Establishing a Multidisciplinary Cavernous Carotid Injury Simulation to Train Neurosurgical, Otolaryngology, and Anesthesia Residents

Summary

This protocol establishes a multidisciplinary model to train learners on management of cavernous carotid artery injury. Cadaveric heads undergo expanded endonasal approach and injury to the cavernous carotid artery, and perfusion pump simulates blood flow to the injury point. Learners are tasked with medical and surgical management over 3 scenarios.

Abstract

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for technique and algorithm development in resident learners. This study develops a realistic cadaveric model for the training of crisis resource management in the setting of cavernous carotid artery injury. An expanded endonasal approach and right cavernous carotid injury is performed on a cadaveric head. The cadaver's right common carotid artery is cannulated and connected to a perfusion pump delivering pressurized simulated blood. A simulation mannequin is incorporated into the model to allow for vital sign feedback. Surgical and anesthesia resident learners are tasked with obtaining vascular control with a muscle patch technique and medical management over the course of 3 clinical scenarios with increasing complexity. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the learners prior to beginning the simulation. An independent reviewer evaluated the learners on communication skills, crisis management algorithms, and implementation of appropriate skill sets. After each scenario, residents were debriefed on how to improve technique based on evaluation scores in areas of situational awareness, decision-making, communications and teamwork, and leadership. After the simulation, learners provided feedback on the simulation and this data was used to improve future simulations. The benefit of this cadaveric model is ease of set-up, cost-effectiveness, and reproducibility.

Introduction

Internal carotid artery injuries are a serious, albeit rare, complication of endoscopic endonasal approaches that require surgical dissection of tumor or vascular pathology adjacent to the cavernous sinus¹. Techniques and algorithms for managing this type of complication can only be obtained through realistic simulation². Wormald and colleagues have pioneered a training protocol for how to manage carotid injuries using a sheep model simulation³. They used a crush muscle patch with direct pressure over the injury site for hemostasis followed by direct vessel closure. This simulation has successfull....

Protocol

Cadaveric heads used in this protocol were acquired from the Oregon Health & Science University Body Donation Program. All methods described have been approved by the Oregon Health & Science University Institutional Review Board (IRB).

1. Head Preparation

1. Secure the fresh cadaveric head in the sink with the neck facing upwards.
2. Using a 1:100 anti-coagulant citrate dextrose solution, rinse out the jugular veins, vertebral, and carotid arteries bilaterally. Start by.......

Discussion

Carotid injury is a rare event but does occur in cases that involve the extended transphenoidal approach⁸. This approach is commonly used for pathology of the sella, suprasellar, parasellar, and clival spaces. Most skull base surgeons will face a carotid vascular injury at some point in their career. The expertise and confidence to handle such a dilemma can only be obtained through adequate training and appropriate crisis management simulation³. Valentine and colleagues hav.......

Materials

Name	Company	Catalog Number	Comments
Anti-coagulant citrate dextose solution	Pierce Laboratories	117037
Embalming solution	Chemisphere
Formalin fixative	Chemisphere	B2915DR55
Zero degree endoscope (4mm and 18 cm length)	Karl Storz	H3-Z TH100
Penfield 1	Jarit	285-365
Kerrison rongeur	Aesculap	FM823R, 3mm/180 mm
Anspach eMax 2 Plus High Speed Drill	Depuy-Synthes	eMax2 plus
3 mm cutting ball	Depuy-Synthes
11-blade surgical blade	Bard-Parker	371111
Arterial cannula clamp
Arterial cannula	Instrument Design & Mfg. Co.	ART187-2-CT
Perfusion Pump	Belmont Instrument Corporation, Billerica, MA, USA	Belmont Fluid Management System 2000
Vampire blood	Forum Novelties, Inc., Melville, NY, USA	65368
Cottonoid surgical patties	Codman	80-1480
Laerdal SimMan	Laerdal Medical, Wappingers Falls, NY, USA	SimMan 3G
Laerdal SimMan Laptop	Laerdal Medical, Wappingers Falls, NY, USA	SimMan 3G
Pituitary rongeur	Aesculap	FF806R
Bayonet	Aesculap	BD 845
Suction - 7 and 10 FR	V. Mueller
IV poles	Pedigo
IV unit	Care Fusion	Alaris PC Unit
Pump modules	Care Fusion	Alaris Pump Module
Kit Arterial Line	Arrow International	RA-04020
Kit Pressure Monitor	ICU/BMP Inc	426340405
Fluid IV NaCl 0.9 1000CC)	Baxter Healthcare	2B1324X
Fluid IV lactated ringers 1000CC	Baxter Healthcare	2B2324X
Integra SL Anesthesia Machine	DRE	00104RS
AVS2 Remote Ventilator	DRE	409AVS2
Sigma Delta ISO Selectatec Vap Pour Fill	DRE	39001O
MP5 Bedside Monitor	Philips Healthcare	PMS-M8105a