F. Elwen, R. King

St George's University Hospitals NHS Foundation Trust, London, UK


Perioperative paediatric anaphylaxis is a rare but potentially life-threatening complication with an incidence of 2.7 cases per 100,000, approximately one quarter of the rate in adults [1]. Prompt recognition and management are essential to avoid poor outcomes. Management of paediatric critical incidents and emergencies can be stressful and challenging, especially for those with less experience in paediatrics. In-situ simulation and use of cognitive aids has been shown to improve teamwork and task performance in managing perioperative anaphylaxis. [2]


St. George’s hospital is a mixed adult and paediatric tertiary hospital, delivering around 5500 paediatric anaesthetics each year, mainly in four dedicated paediatric theatres.

In-situ operating theatre simulation sessions were run during a morning teaching slot between November and December 2023. These were 45 minute sessions where the operating list starts later to facilitate teaching. Sessions were organised where teams primarily manage adult patients, with occasional paediatric exposure.

Targeted at the all members of the multidisciplinary team, candidates maintained their usual working roles whilst participating in realistic scenarios of anaphylaxis in a child undergoing surgery appropriate for that theatre. Scenarios were followed by a consultant led debriefing session, highlighting learning goals, stimulating discussion and collecting feedback. Participants were surveyed before and after the simulation using five-point Likert scales to rate attitudes towards simulation, their role during paediatric emergencies, team-working, and knowledge of escalation procedures.


46 responses were collected in total, with 13 participants after the last session completing pre and post-session questionnaires. The scenarios prompted discussions about the importance of early administration of adrenaline, the need for chest compressions for bradycardia as well as key themes around teamworking and communication. Furthermore, the opportunity to familiarise teams with emergency protocols proved valuable. After the session,  80% of participants agreed or strongly agreed that they knew their role in a paediatric emergency and 72% felt comfortable working as part of the team.

All participants found the session useful, and 93% either agreed or strongly agreed that simulation- based training provided a judgement free way to learn, increasing from 66% before the session. After the session 85% knew who to escalate to in a paediatric emergency, compared to 58% beforehand.



Discussion and conclusion: 

By bringing high fidelity simulation to regular working environments with established teams, we have provided a realistic clinical environment for staff to experience a rare paediatric scenario whilst developing skills in teamwork, communication, situational awareness and resource utilisation.


1) Royal College of Anaesthetists (May 2018). Anaesthesia, Surgery and Life-Threatening Allergic Reactions. 6th National Audit Project: Perioperative Anaphylaxis. Accessed at: https://www.rcoa.ac.uk/sites/default/files/documents/2023-02/NAP6%20Report%202018.pdf

2) Kolawole H, Guttormsen AB, Hepner DL, Kroigaard M, Marshall S.  Use of simulation to improve management of perioperative anaphylaxis: a narrative review. British Journal of Anaesthesia. 2019.123 (1): e104ee109

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