Taking the leap from clinical practice to academic faculty: A beginner's guide.

ABSTRACT: Exploring new roles and responsibilities available to clinicians offers a path to renovate a nurse practitioner's career. The role of academician and nurse faculty broadens career horizons, presents a sense of autonomy, and offers unique opportunities to teach, participate in research, build leadership skills, and contribute to the health care delivery system at a higher level. Advance practice nurses often consider a shift to academia but are concerned about the unfamiliarity of the entire process. This article offers elements a clinician will likely encounter throughout the transition to a faculty role. These include expectations for the application and interview, negotiating for a position, and orientation to the role of an academic.

The use of postpartum hemorrhage protocols in United States academic obstetric anesthesia units.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of severe maternal morbidity, cardiac arrest, and death during the hospitalization for childbirth. Protocol-driven care has been associated with improved outcomes in many settings; the National Partnership for Maternal Safety now recommends that PPH protocols be implemented in every labor and delivery unit in the United States. In this study, we sought to identify the level of PPH protocol availability in academic United States obstetric units. We hypothesized that the majority (>80%) of academic obstetric anesthesia units would have a PPH protocol in place. METHODS: A survey was developed by an expert panel. Domains included hospital characteristics, availability of PPH protocol or plans to develop such a protocol, and protocol components included in the upcoming National Partnership for Maternal Safety obstetric hemorrhage safety bundle initiative. The electronic survey was emailed to the 104 directors of United States academic obstetric anesthesia units. Responses were stratified by PPH protocol availability as appropriate. Univariate statistics were used to characterize survey responses and the probability distribution for PPH protocol availability was estimated using the binomial distribution. RESULTS: The survey response rate was 58%. The percentage of responding units with a PPH protocol was lower than hypothesized (P = 0.03); there was a PPH protocol in 67% of responding units (N = 40, 95% confidence interval [CI]: 53%-78%). The median annual delivery volume for responding units with PPH protocol was 3900 vs 2300 for units without PPH protocol (P = 0.002), with no difference in cesarean delivery rate (P = 0.73) or observed PPH rate (P = 0.69). There was no difference in annual delivery volume between responding and nonresponding hospitals (P = 0.06), suggesting that academic centers with delivery volume >3200 births per year are more likely than smaller volume hospitals to have a PPH protocol in place (odds ratio 3.16 (95% CI: 1.01-9.90). Adjusting for delivery volume among nonresponding hospitals, we estimate that 67% (95% CI: 55%-77%) of all academic obstetric anesthesia units had a PPH protocol in place at the time of this survey. Institutional processes for escalation do not correlate with the presence of a PPH protocol. There was a massive transfusion protocol in 95% of units with a PPH protocol and in 90% of units without (95% CI of difference: -7% to 7%). A PPH code team or rapid response team was available in 57% of responding institutions, with no difference between units with or without a PPH protocol [mean difference 4%, 95% CI (-24% to 32%)]. CONCLUSIONS: Despite increasing emphasis on national quality improvement in patient safety, there are no PPH protocols in at least 20% of U.S. academic obstetric anesthesia units. Delivery volume is the most important variable predicting the presence of a PPH protocol. National efforts to ensure universal presence of a PPH protocol in all academic centers will achieve the greatest impact by focusing on small-volume facilities. Future work is needed to evaluate and facilitate PPH implementation in nonacademic obstetric units.

Blood product replacement for postpartum hemorrhage.

Hemorrhage requiring blood transfusion is a common occurrence in obstetrics. This article reviews each step in the transfusion process, including laboratory preparation of blood, indications for various blood components, complications of blood transfusion, massive transfusion, and alternatives to homologous blood. Current thinking regarding transfusion-related acute lung injury, transfusion-related immunomodulation, early use of plasma for massive transfusion, and the use of adjuvant agents such as activated recombinant factor VII are also discussed.

Fetal oxygen saturation after combined spinal-epidural labor analgesia: a case series.

Fetal oxygen saturation (FSpo(2)) is an emerging technology for intrapartum fetal monitoring. We monitored FSpo(2) before and after combined spinal-epidural analgesia in 8 laboring women requesting neuraxial analgesia. Fetal heart rate (FHR) and FSpo(2) (using the Nellcor N400/FS14 system [Nellcor, Pleasanton, CA]) were recorded at baseline and every minute for 45 minutes after analgesia. We observed no significant changes in FSpo(2) after analgesia (mean DeltaFSpo(2) 2 +/- 7 %, P = 0.46). Fetal oxygen saturation at baseline and after analgesia was 53% +/- 9% and 51% +/- 8%, respectively. We observed no significant FHR changes or any fetal bradycardia following combined spinal-epidural analgesia.

Blood component therapy in obstetrics.

Hemorrhage is the leading cause of intensive care unit admission and one of the leading causes of death in the obstetric population. This emphasizes the importance of a working knowledge of the indications for and complications associated with blood product replacement in obstetric practice. This article provides current information regarding preparation for and administration of blood products, discusses alternatives to banked blood in the obstetric population, and introduces pharmacological strategies for treatment of hemorrhage.

Experimental heat pain for detecting pregnancy-induced analgesia in humans.

Animal studies suggest that increased circulating estrogen and progesterone, and activation of the endorphin system cause prenancy-induced antinociceptive effects. Human studies have provided inconsistent results and have often lacked a nonpregnant control group. In this study, we compared sensitivity to experimental heat and cold pain in pregnant and nonpregnant women. Nineteen healthy nonpregnant female volunteers and 20 pregnant women at term were enrolled. Pain threshold and tolerance were examined using experimental heat-induced pain and cold pressor pain models. Subjects were evaluated pre- and 1-2 days post-delivery (pregnant), or on consecutive days (nonpregnant). Heat pain tolerance was significantly increased in the pregnant women during pre and postdelivery when compared with nonpregnant controls (50.0 +/- 1.0 vs 49.0 +/- 1.2 and 50.1 +/- 0.7 vs 49.2 +/- 1.2 degrees C; mean +/- sd). However, pain induced by the cold pressor test was endured for a similar amount of time by both study groups. Pregnancy-induced analgesic effects at term can be detected in a model of experimental heat pain. These effects persist during the first 24-48 h after delivery. Experimental heat pain is a suitable modality for further characterizing the phenomenon of pregnancy-induced analgesia in humans.

Epidural anesthesia for elective cesarean delivery with intraoperative arterial occlusion balloon catheter placement.

Obstetric hemorrhage is a leading cause of maternal mortality. We describe the anesthetic management of elective cesarean delivery in patients at high risk for hemorrhage. The utility and limitations of intraarterial balloon catheter placement and epidural anesthesia are described.