Scenario in a Nutshell
Local anaesthetic toxicity with seizure then pulseless ventricular tachycardia (VT) requiring perimortem caesarean section in delivery room.
Stage 1: Patient dizzy and unwell after epidural top-up.
Stage 2: Patient suffers tonic–clonic seizure.
Stage 3: Cardiovascular collapse with pulseless VT.
Stage 4: Return of spontaneous circulation.
Target Learner Groups
All members of the multidisciplinary obstetric team: anaesthetists, midwives, obstetricians, operating department practitioners/anaesthetic nurses and emergency response teams.
| Specific learning opportunities |
|---|
| Knowledge of differential diagnosis of acute deterioration following epidural top-up |
| Recognise symptoms and signs of local anaesthetic toxicity |
| Knowledge of Association of Anaesthetists of Great Britain and Ireland (AAGBI) local anaesthetic toxicity guidelines and their location |
| Knowledge of location of intralipid on delivery unit |
| Demonstrate fast and accurate delivery of intralipid |
| Demonstrate safe and effective cardio-pulmonary resuscitation (CPR) and defibrillation |
| Demonstrate timely decision-making to perform perimortem caesarean section |
| Demonstrate good team communication, leadership and decision-making |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic CT2 | √ | |
| Anaesthetic ST3+ | √ | |
| Obstetric ST3+ | √ | |
| Midwife Coordinator | √ | |
| Midwife in room | √ | |
| Operating Department Practitioner (ODP)/anaesthetic nurse | √ | |
| Suggested facilitators | ||
| Faculty to play role of night anaesthetist finishing shift (can be played by facilitator running scenario) | √ | |
| Faculty to play role of patient’s partner | √ |
Details for Facilitators
Patient Demographics
Name: Trisha Age: 22 Gestation: 38+4 Booking weight: 56 kg Parity: P0 |
Scenario Summary for Facilitators
Patient had an epidural sited (for labour analgesia) with difficulty during the night shift. Three attempts were made. On the last attempt, there was blood in the catheter which then cleared on withdrawing 1 cm. Epidural was working well initially but required top-up within last hour.
Patient now requires Category 2 caesarean section for failure to progress.
The night-time anaesthetist who sited the epidural (faculty) administers epidural top-up for theatre, 20 ml 0.5% bupivacaine with 100 μg fentanyl. He hands over to the daytime team – midwife and CT2 anaesthetist – and then goes home.
Patient becomes unwell in labour room. Differential diagnosis of her symptoms of dizziness to be explored.
Patient goes on to experience seizures.
Diagnosis of local anaesthetic toxicity and appropriate management.
Ultimately develops pulseless VT and requires perimortem caesarean section.
Return of spontaneous circulation occurs after second bolus of intralipid and defibrillation.
Set-up Overview for Facilitators
| Clinical setting | In a delivery room, on a delivery bed |
| Patient position | Semi-recumbent |
| Initial monitoring in place | Pulse oximeterNIBP cuffCTG |
| Other equipment | 16G cannula dorsum left hand attached to 1 litre Hartmann’s solution at 80 ml/h and 10 IU syntocinon in 500 ml normal saline running at 48 ml/h |
| Epidural catheter secured to back | |
| Useful manikin functions | Seizures Defibrillation |
Medical Equipment
For core equipment checklist, see Chapter 9, including advanced airway equipment.
| Additional equipment specific to scenario | |||
|---|---|---|---|
| Defibrillator and external pads | Epidural catheter (taped over shoulder) with epidural pump attached | Syntocinon infusion with giving set and infusion pump | |
| Ethyl chloride spray | Perimortem caesarean section pack or scalpel/swabs/cord clamp | ||
| Arterial line | CVP line | Severe local anaesthetic toxicity guidelines + local emergency checklist for local anaesthetic toxicity if available | |
| Intralipid 20% emulsion with giving set and infusion pump | Induction/sedative agents (thiopentone, propofol, benzodiazepine) | Neuromuscular blockers (depolarising and non-depolarising) | Cardiovascular drugs: adrenaline 1 mg, amiodarone 300 mg |
Information Given to the Learners
| Information given to CT2 anaesthetic trainee and midwife who are taking over care at start of their shift. |
| Time: 08:00 |
| This handover is given by a facilitator playing the role of the night anaesthetist who is now going home. Night anaesthetist is just completing epidural top-up as midwife and CT2 anaesthetics come in for handover. |
| The SBAR handover is as follows: |
| Situation: This is an epidural top-up for a category 2 section. |
| Background: Trisha is a 22-year-old, previously fit and well primip who is 38+4 weeks pregnant with no allergies. She had an induction for prolonged rupture of membranes and has failed to progress. She had an epidural sited 2 hours ago. I had multiple attempts at siting it. On my third attempt there was blood in the catheter, but I flushed it, pulled it back 1 cm and it worked well initially. She has had one midwife top-up when the block had regressed a little 40 min ago. |
| Assessment: Observations were all normal. I have got monitoring on ready for transfer and I have just finished giving an epidural top-up of 20 ml 0.5% bupivacaine with 100 μg fentanyl. |
| Recommendation: Are you happy to take over? Theatres said they will be ready for you in about 5 minutes. |
| Brief information given to obstetric team and midwifery coordinator who will respond to the emergency when called.You have arrived on shift and have been told there is a category 2 section for failure to progress being brought around to theatre shortly. |
