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Psoas compartment block (PCB) in children: Part II--generation of an institutional learning curve with a new
1International Research Center, UZ Gent, University of Gent, Gent, Belgium.
Insights
Implementing pediatric psoas compartment blocks (PCB) requires significant experience. Even with a new technique, achieving a high success rate with strict criteria necessitates over 100 procedures for institutional learning.
Area of Science:
- Pediatric Anesthesiology
- Regional Anesthesia
- Pain Management
Background:
- Limited literature exists on institutional learning for pediatric anesthesia procedures.
- Psoas compartment blocks (PCB) in children have only recently been reported in small series.
- This study introduces a new technique and analyzes the institutional learning curve for PCB in pediatric patients.
Purpose of the Study:
- To evaluate the institutional learning process for performing psoas compartment blocks (PCB) in pediatric patients.
- To assess the effectiveness of a new landmark-based technique for pediatric PCB.
- To determine the number of procedures required for proficiency in pediatric PCB.
Main Methods:
- 100 consecutive pediatric PCB were performed using a nerve stimulator and a novel landmark-based approach.
- Residents unfamiliar with the procedure were trained by a single staff member.
- Cumulative sum (CUSUM) analysis and a bootstrap learning curve were employed to track the learning process, with an acceptable failure rate set at 10%.
Main Results:
- All blocks were clinically successful, but only 64% achieved success on the first attempt.
- Vascular puncture occurred in 16% of cases.
- CUSUM analysis demonstrated a clear institutional learning phenomenon, suggesting over 100 procedures may be needed for strict success criteria.
Conclusions:
- Despite a high success and low complication rate, implementing pediatric PCB with strict success criteria is challenging.
- A learning curve analysis indicates at least 55 attempts are needed for a 70% success rate.
- Training programs can utilize CUSUM to monitor institutional learning and ensure adequate experience for pediatric PCB.
Background:
Literature concerning institutional learning processes for anesthesia procedures in pediatric anesthesia is rare. Until recently only small series of psoas compartment blocks (PCB) in children have been reported. We report on a series of 100 consecutive blocks using new landmarks and the institutional learning process.
Methods:
In 100 consecutive children (5.9-106 kg) PCB was performed using a nerve stimulator. In the lateral position, the needle was inserted between the medial 2/3 and the lateral 1/3 on a line from the spinous process of L4 to the posterior superior iliac spine. Residents unfamiliar with PCB were instructed by one single staff member without manual intervention. Failure was defined as a bloody tap, more than one skin perforation with the needle or relinquishing the procedure to senior staff. To evaluate the institutional learning process the cumulative sum (CUSUM) statistical technique was used. CUSUM analysis was performed using an acceptable failure rate of 10%. A learning curve using a bootstrap technique and a least square fit model was also used.
Results:
Although all blocks were clinically successful, only in 64% was a single attempt sufficient. In 16% vascular puncture occurred. Surprisingly the CUSUM analysis showed a clear institutional learning phenomenon. Applying a strict definition for a successful block, more than 100 PCB in an institution may be necessary. Using the generated learning curve, for a success rate of 70% a case load of at least 55 attempts is required.
Conclusions:
Although the described new technique had a very high success rate with a low complication rate, PCB in children is not easily implemented into clinical practice when strict criteria of success were used, despite a well-controlled environment. Training programs could use CUSUM to track the progress of their institutional learning in order to guarantee adequate experience.