Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, SAR, China.
BMC Anesthesiol. 2022 Jun 25;22(1):198. doi: 10.1186/s12871-022-01730-5.
Thoracic epidural placement (TEP) using the conventional anatomic landmark-based technique is technically challenging, may require multiple attempts, and is associated with a high failure rate (12-40%). We hypothesized that real-time ultrasound guidance would be superior in the "first-pass" success rate of TEP, when compared with the conventional technique.
This prospective, randomized, superiority trial was conducted in a University hospital, and recruited 96 patients undergoing elective major abdominal or thoracic surgery and scheduled to receive a TEP for postoperative analgesia. Patients were randomly allocated to receive TEP using either the conventional technique (Gp-Conv, n = 48) or real-time ultrasound guidance (Gp-Usg, n = 48). The success of TEP was defined as eliciting loss of resistance technique and being able to insert the epidural catheter. The primary outcome variable was the "first-pass success rate" meaning the successful TEP at the first needle insertion without redirection or readvancement of the Tuohy needle. The secondary outcomes included the number of skin punctures, number of attempts, the overall success rate, TEP time, and total procedure time.
The first-pass success rate of TEP was significantly higher (p = 0.002) in Gp-Usg (33/48 (68.8%); 95%CI 55.6 to 81.9) than in Gp-Conv (17/48 (35.4%); 95%CI 21.9 to 49.0). There was no statistically significant difference (p = 0.12) in the overall success rate of TEP between the 2 study groups (Gp-Usg; 48/48 (100%) vs. Gp-Conv; 44/48 (91.7%); 95%CI 83.9 to 99.5). Ultrasound guidance reduced the median number of skin punctures (Gp-Usg; 1 [1, 1] vs Gp-Conv; 2 [1, 2.2], p < 0.001) and attempts at TEP (Gp-Usg; 1 [1, 2] vs Gp-Conv; 3 [1, 7.2], p < 0.001) but the procedure took longer to perform (Gp-Usg; 15.5 [14, 20] min vs Gp-Conv; 10 [7, 14] min, p < 0.001).
This study indicates that real-time ultrasound guidance is superior to a conventional anatomic landmark-based technique for first-pass success during TEP although it is achieved at the expense of a marginally longer total procedure time. Future research is warranted to evaluate the role of real-time ultrasound guidance for TEP in other groups of patients.
Thai Clinical Trials Registry; http://www.thaiclinicaltrials.org/ ; Trial ID: TCTR20200522002 , Registration date: 22/05/2020.
使用传统解剖标志定位技术进行胸段硬膜外置管（TEP）在技术上具有挑战性，可能需要多次尝试，并且失败率较高（12-40%）。我们假设与传统技术相比，实时超声引导在 TEP 的“首次通过”成功率方面更具优势。
这项前瞻性、随机、优效性试验在一家大学医院进行，招募了 96 名接受择期大腹部或大胸部手术并计划接受术后镇痛的 TEP 的患者。患者被随机分配接受传统技术（Gp-Conv，n=48）或实时超声引导（Gp-Usg，n=48）进行 TEP。TEP 的成功定义为引出阻力消失技术并能够插入硬膜外导管。主要结局变量是“首次通过成功率”，即在不重新定向或重新推进 Tuohy 针的情况下，首次成功进行 TEP。次要结局包括皮肤穿刺次数、尝试次数、总体成功率、TEP 时间和总手术时间。
Gp-Usg 组（33/48（68.8%）；95%CI 55.6 至 81.9）的 TEP 首次通过成功率明显高于 Gp-Conv 组（17/48（35.4%）；95%CI 21.9 至 49.0）（p=0.002）。两组 TEP 的总体成功率无统计学差异（p=0.12）（Gp-Usg；48/48（100%）vs. Gp-Conv；44/48（91.7%）；95%CI 83.9 至 99.5）。超声引导减少了 TEP 的中位数皮肤穿刺次数（Gp-Usg；1[1,1] vs Gp-Conv；2[1,2.2]，p<0.001）和 TEP 的尝试次数（Gp-Usg；1[1,2] vs Gp-Conv；3[1,7.2]，p<0.001），但手术时间延长（Gp-Usg；15.5[14,20]min vs Gp-Conv；10[7,14]min，p<0.001）。
本研究表明，与传统解剖标志定位技术相比，实时超声引导在 TEP 的首次通过成功率方面具有优势，尽管这是以总手术时间略有延长为代价的。需要进一步研究来评估实时超声引导在其他患者群体中进行 TEP 的作用。
泰国临床试验注册处；http://www.thaiclinicaltrials.org/；试验 ID：TCTR20200522002；登记日期：2020 年 5 月 22 日。
