A Structured Method of Teaching Epidural Block reduces the incidence of accidental dural puncture in inexperienced trainees.

Background: The rate of accidental dural puncture is particularly high during the period of training, especially in novices. The structured epidural teaching model (SETM) includes three standardized video lessons, the construction of a 3D epidural module by trainees and practical training by using an epidural simulator with and without the CompuFlo™ Epidural instrument. In this study we report the retrospective analysis of the accidental dural puncture rate of inexperienced trainees during their 6 months clinical practice rotation in obstetrics before and after the introduction of the SETM in our Institution. Method: We evaluated the incidence of accidental dural puncture before the introduction of the SETM methodology and afterwards by analyzing our departmental database from February 2019 to January 2023. All epidural blocks were executed by trainees who had never previously performed an epidural block and were about to begin their obstetrics rotation. Results: We analyzed 7415 epidurals: 3703 were performed before the introduction of the SETM methodology (control group) and 3712 afterwards (study group). The incidence of accidental dural puncture was 0.37% for the control group and 0.13% for the study group (p<.05). The probability of making an accidental dural puncture was 64% (OR: 0.36) lower for trainees who had the training than for those who did not. Conclusions: After the introduction of the structured teaching method, we observed a significant reduction of accidental dural puncture during the training period. We hope that our observation will encourage a constructive discussion among experts about the need to use standardized and validated tools as a valuable aid in teaching epidural anesthesia.

Eye Movement Modeling Examples as a Teaching Tool for Epidural Block

Introduction: Video examples with task demonstrations by experts, with the expert’s eye movements superimposed on the task, are known as “eye movement modeling examples” (EMME). We performed this study to evaluate if there were improvements in the performance of anesthesia novice trainees when executing the epidural technique after an EMME of epidural block procedure. Methods: We developed an eye movement modeling example (EMME) from eye tracking recordings made by experienced anesthesiologists with more than 20 years of experience. Forty-two PGY3 anesthesia trainees who had never previously performed an epidural block were randomized to receive (study group) or not receive (control group) the EMME video before their institutional training. All the trainees were evaluated every 10 epidural blocks until the end of the rotation period, by an independent, blinded observer using the Global Rating Scale for Epidural Anesthesia (GRS). Results: Trainees who received the EMME training exhibited more respect for the patient’s tissues (P Discussion: This is the first study that has used the EMME for a practical, clinical teaching purpose on real patients and that has used it as an aid in teaching epidural anesthesia. We demonstrated that inexperienced trainees who received the EMME training improved their proficiency at epidural blocks as compared to those who had no EMME training beforehand. Given this result, we welcome further studies to investigate the impact and the role of EMME on clinical teaching in the field of anesthesia.

Changes in Gaze Behavior during the Learning of the Epidural Technique with a Simulator in Anesthesia Novices

Background: Current literature demonstrates the ability of eye tracking to provide reliable quantitative data as an objective assessment tool, with potential applications to medical and surgical training to improve performance. Objective: The aim of this study was to evaluate the changes in gaze behavior in anesthesia novice trainees when performing a simulated epidural technique before and after a hands-on training on the epidural simulator. Methods: We enrolled 48 novice trainees who had never previously performed an epidural block. After a standardized learning module, each trainee practiced the epidural procedure on the epidural simulator while wearing a pair of eye tracking glasses (Tobii Pro Glasses 50 Hz wearable wireless eye tracker). After this baseline recording, each trainee spent two hours practicing with the epidural simulator and afterwards once again performed the eye tracking epidural procedure. Eye tracking metrics and epidural learning (duration of the procedure and number of attempts) before and after the simulated practice were recorded. Results: The duration of the epidural procedure and of the epidural needle advancement phase (P < 0.05) and the number of epidural attempts (P < 0.001) were reduced after the tutorial. When considering the eye tracking metrics, after the tutorial, the number of visit counts decreased and their duration increased (P < 0.05). The number of epidural needle insertions (additional attempts) showed a significant positive correlation with the visits number (aOR = 2.02 (95% CI = 1.26 - 3.55;P = 0.008)) and a significant negative correlation with the visit duration (aOR = 0.65 (95% CI = 0.39 - 0.99;P = 0.05)). Conclusion: We observed significant changes in gaze behavior associated with increased performance during the epidural technique learning with a simulator in anesthesia trainees who had never previously performed an epidural block. These results may create a prototype for future studies on eye tracking technique as a teaching and evaluating tool in simulation.

Accuracy of the SpineNav3DTM Ultrasound Technology in Estimating the Epidural Space Depth for Epidural and Spinal Insertion in Pregnant Obese Patients

Introduction: Ultrasound facilitates neuraxial puncture in obese parturients. Unfortunately, the widespread adoption of neuraxial ultrasound may be limited by the lack of technical expertise or the limited availability of the equipment. A wireless portable ultrasound device (Accuro, Rivanna Medical, Charlottesville, VA) with automated pattern recognition software (SpineNav3DTM technology) has been introduced to obtain the automated real-time identification of interspaces and epidural depth. The primary objective of this study was to assess the accuracy of the SpineNav3DTM ultrasound technology (Accuro) in estimating the epidural space depth compared to the standard ultrasound examination in pregnant obese patients. The secondary aim was to compare the ultrasound measurements with the measured needle depth during epidural and spinal insertion. Methods: The study was conducted at S Gerardo Hospital, Monza, Italy from March 2021 to April 2021. Obese laboring women requesting epidural analgesia or undergoing elective cesarean delivery under spinal anesthesia were recruited. All the subjects had their lumbar area scanned for the measurements of the depth of the epidural space by the SpineNav3DTM ultrasound technology and by the standard US and then both compared with the needle insertion depth in a double-blind fashion. Results: Forty-eight women were enrolled in the study. There was agreement (±0.25 cm) between the epidural depth (in cm) measured with the Accuro, versus the standard ultrasound. There was a significant difference between the mean depth of epidural space s measured by Accuro or Standard US and needle insertion depth (P < 0.001). Conclusions: The handheld ultrasound system with 3D spine navigation technology can automatically identify and measure the epidural depth with the same accuracy as the standard ultrasounds in obese pregnant women.

Confirmation of Epidural Catheter Location by Epidural Pressure Waveform Recordings by the Compuflo^&reg;Cath-Checker System

Background: Pulsatile waveforms originating from the spinal cord and transmitted through the dura in synchrony with heart rate have been used to confirm the epidural location of the catheter. Lumbar epidural space identification using the CompuFlo? instrument has been reported and validated. The aim of this preliminary study was to evaluate the new CompuFlo instrument which allows the identification of pulsatile waveform recordings. Methods: We tested 30 epidural catheters previously successfully used for post cesarean analgesia and about to be removed. All patients were given 5 mL 2% lidocaine to test the catheter before its removal. After priming with 5 mL saline, the catheter was connected to CompuFlo? to record the occurrence of pulsatile waveforms and/or their disappearance during its removal. Results: Pulsatile waveforms were observed in all the catheters properly located in the epidural space and disappeared when the catheter was extracted from the epidural space. No waveforms were recorded in 2 cases in which no sensory block occurred after the test dose (catheter dislodgement). The pressure waveform analysis through the epidural catheter had a sensitivity of 100%, a positive predictive value of 100%, a specificity of 100% and a negative predictive value of 100%. Conclusions: In this preliminary trial pulsatile pressure waveform recording with CompuFlo? CathCheck? System through the epidural catheter resulted in high sensitivity and positive predictive value.