1 / 25

Single Center Prospective Randomized Controlled Study at PCRMC Rolla, MO

Does Ultrasound Mapping Prior to Epidural Placement Decrease the Number of Attempts and the Duration of Placement?. Single Center Prospective Randomized Controlled Study at PCRMC Rolla, MO Charlie Wilson, SRNA, Shelli Stockton, SRNA. Background.

minowa
Download Presentation

Single Center Prospective Randomized Controlled Study at PCRMC Rolla, MO

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Does Ultrasound Mapping Prior to Epidural Placement Decrease the Number of Attempts and the Duration of Placement? Single Center Prospective Randomized Controlled Study at PCRMC Rolla, MO Charlie Wilson, SRNA, Shelli Stockton, SRNA

  2. Background • Two-thirds of patients in labor in the United States receive epidural analgesia. • Goal of epidural: To eliminate pain while preserving motor strength and maternal awareness of contractions to ensure adequate pushing during delivery.

  3. Laboring Epidural Indications Contraindications Patient refusal Coagulopathies Infection at insertion site Increased ICP Aortic stenosis Severe hypovolemia • Active labor • Committed to delivery • Experiencing pain • Desire for epidural

  4. Epidural Anesthesia

  5. Epidural Complications • Backache • Dural sac puncture (“wet tap”) • Total spinal • Neurologic injury • Motor weakness • Persistent parasthesia • Paraplegia • Cauda equina syndrome • Inadequate pain relief • Total Epidural Failure

  6. Epidural Placement Challenges

  7. Obesity in the United States

  8. Purpose • To study the effects of ultrasound mapping prior to epidural placement on the number of attempts and the duration of placement. • Number of attempts • Number of puncture sites • Duration of procedure • Accuracy of epidural depth calculation

  9. Literature Review

  10. Real-time ultrasound guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients • Journal: Critical Care November 2006 • Authors: Dimitri Karikitsos, Nicholas Labropoulos, Eric De Groot, Alexandros P Patrianakos, Gregorious Kouraklis, John Poularas, George Samonis, Dimothenis A Tsoutsos, Manousus M Konstadoulakis and Andreas Karabinis • Purpose: To identify if real-time ultrasound-guided cannulation of the internal jugular vein is superior to landmark method • Conclusion: The use of real-time ultrasound-guidance is superior to the landmark method in critically ill patients

  11. A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurological Symptoms • Journal: Regional Anesthesia July 2009 • Authors: Spencer S Liu MD, Victor M Zayas MD, Micael A Gordon MD, Jonathan C Beathe MD, Daniel B Maalouf MD, Leonardo Paroli MD, Gregory A Liguori MD, Jamie Ortiz MD, Valeria Buschiazzo, Justin Ngeow BA, Teena Shetty MD, Jacques T Ya Deau MD PhD • Purpose:To determine if ultrasound guidance reduces the risk of intrneural injection and subsequent neurolocical symptoms • Conclusion: Ultrasound gudiance reduce the number of needle passes but did not how a decrease in the incidence or severity of neurological symptoms

  12. Ultrasound-Guided regional Anesthesia: Current Concepts and Future Trends • Journal: Regional Anesthesia May 2007 • Authors: Peter Marhofer MD, Vincent W S Chan MD FRCPC • Purpose: To increase the understanding of ultrasound equipment, discuss current outcomes and future trends • Conclusion: The time taken to place blocks and the total amount of local anesthetic used can be reduced

  13. Ultrasonographic Measurement of the Ligamentum Flavum Depth; Is It a Reliable Method to Distinguish True and False Loss of Resistance? • Journal: The Korean Journal of Pain. April 2012 • Authors: Michael Haejin Pak, MD, Won Hyung Lee, MD, Young Kwon Ko, MD, Sang Young So, MD, and Hyun Joong Kim, MD • Purpose: Is ultrasound measurement of the ligamentum flavum accurate? • Conclusion: The use of ultrasound to measure the depth of the ligamentum flavum before placing a cervical epidural block was beneficial and increased success rates of cervical epidural blocks.

  14. Real-Time Ultrasound-Guided Spinal Anaesthesia: A Prospective Observational Study of a New Approach • Journal: Anesthesiology Research and Practice, January 2013 • Authors: P. H. Conroy, C. Luyet, C. J. McCartney, P. G. McHardy • Purpose: To investigate the feasibility of performing a systematic method for real-time ultrasound guided paramedian access to the subarachnoid space with a spinal needle inserted in the plan of the ultrasound beam by a single operator. • Conclusion: Use of real-time ultrasound guided anaesthesia is a clinically feasible procedure

  15. Materials and Methods • Materials • Ultrasound:  GE Logiq 2012  • Epidural Kit:  Braun Custom Kit for PCRMC • Epidural Pump:  Hospira Gemstar Epidural basal plus PCA • Methods • Patients randomly assigned to group • Epidural placed with standard technique after either US mapping or palpation, dependent on group

  16. Ultrasonography

  17. Comparison of BMI and Actual Loss of Resistance

  18. 40% Decrease in Number of Attempts

  19. Accuracy of Ultrasound

  20. Conclusions • Ultrasound guidance decreased the number of attempts by 40% in a varying range of BMIs and showed the same reduction in patients with BMIs greater than 35 • Ultrasound mapping of the depth to the epidural space is accurate and safe due to the fact that it underestimates the depth • Previous thoughts about the average depth to the epidural space are accurate

  21. Discussion • This technique can be applied to patients with a previous history of difficult epidural placement or a wet tap • Can be used in patients with an increased BMI • Can be used to aid practitioners who are inexperienced at placing epidural catheters

  22. Limitations and Future Research • Limitations • Single center, small sample size, limited number of providers and limited participant variability • Future research • Multiple center, larger sample size, multiple providers and broader patient population

  23. Acknowledgements • Thanks to the Anesthesia Department at Phelps County Regional Medical Center • Special Thanks to Mike Burns, CRNA and Chris Black, CRNA for their assistance in data collection and experimental guidance • Michelle Koons, RN, BSN Phelps County Regional Medical Center Labor and Delivery Department • Todd Daniels Missouri State University Rstats Department for assistance in statistical analysis

  24. References • Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., & Stock, C. M. (2009). Clinical Anesthesia (6thth ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. • Chin MD, K. J., Perlas MD, A., Singh MD, M., Arzola MD, C., Prasad MD, A., Chan MD, V., & Brull MD, R. (2009, June 23). An ultrasound-assisted approach facilitates spinal anesthesia for total joint arthroplasty [Electronic version]. Canadian Journal of Anesthesia, 56, 643-650. doi:10.1007/s12630-009-9132-8 • Conroy, P., Luyet, C., McCartney, C., & McHardy, P. (2012, November 15). Real-Time Ultrasound-Guided Spinal Anaesthesia: A Prospective Observational Study of a New Approach. Anesthesiology Research and Practice, 2013. doi:10.1155/2013/525818 • Herth MD, F. F., Eberhardt MD, R., Becker MD, H. D., & Ernst MD, A. (2006, January). Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy in Fluoroscopically Invisible Solitary Pulmonary Nodules [Electronic version]. Chest, 129(1), 147-150. • Liu MD, S. S., Zayas MD, V. M., Gordon MD, M. A., Beathe MD, J. C., Maalouf MD, D. B., Paroli MD, L., & Liguori MD, G. A. (2009, January 8). A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurologic Symptoms [Electronic version]. Anesthesia & Analgesia, 109(1), 265-271. doi:10.1213/ane.0b013e3181a3272c • Karakitos, D., Labropoulos, N., De Groot, E., Patrianakos, A. P., Kouraklis, G., & Poularas, J. (2006, November 17). Real-time ultasound guided catheterisation of the internal jugular vein: a prespective comparison with the landmark technique in critical care patients. Critical Care, 10. doi:10.1186/cc5101 • Marhofer MD, P., & Chan MD, V. S. (2007, January 23). Ultrasound Guided Regional Anesthesia: Current Concepts and Future Trends [Electronic version]. Anesthesia & Analgesia, 104(5), 1265-1269. doi:10.1213/01.ane.0000260614.32794.7b • Miller MD, A. H., Roth MD, B. A., Mills MD, T. J., Woody MD, J. R., Longmoor MD, C. E., & Foster PhD, B. (2002, August). Ultrasound Guidance versus the Landmark Technique for the Placement of Central Venous Catheters in the Emergency Department [Electronic version]. Academy of Emergency Medicine, 9(8), 800-805. • Nagelhout. J. J. & Plaus, K. L. (Eds.). (2010). Nurse anesthesia. St. Louis: Saunders/Elsevier. • Pak MD, M.H., Lee MD, W.H., Ko MD, Y.K., So MD, S.Y., & Kim MD, H.J. (2012, April). Ultrasonographic Measurement of the Ligamentum Flavum Depth, Is it a Reliable Method to Distinguish True and False Loss of Resistance? [Electronic version]. The Korean Journal of Pain, 25(2), 99-104. doi.10.3344/kjp.2012.25.2.99 • Rasoulian, A., Lohser MD, J., Najafi, M., Rafi-Tari, H., Tran PhD, D., Kamani MD, A. A., & Lessoway, V. A. (2011, June 23). Utility of prepuncture ultrasound for localization of the thoracic epidural space [Electronic version]. Canadian Journal of Anesthesia, 58, 815-823. doi:10.1007/s12630-011-9548-9 • Rieker, M. (2011). Labor Epidural. In S. Elisha (Ed.), Case studies in nurse anesthesia. Sudbury, MA: Jones and Bartlett Publishers.

More Related