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Can lumbar ultrasound guidance facilitate lateral labor epidural placement by anesthesiology residents? A randomized controlled trial of placement duration and ultrasound reproducibility
Abstract Number: T-42
Abstract Type: Original Research
Mastery of the lumbar epidural technique with the patient in lateral position can be a challenge for anesthesiology residents and fellows. However, lateral epidural placement may enhance patient comfort and lower the risk of intravascular catheter placement (1,2). Lumbar ultrasound (LUS) has been shown to improve the learning curve of epidural placement in trainees (3). However, LUS is typically performed immediately before epidural placement, which is inconvenient for a woman in active labor. We evaluated the impact of LUS on the success and efficiency of lateral epidural placement by residents and fellows as well as the reproducibility of LUS measurements when performed in the lateral position at two time points: early labor vs. active labor.
Healthy patients in early labor (VAS <3 and/or cervical dilation <3 cm) anticipating epidural placements were randomized to control or study group. Following a baseline lateral LUS, the L3-4 midline insertion point, vertebral level, and lateral positioning in the bed were identified but marked only in the study group. Measurements were repeated for the study group immediately before epidural placement by an independent operator and re-marked if different from baseline. Residents or fellows performed all epidural placements; duration of placement was recorded using standardized start and end times. The primary outcome was duration of placement. Secondary outcomes included epidural placement success indices (number of attempts, need for staff intervention, procedural complications), and reproducibility of LUS measurements (midline, vertebral level and distance to ligamentum flavum [LF]). The primary outcome was analyzed using student’s t-test and secondary outcomes were analyzed using Fisher’s exact test.
To date, 34 of 60 patients have been recruited (19 control, 15 study). The mean duration of epidural placements was similar between groups (p = 0.968). However, reproducibility of LUS measurements in early compared to active labor was 100% for midline insertion point and 87% for vertebral level. Distance to LF measurements by LUS during early and active labor were similar (p=0.76) but significantly underestimated the actual depth by 0.86 cm (p = 0.03). There were no significant differences in other outcomes.
Our preliminary findings suggest that although the duration of lateral epidural placement was similar with and without LUS immediately before placement by anesthesiology residents or fellows, there was excellent reproducibility of LUS midline, vertebral level, and LF depth between early and active labor. We propose that in selected patients where LUS may be useful, it could be done during early labor rather than active labor so that the LUS is not a source of delay for analgesia.
1) Mhyre JM. Anesth Analg 2009
2) Bahar M. Can J Anesth 2004
3) Grau T. Can J Anesth 2003