Anaesthesia

This tutorial covers the techniques to gain access to the epidural space.

This work by WFSA is licensed under a Creative Commons Attribution-NonCommercial-NoDerivitives 4.0 International License.

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Manage techniques to gain access to the epidural space
Understand the loss of resistance phenomenon
Know the risks and benefits associated with techniques such as loss of resistance to saline with continuous pressure (58%), loss of resistance to air with intermittent pressure (21%) or dural puncture epidural

This Stanford course offers opportunities for CME/CPD activity.

What Learners Are Saying

“This course must be given as a reminder for all medical staff in a planned manner, as it is very critical.”

Nurse, Iraq

"I loved this course because it's focus on clinical aspects. Highly relevant to the routine medical practices. The knowledge gained here can be directly used in routine basis life saving activities."

Medical Student, India

“Every topic is explained clearly and concisely, making it easy to apply the knowledge and improve skills for career success.”

Nurse, India

"I've enjoyed the course, the content accuracy was above expectations and the delivery was also on point. This is definitely going to make an impact in my healthcare provision!"

Medical Technician, Kenya

"The knowledge shared is very vital."

Nurse, Kenya

"I have really enjoyed the integration of video materials into the course, which has enhanced the practicality of my training."

Medical Student, Rwanda

World Federation of Societies of Anaesthesiologists

The World Federation of Societies of Anaesthesiologists (WFSA) is the foremost global alliance of anaesthesiologists, with 133 Member Societies representing over 140 countries and 500,000 anaesthesiologists worldwide.

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Practical Considerations to Access the Epidural Space

What's in this tutorial?

This tutorial covers the techniques to gain access to the epidural space.

Anaesthesia

Level

Intermediate

Target Audience

Designed for anaesthesia professionals and other appropriate healthcare providers

Varied activities

Written lectures, illustrations and quizzes.

This WFSA tutorial offers opportunities for CME/CPD activity.

SURGhub and WFSA do not award CME credits directly. It is the responsibility of the individual participant to determine eligibility for CME/CPD credit through a locally-accredited provider. Participants are responsible for downloading and presenting the certificate of completion to a local accrediting body to claim self-directed CME/CPD credits.
Learners can record time spent on each tutorial and claim for CPD credit that corresponds with the extent of their participation.

Course instructor

Kath Fok

Anaesthetic Registrar, Royal Cornwall Hospital, UK

Supervising Consultant: Jonathan Cheung, Anaesthetic Consultant, Royal Cornwall Hospital, UK

Edited by: Dr Jenny Woodbury, Clinical Assistant Professor, University of California, San Francisco, USA

The World Federation of Societies of Anaesthesiologists (WFSA) is the foremost global alliance of anaesthesiologists, with 133 Member Societies representing over 140 countries and 500,000 anaesthesiologists worldwide.

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Professor Emmanuel Malabo Makasa is a Global Health/Global Surgery Consultant, an Academician, a Researcher and an experianced Clinician. He is the founding Executive Director of the Southern Africa Development Community’s University of Witwatersrand based regional-hub and collaboration Centre for Surgical Healthcare Improvement (WITSSURG) and its spoke, the Centre for Surgical Hdealthcare Research (CSHR) in the Republic of Zambia. He chairs SADC’s Technical Experts Working Group on surgical healthcare, the Partnerships Subcommittee of the Pan-African Surgical Health Forum (PASHeF) and he is the current Secretary General of the International Federation of Surgical Colleges (IFSC). Professor Makasa is a member of the Medical Education and Research Board of the Zambia Medical Association (ZMA MERB), he is a committee member of the Zambia Orthopaedics and Trauma Association (ZOTA) and he also on the board of Trustee for the Lusaka Orthopaedics Research and Education Trust (LORET), Community Without Boarders – Zambian Chapter and Africa Directions (AD).

Professor Emmanuel M Makasa has extensive experience in global health diplomacy, in regional and national surgical (peri-operative) health policy formulation and implementation and he has worked as a senior health systems manager, as honourary lecturer and as a specialist clinician in orthopaedics and Trauma Surgery. He is passionate about improving surgical healthcare in LMIC and has a track record of mobilising and coordinating multiple state and none-state actor stakeholders and partners within the United Nations Systems, in the Global Health/Global Surgery community, health professional groups and within clinical care around surgical systems and service delivery improvement. He has presented on and he has published on safe, timely, equitable, appropriate and affordable universal access to surgical (peri-operative) healthcare in Africa and beyond.

John G. Meara is the Kletjian Professor of Global Surgery, Director of the Program in Global Surgery and Social Change, and Professor of Surgery in the Department of Surgery at Harvard Medical School. Dr. Meara serves as the Plastic Surgeon-in-Chief of the Department of Plastic & Oral Surgery at Boston Children's Hospital. He was Co-Chair for the Lancet Commission on Global Surgery and was a commissioner on the Lancet Global Health Commission on High Quality Health Systems in the SDG Era and the Lancet Oncology Commission. In 2008 he created the Paul Farmer Global Surgery Fellowship program. He is also interested in value-based health care and implementation science research, including time driven activity-based cost research and outcomes research. Dr. Meara has led several ICHOM projects focusing on outcomes reporting and international benchmarking.

Dr. Meara's interests and innovation activities lie in the areas of craniofacial anomalies, cleft lip and cleft palate, but he has a particular interest in augmenting the delivery of quality surgical and anesthesia care in low-resource settings through long term capacity building. He is involved in multiple global surgery projects looking at the burden of surgical disease, the surgical capacity and health systems building in low-resource environments, surgical education and the economic impact of untreated surgical disease. He is also interested in value based health care and implementation science research, including time driven activity based cost research and outcomes research. Dr. Meara has led several ICHOM projects focusing on outcomes reporting and international benchmarking. Since 2008, he has directed the Paul Farmer Global Surgery Fellowship program in collaboration with Partners In Health. Its purpose is to strengthen global surgical systems through a combination of research, advocacy, and implementation science as well as train leaders who will further promote surgical care, education, and research pertinent to global surgery.

Dr. Atun is Professor of Global Health Systems at Harvard University and the Faculty Chair of the Harvard Ministerial Leadership Program. In 2008-12 he served as a member of the Executive Management Team of the Global Fund as Director of Strategy, Performance and Evaluation where he chaired the panel that oversaw annual investments of ~US$4 billion each year.

In 2006-2013 Dr. Atun was a Professor of International Health Management at Imperial College London, where he led the Centre for Health Management and was involved as founder, adviser and investor in biotech and health technology companies. He is a visiting professor at University of Kyoto, Japan.

Professor Atun’s research focuses on health system transformation, and innovation. He has published more than 350 papers in leading journals such as NEJM, Lancet, JAMA, Academy of Management Journal, Lancet Oncology, Lancet Global Health and Science Translational Medicine.

Prof Atun has advised more than 30 governments on health policy, strategy and health system reform, and has consulted for the World Bank, WHO and leading organizations such as Medtronic, Merck & Co, Novartis, Hoffman-La Roche. In 2019-20 he was a senior advisor to the G20 Presidency.

Professor Atun served as a member of the U.S. National Academy of Medicine Committee on Health Systems. He also served on the Advisory Boards of WHO Research Centre for Health Development in Japan and the Norwegian Research Council’s Programme for Global Health Research. He Chaired the STOP TB Partnership Coordinating Board in 2009-2011, and was as a member of the UK Medical Research Council’s Global Health Group. He is a member of the Longitude Prize Committee – the largest science prize in the world.

Professor Atun studied medicine at University of London as a Commonwealth Scholar and subsequently completed his postgraduate training in family medicine and public health. He obtained a Masters in Business Administration at University of London and Imperial College London. He is a Fellow of the Royal College of Physicians, the Faculty of Public Health, and the Royal College of General Practitioners.

Professor Atun was appointed President of the GSF Foundation Board in October 2021.

Professor Mark G. Shrime, MD, MPH, PhD, FACS previously served as the O’Brien Chair of Global Surgery at the Royal College of Surgeons in Ireland, as the founder and Director of the Center for Global Surgery Evaluation at the Massachusetts Eye and Ear Infirmary, and as Research Director for the Program in Global Surgery and Social Change at Harvard.

He is the author of seminal papers on the global burden of surgical disease, the financial burden facing surgical patients, and the number of people who cannot access safe surgery worldwide. He served as a co-author on the Lancet Commission on Global Surgery.

Dr. Shrime graduated summa cum laude from Princeton University in 1996 with a BA in molecular biology. He received his MD from the University of Texas in 2001, after taking a year to teach organic chemistry in Singapore. Medical school was followed by a residency in otolaryngology at the joint Columbia/Cornell program in Manhattan, followed, in turn, by a fellowship in head and neck surgical oncology at the University of Toronto in 2007. He completed a second fellowship in microvascular reconstructive surgery, also at the University of Toronto, in 2008. He was the first to identify a novel independent prognostic indicator in head and neck cancer.

To date, he has worked and taught in Liberia, Sierra Leone, Guinea, Benin, Togo, Congo, Haiti, Saudi Arabia, Cameroon, and Madagascar. In May, 2011, he graduated with an MPH in global health from the Harvard School of Public Health, where he was a finalist for both the Albert Schweitzer award and the HSPH Student Recognition award, and in May, 2015, he received his PhD in health policy from Harvard University, with a concentration in decision science.

His research has been supported by the National Institutes of Health, the Iris O’Brien Foundation, the Damon Runyon Cancer Foundation, an anonymous donation to the Center for Global Surgery Evaluation, the GE Foundation’s Safe Surgery 2020 project and the Steven C. and Carmella Kletjian Foundation.

Barnabas Alayande, MBBS, PgDTh, MBA, FMCS (General Surgery) is a general surgeon and Assistant Professor of Surgery with the University of Global Health Equity. He is passionate about equity-based solutions for global surgical care, and works to achieve surgical access for underserved areas within the Center for Equity in Global Surgery through surgical education, research, innovation and improvisation for Low and Middle-Income Countries with an emphasis on sub-Saharan Africa.

He has an academic background in Medicine and Surgery, Theology, and Business, and has specialty training in general surgery with interests in trauma care, and human factors. He has carried out pilot randomized control trial dissertations in thyroid surgery, and benign anorectal haemorrhoid treatments for variable resource settings. Following medical training at a WHO collaborating center for community-based education and service, and a surgically oriented internship in Southwest Nigeria, he served in the South East as a National Youth Service Corps Camp Medical Director, Community Health Team Chair leading a team of volunteer medics serving 4.9 million people of Imo State, and a medical officer covering 19 local government health facilities. He helped start an innovative private practice in North-Central Nigeria, and then transitioned into his surgical residency with training by the West African College of Surgeons and the National Postgraduate Medical College. He graduated from the National Postgraduate Medical College, and subsequently helped establish surgical systems for underserved HIV/AIDS patients in Northern Nigeria, as a volunteer surgeon with the Faith Alive Foundation. He completed a 2-year Global Surgery fellowship with the Harvard Program in Global Surgery and Social Change, serving as chief research fellow, before transferring into a faculty role at the UGHE. He is also a Fogarty Global Health Fellow at the Harvard T.H. Chan School of Public Health.

Dr. Barnabas has contributed to strategic surgical curriculum development for Rwanda, the design of non-technical skills for surgery curriculum for the Nigerian variable resource context, trauma care evaluation and training for the West African sub-region, surgical educational research in the East, Central and Southern Africa region, and the strategic implementation of UGHE’s regional Center for Equity in Global Surgery. His research has been funded by the National Institutes of Health, Fogarty International Center, The Royal College of Surgeons, Edinburgh, Association for Academic Surgery, The UGHE Dean’s Grant. He is the recipient of awards and scholastic honors including the Baxiram S. and Kankuben B. Gelot Community Surgeons Travel Award, poster award from the Trauma Association of Canada, the HBNU Fogarty Global Health Fellowship, the Faculty of Rural Remote and Humanitarian Health Care Fellowship Award, the Association for Academic Surgery Global Surgery Research Grant, the Duro Soleye Annual prize, nomination for the Dr Hamza Olayinka Braimah academic prize, the Shell University Scholarship Award, and the Mobil Producing Nigeria Unlimited Scholarship Awards. Dr Barnabas has contributed numerous presentations, abstracts, and publications within the Global Surgery space, with work in surgical ethics and equity, disparities in access to trauma care, grassroots advocacy, conference equity, surgical quality, surgical history, COVID and surgical care, surgical improvisation, surgical systems strengthening, baselining of surgical access, non-technical skills in surgery, and machine learning and surgery, among others.

He is a member of the Association for Academic Surgery Global Affairs Committee, the West African College of Surgeons, and the Nigerian Medical Association, a fellow with the National Postgraduate Medical College of Nigeria, an international associate fellow with the American College of Surgeons, and a fellow of the Royal College of Surgeons Edinburgh Faculty of Rural, Remote and Humanitarian Healthcare.