Second-Trimester Dilation and Evacuation: A Simulation-Based Team Training Curriculum.

Introduction: Despite the need for providers skilled in second-trimester dilation and evacuation (D&E) procedures, there are few second-trimester abortion training opportunities for OB/GYN residents and other health care trainees. Barriers to such training include restrictive state laws and institutional policies, lack of trained faculty, and limited procedural volume. Simulation-based D&E training is, therefore, a critical tool for OB/GYN residents and other medical professionals to achieve clinical competency. Methods: This simulation for OB/GYN residents centers on a 29-year-old woman at 18 weeks gestation with intrauterine fetal demise, requiring learners to perform a second-trimester D&E and manage an unexpected postprocedural hemorrhage. We designed the simulation to be used with a high-fidelity mannequin. Personnel roles required for the simulation included an anesthesiologist, medical assistant, OR nurse, and two OB/GYN faculty. Learner performance was assessed using a pre- and postsimulation learner evaluation, a critical action checklist, and a focus group with simulation facilitators. Results: Forty-nine residents participated over an 8-year period. Learners demonstrated improved competency performing a second-trimester D&E and increased confidence managing postprocedural hemorrhage after participating in this simulation. In addition, focus group participants reported that a majority of learners demonstrated confidence and effective communication with team members while performing in a decision-making role. Discussion: In addition to improving learners' clinical competency and surgical confidence for second-trimester D&E procedures, this simulation serves as a valuable instrument for the standardized assessment of learners' performance, as well as an opportunity for all participants to practice teamwork and communication in a high-acuity setting.

Safety of deep sedation without intubation during surgical abortion in the independent clinic setting.

OBJECTIVE: To establish the safety of deep sedation without intubation delivered by a certified registered nurse anesthetist (CRNA) in an independent outpatient abortion setting. STUDY DESIGN: We performed a review of clinic Quality and Patient Safety Reports, a daily-maintained report of complications at time of all dilation and curettage (D&C) and dilation and evacuation (D&E) procedures performed at an independently operated, urban, high-volume abortion clinic between March 2013 and August 2017. The clinic provided procedures through 23 weeks 6 days gestation to women at low risk for medical or surgical complications, referring high-risk procedures to a nearby hospital. A CRNA provided anesthesia for all deep sedation procedures. We extracted information on gestational age, risk factors, and clinical course for all patients who experienced any anesthesia-related complication. RESULTS: During the study period, the clinic evaluated 10,297 women for surgical abortion, referring 292 high-risk cases and performing 10,005 procedures (9004 D&C and 1001 D&E), most (9405 [94%]) with deep sedation. We documented six anesthesia-related complications; three (0.03%) in D&C procedures (laryngospasm not requiring intubation [n = 2] and respiratory stridor) and three (0.30%) in D&E procedures (laryngospasm requiring intubation, seizure, and hypotension/bradycardia). Only one patient (0.01%) required intubation. CONCLUSIONS: Anesthesia-related complications in the setting of deep sedation without intubation during surgical abortion were exceedingly rare, supporting the safety of this form of anesthesia for low-risk patients in an independent community clinic setting. IMPLICATIONS: Independent community clinics, where the majority of abortion procedures are performed within the U.S., can provide safe anesthesia care using deep sedation provided by CRNA professionals. This care delivery model, which includes triaging patient eligibility, reassuringly provides anesthesia as safely as other greater resourced care delivery settings.

Concepts in creating an evidence-based anesthetic protocol for robot-assisted laparoscopic pelvic surgery.

BACKGROUND: Robotic-assisted surgery has increased in popularity in recent years. Benefits have been observed for both the patient and hospital system as the technology shifts surgery from the open to the laparoscopic arena. Some of the advantages of robotic-assisted surgery include increased patient satisfaction along with shorter hospital stays, decreased risk of infection, and improved postsurgical cosmetic outcomes. METHODS: We developed an evidence-based protocol for the anesthetic management of the preoperative, intraoperative, and postoperative phases of patient care based on the review of primary literature and consensus from surgeons and anesthesiologists at our institution. RESULTS: Robotic-assisted surgery creates a unique set of anesthetic considerations to ensure patient safety. Anesthetic considerations include the physiological changes associated with steep Trendelenburg patient positioning, pneumoperitoneum, fluid management, management of pressure points, and spatial restrictions imposed by the robot relative to the conventional anesthetic area. CONCLUSION: A perioperative protocol can help ensure optimal clinical care, patient safety, and better patient and provider satisfaction with the utilization of robotic surgery.