Implementation of Guidelines for Preprocedural Ultrasound in Neuraxial Placement for Obstetric Patients with Scoliosis

Neuraxial anesthesia including epidural, spinal, and combined spinal-epidural, is used with 65% of parturients in the United States for the management of pain and discomfort. Conventional landmark palpation has been the mainstay technique for neuraxial anesthesia, but unfamiliar spinal anatomy can lead to incomplete blockade or an increased incidence of complications. Scoliosis causes lateral curvature and rotation of the spine leading to arthritis and soft tissue changes that can present obscure anatomical landmarks, cause difficulty in needle passage, and result in inadequacy of local anesthetic efficacy. The literature illustrates that preprocedural ultrasound is recommended for needle placement in parturients with difficult spinal anatomy and those with moderate to severe scoliosis. Despite the preprocedural ultrasound benefits of enhanced imaging of structures, and needle depth estimation and direction, in the United States, only 22% of obstetric units incorporated preprocedural ultrasound for neuraxial anesthesia. The model used for the DNP (Doctorate in Nursing Practice) project is the practice, evidence, and translation (PET) section of the John Hopkins Evidence-Based Practice Model (JHEBP) for healthcare professionals. This project’s main objective is the implementation of evidence-based practice (EBP) guidelines for the facilitation of neuraxial anesthesia in parturients who present with scoliosis with preprocedural ultrasound or conventional landmark palpation. If implemented, the project can aid in first-pass success, allow for needle redirection accuracy, and decrease procedural time while also decreasing complications of incomplete blockade, vascular puncture, and post-dural puncture headache. Additional project objectives include an algorithmic approach to decision-making for neuraxial anesthesia based on patient characteristics, a comprehensive plan to implement the EBP guidelines, and a method to monitor, measure, and evaluate guidelines.