Steven Lipman

Patient preferences for anesthesia outcomes associated with cesarean delivery

When deciding on neuraxial medication (e.g., spinal opioids) for cesarean delivery (CS) under regional anesthesia, anesthesiologists make treatment decisions that “trade off” relieving pain with the potential for increased risk of side effects. No previous studies have examined obstetric patients’ anesthesia preferences. Researchers administered 100 written surveys to pregnant women attending our institutions’ expectant parent class. We determined patients’ preferences for importance of specific intraoperative and postoperative anesthesia outcomes using priority ranking and relative value scales. We also explored patients’ fears, concerns, and tolerance regarding CS and analgesics. Eighty-two of 100 surveys were returned and analyzed. Pain during and after CS was the greatest concern followed by vomiting, nausea, cramping, pruritus, and shivering. Ranking and relative value scores were closely correlated (R2 = 0.7). Patients would tolerate a visual analog pain score (0–100 mm) of 56 ± 22 before exposing their baby to the potential effects of analgesics they receive. In contrast to previous general surgical population surveys that found nausea and vomiting as primary concerns, we found pain during and after CS as parturients’ most important concern. Common side effects such as pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, e.g., inclusion of spinal opioids given in adequate doses.

Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises.

OBJECTIVE Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance. STUDY DESIGN We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions. RESULTS Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines. CONCLUSION Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.

The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy

This consensus statement was commissioned in 2012 by the Board of Directors of the Society for Obstetric Anesthesia and Perinatology to improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest. The recommendations in this statement were designed to address the challenges of an actual event by emphasizing health care provider education, behavioral/communication strategies, latent systems errors, and periodic testing of performance. This statement also expands on, interprets, and discusses controversial aspects of material covered in the American Heart Association 2010 guidelines.

Intraoperative Forced Air-Warming During Cesarean Delivery Under Spinal Anesthesia Does Not Prevent Maternal Hypothermia

BACKGROUND:Prewarming and intraoperative warming with forced air-warming systems prevent perioperative hypothermia and shivering in patients undergoing elective cesarean delivery with epidural anesthesia. We tested the hypothesis that intraoperative lower body forced air-warming prevents hypothermia in patients undergoing elective cesarean delivery with spinal anesthesia. METHODS:Thirty healthy patients undergoing cesarean delivery with spinal anesthesia were randomly assigned to forced air-warming or control groups (identical cover applied with forced air-warming unit switched off). A blinded investigator assessed oral temperature, shivering, and thermal comfort scores at 15-min intervals until discharge from the postanesthetic care unit. Umbilical cord blood gases and Apgar scores were also measured after delivery. RESULTS:The maximum core temperature changes were similar in the two groups (−1.3°C ± 0.4°C vs −1.3°C ± 0.3°C for the forced air-warming group and control group, respectively; P = 0.8). Core hypothermia (≤35.5°C) occurred in 8 of 15 patients receiving forced air-warming and in 10 of 15 unwarmed patients (P = 0.5). The incidence and severity of shivering did not significantly differ between groups. Umbilical cord blood gases and Apgar scores were similar in both groups (P = NS). CONCLUSIONS:We conclude that intraoperative lower body forced air-warming does not prevent intraoperative hypothermia or shivering in women undergoing elective cesarean delivery with spinal anesthesia.

Use of simulation based team training for obstetric crises in resident education.

Background: Obstetric crises are unexpected and random. Traditionally, medical training for these acute events has included lectures combined with arbitrary clinical experiences. This educational paradigm has inherent limitations. During actual crises insufficient time exists for discussion and analysis of patient care. Our objective was to create a simulation program to fill this experiential gap. Methods: Ten L&D teams participated in high fidelity simulation training. A team consisted of two or three nurses, one anesthesia resident and one or two obstetric residents. Each team participated in two scenarios; epidural-induced hypotension followed by an amniotic fluid embolism. Each simulation was followed by a facilitated debriefing. All simulations were videotaped. Clinical performances of the obstetric residents were graded by two reviewers using the videotapes and a faculty-developed checklist. Recurrent errors were analyzed and graded using Health Failure Modes Effects Analysis. All team members completed a course evaluation. Results: Performance deficiencies of the obstetric residents were identified by an expert team of reviewers. From this list of errors, the “most valuable lessons” requiring further focused teaching were identified and included 1) Poor communication with the pediatric team, 2) Not assuming a leadership role during the code, 3) Poor distribution of workload, and 4) Lack of proper use of low/outlet forceps. Participants reported the simulation course allowed them to learn new skills needed by teams during a crisis. Conclusion: Simulated obstetric crises training offers the opportunity for educators to identify specific performance deficits of their residents and the subsequent development of teaching modules to address these weaknesses.

The Case for OBLS: A Simulation-based Obstetric Life Support Program

Errors by health care professionals result in significant patient morbidity and mortality, and the labor and delivery ward is one of the highest risk areas in the hospital. Parturients today are of higher acuity than anytime previously, and maternal mortality is increasing. Obstetrical staff must therefore be familiar with emergency protocols geared to the maternal-fetal dyad. However, the medical literature suggests that obstetrical providers are not optimally trained to render care during maternal cardiopulmonary arrest. We describe the evolution of immersive learning and simulation in the Neonatal Resuscitation Program, and suggest the development of a multidisciplinary team, simulation-enhanced obstetric crisis training program (OBLS) may likewise benefit obstetrical health care professionals. OBLS would emphasize high quality basic life support, uterine displacement, use of an automatic external defibrillator, and delivery of the fetus within 5 minutes of maternal arrest should resuscitative efforts prove ineffective.

Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance

Objective:We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean.Study Design:Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children’s Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision.Result:The median (interquartile range) from time zero until incision was 9 min 27 s (8:55 to 10:27 min:s).Conclusion:In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery.

Checklists and multidisciplinary team performance during simulated obstetric hemorrhage

BACKGROUND Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage. METHODS Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used. RESULTS The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05). CONCLUSIONS Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage.

Accidental intrathecal sufentanil overdose during combined spinal-epidural analgesia for labor

A laboring woman was accidentally given 45 microg of sufentanil intrathecally in the course of combined spinal-epidural analgesia. She experienced intense pruritus and transient swallowing difficulty without respiratory depression, but still had incomplete pain relief, with delivery and episiotomy repair requiring additional analgesia. This case highlights the importance of adding local anesthetic to intrathecal opioids to facilitate effective analgesia during the second stage of labor. The contributory systems issues and multiple factors that allowed this error to occur are examined.

Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication

As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors’ local experience with obstetric simulation drills and optimization of team communication.