Teaching practices of thoracic epidural catheterizations in different grade of anesthesia residents

Alagöz, Ali; Sazak, Hilal; Tunç, Mehtap; Ulus, Fatma; Kokulu, Serdar; Pehlivanoğlu, Polat; Şahin, Şaziye

doi:10.1016/j.bjane.2014.07.010

Cited by 4 publications

(8 citation statements)

References 12 publications

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“…The first pass-success rate of TEP with real-time ultrasound guidance (68.8%) was significantly higher than that with the conventional technique (35.4%). Currently, there are no comparable data but our first-pass success rate of TEP in the 2 groups are comparable to that reported for conventional (42 to 45%) [ 27 ] and real-time USG TEP (73 to 76%) [ 8 , 17 ]. The near 100% improvement in first-pass success for TEP in Gp-Usg compared to Gp-Conv that we have demonstrated, also confirms that our finding is clinically relevant.…”

Section: Discussionsupporting

confidence: 73%

“…It is also noteworthy that more TEP’s were performed in the mid-thoracic region in Gp-Usg than in Gp-Conv (Table 1 ). Therefore, despite the greater technical difficulty of TEP in the mid-thoracic region (T5-T8) than in the low-thoracic region (T9-T12) [ 5 , 27 ] our higher first-pass success in Gp-Usg is further evidence that real-time ultrasound guided technique is superior for TEP than the conventional technique. Future research to compare the technical success rate and clinical efficacy of TEP using real-time ultrasound guidance in the mid- vs lower-thoracic levels is warranted.…”

Section: Discussionmentioning

confidence: 94%

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Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: a prospective, randomized, superiority trial

et al. 2022

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Background 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. Methods 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. Results 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). Conclusions 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. Trial registration Thai Clinical Trials Registry; http://www.thaiclinicaltrials.org/; Trial ID: TCTR20200522002, Registration date: 22/05/2020.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionmentioning

confidence: 94%

Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: a prospective, randomized, superiority trial

et al. 2022

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“…Besides being associated with high rates of postoperative complications, obesity acts unfavorably on success rates of interventions. [ 7 , 13 , 14 ] These effects become even more prominent in interventions, such as TEC, requiring substantial experience. Failure rates of TEC may be as high as 30% when applied by trainees.…”

Section: Discussionmentioning

confidence: 99%

“…[6,[13][14][15] Obesity which is one of the most important of these factors, may adversely affect the success of the TEC, the pharmacokinetics of the drugs used, and the anatomy of the epidural space. [9,14,15] Although the spread of local anesthetic given to the epidural space has not been fully depicted yet, it has been shown that solutions injected into the epidural space generally disseminate freely and cover the cylindrical dural sac while partially passing through the neural foramina. [15,16] Inter-individual variability in epidural adipose tissue may act on the pharmacokinetics of drugs injected into the epidural space based on whether the given local anesthetic has a significant affinity for epidural fat.…”

Section: Discussionmentioning

confidence: 99%

Is there a relationship between body mass index and postoperative pain scores in thoracotomy patients with thoracic epidural analgesia?

Zengin¹,

Ulger²,

Baldemir³

et al. 2021

Medicine

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Postoperative efficacy of thoracic epidural analgesia (TEA) following thoracic surgery may vary in patients with different body mass index (BMI) values, regardless of the success of the method. This study aimed to investigate the effects of BMI on postoperative pain scores in patients who underwent thoracotomy with TEA. After obtaining the ethical committee approval (Date: May 11, 2021, Number: 2012-KEAK-15/2305) the data of 1326 patients, who underwent elective thoracic surgery in high volume tertiary thoracic surgery center between January 2017 and January 2021, were analyzed retrospectively. Patients between the age of 18 and 80 years, who underwent thoracotomy and thoracic epidural catheterization (TEC), and who were assigned American Society of Anesthesiologists I to III physical status were included to the study. Of the 406 patients, who underwent a successful TEC, 378 received postoperative analgesia for 72 hours. Visual analog scale (VAS) scores of these patients were evaluated statistically. Based on BMI, patients were categorized into the following 5 groups: Group I: BMI < 20 kg/m 2 , Group II: BMI = 20 to 24.9 kg/m 2 , Group III: BMI = 25 to 29.9 kg/m 2 , Group IV: BMI = 30 to 34.9 kg/m 2 , and Group V: BMI ≥ 35 kg/m 2 . There were no statistically significant differences in TEC success across different BMI groups ( P > .05). Catheter problems and VAS scores significantly increased with higher BMI values in the postoperative 72-hours period ( P < .05). Rates of rescue analgesic use were higher in BMI groups of 30 toto 34.9 kg/m 2 and ≥35 kg/m 2 compared to the other BMI groups. This study revealed that higher BMI in patients may increase VAS scores, who administered TEA for pain management following thoracotomy. This correlation was supported by the increased need for additional analgesics in patients with high BMI. Therefore, patients with high BMI values would require close monitoring and follow-up.

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“…This may be because the residents were more likely to insert the epidural needle near the left side of the patient, and so the nerve roots on the left side of the epidural space were more likely to be irritated and cause paresthesia when the catheter was inserted. The catheters used in our study were stiff, which may have induced greater incidence of paresthesia and intravascular cannulation than wire-embedded catheters [ 6 – 8 ]. A previous study reported that the angle formed between the patient’s back skin and the needle in the coronal plane was greater than 90° in groups U and R [ 3 ]; this might increase the risk of the spinal needle being inserted closer to the right side compared with the epidural needle.…”

Section: Discussionmentioning

confidence: 99%

The height of the operating table affects the performance of residents in combined spinal and epidural anesthesia training by affecting the vision of the puncture needle: a randomized controlled trial

et al. 2023

BMC Anesthesiol

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Background The present study aimed to evaluate whether the operating table height affected the success rate and incidences of complications of combined spinal-epidural anesthesia administered by residents during training. Methods One-hundred-and-eighty patients were randomly allocated according to landmarks on the resident’s body: umbilicus (group U), lowest rib margin (R), and xiphoid process (X). The success rates of combined spinal-epidural anesthesia, and the incidences of paresthesia and vessel trauma were recorded. Results There were no differences between the three groups in the success rates of combined spinal-epidural anesthesia, and the incidences of paresthesia and vessel trauma. However, paresthesia during epidural catheter advancement was more common on the left side (66.7%) than the right side (33.3%) (P = 0.03). In group R, the success rate of epidural anesthesia was higher during the residents’ third time (100%) than their first time (50%; P = 0.01). Most residents (83%) preferred the table height at which the needle insertion point was at the level of their lowest rib margin. Conclusions Neither the success nor the complication of combined spinal-epidural anesthesia in lateral decubitus position during residents’ training affected by the operating table height. However, paresthesia was more likely to occur on the left side when a stiff catheter was inserted into the epidural space. It may be better to keep the table height at residents’ lowest rib margin. It was not just preferred by most of residents but also better for their training of performing epidural anesthesia. Trial registration The trial was registered prior to patient enrollment at Chinese Clinical Trial Registry (NCT: ChiCTR1800016078, Principal investigator: Juan Gu, Date of registration: 9 May 2018). Registry URL http://www.chictr.org.cn

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Teaching practices of thoracic epidural catheterizations in different grade of anesthesia residents

Cited by 4 publications

References 12 publications

Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: a prospective, randomized, superiority trial

Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: a prospective, randomized, superiority trial

Is there a relationship between body mass index and postoperative pain scores in thoracotomy patients with thoracic epidural analgesia?

The height of the operating table affects the performance of residents in combined spinal and epidural anesthesia training by affecting the vision of the puncture needle: a randomized controlled trial

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