Comparison of Ultrasound‐Guided and Landmark‐Based Lumbar Punctures in Inexperienced Resident Physicians

Evans, David P.; Tozer, Jordan; Joyce, Michael; Vitto, Michael J.

doi:10.1002/jum.14728

Cited by 12 publications

(20 citation statements)

References 16 publications

(30 reference statements)

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“…Similarly, the number of insertion attempts was reduced with the US use as well as the number of needle redirection. One the other hand, a prospective study that examined the use of US in LP by emergency medicine residents did not find a statistically significant difference in the success rate between the two groups, although a statistically significant difference in the number of attempts was shown in favor of the US group [6].…”

Section: Discussionmentioning

confidence: 84%

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Feel It, See It, Get It: Is Internal Medicine Residents’ Use of Ultrasound in Lumbar Puncture Associated With Higher Success Rate?

Elhassan

Mohameden

Kam³

et al. 2020

Cureus

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Introduction: Multiple emergency medicine and anesthesiology research studies suggest that ultrasound (US) is potentially useful in assisting with needle insertion in a lumbar puncture (LP). However, little is known about its value when utilized by internal medicine (IM) residents. The objective of this study is to examine whether the use of ultrasound in LPs performed by internal medicine residents is associated with a higher success rate than the traditional palpation method. Materials and Methods: We reviewed all LP procedure notes in our hospital's records written by IM residents from June 2017 to December 2018 in a single community teaching hospital. We examined the association between the US use and success using the Chi-squared test and logistic regression model. Results: Among the 152 lumbar punctures documented, 130 specified whether US was used or not. Among these, 39 were ultrasound-assisted and 91 were not. Use of ultrasound was associated with a higher success rate compared to the non-ultrasound-use (87% vs 73%; p=0.1). The association was strengthened using logistic regression but did not reach statistical significance (OR 3.5; CI: 0.9 -13.8; p=0.07). Success was significantly associated with a fewer number of attempts (p<0.001). No statistically significant association was found between success and patients’ body mass index (BMI; p=0.57), or level of training (p=0.11). Conclusions: Use of ultrasound for needle insertion in lumbar punctures performed by internal medicine residents was associated with a higher success rate compared to the palpation method but without statistical significance. Ultrasound is a non-invasive, quick, and safe tool. Our study favors its use as an aid during lumbar puncture when performed by internal medicine residents. Larger studies are needed to gather more evidence in support of this conclusion.

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Section: Discussionmentioning

confidence: 84%

“…This can be difficult in certain patients (e.g., obese or pregnant patients). Ultrasound (US) can be a safe, non-invasive, easy to learn, and cost-effective tool that can assist in identifying the anatomic landmarks [4][5][6][7][8]. The first use of US for this purpose was described by Russian anesthesiologists in 1971 [9].…”

Section: Introductionmentioning

confidence: 99%

Feel It, See It, Get It: Is Internal Medicine Residents’ Use of Ultrasound in Lumbar Puncture Associated With Higher Success Rate?

Elhassan

Mohameden

Kam³

et al. 2020

Cureus

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“…At least 12 randomized controlled studies have been published comparing the use of ultrasound guidance vs landmarks for the performance of LP or spinal anesthesia in adult patients, which were not included in the abovementioned meta‐analyses. These individual studies demonstrated similar benefits of using ultrasound guidance: reduced needle insertion attempts, reduced needle redirections, and increased overall procedural success rates 17,31,37,40,41,43‐49 …”

Section: Recommendationsmentioning

confidence: 89%

“…Therefore, data from these three ultrasound‐guided procedures are often pooled. Currently, at least 33 randomized controlled studies comparing ultrasound‐guided vs landmark‐guided site selection for LP, epidural catheterization, or spinal anesthesia have been published 22‐49 . We present three meta‐analyses below that pooled data primarily from randomized controlled studies comparing ultrasound‐guided vs landmark‐guided site selection for LP or spinal anesthesia.…”

Section: Recommendationsmentioning

confidence: 99%

Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine

Soni

Franco‐Sadud

Kobaidze

et al. 2019

Journal of Hospital Medicine

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EXECUTIVE SUMMARY 1) When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult‐to‐palpate landmarks. 2) We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. 3) We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. 4) We recommend that a low‐frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high‐frequency linear array transducer may be used in nonobese patients. 5) We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. 6) We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. 7) We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. 8) We recommend that novices should undergo simulation‐based training, where available, before attempting ultrasound‐guided lumbar puncture on actual patients. 9) We recommend that training in ultrasound‐guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. 10) We recommend that novice providers should be supervised when performing ultrasound‐guided lumbar puncture before performing the procedure independently on patients.

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“…Another study by Evans et al showed that the use of US guidance to assist in lumbar punctures did not improve the procedural success rate over traditional landmark techniques in an academic setting with novice providers [16]. The reason for the heterogeneity of results could be due to the facts that in many studies the full spectrum of trainees, from junior residents to fellows, is assessed, and because the US scanning is variably done either by the trainees themselves or by the principal investigator depending on the study.…”

Section: Discussionmentioning

confidence: 99%

Does Pre-Procedure Neuraxial Ultrasound Using the GE Logiq® Improve Midline Placement of Combined Spinal Epidural when Compared to a Palpation Technique Performed by Experienced Anesthesiologists? A Prospective Randomized Study

Orlando¹,

Donovan²,

Stein³

et al. 2021

Journal of Scientific Innovation in Medicine

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Background: Neuraxial placement relies on palpation of anatomical landmarks, sometimes challenging to identify. Ultrasound (US) has helped facilitate those procedure. We wanted to assess efficacy of the US compared to landmark techniques when used by experienced obstetric anesthesiologists. Methods:We conducted a randomized prospective trial of healthy parturients requesting neuraxial labor analgesia. Positive CSF through the 27 G Pencan spinal needle at the first interspace attempted was the primary outcome. Secondary outcomes were the number of attempts and the number of needle adjustments within a space, presence of symmetrical analgesia 2 hours after placement, and need for epidural replacement. The procedures were performed by practitioners experienced in obstetric anesthesia, including obstetric anesthesiology fellows, and attending physicians who received a video training of the US technique prior to the study [1].Results: Forty-eight patients were randomized to either the US or landmark group. Two patients (one in each group) were excluded from the study due to delivery within 2 hours of CSE (Combined Spinal Epidural) placement. One patient in the landmark group was excluded due to a wet tap. No statistical difference was found regarding positive CSF flow on first attempt at CSE (p = 0.6). All secondary outcomes were statistically insignificant as well: number of spaces attempted (p = 0.71 95% CI -0.30 to 0.21), number of needle adjustments (p = 0.09, 95% CI -0.10 to 1.28), presence of symmetrical anesthesia at 2 hours (p = 1) and need for epidural replacement (p = 0.48). Conclusions:When placed by an experienced obstetric anesthesiology fellow or attending physician, there is no difference in the successful placement of CSE with US versus landmark technique.

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Comparison of Ultrasound‐Guided and Landmark‐Based Lumbar Punctures in Inexperienced Resident Physicians

Cited by 12 publications

References 16 publications

Feel It, See It, Get It: Is Internal Medicine Residents’ Use of Ultrasound in Lumbar Puncture Associated With Higher Success Rate?

Feel It, See It, Get It: Is Internal Medicine Residents’ Use of Ultrasound in Lumbar Puncture Associated With Higher Success Rate?

Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine

Does Pre-Procedure Neuraxial Ultrasound Using the GE Logiq® Improve Midline Placement of Combined Spinal Epidural when Compared to a Palpation Technique Performed by Experienced Anesthesiologists? A Prospective Randomized Study

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