Analysis of previous training with simulated models on the success rate of ultrasound-guided supraclavicular block. Prospective cohort study | Revista Española de Anestesiología y Reanimación (English Edition)

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"apellidos" => "Orozco Galvis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario de Santander, Universidad Industrial de Santander, Bucaramanga (Santander), Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Anestesiología y Reanimación, Especialidad de Medicina Crítica y Terapia Intensiva, Docencia Universitaria, Epidemiología, Universidad Industrial de Santander, Bucaramanga (Santander), Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Anestesiología y Reanimación, Universidad Industrial de Santander, Bucaramanga (Santander), Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis del entrenamiento previo con modelos simulados en el porcentaje de éxito del bloqueo supraclavicular guiado por ultrasonido. Estudio de cohorte prospectivo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1855 "Ancho" => 1463 "Tamanyo" => 400269 ] ] "descripcion" => array:1 [ "en" => "Accumulated success rates according to year of residency, device management and number of punctures. Punctures vs. successful blockade (p=0.842). Year of residency vs. successful blockade (p=0.224)." ] ] ] "textoCompleto" => "IntroductionSupraclavicular brachial plexus block (BPB) was first performed by Halstedt in 1884, after surgically exposing the brachial plexus. The first single puncture percutaneous approach was performed by Kulenkampff in 1911, and required a thorough knowledge of the regional anatomy and large volumes of local anaesthetic.<a class="elsevierStyleCrossRef" href="#bib0145">1</a>This approach to upper limb brachial plexus block gives the deepest, fastest acting and most effective anaesthesia. However, it is associated with major complications, such as pneumothorax, local anaesthetic toxicity and nerve injury, prompting an ongoing search for alternatives to improve success and reduce the risk of these adverse events.<a class="elsevierStyleCrossRef" href="#bib0150">2</a>This led von Perthes to introduce the neurostimulator in 1911. Despite this, however, nerve blockade remained a partially blind technique, with a complication rate as high as 15%.The search for strategies that could reduce complications and increase the success rate of BPB led Grange, in 1978, to perform the technique using ultrasound for the first time. This succeeded in reducing the volume of local anaesthetic required, with no complications.<a class="elsevierStyleCrossRef" href="#bib0160">4</a>Subsequent advances in ultrasound technology have shown its value in achieving these objectives, although it requires prior knowledge and training, has a considerable learning curve, and is operator-dependent. For these reasons, expert-led training, retraining and extensive reading are recommended.<a class="elsevierStyleCrossRefs" href="#bib0165">5,6</a>Since the 60s, training models have changed in parallel with the progress made in these technologies, and teaching techniques based on simulation and acquisition of skills have been introduced. These methods have brought about a paradigm shift and have restructured the teaching environment by focussing on optimising knowledge and competence to enable clinicians to provide safe, effective, efficient and patient-centred care. Experience has shown them to be optimal educational models for teachers and students, insofar as the give better understanding of clinical cases, improve cognitive and non-cognitive skills, and reduce both the learning curve and the rate of complications in clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0170">6–8</a>Anaesthesiology has been among the specialties that have pioneered this type of teaching, from the emergence of resusci-anne, followed by high-fidelity simulation models that provide scenarios to facilitate the acquisition and assessment of skills (resuscitation, airway management, vascular accesses). Nerve block techniques have evolved from landmark-based techniques, neurostimulator-aided localisation, to the ultrasound-guided techniques prevalent today.<a class="elsevierStyleCrossRefs" href="#bib0170">6–9</a>To reach proficiency in ultrasound-guided nerve blockade (USNB), anaesthesiologists must not only have sound theoretical knowledge, but should also have undergone simulation training and have personalised their own learning curve until they have achieved the required academic goal. This will ensure they approach clinical practice guided by the ethical principle of non-maleficence: prioritise patient safety.<a class="elsevierStyleCrossRefs" href="#bib0165">5,6,8</a>Patient safety requires clinicians to understand the ultrasound device and its use, be able to identify structures using sonoatomy, have the ability to generate images, track the advance of the needle in real time, and correctly evaluate the spread of the local anaesthetic around the peripheral nerve. Competence in these 3 stages (theoretical knowledge, simulation training and operation of the device) will minimise the risk of complications when performing the technique in clinical practices. However, USNBs, being operator-dependent, are not completely fail-safe.<a class="elsevierStyleCrossRefs" href="#bib0170">6,10</a>Simulation-based training has several advantages: it can improve non-technical skills, such as interpersonal relationships, decision-making, or situational awareness; it can be used to reproduce critical and rare clinical cases that are difficult to encounter in clinical practice; it gives immediate feedback; and it allows trainees to practice until they can successfully perform a given procedure. All this leads to fewer complications and increases patient safety.<a class="elsevierStyleCrossRefs" href="#bib0195">11,12</a>Niazi et al. have shown that simulation-based training increases the success rate of ultrasound-guided blockade.<a class="elsevierStyleCrossRef" href="#bib0205">13</a> In their study, which consisted of a theoretical introduction to the basic management of the ultrasound equipment, followed by a practical session in which one group of resident anaesthesiologists without prior experience underwent simulation-based training, the success rate was 64% vs. 51% in the group receiving conventional training. After retraining, the success rate was 80% vs. 40%, respectively.In a recent meta-analysis, Barrington et al. compared peripheral nerve blockade (PNB) performed with a nerve stimulator vs. ultrasound, and found that patients undergoing USNB presented fewer complications (2.2% versus 5.3%), vascular puncture (5.1% vs.13.9%), local anaesthetic toxicity (0.8% vs. 1.2%) and late neurological deficit (0.2% vs. 0.8%).<a class="elsevierStyleCrossRef" href="#bib0210">14</a>Based on the foregoing concepts and evidence, and in the setting of a university project involving acquisition of competences and the availability of a simulation laboratory, we hypothesised that prior training would increase the success rate of ultrasound-guided supraclavicular block (USB), improve management of the ultrasound equipment, and reduce the complication rate compared with reports in the literature. Our primary objective was to evaluate the success of USB of the brachial plexus. Our secondary objectives were to evaluate device management and the incidence of complications in residents that had previously received theoretical and simulation-based training.Materials and methodsWe chose 16 postgraduate residents, R1, R2, R3 and R4, who agreed to participate in the study and signed an informed consent form. The R4 group consisted of residents who had already graduated and were in their first year as practising anaesthesiologists. None of the participants had experience in ultrasound-guided brachial plexus blockade or prior knowledge of the parameters evaluated during performance of the ultrasound-guided technique. All 4 groups underwent a 3-stage training program. The data were collected from February 1, 2017 to March 1, 2018.Stage I: theory, 7 sessions.Stage II: device management, with as many 30-minute sessions as needed until proficiency was acquired.Stage III: performance of peripheral USNB on simulation models in 30-minute sessions until proficiency had been achieved in 4 areas: device management, image optimisation, image interpretation, and needle visualisation. Proficiency was defined on the basis of 4 outcomes: device management, optimisation and interpretation of the image, and view of the needle. The following simulation models were used: Branched Two Vessel Blue Phantom (CAE Healthcare®) for hydrodissection, and animal models (chicken breasts) for puncture and needle visualisation. We also used LM® mannequins for needle viewing and image interpretation.<a class="elsevierStyleCrossRef" href="#bib0215">15</a>After each participant had completed their training stage individually and in their own time, a Canon Vixia HFR700 video camera was placed in the operating room by personnel not involved in the study, and the entire procedure was recorded, without interfering in the anaesthetic decision taken by each participant and their teacher or tutor. The operational variables selected for each procedure were evaluated individually. In order to guarantee anonymity, enlargement lenses that impeded visualisation of the participant were used. All nerve blocks were performed using the Sonosite Edge II ultrasound system. The evaluators did not intervene in the procedure at any time, and the videos were analysed by 2 anaesthesiologists with expertise in ultrasound-guided regional anaesthesia no less than 24h after they had been recorded. Using the video images, the experts evaluated the following variables: device management, optimisation and interpretation of the image, and view of the needle. These were rated as excellent, fair or poor, according to the criteria defined in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> (definition of variables). The following variables were also evaluated:<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Successful blockade: defined as a score of excellent in each area (device management, image optimisation, image interpretation and needle visualisation), in addition to obtaining sufficient motor and sensory blockade to perform the procedure or for postoperative analgesia, and the absence of complications.Unsatisfactory blockade: defined as a score of fair in each area (device management, image optimisation, image interpretation and needle visualisation), in addition to obtaining sufficient motor and sensory blockade to perform the procedure or for postoperative analgesia, and the absence of complications.Failed blockade: defined as a score of poor in each area (device management, image optimisation, image interpretation and needle visualisation), together with failure to obtain sufficient motor and sensory blockade to perform the procedure or for postoperative analgesia, and the presence of complications.Time to needle visualisation: time (minutes) from placement of the transducer on the skin and visualisation of the entire needle path to complete hydrodissection of the brachial plexus.Time to local anaesthetic spread: time (minutes) from placement of the needle tip over the brachial plexus until complete spread of the local anaesthetic.Procedure time: defined as the time (minutes) from skin puncture until ultrasound verification of the spread of the local anaesthetic around the brachial plexus.Number of punctures: 1 puncture was defined as insertion over the brachial plexus identified with the transducer; each additional puncture was defined as the need to completely withdraw the needle to the level of the skin.Complications: arterial puncture confirmed by return of arterial blood into the needle. Haematoma was defined as evidence of blood collecting at the puncture site; Pneumothorax or haemothorax were confirmed by radiological imaging after the puncture.The type and concentration of local anaesthetic used and the volume injected (within therapeutic ranges) were chosen at the discretion of the anaesthesiologist and the resident. The researchers merely collected and analysed these variables.All the variables were evaluated and analysed using the Student's t test, chi-squared or analysis of variance, depending on whether they were dichotomous, ordinal or continuous. A success curve was constructed according to the number of years of residency, number of punctures, and the presence of differences in device management and successful USNB. The data obtained were entered into a codified Excel database and exported to Stata 14.0 for analysis (Stata Products®).ResultsAt total of 156 BPBs were performed in 156 patients with an average age of 37 years; 52% underwent emergency surgery, women were in the minority (43%), and the average body mass index was 23. BPD was performed on the right side in 58% of cases (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The 156 BPBs evaluated were performed by 16 residents, 4 from each year of residency, with an average of 13 blocks per resident. The R4 group comprised anaesthesiologists in their first year of clinical practice. All passed the simulator-based training, based on the success variables, and none had previous experience in ultrasound or in the variables evaluated. The previous experience in landmark-based technique of subjects in the R2, R3 and R4 will be discussed below.Device-related variables, such as management and optimisation and interpretation of the image, were rated excellent, with average values of 83.3% and 91.7%. When evaluated by year of residency, significant differences were observed in only the latter 2 variables (p<0.05), in which the R2 and R3 groups achieved higher success rates (97.6 and 96.9%). With regard to punctures, needle visualisation obtained the lowest excellent rating among residents (25–69%), although significant differences were observed between these groups (p=0.004). The mean time to needle visualisation and local anaesthetic spread did not show significant differences in terms of years of residency (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Similarly, comparing success in terms of time and number of attempts between R1 and R3 showed no significant differences (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>BPB was performed with a single puncture in 73.08% of cases, and only 5.77% required 3 or 4 punctures, specifically, in groups R1 and R2. Subjects in R4 achieved greater first-attempt success in BPB, and although the statistical significance observed when analysing the data by year of residency and number of punctures was dependent on the cutoff point (p=0.05), this result will be discussed later (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).Overall, the BPB success rate was 96.15% (CI 95%: 91.8–98.6; n=150), with a higher first-attempt success rate, although this difference was not statically significant (p=0.842). Neither did we observe significant differences after adjusting for year of residency and choice of anaesthetic agent, with minimum values of 92.75% for R1 and 100% for R3 and R4. After adjusting for number of punctures, time to needle visualisation and spread of local anaesthetic, no significant differences were observed between R1 and R3 (p=0.6154; 0.6275 and 0.356). No significant differences were observed between the first and last blockade performed by each subject evaluated, since the only failed blocks occurred in R1 (n=5) and R3 (n=1). The only significant difference was the ascending curve and the marginally significant difference in the number of attempts (p=0.050) (<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Success measured by the number of punctures was greater than 90%, and when analysed by year of residency, the R3 and R4 groups achieved 100% success at the first puncture, in contrast to R1 and R2, that achieved an average success rate of 90%, and also required up to 4 punctures to achieve 100% success. No significant differences were observed when the data were adjusted for number of punctures and year of residency (p>0.05). The overall success curve calculated on the basis of the number of attempts and device management showed important differences in terms of performance and number of punctures. The accumulated overall first-attempt success rate of the entire cohort was 73.88%, with a gain of 20% at the second puncture (94%). From that point on, the proportional gain in 100% success was minor: 4% and 2%, respectively. The overall success curve shows a linear correlation of r2=0.786, which is defined as good (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).The only complication presented was arterial puncture, which occurred in 0.64% of procedures, with no difference between years of residency.DiscussionIn competency-based learning, simulation-based training plays an important role in unifying theoretical knowledge with real-world scenarios, optimising performance of the simplest to the most complex procedures, increasing success rates and reducing the number of complications.<a class="elsevierStyleCrossRefs" href="#bib0170">6–9,11,12,16–18</a>This hypothesis and these parameters were the basis for this study. We believe that the strength of our work lies in the prior training described in the materials and methods section,<a class="elsevierStyleCrossRef" href="#bib0215">15</a> which was far longer that the time allocated to such simulation-based practise in other studies, which does not exceed 60minutes.<a class="elsevierStyleCrossRef" href="#bib0205">13</a>Several meta-analyses and systematic reviews have shown that simulation-based medical training achieves superior results than conventional methods. Grantcharov and Reznick showed that simulation-based training is more effective than the costly, slow and inconsistent “see one, make one” method. Inselberg et al. also claim that training using simulation models improves technical skills and overall compentence.<a class="elsevierStyleCrossRefs" href="#bib0235">19,20</a>We cannot ignore the fact that ultrasound is “operator-dependent” and this “mutual interaction” based on training and retraining is fundamental to achieve proficiency in BPB. We are certain that giving our subjects to opportunity to learn how to use the ultrasound device and acquire knowledge of upper limb anatomy and sonoatomy in the preliminary stage of our study had a positive influence on the results obtained; this has been supported by studies, guidelines, procedural manuals, and is endorsed by scientific societies.<a class="elsevierStyleCrossRefs" href="#bib0170">6–9,12,14,17,21,22</a>The device management-related variables are not totally “friendly”: we obtained excellent ratings, ranging from a mean of 83% and 91%, for device management, optimisation and interpretation of the image. Image optimisation and interpretation are influenced by the knowledge acquired in the training phase, which also influences device management, and knowledge of upper limb anatomy and sonoatomy. This learning should be supervised by an expert in regional anaesthesia. Mastery in these variables is achieved with good training in simulation models, with knowledge of the ultrasound device, choice of the right transducer and good transducer placement skills to obtain direct visualisation of the plexus. Taken together, these factors can optimise the technique and guarantee the success of the blockade by ensuring good hydrodissection. This, according to the literature, reduces local anaesthetic requirements and minimises the risk of complications.Anaesthesiologists that have received both theoretical and simulation-based training achieve higher success rates than those that have learnt the technique solely in clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0165">5,6,13,19</a> However, proficiency in puncture-related variables was far lower, ranging from 25% to 69%. The R2 and R3 groups achieved the highest rating compared to R4, where the lowest ratings were recorded. One explanation for this could be the more recent training received by the former 2 groups, which illustrates the need for continuous, updated training in these techniques.<a class="elsevierStyleCrossRefs" href="#bib0165">5,6,23</a> Our findings are consistent with those of other authors who found that puncture skills proved the most difficult, and could lead to excessive needle depth and vascular puncture and pneumothorax. These skills can be improved by devoting more time to practising on simulation models.<a class="elsevierStyleCrossRefs" href="#bib0170">6,24</a>Finally, the variables that most influenced the success of BPB in terms of device management were good visualisation of the needle, and image optimisation and interpretation. These findings are consistent with those reported by Niazi et al.<a class="elsevierStyleCrossRef" href="#bib0205">13</a>With respect to the percentage of successful blockade and the learning curve, we found a success rate higher than 94%, with 13 blocks on average. According to the literature, the learning curve for landmark-based supraclavicular nerve block is 40 blocks<a class="elsevierStyleCrossRef" href="#bib0265">25</a> vs. between 4 and 17 for ultrasound-guided block with prior simulation-based training, which is in line with our findings.<a class="elsevierStyleCrossRefs" href="#bib0205">13,26</a>Similarly, between 4 and 17 nerve blocks are required to achieve success in simulation models, while the group without simulation training required more than 17. Our residents achieved a success rate of over 90%, even when adjusted by year of residency and number of punctures. This could be due to previous experience in the case of groups R3 and R4, which gave them a higher first-attempt success rate. It could also suggest that more advanced residents become more confident when they consolidate their technique and achieve success at the first attempt, and that these results could be due to their prior experience in landmark-based techniques. However, studies have shown that experience in landmark-based nerve block does not give greater success than simulation-based training, which has been shown to increase the success of BPB compared to traditional teaching methods.<a class="elsevierStyleCrossRefs" href="#bib0240">20,22</a>Similar findings are obtained when success rates are plotted on CUSUM charts, insofar as procedure-naive anaesthesiologists who underwent simulation-based vs. conventional training achieved a success rate 64% and 51%, respectively, while residents retrained using simulation models achieved a success rate of 80% versus 40% in conventional training methods.<a class="elsevierStyleCrossRef" href="#bib0205">13</a>Our study supports the findings of other authors studying success rates in professionals trained using simulation models and the impact of this approach on patient safety, in terms of fewer complications, fewer punctures, and faster performance times compared to traditional methods and the use of peripheral nerve stimulation.<a class="elsevierStyleCrossRefs" href="#bib0155">3,20–28</a>In examining the strengths and weaknesses of our study, we should mention the absence of a control group, and of a “before and after” on which to compare performance. Nevertheless, the performance of residents was taken as a reference parameter for comparison. The prior training of these professionals became their strength and the method is recommended, because studying the different stages of simulation-based training up to performance of the technique on real patients provides excellent opportunities for feedback and debriefing with the expert. This allowed the residents to acquire different types of skills, cognitive or otherwise, which will maximise their competence. We can also say that the combination of simulation-based training and the latest computer software has paved the way towards competence-based training, not only for residents but also for a particular group of teachers that still view information and communication technologies with suspicion and are reluctant to embrace change.<a class="elsevierStyleCrossRefs" href="#bib0235">19,20,25</a>ConclusionsSimulation-based training increases the success rate and reduces the complications associated with ultrasound-guided nerve block by improving identification of anatomical structures and image interpretation, and helping clinicians develop the skills needed for good visualisation of the needle and the spread of local anaesthetic.FundingThis study was not funded by grants from the public sector, trade sector or non-profit entities.Conflicts of interestThe authors have no conflict of interest to declare.AcknowledgementsWe would like to thank the anaesthesiology residents of the Industrial University of Santander for participating in this study, and the University Hospital of Santander, and the Industrial University of Santander for their cooperation." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1188397" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1108248" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1188398" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1108247" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "sec0036" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-11-17" "fechaAceptado" => "2019-01-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1108248" "palabras" => array:7 [ 0 => "DEcS" 1 => "Nerve block anaesthesia" 2 => "Ultrasound" 3 => "Brachial plexus" 4 => "Simulation training" 5 => "Competency-based education" 6 => "Learning curve" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1108247" "palabras" => array:7 [ 0 => "DeCDS español" 1 => "Anestesia de conducción" 2 => "Ultrasonografía" 3 => "Plexo braquial" 4 => "Simulación" 5 => "Educación basada en competencias" 6 => "Curva de aprendizaje" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionThe teaching based on simulation and acquisition of skills is changing the paradigm of education and restructuring the clinical residences, with the aim of acquiring better skills, increasing procedural success, reducing complications, as well as providing safe, effective, and efficient and focused care of the patient. Peripheral nerve blocks have advanced as techniques for anatomical repairs, use of neurostimulator, and ultrasound. The postgraduate anaesthesiology program implemented a teaching program that included phases of theoretical teaching, training with simulated models, and application in real scenarios. ObjectiveTo analyse the success, the management of the ultrasound equipment and the incidence of complications of ultrasound-guided supraclavicular blocks (BSE) in the clinical scenario, performed by residents of anaesthesiology previously trained with a theoretical and simulated model. MethodsProspective cohort study among residents of anaesthesiology (R1, R2, R3, R4), who received previous theoretical–practical training on simulated models. The evaluation was performed by expert anaesthesiologists, with video analysis of the ultrasound screen performed at the time of BSE initiation. ResultsThe evaluation included 16 residents, who performed 156 BSE. None had previous experience in ultrasound-guided blocks. The success of the block was 96.15%. The team management was excellent (from 86% to 95%), with no significant differences among the residents (p=.61). The incidence of complications was 0.64%, corresponding to arterial puncture. ConclusionsIn BSE, previous training with a theoretical and simulated model could increase the probability of success and reduce complications. With adequate training, first year residents managed to successfully carry out the procedure." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa enseñanza basada en simulación y adquisición de competencias está cambiando el paradigma de la educación y reestructurando las residencias clínicas, con el objetivo de adquirir mejores competencias, aumentar el éxito en los procedimientos, disminuir complicaciones y brindar atención segura, efectiva, eficiente y centrada en el paciente. Los bloqueos nerviosos periféricos han evolucionado en su realización desde técnicas por reparos anatómicos hasta el uso de neuroestimulador y ultrasonido. En nuestro posgrado de anestesiología se implementó un programa de enseñanza que incluye fases de enseñanza teórica, entrenamiento con modelos simulados y aplicación en escenario real. ObjetivoAnalizar el éxito, el manejo del equipo de ecografía y la incidencia de complicaciones de los bloqueos supraclaviculares ecoguiados (BSE) en el escenario clínico, realizados por los residentes de anestesiología previamente entrenados con modelo teórico y simulado. MétodosEstudio de cohorte prospectivo, entre residentes de anestesiología (R1, R2, R3, R4) quienes recibieron entrenamiento previo teórico-práctico en modelos simulados. La evaluación se realizó por anestesiólogos expertos con análisis de video de la pantalla del ecógrafo realizado al momento del inicio del BSE. ResultadosFueron evaluaron 16 residentes, quienes realizaron 156 BSE. Ninguno tenía experiencia previa en bloqueos ecoguiados. El éxito del bloqueo fue del 96,15%, el manejo del equipo fue excelente (del 86 al 95%), sin diferencias significativas entre los residentes (p=0,61). La incidencia de complicaciones fue del 0,64%, correspondiente a punción arterial. ConclusionesEn BSE, el entrenamiento previo con modelo teórico y simulado podría aumentar la probabilidad de éxito y disminuir las complicaciones. Los residentes desde primer año con un adecuado entrenamiento logran ser exitosos en la realización del procedimiento." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "☆ Please cite this article as: Rueda Rojas VP, Meléndez Flórez HJ, Orozco Galvis E. Análisis del entrenamiento previo con modelos simulados en el porcentaje de éxito del bloqueo supraclavicular guiado por ultrasonido. Estudio de cohorte prospectivo. Rev Esp Anestesiol Reanim. 2019;66:241–249." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0065" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1855 "Ancho" => 1463 "Tamanyo" => 400269 ] ] "descripcion" => array:1 [ "en" => "Accumulated success rates according to year of residency, device management and number of punctures. Punctures vs. successful blockade (p=0.842). Year of residency vs. successful blockade (p=0.224)." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Variable evaluated and score</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Device management \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Excellent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fair \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poor \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Basic management</td><td class="td" title="table-entry " align="left" valign="top">Achievement: turn off and on, choice of transducer, depth, overall gain, regional gain, scan mode, device covers, basic care, cleaning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only achieves: on, off, depth and gain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not achieve: depth or gain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Image optimisation</td><td class="td" title="table-entry " align="left" valign="top">Achieves: stability, sharpness, typical, mastery of laterality and centring \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only achieves: stability, typical and mastery of laterality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Image not stable, not typical, no mastery of laterality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Image interpretation with: scanning, Doppler, birefringence, morphology, collapsibility, pulsatility</td><td class="td" title="table-entry " align="left" valign="top">Interpretation of typical image \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sub-optimal image interpretation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No image interpretation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Needle visualisation: in plane, out of plane, bevel, tip, approach and tracking</td><td class="td" title="table-entry " align="left" valign="top">Visualises: approach, bevel, tip, tracking and complete spread of the local anaesthetic in the brachial plexus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Visualises: distal segment, brightness and bevel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Visualises: only proximal segment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No needle visualisation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only visualises tissue movement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">× \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027837.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Operational definition and device management scores." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Fr: frequency." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean SD (min–max) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.62 (15–76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.56 (43–140) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Height \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.764 (1–1.85) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.86 (19.33–48.68) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027834.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% (Fr) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">ASA % (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.21 (83) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.87 (70) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.92 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Surgery % (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scheduled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.92 (81) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emergency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.08 (75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Laterality % (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.33 (91) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.67 (65) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of nerve block % (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Analgesic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.21 (83) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthetic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.79 (73) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027833.png" ] ] ] ] "descripcion" => array:1 [ "en" => "General characteristics." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Fr: frequency.Statistically significant values shown in bold." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable evaluated \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Excellent% (Fr) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fair % (Fr) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Device management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6142 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86.95 (60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.05 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95.23 (40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.77 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93.93 (31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.03 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.70 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.30 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Average \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.03 (142) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Image optimisation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0258 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75.36 (52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23.2 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97.62 (41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.38 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87.70 (29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.09 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">p* \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.97 (131) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Image interpretation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.022 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76.81 (53) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23.19 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88.10 (37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.90 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.97 (32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.03 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.67 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.33 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.33 (130) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Needle visualisation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.13 (27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.72 (35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.90 (26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.10 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.70 (23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.27 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to needle visualisation (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5761 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to spread of local anaesthetic (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6101 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027841.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of punctures % (Fr)</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of punctures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.050 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.2 (45) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.1 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.3 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85.71 (36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.1 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.4 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.8 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.70 (22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.3 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.70 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.3 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027839.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Handling of ultrasound device and puncture, by group." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "(x¯): average concentrations; Vol: volume, ml; Min: minimum; Max: maximum.a No difference between success and concentration local anaesthetic." "tablatextoimagen" => array:5 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Successful block % (Fr) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.15 (150) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Year of residency, n</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.75 (64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.224 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.97 (32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">R4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Punctures, n</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.49 (110) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.842 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.94 (31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027836.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">R1 vs. R3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to needle visualisation (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.78/1.93 minutes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.615 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to spread of local anaesthetic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.21/2.71 minutes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.627 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027835.png" ] ] 2 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difference between first and last block (p) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">R1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">R2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">R3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">R4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.443 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.418 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.451 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027838.png" ] ] 3 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anaesthetic used (Fr)</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lidocaine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 (138) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.471 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bupivacaine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (140) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.348 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Both \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.1 (128) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.892 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027840.png" ] ] 4 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">(x¯) Min–Max \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vol, x¯ (Min–Max) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lidocainea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.5 (0.5, −2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.18 (5, −30) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bupivacainea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.45 (0.15, −0.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.1 (5, −40) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2027842.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Successful block according to punctures, year of residency and anaesthetic." ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 8289 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0145" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anesthesia of the brachial plexus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. 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Analysis of previous training with simulated models on the success rate of ultrasound-guided supraclavicular block. Prospective cohort study

Análisis del entrenamiento previo con modelos simulados en el porcentaje de éxito del bloqueo supraclavicular guiado por ultrasonido. Estudio de cohorte prospectivo

V.P. Rueda Rojasa,

Corresponding author

viparuro11@hotmail.com

Corresponding author.

, H.J. Meléndez Flórezb, E. Orozco Galvisc

a Servicio de Anestesiología y Reanimación, Hospital Universitario de Santander, Universidad Industrial de Santander, Bucaramanga (Santander), Colombia

b Departamento de Anestesiología y Reanimación, Especialidad de Medicina Crítica y Terapia Intensiva, Docencia Universitaria, Epidemiología, Universidad Industrial de Santander, Bucaramanga (Santander), Colombia

c Departamento de Anestesiología y Reanimación, Universidad Industrial de Santander, Bucaramanga (Santander), Colombia

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Supraclavicular brachial plexus block &#40;BPB&#41; was first performed by Halstedt in 1884&#44; after surgically exposing the brachial plexus&#46; The first single puncture percutaneous approach was performed by Kulenkampff in 1911&#44; and required a thorough knowledge of the regional anatomy and large volumes of local anaesthetic&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This approach to upper limb brachial plexus block gives the deepest&#44; fastest acting and most effective anaesthesia&#46; However&#44; it is associated with major complications&#44; such as pneumothorax&#44; local anaesthetic toxicity and nerve injury&#44; prompting an ongoing search for alternatives to improve success and reduce the risk of these adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This led von Perthes to introduce the neurostimulator in 1911&#46; Despite this&#44; however&#44; nerve blockade remained a partially blind technique&#44; with a complication rate as high as 15&#37;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The search for strategies that could reduce complications and increase the success rate of BPB led Grange&#44; in 1978&#44; to perform the technique using ultrasound for the first time&#46; This succeeded in reducing the volume of local anaesthetic required&#44; with no complications&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Subsequent advances in ultrasound technology have shown its value in achieving these objectives&#44; although it requires prior knowledge and training&#44; has a considerable learning curve&#44; and is operator-dependent&#46; For these reasons&#44; expert-led training&#44; retraining and extensive reading are recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Since the 60s&#44; training models have changed in parallel with the progress made in these technologies&#44; and teaching techniques based on simulation and acquisition of skills have been introduced&#46; These methods have brought about a paradigm shift and have restructured the teaching environment by focussing on optimising knowledge and competence to enable clinicians to provide safe&#44; effective&#44; efficient and patient-centred care&#46; Experience has shown them to be optimal educational models for teachers and students&#44; insofar as the give better understanding of clinical cases&#44; improve cognitive and non-cognitive skills&#44; and reduce both the learning curve and the rate of complications in clinical practice&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Anaesthesiology has been among the specialties that have pioneered this type of teaching&#44; from the emergence of <span class="elsevierStyleItalic">resusci-anne</span>&#44; followed by high-fidelity simulation models that provide scenarios to facilitate the acquisition and assessment of skills &#40;resuscitation&#44; airway management&#44; vascular accesses&#41;&#46; Nerve block techniques have evolved from landmark-based techniques&#44; neurostimulator-aided localisation&#44; to the ultrasound-guided techniques prevalent today&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">To reach proficiency in ultrasound-guided nerve blockade &#40;USNB&#41;&#44; anaesthesiologists must not only have sound theoretical knowledge&#44; but should also have undergone simulation training and have personalised their own learning curve until they have achieved the required academic goal&#46; This will ensure they approach clinical practice guided by the ethical principle of non-maleficence&#58; prioritise patient safety&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#44;6&#44;8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patient safety requires clinicians to understand the ultrasound device and its use&#44; be able to identify structures using sonoatomy&#44; have the ability to generate images&#44; track the advance of the needle in real time&#44; and correctly evaluate the spread of the local anaesthetic around the peripheral nerve&#46; Competence in these 3 stages &#40;theoretical knowledge&#44; simulation training and operation of the device&#41; will minimise the risk of complications when performing the technique in clinical practices&#46; However&#44; USNBs&#44; being operator-dependent&#44; are not completely fail-safe&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Simulation-based training has several advantages&#58; it can improve non-technical skills&#44; such as interpersonal relationships&#44; decision-making&#44; or situational awareness&#59; it can be used to reproduce critical and rare clinical cases that are difficult to encounter in clinical practice&#59; it gives immediate feedback&#59; and it allows trainees to practice until they can successfully perform a given procedure&#46; All this leads to fewer complications and increases patient safety&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Niazi et al&#46; have shown that simulation-based training increases the success rate of ultrasound-guided blockade&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a> In their study&#44; which consisted of a theoretical introduction to the basic management of the ultrasound equipment&#44; followed by a practical session in which one group of resident anaesthesiologists without prior experience underwent simulation-based training&#44; the success rate was 64&#37; vs&#46; 51&#37; in the group receiving conventional training&#46; After retraining&#44; the success rate was 80&#37; vs&#46; 40&#37;&#44; respectively&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In a recent meta-analysis&#44; Barrington et al&#46; compared peripheral nerve blockade &#40;PNB&#41; performed with a nerve stimulator vs&#46; ultrasound&#44; and found that patients undergoing USNB presented fewer complications &#40;2&#46;2&#37; versus 5&#46;3&#37;&#41;&#44; vascular puncture &#40;5&#46;1&#37; vs&#46;13&#46;9&#37;&#41;&#44; local anaesthetic toxicity &#40;0&#46;8&#37; vs&#46; 1&#46;2&#37;&#41; and late neurological deficit &#40;0&#46;2&#37; vs&#46; 0&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Based on the foregoing concepts and evidence&#44; and in the setting of a university project involving acquisition of competences and the availability of a simulation laboratory&#44; we hypothesised that prior training would increase the success rate of ultrasound-guided supraclavicular block &#40;USB&#41;&#44; improve management of the ultrasound equipment&#44; and reduce the complication rate compared with reports in the literature&#46; Our primary objective was to evaluate the success of USB of the brachial plexus&#46; Our secondary objectives were to evaluate device management and the incidence of complications in residents that had previously received theoretical and simulation-based training&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0070" class="elsevierStylePara elsevierViewall">We chose 16 postgraduate residents&#44; R1&#44; R2&#44; R3 and R4&#44; who agreed to participate in the study and signed an informed consent form&#46; The R4 group consisted of residents who had already graduated and were in their first year as practising anaesthesiologists&#46; None of the participants had experience in ultrasound-guided brachial plexus blockade or prior knowledge of the parameters evaluated during performance of the ultrasound-guided technique&#46; All 4 groups underwent a 3-stage training program&#46; The data were collected from February 1&#44; 2017 to March 1&#44; 2018&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Stage I&#58; theory&#44; 7 sessions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Stage II&#58; device management&#44; with as many 30-minute sessions as needed until proficiency was acquired&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Stage III&#58; performance of peripheral USNB on simulation models in 30-minute sessions until proficiency had been achieved in 4 areas&#58; device management&#44; image optimisation&#44; image interpretation&#44; and needle visualisation&#46; Proficiency was defined on the basis of 4 outcomes&#58; device management&#44; optimisation and interpretation of the image&#44; and view of the needle&#46; The following simulation models were used&#58; Branched Two Vessel Blue Phantom &#40;CAE Healthcare<span class="elsevierStyleSup">&#174;</span>&#41; for hydrodissection&#44; and animal models &#40;chicken breasts&#41; for puncture and needle visualisation&#46; We also used LM<span class="elsevierStyleSup">&#174;</span> mannequins for needle viewing and image interpretation&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">After each participant had completed their training stage individually and in their own time&#44; a Canon Vixia HFR700 video camera was placed in the operating room by personnel not involved in the study&#44; and the entire procedure was recorded&#44; without interfering in the anaesthetic decision taken by each participant and their teacher or tutor&#46; The operational variables selected for each procedure were evaluated individually&#46; In order to guarantee anonymity&#44; enlargement lenses that impeded visualisation of the participant were used&#46; All nerve blocks were performed using the Sonosite Edge II ultrasound system&#46; The evaluators did not intervene in the procedure at any time&#44; and the videos were analysed by 2 anaesthesiologists with expertise in ultrasound-guided regional anaesthesia no less than 24<span class="elsevierStyleHsp" style=""></span>h after they had been recorded&#46; Using the video images&#44; the experts evaluated the following variables&#58; device management&#44; optimisation and interpretation of the image&#44; and view of the needle&#46; These were rated as excellent&#44; fair or poor&#44; according to the criteria defined in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> &#40;definition of variables&#41;&#46; The following variables were also evaluated&#58;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Successful blockade&#58; defined as a score of excellent in each area &#40;device management&#44; image optimisation&#44; image interpretation and needle visualisation&#41;&#44; in addition to obtaining sufficient motor and sensory blockade to perform the procedure or for postoperative analgesia&#44; and the absence of complications&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Unsatisfactory blockade&#58; defined as a score of fair in each area &#40;device management&#44; image optimisation&#44; image interpretation and needle visualisation&#41;&#44; in addition to obtaining sufficient motor and sensory blockade to perform the procedure or for postoperative analgesia&#44; and the absence of complications&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Failed blockade&#58; defined as a score of poor in each area &#40;device management&#44; image optimisation&#44; image interpretation and needle visualisation&#41;&#44; together with failure to obtain sufficient motor and sensory blockade to perform the procedure or for postoperative analgesia&#44; and the presence of complications&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Time to needle visualisation&#58; time &#40;minutes&#41; from placement of the transducer on the skin and visualisation of the entire needle path to complete hydrodissection of the brachial plexus&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Time to local anaesthetic spread&#58; time &#40;minutes&#41; from placement of the needle tip over the brachial plexus until complete spread of the local anaesthetic&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Procedure time&#58; defined as the time &#40;minutes&#41; from skin puncture until ultrasound verification of the spread of the local anaesthetic around the brachial plexus&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Number of punctures&#58; 1 puncture was defined as insertion over the brachial plexus identified with the transducer&#59; each additional puncture was defined as the need to completely withdraw the needle to the level of the skin&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Complications&#58; arterial puncture confirmed by return of arterial blood into the needle&#46; Haematoma was defined as evidence of blood collecting at the puncture site&#59; Pneumothorax or haemothorax were confirmed by radiological imaging after the puncture&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The type and concentration of local anaesthetic used and the volume injected &#40;within therapeutic ranges&#41; were chosen at the discretion of the anaesthesiologist and the resident&#46; The researchers merely collected and analysed these variables&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">All the variables were evaluated and analysed using the Student&#39;s t test&#44; chi-squared or analysis of variance&#44; depending on whether they were dichotomous&#44; ordinal or continuous&#46; A success curve was constructed according to the number of years of residency&#44; number of punctures&#44; and the presence of differences in device management and successful USNB&#46; The data obtained were entered into a codified Excel database and exported to Stata 14&#46;0 for analysis &#40;Stata Products<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0145" class="elsevierStylePara elsevierViewall">At total of 156 BPBs were performed in 156 patients with an average age of 37 years&#59; 52&#37; underwent emergency surgery&#44; women were in the minority &#40;43&#37;&#41;&#44; and the average body mass index was 23&#46; BPD was performed on the right side in 58&#37; of cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The 156 BPBs evaluated were performed by 16 residents&#44; 4 from each year of residency&#44; with an average of 13 blocks per resident&#46; The R4 group comprised anaesthesiologists in their first year of clinical practice&#46; All passed the simulator-based training&#44; based on the success variables&#44; and none had previous experience in ultrasound or in the variables evaluated&#46; The previous experience in landmark-based technique of subjects in the R2&#44; R3 and R4 will be discussed below&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Device-related variables&#44; such as management and optimisation and interpretation of the image&#44; were rated excellent&#44; with average values of 83&#46;3&#37; and 91&#46;7&#37;&#46; When evaluated by year of residency&#44; significant differences were observed in only the latter 2 variables &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; in which the R2 and R3 groups achieved higher success rates &#40;97&#46;6 and 96&#46;9&#37;&#41;&#46; With regard to punctures&#44; needle visualisation obtained the lowest excellent rating among residents &#40;25&#8211;69&#37;&#41;&#44; although significant differences were observed between these groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#46; The mean time to needle visualisation and local anaesthetic spread did not show significant differences in terms of years of residency &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Similarly&#44; comparing success in terms of time and number of attempts between R1 and R3 showed no significant differences &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">BPB was performed with a single puncture in 73&#46;08&#37; of cases&#44; and only 5&#46;77&#37; required 3 or 4 punctures&#44; specifically&#44; in groups R1 and R2&#46; Subjects in R4 achieved greater first-attempt success in BPB&#44; and although the statistical significance observed when analysing the data by year of residency and number of punctures was dependent on the cutoff point &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; this result will be discussed later &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Overall&#44; the BPB success rate was 96&#46;15&#37; &#40;CI 95&#37;&#58; 91&#46;8&#8211;98&#46;6&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>150&#41;&#44; with a higher first-attempt success rate&#44; although this difference was not statically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;842&#41;&#46; Neither did we observe significant differences after adjusting for year of residency and choice of anaesthetic agent&#44; with minimum values of 92&#46;75&#37; for R1 and 100&#37; for R3 and R4&#46; After adjusting for number of punctures&#44; time to needle visualisation and spread of local anaesthetic&#44; no significant differences were observed between R1 and R3 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;6154&#59; 0&#46;6275 and 0&#46;356&#41;&#46; No significant differences were observed between the first and last blockade performed by each subject evaluated&#44; since the only failed blocks occurred in R1 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41; and R3 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; The only significant difference was the ascending curve and the marginally significant difference in the number of attempts &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;050&#41; &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Success measured by the number of punctures was greater than 90&#37;&#44; and when analysed by year of residency&#44; the R3 and R4 groups achieved 100&#37; success at the first puncture&#44; in contrast to R1 and R2&#44; that achieved an average success rate of 90&#37;&#44; and also required up to 4 punctures to achieve 100&#37; success&#46; No significant differences were observed when the data were adjusted for number of punctures and year of residency &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The overall success curve calculated on the basis of the number of attempts and device management showed important differences in terms of performance and number of punctures&#46; The accumulated overall first-attempt success rate of the entire cohort was 73&#46;88&#37;&#44; with a gain of 20&#37; at the second puncture &#40;94&#37;&#41;&#46; From that point on&#44; the proportional gain in 100&#37; success was minor&#58; 4&#37; and 2&#37;&#44; respectively&#46; The overall success curve shows a linear correlation of <span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#46;786&#44; which is defined as good &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The only complication presented was arterial puncture&#44; which occurred in 0&#46;64&#37; of procedures&#44; with no difference between years of residency&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0180" class="elsevierStylePara elsevierViewall">In competency-based learning&#44; simulation-based training plays an important role in unifying theoretical knowledge with real-world scenarios&#44; optimising performance of the simplest to the most complex procedures&#44; increasing success rates and reducing the number of complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9&#44;11&#44;12&#44;16&#8211;18</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">This hypothesis and these parameters were the basis for this study&#46; We believe that the strength of our work lies in the prior training described in the materials and methods section&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> which was far longer that the time allocated to such simulation-based practise in other studies&#44; which does not exceed 60<span class="elsevierStyleHsp" style=""></span>minutes&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Several meta-analyses and systematic reviews have shown that simulation-based medical training achieves superior results than conventional methods&#46; Grantcharov and Reznick showed that simulation-based training is more effective than the costly&#44; slow and inconsistent &#8220;see one&#44; make one&#8221; method&#46; Inselberg et al&#46; also claim that training using simulation models improves technical skills and overall compentence&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">We cannot ignore the fact that ultrasound is &#8220;operator-dependent&#8221; and this &#8220;mutual interaction&#8221; based on training and retraining is fundamental to achieve proficiency in BPB&#46; We are certain that giving our subjects to opportunity to learn how to use the ultrasound device and acquire knowledge of upper limb anatomy and sonoatomy in the preliminary stage of our study had a positive influence on the results obtained&#59; this has been supported by studies&#44; guidelines&#44; procedural manuals&#44; and is endorsed by scientific societies&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9&#44;12&#44;14&#44;17&#44;21&#44;22</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The device management-related variables are not totally &#8220;friendly&#8221;&#58; we obtained excellent ratings&#44; ranging from a mean of 83&#37; and 91&#37;&#44; for device management&#44; optimisation and interpretation of the image&#46; Image optimisation and interpretation are influenced by the knowledge acquired in the training phase&#44; which also influences device management&#44; and knowledge of upper limb anatomy and sonoatomy&#46; This learning should be supervised by an expert in regional anaesthesia&#46; Mastery in these variables is achieved with good training in simulation models&#44; with knowledge of the ultrasound device&#44; choice of the right transducer and good transducer placement skills to obtain direct visualisation of the plexus&#46; Taken together&#44; these factors can optimise the technique and guarantee the success of the blockade by ensuring good hydrodissection&#46; This&#44; according to the literature&#44; reduces local anaesthetic requirements and minimises the risk of complications&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Anaesthesiologists that have received both theoretical and simulation-based training achieve higher success rates than those that have learnt the technique solely in clinical practice&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#44;6&#44;13&#44;19</span></a> However&#44; proficiency in puncture-related variables was far lower&#44; ranging from 25&#37; to 69&#37;&#46; The R2 and R3 groups achieved the highest rating compared to R4&#44; where the lowest ratings were recorded&#46; One explanation for this could be the more recent training received by the former 2 groups&#44; which illustrates the need for continuous&#44; updated training in these techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#44;6&#44;23</span></a> Our findings are consistent with those of other authors who found that puncture skills proved the most difficult&#44; and could lead to excessive needle depth and vascular puncture and pneumothorax&#46; These skills can be improved by devoting more time to practising on simulation models&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;24</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Finally&#44; the variables that most influenced the success of BPB in terms of device management were good visualisation of the needle&#44; and image optimisation and interpretation&#46; These findings are consistent with those reported by Niazi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">With respect to the percentage of successful blockade and the learning curve&#44; we found a success rate higher than 94&#37;&#44; with 13 blocks on average&#46; According to the literature&#44; the learning curve for landmark-based supraclavicular nerve block is 40 blocks<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a> vs&#46; between 4 and 17 for ultrasound-guided block with prior simulation-based training&#44; which is in line with our findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">13&#44;26</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Similarly&#44; between 4 and 17 nerve blocks are required to achieve success in simulation models&#44; while the group without simulation training required more than 17&#46; Our residents achieved a success rate of over 90&#37;&#44; even when adjusted by year of residency and number of punctures&#46; This could be due to previous experience in the case of groups R3 and R4&#44; which gave them a higher first-attempt success rate&#46; It could also suggest that more advanced residents become more confident when they consolidate their technique and achieve success at the first attempt&#44; and that these results could be due to their prior experience in landmark-based techniques&#46; However&#44; studies have shown that experience in landmark-based nerve block does not give greater success than simulation-based training&#44; which has been shown to increase the success of BPB compared to traditional teaching methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;22</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Similar findings are obtained when success rates are plotted on CUSUM charts&#44; insofar as procedure-naive anaesthesiologists who underwent simulation-based vs&#46; conventional training achieved a success rate 64&#37; and 51&#37;&#44; respectively&#44; while residents retrained using simulation models achieved a success rate of 80&#37; versus 40&#37; in conventional training methods&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Our study supports the findings of other authors studying success rates in professionals trained using simulation models and the impact of this approach on patient safety&#44; in terms of fewer complications&#44; fewer punctures&#44; and faster performance times compared to traditional methods and the use of peripheral nerve stimulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3&#44;20&#8211;28</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">In examining the strengths and weaknesses of our study&#44; we should mention the absence of a control group&#44; and of a &#8220;before and after&#8221; on which to compare performance&#46; Nevertheless&#44; the performance of residents was taken as a reference parameter for comparison&#46; The prior training of these professionals became their strength and the method is recommended&#44; because studying the different stages of simulation-based training up to performance of the technique on real patients provides excellent opportunities for feedback and debriefing with the expert&#46; This allowed the residents to acquire different types of skills&#44; cognitive or otherwise&#44; which will maximise their competence&#46; We can also say that the combination of simulation-based training and the latest computer software has paved the way towards competence-based training&#44; not only for residents but also for a particular group of teachers that still view information and communication technologies with suspicion and are reluctant to embrace change&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">19&#44;20&#44;25</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">Simulation-based training increases the success rate and reduces the complications associated with ultrasound-guided nerve block by improving identification of anatomical structures and image interpretation&#44; and helping clinicians develop the skills needed for good visualisation of the needle and the spread of local anaesthetic&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0245" class="elsevierStylePara elsevierViewall">This study was not funded by grants from the public sector&#44; trade sector or non-profit entities&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span><span id="sec0036" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0106">Acknowledgements</span><p id="par0251" class="elsevierStylePara elsevierViewall">We would like to thank the anaesthesiology residents of the Industrial University of Santander for participating in this study&#44; and the University Hospital of Santander&#44; and the Industrial University of Santander for their cooperation&#46;</p></span></span>"
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            0 => "DEcS"
            1 => "Nerve block anaesthesia"
            2 => "Ultrasound"
            3 => "Brachial plexus"
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            1 => "Anestesia de conducci&#243;n"
            2 => "Ultrasonograf&#237;a"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The teaching based on simulation and acquisition of skills is changing the paradigm of education and restructuring the clinical residences&#44; with the aim of acquiring better skills&#44; increasing procedural success&#44; reducing complications&#44; as well as providing safe&#44; effective&#44; and efficient and focused care of the patient&#46; Peripheral nerve blocks have advanced as techniques for anatomical repairs&#44; use of neurostimulator&#44; and ultrasound&#46; The postgraduate anaesthesiology program implemented a teaching program that included phases of theoretical teaching&#44; training with simulated models&#44; and application in real scenarios&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To analyse the success&#44; the management of the ultrasound equipment and the incidence of complications of ultrasound-guided supraclavicular blocks &#40;BSE&#41; in the clinical scenario&#44; performed by residents of anaesthesiology previously trained with a theoretical and simulated model&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Prospective cohort study among residents of anaesthesiology &#40;R1&#44; R2&#44; R3&#44; R4&#41;&#44; who received previous theoretical&#8211;practical training on simulated models&#46; The evaluation was performed by expert anaesthesiologists&#44; with video analysis of the ultrasound screen performed at the time of BSE initiation&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The evaluation included 16 residents&#44; who performed 156 BSE&#46; None had previous experience in ultrasound-guided blocks&#46; The success of the block was 96&#46;15&#37;&#46; The team management was excellent &#40;from 86&#37; to 95&#37;&#41;&#44; with no significant differences among the residents &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;61&#41;&#46; The incidence of complications was 0&#46;64&#37;&#44; corresponding to arterial puncture&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In BSE&#44; previous training with a theoretical and simulated model could increase the probability of success and reduce complications&#46; With adequate training&#44; first year residents managed to successfully carry out the procedure&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La ense&#241;anza basada en simulaci&#243;n y adquisici&#243;n de competencias est&#225; cambiando el paradigma de la educaci&#243;n y reestructurando las residencias cl&#237;nicas&#44; con el objetivo de adquirir mejores competencias&#44; aumentar el &#233;xito en los procedimientos&#44; disminuir complicaciones y brindar atenci&#243;n segura&#44; efectiva&#44; eficiente y centrada en el paciente&#46; Los bloqueos nerviosos perif&#233;ricos han evolucionado en su realizaci&#243;n desde t&#233;cnicas por reparos anat&#243;micos hasta el uso de neuroestimulador y ultrasonido&#46; En nuestro posgrado de anestesiolog&#237;a se implement&#243; un programa de ense&#241;anza que incluye fases de ense&#241;anza te&#243;rica&#44; entrenamiento con modelos simulados y aplicaci&#243;n en escenario real&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analizar el &#233;xito&#44; el manejo del equipo de ecograf&#237;a y la incidencia de complicaciones de los bloqueos supraclaviculares ecoguiados &#40;BSE&#41; en el escenario cl&#237;nico&#44; realizados por los residentes de anestesiolog&#237;a previamente entrenados con modelo te&#243;rico y simulado&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte prospectivo&#44; entre residentes de anestesiolog&#237;a &#40;R<span class="elsevierStyleInf">1</span>&#44; R<span class="elsevierStyleInf">2</span>&#44; R<span class="elsevierStyleInf">3</span>&#44; R<span class="elsevierStyleInf">4</span>&#41; quienes recibieron entrenamiento previo te&#243;rico-pr&#225;ctico en modelos simulados&#46; La evaluaci&#243;n se realiz&#243; por anestesi&#243;logos expertos con an&#225;lisis de video de la pantalla del ec&#243;grafo realizado al momento del inicio del BSE&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fueron evaluaron 16 residentes&#44; quienes realizaron 156 BSE&#46; Ninguno ten&#237;a experiencia previa en bloqueos ecoguiados&#46; El &#233;xito del bloqueo fue del 96&#44;15&#37;&#44; el manejo del equipo fue excelente &#40;del 86 al 95&#37;&#41;&#44; sin diferencias significativas entre los residentes &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;61&#41;&#46; La incidencia de complicaciones fue del 0&#44;64&#37;&#44; correspondiente a punci&#243;n arterial&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En BSE&#44; el entrenamiento previo con modelo te&#243;rico y simulado podr&#237;a aumentar la probabilidad de &#233;xito y disminuir las complicaciones&#46; Los residentes desde primer a&#241;o con un adecuado entrenamiento logran ser exitosos en la realizaci&#243;n del procedimiento&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara" id="npr0005"><span class="elsevierStyleSup">&#9734;</span> Please cite this article as&#58; Rueda Rojas VP&#44; Mel&#233;ndez Fl&#243;rez HJ&#44; Orozco Galvis E&#46; An&#225;lisis del entrenamiento previo con modelos simulados en el porcentaje de &#233;xito del bloqueo supraclavicular guiado por ultrasonido&#46; Estudio de cohorte prospectivo&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;241&#8211;249&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0305" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0065"
          ]
        ]
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1855
            "Ancho" => 1463
            "Tamanyo" => 400269
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Accumulated success rates according to year of residency&#44; device management and number of punctures&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Punctures vs&#46; successful blockade &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;842&#41;&#46; Year of residency vs&#46; successful blockade &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;224&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Variable evaluated and score</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Device management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Excellent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Basic management</td><td class="td" title="table-entry  " align="left" valign="top">Achievement&#58; turn off and on&#44; choice of transducer&#44; depth&#44; overall gain&#44; regional gain&#44; scan mode&#44; device covers&#44; basic care&#44; cleaning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only achieves&#58; on&#44; off&#44; depth and gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not achieve&#58; depth or gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Image optimisation</td><td class="td" title="table-entry  " align="left" valign="top">Achieves&#58; stability&#44; sharpness&#44; typical&#44; mastery of laterality and centring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only achieves&#58; stability&#44; typical and mastery of laterality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Image not stable&#44; not typical&#44; no mastery of laterality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Image interpretation with&#58; scanning&#44; Doppler&#44; birefringence&#44; morphology&#44; collapsibility&#44; pulsatility</td><td class="td" title="table-entry  " align="left" valign="top">Interpretation of typical image&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sub-optimal image interpretation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No image interpretation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Needle visualisation&#58; in plane&#44; out of plane&#44; bevel&#44; tip&#44; approach and tracking</td><td class="td" title="table-entry  " align="left" valign="top">Visualises&#58; approach&#44; bevel&#44; tip&#44; tracking and complete spread of the local anaesthetic in the brachial plexus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Visualises&#58; distal segment&#44; brightness and bevel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Visualises&#58; only proximal segment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No needle visualisation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only visualises tissue movement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#215;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Operational definition and device management scores&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Fr&#58; frequency&#46;</p>"
          "tablatextoimagen" => array:2 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean SD &#40;min&#8211;max&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;62 &#40;15&#8211;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#46;56 &#40;43&#8211;140&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Height&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;764 &#40;1&#8211;1&#46;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;86 &#40;19&#46;33&#8211;48&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; &#40;Fr&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">ASA &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;21 &#40;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#46;87 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;92 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Surgery &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Scheduled&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&#46;92 &#40;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emergency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;08 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Laterality &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;33 &#40;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;67 &#40;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of nerve block &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Analgesic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;21 &#40;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anaesthetic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;79 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Fr&#58; frequency&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Statistically significant values shown in bold&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable evaluated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Excellent&#37; &#40;Fr&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fair &#37; &#40;Fr&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Device management</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6142&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#46;95 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;05 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&#46;23 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;77 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">93&#46;93 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;03 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#46;70 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;30 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Average&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#46;03 &#40;142&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Image optimisation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;0258</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#46;36 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;2 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#46;62 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;38 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&#46;70 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;09 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">p</span>&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#46;97 &#40;131&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Image interpretation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;022</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&#46;81 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;19 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#46;10 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;90 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#46;97 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;03 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#46;67 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;33 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#46;33 &#40;130&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Needle visualisation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;004</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;13 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#46;72 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#46;90 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#46;10 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#46;70 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;27 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Time to needle visualisation &#40;min&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5761&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Time to spread of local anaesthetic &#40;min&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of punctures &#37; &#40;Fr&#41;</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Number of punctures</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;050&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;2 &#40;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;1 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;3 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;5 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#46;71 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;1 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;4 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;8 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#46;70 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;3 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#46;70 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;3 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Handling of ultrasound device and puncture&#44; by group&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">&#40;x&#175;&#41;&#58; average concentrations&#59; Vol&#58; volume&#44; ml&#59; Min&#58; minimum&#59; Max&#58; maximum&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> No difference between success and concentration local anaesthetic&#46;</p>"
          "tablatextoimagen" => array:5 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Successful block &#37; &#40;Fr&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;15 &#40;150&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Year of residency&#44; n</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;75 &#40;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;224&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;97 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>R<span class="elsevierStyleInf">4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Punctures&#44; n</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;49 &#40;110&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;842&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;94 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">R1 vs&#46; R3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time to needle visualisation &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;615&nbsp;\t\t\t\t\t\t\n
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