From the *Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA; and †Axio Research, Seattle, WA.
Reg Anesth Pain Med. 2017 Mar/Apr;42(2):204-209. doi: 10.1097/AAP.0000000000000540.
The placement of thoracic epidurals can be technically challenging and requires a thorough understanding of neuraxial anatomy. Although ultrasound imaging of the thoracic spine has been described, no outcome studies on the use of this imaging have been performed. We evaluated whether preprocedural ultrasound of the thoracic spine would facilitate the process of epidural catheterization.
Subjects undergoing thoracic or upper abdominal surgery with planned thoracic epidural placement at T10 or higher were enrolled in this randomized double-blind study. Subjects were allocated into 1 of 2 groups for preoperative epidural placement: ultrasound guidance (group US) or palpation (group Palp). Subjects randomized to group US had a preprocedural ultrasound examination to identify pertinent spinal anatomy and make appropriate marks on the skin identifying midline and interlaminar spaces for targeted Tuohy needle insertion. Subjects in group Palp had a skin marking performed by palpation alone. Using the skin markings, all epidurals were performed using a loss of resistance to saline technique. Block levels were assessed with ice and pain scores obtained by a blinded nurse in the postanesthesia care unit. The primary outcome was procedural time from needle insertion to loss of resistance in the epidural space.
Seventy subjects were recruited and completed the study protocol. The median time for epidural needle placement to achieve loss of resistance in group US and group Palp was 188.5 seconds (interquartile range [IQR], 79.0-515.0) and 242.0 seconds (IQR, 87.0-627.0), respectively (P = 0.188). Using ultrasound to mark the skin overlying the targeted epidural space took a median time of 85 seconds (IQR, 69-113) for group US and 35 seconds (IQR, 27-51) for group Palp (P < 0.001). The number of needle passes was not significantly different between the 2 groups (P = 0.31). The use of ultrasound assistance resulted in a decreased number of needle skin punctures to achieve loss of resistance (P = 0.005). Mean pain scores after surgery were lower in group US compared to group Palp: 3.0 versus 4.7, respectively (P = 0.015).
This is the first randomized study to evaluate the efficacy of preprocedural ultrasound marking for placement of thoracic epidural catheters. We observed that preprocedural ultrasound did not significantly reduce the time required to identify the thoracic epidural space via loss of resistance.
NCT02785055 (https://clinicaltrials.gov/).
胸椎硬膜外腔的置管技术具有一定难度，需要对脊神经解剖学有透彻的了解。虽然已经描述了胸椎的超声成像，但尚未对这种成像的使用进行任何结果研究。我们评估了胸椎术前超声检查是否会促进硬膜外导管插入过程。
本随机双盲研究纳入了计划在 T10 或更高水平行胸椎或上腹部手术且需要行胸椎硬膜外阻滞的患者。将患者分为两组进行术前硬膜外置管：超声引导组（group US）或触诊组（group Palp）。接受术前超声检查的 group US 组患者用于识别相关脊柱解剖结构，并在皮肤上做适当标记，以标识用于靶向 Tuohy 针插入的中线和椎间空间。仅接受触诊的 group Palp 组患者进行皮肤标记。使用皮肤标记，所有硬膜外穿刺均采用生理盐水阻力丧失技术进行。使用盲法护士在麻醉后护理单元中评估阻滞平面和疼痛评分。主要结局为从针插入到硬膜外腔阻力丧失的操作时间。
共纳入 70 例患者完成了研究方案。在 group US 和 group Palp 中，硬膜外针置管至达到阻力丧失的中位时间分别为 188.5 秒（四分位距 [IQR]，79.0-515.0）和 242.0 秒（IQR，87.0-627.0）（P = 0.188）。使用超声标记目标硬膜外空间上方的皮肤，group US 组的中位时间为 85 秒（IQR，69-113），group Palp 组的中位时间为 35 秒（IQR，27-51）（P < 0.001）。两组之间的针穿皮次数无显著差异（P = 0.31）。使用超声辅助可减少达到阻力丧失所需的针皮肤穿刺次数（P = 0.005）。与 group Palp 相比，术后 group US 的平均疼痛评分较低：分别为 3.0 与 4.7（P = 0.015）。
这是第一项评估术前超声标记用于放置胸椎硬膜外导管的功效的随机研究。我们观察到，术前超声检查并没有显著缩短通过阻力丧失来确定胸椎硬膜外间隙所需的时间。
NCT02785055（https://clinicaltrials.gov/）。
