart: regular rate and rhythm.
Abdomen: soft, nontender, and nondistended.
Complete Blood Count (CBC)
White blood cell count: 6.6 × 109/L
Hemoglobin: 99 g/L
Platelets: 263 × 109/L
Sodium: 137 mmol/L
Potassium: 3.6 mmol/L
Chloride: 105 mmol/L
Bicarbonate: 21 mmol/L
Blood urea nitrogen: 9.28 mmol/L (26 mg/dL)
Creatinine: 114.9 mol/L (1.3 mg/dl)
Glucose: 9.27 mmol/L (167 mg/dl)
Alanine Transaminase (ALT): 108 U/L
Aspartate Transaminase (AST): 87 U/L
Total bilirubin: 20.5 μmol/L (1.2 mg/dl)
International Normalized Ratio (INR): 1.1
Prothromin Time (PT): 12 seconds
Partial Thromboplastin Time (PTT): 25 seconds
Computed Tomography (CT) sphenoid sinus with hyperdense material and air: no intracranial bleed.
Chest x-ray: small right-sided effusion
Electrocardiogram (EKG) Normal Sinus Rhythm (NSR) with Pulmonary Artery Catheters (PACs): T wave inversions V1-V4
The authors thank Yue-Ming Huang, EdD, for her contributions in the preparation of this article.
4. Moreno R, Berenguer M. Post-liver transplantation medical complications. Ann Hepatol 2006; 5: 77–85.
© 2012 Society for Simulation in Healthcare
5. Watt KD, Pedersen RA, Kremers WK, Heimbach JK, Charlton MR. Evolution of causes and risk factors for mortality post-liver transplant: Results of the NIDDK long-term follow-up study. Am J Transplant 2010; 10: 1420–1427.