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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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Yang H, Zhang Q, Zhong Z, Sun Y, Gong H, Liu Y, Dai X, Lin L, Luo J, Gong G, Yang Y. Administration of combined spinal epidural anesthesia with ultrasound-assisted positioning in obese patients undergoing open hysterectomy: A randomized controlled trial. Medicine (Baltimore) 2023; 102:e36695. [PMID: 38206749 PMCID: PMC10754612 DOI: 10.1097/md.0000000000036695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/27/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Administration of combined spinal epidural anesthesia (CSEA) with traditional landmark-guided positioning can be challenging in patients with high body mass index (BMI). The popularization of ultrasound technology may effectively solve these problems. However, reports on the administration of CSEA ultrasound-assisted positioning in obese populations are relatively limited and have made inconsistent conclusions. We aimed to investigate the ability of ultrasound-assisted positioning to improve the success rate of CSEA in obese patients. METHODS Overall, 118 adult women with a BMI ≥ 30 kg/m2 who scheduled to undergo open hysterectomy and received CSEA were recruited. Finally, 108 patients were enrolled and randomly assigned to 2 groups: the ultrasound-assisted positioning group (group A) and traditional landmark-guided positioning group (group B). Ultrasound-assisted or landmark-guided positioning was employed to locate the puncture interspace before anesthesia. The primary outcomes were the success rate of first attempt and number of attempts. The secondary outcomes were the patient positioning accuracy, positioning time, CSEA operation time, patient-satisfaction scores, anesthesia characteristics, and complications of CSEA. RESULTS The success rate of patient first puncture attempt in group A was significantly higher than that in group B (78.4% vs 52.9%, P = .007). The total number of punctures was lower in group A than that in groups B (average rank 44.54 vs 58.46, P = .005). Using ultrasound positioning as the gold standard, the accuracy of landmark-guided location was only 67%. Positioning time in croup A was longer in group A than that in group B (P = .004), while CSEA operation time spent in Group A was less than that in Group B (P < .001). Patient satisfaction score in group A was significantly higher than that in group B (P = .002). The successful puncture interspace in group A were more likely at L3-4 than that in group B (P = .02). CONCLUSION The success rate of first puncture attempt and positioning accuracy in CSEA with ultrasound-assisted is significantly higher than those based on landmark-guided location in obese patients.
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Affiliation(s)
- Haihong Yang
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
- Department of Anesthesiology, No.950 Hospital, Yecheng, Xinjiang, China
- College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Qin Zhang
- Outpatient department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Zuling Zhong
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yangyang Sun
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Huaqu Gong
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yinghai Liu
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Xuemei Dai
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Lu Lin
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Jingya Luo
- College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Gu Gong
- Department of Anesthesiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yongjian Yang
- College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan, China
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
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Bae J, Kim Y, Yoo S, Kim JT, Park SK. Handheld ultrasound-assisted versus palpation-guided combined spinal-epidural for labor analgesia: a randomized controlled trial. Sci Rep 2023; 13:23009. [PMID: 38155223 PMCID: PMC10754906 DOI: 10.1038/s41598-023-50407-7] [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: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023] Open
Abstract
Preprocedural ultrasound assistance can enhance the efficacy of neuraxial anesthesia in obstetrics. We investigated whether the use of handheld ultrasound can shorten the procedural time of labor combined spinal-epidural (CSE) analgesia compared with conventional landmark-guided methods. Eighty-four women requesting labor analgesia were randomly assigned to either handheld ultrasound-assisted or palpation-guided CSE analgesia. Primary outcome was procedure time of the CSE analgesia. Secondary outcomes included identification time, performance time, number of needle manipulations required for epidural/spinal success, first-attempt success rate, periprocedural pain scores, the incidence of accidental dural puncture, and patient satisfaction. Total procedure time did not significantly differ between the ultrasound and palpation groups (median [IQR], 191.5 [167-224] vs. 204.5 [163-358] s; P = 0.442). However, the performance time was significantly shorter in the ultrasound group (134.5 [115-177] vs. 183 [129-296] s; P = 0.011), although identification time was longer in the ultrasound group (53 [41-72] vs. 30.5 [21-45] s; P < 0.001). The epidural success rate at first insertion attempt was higher in the ultrasound group (85.7% vs. 59.5%, P = 0.014). Preprocedural handheld ultrasound assistance resulted in equivalent total procedure times but reduced performance times and higher first-attempt success rates. Therefore, clinicians may consider this technique for labor CSE analgesia.Trial registration: NCT04759547.
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Affiliation(s)
- Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Youngwon Kim
- Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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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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Zhang Y, Peng M, Wei J, Huang J, Ma W, Li Y. Comparison of ultrasound-guided and traditional localisation in intraspinal anesthesia: a systematic review and network meta-analysis. BMJ Open 2023; 13:e071253. [PMID: 37918920 PMCID: PMC10626869 DOI: 10.1136/bmjopen-2022-071253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 10/19/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES The optimal puncture technique for neuraxial anaesthesia in different populations is unclear. We sought to obtain data from randomised controlled trials comparing the impact of ultrasound-guided technology and traditional positioning technology on the success rate of neuraxial anaesthesia. DESIGN Systematic review and network meta-analysis using study populations, interventions, intervention comparisons, outcome measures and study types. DATA SOURCES PubMed, Embase, Cochrane Library and Web of science were searched until 31 September 2022. ELIGIBILITY CRITERIA We included randomised controlled trials comparing three types of neuraxial anaesthesia: ultrasound-assisted, ultrasound real-time guidance and conventional positioning to describe which neuraxial anaesthesia modality is best for patients and to recommend the appropriate one for different populations. DATA EXTRACTION AND SYNTHESIS Five independent reviewers retrieved, screened and edited included studies using standardised methods. Assess risk of bias using the Cochrane Collaboration and Evidence Project tools. Network meta-analysis was performed using STATA V.15 statistical software. RESULTS Twenty-two studies containing three different interventions were included. The SUCRA values of first-pass success rates for the three neuraxial anaesthesia methods were real-time guidance (82.8%), ultrasound-assisted (67.1%) and traditional positioning (0.1%). Both ultrasound techniques improved first-pass success rates compared with traditional localization, but there was no significant difference between the two. Subgroup analysis showed that the use of real-time ultrasound guidance for neuraxial anaesthesia in pregnant and patients with obesity improved first-pass success rates. Ultrasound-assisted technology can improve first-attempt success rates in older patients with abnormal lumbar spine anatomy. CONCLUSION Compared with conventional positioning, ultrasound guidance technology can improve the first-pass success rate of neuraxial anaesthesia, but there is no significant difference between ultrasound-assisted and real-time guidance technology. The results of subgroup analysis tell us that the most suitable neuraxial anaesthesia method is different for different groups of people. PROSPERO REGISTRATION NUMBER PROSPERO number: CRD42022376041.
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Affiliation(s)
- Yinzhou Zhang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Mingling Peng
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Junying Wei
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jieling Huang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - WuHua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yuhui Li
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Park SK, Cheun H, Kim YW, Bae J, Yoo S, Kim WH, Lim YJ, Kim JT. Ultrasound-assisted spinal anesthesia: A randomized comparison between midline and paramedian approaches. J Clin Anesth 2022; 80:110823. [DOI: 10.1016/j.jclinane.2022.110823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 10/18/2022]
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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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