Randomized comparison between epidural waveform analysis through the needle versus the catheter for thoracic epidural blocks

2019 ◽  
Vol 44 (8) ◽  
pp. 800-804 ◽  
Author(s):  
Amornrat Tangjitbampenbun ◽  
Sebastián Layera ◽  
Vanlapa Arnuntasupakul ◽  
Worapot Apinyachon ◽  
Karen Venegas ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Success Rate ◽  
Epidural Catheter ◽  
Local Anesthetic ◽  
Pressure Transducer ◽  
Test Dose ◽  
Waveform Analysis ◽  
Thoracic Epidural ◽  
Analgesic Consumption ◽  
Performance Time

BackgroundEpidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle/catheter tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. Epidural waveform analysis can be carried out through the tip of the needle (EWA-N) or the catheter (EWA-C). In this randomized trial, we compared the two methods. We hypothesized that, compared with EWA-C, EWA-N would result in a shorter performance time.MethodsOne hundred and twenty patients undergoing thoracic epidural blocks for thoracic or abdominal surgery were randomized to EWA-N or EWA-C. In the EWA-N group, LOR was confirmed by connecting the epidural needle to a pressure transducer. After obtaining a satisfactory waveform, the epidural catheter was advanced 5 cm beyond the needle tip. In the EWA-C group, the epidural catheter was first advanced 5 cm beyond the needle tip after the occurrence of LOR. Subsequently, the catheter was connected to the pressure transducer to detect the presence of waveforms. In both study groups, the block procedure was repeated at different intervertebral levels until positive waveforms could be obtained (through the needle or catheter as per the allocation) or until a predefined maximum of three intervertebral levels had been reached. Subsequently, the operator administered a 4 mL test dose of lidocaine 2% with epinephrine 5 µg/mL through the catheter. An investigator present during the performance of the block recorded the performance time (defined as the temporal interval between skin infiltration and local anesthetic administration through the epidural catheter). Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. Success was defined as a bilateral block in at least two dermatomes. Furthermore, postoperative pain scores, local anesthetic consumption, and breakthrough analgesic consumption were recorded.ResultsNo intergroup differences were found in terms of performance time, success rate, postoperative pain, local anesthetic requirement, and breakthrough analgesic consumption.ConclusionEWA can be carried out through the needle or through the catheter with similar efficiency (performance time) and efficacy (success rate, postoperative analgesia).Trial registration numberNCT03603574.

Preemptive Analgesia: Intraperitoneal Local Anesthetic in Laparoscopic Cholecystectomy

1996 ◽  
Vol 85 (1) ◽  
pp. 11-20 ◽  
Author(s):  
Alberto Pasqualucci ◽  
Verena De Angelis ◽  
Riccardo Contardo ◽  
Francesca Colo ◽  
Giovanni Terrosu ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Blood Glucose ◽  
Postoperative Pain ◽  
Pain Intensity ◽  
Local Anesthetic ◽  
Preemptive Analgesia ◽  
Placebo Control ◽  
Analgesic Consumption ◽  
Surgery Group ◽  
Before And After

Background A controversy exists over the effectiveness and clinical value of preemptive analgesia. Additional studies are needed to define the optimum intensity, duration, and timing of analgesia relative to incision and surgery. Methods One hundred twenty patients undergoing laparoscopic cholecystectomy under general anesthesia plus topical peritoneal local anesthetic or saline were studied. Local anesthetic (0.5% bupivacaine with epinephrine) or placebo solutions were given as follows: immediately after the creation of a pneumoperitoneum (blocking before surgery), and at the end of the operation (blocking after surgery). Patients were randomly assigned to one of four groups of 30 patients each. Group A (placebo) received 20 ml 0.9% saline both before and after surgery, group B received 20 ml 0.9% saline before surgery and 20 ml local anesthetic after surgery, group C received 20 ml local anesthetic both before and after surgery, group P received 20 ml local anesthetic before and 20 ml 0.9% saline after surgery. Pain was assessed using a visual analog scale and a verbal rating scale at 0, 4, 8, 12, and 24 h after surgery. Metabolic endocrine responses (blood glucose and cortisol concentrations) and analgesic requirements also were investigated. Results Pain intensity (visual analog and verbal rating scales) and analgesic requirements were significantly less in the group receiving bupivacaine after surgery compared to placebo. However, in the groups receiving bupivacaine before surgery, both pain intensity and analgesic consumption were less than in the group receiving bupivacaine only after surgery. Blood glucose and cortisol concentrations 3 h after surgery were significantly less in groups receiving bupivacaine before surgery. Conclusions The results indicate that intraperitoneal local anesthetic blockade administered before or after surgery preempts postoperative pain relative to an untreated placebo-control condition. However, the timing of administration is also important in that postoperative pain intensity and analgesic consumption are both lower among patients treated with local anesthetic before versus after surgery.

scholarly journals A Randomized Comparison of Loss of Resistance Versus Loss of Resistance Plus Electrical Stimulation: Effect On Success of Thoracic Epidural Placement

2021 ◽  
Author(s):  
Sean Wayne Dobson ◽  
Robert Stephen Weller ◽  
Christopher Edwards ◽  
James David Turner ◽  
Jonathan Douglas Jaffe ◽  
...  
Keyword(s):  
Success Rate ◽  
Epidural Catheter ◽  
Nerve Stimulation ◽  
Protocol Analysis ◽  
Epidural Catheter Placement ◽  
Thoracic Epidural ◽  
Intention To Treat ◽  
Loss Of Resistance ◽  
Procedural Time ◽  
Treat Analysis

Abstract Background: Loss of resistance (LOR) for epidural catheter placement has been utilized for almost a century. LOR is a subjective endpoint associated with a high failure rate. Nerve stimulation (NS) has been described as an objective method for confirming placement of an epidural catheter. We hypothesized that the addition of NS to LOR would improve the success of epidural catheter placement.Methods: One-hundred patients were randomized to thoracic epidural analgesia (TEA) utilizing LOR-alone or loss of resistance plus nerve stimulation (LOR+NS). The primary endpoint was rate of success, defined as loss of sensation following test dose. Secondary endpoints included performance time. An intention-to-treat analysis was planned, but a per-protocol analysis was performed to investigate the success rate when stimulation was achieved.Results: In the intention-to-treat analysis there was no difference in success rates (90% vs 82% [LOR+NS vs LOR-alone]; P = 0.39). The procedural time increased in the LOR+NS group (33.9 ± 12.8 vs 24.0 ± 8.0 min; P < 0.001). The per-protocol analysis found a statistically higher success rate for the LOR+NS group compared to the LOR-alone group (98% vs. 82%; P = 0.017) when only patients in whom stimulation was achieved were included.Conclusions: Addition of NS technique did not statistically improve the success rate for epidural placement when analyzed in an intention-to-treat format and was associated with a longer procedural time. In a per-protocol analysis a statistically higher success rate for patients in whom stimulation was obtained highlights the potential benefit of adding NS to LOR.Trial registration: ClinicalTrials.gov identifier NCT03087604 on 3/22/2017; Institutional Review Board Wake Forest School of Medicine IRB00039522, Food and Drug Administration Investigational Device Exemption: G160273.

Real-time ultrasound-guided low thoracic epidural catheter placement: technical consideration and fluoroscopic evaluation

2021 ◽  
pp. rapm-2021-102578
Author(s):  
Doo-Hwan Kim ◽  
Jong-Hyuk Lee ◽  
Ji Hoon Sim ◽  
Wonyeong Jeong ◽  
Dokyeong Lee ◽  
...  
Keyword(s):  
Success Rate ◽  
Real Time ◽  
Epidural Catheter ◽  
Epidural Space ◽  
Catheter Placement ◽  
Epidural Catheter Placement ◽  
Thoracic Epidural ◽  
Us Guidance ◽  
Thoracic Epidural Catheter ◽  
First Pass

Background and objectiveThoracic epidural analgesia can significantly reduce acute postoperative pain. However, thoracic epidural catheter placement is challenging. Although real-time ultrasound (US)-guided thoracic epidural catheter placement has been recently introduced, data regarding the accuracy and technical description are limited. Therefore, this prospective observational study aimed to assess the success rate and describe the technical considerations of real-time US-guided low thoracic epidural catheter placement.Methods38 patients in the prone position were prospectively studied. After the target interlaminar space between T9 and T12 was identified, the needle was advanced under real-time US guidance and was stopped just short of the posterior complex. Further advancement of the needle was accomplished without US guidance using loss-of-resistance techniques to normal saline until the epidural space was accessed. Procedure-related variables such as time to mark space, needling time, number of needle passes, number of skin punctures, and the first-pass success rate were measured. The primary outcome was the success rate of real-time US-guided thoracic epidural catheter placement, which was evaluated using fluoroscopy. In addition, the position of the catheter, contrast dispersion, and complications were evaluated.ResultsThis study included 38 patients. The T10–T11 interlaminar space was the most location for epidural access. During the procedure, the mean time for marking the overlying skin for the procedure was 49.5±13.8 s and the median needling time was 49 s. The median number of needle passes was 1.0 (1.0–1.0). All patients underwent one skin puncture for the procedure. The first-pass and second-pass success rates were 76.3% and 18.4%, respectively. Fluoroscopic evaluation revealed that the catheter tips were all positioned in the epidural space and were usually located between T9 and T10 (84.2%). The cranial and caudal contrast dispersion were observed up to 5.4±1.6 and 2.6±1.0 vertebral body levels, respectively. No procedure-related complications occurred.ConclusionReal-time US guidance appears to be a feasible option for facilitating thoracic epidural insertion. Whether or not this technique improves the procedural success and quality compared with landmark-based techniques will require additional study.Trial registration numberNCT03890640.

Treatment of Incomplete Analgesia after Placement of an Epidural Catheter and Administration of Local Anesthetic for Women in Labor 

1998 ◽  
Vol 88 (6) ◽  
pp. 1502-1506 ◽  
Author(s):  
Yaakov Beilin ◽  
Jeffrey Zahn ◽  
Howard H. Bernstein ◽  
Barbara Zucker-Pinchoff ◽  
Wendy J. Zenzen ◽  
...  
Keyword(s):  
Success Rate ◽  
Epidural Catheter ◽  
Epidural Space ◽  
Local Anesthetic ◽  
Labor Analgesia ◽  
Repeated Dosing ◽  
To Receive

Background Approximately 15% of women still have pain after placement of an epidural catheter and administration of local anesthetic for labor analgesia. Two techniques frequently used to treat this pain were compared: (1) withdrawal of the catheter 1 cm and repeated dosing with additional local anesthetic, and (2) repeated dosing with additional local anesthetic without any catheter manipulation. Methods Fifteen minutes after placement of a multiple-orifice epidural catheter 5 cm into the epidural space and administration of 13 ml 0.25% bupivacaine to the parturient in labor, the adequacy of analgesia was assessed. All women who had incomplete analgesia were randomized (first intervention) to receive an additional 5 ml 0.25% bupivacaine (local-anestheticonly group) or to receive 5 ml 0.25% bupivacaine after first withdrawing the epidural catheter 1 cm (catheter-manipulation group). If after 15 min the woman still had pain, then (second intervention) the catheter was withdrawn 1 cm and an additional 5 ml 0.25% bupivacaine was administered to the local-anesthetic-only group, whereas 5 ml 0.25% bupivacaine was given to the catheter-manipulation group without further catheter manipulation. The success rate of the second intervention was assessed 15 min later. Results Seventy-eight women were enrolled in the study, 39 to each group. In the local-anesthetic-only group, 29 (74%) women were successfully treated with the first intervention and the remaining 10 (100%) were successfully treated with the second intervention. In the catheter-manipulation group, 30 (77%) were successfully treated with the first intervention and 7 (100%; 2 patients were not studied because of investigator error) were successfully treated with the second intervention (P=NS). Conclusions Administration of additional local anesthetic without first withdrawing the epidural catheter will effectively treat most women for whom analgesia is incomplete after the placement of an epidural catheter during labor.

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