A Randomized Comparison Between Conventional and Waveform-Confirmed Loss of Resistance for Thoracic Epidural Blocks

Arnuntasupakul, Vanlapa; Zundert, Tom C. R. V. Van; Vijitpavan, Amorn; Aliste, Julián; Engsusophon, Phatthanaphol; Leurcharusmee, Prangmalee; Ah-Kye, Sonia; Finlayson, Roderick J.; Tran, De Q.H.

doi:10.1097/aap.0000000000000369

Cited by 39 publications

(23 citation statements)

References 25 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…This rigorous methodology revealed a consistent 23%-24% primary failure rate in a combined >200 patients across 2 tertiary care, training centers. 25,26 Although additional studies are required to better define the primary failure rate of TEA, the limited evidence available suggests that its occurrence is neither rare nor negligible in teaching institutions.…”

Section: Primary Failure Of Tea In Training Centersmentioning

confidence: 99%

“…In a recent trial, EWA has been proven to increase the success rate of TEA. 26 One hundred patients requiring thoracic epidural blocks were allocated to conventional or EWA-confirmed LOR. 26 Most blocks were performed by trainees.…”

Section: Real-time Confirmation Of Lormentioning

confidence: 99%

“…26 One hundred patients requiring thoracic epidural blocks were allocated to conventional or EWA-confirmed LOR. 26 Most blocks were performed by trainees. The simple step of verifying LOR by transducing the epidural needle in search of pulsatile waveforms resulted in a substantially lower primary failure rate (2% vs 24%; P = 0.002).…”

Section: Real-time Confirmation Of Lormentioning

confidence: 99%

See 2 more Smart Citations

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Tran

Zundert

Aliste

et al. 2016

Regional Anesthesia and Pain Medicine

Self Cite

View full text Add to dashboard Cite

In teaching centers, primary failure of thoracic epidural analgesia can be due to multiple etiologies. In addition to the difficult anatomy of the thoracic spine, the conventional end point-loss-of-resistance-lacks specificity. Furthermore, insufficient training compounds the problem: learning curves are nonexistent, pedagogical requirements are often inadequate, supervisors may be inexperienced, and exposure during residency is decreasing. Any viable solution needs to be multifaceted. Learning curves should be explored to determine the minimal number of blocks required for proficiency. The problem of decreasing caseload can be tackled with epidural simulators to supplement in vivo learning. From a technical standpoint, fluoroscopy and ultrasonography could be used to navigate the complex anatomy of the thoracic spine. Finally, correct identification of the thoracic epidural space should be confirmed with objective, real-time modalities such as neurostimulation and waveform analysis.

show abstract

Section: Primary Failure Of Tea In Training Centersmentioning

confidence: 99%

Section: Real-time Confirmation Of Lormentioning

confidence: 99%

Section: Real-time Confirmation Of Lormentioning

confidence: 99%

See 1 more Smart Citation

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Tran

Zundert

Aliste

et al. 2016

Regional Anesthesia and Pain Medicine

Self Cite

View full text Add to dashboard Cite

show abstract

“…These authors found that the latter led to a substantial decrease in the primary failure rate (2% vs 24%; P = 0.002). 92 Similarly, Parra et al 93 enrolled 100 patients undergoing thoracic epidural blockade and randomized them to a palpation-or fluoroscopy-guided technique. Parra et al also observed that fluoroscopy resulted in a lower failure rate (2% vs 26%; P = 0.01).…”

Section: Solutionsmentioning

confidence: 99%

Beyond Ultrasound Guidance for Regional Anesthesiology

Tran

Boezaart

Neal

2017

Regional Anesthesia and Pain Medicine

View full text Add to dashboard Cite

Despite its popularity, ultrasound (US)-guided regional anesthesiology is associated with significant limitations. The latter can be attributed to either the US machine (ie, decreased ability to insonate deep neural structures, as well as the thoracic spine) or the operator. Shortcomings associated with the operator can be explained by errors in perception (ie, ambiguous criteria for needle/catheter tip-to-nerve proximity and subparaneural local anesthetic injection) or interpretation. Perhaps the greatest confusion afflicting US-guided regional anesthesiology originates from an intellectual misconception pertaining to its application. Increasingly, authors are using US to identify interfascial planes where local anesthetic can be injected thereby "discovering" new truncal blocks. Often these novel blocks suffer from a lack of proper randomized, comparative validation.Fortunately, solutions have been proposed to remedy many shortcomings associated with US guidance. The inability of US to reliably insonate deep neural structures can be circumvented with adjunctive neurostimulation. Fluoroscopy and waveform analysis have been proven to increase the success rate of thoracic epidural blocks. For continuous nerve blocks, combined US-neurostimulation may provide an objective end point (ie, an evoked motor response) for neural proximity and subparaneural positioning of the catheter tip. Finally, the solution to the plethora of nonvalidated US-guided blocks is both elegant and simple. New nerve blocks should answer a specific clinical need, and their first descriptions should take the form of an adequately powered, observer-blinded, randomized comparison against the established standard of care or, at the very least, a large case series (eg, a Brief Technical Report).

show abstract

“…3 This can seldom be ascribed to the beginner's inability to recognize LOR. In fact, the true problem pertains to statistical prevalence and positive predictive value.…”

A Randomized Comparison Between Conventional and Waveform-Confirmed Loss of Resistance for Thoracic Epidural Blocks

Abstract: Compared with its conventional counterpart, EWA-confirmed LOR results in a lower failure rate for thoracic epidural blocks (2% vs 24%) in our teaching centers. Confirmatory EWA provides significant benefits for inexperienced operators.

Cited by 39 publications

References 25 publications

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Beyond Ultrasound Guidance for Regional Anesthesiology

Reply to Dr Carassiti et al

Contact Info

Product

Resources

About