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Harris ZC, Su HK, Xi AS, Somasundaram A, Sabouri AS. Anterior spinal cord syndrome from a spinal epidural hematoma following removal of an epidural catheter. Can J Anaesth 2024; 71:1037-1042. [PMID: 38750348 DOI: 10.1007/s12630-024-02768-4] [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: 01/13/2024] [Revised: 03/05/2024] [Accepted: 03/14/2024] [Indexed: 07/24/2024] Open
Abstract
PURPOSE Spinal epidural hematoma (SEH) is a rare yet significant complication associated with neuraxial anesthesia. Here, we present the case of a 74-yr-old male who underwent open repair of an abdominal aortic aneurysm. Following the removal of an epidural catheter, the patient developed anterior spinal cord syndrome due to an SEH despite having a normal coagulation profile. CLINICAL FEATURES This patient's neurologic presentation was marked by a loss of motor function while maintaining fine touch sensation distal to the spinal cord injury. Initial truncal computed tomography (CT) angiography failed to detect vascular compromise or diagnose the SEH. Subsequently, delayed magnetic resonance imaging (MRI) revealed a multilevel thoracic epidural hematoma, spinal cord infarction, and ischemia. Immediate surgical decompression was performed, but unfortunately, the patient had a poor outcome. CONCLUSION Anterior spinal cord syndrome (ASCS) represents an uncommon neurologic manifestation of SEH, which is typically characterized by a triad of back pain and sensory and motor deficits. Although the initial CT scan was necessary to diagnose the postvascular surgery complication, it did not immediately detect the SEH. In cases of ASCS subsequent to thoracic epidural placement and removal, MRI is the preferred imaging modality for precise diagnosis and assessment of the need for surgical intervention. Despite adherence to anticoagulation guidelines, patients undergoing neuraxial anesthesia may face an elevated risk of developing SEH. Health care professionals should remain vigilant in monitoring for neurologic abnormalities following epidural catheter insertion or removal, particularly in the context of vascular surgery.
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Affiliation(s)
- Zechariah C Harris
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Henry K Su
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Amanda S Xi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alwin Somasundaram
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - A Sassan Sabouri
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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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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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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Kwon HJ, Lee JB, Lee K, Shin JY, Jeong SM, Lee JH, Kim DH. Real-time ultrasound guidance versus fluoroscopic guidance in thoracic epidural catheter placement: a single-center, non-inferiority, randomized, active-controlled trial. Reg Anesth Pain Med 2024; 49:168-173. [PMID: 37353356 DOI: 10.1136/rapm-2023-104406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/07/2023] [Indexed: 06/25/2023]
Abstract
INTRODUCTION Fluoroscopy can improve the success rate of thoracic epidural catheter placement (TECP). Real-time ultrasound (US)-guided TECP was recently introduced and showed a high first-pass success rate. We tested whether real-time US-guided TECP results in a non-inferior first-pass success rate compared with that of fluoroscopy-guided TECP. METHODS In this single-center, non-inferiority, randomized trial, the primary outcome was the comparison of the first-pass success rate of TECP between real-time US guidance (US group) and fluoroscopic guidance (fluoroscopy group). Secondary outcomes included time to identifying epidural space, procedure time, total number of needle passes, number of skin punctures, final success, and cross-over success. RESULTS We randomly assigned 132 patients to the allocated groups. The difference in the first-pass success rate between the groups did not exceed the non-inferiority margin of 15% (US group: 66.7% vs fluoroscopy group: 68.2%; difference -1.5%, 95% exact CI: -14.9% to 11.9%). The difference in the final success rate also did not differ between the groups (98.5% vs 100.0%; difference -1.5%, 95% exact CI: -4.0% to 1.0%). The time to identifying epidural space (45.6 (34-62) vs 59.0 (42-77) s, p=0.004) and procedure time (39.5 (28-78) vs 112.5 (93-166) s, p<0.001) were significantly shorter in the US group. CONCLUSIONS Real-time US guidance provided a non-inferior success rate and shorter time spent on preparation and procedure compared with fluoroscopic guidance in TECP. TRIAL REGISTRATION NUMBER KCT0006521.
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Affiliation(s)
- Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Bok Lee
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kunhee Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Young Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Sivashanmugam T, Archana A, Nandhini P, Rani P. Real-time ultrasound-guided mid-thoracic epidural access using a novel paramedian cross (PX) view and drip infusion technique: a brief technical report. Reg Anesth Pain Med 2024:rapm-2023-105071. [PMID: 38388009 DOI: 10.1136/rapm-2023-105071] [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: 10/09/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Real-time ultrasound guidance (USG) has been applied for lower thoracic epidural access, but the more challenging mid-thoracic epidural (MTE) access remains underexplored. This report presents a technique of real-time US guidance with a novel paramedian cross view, termed "the PX view," for securing MTE catheters, along with an outcome analysis from a retrospective case series. METHODS Medical records of patients who underwent USG-MTE catheter placement with the PX view and drip infusion technique from January to December 2022 were reviewed. All catheters were placed with patients in the prone position under mild to moderate procedural sedation. The process of acquiring the PX view, in-plane needling technique, and the use of drip infusion to identify loss of resistance were detailed. The incidence of successful PX view attainment, the number of attempts, redirections, failures, and any technique-related complications were recorded. RESULTS Fifty-one patients underwent USG-MTE catheter attempts, (42 with median sternotomy, 3 fractured ribs, 3 upper abdominal laparotomies, 2 modified radical mastectomies, and 1 thoracotomy). A satisfactory PX view was obtained in all patients, and the epidural space was identified during the first needle entry in 49 cases, resulting in a 96% first-attempt success rate. Seven patients required needle redirections, while two patients needed a second needle entry. No technique-related complications were documented. CONCLUSION The combination of the PX view and the drip infusion method proved effective for real-time ultrasound-guided MTE catheter placement.
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Affiliation(s)
- T Sivashanmugam
- Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth Deemed to be university, Pondicherry, Puducherry, India
| | - Areti Archana
- Anaesthesia, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - P Nandhini
- Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth Deemed to be university, Pondicherry, Puducherry, India
| | - P Rani
- Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth Deemed to be university, Pondicherry, Puducherry, India
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7
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Chinn GA, Gray AT, Larson MD. Overcoming Obstacles: The Legacy of Fidel Pagés, Founder of the Epidural, 100 Years After His Passing. Anesth Analg 2024; 138:475-479. [PMID: 38048631 PMCID: PMC10840793 DOI: 10.1213/ane.0000000000006706] [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] [Indexed: 12/06/2023]
Abstract
Fidel Pagés, a Spanish surgeon, tragically died in 1923 at the age of 37, just 2 years after his publication "Anestesia Metamérica," the first description of human thoracolumbar epidural anesthesia. In the intervening 100 years, epidural anesthesia has faced countless obstacles, starting with the dissemination of his initial report, which was not widely read nor appreciated at the time. However, the merits of the technique have fueled innovations to meet these challenges over the years. Even today, while epidural anesthesia is widely embraced, particularly in obstetric and chronic pain medicine, the pressures of the operating room for efficiency and a low tolerance for failure, pose modern-day challenges. Here, we revisit Pagés' original report and highlight the key innovations that have allowed for the evolution of this essential anesthesia technique.
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Affiliation(s)
- Gregory A. Chinn
- University of California, San Francisco. Department of Anesthesia and Perioperative Care
| | - Andrew T. Gray
- University of California, San Francisco. Department of Anesthesia and Perioperative Care
| | - Merlin D. Larson
- University of California, San Francisco. Department of Anesthesia and Perioperative Care
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8
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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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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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Huang Y, Li T, Wang T, Wei Y, Xiong L, Wang T, Liu F. Real Time Ultrasound-Guided Thoracic Epidural Catheterization with Patients in the Lateral Decubitus Position without Flexion of Knees and Neck: A Preliminary Investigation. J Clin Med 2022; 11:6459. [PMID: 36362688 PMCID: PMC9655184 DOI: 10.3390/jcm11216459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 09/08/2024] Open
Abstract
Objectives: For some patients, such as pregnant women, it can be difficult to maintain the ideal "forehead to knees" position for several minutes for epidural catheter placement. We conducted this study to investigate the feasibility of real-time ultrasound-guided (US) epidural catheterization under a comfortable lateral position without flexion of knees and neck. Materials and Methods: 60 patients aged 18-80 years with a body mass index of 18-30 kg/m2 after general surgery were included. In a comfortable left lateral position, thoracic epidural catheterization was performed under real-time US for postoperative analgesia. The visibility of the neuraxial structures, procedural time from needle insertion to loss of resistance in the epidural space, the number of needle redirections, success rate of epidural catheter placement and postoperative analgesic effect were recorded. Results: In the paramedian oblique sagittal view, the well visible of vertebral lamina, intervertebral space and posterior complex under ultrasound were as high as 93.33%, 81.67% and 70.00%, respectively. The success rate of thoracic epidural catheterization was as high as 91.67%, and the satisfactory postoperative analgesic effect was 98.2% for patients without nausea, pruritus and other discomfort. Discussion: Thoracic epidural catheterization with patients in the lateral position without flexion of knees and neck under real time ultrasound guidance has a high success rate and strong feasibility. This visual manipulation makes epidural catheterization not only "easier" to perform, but also reduces the requirements of the procedure.
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Affiliation(s)
- Yuexin Huang
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Sichuan University, Chengdu 610044, China
| | - Tingting Li
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Sichuan University, Chengdu 610044, China
| | - Tianhong Wang
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Sichuan University, Chengdu 610044, China
| | - Yanhuan Wei
- Graduate School of Education, Beijing Foreign Studies University, Beijing 100039, China
| | - Liulin Xiong
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
| | - Tinghua Wang
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Sichuan University, Chengdu 610044, China
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
| | - Fei Liu
- Department of Anesthesiology, Institute of Neurological Disease, West China Hospital, Sichuan University, Chengdu 610044, China
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