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.

scholarly journals Measurements of Epidural Space Depth Using Preexisting CT Scans Correlate with Loss of Resistance Depth during Thoracic Epidural Catheter Placement

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
Author(s):  
Nathaniel H. Greene ◽  
Benjamin G. Cobb ◽  
Ken F. Linnau ◽  
Christopher D. Kent
Keyword(s):  
Epidural Catheter ◽  
Strong Association ◽  
Epidural Catheter Placement ◽  
Thoracic Epidural ◽  
Thoracic Surgical Procedures ◽  
Spine Imaging ◽  
Thoracic Epidural Catheter ◽  
Loss Of Resistance ◽  
Resolution Imaging ◽  
Epidural Catheters

Background.Thoracic epidural catheters provide the best quality postoperative pain relief for major abdominal and thoracic surgical procedures, but placement is one of the most challenging procedures in the repertoire of an anesthesiologist. Most patients presenting for a procedure that would benefit from a thoracic epidural catheter have already had high resolution imaging that may be useful to assist placement of a catheter.Methods.This retrospective study used data from 168 patients to examine the association and predictive power of epidural-skin distance (ESD) on computed tomography (CT) to determine loss of resistance depth acquired during epidural placement. Additionally, the ability of anesthesiologists to measure this distance was compared to a radiologist, who specializes in spine imaging.Results.There was a strong association between CT measurement and loss of resistance depth (P<0.0001); the presence of morbid obesity (BMI>35) changed this relationship (P=0.007). The ability of anesthesiologists to make CT measurements was similar to a gold standard radiologist (all individualICCs>0.9).Conclusions.Overall, this study supports the examination of a recent CT scan to aid in the placement of a thoracic epidural catheter. Making use of these scans may lead to faster epidural placements, fewer accidental dural punctures, and better epidural blockade.

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.

Avoid suboptimal perioperative analgesia during major surgery by enhancing thoracic epidural catheter placement and hemodynamic performance

2021 ◽  
pp. rapm-2020-102352
Author(s):  
Sarah A Bachman ◽  
Johan Lundberg ◽  
Michael Herrick
Keyword(s):  
Epidural Catheter ◽  
Treatment Strategies ◽  
Preventive Treatment ◽  
Catheter Placement ◽  
Major Surgery ◽  
Perioperative Analgesia ◽  
Neuraxial Blockade ◽  
Epidural Catheter Placement ◽  
Thoracic Epidural ◽  
Catheter Failure

Thoracic epidural analgesia (TEA) is an established gold standard for postoperative pain control especially following laparotomy and thoracotomy. The safety and efficacy of TEA is well known when the attention to patient selection is upheld. Recently, the use of fascial plane blocks (FPBs) has evolved as an alternative to TEA most likely because these blocks avoid problems such as neurological comorbidity, coagulation disorders, epidural catheter failure and hypotension due to sympathetic denervation. However, if an FPB is performed, postoperative monitoring and adjuvant treatments are still necessary. Also, the true efficacy of FPBs is questioned. Thus, should we prioritize less efficient analgesic regimens with FPBs when preventive treatment strategies for epidural catheter failure and hypotension exist for TEA? It is time to promote and underscore the benefits of TEA provided to patients undergoing major open surgical procedures. In our mind, FPBs and landmark-guided techniques should be limited to less extensive surgery and when either neuraxial blockade is contraindicated or resources for optimal epidural catheter placement and maintenance are not available.

Patient-Controlled Epidural Analgesia/Continuous Epidural Catheters

2016 ◽  
Author(s):  
Devin Peck
Keyword(s):  
Epidural Catheter ◽  
Local Anesthetics ◽  
Catheter Placement ◽  
Labor Pain ◽  
Abdominal Incision ◽  
Tumor Spread ◽  
Epidural Catheter Placement ◽  
Thoracic Epidural ◽  
Cord Injury ◽  
Epidural Catheters

Although useful for management of many types of pain, the most common indication for epidural catheter placement is for management of labor pain. High lumbar and thoracic epidural catheter placement has gained increasing popularity in recent years for the management of postoperative pain. The technique is most commonly employed for procedures in which a thoracic or an extensive abdominal incision is anticipated. Absolute contraindications for epidural catheter placement include patient refusal, uncorrected hypovolemia, increased intracranial pressure, local infection at the planned site of insertion, and patient allergy to amide/ester local anesthetics. Relative contraindications include coagulopathy, an uncooperative patient, severe anatomic abnormalities of the spine, sepsis, and hypertension. The advantages include attenuation of the sympathetic response to surgical stimulation and pain; effects on the cardiovascular, respiratory, and gastrointestinal systems; thromboprotective effects; and possibly limitation of tumor spread. The risks of epidural catheter placement include epidural hematoma, infection, nerve or spinal cord injury, dural puncture, or respiratory or cardiovascular depression from a high block. Epidural opioids provide analgesia without causing motor or sympathetic blockade. Epidurally administered local anesthetics may result in decreased postoperative ileus, nausea, vomiting, and sedation, which can be associated with opioids. Local anesthetics and opioids act additively or synergistically and, when used together, can lead to a reduction in the dose of each drug. 

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.

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