Acute Mental Stress During Lumbar Puncture

Study Overview
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Brief Summary
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This study explores lumbar puncture operators stress associated with their performance of the procedure, across three experience levels: Experts, Intermediates, and Novices. The study will investigate the association of this potential stress to patient experienced stress and patient related outcomes of the lumbar puncture procedure.

Detailed Description
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The consequences of being in a state of Acute Mental Stress are reduced working memory, decreased psychomotor performance, and impaired performance. Although some levels of increased stress response might be beneficial, there seems to be an upper-limit when performance is reduced. According to the Cognitive Activation Theory of Stress (CATS), the stress sensation arises when the requirements exceed the resources for a given task. For the LP procedure, a stress sensation among novice residents might arise due to the combination of the LP being a complex procedure depending on both technical as non-technical aspects combined with residents uncertainties for procedural performance and a fear of doing harm. Despite a growing recognition of stress among residents, the acute mental stress of residents performing invasive procedures has been unacknowledged. Within neurology, internal medicine, and emergency medicine a particular subject for this stress might pertain to residents' first performance of the lumbar puncture. However, for non-surgical invasive procedures as the LP, there is a lack of evidence for measurements of AMS across experience levels and how this potential stress might influence the performance and patient related outcomes. Hence, the aim of this study is to explore stress levels across lumbar puncture experience levels and how this potential stress might affect procedural performance and the patients' experience of stress and outcomes of the procedure. Additionally, the study will explore a potential correlation between patient stress and the risk of developing post-dural puncture headache.

Official Title
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Acute Mental Stress Among the Physician and Patient During Lumbar Puncture, and Its Impact on Performance and Patient Related Outcomes

Conditions
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Stress, Emotional, Spinal; Puncture, Complications, Headache, Lumbar Puncture

Participation Criteria
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Eligibility Criteria
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Physicians: Inclusion Criteria physicians: Medical Doctor or Medical student working as substitute junior medical officer Speaking Danish fluently Understanding and accepting study implications For novice group only: Medical student having clinical rotation at the study sites Exclusion Criteria physicians: N/A For expert group physicians: Consultant (or other senior physician position); LP experience > 100 procedures; supervisor for novice performer; Performing LP on a regular basis. For intermediate group physicians: Performing LP on a regular basis; LP experience of 10-80 procedures. For novice group physicians: No previous lumbar puncture experience For patients enrolled in the study: Inclusion Criteria Patients: Referred to the outpatient clinic for a LP; Glasgow Coma Scale 15; Proficiency in the Danish Language; Age between 18 and 80 years; Understanding and accepting study implications Able to co-operate to the procedure without a need for personal assistance; Providing written and orally informed consent Exclusion Criteria Patients: Lumbar puncture intended on suspicion of Alzheimer or another dementia diagnosis; Cognitive impairment, assessed by the study investigator or local nurse/doctor; - Physical disabilities, requiring personal assistance.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Expert<br>The physicians in the Expert-group will perform a LP following local standard procedure protocol. | |
| Intermediate<br>The physicians in the Intermediate-group will perform a LP following local standard procedure protocol. | |
| Novice<br>The physicians in the novice-group will perform a LP following local standard procedure protocol. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cognitive Appraisal | Cognitive Appraisal explores the individuals perception of resources and demands for the performance (scores range from 1/6 to 6) | Five minutes before performance | 
| State Trait Anxiety Inventory - Short (before performance) | A questionaire exploring the stress related anxiety | Five minutes before performance | 
| State Trait Anxiety Inventory - Short (during performance) | A questionaire exploring the stress related anxiety | Just before needle insertion | 
| Heart Rate Variability before performance (Heart rate) | Heart Rate Variability: Heart rate (bp/min) | A recording of 5 minutes obtained five minutes before performance. | 
| Heart Rate Variability before performance (Spectrum analysis) | Heart Rate Variability: Total power (Sum of Low Frequency, Very Low frequency, High Frequency) (ms) | A recording of 5 minutes obtained five minutes before performance. | 
| Heart Rate Variability before performance (Spectrum analysis) | Heart Rate Variability: LF/HF - ratio | A recording of 5 minutes obtained five minutes before performance. | 
| Heart Rate Variability before performance (Timedomain analysis) | Heart Rate Variability before performance Timedomain analysis: RMSDD (ms), pNN50 (%) | A recording of 5 minutes obtained five minutes before performance. | 
| Heart Rate Variability during performance (Heart rate) | Heart Rate Variability: Heart rate (bp/min) | A recording of 5 minutes obtained five minutes before obtaining liquor or abandoning the procedure. | 
| Heart Rate Variability during performance (Spectrum analysis) | Heart Rate Variability: Total Power (Sum of Low Frequency, Very Low frequency, High Frequency) (ms) | A recording of 5 minutes obtained five minutes before obtaining liquor or abandoning the procedure. | 
| Heart Rate Variability during performance (Spectrum analysis) | Heart Rate Variability: LF/HF - ratio | A recording of 5 minutes obtained five minutes before obtaining liquor or abandoning the procedure. | 
| Heart Rate Variability during performance (Timedomain analysis) | Rate Variability before performance Timedomain analysis: RMSDD (ms), pNN50 (%) | A recording of 5 minutes obtained five minutes before obtaining liquor or abandoning the procedure. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patients State Trait Anxiety Inventory - Short | A questionaire exploring the stress related anxiety (scores range from 6-24) | : Five minutes before performance; Just Before Needle insertion; Five minutes after termination of the procedure | 
| Procedure outcomes | Number of needle insertions, | Registered during procedure operation | 
| Procedure outcomes | Failing/abandoning the procedure performance (yes/no) | Registered during procedure operation | 
| Duration of time to needle insertion | A time stamp from first needle penetration of the skin to obtaining the liquor or abandoning the procedure. | Obtained during procedure, Time from needle penetration of the skin to obtaining liquor (mm:ss) | 
| Confidence in operator | A 10-point anchored Likert scale: 0=not confident - 10=very confident | Assessed five minutes after termination of the procedure | 
| Pain intensity during procedure | A 10-point anchored Likert scale; 0= no pain - 10= Worst imaginable pain. | Assessed five minutes after termination of the procedure | 
| Post Dural Puncture Headache | Post Dural Puncture Headache, following the Lübeckers classification | Telephone interview seven days after the procedure performance date | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Lumbar Puncture, Performance of procedures, Stress