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Does Ultrasound Mapping Prior to Epidural Placement Decrease the Number of Attempts and the Duration of Placement?. Single Center Prospective Randomized Controlled Study at PCRMC Rolla, MO Charlie Wilson, SRNA, Shelli Stockton, SRNA. Background.

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Does Ultrasound Mapping Prior to Epidural Placement Decrease the Number of Attempts and the Duration of Placement?

Single Center Prospective Randomized Controlled Study at PCRMC Rolla, MO

Charlie Wilson, SRNA, Shelli Stockton, SRNA


Background
Background the Number of Attempts and the Duration of Placement?

  • Two-thirds of patients in labor in the United States receive epidural analgesia.

  • Goal of epidural: To eliminate pain while preserving motor strength and maternal awareness of contractions to ensure adequate pushing during delivery.


Laboring epidural
Laboring Epidural the Number of Attempts and the Duration of Placement?

Indications

Contraindications

Patient refusal

Coagulopathies

Infection at insertion site

Increased ICP

Aortic stenosis

Severe hypovolemia

  • Active labor

  • Committed to delivery

  • Experiencing pain

  • Desire for epidural


Epidural anesthesia
Epidural Anesthesia the Number of Attempts and the Duration of Placement?


Epidural complications
Epidural Complications the Number of Attempts and the Duration of Placement?

  • Backache

  • Dural sac puncture (“wet tap”)

  • Total spinal

  • Neurologic injury

    • Motor weakness

    • Persistent parasthesia

    • Paraplegia

    • Cauda equina syndrome

  • Inadequate pain relief

  • Total Epidural Failure


Epidural placement challenges
Epidural Placement Challenges the Number of Attempts and the Duration of Placement?


Obesity in the united states
Obesity in the United States the Number of Attempts and the Duration of Placement?


Purpose
Purpose the Number of Attempts and the Duration of Placement?

  • To study the effects of ultrasound mapping prior to epidural placement on the number of attempts and the duration of placement.

    • Number of attempts

    • Number of puncture sites

    • Duration of procedure

    • Accuracy of epidural depth calculation


Literature review
Literature Review the Number of Attempts and the Duration of Placement?


Real-time ultrasound guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients

  • Journal: Critical Care November 2006

  • Authors: Dimitri Karikitsos, Nicholas Labropoulos, Eric De Groot, Alexandros P Patrianakos, Gregorious Kouraklis, John Poularas, George Samonis, Dimothenis A Tsoutsos, Manousus M Konstadoulakis and Andreas Karabinis

  • Purpose: To identify if real-time ultrasound-guided cannulation of the internal jugular vein is superior to landmark method

  • Conclusion: The use of real-time ultrasound-guidance is superior to the landmark method in critically ill patients


A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurological Symptoms

  • Journal: Regional Anesthesia July 2009

  • Authors: Spencer S Liu MD, Victor M Zayas MD, Micael A Gordon MD, Jonathan C Beathe MD, Daniel B Maalouf MD, Leonardo Paroli MD, Gregory A Liguori MD, Jamie Ortiz MD, Valeria Buschiazzo, Justin Ngeow BA, Teena Shetty MD, Jacques T Ya Deau MD PhD

  • Purpose:To determine if ultrasound guidance reduces the risk of intrneural injection and subsequent neurolocical symptoms

  • Conclusion: Ultrasound gudiance reduce the number of needle passes but did not how a decrease in the incidence or severity of neurological symptoms


Ultrasound guided regional anesthesia current concepts and future trends
Ultrasound-Guided regional Anesthesia: Current Concepts and Future Trends

  • Journal: Regional Anesthesia May 2007

  • Authors: Peter Marhofer MD, Vincent W S Chan MD FRCPC

  • Purpose: To increase the understanding of ultrasound equipment, discuss current outcomes and future trends

  • Conclusion: The time taken to place blocks and the total amount of local anesthetic used can be reduced


Ultrasonographic Measurement of the Ligamentum Flavum Depth; Is It a Reliable Method to Distinguish True and False Loss of Resistance?

  • Journal: The Korean Journal of Pain. April 2012

  • Authors: Michael Haejin Pak, MD, Won Hyung Lee, MD, Young Kwon Ko, MD, Sang Young So, MD, and Hyun Joong Kim, MD

  • Purpose: Is ultrasound measurement of the ligamentum flavum accurate?

  • Conclusion: The use of ultrasound to measure the depth of the ligamentum flavum before placing a cervical epidural block was beneficial and increased success rates of cervical epidural blocks.


Real time ultrasound guided spinal anaesthesia a prospective observational study of a new approach
Real-Time Ultrasound-Guided Spinal Anaesthesia: A Prospective Observational Study of a New Approach

  • Journal: Anesthesiology Research and Practice, January 2013

  • Authors: P. H. Conroy, C. Luyet, C. J. McCartney, P. G. McHardy

  • Purpose: To investigate the feasibility of performing a systematic method for real-time ultrasound guided paramedian access to the subarachnoid space with a spinal needle inserted in the plan of the ultrasound beam by a single operator.

  • Conclusion: Use of real-time ultrasound guided anaesthesia is a clinically feasible procedure


Materials and methods
Materials and Methods Prospective Observational Study of a New Approach

  • Materials

    • Ultrasound:  GE Logiq 2012 

    • Epidural Kit:  Braun Custom Kit for PCRMC

    • Epidural Pump:  Hospira Gemstar Epidural basal plus PCA

  • Methods

    • Patients randomly assigned to group

    • Epidural placed with standard technique after either US mapping or palpation, dependent on group


Ultrasonography
Ultrasonography Prospective Observational Study of a New Approach


Comparison of bmi and actual loss of resistance
Comparison of BMI and Actual Loss of Resistance Prospective Observational Study of a New Approach


40 decrease in number of attempts
40% Decrease in Number of Attempts Prospective Observational Study of a New Approach


Accuracy of ultrasound
Accuracy of Ultrasound Prospective Observational Study of a New Approach


Conclusions
Conclusions Prospective Observational Study of a New Approach

  • Ultrasound guidance decreased the number of attempts by 40% in a varying range of BMIs and showed the same reduction in patients with BMIs greater than 35

  • Ultrasound mapping of the depth to the epidural space is accurate and safe due to the fact that it underestimates the depth

  • Previous thoughts about the average depth to the epidural space are accurate


Discussion
Discussion Prospective Observational Study of a New Approach

  • This technique can be applied to patients with a previous history of difficult epidural placement or a wet tap

  • Can be used in patients with an increased BMI

  • Can be used to aid practitioners who are inexperienced at placing epidural catheters


Limitations and future research
Limitations and Future Research Prospective Observational Study of a New Approach

  • Limitations

    • Single center, small sample size, limited number of providers and limited participant variability

  • Future research

    • Multiple center, larger sample size, multiple providers and broader patient population


Acknowledgements
Acknowledgements Prospective Observational Study of a New Approach

  • Thanks to the Anesthesia Department at Phelps County Regional Medical Center

  • Special Thanks to Mike Burns, CRNA and Chris Black, CRNA for their assistance in data collection and experimental guidance

  • Michelle Koons, RN, BSN Phelps County Regional Medical Center Labor and Delivery Department

  • Todd Daniels Missouri State University Rstats Department for assistance in statistical analysis


References
References Prospective Observational Study of a New Approach

  • Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., & Stock, C. M. (2009). Clinical Anesthesia (6thth ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

  • Chin MD, K. J., Perlas MD, A., Singh MD, M., Arzola MD, C., Prasad MD, A., Chan MD, V., & Brull MD, R. (2009, June 23). An ultrasound-assisted approach facilitates spinal anesthesia for total joint arthroplasty [Electronic version]. Canadian Journal of Anesthesia, 56, 643-650. doi:10.1007/s12630-009-9132-8

  • Conroy, P., Luyet, C., McCartney, C., & McHardy, P. (2012, November 15). Real-Time Ultrasound-Guided Spinal Anaesthesia: A Prospective Observational Study of a New Approach. Anesthesiology Research and Practice, 2013. doi:10.1155/2013/525818

  • Herth MD, F. F., Eberhardt MD, R., Becker MD, H. D., & Ernst MD, A. (2006, January). Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy in Fluoroscopically Invisible Solitary Pulmonary Nodules [Electronic version]. Chest, 129(1), 147-150.

  • Liu MD, S. S., Zayas MD, V. M., Gordon MD, M. A., Beathe MD, J. C., Maalouf MD, D. B., Paroli MD, L., & Liguori MD, G. A. (2009, January 8). A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurologic Symptoms [Electronic version]. Anesthesia & Analgesia, 109(1), 265-271. doi:10.1213/ane.0b013e3181a3272c

  • Karakitos, D., Labropoulos, N., De Groot, E., Patrianakos, A. P., Kouraklis, G., & Poularas, J. (2006, November 17). Real-time ultasound guided catheterisation of the internal jugular vein: a prespective comparison with the landmark technique in critical care patients. Critical Care, 10. doi:10.1186/cc5101

  • Marhofer MD, P., & Chan MD, V. S. (2007, January 23). Ultrasound Guided Regional Anesthesia: Current Concepts and Future Trends [Electronic version]. Anesthesia & Analgesia, 104(5), 1265-1269. doi:10.1213/01.ane.0000260614.32794.7b

  • Miller MD, A. H., Roth MD, B. A., Mills MD, T. J., Woody MD, J. R., Longmoor MD, C. E., & Foster PhD, B. (2002, August). Ultrasound Guidance versus the Landmark Technique for the Placement of Central Venous Catheters in the Emergency Department [Electronic version]. Academy of Emergency Medicine, 9(8), 800-805.

  • Nagelhout. J. J. & Plaus, K. L. (Eds.). (2010). Nurse anesthesia. St. Louis: Saunders/Elsevier.

  • Pak MD, M.H., Lee MD, W.H., Ko MD, Y.K., So MD, S.Y., & Kim MD, H.J. (2012, April). Ultrasonographic Measurement of the Ligamentum Flavum Depth, Is it a Reliable Method to Distinguish True and False Loss of Resistance? [Electronic version]. The Korean Journal of Pain, 25(2), 99-104. doi.10.3344/kjp.2012.25.2.99

  • Rasoulian, A., Lohser MD, J., Najafi, M., Rafi-Tari, H., Tran PhD, D., Kamani MD, A. A., & Lessoway, V. A. (2011, June 23). Utility of prepuncture ultrasound for localization of the thoracic epidural space [Electronic version]. Canadian Journal of Anesthesia, 58, 815-823. doi:10.1007/s12630-011-9548-9

  • Rieker, M. (2011). Labor Epidural. In S. Elisha (Ed.), Case studies in nurse anesthesia. Sudbury, MA: Jones and Bartlett Publishers.


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