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Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial.

ABSTRACT: BACKGROUND:Spinal anesthesia using the midline approach might be technically difficult in geriatric population. We hypothesized that pre-procedural ultrasound (US)-guided paramedian technique and pre-procedural US-guided midline technique would result in a different spinal anesthesia success rate at first attempt when compared with the conventional landmark-guided midline technique in elderly patients. METHODS:In this prospective, randomized, controlled study, one hundred-eighty consenting patients scheduled for elective surgery were randomized into the conventional surface landmark-guided midline technique (group LM), the pre-procedural US-guided paramedian technique (group UP), or the pre-procedural US-guided midline technique (group UM) with 60 patients in each group. All spinal anesthesia were performed by a novice resident. RESULTS:The successful dural puncture rate on first attempt (primary outcome) was higher in groups LM and UM (77 and 73% respectively) than in group UP (42%; P?

SUBMITTER: Rizk MS

PROVIDER: S-EPMC6849309 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial.

Rizk Marwan S MS Zeeni Carine A CA Bouez Joanna N JN Bteich Nathalie J NJ Sayyid Samia K SK Alfahel Waseem S WS Siddik-Sayyid Sahar M SM

BMC anesthesiology 20191111 1

<h4>Background</h4>Spinal anesthesia using the midline approach might be technically difficult in geriatric population. We hypothesized that pre-procedural ultrasound (US)-guided paramedian technique and pre-procedural US-guided midline technique would result in a different spinal anesthesia success rate at first attempt when compared with the conventional landmark-guided midline technique in elderly patients.<h4>Methods</h4>In this prospective, randomized, controlled study, one hundred-eighty c ...[more]

PMID: 31711438

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Project description:BackgroundCombined spinal-epidural (CSE) anesthesia is considerably challenging for elderly patients with hip fractures due to spine degeneration and limitations in positioning. This study aimed to investigate the ability of a modified preprocedural ultrasound-guided technique to improve the success rate and efficacy of CSE anesthesia for elderly patients with hip fractures.MethodsThis prospective, single-blinded, parallel-group randomized controlled trial included 80 patients (aged ≥65 years) who were scheduled for elective hip fracture surgery with CSE anesthesia. Patients were randomly allocated into landmark group (n = 40) or the ultrasound group (n = 40). The primary outcome was first-pass success rate. Secondary outcomes included first-attempt success rate; number of needle insertion attempts; number of needle passes; locating, puncture, and total time; level of block; procedural adverse reactions and postoperative complications; and patient satisfaction score. Patients were blinded to group allocation.ResultsEighty patients completed the study and were included in the final analysis. The first-pass success rates for the landmark and ultrasound groups were 20 and 70%, respectively (P < 0.001). The first-attempt success rates in the landmark and ultrasound groups were 42.5 and 85%, respectively (P < 0.001). The median number of attempts was lower in ultrasound-assisted group (1 [1]) than landmark-guided group (2 [1, 2]), P < 0.001). The median number of needle passes was lower in ultrasound group (1 [1, 2]) than in landmark-guided group (3 [2, 4], P < 0.001). The locating time (P < 0.001) and total time (P = 0.001) were longer in the ultrasound group, while puncture time was shorter (P = 0.003). No significant difference was found regarding the incidence of adverse reactions and complications. More patients in the ultrasound group had a high satisfaction score of 4-5 (P = 0.007). Interestingly, subgroup analysis demonstrated benefits for ultrasound in patients with scoliosis.ConclusionsModified ultrasound-assisted CSE anesthesia increases first-pass and first-attempt success rates, and reduces needle insertion attempts, passes, and puncture time for elderly patients with hip fracture, especially those with scoliosis. This technique improves patient satisfaction and warrants consideration for application in clinical practice.Trial registrationChinese Clinical Trial Register (identifier, ChiCTR1900020819 ; date of registration, January 20, 2019).

Project description:BackgroundThrough previous studies and clinical practice, we have found that real-time ultrasound-guided (UG) spinal anesthesia (SA) and traditional landmark-guided (LG) SA each require a different minimum local anesthetic dose (MLAD) of ropivacaine. For this study, we used Dixon's up-and-down sequential method to analyze and compare the MLAD of different ropivacaine concentrations required for the UG and LG SA methods.MethodsA total of 120 patients undergoing knee surgery were consecutively recruited and randomly divided into four groups (30 patients per group). These groups were categorized as follows: Group I: high ropivacaine ultrasound-guided (HRUG), Group II: low ropivacaine ultrasound-guided (LRUG), Group III: high ropivacaine landmark-guided (HRLG), and Group IV: low ropivacaine landmark-guided (LRLG). SA was established by a bolus administration of up-and-down doses of 0.75% or 0.5% plain ropivacaine. Initial doses of 16, 18, 12, and 14 mg were administered to groups I-IV, and after that, increased or decreased by 1.5 mg according to dose effectiveness. Upon identifying the intervertebral puncture level, a lumbar X-ray was performed with metal markers, and actual radiographic findings were identified and compared to the initial markings.ResultsFor UG groups, the MLAD in the LRUG group was significantly higher than in the HRUG group [20.192 mg (95% CI, 19.256-21.174) versus 17.176 mg (95% CI, 16.276-18.124), respectively; P<0.001]. For LG groups, the MLAD in the LRLG group was significantly higher than in the HLRG group [14.478 mg (95% CI, 13.364-15.500) versus 13.201 mg (95% CI, 11.959-14.571), respectively; P=0.047]. When comparing both high ropivacaine groups (HRGs: I/III) to the low ropivacaine groups (LRGs: II/IV), we found that both UG subgroups (I/II) had a significantly higher MLAD than LG subgroups (III/IV) (P<0.001). US identified L4-5 in up to 90% of cases. Comparatively, palpation was successful in only 33.3% of patients. The rates of cephalad localization by US and palpation were 6.67% vs. 66.67%, respectively (P=0.002).ConclusionsWe found a higher MLAD of ropivacaine was required for UG SA at the L4-5 level due to the method providing a more accurate (less cephalad) localization than traditional LG SA.Trial registrationChinese Clinical Trial Registry ChiCTR2000033158.

Dataset Information

Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial.

Publications

Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial.

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