The Paramedian Technique: A Superior Initial Approach to Continuous Spinal Anesthesia in the Elderly

Rabinowitz, Anna; Bourdet, B.; Minville, Vincent; Chassery, Clément; Pianezza, Antoine; Colombani, Aline; Eychenne, Bernard; Samii, Kamran; Fourcade, Olivier

doi:10.1213/01.ane.0000287655.95619.fa

Cited by 76 publications

(76 citation statements)

References 7 publications

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“…The most important determinants of subarachnoid distribution of local anesthesia are baricity, dosage, and site of injection [28], even though the mean dose of isobaric 0.5% bupivacaine in the hypotension group was not larger than in the nonhypotension group. The paramedian approach has been recommended for subarachnoid puncture in elderly patients and is associated with a high success rate [29]. In the paramedian approach, the needle is often directed in a cephalad direction and isobaric 0.5% bupivacaine may spread to a high sensory level [30]; more hypotension group patients underwent puncture via the paramedian approach than the nonhypotension group.…”

Section: Discussionmentioning

confidence: 99%

Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance

Nakasuji¹,

Suh²,

Nomura³

et al. 2012

Journal of Clinical Anesthesia

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Section: Discussionmentioning

confidence: 99%

Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance

Nakasuji¹,

Suh²,

Nomura³

et al. 2012

Journal of Clinical Anesthesia

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“…5 Mericq O et al concluded that in patients who are elderly and with spinal deformity, PMA is a safe alternative with success rate of 100%. 6 Ahsan ul-haq et al demonstrated that success rate with paramedian approach was 100% with the first attempt success rate of 60%.…”

Section: 4mentioning

confidence: 99%

A comparative evaluation between median and paramedian approaches for sub-arachnoid block in elderly patients

Singh¹,

Agrawal²,

Dwivedi³

et al. 2016

Int J Res Med Sci

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INTRODUCTIONSubarachnoid (spinal) block is a safe and effective form of anaesthesia when the surgical site is located on the lower extremities or perineum. It is simpler, cheaper and offers better physiological benefits with lesser complications than general anaesthesia. 1 It can be given by either median or paramedian approach. For the midline approach, the desired interspace is palpated and local anaesthetic is injected into the skin and subcutaneous tissue. The introducer is placed with a cephalad angle of 10 to 15 degree followed by passing of the spinal needle through the introducer. The needle goes through the subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, dura mater, and subarachnoid mater in order to reach the subarachnoid space. If the patient has a heavily calcified interspinous ligament (as seen in elderly patients) or difficulty in flexing the spine, a paramedian approach is used for spinal anaesthesia.After identifying the correct level for spinal anaesthesia placement, the spinous process is palpated. The needle is inserted 1 cm lateral to this point and directed toward the middle of the interspace. The ligamentum flavum is usually the first resistance felt. When the spinal needle goes though the dura mater, a pop is often appreciated. Accurate identification of the subarachnoid space is very important as multiple attempts at needle ABSTRACT Background: Spinal anaesthesia in elderly patients is frequently associated with significant technical difficulties. Spinal anaesthesia can be given by either paramedian or median approach. Paramedian approach has been used as an alternative in case of failure with median approach. The goal of this study is to determine which of these two approaches should be preferred as a first choice of spinal anaesthesia in elderly patients. Methods: The study included 100 patients of either sex, aged 50 years and above, who received spinal anaesthesia either with the midline approach (group M, n=50) or paramedian approach (group PM, n=50). Results: The success rate of paramedian group was 100% as compared to 96 % in median group. The first attempt success rate was 90% in group PM and 70% in group M. Paraesthesia was felt in 5 patients (10%) in midline group and in 2 patients (4%) in paramedian group. Hemorrhagic tap was seen in 2 patients each in both the groups . None of the patients in Group M had postdural puncture headache (PDPH) as opposed to 2 patients in Group M. Conclusions: Thus the study conclude that paramedian approach is a better approach for spinal anaesthesia in elderly patients in terms of success rate, success at first attempt, complications like paraesthesia, PDPH and failure of subarachnoid block. Thus study recommends the routine use of paramedian approach for sub-arachnoid block in elderly patients as first choice.

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“…The paramedian and median techniques in which combined spinal epidural anesthesia was performed in 40 patients who underwent hip surgery were compared; while there was no difference in terms of complications, paramedian technique was found to be more successful (12). In another study, while the median approach was found to fail in elderly patients who had spinal deformities and for whom general anesthesia was more risky, the paramedian approach was 100% successful, and it was emphasized that the paramedian technique could be an alternative to general anesthesia in this patient profile (13).…”

Section: Discussionmentioning

confidence: 99%

Which Approach is Preferred in Spinal Anesthesia: Median or Paramedian? Comparison of Early and Late Complications

Bayindir¹,

Özcan²,

Koçyiğit³

et al. 2017

Istanbul Med J

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Spinal anesthesia is often preferred in short-term surgeries because it is a low-cost technique that can be applied easily, has a high success rate, and allows fast mobilization and early feeding (1). The side effects in this application can vary with the technique that is used (2). Inadequate spinal anesthesia, high or total spinal block, cardiac arrest, respiratory arrest, systemic toxic reaction, hypotension, bradycardia, nausea/vomiting, headache, spinal puncture pain, meningitis or meningismus, neurological sequelae, urinary retention, and hearing loss may be seen as a result of the effect created by the spread of the local anesthetic agent in the subarachnoid space (3).In our study, we aimed to compare the early and late complication rates of two different techniques (median or paramedian approach) in spinal anesthesia, which is the most preferred anesthetic method in our clinic for short-term surgeries. Material and MethodsOur study was conducted after the ethics committee approval no. 42883194-01/10405, dated November 18th, 2014, was received from the Ethics Committee of Fırat University Hospital. Of 282 patients who underwent short-term surgeries under spinal anesthesia between January 1st, 2014, and March 1st, 2014, 80 patients aged 18-65 years and classified as ASA I/II/III according to the American Society of Anesthesiologists (ASA) classification, who could be reached at telephone numbers that we had on file, were included in the study. Since the study was retrospective, informed consents were not received from the patients. The files of the patients were obtained from the archive, and the patients in whom the median technique was used were included in Group M (n=40), and those in whom the paramedian technique was used were included in Group P (n=40). Demographic data (age, gender, height, weight), ASA, the number of spinal anesthesia applications, duration of surgery, preoperative and intraoperative heart rate (HR), and mean arterial pressure (MAP) were recorded from the anesthesia follow-up chart, and the discharge durations from the hospital and the number of patients who underwent urinary catheterization were recorded from the nurse observation forms. Information was received from the patients who were contacted by phone about postoperative headache, pain at the site of procedure, hearing complaints, and about the other complaints. Which Approach is Preferred in Spinal Anesthesia: Median or Paramedian? Comparison of Early and Late ComplicationsIntroduction: Spinal anesthesia is usually preferred for short-time surgery; the side effects of the process can show difference with techniques. We aimed to compare early and late complications of median and paramedian techniques in spinal anesthesia.Methods: Eighty patients with American Society of Anesthesiologists (ASA) I-III were allocated into the following two groups: Group M (median) and Group P (paramedian). Demographic data of the patients, ASA score, number of spinal anesthesia application, total surgery time, discharge time from the hospital, h...

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The Paramedian Technique: A Superior Initial Approach to Continuous Spinal Anesthesia in the Elderly

Abstract: In summary, after the initial attempt, the paramedian approach is associated with an increased success rate, compared with the midline approach, during the performance of CSA in elderly patients.

Cited by 76 publications

References 7 publications

Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance

Hypotension from spinal anesthesia in patients aged greater than 80 years is due to a decrease in systemic vascular resistance

A comparative evaluation between median and paramedian approaches for sub-arachnoid block in elderly patients

Which Approach is Preferred in Spinal Anesthesia: Median or Paramedian? Comparison of Early and Late Complications

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