Accepted Manuscript Correspondence Evaluation of the Genesis Epidural-Spinal Injection Simulator M.A. Broom, G. Milne, E.M. McGrady PII: DOI: Reference:
S0959-289X(17)30306-0 http://dx.doi.org/10.1016/j.ijoa.2017.08.005 YIJOA 2607
To appear in:
International Journal of Obstetric Anesthesia
Accepted Date:
11 August 2017
Please cite this article as: Broom, M.A., Milne, G., McGrady, E.M., Evaluation of the Genesis Epidural-Spinal Injection Simulator, International Journal of Obstetric Anesthesia (2017), doi: http://dx.doi.org/10.1016/j.ijoa. 2017.08.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Evaluation of the Genesis Epidural-Spinal Injection Simulator
Teaching advanced technical skills to novice anaesthetists is challenging, particularly when there is a risk of significant complications.1 Equally, learning advanced technical skills, by practicing on patients, can be stressful for trainees and may impair performance.2 Simulation is increasingly used in medicine,3-5 is recognised by the Royal College of Anaesthetists in their curriculum6 and may play a role in addressing these issues. The Genesis Epidural-Spinal Injection Simulator7 is a part-task trainer which can be used to replicate both spinal and epidural anaesthesia. The model consists of a base section with integral iliac crests; and a removable vertebral core. The core has bony landmarks, ligaments (replicating supraspinous, interspinous and ligamentum flavum) and a tubular centre representing meninges, filled with pressurised saline ‘CSF’ (Fig. 1). We had previously evaluated the M43B Lumbar Puncture Simulator-II for training purposes,8-9 and felt that the Genesis back simulator might offer an even more realistic feel of anatomy when performing epidural and spinal anaesthesia. We wanted to formally evaluate this using the same methodology we had used previously. We sought local research ethics committee approval but it was deemed not necessary for this study. Consultant obstetric anaesthetists were asked to perform both spinal and epidural placement using the Genesis Epidural-Spinal Injection Simulator (Epimed, Dallas, Texas, USA). Structured feedback forms were completed immediately afterwards, grading the fidelity of the simulator for key aspects relating to the procedures using a Likert Scale (0-very unrealistic, 1-unrealistic, 2-neutral, 3-realistic and 4-very realistic). We also asked whether the model would be useful for training (0-strongly disagree, 1-disagree, 2-neutral, 3-agree, 4-strongly agree) and for free text comments. The simulator was prepared per the manufacturer’s instructions. All components were new at the start of the study. Manufacturers recommend a single core should provide good conditions for up to 500 uses. Consistent with local practice, epidural insertion was performed with an 18-gauge Tuohy needle (Portex Ltd, Hythe, Kent, UK) and a loss-of-resistance to saline technique. Spinal insertion was performed with a 25-gauge Sprotte (with 20-gauge introducer) needle (Pajunk UK Medical Products Ltd, Tyne & Wear, UK). Insertion
level was selected by the operator, with the simulator model offering spaces approximating to levels L3/4, L4/5 and L5/S1. Thirteen consultant obstetric anaesthetists completed both epidural and spinal components of the assessment and all provided feedback (Table 1). Ninety percent of the consultants rated loss-of-resistance to saline as realistic or very realistic. Dural puncture during spinal insertion was similarly rated by 70%. Free text comments were mainly positive. These included “nice and stable”; “improved, useful for practice and recognising ligamentum flavum” (compared to previously used back simulator model 7-8
); “excellent training tool”; “much more realistic ligamentum flavum and loss of
resistance” (compared to previously used back simulator model 7-8). There were three negative comments; “difficult to thread catheter”, “fluid was leaking around needle”, “quite realistic but slightly too elastic feel to tissues”. Results suggest that the Genesis Epidural-Spinal Injection Simulator provides realistic conditions for placement of epidural and spinal anaesthesia and will be a useful addition to training of anaesthetists. Although median scores for superficial anatomical aspects of the procedures were equivocal, the feel of the crucial deeper anatomy and overall impression were felt to be realistic. A clear majority felt the ligamentum flavum and subsequent loss of resistance, two of the most crucial aspects for teaching these techniques, were "realistic" or "very realistic". Overall most consultants "agreed" or "strongly agreed" that the simulator would be useful for training. Overall, these results compare favourably with a previous back simulator evaluation, using a different simulator model.8-9 We cannot make a direct comparison as we did not test both simulators together, however the assessment methodology was similar. We recommend the Genesis Epidural-Spinal Injection Simulator as a useful and realistic training aid in obstetric anaesthesia.
Acknowledgements Image is reproduced with permission from Epimed. The study wwas presented as poster at the congress Obstetric Anaesthesia 2017, Brussels, May 2017. No external funding and no competing interests are declared.
M.A. Broom, G. Milne, E.M. McGrady
Princess Royal Maternity Hospital, Glasgow Royal Infirmary, Glasgow, UK E-mail address: [email protected]
References 1. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009;102:179–90. 2. LeBlanc VR. The effects of acute stress on performance: implications for health professional’s education. Acad Med 2009;84:S25–33. 3. Cumin D, Weller JM, Henderson K, Merry AF. Standards for simulation in anaesthesia: creating confidence in the tools. Br J Anaesth 2010;105:45–51 4. Goodwin MW, French GW. Simulation as a training and assessment tool in the management of failed intubations in obstetrics. Int J Obstet Anesth 2001;10:273–7. 5. Salas E, Burke CS. Simulation for training is effective when… BMJ Qual Safety 2002;11:119–20 6. Curriculum for a CCT in Anaesthetics. Royal College of Anaesthetists 2010; http://www.rcoa.ac.uk/system/files/TRG-CU-CCT-ANAES2010.pdf 7. Genesis Epidural-Spinal Injection simulator. Epimed http://www.epimed.com/products/genesis-epidural-spinal-injector simulator/ 8. Uppal V, Kearns R, McGrady E. Evaluation of M43B Lumbar puncture simulator-II as a training tool for identification of the epidural space and lumbar puncture. Anaesthesia 2011;66:493-6. 9. M43B Lumbar Puncture Simulator-II. Limbs & Things https://www.limbsandthings.com/uk/our-products/category/procedure-lumbarpuncture
Table 1 Likert scores given by consultant anaesthetists for simulator realism (0-very unrealistic, 1-unrealistic, 2-neutral, 3-realistic, 4-very realistic).
Iliac Crest
Median
Range (IQR)
2
0-4 (2-3)
Spinous Process
3
1-4 (3)
Skin Puncture
2
0-3 (1-2)
Subcutaneous Tissue
2
0-3 (1-2)
Initial Ligaments
2
0-4 (2-3)
Ligamentum Flavum
3
0-4 (2-3)
Loss of Resistance
3
0-4 (3-4)
3
0-4 (2-3)
3
0-4 (2-3)
3
0-4 (2-3)
Overall Impression
3
0-4 (2-3)
Usefulness for
3
0-4 (3)
(epidural) Catheter Insertion (epidural) Dural Puncture (spinal) Intrathecal Injection (spinal)
Training
Fig. 1 The Genesis Epidural-Spinal Injection Simulator showing component parts including the removable vertebral core (both in-situ and removed) with tubular centre, pressurised using a saline-filled syringe.
S0959-289X(17)30306-0 http://dx.doi.org/10.1016/j.ijoa.2017.08.005 YIJOA 2607
To appear in:
International Journal of Obstetric Anesthesia
Accepted Date:
11 August 2017
Please cite this article as: Broom, M.A., Milne, G., McGrady, E.M., Evaluation of the Genesis Epidural-Spinal Injection Simulator, International Journal of Obstetric Anesthesia (2017), doi: http://dx.doi.org/10.1016/j.ijoa. 2017.08.005
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Evaluation of the Genesis Epidural-Spinal Injection Simulator
Teaching advanced technical skills to novice anaesthetists is challenging, particularly when there is a risk of significant complications.1 Equally, learning advanced technical skills, by practicing on patients, can be stressful for trainees and may impair performance.2 Simulation is increasingly used in medicine,3-5 is recognised by the Royal College of Anaesthetists in their curriculum6 and may play a role in addressing these issues. The Genesis Epidural-Spinal Injection Simulator7 is a part-task trainer which can be used to replicate both spinal and epidural anaesthesia. The model consists of a base section with integral iliac crests; and a removable vertebral core. The core has bony landmarks, ligaments (replicating supraspinous, interspinous and ligamentum flavum) and a tubular centre representing meninges, filled with pressurised saline ‘CSF’ (Fig. 1). We had previously evaluated the M43B Lumbar Puncture Simulator-II for training purposes,8-9 and felt that the Genesis back simulator might offer an even more realistic feel of anatomy when performing epidural and spinal anaesthesia. We wanted to formally evaluate this using the same methodology we had used previously. We sought local research ethics committee approval but it was deemed not necessary for this study. Consultant obstetric anaesthetists were asked to perform both spinal and epidural placement using the Genesis Epidural-Spinal Injection Simulator (Epimed, Dallas, Texas, USA). Structured feedback forms were completed immediately afterwards, grading the fidelity of the simulator for key aspects relating to the procedures using a Likert Scale (0-very unrealistic, 1-unrealistic, 2-neutral, 3-realistic and 4-very realistic). We also asked whether the model would be useful for training (0-strongly disagree, 1-disagree, 2-neutral, 3-agree, 4-strongly agree) and for free text comments. The simulator was prepared per the manufacturer’s instructions. All components were new at the start of the study. Manufacturers recommend a single core should provide good conditions for up to 500 uses. Consistent with local practice, epidural insertion was performed with an 18-gauge Tuohy needle (Portex Ltd, Hythe, Kent, UK) and a loss-of-resistance to saline technique. Spinal insertion was performed with a 25-gauge Sprotte (with 20-gauge introducer) needle (Pajunk UK Medical Products Ltd, Tyne & Wear, UK). Insertion
level was selected by the operator, with the simulator model offering spaces approximating to levels L3/4, L4/5 and L5/S1. Thirteen consultant obstetric anaesthetists completed both epidural and spinal components of the assessment and all provided feedback (Table 1). Ninety percent of the consultants rated loss-of-resistance to saline as realistic or very realistic. Dural puncture during spinal insertion was similarly rated by 70%. Free text comments were mainly positive. These included “nice and stable”; “improved, useful for practice and recognising ligamentum flavum” (compared to previously used back simulator model 7-8
); “excellent training tool”; “much more realistic ligamentum flavum and loss of
resistance” (compared to previously used back simulator model 7-8). There were three negative comments; “difficult to thread catheter”, “fluid was leaking around needle”, “quite realistic but slightly too elastic feel to tissues”. Results suggest that the Genesis Epidural-Spinal Injection Simulator provides realistic conditions for placement of epidural and spinal anaesthesia and will be a useful addition to training of anaesthetists. Although median scores for superficial anatomical aspects of the procedures were equivocal, the feel of the crucial deeper anatomy and overall impression were felt to be realistic. A clear majority felt the ligamentum flavum and subsequent loss of resistance, two of the most crucial aspects for teaching these techniques, were "realistic" or "very realistic". Overall most consultants "agreed" or "strongly agreed" that the simulator would be useful for training. Overall, these results compare favourably with a previous back simulator evaluation, using a different simulator model.8-9 We cannot make a direct comparison as we did not test both simulators together, however the assessment methodology was similar. We recommend the Genesis Epidural-Spinal Injection Simulator as a useful and realistic training aid in obstetric anaesthesia.
Acknowledgements Image is reproduced with permission from Epimed. The study wwas presented as poster at the congress Obstetric Anaesthesia 2017, Brussels, May 2017. No external funding and no competing interests are declared.
M.A. Broom, G. Milne, E.M. McGrady
Princess Royal Maternity Hospital, Glasgow Royal Infirmary, Glasgow, UK E-mail address: [email protected]
References 1. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009;102:179–90. 2. LeBlanc VR. The effects of acute stress on performance: implications for health professional’s education. Acad Med 2009;84:S25–33. 3. Cumin D, Weller JM, Henderson K, Merry AF. Standards for simulation in anaesthesia: creating confidence in the tools. Br J Anaesth 2010;105:45–51 4. Goodwin MW, French GW. Simulation as a training and assessment tool in the management of failed intubations in obstetrics. Int J Obstet Anesth 2001;10:273–7. 5. Salas E, Burke CS. Simulation for training is effective when… BMJ Qual Safety 2002;11:119–20 6. Curriculum for a CCT in Anaesthetics. Royal College of Anaesthetists 2010; http://www.rcoa.ac.uk/system/files/TRG-CU-CCT-ANAES2010.pdf 7. Genesis Epidural-Spinal Injection simulator. Epimed http://www.epimed.com/products/genesis-epidural-spinal-injector simulator/ 8. Uppal V, Kearns R, McGrady E. Evaluation of M43B Lumbar puncture simulator-II as a training tool for identification of the epidural space and lumbar puncture. Anaesthesia 2011;66:493-6. 9. M43B Lumbar Puncture Simulator-II. Limbs & Things https://www.limbsandthings.com/uk/our-products/category/procedure-lumbarpuncture
Table 1 Likert scores given by consultant anaesthetists for simulator realism (0-very unrealistic, 1-unrealistic, 2-neutral, 3-realistic, 4-very realistic).
Iliac Crest
Median
Range (IQR)
2
0-4 (2-3)
Spinous Process
3
1-4 (3)
Skin Puncture
2
0-3 (1-2)
Subcutaneous Tissue
2
0-3 (1-2)
Initial Ligaments
2
0-4 (2-3)
Ligamentum Flavum
3
0-4 (2-3)
Loss of Resistance
3
0-4 (3-4)
3
0-4 (2-3)
3
0-4 (2-3)
3
0-4 (2-3)
Overall Impression
3
0-4 (2-3)
Usefulness for
3
0-4 (3)
(epidural) Catheter Insertion (epidural) Dural Puncture (spinal) Intrathecal Injection (spinal)
Training
Fig. 1 The Genesis Epidural-Spinal Injection Simulator showing component parts including the removable vertebral core (both in-situ and removed) with tubular centre, pressurised using a saline-filled syringe.
