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ASRA Checklist Improves Trainee Performance During a Simulated Episode of Local Anesthetic Systemic Toxicity
  1. Joseph M. Neal, MD*,
  2. Robert L. Hsiung, MD*,
  3. Michael F. Mulroy, MD*,
  4. Brian B. Halpern, RN,
  5. Alison D. Dragnich, MD* and
  6. April E. Slee, MSc
  1. From the Departments of *Anesthesiology and
  2. Nursing Education, Virginia Mason Medical Center; and
  3. Biostatistics, Axio Research, Seattle, WA.
  1. Address correspondence to: Joseph M. Neal, MD, 1100 Ninth Ave (B2-AN), Seattle, WA 98111 (e-mail: anejmn{at}


Objective Severe local anesthetic systemic toxicity (LAST) is a rare event, the management of which might best be learned using high-fidelity simulation. In its 2010 Practice Advisory, the American Society of Regional Anesthesia and Pain Medicine (ASRA) created a medical checklist to aid in the management of LAST. We hypothesized that trainees provided with this checklist would manage a simulated episode of LAST more effectively than those without it. A secondary aim of the study was to assess the ASRA Checklist’s usability and readability.

Methods Trainees undergoing a simulated LAST event were randomized to the checklist group (n = 12) or the no-checklist group (n = 13). Our primary outcome was the number of medical management tasks completed correctly. Secondary outcomes included assessment of the anesthesiologists’ nontechnical skills and posttest performance.

Results Trainees receiving the checklist demonstrated superior medical management of the simulated LAST event: the checklist group correctly performed 16.0 (2.6) tasks versus the no-checklist group’s 8.8 (3.0) tasks (mean [SD], P < 0.001). The checklist group had higher decision making scores on the anesthesiologists’ nontechnical skills assessment (5.2 [1.8] versus 4.0 [1.35] summed rater score, P = 0.037) and had higher knowledge retention 2 months later (P = 0.031). Of those trainees randomized to receive the checklist, 7 of 12 used it fully (versus partially), which was reflected in higher medical and nontechnical performance scores.

Conclusions Use of the ASRA Checklist significantly improved the trainees’ medical management and nontechnical performance during a simulated episode of severe LAST. Partial use of the checklist correlated with lower overall performance.

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  • The authors declare no conflict of interest.

  • Dr. Neal is the archival investigator for this study; data are archived by the Benaroya Research Institute at Virginia Mason Medical Center.