Conventional landmark palpation vs. preprocedural ultrasound for neuraxial analgesia and anaesthesia in obstetrics – a systematic review and meta‐analysis with trial sequential analyses

Abstract

The aim of this systematic review and meta-analysis was to examine the efficacy, time taken and the safety of neuraxial blockade performed for obstetric patients with the assistance of preprocedural ultrasound, in comparison with the landmark palpation method. The bibliographic databases Central, CINAHL, EMBASE, Global Health, MEDLINE, Scopus and Web of Science were searched from inception to 13 February 2020 for randomised controlled trials that included pregnant women having neuraxial procedures with preprocedural ultrasound as the intervention and conventional landmark palpation as the comparator. For continuous and dichotomous outcomes, respectively, we calculated the mean difference using the inverse-variance method and the risk ratio with the Mantel-Haenszel method. In all, 22 trials with 2462 patients were included. Confirmed by trial sequential analysis, preprocedural ultrasound increased the first-pass success rate by a risk ratio (95%CI) of 1.46 (1.16-1.82), p = 0.001 in 13 trials with 1253 patients. No evidence of a difference was found in the total time taken between preprocedural ultrasound and landmark palpation, with a mean difference (95%CI) of 50.1 (À13.7 to 113.94) s, p = 0.12 in eight trials with 709 patients. The quality of evidence was graded as low and very low, respectively, for these co-primary outcomes. Sub-group analysis underlined the increased benefit of preprocedural ultrasound for those in whom the neuraxial procedure was predicted to be difficult. Complications, including postpartum back pain and headache, were decreased with preprocedural ultrasound. The adoption of preprocedural ultrasound for neuraxial procedures in obstetrics is recommended and, in the opinion of the authors, should be considered as a standard of care, in view of its potential to increase efficacy and reduce complications without significant prolongation of the total time required.

Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: a prospective, randomized, superiority trial

“…The clinical significance of the improved first-pass success rate and reduced number of skin punctures required for the TEP in Gp-Usg of this study is not entirely clear as there are no comparable data in the literature. However, a recent systematic review and meta-analysis [ 29 ] comparing the landmark-based technique with a preprocedural ultrasound scan for neuraxial anesthesia in the obstetric population found that a preprocedural ultrasound significantly increased the first-pass success rate and reduced the incidence of complications including bloody tap or vascular cannulation, and postpartum headache and backache [ 29 ]. The Authors [ 29 ] hypothesized that the reduced skin punctures and needle redirections during the neuraxial block may decrease the potential for the development of micro-hematoma in the back and thus lower the incidence of postpartum backache.…”

Learning US Assisted Neuraxial Technique during a Pandemic: Case Report

“…Intubation and extubation were identified as aerosol generating procedures and high risk for the spread of Covid-19 leading to a preference for regional anaesthesia over GA where possible [7,8]. At the time of this case it was recommended to wear full PPE when conducting general anaesthesia and staff were issued with either an FFP3 mask, a JSP Force 8 or Force 10 mask (JSP, Minster Lovell, UK).…”

Epidural catheter placement in children with baclofen pumps

“…Between spinal curvature, possible spinal hardware, and baclofen pump incision scar tissue, the epidurals placed without image guidance had the potential to be technically challenging, so there is a theoretical benefit to using fluoroscopy, both in terms of total time and number of needle passes. Ultrasound imaging has been shown to be beneficial in parturients with anticipated difficult labor epidural placement 13 ; however, similar data are not available for children. A larger, prospective study would be required to determine any timing differences.…”