- Email: [email protected]
The ‘Epibox’: a simple tool to train epidural injection technique in small animals
Accepted Manuscript The “Epibox”: a simple tool to train epidural injection technique in small animals Yves Moens, Hendrik Lehmann PII:
S1467-2987(17)30151-4
DOI:
10.1016/j.vaa.2016.06.010
Reference:
VAA 139
To appear in:
Veterinary Anaesthesia and Analgesia
Received Date: 3 March 2016 Revised Date:
24 May 2016
Accepted Date: 21 June 2016
Please cite this article as: Moens Y, Lehmann H, The “Epibox”: a simple tool to train epidural injection technique in small animals, Veterinary Anaesthesia and Analgesia (2017), doi: 10.1016/ j.vaa.2016.06.010. 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.
ACCEPTED MANUSCRIPT
LETTER TO THE EDITOR
RI PT
The “Epibox”: a simple tool to train epidural injection technique in small animals
Epidural drug administration is now common in veterinary medicine (Jones 2001). In dogs or cats the epidural space is commonly entered through the lumbosacral foramen. The needle tip
SC
is positioned correctly in the epidural space by using bony landmarks to guide needle
insertion and the “pop” sign when the needle passes through the ligamentum flavum. The
M AN U
technique is technically challenging and can be difficult to teach, because the feel of the needle passing through the relevant tissues is difficult to describe. Learning epidural injection technique on client-owned animals is ethically questionable. An alternative would be to use
TE D
fresh or preserved animal cadavers but these are expensive and in short supply.
In human medicine, training using epidural models has substantial advantages (Vaughan et al. 2013). Unfortunately such models are expensive and do not reproduce the anatomy of
EP
small animals. However in addition to formal training models, some cheap and simple devices have been proposed as teaching aids (Leighton 1989; Raj et al. 2013). Initial epidural
AC C
training using models would also be desirable in veterinary medicine. We know of no commercially available devices, but we were inspired by the simple training devices used in human teaching and developed a simple training tool - the “Epibox” – which uses readily available, inexpensive materials (Fig. 1).
The Epibox is designed to teach identification of landmarks and provide the sensation of ‘the pop’ and loss or lack of resistance. It consists of a plastic box filled with firm polyurethane foam and covered with a removable commercially available animal skin-like fabric (faux 1
ACCEPTED MANUSCRIPT leather). The plastic cover of the box is moulded to imitate three specific bony landmarks and is pierced at the place of the lumbosacral foramen. Self-adhesive photographs of the relevant bony structures are attached to the inside and outside of the cover. The polyurethane “body” has a central cavity where a banana is placed and which also serves to collect injection fluid.
RI PT
The fruit was chosen by asking experienced veterinarians, unaware of the fruit to be tested, to test four different types of fruit placed in a similar box (kiwi, lemon, banana, clementine). In training, the student first has to locate the lumbosacral foramen on basis of palpation of the
SC
landmarks. During needle insertion the Epibox materials mimic passage through the skin, subcutaneous tissue, interarcuate ligament and the final passage through the ligamentum
M AN U
flavum, with the pop sign caused by the needle tip emerging through the distal banana skin. An alternative process can be modelled using a syringe connected to the epidural needle, giving the feel of loss of resistance to injection to air or saline.
The costs of the Epibox are small. The banana is single use and the skin-like fabric on the
TE D
cover may be easily replaced.
Training with this simple model helps the student to become familiar with the sensations found in clinical practice, with spinal landmarks, and improves confidence when clinical
EP
procedures are done. We did not attempt a controlled study to verify these benefits, but it would be reasonable to expect that prior use of the model would 1) facilitate subsequent
AC C
learning and may improve confidence and encourage use of the epidural technique, 2) improve success rate, and 3) reduce possible complications (Freedman et al. 2009). We wish to popularise an affordable training tool and also encourage formal testing of the device to demonstrate the above proposed benefits.
Yves Moens and Hendrik Lehmann Anaesthesiology and perioperative Intensive Care, University of Veterinary Medicine, Vienna 2
ACCEPTED MANUSCRIPT Email: [email protected]
References Freedman Z, Siddiqui N, Katzelson R, Devito I, Bould M, Naik V (2009) Clinical impact of
fidelity model training. Reg Anesth Pain Med 34, 229-232.
RI PT
epidural anesthesia simulation on short- and long-term learning curve: high- versus low-
SC
Jones RS (2001) Epidural analgesia in the dog and the cat- a review. Vet J 161, 123-131.
M AN U
Leighton B (1989) A greengrocer’s model of the epidural Space. Anesthesiology 70, 368– 369.
Raj D, Williamson RM, Young D, Russell D (2013) A simple epidural simulator. A blinded
TE D
study assessing the “feel” of loss of resistance in four fruits. Eur J Anaesthesiol 30, 405-408.
Vaughan N, Dubey VN, Wee MYK, Isaacs R (2013) A review of epidural simulators: where
AC C
EP
are we today? Med Eng Phys 35, 1235–1250.
3
ACCEPTED MANUSCRIPT Figure 1 Left: the Epibox with open cover featuring a banana, a syringe and an epidural needle, Right from top to bottom: the Epibox with closed cover and folded back fabric showing a picture to facilitate landmark identification; palpation of landmarks with epidural needle placement for pop sensation; use of a syringe with saline for loss and lack of
AC C
EP
TE D
M AN U
SC
RI PT
resistance testing.
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
5
S1467-2987(17)30151-4
DOI:
10.1016/j.vaa.2016.06.010
Reference:
VAA 139
To appear in:
Veterinary Anaesthesia and Analgesia
Received Date: 3 March 2016 Revised Date:
24 May 2016
Accepted Date: 21 June 2016
Please cite this article as: Moens Y, Lehmann H, The “Epibox”: a simple tool to train epidural injection technique in small animals, Veterinary Anaesthesia and Analgesia (2017), doi: 10.1016/ j.vaa.2016.06.010. 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.
ACCEPTED MANUSCRIPT
LETTER TO THE EDITOR
RI PT
The “Epibox”: a simple tool to train epidural injection technique in small animals
Epidural drug administration is now common in veterinary medicine (Jones 2001). In dogs or cats the epidural space is commonly entered through the lumbosacral foramen. The needle tip
SC
is positioned correctly in the epidural space by using bony landmarks to guide needle
insertion and the “pop” sign when the needle passes through the ligamentum flavum. The
M AN U
technique is technically challenging and can be difficult to teach, because the feel of the needle passing through the relevant tissues is difficult to describe. Learning epidural injection technique on client-owned animals is ethically questionable. An alternative would be to use
TE D
fresh or preserved animal cadavers but these are expensive and in short supply.
In human medicine, training using epidural models has substantial advantages (Vaughan et al. 2013). Unfortunately such models are expensive and do not reproduce the anatomy of
EP
small animals. However in addition to formal training models, some cheap and simple devices have been proposed as teaching aids (Leighton 1989; Raj et al. 2013). Initial epidural
AC C
training using models would also be desirable in veterinary medicine. We know of no commercially available devices, but we were inspired by the simple training devices used in human teaching and developed a simple training tool - the “Epibox” – which uses readily available, inexpensive materials (Fig. 1).
The Epibox is designed to teach identification of landmarks and provide the sensation of ‘the pop’ and loss or lack of resistance. It consists of a plastic box filled with firm polyurethane foam and covered with a removable commercially available animal skin-like fabric (faux 1
ACCEPTED MANUSCRIPT leather). The plastic cover of the box is moulded to imitate three specific bony landmarks and is pierced at the place of the lumbosacral foramen. Self-adhesive photographs of the relevant bony structures are attached to the inside and outside of the cover. The polyurethane “body” has a central cavity where a banana is placed and which also serves to collect injection fluid.
RI PT
The fruit was chosen by asking experienced veterinarians, unaware of the fruit to be tested, to test four different types of fruit placed in a similar box (kiwi, lemon, banana, clementine). In training, the student first has to locate the lumbosacral foramen on basis of palpation of the
SC
landmarks. During needle insertion the Epibox materials mimic passage through the skin, subcutaneous tissue, interarcuate ligament and the final passage through the ligamentum
M AN U
flavum, with the pop sign caused by the needle tip emerging through the distal banana skin. An alternative process can be modelled using a syringe connected to the epidural needle, giving the feel of loss of resistance to injection to air or saline.
The costs of the Epibox are small. The banana is single use and the skin-like fabric on the
TE D
cover may be easily replaced.
Training with this simple model helps the student to become familiar with the sensations found in clinical practice, with spinal landmarks, and improves confidence when clinical
EP
procedures are done. We did not attempt a controlled study to verify these benefits, but it would be reasonable to expect that prior use of the model would 1) facilitate subsequent
AC C
learning and may improve confidence and encourage use of the epidural technique, 2) improve success rate, and 3) reduce possible complications (Freedman et al. 2009). We wish to popularise an affordable training tool and also encourage formal testing of the device to demonstrate the above proposed benefits.
Yves Moens and Hendrik Lehmann Anaesthesiology and perioperative Intensive Care, University of Veterinary Medicine, Vienna 2
ACCEPTED MANUSCRIPT Email: [email protected]
References Freedman Z, Siddiqui N, Katzelson R, Devito I, Bould M, Naik V (2009) Clinical impact of
fidelity model training. Reg Anesth Pain Med 34, 229-232.
RI PT
epidural anesthesia simulation on short- and long-term learning curve: high- versus low-
SC
Jones RS (2001) Epidural analgesia in the dog and the cat- a review. Vet J 161, 123-131.
M AN U
Leighton B (1989) A greengrocer’s model of the epidural Space. Anesthesiology 70, 368– 369.
Raj D, Williamson RM, Young D, Russell D (2013) A simple epidural simulator. A blinded
TE D
study assessing the “feel” of loss of resistance in four fruits. Eur J Anaesthesiol 30, 405-408.
Vaughan N, Dubey VN, Wee MYK, Isaacs R (2013) A review of epidural simulators: where
AC C
EP
are we today? Med Eng Phys 35, 1235–1250.
3
ACCEPTED MANUSCRIPT Figure 1 Left: the Epibox with open cover featuring a banana, a syringe and an epidural needle, Right from top to bottom: the Epibox with closed cover and folded back fabric showing a picture to facilitate landmark identification; palpation of landmarks with epidural needle placement for pop sensation; use of a syringe with saline for loss and lack of
AC C
EP
TE D
M AN U
SC
RI PT
resistance testing.
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
5