Makino Yuto, Miyake Kentaro, Roche David, Yoshimura Satoshi, Nahara Isao, Sahker Ethan, Watanabe Norio
Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
Department of Pharmacoepidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan, Kyoto University, Kyoto, Japan.
Cochrane Database Syst Rev. 2025 May 27;5(5):CD014964. doi: 10.1002/14651858.CD014964.pub2.
Neuraxial anaesthesia can be difficult to administer successfully, because the targeting space imagined by palpation of anatomical position can deviate from the actual position. Successful neuraxial anaesthesia, with as few punctures as possible, is important to reduce complications and increase patient satisfaction. Neuraxial anaesthesia by ultrasound guidance may be a useful way to increase success rates.
To assess the clinical efficacy and safety of ultrasound guidance compared with anatomical landmarks for neuraxial anaesthesia in adults.
We searched CENTRAL, MEDLINE, Embase, Web of Science, and two trials registries, together with reference checking and citation searching, to identify studies that are included in the review. After the original search on 11 October 2022, we updated the electronic searches on 28 November 2023.
We included randomised controlled trials (RCTs) that compared ultrasound guidance with the use of conventional anatomical landmarks for neuraxial anaesthesia in adults (≥ 18 years). We excluded studies on non-anaesthetic neuraxial procedures, such as lumbar puncture for diagnosis.
Our critical outcomes were: (1) number of attempts until success or procedure termination; (2) procedure time; and (3) participant satisfaction during the procedure. Our important outcomes were: (1) first-attempt success; (2) technical failure; (3) pain during the procedure; and (4) any adverse events.
We used the Cochrane RoB 2 tool to assess risk of bias in the included studies for the seven critical and important outcomes.
We synthesised results for each outcome, where possible, by using a random-effects analytical model. We calculated risk ratios (RR) for dichotomous outcomes, and mean differences (MD) or standardised mean difference (SMD) for continuous outcomes, each with 95% confidence intervals (CI). Where meta-analysis was not possible due to the nature of the data, we summarised the results narratively. We used GRADE to assess the certainty of evidence for each outcome.
We included a total of 65 studies with 6823 participants. The studies were conducted in Africa, Asia, Europe, the Middle East, North America, and Oceania, and were published between 2001 and 2023. Thirty-two studies evaluated obstetric populations undergoing labour epidural or caesarean section (3149 participants); the remaining studies evaluated participants who received surgery under neuraxial anaesthesia. Thirty-three studies evaluated spinal anaesthesia, 15 studies evaluated lumbar epidural anaesthesia, 12 studies evaluated combined spinal and epidural anaesthesia, and the remaining four studies evaluated thoracic epidural anaesthesia. Four studies evaluated real-time ultrasound as an intervention arm. Two studies were three-arm trials, which evaluated pre-procedural ultrasound and real-time ultrasound. For participant satisfaction, a variety of measurement scales were used, so we synthesised participant satisfaction using SMD.
Our meta-analyses demonstrated that compared with anatomical landmarks, ultrasound guidance reduces the number of attempts until success or procedure termination (MD -0.41 attempts, 95% CI -0.51 to -0.31; 57 studies, 6192 participants; high-certainty evidence), and procedure (needling) time (MD -33.8 seconds, 95% CI -47.22 to -20.39; 43 studies, 4178 participants; high-certainty evidence). Ultrasound guidance likely increases the rate of first-attempt success (RR 1.40, 95% CI 1.29 to 1.52; 50 studies, 5205 participants; moderate-certainty evidence). Ultrasound guidance may result in little to no difference in participant satisfaction (SMD 0.16, 95% CI -0.03 to 0.35; 25 studies; low-certainty evidence), or in technical failure (RR 0.89, 95% CI 0.62 to 1.29; 40 studies, 4581 participants; low-certainty evidence). The evidence is very uncertain about the effects of ultrasound guidance on pain during the procedure (MD -0.20 points, 95% CI -0.52 to 0.13; 13 studies, 1532 participants; very low-certainty evidence), and adverse effects (RR 0.71, 95% CI 0.48 to 1.03; 15 studies, 1692 participants; very low-certainty evidence).
AUTHORS' CONCLUSIONS: Compared to anatomical landmarks, ultrasound guidance for neuraxial anaesthesia in adults reduces the number of attempts required for success and reduces procedure (needling) time. It likely increases the rate of first-attempt success. Low-certainty evidence suggests that ultrasound guidance may result in little to no difference in participant satisfaction or technical failure. The evidence is very uncertain about the effect of ultrasound guidance on pain and adverse events. Although ultrasound guidance can be beneficial for neuraxial anaesthesia without increased risk, these results should be interpreted with caution due to some uncertainties in the evidence.
None.
Protocol available via doi.org/10.1002/14651858.CD014964.
神经轴索麻醉可能难以成功实施，因为通过触诊解剖位置所设想的目标间隙可能与实际位置存在偏差。尽可能减少穿刺次数以成功实施神经轴索麻醉，对于减少并发症和提高患者满意度至关重要。超声引导下的神经轴索麻醉可能是提高成功率的一种有效方法。
评估与解剖标志相比，超声引导用于成人神经轴索麻醉的临床疗效和安全性。
我们检索了Cochrane系统评价数据库、医学期刊数据库、Embase数据库、科学引文索引数据库以及两个试验注册库，并进行参考文献核对和引文检索，以识别纳入本综述的研究。在2022年10月11日进行初始检索后，我们于2023年11月28日更新了电子检索。
我们纳入了比较超声引导与使用传统解剖标志用于成人（≥18岁）神经轴索麻醉的随机对照试验（RCT）。我们排除了关于非麻醉性神经轴索操作的研究，如用于诊断的腰椎穿刺。
我们的关键结局指标为：（1）直至成功或手术终止的尝试次数；（2）手术时间；（3）手术过程中参与者的满意度。我们的重要结局指标为：（1）首次尝试成功；（2）技术失败；（3）手术过程中的疼痛；（4）任何不良事件。
我们使用Cochrane偏倚风险2工具评估纳入研究中七个关键和重要结局的偏倚风险。
我们尽可能使用随机效应分析模型对每个结局的结果进行综合分析。我们计算二分结局的风险比（RR）以及连续结局的平均差（MD）或标准化平均差（SMD），并给出95%置信区间（CI）。由于数据性质无法进行Meta分析时，我们对结果进行叙述性总结。我们使用GRADE评估每个结局证据的确定性。
我们共纳入了65项研究，涉及6823名参与者。这些研究在非洲、亚洲、欧洲、中东、北美和大洋洲开展，发表时间为2001年至2023年。32项研究评估了接受分娩硬膜外麻醉或剖宫产的产科人群（3149名参与者）；其余研究评估了接受神经轴索麻醉手术的参与者。33项研究评估了蛛网膜下腔麻醉，15项研究评估了腰段硬膜外麻醉，12项研究评估了腰麻-硬膜外联合麻醉，其余4项研究评估了胸段硬膜外麻醉。4项研究将实时超声作为干预组。2项研究为三臂试验，评估了术前超声和实时超声。对于参与者满意度，使用了多种测量量表，因此我们使用SMD对参与者满意度进行综合分析。
我们的Meta分析表明，与解剖标志相比，超声引导可减少直至成功或手术终止的尝试次数（MD -0.41次尝试，95%CI -0.51至-0.31；57项研究，6192名参与者；高确定性证据）以及手术（进针）时间（MD -33.8秒，95%CI -47.22至-20.39；43项研究，4178名参与者；高确定性证据）。超声引导可能会提高首次尝试成功率（RR 1.40，95%CI 1.29至1.52；50项研究，5205名参与者；中等确定性证据）。超声引导可能在参与者满意度方面几乎没有差异（SMD 0.16，95%CI -0.03至0.35；25项研究；低确定性证据），在技术失败方面也可能没有差异（RR 0.89，95%CI 0.62至1.29；40项研究，4581名参与者；低确定性证据）。关于超声引导对手术过程中疼痛的影响（MD -0.20分，95%CI -0.52至0.13；13项研究，1532名参与者；极低确定性证据）以及不良反应的影响（RR 0.71，95%CI 0.48至1.03；15项研究，1692名参与者；极低确定性证据），证据非常不确定。
与解剖标志相比，超声引导用于成人神经轴索麻醉可减少成功所需的尝试次数并缩短手术（进针）时间。它可能会提高首次尝试成功率。低确定性证据表明，超声引导在参与者满意度或技术失败方面可能几乎没有差异。关于超声引导对疼痛和不良事件的影响，证据非常不确定。尽管超声引导对神经轴索麻醉有益且不会增加风险，但由于证据存在一些不确定性，这些结果应谨慎解读。
无。
方案可通过doi.org/10.1002/14651858.CD014964获取。
