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

Abstract

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.

Overcoming Obstacles: The Legacy of Fidel Pagés, Founder of the Epidural, 100 Years After His Passing

“…41 Recently, Kim et al 42 reported a case series of 38 patients undergoing epidural placement with realtime needle guidance, with final loss-of-resistance confirmation without ultrasound. Similarly, Pakpirom et al 43 demonstrated increased first-pass success with this hybrid technique compared to conventional approach. However, while they reported fewer skin punctures and attempts, the procedure time was longer using ultrasound.…”

Comparison of ultrasound-guided and traditional localisation in intraspinal anesthesia: a systematic review and network meta-analysis

“…Nineteen two-arm studies and one three-arm study documented first-pass success rates and were pooled for analysis 2 3 11–17 19–27 29 30. Across all studies, traditional positioning was the most frequently cited (online supplemental figure 1A).…”

“…A total of 16 trials provided data on first-attempt success rates 2 3 11 12 14 18–22 24–28 30. The network node diagram is shown in online supplemental figure 2A.…”

“…The network diagrams and forest diagrams of each study are shown in online supplemental figure 3A,B. The results2 3 11 12 17–19 21–23 26 27 30 show that the traditional positioning method has the shortest positioning time (online supplemental figure 3D), but the ultrasound-assisted and real-time guided puncture positioning time does not show significant differences (online supplemental figure 3C). The funnel plot is shown in figure 3SE.…”

Real Time Ultrasound-Guided Thoracic Epidural Catheterization with Patients in the Lateral Decubitus Position without Flexion of Knees and Neck: A Preliminary Investigation

“…Furthermore, Daniel J. Pak [ 12 ] described the successful real-time ultrasound-guided thoracic epidural technique in a paramedian sagittal oblique view. Recently, Karmakar and his colleagues reported a prospective, randomized superiority trial, which indicates that real-time ultrasound guidance is superior to a conventional anatomic landmark-based technique for first-pass success during TEP [ 15 ]. Since 2015, the author Fei Liu started to do ultrasound-guided epidural anesthesia replacing landmark based thoracic epidural anesthesia for postoperative pain in patients after abdominal surgery.…”