ANZCA Bulletin June 2011 - Australian and New Zealand College of ...

From left: Dr Nico Terblanche
demonstrates preprocedural neuraxial
ultrasound probe orientations on a
pregnant model; The probe is held in the
transverse plane; The scan is performed
in the paramedian sagittal oblique plane.
“ An audit of my high-risk
obstetric anaesthesia
practice over three years
(2006-2008) revealed that
150 women had a body
mass index (BMI) of more
than 45.”
The challenges for practitioners
posed by obesity are not confined to
urban Africa where urbanisation has
diet and weight gain implications,
or to the fast-food society of North
America. The obesity epidemic is now in
Australian living rooms with more than
20 per cent of the population classified
as obese.
When I moved to Canberra, the
anaesthesia department at Calvary
Hospital was very supportive of giving
me the time and opportunity to teach
and research ultrasound-guided
epidurals and I focused on teaching the
technique to anaesthesia trainees. This
is the cohort with the highest prevalence
of dural punctures of around 1.4 per
cent as previous Australian research has
shown 3 .
Research also has shown that
ultrasound can improve the learning
curve of trainees successfully
performing epidurals 4 . However, a
national audit of training practices
in Australia by my Canberra Hospital
colleague Dr Dane Blackford and myself
in 2009 (73 per cent response rate;
unpublished data) showed that none
of the obstetric module supervisors
who responded were using epidural
ultrasound for training purposes despite
ultrasound being readily available from
theatre, especially in urban centres.
This may have improved slightly
subsequently.
The reason for this is probably a
lack of a critical mass of anaesthetists
and programs teaching the technique.
So how can we promote epidural
ultrasound and in the process advance
practice I have developed a fourpronged
approach:
1. Creating awareness: Doing
departmental and anaesthetic
meeting presentations. A national
survey that we conducted created
awareness among obstetric
anaesthesia supervisors.
2. Distributing and creating material
on how to perform the technique:
Anaesthetist colleague Dr Rowena
Lawson helped me to develop and
validate an epidural ultrasound
training program 5 , a narrated
Powerpoint presentation of “the 10
easy steps to performing epidural
ultrasound”.
3. Hands-on teaching: This includes
one-on-one teaching on caesarean
delivery lists, departmental
workshops in the Royal Hobart
Hospital and on invitation in
Tasmania and elsewhere.
4. Conducting and publishing research
in the area of neuraxial ultrasound in
order to advance the technique and
improve the safety of our patients.
There is also a perception that
neuraxial ultrasound is an advanced
ultrasonography technique that only
a few can perform. Although it is true
that in order to perfect the technique it
will take a lot of practice, we know that
it is possible to recognise important
neuraxial structures and perform
important tasks successfully after only
a couple of scans.
A Canberra Hospital colleague,
Dr Andrew Deacon, helped me with a
study where we aimed to establish the
number of practice scans required to
reach competency in three important
components of pre-procedural epidural
ultrasound. We showed that the
five trainees who participated could
accurately identify the specified lumbar
interspace and also the distance from
the skin to the ligamentum flavum
within 20 scans 6 . Consistent with
previous research we showed that it was
much more difficult to accurately mark
the needle insertion point 7 .
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ANZCA Bulletin June 2011 43