Current Practice of Spinal Anesthesia Among Anesthetists working in Injibara General Hospital North west Ethiopia 2026 Quality improvement Clinical Audit

Belete Destaw^*, Temesgen Misganaw, Ezra Ejigu, Robel Asegid, Mekuanint Asmare, Zemenu Muluken, Melese Tadele

Department of Anaesthesia, College of Medicine & Health Sciences, Injibara University, Injibara, Ethiopia

*Corresponding Author: Belete Destaw, Department of Anaesthesia, College of Medicine & Health Sciences, Injibara University, Injibara, Ethiopia, Email: baleanst@gmail.com

Abstract

Background: Spinal anesthesia is a type of regional anesthesia where a small dose of local anesthetic is injected into the subarachnoid space to produce rapid, dense sensory and motor block. Aim: To improve patient safety by evaluating the compliance of current practice of spinal anesthesia with NYSORA standard at IGH, 2026.

Method: A cross-sectional study design was conducted in Injibara General Hospital from December 2025 to January 2026. 14 anesthesia professionals who are working in the study hospital were surveyed by the total population sampling technique. A standardized structured checklist prepared from recommendations of NYSORA guideline regarding the current Practice of spinal anesthesia was used to collect the data. Descriptive statistics were employed to summarize the results.

Result: Overall compliance with NYSORA standards for spinal anesthesia practice was 70.8%. it ranges from excellent compliance (100%) was observed up to Poor compliance (0%) was identified including; hand hygiene and use of sterile drapes.

Conclusion: Even though Anesthetists in Injibara general hospital had excellent adherence to the technical components of spinal anesthesia, compliance with several key NYSORA recommended non-technical standards remains substandard. It would be better considering training and enforcement of standard.

Keywords: Spinal anesthesia; Clinical audit; NYSORA standards; Patient safety; Aseptic technique; Informed consent; Compliance; Anesthesia practice; Injibara General Hospital; Ethiopia

Introduction

Spinal anesthesia is one of the most frequently performed regional anesthesia techniques worldwide and is a cornerstone of anesthesia practice in obstetrics, general surgery, orthopaedics, urology, and lower abdominal procedures. It involves the injection of a local anesthetic into the subarachnoid space, producing rapid, profound sensory and motor blockade. Since its first clinical application by August Bier in 1898, spinal anesthesia has evolved into a highly reliable technique due to advancements in needles, local anesthetics, and monitoring standards [1]. Compared with general anesthesia, spinal anesthesia offers advantages such as reduced airway manipulation, decreased blood loss, improved postoperative pain control, and lower rates of thromboembolic complications [2].

Despite these advantages, the effectiveness and safety of spinal anesthesia heavily depend on the technical proficiency of the anesthetists and adherence to evidence-based standards. Inconsistent practice, inadequate technique, and deviation from guidelines increase the risk of complications, block failure, and adverse maternal or surgical outcomes. As a result, evaluating current practice through a structured clinical audit is critical for ensuring high-quality patient care [2,3].

The success of spinal anesthesia depends on several key steps, including proper patient assessment, correct identification of anatomical landmarks, aseptic preparation, appropriate needle selection, correct dosing, and effective monitoring. Optimal patient positioning either sitting or lateral ensures accurate midline or para-median needle insertion. Ultrasound guidance, although increasingly recommended, is still underutilized in many low-resource settings [3].

Standard practice guidelines emphasize the importance of the following technical elements: aseptic technique to reduce infection risk, appropriate needle choice (e.g., 25G pencil-point) to minimize post-dural puncture headache, correct level of insertion, commonly at L3–L4 or L4–L5, accurate drug dosing based on procedure type, patient height, assessment of sensory and motor block height, continuous hemodynamic monitoring, proper documentation of technique, complications, outcomes and failure to consistently perform these steps contributes to preventable complications and practice variation among anesthetists [4].

The most common complication is maternal hypotension, with an incidence between 30–80%, depending on adherence to prophylactic vasopressor protocols [5]. Other complications include high spinal block, failed block, post-dural puncture headache (PDPH), nerve injury, infection and cardiovascular collapse [6]. Failed or inadequate spinal anesthesia occurs in 3–13% of cases globally and up to 15% in low-income settings. Failures may require repeat injection or conversion to general anesthesia both associated with increased complications, anxiety, and medico-legal risks [7].

Evidence from multiple regions shows that spinal anesthesia techniques vary widely across institutions and among anesthetists, affecting patient outcomes. In high-income countries, despite standardized guidelines, practice variation persists regarding needle choice, dosing, monitoring, and documentation [8]. In low- and middle-income countries (LMICs), this variation is even more pronounced due to resource limitations, limited access to training, and lack of institutional protocols [9].

Spinal anesthesia remains a fundamental part of the modern practice of anesthesia because of its proven success, predictability, increased patient satisfaction, and low complication rate [10]. Advancements in technology in terms of spinal needle diameter and tip designs have been responsible for a reduction in complications such as post-dural puncture headaches (PDPHs) [11]. New imaging modalities are available to assist with difficult spinal placement [12]. Subspecialty practices such as cardiac anesthesia have incorporated regional techniques into the practice to adapt to changing trends of fast-tracking cardiac patients for early tracheal extubation. A number of ambulatory surgical procedures are well suited for spinal anesthesia [13].

The combined spinal-epidural (CSE) technique has been incorporated into the practice of obstetrical anesthesia, both for labor analgesia and surgical cesarean section. Local anesthetic agents, doses and agent baricity are selected based on specific surgical procedures [14-19]. Guidelines for patients taking anticoagulant or anti-fibrinolysis medications are reviewed. The practice of spinal anesthesia continues to adapt in response to new equipment, techniques, local anesthetics and adjuvants, and clinical indications [13].

Methods

Study Design, Area and Period

A prospective cross-sectional study was conducted from December 2025 to January 2026 at Injibara General Hospital (IGH), located in Injibara town, Awi Zone, Amhara National Regional State, Ethiopia, approximately 447 km northwest of Addis Ababa. IGH is a public referral hospital serving a catchment population of about 1.2–1.32 million people in the Awi Zone and surrounding areas. The hospital has four operating rooms, including two major operating rooms, one orthopedic room, and one designated for emergency procedures.

Sample Size and Sampling procedure

A survey (total population) sampling technique was employed, whereby 14 anesthesia professionals available and practicing spinal anesthesia during the study period at Injibara General Hospital were included in the audit.

Audit Standards

The audit standards used in this study were derived from the recommendations of the New York School of Regional Anesthesia (NYSORA), an internationally recognized authority in regional anesthesia practice. NYSORA provides comprehensive, evidence-based guidance on the safe performance of spinal anesthesia, encompassing pre-procedural assessment and informed consent, preparation of equipment, aseptic technique, patient positioning, technical execution of the block, continuous monitoring, and post-procedural assessment. These standards emphasize that strict adherence to each step is essential to minimize complications, improve patient safety, and ensure high-quality anesthesia care. For this reason, NYSORA recommendations were used with a target compliance of 100% set for all assessed standards.

Operational definitions

Informed consent obtained: giving information explaining about risks, benefits of spinal anesthesia, other options of spinal anesthesia sign taken [20].

Patient monitored: SA given patient monitored with a pulse oximeter, BP, and ECG [20].

Anesthesia equipment Prepare and check all necessary: ETT, LMA, Laryngoscope, and monitoring before SA prepare and checked [20].

Equipment for the spinal blockade ready: spinal needle, gauze, artery and disinfectant solutions) should be ready for use [20].

Data collection method

Data were collected prospectively using a structured audit checklist (proforma) adapted from New York School of Regional Anesthesia (NYSORA) guidelines. The proforma was designed to assess the practice of anesthetists during the administration of spinal anesthesia, including patient preparation, aseptic technique, positioning, drug selection and dosing, monitoring, and post-procedure care. Observations were conducted in real time during spinal anesthesia procedures by trained data collectors to ensure accurate assessment of clinical practice. Data collectors were oriented on the audit tool to maintain consistency and minimize observer variation. Completed checklists were reviewed daily for completeness and accuracy, and any unclear observations were clarified immediately [Table 1]. Audit Proforma.

Table 1: Audit proforma

Data quality control management

To ensure the reliability and validity of the audit, the data collectors were thoroughly trained and well suited for the job. There was also be daily supervision of data collection and completed questionnaires were checked at random.

Data analysis and Processing

Data was checked manually for completeness and then by using Descriptive statistic Microsoft Excel 2016; tables, graphs of sums and percentages of items identified study for this audit.

Result

Overall compliance with NYSORA standards for spinal anesthesia practice was 70.8%. Excellent compliance (100%) was observed in equipment preparation, patient positioning, technical execution of spinal anesthesia, availability of skilled assistance, and intra-operative monitoring. Moderate compliance was noted in intravenous access, patient monitoring during spinal placement, assessment of sensory and motor block, and post-procedural vital sign monitoring. Poor compliance was identified in aseptic practices, including hand hygiene and use of sterile drapes, as well as in obtaining and documenting informed consent [Table 2] and [Figure 1].

Table 2: Audit Result in table

Figure 1: Result of Spinal Anesthesia Practice at IGH

References

1. Mulroy M (2014). A history of regional anesthesia. In: The wondrous story of anesthesia. Springer. 859–870.
2. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, et al. (2000). Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ. 321(7275):1493.
3. Lam K, Leung MK, Irwin MG (2020). Labour analgesia: Update and literature review.
4. Cook TM, Counsell D, Wildsmith JAW (2009). Major complications of central neuraxial block: Report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth. 102(2):179–190.
5. Kinsella SM, Carvalho B, Dyer RA, Fernando R, McDonnell N, et al. (2018). International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Obstet Anesth Dig. 38(4):171–172.
6. Fettes PDW, Jansson JR, Wildsmith JAW (2009). Failed spinal anaesthesia: Mechanisms, management, and prevention. Br J Anaesth. 102(6):739–748.
7. Rae JD, Fettes P (2023). Mechanisms and management of failed spinal anesthesia. Pain. 2023.
8. Bauchat JR, Weiniger CF, Sultan P, Habib AS, Ando K, et al. (2019). Society for Obstetric Anesthesia and Perinatology consensus statement: Monitoring recommendations for prevention and detection of respiratory depression associated with administration of neuraxial morphine for cesarean delivery analgesia. Anesth Analg. 129(2):458–474.
9. Habtu E, Nigatu M, Ayele Y, Tila M, Demissie WR (2021). Practice of regional anesthesia and its associated factors among anesthesia professionals working in teaching referral hospitals of Ethiopia: A multicenter study. Open Pain J. 14(1).
10. Veličković I, Pujic B, Baysinger CW, Baysinger CL (2017). Continuous spinal anesthesia for obstetric anesthesia and analgesia. Front Med (Lausanne). 4:133.
11. Akyol D, Çelik M, Ay N, Yıldız G (2024). The effect of spinal needle type on post-dural puncture headache in spinal anesthesia: Prospective randomized study. Eurasian J Med. 56(1):42–46.
12. Gurunathan U, Kunju SM, Hay KE, van Alphen S (2018). Usefulness of a visual aid in achieving optimal positioning for spinal anesthesia: A randomized trial. BMC Anesthesiol. 18(1):11.
13. Roofthooft E, Rawal N, Van de Velde M (2023). Current status of the combined spinal-epidural technique in obstetrics and surgery. Best Pract Res Clin Anaesthesiol. 37(2):189–198.
14. Tsutsui T, Nakamura K, Muranaka K (1998). Combined spinal-epidural anesthesia for cesarean section: Needle-through-needle approach. J Anesth. 12(1):13–16.
15. Obilo CS, Ewah RL, Ugoji D-PC (2024). Comparison of prophylactic diclofenac sodium suppository with intravenous tramadol in the prevention of post-spinal anaesthesia shivering in parturients undergoing caesarean section. Afr J Health Soc Sci. 1(1):19–28.
16. Turnbull DK, Shepherd DB (2003). Post-dural puncture headache: Pathogenesis, prevention and treatment. Br J Anaesth. 91(5):718–729.
17. Baer ET, Warltier DC (2006). Post-dural puncture bacterial meningitis. Anesthesiology. 105(2):381–393.
18. Admassie BM, Admass BA, Melesse DY (2024). Practice and challenges related to regional anesthesia in Amhara regional hospitals, Northwest Ethiopia: A web-based survey study. BMC Anesthesiol. 24(1):398.
19. Abate TW, Zeleke B, Genanew A, Abate BW (2021). The burden of stroke and modifiable risk factors in Ethiopia: A systematic review and meta-analysis. PLoS One. 16(11):e0259244.
20. Hadzic A (2022). NYSORA nerve block manual. NYSORA Inc.