Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta.

PURPOSE: We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage. CLINICAL FEATURES: A 34-yr-old parturient (G3P2) was scheduled for Cesarean delivery and possible hysterectomy at 35(+3) weeks due to suspected placenta accreta. Her body mass index was 21 kg·m(-2) and she had a reassuring airway. Inadvertent dural puncture occurred during combined spinal-epidural (CSE) placement, and a decision was made to thread the epidural catheter and utilize a CSA technique. Following delivery of a healthy infant, morbid adherence of the placenta to the myometrium was confirmed, and a supracervical hysterectomy was performed. Eight litres of blood loss occurred postpartum requiring resuscitation with crystalloid 3,800 mL, colloid 1,500 mL, red blood cells 16 units, fresh frozen plasma 16 units, platelets 4 units, and cryoprecipitate 1 unit. The patient developed pulmonary edema requiring conversion to general anesthesia. The patient's cardiovascular status was stable throughout surgery, and her lungs were mechanically ventilated for 18 hr postoperatively in the intensive care unit. The intrathecal catheter was removed 24 hr after placement. She developed no adverse neurological sequelae and reported no postdural puncture headache. The pathology report confirmed placenta increta. CONCLUSION: A CSA technique may be a viable option in the event of inadvertent dural puncture during planned CSE or epidural placement in patients with a reassuring airway undergoing Cesarean delivery. Although a catheter-based neuraxial technique is appropriate for Cesarean hysterectomy for abnormal placentation, conversion to general anesthesia may be required in the event of massive perioperative hemorrhage and fluid resuscitation.

What were the perceptions of primary care teams on learning from a single multidisciplinary simulation-based training intervention?

Medical emergencies in general practice are uncommon and their management requires good teamwork, communication and effective use of the available resources by the whole primary care team. To address this need the Montagu Clinical Simulation Centre developed and delivered a half-day simulation-based medical emergencies course for primary care teams (GPs, practice nurses and administrative staff). Each half-day course comprises two simulated medical emergencies, which are video-taped and then debriefed. The course was evaluated using a multi-level approach by seeking the staff's reactions to the course, their learning, the behaviour changes produced and the results for the organisation. We gained this information through self-reporting using end-of-course and follow-up questionnaires. The immediate feedback was very positive, showing they had learnt the objectives set. We then surveyed all those who had attended training between 2003 and 2007. A follow-up questionnaire was developed and sent to the practice managers who then co-ordinated their completion and return using a pre-paid return envelope. The survey was carried out in two cohorts. The first set of follow-up questionnaires was sent out in September 2004 to all those that had attended up to the end of May 2004 and the second set sent out in May 2008 to those who had attended between June 2004 and May 2007. Of the 338 available to complete the follow-up questionnaire, 208 responded, giving a response rate of 62%. Eighty percent of practices had made changes to equipment, emergency protocols or training and 20% of the participants had been involved in managing a medical emergency since attending the course. Of those, 86% indicated that their management and confidence had improved, that they were better able to take a lead role, give instruction and delegate tasks as required. Based on the self-reported perceptions of learning, we believe that the lessons learnt have been translated into positive changes at a personal and practice level for all members of the primary care team. The participants valued the chance to train as a complete unit. We plan to evaluate simulation-based training in the workplace to see if this has a greater impact.