Department of Anaesthesia and Peri-operative Medicine, North Shore Hospital, Auckland, New Zealand.
Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
Anaesthesia. 2021 Aug;76(8):1060-1067. doi: 10.1111/anae.15370. Epub 2021 Jan 25.
Accidental dural puncture is a recognised complication of labour epidural placement and can cause a debilitating headache. We examined the association between labour epidural case volume and accidental dural puncture rate in specialist anaesthetists and anaesthesia trainees. We performed a retrospective cohort study of labour epidural and combined spinal-epidural nerve blocks performed between 1 July 2013 and 31 December 2017 at Waitemata District Health Board, Auckland, New Zealand. The mean (SD) annual number of obstetric epidural and combined spinal-epidural procedures for high-case volume specialists was 44.2 (15.0), and for low-case volume specialists was 10.0 (6.8), after accounting for caesarean section combined spinal-epidural procedures. Analysis of 7976 labour epidural and combined spinal-epidural procedure records revealed a total of 92 accidental dural punctures (1.2%). The accidental dural puncture rate (95%CI) in high-case volume specialists was 0.6% (0.4-0.9%) and in low-case volume specialists 2.4% (1.4-3.9%), indicating probable skill decay. The odds of accidental dural puncture were 3.77 times higher for low- compared with high-case volume specialists (95%CI 1.72-8.28, p = 0.001). Amongst trainees, novices had a significantly higher accidental dural puncture complication rate (3.1%) compared with registrars (1.2%), OR (95%CI) 0.39 (0.18-0.84), p = 0.016, or fellows (1.1%), 0.35 (0.16-0.76), p = 0.008. Accidental dural puncture complication rates decreased once trainees progressed past the 'novice' training stage.
意外硬脊膜穿刺是分娩硬膜外置管的一种公认并发症，可导致严重头痛。我们研究了在专业麻醉师和麻醉住院医师中，分娩硬膜外病例量与意外硬脊膜穿刺率之间的关联。我们对新西兰奥克兰怀塔姆区卫生局在 2013 年 7 月 1 日至 2017 年 12 月 31 日期间进行的分娩硬膜外和联合脊髓-硬膜外神经阻滞进行了回顾性队列研究。高病例量专家的产科硬膜外和联合脊髓-硬膜外操作的平均（SD）年度数量为 44.2（15.0），低病例量专家为 10.0（6.8），在剖宫产联合脊髓-硬膜外操作后进行了计算。对 7976 例分娩硬膜外和联合脊髓-硬膜外操作记录的分析显示，共有 92 例意外硬脊膜穿刺（1.2%）。高病例量专家的意外硬脊膜穿刺率（95%CI）为 0.6%（0.4-0.9%），低病例量专家为 2.4%（1.4-3.9%），表明可能存在技能衰退。与高病例量专家相比，低病例量专家发生意外硬脊膜穿刺的几率高 3.77 倍（95%CI 1.72-8.28，p=0.001）。在住院医师中，新手的意外硬脊膜穿刺并发症发生率明显高于注册医师（3.1%对 1.2%），比值比（95%CI）为 0.39（0.18-0.84），p=0.016，或研究员（1.1%），0.35（0.16-0.76），p=0.008。一旦住院医师超过“新手”培训阶段，意外硬脊膜穿刺并发症发生率就会下降。
