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Ranganath YS, Ramanujam V, Al-Hassan Q, Sibenaller Z, Seering MS, Singh TSS, Punia S, Parra MC, Wong CA, Sondekoppam RV. Loss-of-Resistance Versus Dynamic Pressure-Sensing Technology for Successful Placement of Thoracic Epidural Catheters: A Randomized Clinical Trial. Anesth Analg 2024; 139:201-210. [PMID: 38190338 DOI: 10.1213/ane.0000000000006792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND The traditional loss-of-resistance (LOR) technique for thoracic epidural catheter placement can be associated with a high primary failure rate. In this study, we compared the traditional LOR technique and dynamic pressure-sensing (DPS) technology for primary success rate and secondary outcomes pertinent to identifying the thoracic epidural space. METHODS This pragmatic, randomized, patient- and assessor-blinded superiority trial enrolled patients ages 18 to 75 years, scheduled for major thoracic or abdominal surgeries at a tertiary care teaching hospital. Anesthesiology trainees (residents and fellows) placed thoracic epidural catheters under faculty supervision and rescue. The primary outcome was the success rate of thoracic epidural catheter placement, evaluated by the loss of cold sensation in the thoracic dermatomes 20 minutes after injecting the epidural test dose. Secondary outcomes included procedural time, ease of catheter placement, the presence of a positive falling meniscus sign, early hemodynamic changes, and unintended dural punctures. Additionally, we explored outcomes that included number of attempts, needle depth to epidural space, need for faculty to rescue the procedure from the trainee, patient-rated procedural discomfort, pain at the epidural insertion site, postoperative pain scores, and opioid consumption over 48 hours. RESULTS Between March 2019 and June 2020, 133 patients were enrolled; 117 were included in the final analysis (n = 57 for the LOR group; n = 60 for the DPS group). The primary success rate of epidural catheter placement was 91.2% (52 of 57) in the LOR group and 96.7% (58 of 60) in the DPS group (95% confidence interval [CI] of difference in proportions: -0.054 [-0.14 to 0.03]; P = .264). No difference was observed in procedural time between the 2 groups (median interquartile range [IQR] in minutes: LOR 5.0 [7.0], DPS 5.5 [7.0]; P = .982). The number of patients with epidural analgesia onset at 10 minutes was 49.1% (28 of 57) in the LOR group compared to 31.7% (19 of 60) in the DPS group ( P = .062). There were 2 cases of unintended dural punctures in each group. Other secondary or exploratory outcomes were not significantly different between the groups. CONCLUSIONS Our trial did not establish the superiority of the DPS technique over the traditional LOR method for identifying the thoracic epidural space ( Clinicaltrials.gov identifier: NCT03826186).
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Affiliation(s)
- Yatish S Ranganath
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Vendhan Ramanujam
- Department of Anesthesiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Zita Sibenaller
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Melinda S Seering
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Sangini Punia
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Michelle C Parra
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Tran DQ, Booysen K, Botha HJ. Primary failure of thoracic epidural analgesia: revisited. Reg Anesth Pain Med 2024; 49:298-303. [PMID: 38124196 DOI: 10.1136/rapm-2023-105151] [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: 11/07/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
Primary failure of thoracic epidural analgesia (TEA) remains an important clinical problem, whose incidence can exceed 20% in teaching centers. Since loss-of-resistance (LOR) constitutes the most popular method to identify the thoracic epidural space, the etiology of primary TEA failure can often be attributed to LOR's low specificity. Interspinous ligamentous cysts, non-fused ligamenta flava, paravertebral muscles, intermuscular planes, and thoracic paravertebral spaces can all result in non-epidural LORs. Fluoroscopy, epidural waveform analysis, electrical stimulation, and ultrasonography have been proposed as confirmatory modalities for LOR.The current evidence derived from randomized trials suggests that fluoroscopy, epidural waveform analysis, and possibly electrical stimulation, could decrease the primary TEA failure to 2%. In contrast, preprocedural ultrasound scanning provides no incremental benefit when compared with conventional LOR. In the hands of experienced operators, real-time ultrasound guidance of the epidural needle has been demonstrated to provide comparable efficacy and efficiency to fluoroscopy.Further research is required to determine the most cost-effective confirmatory modality as well as the best adjuncts for novice operators and for patients with challenging anatomy. Moreover, future trials should elucidate if fluoroscopy and electrical stimulation could potentially decrease the secondary failure rate of TEA, and if a combination of confirmatory modalities could outperform individual ones.
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Affiliation(s)
- De Q Tran
- Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Karin Booysen
- Private Anesthesiology Practice, Pretoria, Gauteng, South Africa
| | - Hendrik J Botha
- Private Anesthesiology Practice, Pretoria, Gauteng, South Africa
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Chen YC, Yang FC, Huang GS, Chang WC, Hsu YC. Value of CT in targeted CT-guided epidural blood patching: Predictors for successful epidural punctures. J Neuroradiol 2024; 51:204-209. [PMID: 37758171 DOI: 10.1016/j.neurad.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: 06/04/2023] [Revised: 07/24/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND PURPOSE Differentiating epidural from intrathecal punctures before computed tomography (CT)-guided epidural blood patching (EBP) is subjective, relying on operator experience. This study aimed to investigate CT findings for epidural and intrathecal punctures and identify reliable predictors for successful epidural punctures before targeted CT-guided EBP. MATERIALS AND METHODS We included 65 patients with low-cerebrospinal fluid (CSF)-pressure headache receiving targeted CT-guided EBP between January 2021 and October 2022 in this retrospective study. We analyzed clinical data, technical information, and CT features before EBP. Fisher's exact test was used for discrete variables, while Mann-Whitney U test was used for continuous variables. Positive (PLR) and negative likelihood ratios (NLR) were calculated to identify predictors for confirming epidural punctures. RESULTS We confirmed 43 patients as epidural punctures and 22 patients as intrathecal punctures. Before contrast injection, epidural fat at the needle tip in the epidural group was higher than the intrathecal group (37.2 % [16/43] vs. 4.5 % [1/22], p = 0.006). After contrast injection, the "contrast-needle tip connection" sign was mostly observed in the epidural group than the intrathecal group (95.3 % [41/43] vs. 9.1 % [2/22], p < 0.001). Additionally, the epidural group had significantly higher boomerang-shaped contrast morphology than the intrathecal group (65.1 % [28/43] vs. 9.1 % [2/22], p < 0.001). The "contrast-needle tip connection" sign had the highest PLR (10.49) and lowest NLR (0.05). CONCLUSION Identifying epidural fat at the needle tip, "contrast-needle tip connection" sign, and boomerang-shaped contrast morphology on CT scans are useful for confirming proper placement of the needle tip within the epidural space.
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Affiliation(s)
- Ya-Che Chen
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan; Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Yi-Chih Hsu
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan.
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Huang C, Chen Y, Kou M, Wang X, Luo W, Zhang Y, Guo Y, Huang X, Meng L, Xiao Y. Evaluation of a modified ultrasound-assisted technique for mid-thoracic epidural placement: a prospective observational study. BMC Anesthesiol 2024; 24:31. [PMID: 38243195 PMCID: PMC10797981 DOI: 10.1186/s12871-024-02415-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/12/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Although mid-thoracic epidural analgesia benefits patients undergoing major surgery, technical difficulties often discourage its use. Improvements in technology are warranted to improve the success rate on first pass and patient comfort. The previously reported ultrasound-assisted technique using a generic needle insertion site failed to demonstrate superiority over conventional landmark techniques. A stratified needle insertion site based on sonoanatomic features may improve the technique. METHODS Patients who presented for elective abdominal or thoracic surgery requesting thoracic epidural analgesia for postoperative pain control were included in this observational study. A modified ultrasound-assisted technique using a stratified needle insertion site based on ultrasound images was adopted. The number of needle passes, needle skin punctures, procedure time, overall success rate, and incidence of procedure complications were recorded. RESULTS One hundred and twenty-eight subjects were included. The first-pass success and overall success rates were 75% (96/128) and 98% (126/128), respectively. In 95% (122/128) of patients, only one needle skin puncture was needed to access the epidural space. The median [IQR] time needed from needle insertion to access the epidural space was 59 [47-122] seconds. No complications were observed during the procedure. CONCLUSIONS This modified ultrasound-assisted mid-thoracic epidural technique has the potential to improve success rates and reduce the needling time. The data shown in our study may be a feasible basis for a prospective study comparing our ultrasound-assisted epidural placements to conventional landmark-based techniques.
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Affiliation(s)
- Chanyan Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Ying Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Mengjia Kou
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Xuan Wang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Wei Luo
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Yuanjia Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Yuting Guo
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiongqing Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China
| | - Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Ying Xiao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, China.
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Pangthipampai P, Sutthibenjakul K. Incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years. J Anaesthesiol Clin Pharmacol 2022; 38:652-657. [PMID: 36778829 PMCID: PMC9912884 DOI: 10.4103/joacp.joacp_253_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/08/2021] [Accepted: 08/19/2021] [Indexed: 12/30/2022] Open
Abstract
Background and Aims Postoperative pain in pediatric patients is one of most inadequately treated conditions. This study aimed to investigate the incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years at Siriraj Hospital-Thailand's largest national tertiary referral center. Material and Methods This retrospective study included pediatric patients aged 0-8 years who underwent surgery with epidural catheter during January 2015 to January 2020. Patients with missing data were excluded. Records from both the ward staff and the acute pain service were reviewed. All relevant data were extracted until the epidural catheters were removed. Results One hundred and fifty pediatric patients were included. The median age was 29 months and the range varied from 12 days to 98 months on the day of surgery, and 86 (57.3%) were male. The incidence of inadequate epidural analgesia was 32%. Most patients (95.8%) had an unacceptably high pain score within 4 hours after arriving at the ward. Univariate analysis revealed direct epidural placement, the length in epidural space less than 5 cm, and postoperative leakage to be substantially higher in the inadequate pain epidural analgesia group. When those factors were included in multivariate analysis, only length in epidural space less than 5 cm was identified as an independent risk factor. Conclusion The incidence of inadequate epidural analgesia in this pediatric study was 32%. Multivariate analysis showed length of catheter in epidural space less than 5 cm to be the only factor independently associated with inadequate epidural analgesia.
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Affiliation(s)
- Pawinee Pangthipampai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Karuna Sutthibenjakul
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Martinez i Ferré B, Corletto F, Shing H, Bhalla R. Epidural catheter misplacement and knot formation within the hypoaxial musculature of a dog. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Sensitivity and specificity of waveform analysis for assessing postoperative epidural function. J Clin Anesth 2021; 77:110630. [PMID: 34922049 DOI: 10.1016/j.jclinane.2021.110630] [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: 08/08/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVES To characterize the accuracy of epidural waveform analysis (EWA) in assessing the functionality of thoracic epidural catheters in the immediate postoperative period (primary objective), and to determine the inter-rater reliability between EWA waveform observers (secondary outcome). DESIGN Single center, prospective diagnostic accuracy cohort study. SETTING Post-anesthetic care unit of a university teaching hospital. PATIENTS 84 adult patients undergoing elective thoracic, gynecologic, vascular, urologic, or general surgery with preoperative placement of a thoracic epidural catheter for perioperative analgesia. INTERVENTIONS EWA tracings were video recorded in the immediate postoperative period through the epidural catheter in the post-anesthetic care unit. MEASUREMENTS Postoperative EWA tracings were compared with clinical assessments of the sensory block to ice produced by epidural local anesthetic in the immediate postoperative period. Additionally, intra-class correlation analysis of agreement between 3 independent (and blinded) EWA waveform observers was carried out. RESULTS Among 80 patients with thoracic epidurals who completed the study protocol, 73 demonstrated postoperative functional epidurals with sensory block to ice and 7 demonstrated non-functional epidurals. EWA yielded 65 true positives, 6 true negatives, 8 false negatives, and 1 false positive. Postoperative EWA sensitivity, specificity, positive predictive value and negative predictive value, along with the 95% confidence intervals (CI) were 89% (79-95%), 86% (42-100%), 98% (92-100%), and 43% (18-71%) respectively. Intra-class correlation between waveform assessors was 0.870 (95% CI 0.818-0.910, p < 0.001). CONCLUSIONS EWA is useful in assessing the position of thoracic epidural catheters in the immediate postoperative period, demonstrating high sensitivity and specificity as well as robust inter-rater reliability. For patients in whom sensory block to ice cannot be reliably assessed postoperatively, EWA may provide a useful adjunct for assessing epidural functionality.
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Orbach‐Zinger S, Eidelman LA, A.Wazwaz S, Ben‐Haroush A, Fireman S, Heesen M, Hadar E, Weiniger CF, Kornilov E. The relationship between resited epidural catheters after secondary epidural catheter failure and vaginal delivery: A retrospective case-control study. Acta Anaesthesiol Scand 2021; 65:397-403. [PMID: 33147366 DOI: 10.1111/aas.13734] [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: 03/22/2020] [Revised: 08/20/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are cases where epidural analgesia is initially effective but subsequently fails and needs to be resited. We evaluated the rate of normal vaginal delivery and operative delivery among parturients who had resited epidurals compared to parturients with epidurals that were not resited. METHODS A retrospective electronic medical review of parturients with a singleton gestation attempting normal vaginal delivery under epidural analgesia between the years 2012-2016 was conducted. Resited epidurals were defined as epidurals that were considered effective but subsequently removed and reinserted. For each resited epidural, two previous and two consecutive deliveries of parturients with normally functioning epidural catheter inserted by the same anesthesiologist were matched controls (non-resited epidurals). RESULTS There were 35,984 attempted vaginal deliveries with 118 resited epidurals and 472 non-resited epidurals. When adjusted for nulliparity, oxytocin administration, sex and weight of the baby, and maternal BMI, labor epidural catheter replacement was not associated with need for instrumental or caesarean delivery, (OR 1.5, 95% CI 0.91-2.49, P = .11). CONCLUSIONS Need for labor epidural catheter replacement does not appear to be associated with need for operative delivery based on this single-centre cohort analysis.
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Affiliation(s)
- Sharon Orbach‐Zinger
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Leonid. A. Eidelman
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Susan A.Wazwaz
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Avi Ben‐Haroush
- Department Maternal‐Fetal Medicine Unit Helen Schneider Hospital for ParturientsRabin Medical Center Petach Tikva Israel
| | - Shlomo Fireman
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
| | - Michael Heesen
- Department of Anesthesia Kantonsspital Baden Baden Switzerland
| | - Eran Hadar
- Department Maternal‐Fetal Medicine Unit Helen Schneider Hospital for ParturientsRabin Medical Center Petach Tikva Israel
| | - Carolyn F Weiniger
- Department of Anesthesia Critical Care and Pain Medicine Tel Aviv Medical Centre Tel‐Aviv Israel
| | - Evgeniya Kornilov
- Department of Anesthesia Rabin Medical Center Beilinson Hospital, Petach Tikva Israel and Sackler Faculty of Medicine Tel Aviv University Tel‐Aviv Israel
- Department of Neurobiology Weizmann Institute of Science Rehovot Israel
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Arici T. An Operator's Experience of the Loss-of-Resistance Technique in Epidural Injections: An Observational Study. Eurasian J Med 2021; 53:48-52. [PMID: 33716530 DOI: 10.5152/eurasianjmed.2021.20014] [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] [Indexed: 11/22/2022] Open
Abstract
Objective A successful interlaminar epidural injection relies on correct epidural space needle placement. Most interlaminar epidural steroid injection (ESI) procedures are performed with a blind technique known as loss-of-resistance (LOR) without an imaging guide. This study aims to evaluate the success rate of the LOR technique in interlaminar epidural steroid injection under fluoroscopic control. Materials and Methods Patients who underwent interlaminar ESI owing to a history of at least 3 months of chronic low back and leg pain not responding to medications and physical therapies were included in an observational trial. Participants' age was between 27 and 88 years, and they had an American Society of Anesthesiologists physical status of I-III. The patients were placed in a prone position, and a Tuohy needle was introduced at the level of the L5-S1 interlaminar foramen using fluoroscopic image with an anteroposterior view. A lateral view was obtained when the LOR was felt. The procedures that achieved epidural spread by contrast agent in the first attempt were deemed successful. Those that did not and those that had false positive LOR were regarded as unsuccessful. Results Interlaminar ESİ was administered to 150 patients. The procedure's success and failure rates were 76% (114 patients) and 24% (36 patients), respectively. A total of 58.3% (21 patients) of patients who underwent an unsuccessful procedure had a false LOR, whereas 41.6% (15 patients) of the same group exhibited other causes. Sex, age, and body mass index (BMI) showed no statistical significance in terms of procedural success. There were statistically significant differences in the distance between the skin and the epidural space according to the body mass index groups. Conclusion The LOR technique identified the epidural space in most epidural procedures. However, in some cases, LOR was shown to be inadequate. Therefore, we suggest that the LOR technique must be supported by imaging such as fluoroscopy during epidural injections.
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Affiliation(s)
- Tulin Arici
- Department of Anaesthesiology and Reanimation, Dr Ersin Arslan Training and Research Hospital, Gaziantep, Turkey
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10
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Yeap YL, Randolph T, Lemmon AJ, Mann MD, Stewart J, Wolfe JW. Effect of Prior Formal Education on Successful Thoracic Epidural Placement By Anesthesia Residents. J Cardiothorac Vasc Anesth 2020; 34:3044-3048. [DOI: 10.1053/j.jvca.2020.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 11/11/2022]
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Grant GJ, Echevarria GC, Agoliati AP, Lax J, Cohen S. Epidural gravity flow technique for labor analgesia. Reg Anesth Pain Med 2020; 45:rapm-2019-101192. [PMID: 32071101 DOI: 10.1136/rapm-2019-101192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Gilbert J Grant
- Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Ghislaine C Echevarria
- Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Andrew P Agoliati
- Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Jerome Lax
- Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Shaul Cohen
- Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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12
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Gebhard RE, Moeller-Bertram T, Dobecki D, Peralta F, Pivalizza EG, Rupasinghe M, Ilic S, Hochman M. Objective Epidural Space Identification Using Continuous Real-Time Pressure Sensing Technology: A Randomized Controlled Comparison With Fluoroscopy and Traditional Loss of Resistance. Anesth Analg 2019; 129:1319-1327. [PMID: 31237571 DOI: 10.1213/ane.0000000000003873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Performance of epidural anesthesia and analgesia depends on successful identification of the epidural space (ES). While multiple investigations have described objective and alternative methodologies to identify the ES, traditional loss of resistance (LOR) and fluoroscopy (FC) are currently standard of care in labor and delivery (L&D) and chronic pain (CP) management, respectively. While FC is associated with high success, it exposes patients to radiation and requires appropriate radiological equipment. LOR is simple but subjective and consequently associated with higher failure rates. The purpose of this investigation was to compare continuous, quantitative, real-time, needle-tip pressure sensing using a novel computer-controlled ES identification technology to FC and LOR for lumbar ES identification. METHODS A total of 400 patients were enrolled in this prospective randomized controlled noninferiority trial. In the CP management arm, 240 patients scheduled to receive a lumbar epidural steroid injection had their ES identified either with FC or with needle-tip pressure measurement. In the L&D arm, 160 female patients undergoing lumbar epidural catheter placements were randomized to either LOR or needle-tip pressure measurement. Blinded observers determined successful ES identification in both arms. A modified intention-to-treat protocol was implemented, with patients not having the procedure for reasons preceding the intervention excluded. Noninferiority of needle-tip pressure measurement regarding the incidence of successful ES identification was claimed when the lower limit of the 97.27% confidence interval (CI) for the odds ratio (OR) was above 0.50 (50% less likely to identify the ES) and P value for noninferioirty <.023. RESULTS Demographics were similar between procedure groups, with a mild imbalance in relation to gender when evaluated through a standardized difference. Noninferiority of needle-tip pressure measurement was demonstrated in relation to FC where pain management patients presented a 100% success rate of ES identification with both methodologies (OR, 1.1; 97.27% CI, 0.52-8.74; P = .021 for noninferiority), and L&D patients experienced a noninferior success rate with the novel technology (97.1% vs 91%; OR, 3.3; 97.27% CI, 0.62-21.54; P = .019) using a a priori noninferiority delta of 0.50. CONCLUSIONS Objective lumbar ES identification using continuous, quantitative, real-time, needle-tip pressure measurement with the CompuFlo Epidural Computer Controlled Anesthesia System resulted in noninferior success rates when compared to FC and LOR for CP management and L&D, respectively. Benefits of this novel technology may include nonexposure of patients to radiation and contrast medium and consequently reduced health care costs.
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Affiliation(s)
- Ralf E Gebhard
- From the Department of Anesthesiology, University of Miami, Miller School of Medicine, Miami, Florida
| | | | | | - Feyce Peralta
- Department of Anesthesiology, Northwestern University, Chicago, Illinois
| | - Evan G Pivalizza
- Department of Anesthesiology, University of Texas, McGovern Medical School, Houston, Texas
| | - Madhumani Rupasinghe
- Department of Anesthesiology, University of Texas, McGovern Medical School, Houston, Texas
| | - Sanja Ilic
- CRQ Management Solutions, Carlsbad, California
| | - Mark Hochman
- Department of Restorative Dentistry, Stony Brook School of Dental Medicine, New York, New York
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Contreras F, Morales J, Bravo D, Layera S, Jara Á, Riaño C, Pizarro R, De La Fuente N, Aliste J, Finlayson RJ, Tran DQ. Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles. Reg Anesth Pain Med 2019; 44:rapm-2019-100608. [PMID: 31118278 DOI: 10.1136/rapm-2019-100608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/26/2019] [Accepted: 05/08/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND This double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial. METHODS One hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed.A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0-10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache. RESULTS Out of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: -3.2 to -0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache. CONCLUSION Dural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies. TRIAL REGISTRATION NUMBER NCT03389945.
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Affiliation(s)
- Felipe Contreras
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Juan Morales
- Department of Anesthesiology, Hospital De La Florida, Santiago, Chile
| | - Daniela Bravo
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Sebastián Layera
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Álvaro Jara
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Carlos Riaño
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Rodrigo Pizarro
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | | | - Julián Aliste
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | | | - De Q Tran
- Department of Anesthesiology, McGill University, Montreal, Québec, Canada
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Differentiating False Loss of Resistance from True Loss of Resistance While Performing the Epidural Block with the CompuFlo® Epidural Instrument. Anesthesiol Res Pract 2019; 2019:5185901. [PMID: 30863447 PMCID: PMC6378074 DOI: 10.1155/2019/5185901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/13/2019] [Indexed: 11/30/2022] Open
Abstract
Background The occurrence of false losses of resistance may be one of the reasons for inadequate or failed epidural block. A CompuFlo® epidural instrument has been introduced to measure the pressure of human tissues in real time at the orifice of a needle and has been used as a tool to identify the epidural space. The aim of this study was to investigate the sensitivity and the specificity of the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance encountered during the epidural space identification procedure. Method We performed epidural block with the CompuFlo® epidural instrument in 120 healthy women who requested labor epidural analgesia. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase in the pitch of the audible tone) was followed by a sudden and sustained drop in pressure for more than 5 seconds accompanied by a sudden decrease in the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau. We evaluate the sensitivity, specificity, and positive and negative predictive values of the ability of CompuFlo® recordings to correctly identify the true LOR from the false LOR. Results The drop in pressure associated with the epidural space identification was significantly greater than that recorded after the false loss of resistance (73% vs 33%) (P=0.000001). The sensitivity was 0.83, and the AUC was 0.82. Discussion We have confirmed the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance and established its specificity and sensitivity. Conclusion An easier identification of dubious losses of resistance during the epidural procedure is essential to reduce the number of epidural attempts and/or needle reinsertions with the potential of a reduced risk of accidental dural puncture especially in difficult cases or when the procedure is performed by trainees.
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Double Assurance of Epidural Space Detection Using Fiberoptics-Based Needle Design and Autofluorescence Technologies for Epidural Blockade in Painless Labor. SENSORS 2018; 18:s18113592. [PMID: 30360473 PMCID: PMC6264018 DOI: 10.3390/s18113592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/24/2018] [Accepted: 10/19/2018] [Indexed: 11/17/2022]
Abstract
Purpose: Technology of reflectance spectroscopy incorporated with auto-fluorescence spectroscopy were employed to increase the safety of epidural placement in regional anesthesia which is generally used for surgery, epidural anesthesia, post-operative pain control and painless childbirth. Method: Ex vivo study of auto-fluorescence spectroscopy was performed for the para-vertebral tissues contained fat, interspinous ligament, supraspinous ligament and ligamentumflavum by multimode microplate reader at wavelength 405 nm for the purpose of tissue differentiation. A specially designed optic-fiber-embedded needle was employed to incorporate with both reflectance and autofluorescence spectroscopies in order to probe the epidural space as double assurance demands. In vivo study was carried out in a Chinese native swine weighted about 30 kg under intubated general anesthesia with ventilation support. The reflective (405 nm) and autofluorescence signals (λ and λ*) were recorded at 5 different sites by an oscilloscope during the needle puncture procedure from skin to epidural space in the back of the swine. Results: Study of either autofluorescence spectroscopy for tissue samples or ex vivo needle puncture in porcine trunk tissues indicates that ligmentumflavum has at least 10-fold higher fluorescence intensity than the other tissues. In the in vivo study, ligamentumflavum shows a double-peak character for both reflectance and autofluorescence signals. The epidural space is located right after the drop from the double-peak. Both peaks of reflectance and fluorescence are coincident which ensures that the epidural space is correctly detected. Conclusions: The fiber-optical technologies of double-assurance demands for tissue discrimination during epidural needle puncture can not only provide an objective visual information in a real-time fashion but also it can help the operator to achieve much higher success rate in this anesthesia procedure.
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Abstract
The identification of epidural space with loss of resistance (LOR) is commonly performed. But it lacks specificity. Epidural pressure waveform analysis (EPWA) provides a simple confirmative adjunct for LOR. If the needle is located within the epidural space, measurement of the pressure at its tips shows a pulsatile waveform. Previous studies demonstrated satisfactory sensitivity and specificity of EPWA. However, success or failure of epidural injection was confirmed by the pinprick test, which is limited for patients in the setting of the pain clinic. In this study, we evaluated the sensitivity, specificity, as well as positive and negative predictive values of EPWA for cervical epidural steroid injection (CESI) confirmed by fluoroscopy.One hundred and five CESIs of 75 patients suffering from neck and radicular arm pain of over 3 months duration were enrolled. The physician injected 5 mL of normal saline after a feeling of satisfactory LOR. Saline filled extension tubing, connected to a pressure transducer, was attached to the needle. A 3 mL bolus of contrast medium was injected to confirm the success of CESI.The incorrect identification of epidural space with LOR (false LOR) was 29.5%. Of these 31 failed CESIs, 2 showed epidural waveform and 29 did not. The sensitivity, specificity, positive and negative predictive value of EPWA was 94.5%, 93.5%, 97.2%, and 87.7%, respectively.EPWA shows satisfactory reliability and is a simple adjunct to decrease false LOR for CESI. Further confirmative studies are required before its routine use in clinical practice.
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Affiliation(s)
- Ji H. Hong
- Department of Anesthesiology and Pain Medicine
| | - Sung W. Jung
- Department of Psychiatry, Keimyung University DongSan Hospital, DaeGu, Korea
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Pesteie M, Lessoway V, Abolmaesumi P, Rohling RN. Automatic Localization of the Needle Target for Ultrasound-Guided Epidural Injections. IEEE TRANSACTIONS ON MEDICAL IMAGING 2018; 37:81-92. [PMID: 28809679 DOI: 10.1109/tmi.2017.2739110] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Accurate identification of the needle target is crucial for effective epidural anesthesia. Currently, epidural needle placement is administered by a manual technique, relying on the sense of feel, which has a significant failure rate. Moreover, misleading the needle may lead to inadequate anesthesia, post dural puncture headaches, and other potential complications. Ultrasound offers guidance to the physician for identification of the needle target, but accurate interpretation and localization remain challenges. A hybrid machine learning system is proposed to automatically localize the needle target for epidural needle placement in ultrasound images of the spine. In particular, a deep network architecture along with a feature augmentation technique is proposed for automatic identification of the anatomical landmarks of the epidural space in ultrasound images. Experimental results of the target localization on planes of 3-D as well as 2-D images have been compared against an expert sonographer. When compared with the expert annotations, the average lateral and vertical errors on the planes of 3-D test data were 1 and 0.4 mm, respectively. On 2-D test data set, an average lateral error of 1.7 mm and vertical error of 0.8 mm were acquired.
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Raman Spectroscopy Differentiates Each Tissue from the Skin to the Spinal Cord: A Novel Method for Epidural Needle Placement? Anesthesiology 2017; 125:793-804. [PMID: 27466032 DOI: 10.1097/aln.0000000000001249] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Neuraxial anesthesia and epidural steroid injection techniques require precise anatomical targeting to ensure successful and safe analgesia. Previous studies suggest that only some of the tissues encountered during these procedures can be identified by spectroscopic methods, and no previous study has investigated the use of Raman, diffuse reflectance, and fluorescence spectroscopies. The authors hypothesized that real-time needle-tip spectroscopy may aid epidural needle placement and tested the ability of spectroscopy to distinguish each of the tissues in the path of neuraxial needles. METHODS For comparison of detection methods, the spectra of individual, dissected ex vivo paravertebral and neuraxial porcine tissues were collected using Raman spectroscopy (RS), diffuse reflectance spectroscopy, and fluorescence spectroscopy. Real-time spectral guidance was tested using a 2-mm inner-diameter fiber-optic probe-in-needle device. Raman spectra were collected during the needle's passage through intact paravertebral and neuraxial porcine tissue and analyzed afterward. The RS tissue signatures were verified as mapping to individual tissue layers using histochemical staining and widefield microscopy. RESULTS RS revealed a unique spectrum for all ex vivo paravertebral and neuraxial tissue layers; diffuse reflectance spectroscopy and fluorescence spectroscopy were not distinct for all tissues. Moreover, when accounting for the expected order of tissues, real-time Raman spectra recorded during needle insertion also permitted identification of each paravertebral and neuraxial porcine tissue. CONCLUSIONS This study demonstrates that RS can distinguish the tissues encountered during epidural needle insertion. This technology may prove useful during needle placement by providing evidence of its anatomical localization.
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McKendry RA, Muchatuta NA. Pressure waveforms to assess epidural placement: is there a role on delivery suite? Anaesthesia 2017; 72:815-820. [PMID: 28419411 DOI: 10.1111/anae.13904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- R A McKendry
- Department of Anaesthesia, St Michael's Hospital, University Hospitals, Bristol, UK
| | - N A Muchatuta
- Department of Anaesthesia, St Michael's Hospital, University Hospitals, Bristol, UK
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Al-Aamri I, Derzi SH, Moore A, Elgueta MF, Moustafa M, Schricker T, Tran DQ. Reliability of pressure waveform analysis to determine correct epidural needle placement in labouring women. Anaesthesia 2017; 72:840-844. [PMID: 28419420 DOI: 10.1111/anae.13872] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 11/30/2022]
Abstract
Pressure waveform analysis provides a reliable confirmatory adjunct to the loss-of-resistance technique to identify the epidural space during thoracic epidural anaesthesia, but its role remains controversial in lumbar epidural analgesia during labour. We performed an observational study in 100 labouring women of the sensitivity and specificity of waveform analysis to determine the correct location of the epidural needle. After obtaining loss-of-resistance, the anaesthetist injected 5 ml saline through the epidural needle (accounting for the volume already used in the loss-of-resistance). Sterile extension tubing, connected to a pressure transducer, was attached to the needle. An investigator determined the presence or absence of a pulsatile waveform, synchronised with the heart rate, on a monitor screen that was not in the view of the anaesthetist or the parturient. A bolus of 4 ml lidocaine 2% with adrenaline 5 μg.ml-1 was administered, and the epidural block was assessed after 15 min. Three women displayed no sensory block at 15 min. The results showed: epidural block present, epidural waveform present 93; epidural block absent, epidural waveform absent 2; epidural block present, epidural waveform absent 4; epidural block absent, epidural waveform present 1. Compared with the use of a local anaesthetic bolus to ascertain the epidural space, the sensitivity, specificity, positive and negative predictive values of waveform analysis were 95.9%, 66.7%, 98.9% and 33.3%, respectively. Epidural waveform analysis provides a simple adjunct to loss-of-resistance for confirming needle placement during performance of obstetric epidurals, however, further studies are required before its routine implementation in clinical practice.
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Affiliation(s)
- I Al-Aamri
- Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Canada
| | - S H Derzi
- Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Canada
| | - A Moore
- Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Canada
| | - M F Elgueta
- Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Canada
| | - M Moustafa
- Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Canada
| | - T Schricker
- Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Canada
| | - D Q Tran
- Department of Anaesthesia, Montreal General Hospital, McGill University Health Centre, Montreal, Canada
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SLIDE: automatic spine level identification system using a deep convolutional neural network. Int J Comput Assist Radiol Surg 2017; 12:1189-1198. [PMID: 28361323 DOI: 10.1007/s11548-017-1575-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/20/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE Percutaneous spinal needle insertion procedures often require proper identification of the vertebral level to effectively and safely deliver analgesic agents. The current clinical method involves "blind" identification of the vertebral level through manual palpation of the spine, which has only 30% reported accuracy. Therefore, there is a need for better anatomical identification prior to needle insertion. METHODS A real-time system was developed to identify the vertebral level from a sequence of ultrasound images, following a clinical imaging protocol. The system uses a deep convolutional neural network (CNN) to classify transverse images of the lower spine. Several existing CNN architectures were implemented, utilizing transfer learning, and compared for adequacy in a real-time system. In the system, the CNN output is processed, using a novel state machine, to automatically identify vertebral levels as the transducer moves up the spine. Additionally, a graphical display was developed and integrated within 3D Slicer. Finally, an augmented reality display, projecting the level onto the patient's back, was also designed. A small feasibility study [Formula: see text] evaluated performance. RESULTS The proposed CNN successfully discriminates ultrasound images of the sacrum, intervertebral gaps, and vertebral bones, achieving 88% 20-fold cross-validation accuracy. Seventeen of 20 test ultrasound scans had successful identification of all vertebral levels, processed at real-time speed (40 frames/s). CONCLUSION A machine learning system is presented that successfully identifies lumbar vertebral levels. The small study on human subjects demonstrated real-time performance. A projection-based augmented reality display was used to show the vertebral level directly on the subject adjacent to the puncture site.
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A Randomized Comparison Between Conventional and Waveform-Confirmed Loss of Resistance for Thoracic Epidural Blocks. Reg Anesth Pain Med 2017; 41:368-73. [PMID: 26894628 DOI: 10.1097/aap.0000000000000369] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. In this randomized trial, we compared conventional and EWA-confirmed LOR in 2 teaching centers. Our research hypothesis was that EWA-confirmed LOR would decrease the failure rate of thoracic epidural blocks. METHODS One hundred patients undergoing thoracic epidural blocks for thoracic surgery, abdominal surgery, or rib fractures were randomized to conventional LOR or EWA-LOR. The operator was allowed as many attempts as necessary to achieve a satisfactory LOR (by feel) in the conventional group. In the EWA-LOR group, LOR was confirmed by connecting the epidural needle to a pressure transducer using a rigid extension tubing. Positive waveforms indicated that the needle tip was positioned inside the epidural space. The operator was allowed a maximum of 3 different intervertebral levels to obtain a positive waveform. If waveforms were still absent at the third level, the operator simply accepted LOR as the technical end point. However, the patient was retained in the EWA-LOR group (intent-to-treat analysis).After achieving a satisfactory tactile LOR (conventional group), positive waveforms (EWA-LOR group), or a third intervertebral level with LOR but no waveform (EWA-LOR group), the operator administered a 4-mL test dose of lidocaine 2% with epinephrine 5 μg/mL. Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. RESULTS Compared with LOR, EWA-LOR resulted in a lower rate of primary failure (2% vs 24%; P = 0.002). Subgroup analysis based on experience level reveals that EWA-LOR outperformed conventional LOR for novice (P = 0.001) but not expert operators. The performance time was longer in the EWA-LOR group (11.2 ± 6.2 vs 8.0 ± 4.6 minutes; P = 0.006). Both groups were comparable in terms of operator's level of expertise, depth of the epidural space, approach, and LOR medium. In the EWA-LOR group, operators obtained a pulsatile waveform with the first level attempted in 60% of patients. However, 40% of subjects required performance at a second or third level. CONCLUSIONS Compared with its conventional counterpart, EWA-confirmed LOR results in a lower failure rate for thoracic epidural blocks (2% vs 24%) in our teaching centers. Confirmatory EWA provides significant benefits for inexperienced operators.
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Confirming Loss of Resistance for Epidural Analgesia: A New Role for Technology. Reg Anesth Pain Med 2015; 40:389-90. [PMID: 26079355 DOI: 10.1097/aap.0000000000000256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Reliability of Waveform Analysis as an Adjunct to Loss of Resistance for Thoracic Epidural Blocks. Reg Anesth Pain Med 2015; 40:694-7. [DOI: 10.1097/aap.0000000000000313] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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