Perfecting Spinal Injections
With over 50% of pregnant women requesting epidural pain relief during their labor, it’s no wonder that there is an increasing need for medical staff to be trained to deliver accurate & safe spinal injections.
Epidural injections are used in a variety of medical circumstances for the administration of anaesthetics and to determine diagnoses.
It was American neurologist James Leonard Corning who, in 1885, was the first to inject 111mg of cocaine into the epidural space of a healthy male volunteer. Although, it was later noted that he had originally thought he was injecting the drugs into the subarachnoid space. It was not until 1921 that Fidel Pagés developed the ‘single-shot’ technique whilst performing lumbar epidural anaesthesia. This procedure was later adopted and popularised by Italian surgeon Achille Mario Dogliotti.
Continuous caudal anaesthesia with an indwelling needle was only developed in the 1940’s with the help of Robert Hingson and Waldo Edwards. Women in labour only received the benefit of pain relief via epidural injections from 1942.
Caudal blocks (via the sacral area) are rarely used these days due to their requirement for higher doses of anaesthetic and because they are technically much more difficult to administer. There is also the risk of accidentally inserting the needle and anaesthetic into the baby’s head. Therefore, the lumbar area of the woman’s spine is the preferred administration point.
Due to higher levels in medical training, epidurals became significantly more popular during the 1970’s. Obstetricians were more adept at dealing with the procedure and any associated side effects. As these health care professionals became more likely to use epidurals, women also became more likely to ask for them for pain relief, which, in turn, increased their popularity.
Lidocaine and bupivacaine are both ‘local’ types of anaesthetics used primarily during the 1990’s for epidurals during labor. However, today the doses used are much lower than those used back then. In the past, doses were more likely to be similar to the doses need for surgical operations such as Caesareans. The problems that women encountered were that the drugs numbed almost all her sensations during labour and made it far harder for her to ‘push’ her baby out.
Today lighter doses of ‘local’ anaesthetic (eg 0.25% lidocaine or 0.125% bupivacaine) are used. Sometimes these are mixed with narcotic medications such as Fentanyl, Morphine or Pethidine to help reduce some of the side effects experienced.
To ensure that the administration of epidural anaesthesia is done safely and effectively, it is useful to refer to the four p’s – preparation, position, projection and puncture.
- Prepare the patient with relevant information and set their expectations,
- Accurate positioning is essential – which will you use: lateral decubitus, sitting or prone?
- Identification of midline and depth required to assess projection
- Hanging drop technique to assist puncture
As with any medical procedure it’s important to be taught what can go wrong and how to deal with the consequences:
- Bone can be encountered by the needle
- Inability to thread the catheter
- Fluid returns through the needle
- Blood returns in the catheter or needle
- Patient feels pain due to needle insertion
- Patient feels pain as epidural catheter is inserted
- Injection pain
Epidural and spinal injection trainers from 3B Scientific provide extremely realistic haptic feeback and the use of high-quality, hard-wearing materials. These simulators have been developed in close cooperation with epidural anaethesia specialists in settings that have been deemed as realistic as possible. Giving the opportunity to train health professionals in safe procedures is essential in continuing high quality patient care.
Do you have access to epidural and spinal injection trainers? What lessons do you think are the most important when training new medical professionals with these procedures?