High Neuraxial Blockade in a Parturient After Epidural Placement: A Quality Improvement Simulation

TL;DR

A simulation training program was developed to teach anesthesiology residents how to manage a rare but serious complication of epidural anesthesia during childbirth.

Contribution

The paper introduces a novel simulation-based training approach for managing high neuraxial blockade in obstetric anesthesia.

Findings

Participants reported increased confidence in managing high neuraxial blockade after the simulation.

The simulation effectively reinforced critical skills like endotracheal intubation and epidural catheter placement.

Feedback suggested improvements such as using a real labor and delivery bed for greater realism.

Abstract

Background

Epidural anesthesia is a commonly used procedure in obstetrics for managing labor pain, with a potential complication of high neuraxial blockade. Proficiency in performing epidural or spinal anesthesia and promptly recognizing and managing high neuraxial blockade are critical components of anesthesiology residency training.

Methods

A simulated case was designed involving a 21-year-old female in labor receiving epidural anesthesia. After the administration of local anesthetic, she develops symptoms of nausea, hypotension, and respiratory distress, progressing to high neuraxial blockade. The simulation environment included a labor and delivery suite setup, an epidural cart, airway supplies, a Laerdal SimMan 3G PLUS mannequin (Laerdal Medical, Stavanger, Norway), and an M43B Kyoto Kagaku Lumbar Puncture Simulator II (Kyoto Kagaku, Kyoto, Japan). Post-simulation, participants completed surveys via REDCap (Vanderbilt University, Nashville, USA) to assess their comfort levels in recognizing and managing high neuraxial blockades.

Results

Nine participants, including anesthesiology residents (PGY1-4) and student registered nurse anesthetists (SRNAs), completed the pilot simulation. Survey feedback was collected to evaluate the simulation’s impact on participants' learning and confidence.

Discussion

Participants provided positive feedback, highlighting the simulation’s value in their training and its realism. Suggestions for improvement included using an actual labor and delivery bed to better mimic real-world challenges. A limitation of the study is the small sample size, additional sessions with future cohorts will help further assess the simulation’s efficacy. Plans are in place to incorporate this simulation annually into the anesthesiology residency curriculum at the institution.

Conclusion

Simulation-based training in anesthesiology residency programs enables learners to practice managing complex and high-stakes scenarios in a controlled environment. This simulation effectively reinforced critical skills, including endotracheal intubation, epidural catheter placement, and the management of a hemodynamically unstable pregnant patient. Furthermore, it provided valuable experience in recognizing and treating high neuraxial blockade, a serious but rare complication of epidural anesthesia.