Background. The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4-L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment. Methods. Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbar puncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The 'counting--up' approach starting with the L5-S1 space was applied. Results. One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences found in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture. Conclusions. The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.

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Background: Ultrasound-guided (US-guided) regional anaesthesia has gained worldwide popularity in recent years owing to the benefits the method offers to patients. The 1 st Department of Anaesthesiology and Intensive Care of Warsaw Medical University was one of the first centres in Poland to employ US-guided peripheral nerve blocks (PNB) on a routine basis. The technique was incorporated into the institution's clinical practice from 2007. The purpose of this study was to retrospectively assess changes in the clinical practice of US-guided versus non US-guided PNBs over six years of experience with the technique. Methods: Retrospective analysis assessing the prevalence of PNB methods, local anaesthetic (LA) injection techniques (i.e. single injection vs. multiple), LA volumes used, success rates and the incidence of complications. Results: This study included 4,066 PNBs performed between January 2006 and June 2012. The results showed systematic growth in the prevalence of US-guided blocks in the total number of PNBs, from 8.6% in 2007 up to 53.3% in 2012. The mean LA volume used in PNB was significantly lower in US-guided blocks compared to traditional PNB techniques (respectively, 21.83 mL vs. 31.41 mL, P < 0.05) without a decrease in the success rate (respectively, 76% vs. 74%, P > 0.05). A shift in the prevailing block technique from single injection to multiple injections was observed, regardless of the nerve location technique employed (from 29% up to 84% of PNBs performed using multiple injection technique). Conclusions: The use of ultrasound optimizes the technique of peripheral blocks and the amount of local anaesthetic used. Ultrasonography does not affect the safety of peripheral blocks.

Background: The conventional, loss of resistance technique for identification of the epidural space is highly dependent on the anaesthetist's personal experience and is susceptible to technical errors. Therefore, an alternative, automated technique was devised to overcome the drawbacks of the traditional method. The aim of the study was to compare the efficacy of epidural space identification and the complication rate between the two groups -the automatic syringe and conventional loss of resistance methods. Methods: 47 patients scheduled for orthopaedic and gynaecology procedures under epidural anaesthesia were enrolled into the study. The number of attempts, ease of epidural space identification, complication rate and the patients' acceptance regarding the two techniques were evaluated. Results: The majority of blocks were performed by trainee anaesthetists (91.5%). No statistical difference was found between the number of needle insertion attempts (1 vs. 2), the efficacy of epidural anaesthesia or the number of complications between the groups. The ease of epidural space identification, as assessed by an anaesthetist, was significantly better (P = 0.011) in the automated group (87.5% vs. 52.4%). A similar number of patients (92% vs. 94%) in both groups stated they would accept epidural anaesthesia in the future. Conclusion:The automated and loss of resistance methods of epidural space identification were proved to be equivalent in terms of efficacy and safety. Since the use of the automated technique may facilitate epidural space identification, it may be regarded as useful technique for anaesthetists inexperienced in epidural anaesthesia, or for trainees.

Objectives: Conventional loss of resistance (LOR) technique for identifying the epidural space (EDS) predominantly depends on experience of the anaesthetist. A technique using automated syringe for EDS identification was invented as an alternative to the traditional method. The aim of the study was to compare the efficacy and risk for complications between automatic LOR syringe -Epimatic® (Vygon, Ecouen, France) and conventional LOR -Perifix® (B.Braun Melsungen AG, Melsungen, Germany) techniques for EDS identification.Material and methods: A total of 170 patients were enrolled into the study and 153 cases were analysed. Number of attempts, time to EDS identification, ease of EDS identification, complication rate and patient procedure-related discomfort were evaluated and compared. Results:No statistically significant differences were found in the number of needle insertion attempts (1.3 in both groups), time to EDS identification (31 sec. vs. 27 sec.), efficacy of epidural analgesia (100% in both groups), or complication rate between both groups. Conclusions:The automatic and the conventional LOR techniques are comparable in terms of efficacy and safety for the epidural space identification.