Table 2.
States for Scenario 2: Postoperative Atrioventricular Septal Defect Repair Handoff Communication
| State | Patient Status | Learner Action | |
|---|---|---|---|
| Called to room | • In ICU room, on bed, supine, sedated • VS: Sinus rhythm, HR 130, RR 20, BP 71/50 (arterial line), 75/50 (cuff), SpO2 99%, ETco2 40 mm Hg, CVP 12 cm H2O • Ventilator: PSIMV rate 20, PiP 25 cm H2O, PEEP 5 cm H2O, FiO2 40% • Infusions: epinephrine 0.02 μgkg−1 min−1, nitroprusside 1 μgkg−1 min−1 |
• Attaches patient to ECG monitor, pulse oximeter, and BP cuff • Attaches patient lines to CVP transducer, a-line transducer • Attaches ETT to ventilator tubing |
Trigger to enter state: • Start of session |
| Hypoxia | • SpO2 decreases to 85% over 1 min | • Notes hypoxia • Increases FiO2 on ventilator • Administers sedation/paralysis • Increases PiP or PEEP |
Operator: • Patient is hypoxic secondary to pulmonary hypertension • If FiO2 is increased or sedation/paralysis is administered, SpO2 increases to 95% over 1 min • IfPiP/PEEP are manipulated, state remains unchanged Trigger to enter state: • Simulation time 1:30 min Teaching points: • Recognition and differential diagnosis for hypoxia in the postoperative patient • Acute management of pulmonary hypertension in an intubated patient • Applying information provided during handoff communication in the acute management of the postoperative patient |
| Tachycardia | • Rhythm changes to supraventricular tachycardia; HR suddenly increases to 205 | • Notes tachycardia • Administers sedation • Decreases epinephrine • Administers volume • Attempts to overdrive pace |
Operator: • Patient is tachycardic secondary to junctional ectopic tachycardia (JET) • If sedation is administered or epinephrine is decreased, JET resolves and HR returns to 130 over 30 s • If volume is administered, state remains unchanged • If pacemaker turned on, HR remains unchanged (unable to capture) Trigger to enter state: • Simulation time 3:00 min Teaching points: • Recognition and differential diagnosis for postoperative tachycardia • Acute management of JET • Applying information provided during handoff communication in the acute management of the postoperative patient |
| Hypotension | • BP decreases to 40/25 over 2 min; CVP remains at 12 cm H2O | • Notes hypotension • Decreases nitroprusside • Increases epinephrine • Administers calcium • Administers volume • Orders echocardiogram |
Operator: • Patient is hypotensive secondary to diastolic dysfunction and decreased contractility • If nitroprusside is decreased, epinephrine is increased, or calcium is administered, BP increases to 71/50 • If volume is administered, BP remains unchanged and CVP rises to 14 • If echocardiogram is ordered, report suggests minimal pericardial effusion Trigger to enter state: • Simulation time 5:00 min Teaching points: • Recognition and differential diagnosis for postoperative hypotension • Acute management of decreased contractility |
FiO2 indicates fraction of inspired oxygen.
VS, vital signs; HR, heart rate; RR, respiratory rate; BP, blood pressure; SpO2, saturation of oxygen by pulse oximetry; ETCO2, end-tidal carbon dioxide; CVP, central venous pressure; PSIMV, synchronized intermittent mandatory ventilation, pressure limited; PiP, peak inspiratory pressure; PEEP, positive end-expiratory pressure; FiO2, fraction of inspired oxygen; ECG, electrocardiogram; a-line, arterial line; ETT, endotracheal tube; BMV, bag-mask ventilation; JET, junctional ectopic tachycardia.