Oral Themed Presentation
Background: : Although a required skill in pediatric residency programs, success rate of neonatal endotracheal intubation (ETI) among trainees is known to be inadequate (1, 2). Currently, it is taught using simulation and focusing on limited short term retention of skill (3). In the clinical setting, ETI is often associated with stress, which could explain the limited educational impact of simulation training. The effect of stress on the success of this procedure is poorly studied. This topic is important as it could refine our teaching strategy of this procedural skill.
Research Question: : Our research aims to study the impact of stress on the success of simulated neonatal ETI. Our primary hypothesis is that stressful conditions will negatively impact residents’ success of endotracheal intubation on neonatal manikins. We also hypothesize that stressful conditions will be associated with an increased time to successful intubation and decreased performance on a validated intubation checklist.
Methodology: : Crossover randomized trial held at the simulation center of Sainte-Justine Hospital (Montreal, Canada). Subjects were pediatric and pediatric subspecialty residents. Residents were randomized using sealed envelopes to perform neonatal ETI in a low (LS) or a high stress (HS) environment, and then crossover. Stress was created by using audio alarms, third party supervisors and simulated manikin instability. Level of stress of participants was assessed at rest, upon arrival to the simulation center and after each simulated scenario. This was done using salivary cortisol, heart rate and the State Anxiety Inventory (STAI) questionnaire. ETI procedures were videotaped and performance will be assessed by two external reviewers (data to come). Primary and secondary outcomes include: success rate, checklist performance, time to successful intubation and stress levels (cortisol, heart rate and questionnaire). Success rate was analyzed using chi2 and continuous variables were analyzed using paired t-test and repeated measures ANOVA.
Results: : Of the 65 expected participants, 50 residents have been recruited and 32 have completed the study, with a total of 64 intubations. Success rate in the HS group was 78% vs 63% in LS (p=0.14). There was no significant difference (HS vs LS) with regards to duration of ETI (22 vs 27 sec, p=0.13), duration of scenario (471 vs 473 sec, p =0.96) or salivary cortisol (pre: 22.6 vs 21.5 ng/ml; post: 23.6 vs 23.2 ng/ml, p=0.62). Heart rate was significantly different between HS and LS groups (pre: 92 vs 94 beats per min; post 105 vs 95 beats per min, p=0.001). The STAI result was not significantly different between HS and LS.
Discussion/Conclusions: : At present, success of ETI is higher in the HS setting. Among the stress markers, only the heart rate increases significantly more in the HS setting. The stable cortisol level and STAI results suggest that stress lived by the resident does not create a sense of loss of control or distress. These findings suggest that the HS setting is an appropriate training tool for stress preparedness for neonatal ETI. Resident performance on the intubation checklist has yet to be analyzed. This might reveal finer deficits in ETI competence of residents which need to be addressed during ETI stress preparedness training.