Robert R. Gaiser

To identify newly identified risk factors for the development of a postdural puncture headache (PDPH) as well as to outline the key points in the management of unintentional dural puncture and of PDPH. The lack of experience of the proceduralist and a vaginal delivery are two risk factors that increase the risk of the patient developing a PDPH. The use of intrathecal catheters for the prevention of a headache is not of value, although an intrathecal catheter may prove to be the best method for providing analgesia for the patient. When performing an epidural blood patch, the optimal amount of blood is 20 ml, as long as the patient does not develop the symptoms of back pain or leg pain during the injection. Many practitioners do not practice an evidence-based approach to the management of unintentional dural puncture and PDPH. Written institutional protocols are important to insure that patients receive the optimal care.

Objective: To evaluate resident performance in the obstetric-anesthesia rotation using resident portfolios and their In-Training Examination scores, which are provided by the American Board of Anesthesiology/American Society of Anesthesiologists. Methods: We reviewed academic portfolios for second- and third-year anesthesiology residents at a single institution from 2006–2008 to examine United States Medical Licensing Exam Step 1 and 2 scores, grade for obstetrics-gynecology in medical school, and performance on the In-Training Examination. Faculty evaluation of medical knowledge and correlations for the various scores were obtained. Results: We examined scores for 43 residents. The subtest score for obstetric anesthesia increased after completing a rotation in obstetric anesthesia, 26.1 ± 10.3 versus 36.3 ± 10.6 ( P = .02). The subtest score correlated with United States Medical Licensing Exam Step 2, r = 0.46 ( P = .027) but not with United States Medical Licensing Exam Step 1 or with the grade obtained in medical school. There was no correlation between faculty evaluations of medical knowledge and resident subtest scores in obstetric anesthesia. Conclusions: Subtest scores in obstetric anesthesia are valid and provide a tool for the assessment of the educational program of a rotation. Knowledge as assessed by a faculty member is different from the knowledge assessed on a written examination. Both methods can help provide a more complete assessment of the resident and the rotation.

Educators came to realize what internists and pediatricians have known all along: adults and children are not the same. They differ in physiology, pharmacology, and learning. To approach teaching of the adult learner as one would a child is likely to fail. To effectively design and execute a curriculum for the adult, the teacher must consider the role of personal experience, learning preparedness, learning orientation, and motivation to learn. Although these principles may seem novel, they represent good judgment when teaching the adult. The key factor for the educator is to determine the needs of the adult (which is typically based upon personal experience) and then design and implement a curriculum based upon these needs. This approach is backward from the approach used in children in which the curriculum is established without any input from the learner. One other means to improve success is to foster personal reflection upon the teaching by the adult learner. This reflection may develop from carefully phrased questions, from activities in applying the knowledge, or from within the learner. By helping the learner to reflect, the true goals of the teaching may be achieved and the teacher is rewarded by having a more knowledgeable provider, who is able to use and to question the new knowledge. The cycle of adult learning is completed but also starts again.

Professionalism is one of the core competencies to be taught and evaluated during residency. A review of the literature suggests that professionalism is not completely understood or practiced. The teaching of professionalism has been incorporated into the educational programs for residents. However, residents learn from two curriculums: the stated curriculum and a hidden curriculum. The hidden curriculum represents the actions observed by the resident of the faculty in the hospital. The impact of this hidden curriculum upon professional behavior by the resident is significant. Due to the hidden curriculum, a possible means of improving professionalism involves the development of a program for faculty. This program must include not only topics but time for personal reflection of one's knowledge and actions. Self-reflection allows for the development of a true understanding and practice of professionalism and may improve professional behavior.

Postdural puncture headache remains the most frequent complication of neuraxial anesthesia. It can occur following uncomplicated spinal anesthesia as well as unintended dural puncture during epidural anesthesia. The incidence following accidental dural puncture is not as high as previously thought--approximately 50%. There are not many maneuvers that prevent postdural puncture headache. The most promising is an intrathecal catheter as it avoids further dural puncture and seals the hole during the time it is in place, decreasing cerebrospinal fluid loss. Several means to treat a postdural puncture headache exist. Medications that increase cerebral vascular resistance are the ones advocated. Methergine (methylergonovine maleate) has been advocated for postdural puncture headache following spinal anesthesia; it has not been studied for accidental dural puncture with a large bore needle. Epidural blood patch remains the treatment of choice. An epidural blood patch should not be performed until 24 h after dural puncture to increase its success; however, it should not be delayed beyond that period in the symptomatic patient, as this delay increases the amount of time the patient suffers.

The use of epidural analgesia for labor continues to increase dramatically. It has been suggested that epidural analgesia increases the risk of cesarean section, operative vaginal delivery, and prolonged labor. These issues have been extensively investigated. The use of epidural analgesia does not increase the risk of cesarean section. It may affect the incidence of forceps delivery, but it depends on the medications used. Epidural analgesia does prolong labor, although the clinical significance of this prolongation has not been shown.