BACKGROUND: Although included within the American Society of Anesthesiologists difficult airway algorithm, the use of "invasive airway access" is rarely needed clinically. In conjunction with highly associated morbidity and liability risks, it is a challenge for the average anesthesiologist to develop and maintain competency. The advancement of high-fidelity simulators allows for practice of rarely encountered clinical scenarios, specifically those requiring invasive subglottic airway techniques. METHODS: Sixty board-certified academic anesthesiologists were enrolled and trained in dyads in a simulation-based, mastery-based learning (MBL) course directed at 2 emergency airway subglottic techniques: transtracheal jet ventilation (TTJV) and bougie cricothyrotomy (BC). Performance metrics included: pretest, posttest, specific skill step error tracking, and 15-month period retest. All were pretested and trained once on the Melker cricothyrotomy (MC) kit. All pretest assessment, training, posttesting, and 15-month retesting were performed by a single expert clinical and educational airway management faculty member. RESULTS: Initial testing showed a success rate of 14.8% for TTJV, 19.7% for BC, and 25% for MC. After mastery-based practice, all anesthesiologists achieved successful invasive airway placement with TTJV, BC, and MC. Repeated performance of each skill improved speed with zero safety breaches. BC was noted to be the fastest performed technique. Fifteen months later, retesting showed that 80.4% and 82.6% performed successful airway securement for TTJV and BC, respectively. For safety, average placement time and costs, MC was discarded after initial training results. CONCLUSIONS: We discovered that only ~20% of practicing anesthesiologists were able to successfully place an invasive airway in a simulated life or death clinical setting. Using mobile simulation (training performed in department conference room) during a 2.5-hour session using mastery-based training pedagogy, we increased our success rate of invasive airway placement to 100%, while also increasing the successful speed to ventilation (TTJV, 32 seconds average; BC, 29 seconds average). Finally, we determined that there was a 15-month 80% retention rate of the airway skills learned, indicating that skills last at least a year before retraining is required using this training methodology. (Anesth Analg 2022;135:143-51) KEY POINTS• Question: How successful are attending anesthesiologists at simulator-based, subglottic airway placement, and can the technique success through mastery-based learning (MBL) continue up to 15 months later? • Findings: Success rates were very low at successful subglottic airway placement (14.8%-25%) but were retained at 15 months later by about 80%. • Meaning: Simulation-based, subglottic airway placement should undergo routine training to maintain a skill that is rarely experienced clinical, but nonetheless, devastating when it occurs.

Background: Awareness under general anesthesia occurs rarely, but can result in emotional trauma. Although well-studied in adults, there is a paucity of data on unintentional awareness in children.Aims: This case series examines instances of self-reported awareness registered with Wake Up Safe, a patient safety organization that maintains a database of adverse events in pediatric anesthesia.Methods: Cases of self-reported intraoperative awareness submitted to Wake Up Safe from January 1, 2010 to May 31, 2020 were reviewed for circumstances, causative factors, and level of harm.Results: Fourteen cases of self-reported intraoperative awareness out of 555 360 cases in patients aged 5-20 years were noted during the study period. Overall incidence of awareness was 2.52 (95% CI: 1.38-4.23) cases per 100 000 patients, or approximately 1:40 000. Self-reported intraoperative awareness was more frequently associated with cardiac and gastrointestinal endoscopic procedures. Incidence for cardiac procedures was 20.34 (95% CI: 8.18-41.90) cases per 100 000 patients.Incidence for gastrointestinal endoscopic procedures was 7.74 (95% CI: 1.60-22.62) cases per 100 000 patients. Most patients were assessed to have suffered harm. Conclusions: Self-reported intraoperative awareness is a rare complication in pediatric patients that has implications for harm. Compared to awareness cases elicited by a questionnaire method, cases of self-reported awareness during general anesthesia may represent those that have a greater impact. A preoperative discussion of intraoperative awareness should be considered for procedures that carry a higher likelihood of awareness in order to mitigate harm. K E Y W O R D Sadverse events, awareness under general anesthesia, pediatric recall, Wake Up Safe What is already knownAwareness during anesthesia has been studied primarily in adults, with an incidence of about 0.1% to 0.2%. Individual cohort studies in children have shown an incidence of 0.2% to 1.2%.

Introduction The pediatric perioperative setting is a dynamic clinical environment where multidisciplinary interprofessional teams interact to deliver complex care to patients. This environment requires clinical teams to possess high levels of complex technical and nontechnical skills. For perioperative teams to identify and maintain clinical competency, well-developed and easy-to-use measures of competency are needed. Methods Tools for measuring the technical and nontechnical performance of perioperative teams were developed and/or identified, and a group of raters were trained to use the instruments. The trained raters used the tools to assess pediatric teams managing simulated emergencies. A psychometric analysis of the trained raters' scores using the different instruments was performed and the agreement between the trained raters' scores and a reference score was determined. Results Five raters were trained and scored 96 recordings of perioperative teams managing simulated emergencies. Scores from both technical skills assessment tools demonstrated significant reliability within and between ratings with the scenario-specific performance checklist tool demonstrating greater interrater agreement than scores from the global rating scale. Scores from both technical skills assessment tools correlated well with the other and with the reference standard scores. Scores from the Team Emergency Assessment Measure nontechnical assessment tool were more reliable within and between raters and correlated better with the reference standard than scores from the BARS tool. Conclusions The clinicians trained in this study were able to use the technical performance assessment tools with reliable results that correlated well with reference scores. There was more variability between the raters' scores and less correlation with the reference standard when the raters used the nontechnical assessment tools. The global rating scale used in this study was able to measure the performance of teams across a variety of scenarios and may be generalizable for assessing teams in other clinical scenarios. The Team Emergency Assessment Measure tool demonstrated reliable measures when used to assess interprofessional perioperative teams in this study.

Background Harlequin syndrome presents as differences in facial coloring due to unilateral flushing. This is the result of the inability to flush on the affected side due to the disruption of vasomotor and sudomotor sympathetic activity. The neurologically intact side appears flushed. A 2°C temperature difference between the flushed and nonflushed sides of the face has been detected in patients presenting with Harlequin syndrome. This difference in temperature might be detectable even in the absence of unilateral flushing, and this subclinical manifestation of the syndrome may occur more often than realized. Aim To measure and compare the difference in the change in temperature on both sides of the face in patients with a thoracic epidural. Methods Fifteen pediatric patients receiving thoracic epidurals for the correction of pectus excavatum via Nuss procedure were enrolled. Temperature measurements on each side of the face were collected at three time points: prior to epidural placement in the holding area, one hour after epidural analgesia had been instituted, and after the patient awakened in the recovery area. The primary outcome is whether or not a temperature difference occurred between the two sides of the face over time. Results Comparing the pre‐op temperature change to post‐op temperature change for each side of the face, patient 2 had a large increase in temperature on the left side of the face with a decrease in temperature on the right side of the face. The largest observed difference between the changes in temperature from pre‐op to post‐op between the right and left sides of the face was 1.85°C in patient 2. This was more than two standard deviations from the mean difference in the patient population. Patient 15 also had a large difference in change in temperature from pre‐op to post‐op between the right and left sides of the face with an observed difference of 1.14°C, although this was not more than two standard deviations from the mean. None of the patients had unilateral facial flushing. Conclusion Asymmetric effects or distribution of local anesthetic used in thoracic epidurals may result in asymmetric blockade of efferent sympathetic nervous system activity. This may cause differences in temperature between the two sides of the face without unilateral flushing. This phenomenon has previously been termed subclinical Harlequin syndrome. Subclinical Harlequin syndrome may be more common than anticipated and may be detected by comparing temperature differences in patients.

This a preprint and has not been peer reviewed. Data may be preliminary.