Role of simulators in

anesthesia practice

Speaker- Dr. Sangeeta

Moderator- Dr. Surendra Kumar
• Simulation refers to the artificial replication
of sufficient elements of a real-world
domain to achieve a stated goal
 Goals
1. understanding the domain better.
2.training personnel to deal with the
domain.
3. testing the capacity of personnel to work
in the domain.
 Fidelity
• refers to how closely it replicates the
domain.
• It is determined by the number of elements
that are replicated and the discrepancy
between each element and the real world.
• Preparation for warfare had helped in
development of simulation technologies,
especially for aviation, shipping, and the
operation of armored vehicles .
Commercial aviation has also contributed
 History
• The first anaesthesia simulator, SIM1, was
described in 1969 by Denson and
Abrahamson.
• Developed as a an aid in learning to
intubate and to induce anesthesia
• Consist of mannequin with intubatable
airway, upper torso and arms
• In mid 1980’s computer based simulator were developed like
“SLEEPER AND BODY”.
• In 1986 Gaba and DeAnda, developed a full-scale simulator
called the Comprehensive Anesthesia Simulation Environment
(CASE) to study the decision-making processes of
anaesthetists during critical events.
• Gaba, Fish and Howard refined CASE to be used in the
development of the Anesthesia Crisis Resource Management
(ACRM) course.
• Drs Michael Good and JS Gravenstein developed the
Gainesville Anesthesia Simulator (GAS), which later became
the prototype for the Medical Education Teachnologies Inc
(METI) simulator.
• Team Oriented Medical Simulation (TOMS), developed in 1994
by Helmreich, Schaefer and colleagues at the University of
Basel
 Applications
• Education
• Training
• Research
• Risk management and public relations
• Performance assessment
 CLASSIFICATION OF PATIENT
SIMULATORS
1. mannequin-based simulators(full-scale
simulator, hands-on simulator, realistic
simulator,high-fidelity simulator)
2. screen-only or screen-based simulator
("microsimulator").
3. virtual reality simulator
Components of a Patient
Simulator
• A set of outputs make up a representation of the patient, the
clinical environment, and diagnostic and therapeutic equipment.
• control logic- changes in the simulated patient's condition can
be generated, controlled, and sent to the appropriate output of
the representation.
Types
• 1. software as a fixed sequence of events.
• 2. manual control logic allows scripting of combinations of
changes in control input .
• 3. mathematical differential equations model a patient's
physiology and pharmacology to provide the bulk of the control
logic.
• 4. finite-state models- instructor initiation of abnormal events,
and even manual modulation of modeled parameters
• instructor/operator's station (IOS) --allows the instructor to
create specific patients, select and implement abnormal events
and faults, and monitor the progress of the simulation session.
Prototypic example of a simulation center
 Mannequin-Based Simulators (Realistic, Full-
Scale, High-Fidelity "Macro" Simulators)

• In 1986, Gaba and DeAnda began developing the Comprehensive

Anesthesia Simulation Environment (CASE) with a primary goal of
conducting research into decision making by anesthetists
• CASE used a commercially available mannequin modified to
 enable occlusion of the left main stem bronchus,
 infusion of CO2
 insertion of intravenous lines.
This mannequin allowed mask ventilation, intubation, and
auscultation of breath sounds,but it did not have palpable pulses or
spontaneous ventilation and lack physiologic and pharmacologic
models
• CASE extensively used in anesthesia crisis resource management
(ACRM) training program
 High-fidelity patient simulator system (MedSim Eagle Patient Simulator). The mannequin is in
middle and is the interface of trainees with the simulation. from left to right: opened simulator
chest with fully functional lungs, pneumatic systems, sensors, and electronics cables; eyes with movable lids and
reactive controllable pupils; and interface cart with gas analyzer and servo control boards. Lower pictures from left to
right: interface cart with built-in network personal computer, umbilical cords from the interface cart to the
mannequin, clinical monitoring and the main simulation workstation, and interface cart with noninvasive blood
pressure simulator (NIBP) for oscillometric measurements.
• These high fidelity patient simulator is
completely operated by physiologic,
pharmacologic and finite-state models with
detailed models of cardiovascular,
pulmonary, fluid, acid-base-electrolyte,
and thermal physiology.
 Gainesville Anesthesia Simulator
(GAS)and METI Human Patient Simulator

• An interesting component of the Gainesville

Anesthesia Simulator (GAS) was an anesthesia
machine modified to incorporate a variety of
mechanical faults that could be triggered
electronically.
• Also featured a complex, quantitatively accurate
physical simulation of multiple gas exchange.
• lung concentrations of O2 , N2 O, N2 , and one
volatile anesthetic could be physically made to
match the alveolar gas content predicted by a
mathematical model of gas exchange and
anesthetic uptake and distribution.
• GAS further developed by Medical Education
Technologies, Inc. (METI, Sarasota, FL). Now
called the Human Patient Simulator (HPS) it
also uses full physiologic and pharmacologic
mathematical models.
• METI offers a child-sized mannequin (PediaSim)
that has the same functionality as the adult
model
• can be controlled by the same base computer
and IOS. Recently, METI released a more
mobile and much less expensive simulator
called "Emergency Care Simulator (ECS)."
The METI Human Patient Simulator. The mannequin rests on a standard ICU
bed. Interface and linkagehardware is contained in a separate cart. A
loudspeaker in the headrest provides the "patient's voice" to allow the
mannequin to act as a "standardized patient."
The METI instructor/operator's station (IOS) allows full control over the model-based physiology and
pharmacology of the "patient." The numbers over the mannequin show the status of all physiologic
variables of the
model (e.g., blood gases, cardiocirculatory parameters). At the IOS more than one patient can be run
at a time and dynamically allocated to different mannequins.
 Laerdal SimMan

• Laerdal (Stavanger, Norway) manufacturer of basic life

support and advanced cardiac life support training
devices ranging from cardiopulmonary resuscitation
mannequins to mega-code training stations
• Introduced SimMan simulator in 2000
• it uses a virtual monitor rather than clinical monitoring
systems.
• SimMan's control logic is provided by direct instructor
control of individual data values and settings
• augmented by a script-based control logic (i.e., there are
no mathematical models)
The SimMan mannequin (Laerdal) during trauma resuscitation training. The mobility and
advanced airway features with some manual task training possibilities (such as chest
tube placement, manual blood pressure measurements) make this type of simulator well
suited for training sessions outside simulation centers.
Desirable features of future mannequin-based
• Advanced skin signs such as
Change in skin color to cyanotic or pale
Diaphoresis
Change in skin temperature (e.g., as a result of shock or fever)
Rash, hives, or generalized edema
• Regurgitation, vomiting, airway bleeding or secretions
• Physical coughing (currently only sounds are simulated)
• Convulsions
• Purposeful movements of extremities
• Support for spinal, epidural, or other regional anesthesia procedures
• EEG signals (e.g., for BIS, AEP)
• Intracranial pressure
• Support for physical central venous cannulation
• Fetal/maternal cardiotocogram (CTG)
• A fully interactive simulator of a neonate or infant
 Screen-Based Simulators
• SLEEPER and BODY
• SLEEPER used complex transport model to deal with
gas exchange and drug distribution. Predict
concentration of drugs in specific anatomic region
(myocardium)
• Anesoft Anesthesia simulator- Anesthesia simulator
consultant (ASC) - provides graphic representations of
mock monitoring displays and clinical equipments, also
photographs to display patient and actions taken on it.
-Uses pharmacokinetic and pharmacodynamic models.
 Virtual Reality Simulators

• Virtual reality refers to a set of techniques

in which one interacts with a synthetic
("virtual") environment that exists solely in
the computer
• The actions of the user in the environment
are translated directly from typical physical
activities, not through manipulating a
special pointing device
complete virtual reality patient simulator would be very
complicated because it requires--
1. A complete computer model of the patient, the
environment, and the function of every object in the
environment that could be used (e.g., monitoring
devices, carts)
2. A means of tracking visual, audio, and touch fields of
the user to determine what is to be displayed and to
identify what physical actions are being performed
3. Appropriate display hardware for every sensory
modality and appropriate input hardware for each action
pathway (e.g., touch, speech)
4. Hardware to compute all the models, to conduct the
tracking, and to produce all the output to the display
hardware in real time
virtual reality is still under development.
 ANESTHESIA CRISIS RESOURCE MANAGEMENT
(ACRM)

Key points in anesthesia crisis resource management (ACRM)

• Know the environment
• Anticipate and plan
• Call for help early
• Exercise leadership and followership
• Distribute the workload
• Mobilize all available resources
• Communicate effectively
• Use all available information
• Prevent and manage fixation errors
• Cross (double) check
• Use cognitive aids
• Re-evaluate repeatedly
• Use good teamwork
• Allocate attention wisely
• Set priorities dynamically
 The ACRM curriculum uses several teaching modalities to
achieve these goals, including
1. A comprehensive textbook on anesthesia crisis
management (Crisis Management in Anesthesiology)
2. A brief presentation reviewing the principles of ACRM
and anesthesia safety.
3. Analysis of a videotape of an aviation accident.
4. Small group exercises analyzing a videotape of an
actual anesthetic mishap or analyzing written or video
presentations about difficult cases.
5. Several hours of complex multifaceted realistic
simulations in which training participants rotate through
different roles, including primary anesthesiologist, first
responder (called "cold" with no knowledge of the
situation), and scrub nurse. Other personnel play the
roles of surgeons, nurses, and technicians as in a real
OR. Each situation is followed by a detailed debriefing
with video feedback.
 Use of Patient Simulation for Training Health Care
Personnel outside Anesthesia

• The ICU
• The emergency department or trauma center
• The delivery room
• Cardiac arrest response teams
• Radiology
• Field response by ambulance staff and combat casualty
care in the military
• training for the management of chemical, biologic,
nuclear threats from accidents, weapons of mass
destruction or terrorism.
Realistic patient simulation for studying the performance of medical
rescue teams in full chemical protection gear. Teams wore normal
uniforms or full protection suits while performing basic resuscitation
actions
In rescue situations with full protective gear, communication
within the team and with the patient is
difficult.
 USE OF PATIENT SIMULATION IN SUPPORT OF
BIOMEDICAL INDUSTRIES
• Numerous centers offer training to executives and sales
representatives of equipment and pharmaceutical
manufacturers.
• simulator allows these individuals to gain some
understanding of the clinician's task demands
during patient care and the situations in which their
company's drugs or devices could be useful.
• Simulators used to train the manufacturer's
representatives and clinicians in safe use of the drug.
• to conduct research on human factors issues in the
development of new monitoring and therapeutic devices.
• It was possible to train anesthetists in the application of
remifentanil with the simulator, even before remifentanil
was approved by the Food and Drug Administration in
the United States
 OTHER USES
• Some centers use simulators for conducting "outreach"
programs with high-school or college students interested
in health care.
• Simulators used to produce educational videotapes on
various patient safety issues.
• Used as adjuncts in medicolegal proceedings.
• Can be used to illustrate typical perioperative situations
and the role of different monitors and therapeutic actions
• Nontechnical skills assessment-
- Cognitive and mental skills, including decision making,
planning, and situation awareness
- Social and interpersonal skills with aspects of team
working, communication, and leadership
 EFFECTIVENESS OF SIMULATION TRAINING

simulation has many advantages as a training tool.

1. There is no risk to a patient.
2. Exercises in routine procedures can be repeated intensively,
whereas situations and events involving uncommon, but serious
problems can be presented at will.
3. Participants can learn to use actual complex devices (with a hands-
on simulator).
4. The same situation can be presented independently to multiple
subjects for evaluating individual or group performance.
5. Errors can be allowed to occur that in a clinical setting would require
immediate intervention by a supervisor.
6. The simulation can be frozen to allow discussion of the situation and
its management, and it can be restarted or begun anew to
demonstrate alternative techniques.
7. Recording, replay, and critique of performance are facilitated
because patient safety or confidentiality is not an issue.
 Research issues that can be addressed by using
anesthesia simulators

• Cognitive Science of Dynamic Decision Making

• Human-Machine Interactions
• Teaching Anesthesia in the Operating Room
How much teaching can be accomplished in the operating room
without sacrificing the anesthesia crew's vigilance?
How well can faculty detect and categorize the performance of
anesthesia trainees?
What teaching styles are best integrated with case management in
the operating room?
• Issues of Teamwork
How does the anesthesia crew (attending plus resident or certified
registere nurse anesthetist pair) interact during case and crisis
management?
How is workload distributed among individuals?
How do crew members communicate with each other, and how do
they communicate with other members of the operating room team?
• Effects of Performance-Shaping Factors on
Anesthetist Performance
How do sleep deprivation, fatigue, aging, or the carryover
effects of over-the-counter medications, coffee, or
alcohol affect the performance of anesthetists?
• Intelligent Decision Support
Can smart alarm systems or artificial intelligence provide
correct and clinically meaningful decision support in the
operating room or intensive care unit?
• Development of new devices and applications
• Research Regarding the Technique of
Simulation Itself
 FUTURE OF PATIENT SIMULATION IN ANESTHESIA

 Patient simulators have emerged from their purely

experimental phase to become an accepted, though still
new component of research and training in health care.

 It is highly likely that simulators will become a regular part

of the initial and recurrent training of most anesthetists
and many other clinicians.
 The anesthesia community can be proud of its pioneering
role in developing patient simulation technology and
simulation-based training curricula.
 As this process continues, it is also likely that anesthetists
will continue to lead the rest of health care in the evolution
of this technology and its educational, research, and
evaluation applications
 Refrences
 Miller’s Anaesthesia, 6th ed.
 International Practice of Anaesthesia. Prys-Roberts.
 Recent advances
 Chopra V, Gesink BJ, deJong J, Bovill JG, Spierdijk J, Brand R.
Does training on an anaesthesia simulator lead to improvement in
performance? Br J Anaesth 1994; 73: 293-7.

 Morgan PJ, Cleave-Hogg D, McIlroy J, Devitt JH. A comparison of

experiential and visual learning for undergraduate medical students.
Anesthesiology 2002; 96: 10-16.

 Nyssen AS, Larbuisson R, Janssens M, Pendeville P, Mayne A. A

comparison of the training value of two types of anesthesia simulators:
computer screen-based and mannequin-based simulators. Anesth Analg
2002; 94: 1560-5.

 Yee B, Naik V, Joo HS et al. Nontechnical skills in anesthesia crisis

management with repeated exposure to simulation-based education.
Anesthesiology 2005; 103: 241-8.