Prakash Smita, Mullick Parul, Kumar S Suresh, Diwan Sahil, Singh Rajvir
Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
Department of Anaesthesia and Critical Care, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India.
J Anaesthesiol Clin Pharmacol. 2021 Jul-Sep;37(3):395-401. doi: 10.4103/joacp.JOACP_196_19. Epub 2021 Oct 12.
Several factors determine the success of dural puncture. We aimed to assess the association of first puncture success and number of attempts with characteristics of the patient, provider, technique and equipment.
This prospective, observational study was performed in 1647 adult patients undergoing surgery under spinal anesthesia. Patient characteristics, anatomical landmarks, spinal bony deformity, provider experience, technique, skin punctures, needle redirections, subarachnoid space depth, and complications, if any, were noted. Difficult dural puncture was assessed by first puncture success and number of attempts (skin punctures plus needle redirections) required for successful needle placement.
First puncture success was obtained in 872 (52.9%) patients. Failed dural puncture occurred in 4 (0.2%) of 1647 patients. Multivariate logistic regression analysis revealed that longer distance from C7 vertebral spine to tip of coccyx ( = 0.04), lower subarachnoid space depth ( = 0.001), good quality of bony landmarks ( = 0.001) and absence of crowded spine ( = 0.02) were associated with first puncture success. Male gender, poor or no spinal landmarks, presence of bony deformity and lower level of provider's experience predicted increased number of attempts for successful dural puncture.
First puncture success of spinal block was influenced only by patient's anatomical factors, whereas the number of attempts required for successful block were predicted by both provider and patient factors.
多种因素决定硬膜穿刺的成功与否。我们旨在评估首次穿刺成功及穿刺次数与患者、操作者、技术和设备特征之间的关联。
本前瞻性观察性研究纳入了1647例接受脊髓麻醉下手术的成年患者。记录患者特征、解剖标志、脊柱骨质畸形、操作者经验、技术、皮肤穿刺、针的重新定向、蛛网膜下腔深度以及并发症（如有）。通过首次穿刺成功情况和成功置入针所需的穿刺次数（皮肤穿刺加针的重新定向）来评估困难硬膜穿刺。
872例（52.9%）患者首次穿刺成功。1647例患者中有4例（0.2%）硬膜穿刺失败。多因素逻辑回归分析显示，从C7椎体棘突到尾骨尖的距离更长（P = 0.04）、蛛网膜下腔深度较低（P = 0.001）、骨质标志质量良好（P = 0.001）以及无脊柱拥挤（P = 0.02）与首次穿刺成功相关。男性、脊柱标志不佳或无脊柱标志、存在骨质畸形以及操作者经验水平较低预示着成功硬膜穿刺所需的穿刺次数增加。
脊髓阻滞的首次穿刺成功仅受患者解剖因素影响，而成功阻滞所需的穿刺次数则由操作者和患者因素共同预测。
