Recent advances of simulation in obstetric anesthesia.

PURPOSE OF REVIEW: Simulation training in obstetric anesthesia has become widespread in recent years. Simulations are used to train staff and trainees, assess and improve team performance, and evaluate the work environment. This review summarizes current research in these categories. RECENT FINDINGS: Simulation to improve individual technical skills has focused on induction of general anesthesia for emergent cesarean delivery, an infrequently encountered scenario by anesthesia trainees. Low- and high-fidelity simulation devices for the learning and practicing neuraxial and non-neuraxial procedures have been described, and both are equally effective. The use of checklists in obstetric emergencies has become common as and post-scenario debriefing techniques have improved. Although participant task performance improves, whether participants retain learned skills or whether simulation improves patient outcomes has not yet been established. Tools to assess teamwork during simulation have been developed, but none have been rigorously validated. In-situ vs. offsite simulations do not differ in effectiveness. SUMMARY: Simulation allows for practice of tasks and teamwork in a controlled manner. There is little data whether simulation improves patient outcomes and metrics to predict the long-term retention of skills by simulation participants have not been developed.

Individualized Compared With Standard Postdischarge Oxycodone Prescribing After Cesarean Birth: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether individualized postdischarge oxycodone prescribing guided by inpatient opioid use reduces the number of unused opioid tablets after cesarean birth. METHODS: We conducted a randomized, controlled trial of women aged 18 years or older undergoing cesarean birth. Participants were randomized at discharge in a 1:1 ratio to a standard (30 tablets of 5 mg oxycodone) or an individualized oxycodone prescription (predicted based on each patient's inpatient opioid use). All women were contacted starting 14 days after cesarean birth to assess number of oxycodone tablets used and adequacy of pain control. The Tennessee Controlled Substance Monitoring Database was accessed to confirm dispensed opioids. The primary outcome was number of unused oxycodone tablets prescribed for pain control after cesarean birth. A total sample size of 160 women was necessary to detect a 30% difference in leftover tablets between groups with 80% power and α of 0.05. RESULTS: Between June 14, 2017, and August 26, 2017, we screened 323 women and randomized 172. Baseline characteristics and inpatient opioid use were similar between groups. Women in the individualized group were prescribed fewer tablets (14 [interquartile range 12-16] vs 30 [interquartile range 30-30], P<.001) and had 50% fewer unused tablets than women in the standard group (5 [interquartile range 1-8] vs 10 [interquartile range 0-22], P<.001). Overall, 13% (23/172) used no opioids after discharge and 26% (44/172) used all prescribed opioids. There were no differences between the standard and individualized groups in the proportion of women who used no opioids or all opioids and no difference in the proportion of dispensed opioids used (60% [interquartile range 23-100] vs 61% [29-89], P=.93). Women in the individualized group used only half the number of prescribed opioids as women in the standard group (8 [interquartile range 4-14] vs 15 [interquartile range 6-30], P<.001). Patient-reported pain outcomes did not differ significantly by group. CONCLUSION: Individualized opioid prescribing based on inpatient use reduces the number of unused oxycodone tablets compared with standard prescribing. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov, NCT03168425.

Postdischarge Opioid Use After Cesarean Delivery.

OBJECTIVE: To characterize postdischarge opioid use and examine factors associated with variation in opioid prescribing and consumption. METHODS: We conducted a prospective observational cohort study by recruiting all women undergoing cesarean delivery during an 8-week period, excluding those with major postoperative morbidities or chronic opioid use. Starting on postoperative day 14, women were queried weekly regarding number of opioid pills used, amount remaining, and their pain experience until they had stopped opioid medication. Demographic and delivery information and in-hospital opioid use were recorded. The state Substance Monitoring Program was accessed to ascertain prescription-filling details. Morphine milligram equivalents were calculated to perform opioid use comparisons. Women in the highest quartile of opioid use (top opioid quartile use) were compared with those in the lowest three quartiles (average opioid use). RESULTS: Of 251 eligible patients, 246 (98%) agreed to participate. Complete follow-up data were available for 179 (71% of eligible). Most women (83%) used opioids after discharge for a median of 8 days (interquartile range 6-13 days). Of women who filled their prescriptions (165 [92%]), 75% had unused tablets (median per person 75 morphine milligram equivalents, interquartile range 0-187, maximum 630) and the majority (63%) stored tablets in an unlocked location. This amounts to an equivalent of 2,540 unused 5-mg oxycodone tablets over our study period. Women who used all prescribed opioids (n=40 [22%]) were more likely to report that they received too few tablets than women who used some (n=109 [61%]) or none (n=30 [17%]) of the prescribed opioids (33% compared with 4% compared with 5%, P<.001). The top quartile was more likely to be smokers than average users and consumed more opioid morphine milligram equivalents per hour of inpatient stay than average opioid users (1.6, interquartile range 1.1-2.3 compared with 1.0, interquartile range 0.5-1.4, P<.001). CONCLUSION: Most women-especially those with normal in-hospital opioid use-are prescribed opioids in excess of the amount needed.