Optimal Management During Systemic Lupus Erythematosus Cesarean Section: An Educational Module

Abstract Importance: Systemic lupus erythematosus (SLE) is a lifelong multisystem autoimmune disorder characterized by the presence of autoantibodies that are directed against nuclear antigens. The disease is the most common type of lupus that has a heterogeneous presentation, and an affinity for the female gender with a peak onset in normative childbearing years. It becomes important for anesthesia providers to understand the potential complications that they may encounter during the obstetric management of this population, during cesarean sections. Recommendations that address the disease’s heterogeneous presentation and effect on the parturient organ systems provide a template for anesthesia providers during the perioperative management of the obstetric SLE patient. Objective: This quality improvement (QI) project aims to improve healthcare provider knowledge regarding the clinical implications of SLE, during the obstetric management for a cesarean section, to reduce morbidity and mortality for mother and newborn. Setting: A 716-bed acute care hospital in Broward County, Florida, which has a large obstetric population requiring anesthetic services. Anesthesia providers at this facility will be educated on the maternal-fetal dyad that can present during the management of the SLE mother during a cesarian section. Methods: A pretest survey will be administered to assess anesthesia providers’ knowledge, attitudes, and behaviors regarding the management of the SLE parturient during a cesarian section. An educational module will then be provided. Finally, a posttest survey containing the same questions as the pretest will be administered to participants. Results: Following the educational intervention, there was an increase in knowledge scores and stronger attitudes and beliefs regarding the role of anesthesia providers in the management of the SLE parturient during a cesarean section. Furthermore, most participants reported that they were highly likely to implement this into their clinical practice. Conclusion: An educational module can enhance anesthesia provider knowledge and increase the likelihood of improved outcomes for mother and neonate, during the anesthetic management of an SLE parturient during a cesarean section

Education Intervention Regarding Utilization of the Quadratus Lumborum Block for Post-Operative Analgesia Following Abdominal Surgery

Background: Poor post-operative pain control is associated with patient dissatisfaction, contributes to a delayed recovery, and increases the incidence of post-operative morbidity. The conventional transversus abdominis plane block (TAPB) results in exerting analgesic effects on the muscle, skin, and parietal peritoneum of the anterior abdominal wall, providing somatic analgesia with little to no visceral blockade. The need for visceral blockade to provide optimal postoperative pain relief has led to a more posterior approach that involves injecting the anesthetic adjacent to the quadratus lumborum muscle. The quadratus lumborum block (QLB) results in the spread of local anesthetic solution along the endothoracic and thoracolumbar fascia into the paravertebral space. This space, surrounded by adipose tissue, results in delayed local anesthetic uptake into systemic circulation, leading to prolonged analgesia. Evidence suggests efficacy of the TAPB may be more limited, and that QLB implementation should be considered to provide optimal outcomes for all patients undergoing abdominal surgery. Objectives: (1) To determine the more effective regional anesthesia technique as it relates to superior post-operative analgesia for patients undergoing abdominal surgery utilizing four databases: Cochrane, MedLine, CINAHL, and PubMed. This systematic review will serve as the basis for objective two. (2) To demonstrate an increase in knowledge in anesthesia providers pertaining to the utilization of the QLB for post-operative analgesia following abdominal surgery. Methodology: Seven randomized controlled trials (RCTs) were evaluated in this systematic review containing a total of 469 surgical patients. The RCTs found that the QLB provided longer and more effective postoperative analgesia. A majority of the studies also found that patients who received the QLB required fewer opioid analgesics postoperatively, and had lower overall pain scores as compared to the patients who received the TAPB. With this information, a pre-test, educational module, and post-test were created for anesthesia providers to evaluate both baseline knowledge and knowledge growth. Results: The statistical analysis between the pre-test and post-test showed an increase in provider knowledge. There was also an increase in the providers’ likelihood to utilize the QLB for patients undergoing abdominal surgery. Conclusions: The QLB provides superior pain management with a longer duration of post-operative analgesia, reduced total opioid consumption, and is associated with better overall pain scores than the TAPB after abdominal surgery. Continual implementation of this quality improvement project has the potential to improve the outcomes of surgical patients, ensure more optimal post-operative pain management, and decrease opioid use in patients undergoing abdominal surgery. Overall, the intervention was effective in increasing anesthesia providers’ knowledge and confidence regarding the utilization of the QLB as an alternative to the TAPB