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  • Stress Response and Task Performance During Cadaveric Simulation of Internal Carotid Artery Injury in Endoscopic Skull Base Surgery

    Final Number:

    Daniel Donoho MD; Michael Minneti; Ian Andre Buchanan MD; Vance Fredrickson; Ben Allen Strickland MD; Bozena Wrobel; Gabriel Zada MD MS

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Heightened stress-responses may affect task performance during time-sensitive, cognitive and technically challenging tasks such as carotid artery injury management. The physiologic response of surgeons managing an acute internal carotid artery injury is not known.

    Methods: articipants completed a cadaveric perfusion-based carotid artery injury control task in a high-fidelity mock operating room. Participants made a first attempt (“trial one”) at injury control without coaching and then received a brief educational intervention and coaching. A repeat attempt was then made (“trial two”). Success was defined as task completion within five minutes. Participants completed pre- and post-task questionnaires. Heart rate (HR) monitoring was performed using an Apple Watch (Watch OS 3.1, Apple, Cupertino, CA).

    Results: Fifty-seven neurosurgery and otolaryngology attending and resident surgeons participated. The average HR at baseline was 88.3±14.3 (mean±SD) beats per minute (bpm). Compared to baseline, average and peak HR were significantly elevated during trial one and trial two (p<0.001), and lower in trial two than trial one (p<0.01). Tachycardia (HR=100) occurred in 66.1% of participants during the simulation. In univariate analysis, there were no associations between HR and surgeon factors, except for baseline aerobic exercise. Although HR was not associated with success on trial one, HR at baseline was associated with success on trial two (failures 76.6±11.0 bpm, successes 89.7±14.1 bpm, p=0.03). HR during trial two had a trend-level association with success (failures 83.3±13.6 bpm, successes 96.4±15.7 bpm, p=0.055). Even after controlling for aerobic exercise, surgeons with lower baseline HR had increased odds of trial two failure (OR 1.09, CI 1.01-1.22).

    Conclusions: Surgeons of all levels of experience exhibited tachycardia indicative of a physiological stress response, supporting the validity of this ICA injury cadaveric simulation model. Increased HR response was not associated with adverse task performance. The paradoxical relationship of lower HR to task success underscores the complexity of the stress-performance relationship.

    Patient Care: We hope to understand the relationship between surgeon stress and performance in order to improve performance during intraoperative crises. Our ability to replicate surgeon stress during simulation demonstrates the fidelity and validity of cadaveric training and supports its use to improve performance during intraoperative catastrophes.

    Learning Objectives: feasibility of physiologic monitoring, objective validation of simulation model, stress response to training


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