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de Carvalho CC, Porto Genuino W, Vieira Morais MC, de Paiva Oliveira H, Rodrigues AI, El-Boghdadly K. Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials. Reg Anesth Pain Med 2024:rapm-2024-105547. [PMID: 38876801 DOI: 10.1136/rapm-2024-105547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/04/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Data suggest that preprocedural ultrasound may improve the efficacy of central neuraxial puncture. However, it remains uncertain whether these findings can be extended to various clinical scenarios, including diverse patient populations and the application of real-time ultrasound guidance. Additionally, it is unclear whether ultrasound-guided techniques improve safety and patient-centered outcomes. METHODS We searched six databases for randomized trials of adult patients undergoing neuraxial puncture, comparing real-time ultrasound, preprocedural ultrasound, and landmark palpation for efficacy, safety and patient-centered outcomes. Our primary outcome was a failed first-attempt neuraxial puncture. After two-person screening and data extraction, meta-analyses were conducted and the Grading of Recommendations Assessment, Development and Evaluation approach was applied to assess the certainty of evidence. RESULTS Analysis of 71 studies involving 7153 patients, both real-time ultrasound (OR 0.30; 95% credible interval (CrI) 0.15 to 0.58; low certainty) and preprocedural ultrasound (OR 0.33; 95% CrI 0.24 to 0.44; moderate certainty) showed a significant reduction in the risk of a failed first neuraxial puncture. Real-time ultrasound had the best performance for preventing first-attempt failures (low certainty evidence). Although real-time ultrasound was also the leading method for reducing the risk of complete neuraxial puncture failure, the results did not show a statistically significant difference when compared with landmark palpation. Preprocedural ultrasound, however, significantly reduced the odds of complete puncture failure (OR 0.29; 95% CrI 0.11 to 0.61). These ultrasound-guided approaches also contributed to a reduction in certain complications and increased patient satisfaction without any other significant differences in additional outcomes. Trial sequential analysis confirmed that sufficient information was achieved for our primary outcome. CONCLUSIONS Ultrasound-guided neuraxial puncture improves efficacy, reduces puncture attempts and needle redirections, reduces complication risks, and increases patient satisfaction, with low to moderate certainty of evidence. Despite real-time ultrasound's high ranking, a clear superiority over preprocedural ultrasound is not established. These results could prompt anesthesiologists and other clinicians to reassess their neuraxial puncture techniques.
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Affiliation(s)
- Clístenes Crístian de Carvalho
- Academic Unit of Medicine, Federal University of Campina Grande, Campina Grande, Brazil
- Real Hospital Português, Recife, Pernambuco, Brazil
| | | | | | - Heleno de Paiva Oliveira
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Adolfo Igor Rodrigues
- Academic Unit of Medicine, Federal University of Campina Grande, Campina Grande, Brazil
| | - Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Medicine, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
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Kamimura Y, Yamamoto N, Shiroshita A, Miura T, Tsuji T, Someko H, Imai E, Kimura R, Sobue K. Comparative efficacy of ultrasound guidance or conventional anatomical landmarks for neuraxial puncture in adult patients: a systematic review and network meta-analysis. Br J Anaesth 2024; 132:1097-1111. [PMID: 37806932 DOI: 10.1016/j.bja.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/14/2023] [Accepted: 09/02/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Preprocedural, real-time, and computer-aided three-dimensional ultrasound has been widely used for neuraxial puncture; however, the optimal guidance is unclear. We examined the comparative efficacy of three ultrasound guidance and anatomical landmarks for neuraxial puncture in adults. METHODS We searched for randomised controlled studies comparing the efficacy of ultrasound guidance and anatomical landmarks for neuraxial puncture in adults using electronic databases and unpublished studies. The primary outcomes were first-pass success and patient satisfaction. A random-effects network meta-analysis (NMA) was used. RESULTS We identified 74 eligible studies (7090 patients). Preprocedural ultrasound and real-time ultrasound-guided neuraxial puncture improved first-pass success compared with anatomical landmarks (risk ratio [RR] 1.6; 95% credible interval [CrI] 1.3-1.9; RR 1.9; 95% CrI 1.3-2.9, respectively, moderate confidence). Computer-aided ultrasound-guided neuraxial puncture also increased first-pass success (RR 1.8; 95% CrI 0.97-3.3, low confidence), although estimates were imprecise. However, real-time ultrasound-guided neuraxial puncture resulted in minimal difference in first-pass success compared with preprocedural ultrasound (RR 1.2; 95% CrI 0.8-1.8, moderate confidence). Preprocedural ultrasound improved patient satisfaction slightly compared with anatomical landmark use (standardised mean differences 0.28; 95% CrI 0.092-0.47, low confidence). CONCLUSIONS This NMA provides evidence supporting ultrasound-guided neuraxial puncture compared with use of anatomical landmarks, including indirect comparisons. Among the three ultrasound guidance methods, preprocedural ultrasound appears to be a better adjunctive option.
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Affiliation(s)
- Yuji Kamimura
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan; Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Norio Yamamoto
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Orthopaedic Surgery, Miyamoto Orthopaedic Hospital, Okayama, Japan; Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.
| | - Akihiro Shiroshita
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Takanori Miura
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Orthopaedic Surgery, Akita Rosai Hospital, Akita, Japan
| | - Tatsuya Tsuji
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan; Department of Anesthesiology, Okazaki City Hospital, Okazaki, Japan
| | - Hidehiro Someko
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of General Internal Medicine, Asahi General Hospital, Chiba, Japan
| | - Eriya Imai
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Division of Anesthesia, Mitsui Memorial Hospital, Tokyo, Japan
| | - Ryota Kimura
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Orthopaedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Kazuya Sobue
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Sharapi M, Afifi E, Al Mawla AM, Yassin MNA, Awwad SA, El-Samahy M. Ultrasound-based Accuro system versus traditional palpation technique for neuraxial anaesthesia: A systematic review and meta-analysis of randomised controlled trials. J Perioper Pract 2023:17504589231215927. [PMID: 38149589 DOI: 10.1177/17504589231215927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
INTRODUCTION This review evaluates the efficacy and safety of Accuro, a handheld ultrasound device, compared to the palpation technique for neuraxial anaesthesia. Accuro provides real-time imaging guidance, potentially improving accuracy and efficiency. METHODS A comprehensive search across six electronic databases identified randomised clinical trials comparing Accuro with palpation for neuraxial anaesthesia. Risk ratios or mean differences with 95% confidence intervals (CIs) were calculated using a random-effects model. Bias risk was evaluated using the Cochrane Risk of Bias tool. RESULTS Five studies (n=369) met the inclusion criteria. Accuro showed a favourable risk ratio for first insertion success (1.44 [95% CI [1.01, 2.05], p=0.05]). It significantly reduced needle skin passes (MD -0.63; 95% CI [-1.05, -0.21]; p<0.01), but not needle redirection (MD -1.31; 95% CI [-2.71, 0.11]; p=0.07). Procedure time was shorter in palpation (MD 127.82; 95% CI [8.68, -246.97]; p=0.04). Four studies had a low risk of bias; one had some concerns. CONCLUSION Accuro can potentially improve success rates and reduce skin passes in neuraxial anaesthesia. Further trials with larger samples are needed, especially in patients with anticipated difficulties.
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Affiliation(s)
| | - Eslam Afifi
- Faculty of Medicine, Benha University, Benha, Egypt
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Dumitrascu CI, Eneh PN, Keim AA, Kraus MB, Sharpe EE. Anesthetic management of parturients with achondroplasia: a case series. Proc AMIA Symp 2023; 37:63-68. [PMID: 38173994 PMCID: PMC10761160 DOI: 10.1080/08998280.2023.2261084] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/14/2023] [Indexed: 01/05/2024] Open
Abstract
Background Achondroplasia is the most common form of dwarfism, and cesarean delivery is often required in parturients with achondroplasia due to cephalopelvic disproportion. Given the challenges for both regional and general anesthetic techniques, there is no consensus on the optimal anesthetic management for cesarean delivery in these patients. Method A search of our electronic medical records for all female patients who had a diagnosis of achondroplasia and had a delivery in our health system from January 1, 2001 through June 16, 2023 was performed. Institutional review board exemption was obtained. Results We identified seven achondroplastic patients with 12 cesarean deliveries and described their anesthetic management during labor and delivery. Conclusion Despite the historical preference of general anesthesia in achondroplastic patients due to concerns of unpredictable spinal anatomy and unreliable local anesthetic spread, neuraxial anesthesia was successfully utilized in achondroplastic parturients and is a viable option in carefully selected patients. Reduction of intrathecal local anesthetic dose that minimizes the risk of high spinal and emergent intubation, as well as a titratable neuraxial technique, can be effective in this patient population.
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Affiliation(s)
| | - Peace Nnenna Eneh
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Molly Boyle Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Emily Elizabeth Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Gonzalez Fiol A, Acevedo Rodriguez P, Zhao X, Gaiser R, Herrera A, Alian A. A Prospective Cohort Study to Evaluate Needle Passes Using a Portable Ultrasound Device versus Traditional Landmark Approach for Epidural Anesthesia in a Busy Obstetric Tertiary Care Center. POCUS JOURNAL 2023; 8:153-158. [PMID: 38099155 PMCID: PMC10721287 DOI: 10.24908/pocus.v8i2.16298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Despite its many cited benefits, ultrasound guidance for neuraxial procedures is not widespread in anesthesiology. Some cited limitations include device cost and accessibility. We test the hypothesis that a handheld and relatively inexpensive ultrasound can improve neuraxial proficiency (e.g., decreased needle manipulations and block time). This prospective study compared the number of needle passes, redirections, and procedural time between epidural placed with a handheld ultrasound versus landmarks. Needle passes and attempts were defined as the number of times the Tuhoy needle was redirected, and the times skin was punctured (re-insertion). Procedural time was defined as the time from local anesthetic infiltration until loss of resistance was obtained. The impact of level of training and accuracy of the device were also analyzed. 302 patients receiving labor epidural were included in the study. No difference in body mass index (BMI) nor distribution of level of training was noted between the groups. Regression analysis adjusted for BMI demonstrated a decrease in needle passes (-1.75 (95% CI -2.62, -0.89), p < 0.001), needle attempts (-0.51 (95% CI -0.97, -0.04), p = 0.032) and procedural time (-154.67s 95% CI -303.49s, -5.85s), p = 0.042) when a handheld ultrasound was utilized. The mean (95% Confidence interval) difference between needle depth and ultrasound depth was 0.39 cm (0.32, 0.46), p < 0.001. The use of a handheld device resulted in statistically significant decrease of needle manipulations and block time. More research is needed to evaluate the impact of and increase in accessibility of ultrasound technology.
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Affiliation(s)
| | | | - Xiwen Zhao
- Department of Anesthesiology, Yale School of MedicineNew Haven, Connecticut
| | - Robert Gaiser
- Department of Anesthesiology, Yale School of MedicineNew Haven, Connecticut
| | - Adriana Herrera
- Department of Anesthesiology, Yale School of MedicineNew Haven, Connecticut
| | - Aymen Alian
- Department of Anesthesiology, Yale School of MedicineNew Haven, Connecticut
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Gorle Y, Munireddy Papireddy S, Tarigonda S. Evaluation of Lumbar Sonography as a Learning Aid for Performing Subarachnoid Block Using the Paramedian Approach by Medical Junior Resident Anaesthesiologists: A Randomized Controlled Trial. Cureus 2023; 15:e38871. [PMID: 37303389 PMCID: PMC10257345 DOI: 10.7759/cureus.38871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Pre-procedural ultrasound can be used to identify the subarachnoid space in difficult spinal procedures. However, multiple punctures can result in numerous complications, including post-dural puncture headache, neural trauma, and spinal and epidural haematoma. Thus, the following hypothesis was proposed: in contrast to the conventional blind paramedian dural puncture, pre-procedural ultrasound results in a successful dural puncture on the first attempt. METHODS In this prospective, randomised controlled study, 150 consenting patients were randomly assigned to one of the two groups: ultrasound-guided paramedian (UG) and conventional blind paramedian (PG). In the UG paramedian group, pre-procedural ultrasound was performed to mark the insertion site, whereas, in the PG group, the landmark technique was used. A total of 22 different anaesthesiology residents performed all subarachnoid blocks. RESULTS The time taken to perform spinal anaesthesia in the UG group was 38-49.5 s, which is shorter than the time taken in the PG group, which was 38-55 s, with a p-value < 0.046, which is statistically significant. The primary outcome of a successful dural puncture on the first attempt was not significantly higher in the UG group (49.33%) than in the PG group (34.67%), with a p-value < 0.068. The number of attempts taken for a successful spinal tap in the UG group was a median of 2.0 (1 to 2), and the PG group had a median of 2 (1 to 2.5), with a p-value < 0.096, which is statistically non-significant. CONCLUSION Ultrasound guidance showed improvement in the success rate of paramedian anaesthesia. In addition, it improves the success rate of dural puncture and the rate of puncture on the first attempt. It also shortens the time required for a dural puncture. In the general population, the pre-procedural UG paramedian group did not outperform the PG paramedian group.
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Weiniger CF, Carvalho B, Ronel I, Greenberger C, Aptekman B, Almog O, Kagan G, Shalev S. A randomized trial to investigate needle redirections/re-insertions using a handheld ultrasound device versus traditional palpation for spinal anesthesia in obese women undergoing cesarean delivery. Int J Obstet Anesth 2021; 49:103229. [PMID: 34670725 DOI: 10.1016/j.ijoa.2021.103229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/05/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ultrasound may be useful to identify the spinal anesthesia insertion point, particularly when landmarks are not palpable. We tested the hypothesis that the number of needle redirections/re-insertions is lower when using a handheld ultrasound device compared with palpation in obese women undergoing spinal anesthesia for cesarean delivery. METHODS Study recruits were obese (body mass index (BMI) >30 kg/m2) women with impalpable bony landmarks who were undergoing spinal anesthesia for elective cesarean delivery. Women were randomized to ultrasound or palpation. The primary study outcome was a composite between-group comparison of total number of needle redirections (any withdrawal and re-advancement of the needle and/or introducer within the intervertebral space) or re-insertions (any new skin puncture in the same or different intervertebral space) per patient. Secondary outcomes included insertion site identification time and patient verbal numerical pain score (0-10) for comfort during surgical skin incision. RESULTS Forty women completed the study. The mean BMI (standard deviation) for the ultrasound group was 39.8 (5.5) kg/m2 and for the palpation group 37.3 (5.2) kg/m2. There was no difference in the composite primary outcome (median (interquartile range) [range]) between the ultrasound group (4 (2-13) [2-22]) and the (6 (4-10) [1-17]) palpation group (P=0.22), with the 95% confidence interval of the difference 2 (-1.7 to 5.7). There were no differences in the secondary outcomes. CONCLUSIONS Handheld ultrasound did not demonstrate any advantages over traditional palpation techniques for spinal anesthesia in an obese population undergoing cesarean delivery, although the study was underpowered to show a difference.
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Affiliation(s)
- C F Weiniger
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.
| | - B Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - I Ronel
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - C Greenberger
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - B Aptekman
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - O Almog
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - G Kagan
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - S Shalev
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Gayathri B, Swetha Ramani CK, Urkavalan K, Pushparani A, Rajendran A. Comparison of the time taken for subarachnoid block using ultrasound-guided method versus landmark technique for cesarean section - A randomized controlled study. J Anaesthesiol Clin Pharmacol 2021; 37:205-209. [PMID: 34349367 PMCID: PMC8289655 DOI: 10.4103/joacp.joacp_35_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 10/08/2020] [Accepted: 12/02/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Spinal anesthesia is the regional technique preferred for cesarean section and is usually administered using the traditional landmark technique. Ultrasonography of the spine appears to be helpful in locating the puncture site and increasing the success rate. The primary objective of this study was to assess the use of ultrasonogram in locating the lumbar interspinous space for spinal anesthesia in laboring parturients brought for elective cesarean section. Material and Methods: Sixty parturients scheduled to undergo elective cesarean section under spinal anesthesia were included in this prospective randomized controlled trial, after obtaining the institutional ethical clearance. In Group I, 30 patients received spinal anesthesia by landmark technique and in Group II, 30 patients underwent ultrasound-guided spinal anesthesia. The statistical analysis was done using SPSS software version 17 (SPSS Inc., Chicago, Illinois, USA) for Microsoft windows. Results: The time taken for spinal in Group I was longer than in Group II (62 ± 18s; 41 ± 11s; P = 0.0001). The number of attempts of needle insertion was significantly less in Group II (group I 1.86 ± 1.04: group II 1.06 ± 0.25). However, the total preparation time (28 8.30 ± 92 vs 804.73 ± 77; P = 0.0001) was more in the ultrasound-guided than in the landmark group. The patients had better satisfaction in group II. Conclusion: Preprocedural ultrasound is a useful tool for successful lumbar puncture in parturients as it minimizes the number of attempts of needle insertion and provides better patient satisfaction.
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Affiliation(s)
- B Gayathri
- Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India
| | - C K Swetha Ramani
- Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India
| | - Karthika Urkavalan
- Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India
| | - A Pushparani
- Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chengalpattu, Tamil Nadu, India
| | - A Rajendran
- Department of Anaesthesiology, Government Dharmapuri Medical College Hospital, Dharmapuri, Tamil Nadu, India
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Shaikh F, Arzola C, Alexander S, Carvalho JCA, Everett T, Shroff M, Doria AS, Trottier L, To T, Sung L. Feasibility of ultrasound-assisted lumbar punctures performed by pediatric oncologists at the point of care. Pediatr Blood Cancer 2021; 68:e29015. [PMID: 33764681 DOI: 10.1002/pbc.29015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/14/2021] [Accepted: 02/22/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Ultrasound assistance improves success rates and reduces adverse outcomes of lumbar punctures (LPs) among adult patients in the emergency room and the operating room, but has not been evaluated in pediatric patients with cancer. Our objectives were (1) to determine whether pediatric oncologists could perform ultrasound-assisted LPs following a structured teaching curriculum, and (2) to determine the feasibility of recruiting pediatric cancer patients to a clinical trial of this procedure. METHODS Three pediatric oncologists completed a curriculum composed of didactic teaching followed by hands-on workshops. Each learner was evaluated during 20 attempts at three ultrasound tasks using the cumulative sum method. The three pediatric oncologists then performed ultrasound assessments prior to routinely scheduled LPs. Feasibility was defined as ability to perform at least 30 ultrasound-assisted LPs within 6 months. Secondary outcomes were the proportion of successful, bloody, or traumatic LPs, time required, and perceived helpfulness of ultrasound. RESULTS All three pediatric oncologists achieved competence in the three tasks of ultrasound scanning within 20 evaluated attempts. We recruited 62 patients within 1 month, and 58 underwent an ultrasound-assisted LP. All LPs were successful. Two LPs (4%) had ≥500 red blood cells (RBCs)/μl, and nine (16%) had ≥10 RBCs/μl. Median time to conduct the scan was 1.9 minutes (range 0.8-4.0 minutes). In 37 (64%) of the LPs, ultrasound assistance was considered helpful or very helpful. CONCLUSIONS Pediatric oncologists readily achieved competence in ultrasound-assisted LPs, and ultrasound was commonly perceived as helpful. It is feasible to proceed to a randomized trial of this procedure in pediatric cancer.
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Affiliation(s)
- Furqan Shaikh
- Division of Haematology/Oncology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Cristian Arzola
- Department of Anesthesia and Pain Management, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Sarah Alexander
- Division of Haematology/Oncology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Jose C A Carvalho
- Department of Anesthesia and Pain Management, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Tobias Everett
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Andrea S Doria
- Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Luc Trottier
- Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Orlando B, Donovan J, Stein D, Saloum M, Epstein J, Marenco J, Mahoney B, Kassapidis D. Does Pre-Procedure Neuraxial Ultrasound Using the GE Logiq® Improve Midline Placement of Combined Spinal Epidural when Compared to a Palpation Technique Performed by Experienced Anesthesiologists? A Prospective Randomized Study. JOURNAL OF SCIENTIFIC INNOVATION IN MEDICINE 2021. [DOI: 10.29024/jsim.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Wong AV, Abcejo AS, Dahl ARD, Sharpe EE. Labor Analgesia in a Patient with Severe Dystrophic Calcinosis Cutis. PAIN MEDICINE 2021; 21:3237-3239. [PMID: 33580800 DOI: 10.1093/pm/pnaa249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Calcinosis cutis is a condition characterized by pathologic calcium deposition into superficial dermal skin layers. It is often associated with an autoimmune disease. However, it may also occur after minor localized trauma and infection. DESCRIPTION OF PROBLEM We report a case of lumbar epidural placement of labor analgesia in a parturient with severe dystrophic calcinosis cutis without apparent complications. CLINICAL SOLUTION We recommend fastidious optimization of epidural placement conditions for all patients who may be at high risk for neuraxial anesthesia, including consideration of ultrasound use, use of an experienced anesthesia provider for neuraxial placement, and placement in early labor. Additionally, judicious discussion of risks, benefits, and alternatives when obtaining informed consent is critical, ideally with the patient identified for a comprehensive visit in a preoperative obstetric anesthesia clinic before delivery.
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Affiliation(s)
- Ashley V Wong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Arnoley S Abcejo
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ashley R D Dahl
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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12
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Ravi PR, Naik S, Joshi MC, Singh S. Real-time ultrasound-guided spinal anaesthesia vs pre- procedural ultrasound-guided spinal anaesthesia in obese patients. Indian J Anaesth 2021; 65:356-361. [PMID: 34211192 PMCID: PMC8202802 DOI: 10.4103/ija.ija_446_20] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/09/2020] [Accepted: 03/18/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIMS Spinal anaesthesia is conventionally performed using a landmark-guided midline approach. These surface landmarks may be absent, indistinct or distorted in the presence of obesity, previous spinal surgeries, deformities, or degenerative changes associated with ageing. In the present study, we compared the efficacy of real-time ultrasound (RUS)-guided paramedian approach, and pre-procedure ultrasound (PUS) landmark-guided paramedian approach in obese patients. METHODS Eighty patients with body mass index (BMI) >30 kg/m2 were included in the study. The participants were randomly assigned to two intervention groups, i.e., RUS and PUS approach. The primary end point was to attain a successful lumbar puncture. Variables like the number of attempts, the number of passes, the time taken for identifying landmark(s), and time for a successful lumbar puncture(s) were secondary end points and were recorded in both the groups. RESULTS The median number of attempts were 4 (IQR 2-4) and 2 (IQR 1-2), respectively, in the PUS and RUS group (P-value < 0.001). The median number of passes, the median time for identifying space, and the time for successful lumbar puncture was statistically significantly less in the RUS group, than the PUS group. CONCLUSION The time taken for the identification of the space, the number of attempts, number of passes, and the time taken for successful lumbar puncture was more in the PUS group as compared to the RUS group.
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Affiliation(s)
| | | | | | - Seema Singh
- Military Hospital Bathinda, Bathinda, Punjab, India
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13
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Pre-Procedural Lumbar Neuraxial Ultrasound-A Systematic Review of Randomized Controlled Trials and Meta-Analysis. Healthcare (Basel) 2021; 9:healthcare9040479. [PMID: 33920621 PMCID: PMC8072649 DOI: 10.3390/healthcare9040479] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 12/29/2022] Open
Abstract
A pre-procedural ultrasound of the lumbar spine is frequently used to facilitate neuraxial procedures. The aim of this review is to examine the evidence sustaining the utilization of pre-procedural neuraxial ultrasound compared to conventional methods. We perform a systematic review of randomized controlled trials with meta-analyses. We search the electronic databases Medline, Cochrane Central, Science Direct and Scopus up to 1 June 2019. We include trials comparing a pre-procedural lumbar spine ultrasound to a non-ultrasound-assisted method. The primary endpoints are technical failure rate, first-attempt success rate, number of needle redirections and procedure time. We retrieve 32 trials (3439 patients) comparing pre-procedural lumbar ultrasounds to palpations for neuraxial procedures in various clinical settings. Pre-procedural ultrasounds decrease the overall risk of technical failure (Risk Ratio (RR) 0.69 (99% CI, 0.43 to 1.10), p = 0.04) but not in obese and difficult spinal patients (RR 0.53, p = 0.06) and increase the first-attempt success rate (RR 1.5 (99% CI, 1.22 to 1.86), p < 0.0001, NNT = 5). In difficult spines and obese patients, the RR is 1.84 (99% CI, 1.44 to 2.3; p < 0.0001, NNT = 3). The number of needle redirections is lower with pre-procedural ultrasounds (SMD = −0.55 (99% CI, −0.81 to −0.29), p < 0.0001), as is the case in difficult spines and obese patients (SMD = −0.85 (99% CI, −1.08 to −0.61), p < 0.0001). No differences are observed in procedural times. Ιn conclusion, a pre-procedural ultrasound provides significant benefit in terms of technical failure, number of needle redirections and first attempt-success rate. Τhe effect of pre-procedural ultrasound scanning of the lumbar spine is more significant in a subgroup analysis of difficult spines and obese patients.
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Boselli E, Hopkins P, Lamperti M, Estèbe JP, Fuzier R, Biasucci DG, Disma N, Pittiruti M, Traškaitė V, Macas A, Breschan C, Vailati D, Subert M. European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia. Eur J Anaesthesiol 2021; 38:219-250. [PMID: 33186303 DOI: 10.1097/eja.0000000000001383] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.
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Affiliation(s)
- Emmanuel Boselli
- From the Department of Anaesthesiology, Pierre Oudot Hospital, Bourgoin-Jallieu, University Claude Bernard Lyon I, University of Lyon, France (EB), Leeds Institute of Medical Research at St James's School of Medicine, University of Leeds, Leeds, UK (PH), Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates (ML), Department of Anaesthesiology, Intensive Care and Pain Medicine, University hospital of Rennes, Rennes, France (JPE), Department of Anaesthesiology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France (RF), Intensive Care Unit, Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (DGB), Department of Anaesthesiology, IRCCS Istituto Giannina Gaslini, Genova, Italy (ND), Department of Surgery, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy (MP), Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania (VT, AM), Department of Anaesthesia, Klinikum Klagenfurt, Austria (CB), Anaesthesia and Intensive Care Unit, Melegnano Hospital (DV) and Department of Surgical and Intensive Care Unit, Sesto San Giovanni Civic Hospital, Milan, Italy (MS)
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15
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Uyel Y, Kilicaslan A. Preprocedural Ultrasonography Versus Landmark-Guided Spinal Anesthesia in Geriatric Patients with Difficult Anatomy: A Prospective Randomized Trial. Eurasian J Med 2020; 53:9-14. [PMID: 33716523 DOI: 10.5152/eurasianjmed.2020.20215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/28/2020] [Indexed: 01/20/2023] Open
Abstract
Objective This study was aimed to determine whether preprocedural ultrasonography (USG) affects the technical performance of spinal anesthesia in elderly patients with difficulty in palpating landmarks, scoliosis, or previous spine surgery. Materials and Methods This prospective study was conducted in 156 elderly patients scheduled for elective orthopedic lower extremity surgery. The patients were randomly divided into 2 groups to receive spinal anesthesia by the preprocedural USG examination (group U) or conventional landmark palpation technique (group P). The primary finding of our study was the rate of successful access to the subarachnoid space on initial needle insertion attempt. Secondary achievements included number of needle insertion attempts, number of needle redirections, total procedure time, needle pain scores, patient satisfaction, and complications of spinal anesthesia. Results The rate of successful access to the subarachnoid space at the first needle insertion attempt was significantly higher in group U than in group P (74.4% vs 53.8%, p=0.008). Medians (interquartile range) of both needle insertion attempts (group P, 2 [1-3] vs group U, 1 [1-2]; p=0.038) and needle redirections (group P, 3 [2-5] vs group U, 2 [1-4]; p=0.028), requiring to achieve dural puncture, were significantly higher among the patients in group P than those in group U. No statistically significant difference was found between the groups regarding total procedure time, pain scores, patient satisfaction scores, and spinal anesthesia-induced complications (p>0.05). Conclusion Our study findings showed that preprocedural neuroaxial USG improves technical performance of spinal anesthesia in elderly patients with difficult anatomy.
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Affiliation(s)
- Yasin Uyel
- Department of Anaesthesiology and Reanimation, Necmettin Erbakan University, Meram Medical Faculty, Konya, Turkey
| | - Alper Kilicaslan
- Department of Anaesthesiology and Reanimation, Necmettin Erbakan University, Meram Medical Faculty, Konya, Turkey
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16
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Shu L, Huang J, Liu JC. Efficacy of ultrasound guidance for lumbar punctures: a systematic review and meta-analysis of randomised controlled trials. Postgrad Med J 2020; 97:40-47. [PMID: 33148780 DOI: 10.1136/postgradmedj-2020-138238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/17/2020] [Accepted: 08/24/2020] [Indexed: 11/04/2022]
Abstract
Ultrasound guidance has been reported to facilitate the performance of lumbar punctures (LPs). However, the use of ultrasound guidance has not yet received consistent conclusions. We performed a systematic review and meta-analysis to determine the efficacy of ultrasound-guided LPs. PubMed, Embase and the Cochrane Library were searched for randomised controlled trials comparing ultrasound guidance with traditional palpation for LPs in adults. The primary outcome was risk of failed procedures. A random-effects Mantel-Haenzsel model or random-effects inverse variance model was used to calculate relative risks (RRs) or standardised mean differences (SMDs) with 95% CIs. Twenty-eight trials (N=2813) met the inclusion criteria. Ultrasound-guided LPs were associated with a reduced risk of failed procedures (RR=0.58, 95% CI 0.39 to 0.85, p=0.005). No significant heterogeneity was detected (I2=27%) among these trials. It further decreased first attempt to failure (RR=0.43, 95% CI 0.30 to 0.62, p<0.00001), mean attempts to success (SMD=-0.61, 95% CI -0.80 to -0.43, p=0.00001) and incidences of complications of headache and backache (RR=0.63, 95% CI 0.46 to 0.85, p=0.003). Ultrasound guidance is an effective technique for LPs in adults.
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Affiliation(s)
- LiPei Shu
- Department of Anesthesiology, First Affiliated Hospital of Guangxi Medical University, Nannig, China
| | - Jiao Huang
- Department of Anesthesiology, First Affiliated Hospital of Guangxi Medical University, Nannig, China
| | - Jing Chen Liu
- Department of Anesthesiology, First Affiliated Hospital of Guangxi Medical University, Nannig, China
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17
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Young B, Onwochei D, Desai N. Conventional landmark palpation vs. preprocedural ultrasound for neuraxial analgesia and anaesthesia in obstetrics - a systematic review and meta-analysis with trial sequential analyses. Anaesthesia 2020; 76:818-831. [PMID: 32981051 DOI: 10.1111/anae.15255] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 12/12/2022]
Abstract
The aim of this systematic review and meta-analysis was to examine the efficacy, time taken and the safety of neuraxial blockade performed for obstetric patients with the assistance of preprocedural ultrasound, in comparison with the landmark palpation method. The bibliographic databases Central, CINAHL, EMBASE, Global Health, MEDLINE, Scopus and Web of Science were searched from inception to 13 February 2020 for randomised controlled trials that included pregnant women having neuraxial procedures with preprocedural ultrasound as the intervention and conventional landmark palpation as the comparator. For continuous and dichotomous outcomes, respectively, we calculated the mean difference using the inverse-variance method and the risk ratio with the Mantel-Haenszel method. In all, 22 trials with 2462 patients were included. Confirmed by trial sequential analysis, preprocedural ultrasound increased the first-pass success rate by a risk ratio (95%CI) of 1.46 (1.16-1.82), p = 0.001 in 13 trials with 1253 patients. No evidence of a difference was found in the total time taken between preprocedural ultrasound and landmark palpation, with a mean difference (95%CI) of 50.1 (-13.7 to 113.94) s, p = 0.12 in eight trials with 709 patients. The quality of evidence was graded as low and very low, respectively, for these co-primary outcomes. Sub-group analysis underlined the increased benefit of preprocedural ultrasound for those in whom the neuraxial procedure was predicted to be difficult. Complications, including postpartum back pain and headache, were decreased with preprocedural ultrasound. The adoption of preprocedural ultrasound for neuraxial procedures in obstetrics is recommended and, in the opinion of the authors, should be considered as a standard of care, in view of its potential to increase efficacy and reduce complications without significant prolongation of the total time required.
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Affiliation(s)
- B Young
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - D Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
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Abstract
PURPOSE OF REVIEW There has been a recent surge of interest in clinical applications of ultrasound, which has revolutionized acute pain management. This review is to summarize the current status of ultrasound utilization in neuraxial anesthesia, the most common type of regional anesthesia. RECENT FINDINGS Ultrasound-assisted and ultrasound-guided neuraxial anesthesia has improved clinical accuracy and patient safety through landmark identification including proper vertebral level and midline, as well as via measurements on neuraxial space. Direct needle or catheter visualization during the entire procedure has not yet been achieved consistently. The recent introduction of ultrasound into neural anesthesia has clinical performance benefits and patient safety implications, with documented improvement on overall efficacy with higher first attempt success rate as well as less needle pass. More controlled studies are needed for the overall impact of ultrasonography in neuraxial anesthesia in obstetric and non-obstetric patients.
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Affiliation(s)
- Jinlei Li
- Department of Anesthesiology, Yale University, New Haven, CT, USA.
| | - Ramya Krishna
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Yang Zhang
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, NY, USA
| | - David Lam
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University, New Haven, CT, USA
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19
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Could preprocedural ultrasound increase the first-pass success rate of neuraxial anesthesia in obstetrics? A systematic review and meta-analysis of randomized controlled trials. J Anesth 2020; 34:434-444. [PMID: 32133540 DOI: 10.1007/s00540-020-02750-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 02/10/2020] [Indexed: 11/27/2022]
Abstract
Neuraxial anesthesia is a common practice in obstetrics. Evidence suggests that preprocedural ultrasound versus the conventional landmark location method accurately identifies a given intervertebral space and predicts the needle insertion depth required to reach the spinal canal. However, whether the preprocedural ultrasound examination improves the first-pass success (FPS) rate remains elusive. Major databases were systematically searched for all relevant studies published in English up to June 2019. Eighteen randomized controlled trials including 1844 patients were enrolled. The quality of eligible studies was assessed, and predefined outcomes were synthesized by meta-analysis. The primary results showed that preprocedural ultrasound increased the FPS rate in patients with predicted puncture difficulty but not in patients who were easily punctured. Preprocedural ultrasound reduced the number of redirections and punctures and decreased the incidence of vascular puncture and backache. There was no evidence of a reduction in failed punctures. We also noted that preprocedural ultrasound prolonged the identification time but not the procedure time. Thus, this systematic review provides evidence that preprocedural ultrasound does not improve the FPS rate of neuraxial anesthesia in patients who are easily palpated, although it increases the FPS rate in patients who are difficult to palpate.
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20
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Tubinis MD, Lester SA, Schlitz CN, Morgan CJ, Sakawi Y, Powell MF. Utility of ultrasonography in identification of midline and epidural placement in severely obese parturients. Minerva Anestesiol 2019; 85:1089-1096. [DOI: 10.23736/s0375-9393.19.13617-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Soni NJ, Franco-Sadud R, Kobaidze K, Schnobrich D, Salame G, Lenchus J, Kalidindi V, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP. Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:591-601. [PMID: 31251163 PMCID: PMC6817310 DOI: 10.12788/jhm.3197] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks. We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients. We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients. We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.
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Affiliation(s)
- Nilam J Soni
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
- Corresponding Author: Nilam J Soni, MD, MSc; E-mail: ; Telephone: 210-743-6030
| | - Ricardo Franco-Sadud
- Division of Hospital Medicine, Naples Community Hospital, Naples, Florida
- Department of Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Ketino Kobaidze
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta,
Georgia
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Gerard Salame
- Division of Hospital Medicine, University of Colorado and Denver Health and Hospital Authority, Denver, Colorado
| | - Joshua Lenchus
- Division of Hospital Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Michael J Mader
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont
| | | | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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Singla P, Dixon AJ, Sheeran JL, Scalzo D, Mauldin FW, Tiouririne M. Feasibility of Spinal Anesthesia Placement Using Automated Interpretation of Lumbar Ultrasound Images: A Prospective Randomized Controlled Trial. ACTA ACUST UNITED AC 2019; 10. [PMID: 31179158 PMCID: PMC6555430 DOI: 10.4172/2155-6148.1000878] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: This study evaluated the efficacy of spinal anesthesia administration by resident physicians when using an ultrasound system with automated neuraxial landmark detection capabilities. Methods: 150 patients were enrolled in this trial. Anesthesiology residents placed spinals in subjects undergoing scheduled cesarean delivery using one of three techniques to identify neuraxial landmarks: palpation, ultrasound, or combined palpation and ultrasound. Ultrasound was performed using a handheld system that automatically identified neuraxial landmarks (e.g. midline, intervertebral spaces). All residents watched a 10-minute video and received 20 minutes of hands-on training prior to participating in the study. First insertion success rate was the primary end point. Results: Among all patients, use of ultrasound resulted in a 11% greater first-insertion success rate (RR: 1.11 [0.85–1.47], p=0.431), a 15% reduction in needle insertions (RR: 0.85, p=0.052), and a 26% decrease in needle passes (RR: 0.74, p=0.070). In obese patients of BMI ≥ 30 kg/m2, use of ultrasound resulted in 26% greater first-insertion success rates (RR: 1.26, p=0.187), a 21% decrease in needle insertions (RR: 0.79, p=0.025), a 38% decrease in needle passes (RR: 0.62, p=0.030), and a 75% decrease in patients reporting neutral or low patient satisfaction with anesthesia administration (RR: 0.25, p=0.004). Discussion: Resident anesthesiologists competently utilized the ultrasound system after receiving minimal training. Technical endpoints and patient satisfaction trended towards improvement when ultrasound was used prior to spinal placement, with stronger trends observed in obese patients. Additional study is required to fully characterize the impact of the ultrasound system on clinical efficacy.
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Affiliation(s)
- Priyanka Singla
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, Virginia, USA
| | - Adam J Dixon
- Rivanna Medical, LLC, 107 E Water St, Charlottesville, VA 22902, Virginia, USA.,Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, Virginia, USA
| | - Jessica L Sheeran
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, Virginia, USA
| | - David Scalzo
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, Virginia, USA
| | - Frank W Mauldin
- Rivanna Medical, LLC, 107 E Water St, Charlottesville, VA 22902, Virginia, USA.,Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, Virginia, USA
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, Virginia, USA
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Morrow D, Cupp J, Schrift D, Nathanson R, Soni NJ. Point-of-Care Ultrasound in Established Settings. South Med J 2018; 111:373-381. [PMID: 29978220 DOI: 10.14423/smj.0000000000000838] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The original and most widely accepted applications for point-of-care ultrasound (POCUS) are in the settings of trauma, shock, and bedside procedures. Trauma was the original setting for the introduction of POCUS and has been standardized under the four-plus view examination called the Focused Assessment with Sonography in Trauma (FAST). This examination was found to be especially practice changing for achieving rapid diagnoses in critically ill patients who are too unstable for the delays and transportation inherent in more advanced imaging with computed tomography. This application was broadened from the critically ill trauma patient to any critically ill patient, particularly the patient in undifferentiated shock. Although the Focused Assessment with Sonography in Trauma examination originally focused on sources of hemorrhage causing hypovolemic shock, POCUS also can quickly differentiate cardiogenic, obstructive, and distributive shock and help identify the more specific etiology such as massive pulmonary emboli, pericardial tamponade, and pneumothoraces. By expediting diagnosis, POCUS facilitates faster definitive treatment of life-threatening conditions. In pursuing treatment, US continues to serve a role in the form of visually guiding many procedures that were previously done blindly. US guidance of procedures has improved the safety of central line insertion, thoracentesis, and paracentesis, and has an emerging role in lumbar puncture. Experience in bedside US is becoming a vital tool in the clinician's bedside assessment and management, filling a void between the stethoscope and the more advanced studies and interventions available through radiology. Understanding the strengths and limitations of US enables clinicians to identify the appropriate situations in which they can apply this tool confidently.
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Affiliation(s)
- Dustin Morrow
- From the Departments of Emergency Medicine and Internal Medicine, Greenville Health System, University of South Carolina School of Medicine, Greenville, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of South Carolina School of Medicine, Columbia, and the Department of Medicine, Division of General and Hospital Medicine, University of Texas Health, San Antonio
| | - Julia Cupp
- From the Departments of Emergency Medicine and Internal Medicine, Greenville Health System, University of South Carolina School of Medicine, Greenville, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of South Carolina School of Medicine, Columbia, and the Department of Medicine, Division of General and Hospital Medicine, University of Texas Health, San Antonio
| | - David Schrift
- From the Departments of Emergency Medicine and Internal Medicine, Greenville Health System, University of South Carolina School of Medicine, Greenville, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of South Carolina School of Medicine, Columbia, and the Department of Medicine, Division of General and Hospital Medicine, University of Texas Health, San Antonio
| | - Robert Nathanson
- From the Departments of Emergency Medicine and Internal Medicine, Greenville Health System, University of South Carolina School of Medicine, Greenville, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of South Carolina School of Medicine, Columbia, and the Department of Medicine, Division of General and Hospital Medicine, University of Texas Health, San Antonio
| | - Nilam J Soni
- From the Departments of Emergency Medicine and Internal Medicine, Greenville Health System, University of South Carolina School of Medicine, Greenville, the Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of South Carolina School of Medicine, Columbia, and the Department of Medicine, Division of General and Hospital Medicine, University of Texas Health, San Antonio
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25
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Ida M, Enomoto J, Yamamoto Y, Onodera H, Kawaguchi M. Factors associated with anesthetic satisfaction after cesarean delivery under neuraxial anesthesia. JA Clin Rep 2018; 4:66. [PMID: 32026016 PMCID: PMC6966755 DOI: 10.1186/s40981-018-0206-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/03/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction Evaluating patient satisfaction with anesthesia is critical for improving their experiences. We investigated perioperative anesthetic satisfaction and associated predictive factors in patients receiving cesarean delivery under neuraxial anesthesia (spinal anesthesia only or combined spinal-epidural anesthesia). Methods This was an institutionally approved retrospective chart review of patients who received cesarean delivery under spinal anesthesia and postoperative evaluation administered by anesthesiologists from January 2009 to December 2013. Multiple pregnancies and patients reporting headache prior to cesarean delivery were excluded. Patients were divided into satisfied and not satisfied groups according to their scores from the 4-point Likert scale. Multivariate analysis was used to identify explanatory factors associated with satisfaction. Results Of 813 patients enrolled, 425 (52.2%) were classified as satisfied. Combined spinal–epidural anesthesia (CSEA) (odds ratio, 3.3; 95% confidence interval, 1.08–10.1) was positively associated with satisfaction. Paresthesia during needle insertion (odds ratio, 0.56; 95% confidence interval, 0.42–0.76), lightning pain during neuraxial anesthesia (odds ratio 0.62; 95% confidence interval, 0.39–0.98), failed block (odds ratio 0.28; 95% confidence interval, 0.09–0.87), and intraoperative use of antiemetic (odds ratio 0.71; 95% confidence interval, 0.53–0.94) were negatively associated with satisfaction. In the 792 patients receiving spinal anesthesia only, the same factors except for CSEA were associated with satisfaction. Conclusions The addition of epidural to spinal anesthesia for cesarean delivery can increase patient satisfaction, whereas paresthesia during needle insertion, lightning pain, failed block, and the use of intraoperative antiemetic were major obstacles to patient satisfaction.
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Affiliation(s)
- Mitsuru Ida
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Junko Enomoto
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yumiko Yamamoto
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Hiroki Onodera
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Martinez M, Duchenne J, Bobbia X, Brunet S, Fournier P, Miroux P, Perrier C, Pès P, Chauvin A, Claret PG. Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.
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Weiniger CF, Cobb B, Wang RR, Carvalho B. Observational Study Using Ultrasound to Assess Midline Labor Epidural Analgesia Placement and Analgesic Efficacy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1693-1699. [PMID: 29274080 DOI: 10.1002/jum.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 09/09/2017] [Accepted: 09/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Labor epidural analgesia failure may relate to nonmidline placement of epidural catheters. We hypothesized that greater deviations of the epidural catheter insertion point from the ultrasound (US)-determined midline would be associated with less effective labor analgesia. METHODS A prospective ethically approved cohort study was conducted. Fifty-two healthy average-sized women receiving labor epidural analgesia, inserted by the landmark technique, were approached after delivery. Immediately after removing the epidural catheter, we determined the epidural space midline using US and compared it to the epidural catheter insertion point and to the patient-identified midline (assessed by a pinprick in 1-mm increments). Correlations between the US midline-to-catheter insertion point distance and additional epidural local anesthetic requirements (primary outcome), pain verbal numeric rating scale scores (0-10) 1 hour after epidural insertion, and maternal satisfaction with analgesia were determined. The differences in distances were assessed by a Bland-Altman analysis. RESULTS There were no significant correlations between the US midline-to-epidural catheter insertion point distance and additional epidural local anesthetic requirements (R2 = 0.138; P = .33), pain verbal numeric rating scale scores 1 hour after the epidural (R2 = 0.121; P = .40) or maternal satisfaction (R2 = 0.085; P = .57). The Bland-Altman analysis revealed that the mean ± SD US midline-to-epidural catheter insertion point distance and patient-identified midline distances were 0.38 ± 0.31 and 0.35 ± 0.46 cm, respectively. CONCLUSIONS In our laboring population, the hypothesis that nonmidline epidural insertion is associated with less-effective labor analgesia was not confirmed in this study cohort. We found minimal differences in distances between the US midline to epidural catheter insertion point and US midline to patient-identified midline.
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Affiliation(s)
- Carolyn F Weiniger
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Benjamin Cobb
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Rachel R Wang
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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Aiudi CM, Sharpe EE, Arendt KW, Pasternak JJ, Sviggum HP. Anesthetic management of two parturients with cerebral palsy and prior selective dorsal rhizotomy. Int J Obstet Anesth 2018; 34:105-108. [PMID: 29352624 DOI: 10.1016/j.ijoa.2017.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/16/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Abstract
Selective dorsal rhizotomy is a surgical spine procedure used to reduce spasticity in patients with upper motor neuron dysfunction caused by conditions such as cerebral palsy. The optimal anesthetic approach for obstetric patients who have undergone a selective dorsal rhizotomy is unknown. The use and efficacy of neuraxial anesthesia in these patients has not been described. We describe the use of neuraxial anesthesia in two patients with prior selective dorsal rhizotomy. Unless contraindicated for other reasons, a neuraxial anesthetic approach appears to be an effective option in patients with a history of a selective dorsal rhizotomy.
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Affiliation(s)
- C M Aiudi
- Mayo Clinic School of Medicine, Rochester, MN, USA
| | - E E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
| | - K W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - J J Pasternak
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - H P Sviggum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Lee A, Loughrey JP. The role of ultrasonography in obstetric anesthesia. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2016.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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