Simulation of Management of Internal Carotid Artery Injury in Endoscopic Sinus Surgery

Rationale: Injury to the internal carotid artery (ICA) is a serious and devastating complication for the skull base surgeon. It is an uncommon injury and therefore limited training is received in the management of this complication. Our group aimed to develop a simulation scenario of an ICA injury during endoscopic surgery based on the principles of developing skills related to crisis resource management and interprofessional/interdisciplinary team communication. A modified Delphi approach was previously used to develop a protocol for management of ICA injury known as the alert–control–transfer protocol and we sought to develop this algorithm into an educational simulation teaching tool for post-graduate residents.

Methods: A literature search of endoscopic surgical simulation, crisis resource management and multidisciplinary teamwork simulation in medicine as well and the development of ICA injury management protocols. A 20-minute simulation-based scenario based on the alert–control–transfer protocol was developed in a flow-chart model with structured learning objectives and debriefing session. A pre- and post-participation questionnaire was administered to collect information regarding each participant’s experience level using a 5-point Likert scale and qualitative feedback regarding the simulation. A global and task-specific structured checklist was developed that will serve to provide construct validity of the simulation model which was graded by two individual evaluators (N.V. and D.N.) evaluating situational awareness, decision making, communication and teamwork and leadership using a 5-point Likert scale. Otolaryngology residents in a postgraduate training program at a single institution were divided into two groups either junior (PGY1–3, n = 5) or senior (PGY4–5, n = 5) in two sessions between 2022 and 2023. A structured de-brief session was developed in accordance with educational objectives outlined in the study.

Results: Situational awareness, decision making, and communication and teamwork, as well as leadership attributes were on average graded as 4/5, 3.7/5, 4.3/5, and 4.5/5 for senior residents, respectively, compared to 3/5, 3/5, 3.5/5, and 3.5/5 for junior residents (p < 0.05). The average level of experience of senior residents versus junior residents in number of cases was 20 cases versus 5 cases, respectively. The pre-simulation and post-simulation comfort levels regarding steps in management of internal carotid artery injury was self-reported as 3/5 compared to 4/5 across all groups.

Conclusion: ICA injury remains a devastating complication requiring complex interventions in order to manage appropriately in the acute settings with a wide range of expertise. This initial study suggests the predictive validity of the simulation station with differences seen across less and more experienced trainees with benefits noted by trainees of all experience levels. The implementation of an educational simulation tool would be useful for rare and complex scenarios in order to provide a safe learning environment for the trainee and receive appropriate feedback.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024