title: Spinal anesthesia for orthopedic surgery: a detailed video assessment of quality.
abstract: BACKGROUND
  Subarachnoid blocks are considered routine anesthetic procedures important in the daily practices of most anesthesiologists. However, few data exist regarding modern failure rates or quality-compromising behaviors.
  
  
  METHODS
  Sixty adult patients having orthopedic surgery under spinal anesthesia were enrolled in this prospective and observational video study. Through a detailed high definition video review, we aimed to define our subarachnoid block failure rate and identify associated quality-compromising behaviors.
  
  
  RESULTS
  An intrathecal injection either failed to generate a surgical block or was aborted secondary to difficulty in 7 patients (11.6%). A procedurally difficult subarachnoid block occurred in 17 patients (29%). Eight patients required greater than 10 mins of needling to complete the subarachnoid block. Body mass index represented an independent risk factor for long procedure times. There were 27 incidences of quality-compromising behaviors that included likely violation of aseptic technique, hemorrhage, poor positioning, damaged needles, thecal sac transfixation, high-lumbar needle placement, repetition of previously failed maneuvers, failure to provide skin anesthesia, and prolonged procedure times. Certified registered nurse anesthetist status predicted a greater-than-4-fold risk of subarachnoid block failure.
  
  
  CONCLUSIONS
  The failure rate and quality-compromising behaviors identified in this study challenge the generalized assumption that performing a subarachnoid block in the orthopedic population is a simple procedure. The number and nature of the combined failed and difficult subarachnoid blocks suggest the need for quality improvement. Further research is needed to assess whether the use of image guidance may be a possible solution to navigate difficult anatomical pathology and confirm correct needle and drug placement.
authors: Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors: Jonathan
authors: J
authors: Weed
authors: Kevin
authors: K
authors: Finkel
authors: Michael L
authors: ML
authors: Beach
authors: Christopher B
authors: CB
authors: Granger
authors: John D
authors: JD
authors: Gallagher
authors: Brian Daniel
authors: BD
authors: Sites
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000775:Anesthesia, Spinal / Q000009:adverse effects* / Q000451:nursing; D015992:Body Mass Index; D016009:Chi-Square Distribution; D002983:Clinical Competence; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007278:Injections, Spinal; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009407:Nerve Block / Q000009:adverse effects* / Q000451:nursing; D009513:New Hampshire; D009719:Nurse Anesthetists; D019637:Orthopedic Procedures; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012044:Regression Analysis; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure; D014741:Video Recording