Patients undergoing anesthesia rely on the clinical expertise of their anesthesiology team. Personalizing anesthesia delivery may support optimal outcomes, but achieving anesthetic goals can be difficult because of the varying nature of patients and how they respond to anesthetic agents. To support anesthesiology professionals with education around hypothesizing anesthesia management, Level Ex teamed up with Medtronic to collaborate on a new challenge in our Airway Ex mobile game.
Aptly named the TIVA Challenge, based on the practice of total intravenous anesthesia (TIVA), the challenge is designed to be entertaining while still being educational. It allows anesthesia professionals, for example, to titrate ideal levels of anesthesia to hypothetical patients as well as refine critical-thinking skills using game design principles. Aiming to accelerate healthcare education through experiential, interactive learning, this challenge focuses on furthering discussions around anesthetic monitoring and management of protocols and practices.
Although playing a video game may seem anomalous when it comes to medical education, the science behind educational video games exists.1 TIVA management is a complex task requiring considerations of multiple factors for personalized anesthesia delivery. The TIVA Challenge isn’t intended to replace TIVA titration or BIS™ system training; it was designed to support learning and evoke conversation. Developed using hypothetical scenarios for anesthesia professionals, the game, for example, allows application of the BIS™ system in personalizing anesthesia delivery to hypothetical patients.
Through the game, the player is challenged to bolus and titrate sedative-hypnotic and opiate analgesia to maintain an optimal level of anesthesia. Such information includes the BIS™ index value, patient medical history, and vital signs. From there, the player carefully titrates for optimum dosage — aiming for steady anesthetic and patient stability. If dosing is too high or too low, this is reflected in the feedback to the player.
As the player becomes familiar with the initial hypothetical patient, additional patients emerge requiring initial bolus, titration, and simultaneous monitoring. The game also presents hypothetical complications that may occur including “blackout” periods and intravenous tubing kinks — all to ensure experiential learning reflects real life potential complicating factors and keeping them on their toes. The ultimate goal of the game is to deliver individualized anesthesia and promote positive patient outcomes while minimizing over- or under-dosing.
The TIVA Challenge, as part of Airway Ex, was developed through continuous provider input and robust playtesting. One of the main features within the TIVA Challenge is the ability to remove passivity from the learning environment and strive toward more active learning — embracing the concept of experiential learning over standard reading and memorization.
Research suggests that experiential learning — in which unique and challenging environments are presented — may result in increased learning as determined through self-evaluation.3 The goal is for anesthesia professionals to learn through immersion in the simulated patient scenarios and take that knowledge back to their clinical environments. More than 700,000 healthcare professionals are already playing Level Ex’s mobile games.
The TIVA Challenge includes an integrated BIS™ system simulator for clinicians that may or may not have access to the technology. In the real world, BIS™ monitoring technology is gaining traction as part of Enhanced Recovery After Surgery (ERAS™) protocols to strengthen patient outcomes. The patient-centered, evidenced-based practices are standardizing sedation administration to help prevent unfavorable short- and long-term patient effects.
For example, studies show that BIS™ technology-guided anesthesia reduces the use of anesthesia on patients by as much as 38 percent.2, 4-9 Studies also found that there is less incidence of postoperative delirium in elderly and at-risk patients when using the BIS™ system.6, 8, 9, 11–16
Additionally, research shows that patients receiving appropriate levels of sedation fluctuating within the optimal BIS™ system range of 40 to 60 experience better outcomes, such as: 2, 4, 5, 9, 17
Improving educational awareness around BIS™ and advancing ERAS™ protocols may lead to overall better outcomes.
* Managing patients receiving TIVA is a complex task that requires multiple considerations during which complications can arise from both under dosing as well as overdosing. The BIS™ Monitoring System virtual patient cases presented here are accelerated, hypothetical patient cases are designed for educational purposes only and are not meant to provide comprehensive or patient-specific clinical practice recommendations for BIS™ monitoring technology. This game is meant to serve as a tool that provides both entertainment and education in its ability to evoke discussion around certain scenarios and how you may consider managing them with formal training. This case is not a substitute for safe and effective use training with BIS™ monitoring technology. Please consult the instructions for use and online materials for more information.
**The BIS™ monitoring system should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment. Reliance on BIS™ alone for intraoperative anesthetic management is not recommended.
1. Barr, Matthew. Video games can develop graduate skills in higher education students: A randomized trial. School of Humanities, University of Glasgow. Computers & Education. 2017: 113: 86–97.
2. Punjasawadwong Y, Chau-In W, Laopaiboon M, Punjasawadwong S, Pin-On P. Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults. Cochrane Database Syst Rev. 2018;5:CD01128.
3. Marlow, M.P., McLain, B. Assessing the impacts of experiential learning on teacher classroom practice. Research in Higher Education Journal. 2011; v14: 15.
4. Gan T, Glass P, Windsor A, et al. Bispectral index monitoring allows faster emergence and improved recovery from Propofol, alfentanil, and nitrous oxide anesthesia. Anesthesiology. 1997;87(4):808–815.
5. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery (Review). Cochrane Database Syst Rev. 2014;17;(6):CD003843.
6. Chan M, Cheng B, Lee T, Gin T, Trial Group. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013;25(1):33–42.
7. Lewis SR, Pritchard MW, Fawcett LJ, Punjasawadwong Y. Bispectral index for improving intraoperative awareness and early postoperative recovery in adults. Cochrane Database Syst Rev. 2019; 26;9:CD003843.
8. Liu SS. Effects of bispectral Index monitoring on ambulatory anesthesia: a metaanalysis of randomized controlled trials and a cost analysis. Anesthesiology. 2004;101(2):311–315.
9. Song D, Joshi GP, White PF. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia. Anesthesiology. 1997;87(4):842–848.
10. Myles P, Leslie K, McNeil J, Forbes A, Chan M. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomised controlled trial. Lancet. 2004;363(9423):1757–1763.
11. Radtke F, Franck M, Lendner J, Kruger S, Wernecke K, Spies C. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth. 2013;110(S1):98–105.
12. Sieber F, Zakriya K, Gottschalk A, et al. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010;85(1):18–26.
13. Ahmad S, Yilmaz M, Marcus RJ, Glisson S, Kinsella A. Impact of bispectral index monitoring on fast tracking of gynecologic patients undergoing laparoscopic surgery. Anesthesiology. 2003 Apr;98(4):849–852.
14. Satisha M, Sanders GM, Badrinath MR, Ringer JM, Morley AP. Introduction of Bispectral index monitoring in a district general hospital operating suite: a prospective audit of clinical and economic effects. Eur J Anaesthesiol. 2010 27(2):196–201.
15. Shepherd J, Jones J, Frampton G, Bryant J, Baxter L, Cooper K. Clinical effectiveness and cost-effectiveness of depth of anaesthesia monitoring (E-Entropy, Bispectral Index and Narcotrend): a systematic review and economic evaluation. Health technology assessment (Winchester, England). 2013;17(34):1–264.
16. Whitlock E, Torres B, Lin N, et al. Postoperative delirium in a substudy of cardiothoracic surgical patients in the bag-recall clinical trial. Anesth Analg. 2014;118(4)809–817.
17. Luginbühl M, Wüthrich S, Petersen-Felix S, Zbinden AM, Schnider TW. Different benefit of bispectal index (BISTM) in desflurane and propofol anesthesia. Acta Anaesthesiol Scand. 2003;47(2):165–173.