Ružman Tomislav, Gulam Danijela, Haršanji Drenjančević Ivana, Venžera-Azenić Darija, Ružman Nataša, Burazin Jelena
Department of Anesthesiology, Resuscitation, and Intensive Care Unit, University Hospital Osijek, Osijek, Croatia ; Faculty of Medicine, University of Osijek, Osijek, Croatia.
Department of Anesthesiology, Resuscitation, and Intensive Care Unit, University Hospital Osijek, Osijek, Croatia.
Local Reg Anesth. 2014 Oct 8;7:47-52. doi: 10.2147/LRA.S68451. eCollection 2014.
Spinal and epidural blocks are common practice in anesthesia and are usually used for various surgical or endoscopic procedures. Correct identification and puncture of the epidural or subarachnoid space determine the success or failure of the technique. Multiple attempts and difficult access to the epidural or subarachnoid space is a frequent problem in operating theaters and may be hazardous due to a number of possible acute or long-term complications. In addition, multiple punctures are associated with increased pain and patient discomfort. The aim of this study was to determine the factors associated with a difficult spinal or epidural block, dependent on the patient (age, gender, height, weight, body mass index, and quality of anatomical landmarks), the technique (type of blockade, needle gauge, and patient positioning), and the provider (level of experience). The study was conducted at the Department of Anesthesiology, Resuscitation, and Intensive Care Unit of University Hospital Osijek (Osijek, Croatia) and it included 316 patients who underwent a range of different surgical procedures in neuraxial blocks. There were 219 cases of first puncture success, while the overall success of neuraxial blocks was 97.5%. Five patients (1.6%) were submitted to the alternative technique, ie, general anesthesia. In three patients (0.9%), neuraxial block was partial so they required supplementation of intravenous anesthetics and analgesics. Furthermore, it was found that first puncture success was associated with younger age (P=0.007), lower weight (P=0.032), and body mass index (P=0.020). Spine deformity (P=0.015), poor identification of interspinous space (P=0.005), recumbent patient position during the puncture (P=0.001), and use of a paramedian approach were associated with first puncture failure. Adequate preoperative prediction of difficulties can help to reduce the incidence of multiple attempts, rendering the technique more acceptable and less risky to the patient, and consequently leading to improvement of medical care quality. The attending anesthesiologist should consider an alternative technique (general anesthesia or peripheral nerve block) for a patient if certain difficulties can be predicted.
脊髓和硬膜外阻滞是麻醉中的常见操作，通常用于各种外科手术或内镜手术。正确识别和穿刺硬膜外腔或蛛网膜下腔决定了该技术的成败。在手术室中，多次尝试以及难以进入硬膜外腔或蛛网膜下腔是一个常见问题，并且由于一些可能的急性或长期并发症，这可能是危险的。此外，多次穿刺会增加疼痛和患者不适。本研究的目的是确定与困难脊髓或硬膜外阻滞相关的因素，这些因素取决于患者（年龄、性别、身高、体重、体重指数和解剖标志的质量）、技术（阻滞类型、针号和患者体位）以及操作者（经验水平）。该研究在奥西耶克大学医院（克罗地亚奥西耶克）麻醉、复苏和重症监护科进行，纳入了316例行各种不同手术的神经轴阻滞患者。首次穿刺成功219例，神经轴阻滞的总体成功率为97.5%。5例患者（1.6%）采用了替代技术，即全身麻醉。3例患者（0.9%）神经轴阻滞不完全，因此需要补充静脉麻醉药和镇痛药。此外，发现首次穿刺成功与年龄较小（P = 0.007）、体重较低（P = 0.032）和体重指数较低（P = 0.020）有关。脊柱畸形（P = 0.015）、棘突间隙识别不清（P = 0.005）、穿刺时患者卧位（P = 0.001）以及采用旁正中入路与首次穿刺失败有关。对困难进行充分的术前预测有助于降低多次尝试的发生率，使该技术对患者更易接受且风险更低，从而提高医疗质量。如果可以预测某些困难，主治麻醉医生应为患者考虑替代技术（全身麻醉或外周神经阻滞）。
