Original Publication
Open Access

Critical Care Medicine Simulation: 72-Year-Old Female with Fever, Hypotension, and Altered Mental Status

Published: July 17, 2012 | 10.15766/mep_2374-8265.9198

Included in this publication:

  • Sepsis Simulation.pdf
  • Crit Case 6 - 72-year-old unresponsive female.pdf

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.


Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications.

Abstract

This simulation presents participants with a patient in septic shock. The target audience includes all of levels of providers who practice within a critical care or emergency room setting. The pilot simulation was targeted at Anesthesiology residents of all training levels within the Department of Anesthesiology and Pain Medicine at the University of Washington. The learning objectives or assessment objectives include the following: recognize the characteristics of septic shock, manage the hemodynamics of a patient presenting with septic shock, manage the respiratory mechanics in a patient with septic shock, and investigate and treat sources of infection in a patient who presents with septic shock. The simulation builds into the scenario a Critical Actions Checklist. This list ensures the educational/assessment goals of this simulation are met. This list includes the following: simple checklist of critical actions (which are built into the case narrative), a scoring system based on performance actions (which are built into the case narrative), duration of critical actions (which are built into the case narrative), and optimal sequence of critical actions which center on the cardiovascular and respiratory support of the septic patient followed by identification/management of the source of the septic shock. The environment for this computerized simulation is available as download via Anesoft Corporation and is free for any participant who gets permission from Anesoft. The simulation resource file for the Anesoft program can be downloaded from MedEdPortal.com and uploaded into the Anesoft program via the instructions listed in this resource. The actor for this simulated patient will be present in the simulation. Participants in the scenario will act as the primary care giver within a critical care environment when a patient with septic shock arrives to the ICU.

This scenario has been simulated for over 22 months by CA-1. CA-2, and CA-3 Anesthesiology residents at the University of Washington. A total of over 30 residents per month participate in an ICU rotation. This simulation has been implemented for a broad based teaching scenario for all residents within UW. This should provide well over 300+ residents per year participating, which will allow for further refinement and enhancement to meet educational needs. While pilot testing and revising the simulation expectation, several anticipated management mistakes were identified: 1. many residents utilize vasopressor/intotrope therapy prior to maximizing volume administration (this exercise will focus on the proper use of early and aggressive volume resuscitation using early goal directed therapy), 2. many residents are unfamiliar with the association between ARDS and septic shock (this fact accounts for the low utilization of “low tidal volume, plateau pressure limited” protective ventilation strategies for ARDS in patients who present with septic shock), and 3. many residents did not understand the concept of source control and providing the appropriate antibiotic selection based on the risk factors for community, healthcare associated, and hospital acquired infections.

We also included an evaluation form for any participant. Thus, each participant receives a detailed printed record of the case simulation and printed debriefing of their case management.

Each resident takes a written pretest at the initiation of each rotation. At the end of each rotation, each resident will finish the rotation with a written post test. Based on aggregate pre and post tests scores for each CA-2 (third year) resident on the critical care medicine rotations within the VA Puget Sound SICU, correct answers on questions related to sepsis, severe sepsis, and septic shock increased by 40% after the implementation of this simulation during the academic year from 2009 to 2010.

Educational Objectives

Learning Objectives include the following:

  1. Recognize the characteristics of septic shock.
  2. Manage the hemodynamics of a patient presenting with septic shock.
  3. Manage the respiratory mechanics in a patient with septic shock.
  4. Investigate and treat sources of infection in a patient who presents with septic shock.

Author Information

  • Allen Gustin, MD: University of Chicago Division of the Biological Sciences The Pritzker School of Medicine

Disclosures
None to report.

Funding/Support
None to report.


References

  1. Rivers E, Nguyen B, Havstad S, Ressler,J, Muzzin A, Knoblich B, Peterson E, Tomlanov M for the Early Goal Directed Therapy Collaborative Group: Early goal directed therapy in the treatment of severe sepsis and septic shock, New England Journal of Medicine 2001; 345 (19): 1368-1377. http://dx.doi.org/10.1056/NEJMoa010307
  2. Martin GS, Bernard GR: Airway and lung in sepsis. Intensive Care Med 2001; 27:S63-S79. http://dx.doi.org/10.1007/PL00003798
  3. Milberg JA, Davis DR, Steinberg KP, Hudson LD: Improved survival of patients with acute respiratory distress syndrome: 1983-1993. JAMA 1995; 273: 306-309. http://dx.doi.org/10.1001/jama.1995.03520280052039
  4. The Acute Respiratory Distress Syndrome Network; Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine 2000, 342: 1301-1308. http://doi.org/10.1056/NEJM200005043421801
  5. Dellinger, RP, Carlit JM, Maser H, Herat, H, Caler, T, Cohen J, Gea-Banacloche J, Keh D, Marshall J, Parker M, Ramsay G, Zimmerman JL, Vincent JL, Levy MM, for the Surviving Sepsis Campaign Management Guidelines Committee: Surviving sepsis campaign: Management of severe sepsis and septic shock, Crit Care Med 2004; 32(3): 858-872. http://dx.doi.org/10.1097/01.CCM.0000117317.18092.E4


Citation

Gustin A. Critical care medicine simulation: 72-year-old female with fever, hypotension, and altered mental status. MedEdPORTAL. 2012;8:9198. https://doi.org/10.15766/mep_2374-8265.9198