Improving safety, efficiency and efficacy of neuraxial blockade through enhanced operator peformance

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Kallidaikurichi Srinivasan, Karthikeyan
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University College Cork
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The objective of this thesis was to enhance operator performance to improve efficiency, safety and efficacy of neuraxial blocks. Methodology Efficiency In study 1 and 1a, a metric based assessment tool for labour epidural catheter placement was developed and validated. The effect of proficiency based progression training (PBP) in provision of labour epidural analgesia was then studied. Safety Study 2 was undertaken to improve the accuracy of palpated landmarks for administering spinal anaesthesia in patients undergoing caesarean section. Efficacy In study 3, clinically relevant association and correlation(s) between i. ultrasound images and ii. Magnetic Resonance Imaging (MRI) of lumbar spine was studied. In study 4a and 4b, landmark-guided midline approach was compared to pre-procedure ultrasound guided paramedian techniques in spinal anaesthesia. Results PBP (study 1, 1a, n=17) group had a significantly (p= 0.04) lower failure rate (13.3%) compared to simulation only group (28.7%). Study 2 (n=112) showed that inserting the spinal needle below the intercristal line significantly reduces the incidence of spinal anaesthesia performed at or above L2-3 interspace compared to at or above intercristal line (absolute risk reduction of 38.2%, p<0.001). In study 3 it was observed that the odds of obtaining a poor view in neuraxial ultrasound was seven times higher in the presence of facet joint degeneration (95% CI 1.7-28.9, p=0.007). Study 4a (n=100), it was observed that the number of passes to achieve successful dural tap was significantly lower in the ultrasound group (mean 4, SD 4) compared to the conventional group (mean 8.2, SD 12.3).In study 4b (n=120), we found no difference between groups in the number of passes or attempts to achieve successful dural puncture when L5S1 paramedian space was selectively used in the ultrasound group. Conclusion Significant improvements in safety, efficiency and efficacy of neuraxial blocks were demonstrated.
Neuraxial ultrasound , Spinal anaesthesia , Proficiency based progression , Labor epidural
Kallidaikurichi Srinivasan, K. 2016. Improving safety, efficiency and efficacy of neuraxial blockade through enhanced operator peformance. PhD Thesis, University College Cork.