Confirmation of Loss-of-Resistance for Epidural Analgesia

Tran, De Q.H.; González, Andrea P.; Bernucci, Francisca; Finlayson, Roderick J.

doi:10.1097/aap.0000000000000217

Cited by 36 publications

(38 citation statements)

References 96 publications

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“…In other words, if cerebrospinal fluid return is obtained through the spinal needle, the epidural needle tip is most likely positioned in the epidural space. This confirmatory measure can be especially useful for technically challenging epidural blocks 10. If DPEA is performed for this purpose, onset becomes a lesser concern, and the operator should use the smallest spinal needle size available to minimize the incidence of post meningeal puncture headache.…”

Section: Discussionmentioning

confidence: 99%

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

Contreras

Morales²,

Bravo

et al. 2019

Reg Anesth Pain Med

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BackgroundThis 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.MethodsOne 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.ResultsOut 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.ConclusionDural 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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Section: Discussionmentioning

confidence: 99%

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles

Contreras

Morales²,

Bravo

et al. 2019

Reg Anesth Pain Med

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“…27 Using computed tomography scanning, Hogan 28 has previously reported adequate epidural blocks with a variety of catheter tip positions. In fact, the author concluded that "the epidural space is a forgiving system, and markedly different sites of catheter tips and spread of injected solution resulted are compatible with adequate anesthetic effect."…”

Section: Primary Failure Of Tea In Training Centersmentioning

confidence: 99%

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Tran

Zundert

Aliste

et al. 2016

Regional Anesthesia and Pain Medicine

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In teaching centers, primary failure of thoracic epidural analgesia can be due to multiple etiologies. In addition to the difficult anatomy of the thoracic spine, the conventional end point-loss-of-resistance-lacks specificity. Furthermore, insufficient training compounds the problem: learning curves are nonexistent, pedagogical requirements are often inadequate, supervisors may be inexperienced, and exposure during residency is decreasing. Any viable solution needs to be multifaceted. Learning curves should be explored to determine the minimal number of blocks required for proficiency. The problem of decreasing caseload can be tackled with epidural simulators to supplement in vivo learning. From a technical standpoint, fluoroscopy and ultrasonography could be used to navigate the complex anatomy of the thoracic spine. Finally, correct identification of the thoracic epidural space should be confirmed with objective, real-time modalities such as neurostimulation and waveform analysis.

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“…When the needle tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform synchronized with arterial pulsations. 1 In a recent case series of 160 thoracic epidural blocks, the sensitivity, specificity, positive, and negative predictive values of EWA were found to be 91.1%, 83.8%, 94.9%, and 73.8%, respectively. 9 In our teaching institutions, the primary failure rate of thoracic epidural blocks is 23.1%.…”

mentioning

confidence: 95%

“…T he thoracic epidural space is most commonly identified with loss of resistance (LOR) to air or normal saline. 1 Although sensitive, LOR lacks specificity, as cysts in interspinous ligaments, 2 gaps in ligamentum flavum, [3][4][5] paravertebral muscles, 6 thoracic paravertebral spaces, 7 and intermuscular planes 8 can yield nonepidural LOR. Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for LOR.…”

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confidence: 99%