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Use of neuraxial ultrasound versus palpation for epidural catheter placement by anesthesia trainees: A randomized controlled trial
Abstract Number: F4D-4
Abstract Type: Original Research
BACKGROUND: The use of ultrasound for neuraxial anesthesia in labor may improve the accuracy of the procedure, while decreasing the number of attempts, particularly when used with anesthesia trainees. In this randomized controlled trial, we hypothesized that using preprocedural ultrasound would decrease the number of attempts required for a junior anesthesia resident to place an epidural more accurately at the L4-5 level, without increasing total procedural time.
METHODS: ASA I or II patients requesting neuraxial for labor were enrolled. Exclusion criteria were ASA III or IV, unable to participate due to severe pain, contraindications to neuraxial analgesia, prior surgery in the lumbar or sacral area, significant scoliosis or BMI ≥ 40. Patients were randomized to epidural placement with landmark identification by ultrasound or palpation. An obstetric anesthesia fellow trained in ultrasound placed a standard mark at L4-5 using the assigned technique. A junior anesthesia resident placed the epidural. Number of needle insertions, redirections and need to use an alternate level were noted. Start time was defined as giving Bicitra, immediately prior to positioning the patient and either performing the ultrasound or palpating the patient’s back. End time was defined as loss of resistance. After completion of the procedure, a blinded attending anesthesiologist, proficient in neuraxial ultrasound, assessed the final level of epidural placement by ultrasound.
RESULTS: 89 patients (of 120 total) have been enrolled. Baseline demographic data were similar between groups. There was no difference in time from start to end time (8m26s +/- 3m19s in palpation v. 9m2s +/- 3m28s in ultrasound, P=0.41). There was no difference in the number of attempts between groups (2.46 for palpation v. 1.9 for ultrasound, P=0.2). The desired level of insertion (L4-5) was more accurately identified in the ultrasound group (P=0.006).
CONCLUSIONS: Ultrasound use for epidural placement is more accurate in identifying the desired level of entry. In the educational setting, expert identification of the site by either ultrasound or palpation does not improve trainees’ procedural time or success.