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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 630-635  

Critical thinking among anesthesiology residents – “Epidural test dose”-Based experiment


Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission08-Jul-2019
Date of Decision02-Oct-2019
Date of Acceptance20-Dec-2019
Date of Web Publication6-Nov-2020

Correspondence Address:
Sumitra G Bakshi
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_194_19

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  Abstract 


Introduction: During the postgraduate course, one is expected to think critically, analyze the clinical situation, and react appropriately. The practice of test dose administration among anesthesiologists is variable. As an initial experiment, we decided to study the common practice of test dose administration through epidural catheters in anesthesia postgraduate students. Methods: After approval from the institutional ethics review board, during a national academic meet for postgraduates, the delegates were asked to fill a 12-item-based survey questionnaire, in English, pertaining to the practice of test dose administration and its interpretation. Results: Eighty-five percent of delegates replied that they were practicing administration of test dose after epidural catheter insertion. Seven percent got the purpose of test dose right. Around 10% of delegates could give correct answer for composition of test dose and 9% of delegates could rightly differentiate between interpretation of test dose for thoracic and lumbar-placed epidural catheters. Discussion and Conclusion: Young anesthesiologists do have a lacuna in knowledge about the basics of administration of test dose, the key components, and the effect it can produce. The students also lack the ability to analyze the effect that the test dose would produce when administered at different segmental levels. Future research critically evaluating our current education process is probably the need of the hour.

Keywords: Critical thinking, epidural test dose, knowledge development and utilization


How to cite this article:
Patil VP, Bakshi SG, Patil P. Critical thinking among anesthesiology residents – “Epidural test dose”-Based experiment. Med J DY Patil Vidyapeeth 2020;13:630-5

How to cite this URL:
Patil VP, Bakshi SG, Patil P. Critical thinking among anesthesiology residents – “Epidural test dose”-Based experiment. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Nov 26];13:630-5. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/630/300128




  Introduction Top


Critical thinking (CT) is an essential cognitive process for knowledge development and utilization.[1] CT plays an important role in problem-solving and decision-making.[1] Assessment and enhancement of CT is gaining importance.[2],[3],[4] With newer evidence, better understanding, newer challenges, application of current knowledge is essential in the medical field. CT, hence, is an essential skill for medical postgraduate students.[1]

During the postgraduate course, one is expected to think critically, analyze the clinical situation, and react appropriately. There is recognition of the need to develop thinkers;[1] however, this concept has not merged in our subcontinent. As an initial experiment, we decided to study the concepts postgraduate students have with respect to a common practice in regional anesthesia – test dose. We selected the topic of test dose as we believed that it is routinely practiced. Although there are certain controversies and multiple components with respect to test dose, the interpretation of the test dose includes rational thinking based on each component that is being used and also on the level of administration of the test dose.[5] This study presents the data of our survey about interpretation of test dose from anesthesia trainees about to appear for qualifying examination. The study aimed at capturing the students reasoning skill of why an intervention was done and difference in results expected when the same intervention was done at two different levels – lumbar and thoracic levels.


  Methods Top


This study was approved by the institutional ethics review board. A survey-based observational study was done during a national academic meet for postgraduates. All delegates were given a survey questionnaire in English. The willingness of completing and submitting the questionnaire was considered as implied consent for participation. The identity of delegates was not captured to ensure anonymity.

All delegates were approached and were given a 12-item-based survey questionnaire, in English, refer Annexure 1. Questionnaire was given to residents as handouts during the review course, and they were asked to fill the same and revert as our volunteers waited for them to return their responses. This ensured that no referral to books or group discussion was done prior to filling of the questionnaire. Questions (1–4) were focused on practice with respect to epidural analgesia and test dose and to gauge their experience. The questions included how many epidural catheters are placed by the respondent per week, and how many are thoracic epidurals. Furthermore, whether the respondent practiced administration of test dose before use of the epidural catheter.

Question (5) was on composition of standard test in an adult nonobstetric patient. Questions on interpretation of test dose (6–11) included five questions on signs that one should look for in case of malplacement of catheter in the lumbar/thoracic region with respect to motor and sensory symptoms and also with respect to heart rate, blood pressure, and electrocardiogram.

The last question was focused on source of information about test dose. The respondent had to choose from options which included textbooks, seniors, journal article, or any other (details to be provided).

Analysis of questionnaire was done as follows: experience-based questions were captured as percentage. Answers to open questions were analyzed by independent experts. Questions with multiple components to be answered were marked as correct, partially correct, and inappropriate/wrong by independent reviewers, for example, for the test dose – which essentially has two components: local anesthetic for intrathecal/subdural placement and vasopressor for identification of intravascular catheter placement; was marked as correct (if both components answered right), partially correct if one of the components was right, and inappropriate if both components were wrong. Other questions on interpretations of test dose were similarly corrected. Answer not attempted was taken as missing data.


  Results Top


A total of 230 delegates registered for review course and out of that 111 questionnaires were returned. The overall response rate was 48.3%. Although filling of questionnaire was not time bound, average time to fill the questionnaire was around 5 min.

Eighty percent of delegates replied positively for inserting thoracic epidurals, and 36% of delegates were placing more than five epidurals per week [Table 1] – experience of delegates]. Eighty-five percent of delegates replied that they were practicing administration of test dose after epidural catheter insertion. Only 7% got the purpose of test dose right (mentioned both intravascular and intrathecal) [Table 2].[5],[6],[7],[8],[9] Around 10% delegates gave correct answer for composition of test dose. Results for the assessment of test dose are summated in [Table 2]. Only 9% of delegates could rightly differentiate between interpretation of test dose for thoracic and lumbar-placed epidural catheters.
Table 1: Response of delegates with respect to experience with epidural insertions (n=111)

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Table 2: Questions related to the analysis of test dose with delegates response (n=111)

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With respect to signs in case of intravascular placement of a thoracic epidural catheter, 30% of respondents responded that hypotension will be presenting sign, whereas 15% of respondents felt that bradycardia could be a presenting sign. Five respondents believed that cardiac arrest could be a sequel of test dose administration in catheter that was wrongly placed in the intrathecal space. When asked about source of information, 61% respondents had marked textbooks, 60% marked seniors, 9% stood by journals and articles, and 3% replied as other sources.


  Discussion Top


Our study shows that though epidural test dose administration is a common practice, only 7% of respondents got the purpose right and the majority (72.1%) were partially right. About 9% of delegates could not differentiate between interpretation of test dose for thoracic and lumbar-placed epidural catheters.

The American Philosophical Association has defined CT as purposeful, self-regulatory judgment that uses cognitive tools.[10] Prerequisite for CT is knowledge, and CT should be viewed as a domain-specific construct that evolves as one which acquires domain-specific knowledge.[11] Epidural analgesia is used for variety of surgical procedures.[12] Among all methods available to identify malplacement, there is reasonable evidence to recommend the use of epidural test dose.[5],[6]

The components of the test dose include 45 mg of lidocaine with 15ug of adrenaline.[6] Since there are reservations about the use of epinephrine in pregnant patients, we restricted the use of test dose to adult and nonobstetric patients.[6] In our study, some delegates failed to mention adrenaline as a component of test dose but stated the role of test dose in detection of intravascular placement, suggesting a void in understanding basic principles. One may argue that this is just a reflection of lack of knowledge and not CT. The final-year students were included considering their clinical experience and optimum bookish knowledge attainted by that time frame; however, we agree that failure to mention adrenaline as part of the test dose could be just a reflection of lack of knowledge. To further analyze CT, we asked for expected results of a misplaced catheter at two different levels: thoracic and lumbar. We feel answering these questions rightly would involve deeper thinking. Although 46% of the delegates got the answers right with respect to lumbar catheter placement including the time of onset of intrathecal signs, only 9% of the students could analyze the difference in interpretation of results of test dose at these two levels.

The lumbar intrathecal block would present as motor weakness of lower limb within 4 min.[6],[7] In thoracic intrathecal block, motor component will not be clinically evident and early demonstrable sensory blockade in widespread dermatomes at congruent level should arouse suspicion of intrathecal placement. Most of the delegates gave similar answers for intrathecal placement at both levels as lower limb weakness, suggesting failure to analyze and interpret available knowledge in different scenarios. Although unexpected adverse side effects have been reported in literature,[13],[14] the aim of an epidural test dose is to avoid the consequences of injecting a critical amount of local anesthetic through a malplaced catheter.[6] Five respondents believed that cardiac arrest could occur after epidural test dose.

Learning engages two processes: deep and surface,[15] while deep learning focuses on true understanding of the topic and surface focuses on recall and superficial comprehension. It has been proposed that the student will use both the deep and surface learning depending upon the demands of the task, time available, guidance provided, and learning resources available.[15] In the last two decades, anesthesia specialty has changed its focus from the management of patient only in operation theater to encompass the wider responsibility of perioperative physician. At the same, time management of patients is becoming more protocolized and guidelines based which is probably taking away bedside thinking skills of students.[16] As teachers, we should help students develop their CT by creating an environment that promotes reasoning, analyzing the situation, implementing treatment, and reanalyzing the situation. It is probably time that we relook into our teaching practices. Active learning models which encourage students to meaningful listen, reflect on ideas, and view are the way ahead.[17] Learning strategies such as concept mapping and problem-based learning, which promote CT should be adapted.[17]

This knowledge-based survey is not without limitations. We did not use a pretested method such as Watson–Glaser Critical Thinking Appraisal to assess CT,[18] instead we asked students questions on a common clinical practice. Furthermore, our survey tool has not been formally validated. This design was deliberately selected as open-ended questions, as multiple-choice questions often fails to elicit students thought process.[19] Eighty percent of students answered positively in favor of the practice of test dose, suggesting that the selection of topic has been fair and relevant. Results of our study reveal that the current teaching program is probably more focused on superficial learning, and we might be losing out on “thinkers.”


  Conclusion Top


The knowledge regarding key components of the epidural test dose and CT about difference in the effect of test dose at various spinal segmental levels is lacking in the young anesthesiologists. Future research critically evaluating our current education process is probably the need of the hour.

Financial support and sponsorship

Departmental funding only.

Conflicts of interest

There are no conflicts of interest.


  Annexure Top


Annexure 1: Survey form

Please answer the following questions appropriately and honestly

  1. How many epidural catheters you site per week?


  2. Do you place thoracic epidural catheters? No Yes


  3. If yes, how many per month?

  4. Do you practice giving test dose before use of epidural? No Yes


  5. What is the purpose of epidural test dose?


  6. What drugs and dosages you use for epidural test dose in adult nonobstetric patient?


  7. What signs would you see in case of intrathecal placement of lumbar epidural catheter with respect of sensory symptoms and motor symptoms?


  8. What signs would you see in case of intravascular placement of lumbar epidural catheter with respect to Heart
  9. rate BP ECG

  10. What signs would you see in case of intrathecal placement of thoracic epidural catheter with respect of sensory symptoms and motor symptoms?


  11. What signs would you see in case of intravascular placement of thoracic epidural catheter with respect to Heart
  12. rate BP ECG

  13. Within how much time do you test for signs suggestive of intravascular placement?
  14. Within how much time do you test for signs suggestive of intrathecal placement?
  15. What is the source of your knowledge regarding test dose for epidural catheter placement? – from


□ Textbook □ seniors □ journal article □ others (please specify)

Thank you for filling the questionnaire. The information obtained from above survey may be used for medical writing. No personal information revealing identity has been asked for, ensuring anonymity.



 
  References Top

1.
Athari ZS, Sharif SM, Nasr AR, Nematbakhsh M. Assessing critical thinking in medical sciences students in two sequential semesters: Does it improve? J Educ Health Promot 2013;2:5.  Back to cited text no. 1
    
2.
Young JS, Smith RL, Guerlain S, Nolley B. How residents think and make medical decisions: Implications for education and patient safety. Am Surg 2007;73:548-53.  Back to cited text no. 2
    
3.
Papathanasiou IV, Kleisiaris CF, Fradelos EC, Kakou K, Kourkouta L. Critical thinking: The development of an essential skill for nursing students. Acta Inform Med 2014;22:283-6.  Back to cited text no. 3
    
4.
Sharples JM, Oxman AD, Mahtani KR, Chalmers I, Oliver S, Collins K, et al. Critical thinking in healthcare and education. BMJ 2017;357:j2234.  Back to cited text no. 4
    
5.
Gualdron LA. Test dose in regional anesthesia. Colomb J Anesthesiol 2014;42:47-52.  Back to cited text no. 5
    
6.
Guay J. The epidural test dose: A review. Anesth Analg 2006;102:921-9.  Back to cited text no. 6
    
7.
Colonna-Romano P, Padolina R, Lingaraju N, Braitman LE. Diagnostic accuracy of an intrathecal test dose in epidural analgesia. Can J Anaesth 1994;41:572-4.  Back to cited text no. 7
    
8.
Pratt S, Vasudevan A, Hess P. A prospective randomized trial of lidocaine 30 mg versus 45 mg for epidural test dose for intrathecal injection in the obstetric population. Anesth Analg 2013;116:125-32.  Back to cited text no. 8
    
9.
Moore DC, Batra MS. The components of an effective test dose prior to epidural block. Anesthesiology 1981;55:693-6.  Back to cited text no. 9
    
10.
American Philosophical Association. Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction. ERIC Document, ED. American Philosophical Association. ERIC Document, ED; 1990. p. 315-423.  Back to cited text no. 10
    
11.
National Research Council. Assessing 21st Century Skills: Summary of a Workshop. Washington, DC: The National Academies Press; 2011. Available from: https://doi.org/10.17226/13215. [Last accessed on 2020 Jan 27].  Back to cited text no. 11
    
12.
Nimmo SM. Benefit and outcome after epidural analgesia. Contin Edu Anaesth Crit Care Pain 2004;4:44-7.  Back to cited text no. 12
    
13.
Richardson MG, Lee AC, Wissler RN. High spinal anesthesia after epidural test dose administration in five obstetric patients. Reg Anesth 1996;21:119-23.  Back to cited text no. 13
    
14.
Palkar NV, Boudreaux RC, Mankad AV. Accidental total spinal block: A complication of an epidural test dose. Can J Anaesth 1992;39:1058-60.  Back to cited text no. 14
    
15.
Harasym PH, Tsai TC, Hemmati P. Current trends in developing medical students' critical thinking abilities. Kaohsiung J Med Sci 2008;24:341-55.  Back to cited text no. 15
    
16.
Berg M. Problems and promises of the protocol. Soc Sci Med 1997;44:1081-8.  Back to cited text no. 16
    
17.
Zayapragassarazan Z, Menon V, Kar SS, Batmanabane G. Understanding critical thinking to create better doctors. J Adv Med Edu Res 2016;1:9-13.  Back to cited text no. 17
    
18.
Frye B, Alfred N, Campbell M. Use of the Watson-Glaser critical thinking appraisal with BSN students. Nurs Health Care Perspect 1999;20:253-5.  Back to cited text no. 18
    
19.
Kim S, Spielberg F, Mauksch L, Farber S, Duong C, Fitch W, et al. Comparing narrative and multiple-choice formats in online communication skill assessment. Med Educ 2009;43:533-41.  Back to cited text no. 19
    



 
 
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