SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

DISSERTATION PROPOSAL

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON SPINAL ANESTHESIA COMPLICATION AMONG NURSES IN A SELECTED HOSPITALS AT BANGALORE

MEDICAL SURGICAL NURSING

SUBMITTED BY

NITHIN BABY N

MSc NURSING 1ST YEAR

JOSCO COLLEGE OF NURSING

NELAMANGALA

BANGALORE.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / NITHIN BABY N
: JOSCO COLLEGE OF NURSING
NELAMANGALA
BANGALORE
2 / NAME OF THE INSTITUTION / JOSCO COLLEGE OF NURSING
JOSCO NELAMANGALA
BANGALORE
3 / COURSE OF THE STUDY AND SUBJECT / M.Sc NURSING 1ST YEAR
MEDICAL AND SURGICAL NURSING
4 / DATE OF ADMISSION / 15/06/2009
5 / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON SPINAL ANESTHESIA COMPLICATION AMONG NURSES IN A SELECTED HOSPITALS AT BANGALORE

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR STUDY

Serious neurological complications after spinal anesthesia are rare, but do occur. The most common are post dural puncture headache and hypotension. Hypotension after spinal anesthesia is a physiological consequence of sympathetic blockade.

Bier while describing the first spinal anaesthetic also provided the first description of post dural puncture headache (PDPH). PDPH is one of the most common complications of neuraxial block, with an overall incidence that may be as high as 7 %1

Transient neurological symptoms (TNS) were first reported in 1993 by Schneider et al who described the development of severe radicular back pain after resolution of an uneventful, lidocain spinal anaesthetic. However, up to 30% of patients with TNS report severe pain2.

Incidence of neurologic central neuraxial blockade (CNB) complications is estimated to be between 1/1000 and 1/1,000,000. A very large survey of regional anaesthesia from France showed relatively low incidence of serious complications of regional anaesthesia6. The incidence of complications was higher for spinal than for epidural anesthesia. The majority of instances of fatal cardiac arrest could not be directly attributed to spinal anaesthesia. Eighty five percent of patients with neurological deficits had complete recovery within three months. These complications may be caused either due to mechanical injury from needle or catheter placement and /or adverse physiological responses and /or drug toxicity3.

Epidural abscess is a serious complication after neuraxial block. The incidence varies from 0.015% to 0.7% according to different studies4.

Epidural or spinal haematoma is a rare. The incidence of such hematomas has been estimated to be about 1:150,000 for epidural blocks and 1:220,000 for spinal anaesthetics5.

Recently Charuluxananan et al reported the incidence of cardiac arrest following spinal anaesthesia is 2.73/10000 patients6.

Spinal anesthesia medicine is injected into the fluid that surrounds the spinal cord (cerebrospinal fluid). The most common complication of spinal anesthesia is a headache caused by leaking of this fluid. With current techniques of giving spinal anesthesia, this occurs in about 1% to 2% of all people who have spinal anesthesia and is more common in younger people. A spinal headache may be treated quickly with a blood patch to prevent further complications. A blood patch involves injecting a small amount of the person's own blood into the area where the leak is most likely occurring to seal the hole and to increase pressure in the spinal canal and relieve the pull on the membranes surrounding the canal7.

A study investigated Incidence and prevention of Complications of regional anaesthesia

If there is significant risk of injury, then these techniques should be avoided. Central neural blockade (CNB) still accounts for more than 70% of regional anaesthesia procedures. Permanent neurological injury is rare (0.02 to 0.07%); however, transient injuries do occur and are more common (0.01 to 0.8%). Pain on injection and paraesthesiae while performing regional anaesthesia are danger signals of potential injury and must not be ignored. The incidence of systemic toxicity to local anaesthetics has significantly reduced in the past 30 years, from 0.2 to 0.01%. Peripheral nerve blocks are associated with the highest incidence of systemic toxicity (7.5 per 10 000) and the lowest incidence of serious neural injury (1.9 per 10 000. Severe bradycardia and even cardiac arrest have been reported in healthy patients following neuraxial anaesthesia, with a reported incidence of cardiac arrest of 6.4 per 10 000 associated with spinal anaesthesia8.

A study conducted on Determinants of learning to perform spinal anaesthesia. The aim was to identify key factors related to learning and teaching processes which were perceived to influence the acquisition of competence in spinal anaesthesia. The study was carried out at a busy acute tertiary referral teaching hospital over a period of 1 yr. It applied a qualitative research approach in three phases, namely (i) completion of preliminary questionnaires, (ii) completion of focused questionnaires and (iii) focus group discussions. The study highlighted the need for a formal and structured training programme in spinal anaesthesia, through which many of the undesirable and discouraging factors (such as stress, adverse trainer–trainee interaction and time constraints) identified in the study could be minimized. Further studies are needed to validate the results in other hospital settings, as well as to define the relative importance of each of the proposed determinants and their interrelationships9.

An article describes the Crisis management during regional anesthesia including peripheral nerve block, epidural anesthesia and spinal anesthesia. Common crisis which is encountered during regional anesthesia includes toxic reaction to local anesthetic drugs, allergic reaction induced by local anesthetic drugs, reaction induced by epinephrine, nerve injury, hematoma etc. Concerning peripheral nerve block, crisis encountered during brachial plexus block, interscalene block and supraclavicular block used for surgical operation of upper extremity was discussed. On the other hands, there are various common crises encountered during epidural anesthesia and spinal anesthesia. These crises include hypotension, bradycardia, total spinal anesthesia, post spinal headache and infection, and hematoma in the spinal canal. Especially, epidural hematoma and epidural abcess have possibility to cause nerve defect symptoms such as motor paralysis and sensory disturbance if appropriate treatment was not started in early stage. Moreover crisis such as cauda equina syndrome and anterior spinal cord syndrome have possibility to remain permanent and hard to cure. We anesthesiologists should make efforts to prevent crisis, to detect crisis in early stage, and to treat it in early stage10

All these review of literature and statistical analysis revealed that spinal anesthesia complication are very rare. But most of the complications are seen to be post dural puncture headache (PDPH, spinal abscess, and infection. And quality of nursing nurse needed for preventing these complication

Common complications of spinal anesthesia are infection, and hematoma, post dural puncture headache, bradycardia.. All researcher investigated nurses have great responsibility before; during and after spinal anesthesia so nurse should have more knowledge regarding this topic and also very less study conducted for increasing nurse’s knowledge regarding spinal anesthesia complication, motivate the researcher to do this study.

Evaluate the Structured teaching programme is the effective method for assessing the progress of nurses knowledge regarding spinal anesthesia complication The structured teaching programme included meaning, indications, uses, equipments setting, clinical interventions, complications and management and prevention The projected outcome of this study will be the knowledge of nurse’s increase after the structured teaching programme.

6.2 REVIEW OF LITERATURE

Review of literature provides basis for future investigations, justifies the need for replication, throws light up on feasibility of the study, and indicates constraints of data collection and help to relate findings of one another.

Review of literature is an integral component of any study or research project. It enhances the depth of knowledge and inspires a clear insight into the crux of the problems. Literature review throws light on the study and their finding reported about the problems under study.

A. STUDIES RELATED TO INCIDENCE

A study conducted on the Thai Anesthesia Incidents Study (THAI study) of morbidity after spinal anesthesia in a multi-centered registry of 40,271 anesthetics. The objective of the study was complications after spinal anesthesia. During the 12 month period (March 1, 2003 - February 28, 2004), a prospective multicentered descriptive study was conducted in 20 hospitals comprised of seven university, five tertiary, four general and four district hospitals across Thailand Anesthesia personnel filled up patient-related, surgical-related, and anesthesia-related variables and adverse outcomes of all consecutive patients receiving anesthesia on a structured data entry form. The data were collected during pre-anesthetic, intra-operative, and 24 hr post operative period Adverse event specific forms were used to record when these incidents occurred. This was registry of 40,271 spinal anesthetics from 172,697 anesthetics. The incidence of total spinal anesthesia, neurological complications, suspected myocardial ischemia, or infarction and oxygen desaturation per 10000 spinal anesthetics were 3.48 (95% CI 1.66-5.30), 1.49 (95% CI 0.30-2.68), 2.73 (95% CI 1.12-4.35), 0.99 (95% CI 0.39-2.56), and 6.46 (95% CI 3.98-8.94) respectively11

A prospective cohort study was performed in 800 parturients undergoing elective caesarean section under spinal anaesthesia from May 2005 to April 2006 in a large maternity hospital in Singapore, in order to determine the incidence of and risk factors for total and partial failure of spinal anaesthesia. A routine single-shot spinal technique using intrathecal 0.5% heavy bupivacaine 2.0 mL (10 mg) and morphine 100 microg was administered with a 27-gauge Whitacre spinal needle via a 20-gauge introducer. Demographic, surgical and anaesthetic data were collected to determine risk factors for failure of spinal anaesthesia. Results was Incidence of total failure requiring conversion to general anaesthesia was 0.5% (4 cases) in which three cases had inadequate block (loss of sensation to cold less than T6) and one case had no sensory block. Thirty-three parturients (4.1%) required intravenous fentanyl and seven (0.9%) required Entonox for intraoperative analgesic supplementation. Postpartum sterilization was an independent risk factor for partial failure requiring intravenous fentanyl and Entonox.12

A study conducted on incidence of postdural puncture headache remains a major complication of subarachnoid anaesthesia that bothers the anaesthetist and the young mother. Identification of factors that may affect PDPH after caesarean section under subarachnoid anaesthesia could be critical to policy formulation in an emerging obstetric anaesthesia unit. Only patients in whom 25G Quincke needles were employed for lumbar puncture were recruited for analysis. Patients who met criteria for postdural puncture headache were interviewed on postoperative day 3. The PDPH was further characterized to establish the time of onset, location of headache, limitation of activity of daily living, and methods of management. A total of 119 patients had lumbar puncture for spinal anaesthesia. Spinal anaesthesia was successful in 112 patients, inadequate in 6 patients and failed in one. Twenty-seven patients (22.7%) developed PDPH. There was no difference in the demographic features in the patients who developed PDPH and those without headache. Clinical variables like site and number of attempts at dural puncture (p = 0.82. Chi-square test), traumatic attempts. parasthesia and volume of bupivacaine were not found to be determinants of PDPH. Successful dural puncture was achieved on first attempt in 42.0% (n = 47) of the patients13. .

A study examines on Neurological Complications After Regional Anesthesia and Contemporary Estimates of Risk Regional anesthesia (RA) provides excellent anesthesia and analgesia for many surgical procedures. Anesthesiologists and patients must understand the risks in addition to the benefits of RA to make an informed choice of anesthetic technique. Researchers reviewed all 32 studies published between January 1, 1995 and December 31, 2005 where the primary intent was to investigate neurological complications of Regional anesthesia. The sample size of the studies that investigated neurological complications after central and peripheral (PNB) nerve blockade ranged from 4185 to 1,260,000 and 20 to 10,309 blocks, respectively. The rate of neuropathy after spinal and epidural anesthesia was 3.78:10,000 (95% CI: 1.06–13.50:10,000) and 2.19:10,000 (95% CI: 0.88–5.44:10,000), respectively. For common PNB techniques, the rate of neuropathy after inter scalene brachial plexus block, axillary brachial plexus block, and femoral nerve block was 2.84:100 (95% CI 1.33–5.98:100), 1.48:100 (95% CI: 0.52–4.11:100), and 0.34:100 (95% CI: 0.04–2.81:100), respectively. The rate of permanent neurological injury after spinal and epidural anesthesia ranged from 0–4.2:10,000 and 0–7.6:10,000, respectively14.

B. STUDIES RELATED COMPLICATIONS

A study conducted on shivering complication of spinal anesthesia. The objective of the study was Post operative shivering is a complication commonly observed in post spinal anesthesia. For prevention and treatment of this complication different drugs are used. This study evaluated the effects of tramadol for post operative shivering prevention in parturients carried out by help of spinal anesthesia (SA) for cesarean section. In this randomized double blind cross-sectional study, 90 patients who were candidates for cesarean section with American Society of Anesthesiologist (ASA) I or II, from April 2005 until February 2006 were randomly allocated to one of two groups (study and control). All patients underwent spinal anesthesia. Near the end of operation, 1mg/kg tramadol in 20ml (diluted by normal saline) to study group and 20ml of normal saline to control group was slowly injected intravenously. Patients were evaluated regarding their hemodynamic signs, arterial oxygen saturation percentage, oral temperature, presence and intensity of shivering and nausea and vomiting. Collected data was analysed by using of Chi-square test. This study concluded that Tramadol is an effective drug in prevention of post spinal anesthesia shivering. In addition, this does not lead to any hemodynamic complications. As such drug is safe and effective for prevention of post spinal anesthesia shivering15.

A randomized study explains does anesthesia cause postoperative cognitive dysfunction among 438 elderly patients. Postoperative cognitive dysfunction (POCD) is a common complication after cardiac and major non-cardiac surgery with general anaesthesia in the elderly. We hypothesized that the incidence of Postoperative cognitive dysfunction would be less with regional anaesthesia rather than general. We included patients aged over 60years undergoing major non-cardiac surgery. After giving written informed consent, patients were randomly allocated to general or regional anaesthesia. Cognitive function was assessed using four neuropsychological tests undertaken preoperatively and at 7days and 3months postoperatively. Results wasat 7days, Postoperative cognitive dysfunction was found in 37/188 patients (19.7%, [14.3–26.1%]) after general anaesthesia and in 22/176 (12.5%, [8.0–18.3%]) after regional anaesthesia, After 3months, Postoperative cognitive dysfunction was present in 25/175 patients (14.3%, [9.5–20.4%]) after general anaesthesia vs. 23/165 (13.9%, [9.0–20.2%]) after regional anaesthesia, The incidence of Postoperative cognitive dysfunction after 1week was significantly greater after general anaesthesia when we excluded patients who did not receive the allocated anaesthetic16.