Preprocedural ultrasound examination versus manual palpation for thoracic epidural catheter insertion

Hasanin, Ahmed; Mokhtar, Ali; Amin, Shereen; Sayed, Ahmed A. Hameed

doi:10.4103/1658-354x.197345

Cited by 17 publications

(9 citation statements)

References 15 publications

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“…Of the initial 4978 unique article citations we identified, 18 randomised controlled trials met the inclusion criteria 11–28 . Cohen's kappa was 0.61, demonstrating substantial agreement between the two authors conducting the screening.…”

Section: Resultsmentioning

confidence: 93%

“…Of the initial 4978 unique article citations we identified, 18 randomised controlled trials met the inclusion criteria. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] Cohen's kappa was 0.61, demonstrating substantial agreement between the two authors conducting the screening. Details of the screening process are depicted in Figure 1 and the results of the risk of bias assessment are illustrated in Figure 2.…”

Section: Study Selection and Risk Of Bias Within Studiesmentioning

confidence: 99%

“…In one trial, the indication for the neuraxial procedure was steroid injection, 14 in 11 trials it was for surgery, 12,13,[16][17][18]20,23,24,[26][27][28] and in five trials it was lumbar puncture. 15,19,21,22,25 The nature of the neuraxial technique was spinal in most trials, 11,13,15,16,[19][20][21][22][23][24][25][26][27][28] and lumbar epidural, 14 thoracic epidural 12,17 or combined spinalepidural 18 in one, two and one trials, respectively. In four, six and eight trials, the ultrasonographer and interventionalist were the same, 17,21-23 different 12,14,18,24,26,28 or not specified, 11,13,15,16,19,20,25,27 respectively.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…15,19,21,22,25 The nature of the neuraxial technique was spinal in most trials, 11,13,15,16,[19][20][21][22][23][24][25][26][27][28] and lumbar epidural, 14 thoracic epidural 12,17 or combined spinalepidural 18 in one, two and one trials, respectively. In four, six and eight trials, the ultrasonographer and interventionalist were the same, 17,21-23 different 12,14,18,24,26,28 or not specified, 11,13,15,16,19,20,25,27 respectively. In all of the trials, the ultrasonographer was experienced and in none of the trials was the difficulty of the neuraxial technique predicted to be easy.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…The predicted difficulty of the neuraxial technique was difficult in four trials 13,14,18,24 and heterogeneous in the remaining 14 trials. 11,12,[15][16][17][19][20][21][22][23][25][26][27][28] Synthesis of results and risk of bias across studies Our first co-primary outcome, the first pass success rate, was reported in 943 patients by nine trials. 13,14,16,18,23,24,[26][27][28] None of these trials was at overall high risk of bias.…”

Section: Study Characteristicsmentioning

confidence: 99%

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Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients

Onwochei

Nair

Young

et al. 2021

European Journal of Anaesthesiology

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BACKGROUND Central neuraxial modalities can occasionally be challenging to perform, particularly if the underlying anatomy is altered or obscured. OBJECTIVES To compare the efficacy, efficiency and the safety of preprocedural ultrasound to landmark palpation in the nonobstetric adult population. DESIGN Systematic review of randomised controlled trials with meta-analysis and trial sequential analysis. DATA SOURCES Systematic search of Central, CINAHL, Embase, Global Health, MEDLINE, Scopus and Web of Science to 13th February 2020. ELIGIBILITY CRITERIA Randomised controlled trials of nonobstetric adult patients having diagnostic and/or therapeutic neuraxial procedures using standard preprocedural ultrasound interpreted by the operator as the intervention and conventional landmark palpation as the comparator. KEY DEFINITIONS A skin puncture was defined as the insertion or reinsertion of the needle through the skin; needle redirection was the backward followed by the forward movement of the needle without its removal from the skin; first skin puncture referred to a single skin puncture with or without needle redirections; and first pass was a single skin puncture with no needle redirection. RESULTS In all, 18 randomised controlled trials with 1800 patients were included. The first pass success rate was not different between landmark and ultrasound methods [risk ratio 1.46; 95% confidence interval (CI), 0.99 to 2.16; P = 0.06, I 2 = 76%; moderate quality of evidence] and the trial sequential analysis demonstrated the futility of further randomisation of patients in modifying this finding. Preprocedural ultrasound increased the total time taken (mean difference 110.8 s; 95% CI, 31.01 to 190.65; P = 0.006; I 2 = 96%; moderate quality of evidence). Subgroup analyses revealed no influence of the predicted difficulty of the neuraxial procedure on outcomes. Compared with the landmark method, ultrasound increased the first skin puncture success rate (risk ratio 1.36; 95% CI, 1.18 to 1.57; P < 0.001; I 2 = 70%), and decreased the need for three or more skin punctures (risk ratio 0.46; 95% CI, 0.33 to 0.64; P < 0.001; I 2 = 29%) and the number of needle redirections (mean difference -1.24; 95% CI, -2.32 to -0.17; P = 0.020; I 2 = 83). The incidence of bloody tap was reduced with the use of ultrasound (risk ratio 0.61; 95% CI, 0.40 to 0.93; P = 0.020; I 2 = 42%). CONCLUSIONS The use of preprocedural ultrasound for neuraxial procedures in the nonobstetric adult population did not enhance the first pass success rate and increased the total time taken to a clinically insignificant extent. Improvement in secondary outcomes, including other markers of efficacy, should be interpreted with caution.

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Section: Resultsmentioning

confidence: 93%

Section: Study Selection and Risk Of Bias Within Studiesmentioning

confidence: 99%

Section: Study Characteristicsmentioning

confidence: 99%

Section: Study Characteristicsmentioning

confidence: 99%

Section: Study Characteristicsmentioning

confidence: 99%

See 3 more Smart Citations

Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients

Onwochei

Nair

Young

et al. 2021

European Journal of Anaesthesiology

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Effectiveness of preoperative thoracic epidural testing strategies: a retrospective comparison of three commonly used testing methods

dos Santos Fernandes,

Siddiqui,

Peacock

et al. 2023

Can J Anesth/J Can Anesth

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Ultrasound Imaging of the Spine for Central Neuraxial Blockade: a Technical Description and Evidence Update

Kalagara

Nair

Kolli

et al. 2021

Curr Anesthesiol Rep

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Purpose of Review This article describes the anatomy of the spine, relevant ultrasonographic views, and the techniques used to perform the neuraxial blocks using ultrasound imaging. Finally, we review the available evidence for the use of ultrasound imaging to perform neuraxial blocks. Recent Findings Central neuraxial blockade using traditional landmark palpation is a reliable technique to provide surgical anesthesia and postoperative analgesia. However, factors like obesity, spinal deformity, and previous spine surgery can make the procedure challenging. The use of ultrasound imaging has been shown to assist in these scenarios. Summary Preprocedural imaging minimizes the technical difficulty of spinal and epidural placement with fewer needle passes and skin punctures. It helps to accurately identify the midline, vertebral level, interlaminar space, and can predict the depth to the epidural and intrathecal spaces. By providing information about the best angle and direction of approach, in addition to the depth, ultrasound imaging allows planning an ideal trajectory for a successful block. These benefits are most noticeable when expert operators carry out the ultrasound examination and for patients with predicted difficult spinal anatomy. Recent evidence suggests that pre-procedural neuraxial ultrasound imaging may reduce complications such as vascular puncture, headache, and backache. Neuraxial ultrasound imaging should be in the skill set of every anesthesiologist who routinely performs lumbar or thoracic neuraxial blockade. We recommend using preprocedural neuraxial imaging routinely to acquire and maintain the imaging skills to enable success for challenging neuraxial procedures.

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Preprocedural ultrasound examination versus manual palpation for thoracic epidural catheter insertion

Cited by 17 publications

References 15 publications

Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients

Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients

Effectiveness of preoperative thoracic epidural testing strategies: a retrospective comparison of three commonly used testing methods

Ultrasound Imaging of the Spine for Central Neuraxial Blockade: a Technical Description and Evidence Update

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