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
• 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
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 Complications
•
•
•
•
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
Obesity in the United States
Purpose
• 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
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
• 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
• 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
– 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
Comparison of BMI and Actual Loss
of Resistance
40% Decrease in Number of Attempts
Accuracy of Ultrasound
Conclusions
• 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
• 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
– 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
• 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
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 UltrasoundGuided 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.
•
•
•
•
•
•
•
•