Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: Results from the israeli board of anesthesiologists

BACKGROUND:: Cardiac arrest in the parturient is often fatal, but appropriate resuscitation in this special situation may save the lives of the mother and/or unborn baby. Concern has arisen as to application of recommended techniques for resuscitation in the obstetric patient. The Israel Board of Anesthesiology has incorporated simulation assessment into accreditation examinations. The candidates represent a unique national cohort in which we were able to assess competence in the simulated scenario of cardiorespiratory arrest in the parturient. METHODS: A simulated scenario of preeclampsia with magnesium toxicity leading to cardiac arrest in a pregnant patient was performed by 25 senior anesthesiology residents. A unique two-stage simulation examination consisting of high fidelity simulation followed immediately by oral debriefing was conducted. The assessment was scored using a predetermined checklist of key actions and answers to clarifying questions. Simulation performance was compared to debriefing performance. RESULTS: During the board examination, resuscitation not specific to the pregnant patient was performed well (commencing chest compressions, bag-mask ventilation, cardiac defibrillation); however actions specific to the parturient were performed poorly. Left uterine displacement, cricoid pressure during bag-mask ventilation, and instructing preparations to be made for perimortem cesarean delivery within 5 minutes were performed by 68%, 48%, and 40% of candidates respectively (lower 99% confidence limit 42%, 25%, and 19%, respectively). Cricoid pressure during bag-mask ventilation was performed by 48% (25%) but described in debriefing by 80% of candidates (53%) (P = 0.08), and time setting for perimortem cesarean delivery was performed by 40% (29%) but described by 80% (53%) (P = 0.05) of examinees. CONCLUSIONS: Senior anesthesiology residents have poor knowledge of resuscitation of the pregnant patient. The results suggest 2-stage simulation including an oral component may reveal disparities in knowledge not assessed by simulation alone, but definitive conclusions require further study.