Autonomic Dysreflexia in the Peripartum Patient: A Multidisciplinary and Interprofessional Simulation Scenario

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (ob/gyn) and anesthesiology. Consultation with a nurse educator maintained quality and relevance of objectives for nursing participants. The curriculum was prepared to train ob/gyn and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow ob/gyn and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluation data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for “Was an effective use of my educational time” and “Will influence/enhance my future practice”. In this scenario, participants must recognize and manage a parturient with spinal cord injury in active labour who develops autonomic dysreflexia. The fetal heart tracing becomes abnormal and the team must respond with urgent delivery. This scenario requires a mannequin for a pelvic exam and a pregnant abdomen. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.


Introduction
Due to improvements in the acute management and rehabilitation of patients with spinal cord 1 2 3 2 1 4 injuries (SCI) as well as advances in reproductive technologies, an increasing number of these women are becoming pregnant. Complications of chronic SCI may be exacerbated by the physiologic changes of pregnancy, labour, and delivery. Autonomic dysreflexia (AD) is a common syndrome that occurs in patients with an injury at or above T6, characterized by acute hypertension, bradycardia, headaches, arrhythmias, and in severe cases respiratory failure, intracranial hemorrhage or hypertensive encephalopathy. Pregnant patients will also present with fetal distress due to uteroplacental vasoconstriction. This life threatening presentation, for both mother and baby, must be immediately recognized and appropriately managed. Most trainees and clinicians will see very few such patients in their career, making diagnosis and management challenging.
This simulation scenario was created in order to allow anesthesiology residents, obstetrics residents and nurses to practice the diagnosis and management of a patient with a SCI presenting with acute AD. Effective coordination and communication between these three services is essential to ensure the safety of both mother and baby [1][2].
This scenario is part of a four-year interdisciplinary curriculum for ob/gyn and anesthesiology residents developed at the University of Ottawa Skills and Simulation Centre (see Appendix E). Obstetricians and anesthesiologists often work together in acute, high stakes situations. This curriculum was designed in order to allow residents in both fields to practice both technical and crisis resource management skills in a safe and risk-free environment. Further, the interdisciplinary aspect of this curriculum allows both fields to learn about each other's knowledge, roles, and priorities during a crisis.
The target audience is ob/gyn residents, anesthesiology residents, and practicing nurses as part of a comprehensive interdisciplinary curriculum of theatre-based simulation. Three to five learners participate in each session, and the duration of training is one hour.
The goals of the scenario are for the team to recognize and appropriately manage autonomic dysreflexia in a labouring patient, to manage a patient with a chronic spinal cord injury presenting with an abnormal fetal heart tracing, and to demonstrate effective crisis resource management skills.

Team objectives
(Adapted from the Ottawa Global Rating Scale [3]) 1. Demonstrates leadership skills by remaining calm and in control, making firm decisions, and maintaining a global perspective.
2. Demonstrates problem solving skills by conducting a thorough, but efficient airway, breathing and circulation (ABC) assessment using a concurrent management approach and considering most likely alternatives in crisis.
3. Demonstrates situational awareness skills by avoiding fixation error, reassessing and reevaluating situations, anticipating likely events. 4. Demonstrates resource utilization skills by using resources to maximal effectiveness, setting clear task priority, asking for help early.
5. Demonstrates communication skills by communicating clearly and concisely, encouraging input and listening to staff feedback, using directed verbal/non-verbal communication.
Ob/gyn resident objectives 1. Demonstrate management of hypertension in a labouring patient with a chronic spinal cord injury.
2. Demonstrate an approach to assessment and management of labour in a patient with a chronic spinal cord injury.
3. Recognize and demonstrate the management of an abnormal fetal heart tracing.

Case summary
A 26-year-old gravida 1 para 0 patient with a history of T5 spinal cord injury due to a motor vehicle accident two years ago presents at 37 weeks gestational age with a new onset headache, which is a result of autonomic dysreflexia (AD) precipitated by labour. After initial assessment by a triage nurse, an obstetric resident is asked to assess the patient and initiate management. Upon pelvic examination, the patient develops worsening AD and fetal bradycardia. This prompts the ob/gyn resident to prepare for an emergency caesarean section and to call for the ob/gyn "attending" and anesthesiologist. Once in the operating room, the fetal heart rate stabilizes, allowing the team to have a discussion regarding the appropriate management of this patient's labour and delivery. The fetal heart rate once again decelerates prompting induction of general anesthesia for an emergency caesarean section.

Learner preparation
We advocate for a comprehensive pre-briefing prior to any theatre-based simulation session, as described by Rudolph, et al. [4].
Nurse: You are working in obstetrical triage. Your next patient in triage is a 26-year-old G1P0 patient at 37 weeks who is complaining of a worsening headache as well as vaginal spotting.
Junior ob/gyn resident: You are the senior ob/gyn resident on call in a tertiary hospital. Your staff ob/gyn is also in the hospital.
Senior ob/gyn resident: You are the ob/gyn attending physician on call in a tertiary hospital. You have a senior ob/gyn resident also on call with you.
Anesthesiology resident: You are the attending anesthesiologist on call for ob/gyn in a tertiary hospital.

Equipment/Environment
This scenario takes place during a call shift in a tertiary care hospital obstetrical triage and operating room.
Two rooms are required (#1 set up as an obstetrical triage, #2 set up as an operating room) OR A single simulation room (initially set up as an obstetrical triage with hidden operating room equipment in the periphery that will be uncovered and moved into place once the team "enters" the operating room) Part

Learners
Senior anesthesiology resident -attending anesthesiologist Senior ob/gyn resident -attending obstetrician Mid level ob/gyn resident -obstetric resident Obstetric nurse -obstetric nurse, functioning as the triage nurse and the patient's primary nurse The baseline state of the mannequin is described in Table 1.

Overall Appearance
The patient is lying flat on her back with a cold cloth on their forehead. Blood pressure monitor, saturation probe, and fetal heart monitor have been applied and the monitor is beside the patient. The patient's partner is by her side looking anxious. The patient is awake, alert, but anxious.

Actors and roles in the room at case start
Patient -High fidelity mannequin, being voiced from control room, with pregnant abdomen Partner -Confederate actor (could be played by an extra resident or simulation instructor)

HPI
When asked, the patient will state that she is 26 years old and 37 weeks pregnant with her first pregnancy. She woke up this morning with a headache that worsened throughout the day. She is also sweating and has had a small amount of vaginal spotting. She has no visual changes, epigastric pain or swelling of her legs. She does not feel fetal movements due to her spinal cord injury. She has not noticed any leakage of fluid or rupture of membranes. Her husband will volunteer that they were seen in the pre anesthetic clinic and were told by the anesthesiologist that they needed an early epidural when she went into labour.

Past Medical/Surgical History Medications Allergies Family History
OB -Her pregnancy has been uncomplicated. Her previous ultrasounds were normal. She had several urinary tract infections during her first and second trimesters but none recently. PMHx-She was involved in a motor vehicle accident 2 years ago which resulted in a T5 spinal cord injury (will provide level if asked). Because of her paraplegia she has recurrent urinary tract infections due to self-catheterization. She has had episodes of autonomic dysreflexia in the past due to urinary tract infections. She has no history of head trauma or migraines or previous headache. No previous surgery.

Prenatal vitamins None
None, including no history of problems with anesthetics.

Physical Examination
General Awake, alert, anxious. Flushed and diaphoretic.

HEENT Normal
Neck Normal

Lungs
Breath sounds equal bilaterally and clear to auscultation

No movement of lower extremities Hyperreflexic in lower extremities
Skin Diaphoretic

Ideal scenario flow
The nurse enters the room (obstetrical triage) to find a pregnant patient, anxious with a headache. She takes an initial history and applies monitors, including a fetal heart rate monitor and recognizes severe hypertension with no fetal distress. The ob/gyn resident is paged to assess the patient. The ob/gyn resident takes a history, orders initial investigations, and orders labetalol or hydralazine to decrease the patient's blood pressure. They may ask for the anesthesiologist to be paged. The patient develops worsening autonomic dysreflexia, precipitated by a pelvic exam performed by the resident, with a resulting fetal bradycardia. This prompts the ob/gyn resident to call for an emergency caesarean section. At this point, depending on the resources of the simulation centre, the patient is transferred to another simulation room prepared as an operating room or equipment is brought into the room and the team will be told they are now in an operating room. At this time the ob/gyn and anesthesiologist enter the simulation. The team reassesses the patient and recognizes that the fetal heart rate has stabilized. The anesthesiologist assesses the patient and the ob/gyn receives handover from the ob/gyn resident. The team discusses the optimal management of this patient's labour and delivery. The fetal heart rate once again decelerates prompting induction of general anesthesia for an emergency caesarean section. The scenario ends after anesthesia is induced. Table 2 provides notes for the instructor based on branching points during the scenario based on participant actions.

Intervention / Time point Change in Case Additional Information
If the team mistakenly diagnoses the patient with pregnancy induced hypertension or any other hypertensive disorder of pregnancy They will be allowed to continue managing according to their differential diagnosis. Their management will be ineffective and the patient and fetus will continue to deteriorate If the nurse or the ob/gyn resident want to move the patient from triage to an inpatient room They will be told that a room is being prepared for the patient but this will take five to ten minutes Two minutes into the case Patient will volunteer that she is paraplegic if this information has not already been elicited Husband will say "We were told at the pre anesthesia clinic that she needs an epidural as soon as she goes into labour"

Critical actions
The nurse assesses the patient in obstetrical triage and recognizes uncontrolled hypertension in a pregnant patient.
The nurse calls the ob/gyn resident to assess the patient.
The ob/gyn resident assesses the patient in triage, orders initial investigations (complete blood count (CBC), electrolytes, liver function tests, coagulation tests, urinalysis). They order medications to treat the patient's blood pressure including labetalol or hydralazine.
The ob/gyn resident and nurse recognize the fetal heart rate deceleration and prepare for an emergency caesarean section, calling both the ob/gyn and anesthesiologist.
The anesthesiologist performs a focused assessment of the patient.
The ob/gyn receives handover from the ob/gyn resident.
In the operating room the team recognizes that the fetal heart rate has stabilized.
The team discusses the management of this patient's labour and delivery, including the options of epidural analgesia, spinal anesthesia, and general anesthesia.
The team recognizes the fetal heart rate deceleration and prepares for an emergency caesarean section.
The anesthesiologist induces the patient using a general anesthetic, using a technique that is sensitive to an existing spinal cord injury and while being sensitive to the severe hypertension by blunting the laryngoscopy response.
The nurse assists the anesthesiologist in induction of general anesthesia.
The ob/gyn team prepares to perform a caesarean section.

Anticipated management errors
The following is a list of management errors or difficulties that are commonly encountered when using this simulation case.

Failure to Recognize Autonomic Dysreflexia
Many of our learners do not recognize the presentation of autonomic dysreflexia and instead manage the patient as if she has preeclampsia. We specifically cover this information during the initial part of our debriefing and send the learners a handout after the session.

Failure to Recognize Changes in the Fetal Heart Rate
Some of our learners do not recognize the deceleration of the fetal heart rate in triage or the recovery in the OR. We allow the confederate nurse to prompt the learners to look at the tracing.

Assessment & debriefing guide
Assessment This scenario was developed as a formative assessment tool with a focus on non-technical skills and crisis resource management. There are multiple suitable assessment methods that can be used. We utilize a performance checklist, as well as a Crisis Resource Management Checklist (Ottawa GRS [3]). Please refer to Appendix B for the performance checklist.

Debriefing
We suggest an interprofessional, multidisciplinary team debriefing guided by an experienced simulation instructor. The goal of the debriefing is to allow learners to actively reflect on their own and the team's performance, which is an essential step in adult experiential learning. Instructors should strive to create a safe, supportive, and respectful environment where all learners are encouraged to participate. Debriefing should focus on the educational objectives, both technical and non technical. We advocate for the use of the promoting excellence and reflective learning (PEARLS) framework to organize the debrieifing [5]. Where available, we advocate for the use of video review during the debriefing. Be cognizant of timing; the debriefing should take 30-40 minutes. Strategies to debrief common errors can be found in Table 3, and a complete debriefing guide can be found in Appendix C.

Program evaluation
We emphasize collecting evaluative data from participants after their simulation sessions. Our evaluation tool can be found in Appendix D. The results of our initial program evaluation can be found in Table 4.

(strongly disagree) 2 3 4 5 (strongly agree)
The objectives were made clear 3 13 The scenarios were relevant to my practice 16 The simulation team behaved in an appropriate and believable manner during the scenario 3 13 There was sufficient time allotted for hands-on participation and group interaction 16 The staff met the stated learning objectives 1 15 The staff were knowledgeable and informed 16 The staff provided adequate and appropriate feedback 1 15 The debriefing sessions were logically organized and clarified important issues 16 The knowledge gained from this session will enhance/influence my practice 16 The

Discussion
This scenario, as well as the rest of the 'Ob/Gyn Anesthesia Nursing Simulation Curriculum' (see Appendix E) ( Table 5), was developed to allow learners to practice managing rare and important clinical scenarios that they may not experience sufficiently during their period of training to achieve competence. Autonomic dysreflexia is a rare presentation; however, misdiagnosis and management leads to significant morbidity and mortality for the mother and fetus. This scenario highlighted an important clinical knowledge gap. Furthermore, it allowed for interdisciplinary practice of crisis resource management skills that can be applied to a multitude of clinical situations. This scenario provided an opportunity for the anesthesiology residents to recognize medical expertise they have, which other members of the team may not. In order to provide safe patient care they had to share their mental model effectively with the ob/gyn and nursing teams. The ob/gyn residents and nurses, used to managing hypertension due to pregnancy induced hypertension, were given the opportunity to practice developing a broad differential diagnosis and avoid fixation errors. This was reflected in the positive feedback from learners regarding the clinical relevance of the scenario and applicability to practice. Several learners stated the usefulness of having to diagnose and manage a rare medical condition.
During the development, piloting, and running of this scenario two main challenges were encountered. First, there was a lack of adequate resources to run this simulation using two separate rooms, "an obstetrical triage" and a separate "operating room". The decision was made to hold the entire scenario in one simulation room. After the decision had been made by the team to proceed for an operative delivery, equipment, which had been hidden under covers in the periphery of the room, was uncovered and positioned to simulate an operating room. This does not appear to significantly affect realism for the learners in the scenario. The second challenge was that the majority of learners did not recognize the patient was at risk for autonomic dysreflexia and proceeded with routine medical management of an obstetrical patient in triage, including a pelvic exam leading to deterioration of the patient's condition. We had to be sure to address this medical error during the debriefing in a way that was respectful of the students' experience and the stress of participating in simulation. Overall, the simulation and debriefing was a positive learning experience for the students. A majority of students felt that feedback was given in an appropriate manner and stated that they would like to attend additional simulation sessions.
There are limitations to this modality of teaching. Simulation requires many resources including equipment, instructor and learner time, and instructor expertise. It is also heavily dependent on learner engagement and their willingness to participate and share their experiences with their colleagues. With the appropriate support from departments and learners along with adequate preparation, we feel that it is an invaluable resource especially for teaching around rare medical conditions and crisis resource management skills.

Conclusions
We describe the design and implementation of an interprofessional and multidisciplinary simulation scenario to teach ob/gyn residents, anesthesiology residents, and nurses about the management of autonomic dysreflexia in the peripartum patient. Debriefing points and common pitfalls are elaborated along with program evaluation data. This scenario is one component of a comprehensive theatre-based simulation curriculum, the goal of which is to provide formative assessment around less common obstetrical emergencies, and crisis resource management.

Appendices Appendix A: Equipment
General 2 simulation rooms (#1 set up as an obstetrical triage, #2 set up as an operating room (OR)) or 1 simulation room (initially set up as an obstetrical triage with hidden OR equipment in the periphery that will be uncovered and moved into place once the team "enters" the OR) Assists with initial intrauterine resuscitation;

Mannequin
Collaborates with obstetrics and anesthesia during urgent cesarean section. following: Confidentiality: instructors should sign a confidentiality form agreeing not to discuss the learners' performance during the scenario or discussion during the debriefing outside of the simulation environment. Learners should sign a confidentiality form agreeing not to discuss any aspects of the case or debriefing outside of the simulation environment.
Equipment: instructors should describe the function of the simulation mannequin (what types of procedures can be performed, where to feel for pulses, where to listen for breath sounds, etc), how to operate the monitors in the room, how to get extra resources (location of phone, phone number to call, resuscitation cart, difficult airway cart, etc).
Fidelity: the learners should be encouraged to treat the scenario as they would a real clinical experience. Learners should be advised that if they are unsure that a clinical finding or event is intended or an artifact, to state this aloud so they can be appropriately directed.

Debriefing
Reactions phase: allows learners to express their initial thoughts and feelings -Ask one or two participants to summarize the case in two to three sentences to avoid a detailed play-by-play of the scenario -Ensure participants from all disciplines are able to contribute -Make note of any disagreements between the learners as to the medical content (differential diagnosis, management plan, etc) which can serve as a point of discussion during the 'Analysis' phase -Clarify any misconceptions, correct any errors regarding the main presentation and diagnosis, i.e."This case was meant to portray a patient with a chronic spinal cord injury presenting with severe autonomic dysreflexia due to labour"

Key Clinical Points
Anesthesiology: Autonomic dysreflexia may occur in patients with spinal cord injury above T5 and is due to a loss of control of sympathetic spinal reflexes distal to the spinal cord injury. Noxious stimuli below the level of injury causes reflex sympathetic activation, catecholamine release and vasoconstriction resulting in hypertension, arrhythmias, flushing, respiratory distress, and in the pregnant patient, uteroplacental vasoconstriction and fetal hypoxia.
Any noxious stimuli should be avoided or immediately treated, including the stimulation caused by uterine contraction.
Spinal or epidural anesthesia will prevent autonomic dysreflexia by inhibiting the stimulation caused by uterine contraction.
Autonomic dysreflexia should be treated with titratable agents such as nitroglycerin, hydralazine, and nitroprusside. Obstetrics: Labour or cervical examination can stimulate or worsen autonomic dysreflexia in patients with longstanding spinal cord injuries.
Early regional anesthesia (spinal or epidural) is the preferred approach to effectively treat autonomic dysreflexia and maximize opportunity for spontaneous vaginal delivery Early consultation with anesthesiology is recommended Nursing: Patients with chronic spinal cord injury require early medical intervention in labour and early obstetrical and anesthesia assessment due to the risk of autonomic dysreflexia Analysis phase: allows learners to practice reflective learning by exploring and analyzing positive performances and performance gaps Tips: -Be genuinely curious! -Maintain the basic assumption that everyone is smart and is doing their best for the patient! -Focus on two to three points including both technical and non-technical skills in your discussion -Include discussion points based on your own observation as well as those generated by the learners in the 'Reactions' and "Descriptive' phases -Select appropriate tools including advocacy-inquiry, plus/delta, and directive feedback according to the type of performance gaps observed, the time available, the experience and insight of the learners, your experience as a debriefer.
"What went well? What would you have wanted to change or do differently?" "What are some pros and cons of ... [observed action or behaviour]?" "What was going through your mind when you did/said ... ?" "What was your differential diagnosis?" Normalize mistakes "We specifically put you into a challenging situation and we did not expect you to manage everything perfectly" "In our normal practice we are used to those around us acting in a specific way, things are different in the simulator" Generalize to clinical practice "Have you ever experienced anything similar in your practice?" "What strategies have you seen people use in your clinical experience?" Before moving to the 'Summary' phase ask the learners if there are any other issues they would like to discuss Summary phase: allows learners to review and summarize what was learnt and to apply this to their clinical practice, and allows instructors to confirm if the learning objectives of the scenario were achieved Tips: -Avoid bringing up new discussion points or topics -Ask the learners to summarize their main take-home points, i.e. "Tell me one thing you did well, one thing you would do differently, and one thing you learnt that you will apply to your clinical practice" -Summarize the main points of the discussion -Ensure everyone contributes, even learners who participated as confederates can share what they learnt from participating in the scenario and debriefing. 3) The degree of difficulty of the scenario was appropriate