Epidural Needle Research Articles

Electric stimulation-guided epidural analgesia for vaginal delivery: A randomized prospective study.

BackgroundThe failure rate of epidural anesthesia using the loss of resistance technique is 13–23%.ObjectivesTo investigate the efficacy of epidural electric stimulation-guided epidural analgesia in vaginal delivery.Study designAn open label randomized prospective study.MethodsLaboring women were randomized to two groups: epidural catheter insertion using only a loss of resistance technique or a loss of resistance technique with confirmation by electric stimulation. Catheters in both groups were initially tested with 3 ml of 1% lidocaine and those with any evidence of motor blockade were considered intrathecal. Sensory blockade and an 11 point numerical rating score for pain were assessed 30 minutes after administration of an epidural bolus of 10 ml of 0.22% ropivacaine with fentanyl. Successful epidural analgesia was defined as a decrease of 2 or more in the pain score and a bilateral L1-T10 sensory blockade.ResultsThirty-one patients were randomized to each group. The first 20 patients in each group were enrolled in a pilot study and were also included in the final analysis. One patient in the electric stimulation group was excluded owing to dural puncture by the Tuohy needle. One patient in each group demonstrated motor blockade after test dose and were considered failures. The number (% (95% confidence interval)) of successful cases were 29 out of 30 (97% (85, 100%)) in the electric stimulation group and 24 out of 31 (77% (61, 89%)) in the loss of resistance group (P = 0.053). However, analysis of only patients with absence of motor blockade revealed that 29 out of 29 (100% (92, 100%)) patients in the electric stimulation group and 24 of 29 (80% (63, 91%)) patients in the loss of resistance group had adequate analgesia (P = 0.024).ConclusionsAlthough limited by lack of blinding, small study size and inclusion of pilot study data, this study suggests epidural electric stimulation improves the success rate of subsequent labor analgesia.

The comparative accuracy of a handheld and console ultrasound device for neuraxial depth and landmark assessment

BackgroundThe study aimed to compare the accuracy of epidural depth estimation of a handheld ultrasound device, with an integrated algorithm that estimates epidural depth (AU; Accuro, Rivanna Medical), to that of a console ultrasound machine (GU; GE LOGICTM S8). MethodsWomen requesting labor epidural analgesia consented to this prospective cohort study. The L2/3, L3/4, and L4/5 interspaces and the respective depths to the epidural space were identified, marked and measured using an AU and GU. An anesthesia provider who was blinded to ultrasound depth measurements performed epidural analgesia at one of the ultrasound identified insertion points and recorded the Tuohy needle depth at loss-of-resistance. Bland Altman analysis was used to measure the agreement between the epidural depths measured by the AU and GU. ResultsA total of 47 women were analyzed. The mean ± standard deviation body mass index of the study cohort was 29 ± 5 kg/m2 [range 23–45]. The mean difference between the epidural depths measured by the AU and GU was −0.29 cm [95% limit of agreement 0.50 to −0.91]. The mean difference between the depth to the epidural space measured by the GU versus the needle depth was −0.33 cm [95% CI −0.49 to −0.16]. The previously reported AU versus needle depth was −0.61 cm [95% CI −0.79 to −0.44]. ConclusionThe AU and GU provided comparable epidural depth estimates. The AU device may be a reasonable alternative to more sophisticated ultrasound devices in determining the epidural space and depth in a non-obese obstetric population.

Transient isolated unilateral oculomotor nerve palsy following accidental dural puncture after bilateral total knee replacement.

Transient isolated unilateral oculomotor nerve palsy following accidental dural puncture after bilateral total knee replacement.

The correlation between the depth extent of Tuohy epidural needle with body mass index (BMI) to achieve loss of resistance in patients undergoing epidural anesthesia

Background: Anesthesia management in obesity is quite challenging. Epidural anesthesia become one of the choices. The attention should be addressed in order to prevent the misidentification of epidural space. The estimation of the depth extent of epidural space becomes crucial, especially in obese patients due to an accumulation of subcutaneous and epidural adipose tissue, which consequently complicate the epidural catheter insertion. This study aimed to analyze the correlation of the depth extent of Tuohy epidural needle to achieve loss of resistance between normal-weighted and obese patients. Method: This study was conducted with 56 adult patients aged 17 to 65 years who underwent elective surgery by epidural anesthesia inserted at level L2-L3 or L3-L4 interspace. Subjects are divided into normal and obese groups. Shapiro-Wilk and chi-square tests were used in the normality test. For normally distributed data, an independent t-test was used to test the hypothesis, otherwise, we used Mann-Whitney test Results: The results showed that the loss of resistance in epidural needle insertion procedures was 60 mm in a patient with BMI more than 30 kg/m2 and 50 mm in those with BMI <30 kg/m2 (p<0.001). Conclusion: The loss of resistance depth in epidural Tuohy needle insertion is significantly determined by BMI.

Influence of Epidural Needle Treatment at the Heel of the Bevel on Catheter Breakage

Background: Epidural anesthesia continues to play a central role in postoperative analgesia. Epidural catheter breakage and fragment retention in the body is a complication related to epidural anesthesia. To reduce the risk of epidural catheter damage by epidural needles, needles with special changes to the heel of the bevel are commercially available. The present study aimed to assess the effectiveness of blasting and drilling treatments at the heel of the epidural needle bevel to determine which treatment is more appropriate. Methods: The epidural needles with blasting, drilling, or no treatment to the heel of the bevel were prepared. The catheter was pulled out from the tip of the epidural needle, folded back 180˚, and then pulled up at a speed of 400 mm/min until it was fractured. The force needed to break the catheter (FB) was measured. Subsequently, low-density polyethylene (0.05 mm) was vertically penetrated with the needles at a speed of 200 mm/min, and the maximum force at penetration (FP) was measured. Results: The FB values for the blasted, drilled, and control needles were 21.3, 12.23, and 6.27 N, respectively (p Conclusion: Blasting treatment is the most effective approach for the prevention of catheter rupture; however, it can increase the puncture force.

Effect of intrathecal catheterisation on incidence of postdural puncture headache after accidental dural puncture in non-obstetric patients.

Background and Aims:After accidental dural puncture (ADP) with large bore epidural needles, postdural puncture headache (PDPH) develops in 16%–86% of patients, which is unpleasant and interferes with activities of daily life of the patient. Hence we aimed to assess the effect of intrathecal catheter insertion after ADP with 18G Tuohy needle on incidence of PDPH.Material and Methods:In all, 173 patients after ADP were enrolled and divided into two groups according to the choice of treating anesthesiologist. Group IC included 74 patients who had intrathecal catheter placed in subarachnoid space. In group NIC, which included 99 patients, one of the following was done: epidural catheter was cited in a different intervertebral space, or the procedure was abandoned and general anesthesia was administered or single-shot spinal anesthesia was administered through the Tuohy needle itself. The catheters were left in situ for 36–48 h. Patients were monitored for the next 7 days after ADP for the incidence of PDPH, its severity and requirement of analgesics, and duration of catheter in situ from the time of ADP.Results:The incidence of PDPH in group IC was 36% in comparison to 59% in group NIC (P = 0.001). The severity of PDPH and requirement of analgesics was significantly less in group IC.Conclusion:Insertion of intrathecal catheter at the site of ADP significantly reduces the incidence and severity of PDPH.

A kinked epidural catheter.

Sir, The rate of failed epidural anesthesia ranges from 13% to 47%. Anatomical catheter location, patient position, puncture site, approach type, localization of the epidural space, catheter insertion and fixation, test dose application, equipment used, local anesthetic dose or volume, choice of local anesthetic, and addition of opioids and epinephrine are all the factors that influence the success of epidural anesthesia.[1] Here, we report a failed epidural catheterization due to kinking of the catheter tube. A 22-year-old man who underwent laparoscopic acute appendectomy under general anesthesia without any complications needed to undergo surgical exploration because of hemorrhagic drainage during the postoperative period. As the patient was pale and cold, with a significantly reduced hemoglobin level, an emergency surgery was planned. Combined spinal epidural anesthesia was decided as the patient's fasting duration was not appropriate for general anesthesia. After appropriate preoperative preparation, combined spinal epidural anesthesia was performed at the L4–5 level via loss of resistance technique with saline, and 15 mg of 0.5% bupivacaine was injected intrathecally. The epidural space was entered at the 8th cm under the skin. While inserting the epidural catheter through the Tuohy needle, resistance was felt. Telling the patient to take a deep breath, the catheter was pushed against the resistance, which was lost for 1 cm, and the catheter was pushed until the 14th cm. No check with a saline injection was made after fixing the catheter; however, aspiration was negative. The catheter was fixed and surgery was initiated after ensuring successful spinal anesthesia. After 3 h of surgery, the patient started to feel pain. The surgeon was warned to wait, and the level of spinal anesthesia was checked and found to be insufficient. On attempting local anesthetic injection through the epidural catheter, negative aspiration was noted but an abnormal resistance was felt. After another failed attempt, the epidural catheter connection point was checked and recapped, but no difference was noted. As a result of the failed catheterization, general anesthesia was administered with fast track intubation. No complications, such as vomiting and aspiration, were noted. After surgery, during extubation, an attempt was made to pull out the epidural catheter. The first few centimeters of the catheter came out easily, but then a resistance was felt. Applying a small force, the catheter was pulled out totally and a kink was observed at the 9th cm [Figure 1].Figure 1: Kinking in the epidural catheter (expressed in red circle)There are many examples of epidural catheter kinking under the skin in the literature.[234] Hence, it is very important to check the epidural catheter after insertion using saline injection in addition to negative aspiration, to ensure proper functioning. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Epidural Space Identification Using Continuous Real-Time Pressure Sensing Technology (CompuFlo&amp;lt;sup&amp;gt;&amp;amp;reg;&amp;lt;/sup&amp;gt;): A Report of 600 Consecutive Cases

Introduction. The aim of this open, prospective, single operator study was to report the clinical experience with the CompuFlo? Epidural Instrument. Method. Epidural block was performed with the CompuFlo? Epidural Instrument in all consecutive patients undergoing an epidural or thoracic block under the author’s care over a two years period. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase of the pitch of the audible tone) was followed by a sudden and sustained drop in pressure of more than 5 seconds accompanied by a sudden decrease of the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau on the instrument’s visual display. The following outcomes were evaluated: incidence of accidental dural puncture, success of anesthesia, procedure time, volume of saline used for the epidural procedure, number of epidural attempts to reach the epidural space, number of needle redirections, and the operator’s agreement with his tactile sensation of loss of resistance and the CompuFlo? pattern. Results. A total of 600 cases were studied. All the epidural blocks were successful and no accidental dural punctures were noted. Epidural space was correctly identified on the first attempt in 91% of cases, in 95% of cases the operator judged as a perfect correlation between his tactile sensations and the CompuFlo? recordings. Conclusion. The major finding of this paper is the very high success rate of the epidural blocks, no matter in what clinical setting (obstetrical, surgical or blood patch intervention) or at which vertebral level (thoracic or epidural) were done. Most importantly, the reporting of zero incidence of any accidental dural puncture.

Abdominal girth has a strong correlation with actual and ultrasound estimated epidural depth

Background/aim This study aimed to assess the correlations of actual epidural depth (ND) and ultrasound estimated epidural depth in the paramedian sagittal oblique plane (ED/PSO) and transverse median plane (ED/TM) with the abdominal girth (AG), body mass index (BMI), and weight of patients. Materials and methods One hundred and thirty patients of either sex scheduled for unilateral inguinal hernia repair were enrolled. ED/PSO and ED/TM were assessed with a 2–5 MHz curved array probe at the L3–4 intervertebral space. The epidural needle was marked with a sterile marker upon locating the epidural space. The ND was assessed by measuring the distance from the sterile marker to the tip of the epidural needle with a linear scale. Anthropometric measures of the patients were recorded. Results ED/PSO was 49.6 ± 7.9 mm, ED/TM was 49.5 ± 7.9 mm, and ND was 50.0 ± 8.0 mm. AG was 99.8 ± 12.9 cm. The Pearson correlation coefficient between ND and ED/PSO was 0.997 and with ED/TM was 0.996 (P < 0.001 for both). Pearson correlation coefficients for ND with AG, BMI, and weight were 0.757, 0.547, and 0.638, respectively (P < 0.001 for all).Conclusion AG, weight, and BMI have strong correlations with ND.

Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy.

Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy.

Comparison of Postoperative Analgesia Following Epidural Bupivacaine and Epidural Bupivacaine with Verapamil in Orthopaedic Lower Limb Surgeries

Comparison of Postoperative Analgesia Following Epidural Bupivacaine and Epidural Bupivacaine with Verapamil in Orthopaedic Lower Limb Surgeries

The Comparative Study of Epidural Anesthesia between Isobaric Ropivacaine 0.5% and Isobaric Bupivacaine 0.5% for Lower Abdominal Surgery.

Aim:The aim of the study was to compare the effectiveness of ropivacaine (0.5%) and bupivacaine (0.5%) in epidural neuraxial blockade for elective lower abdominal surgeries.Methods:The present study was conducted in sixty patients undergoing elective lower abdominal surgeries under epidural anesthesia who were included after satisfying the eligibility criteria. The patients were randomly divided into two groups. An epidural catheter was inserted in cephalad direction using Tuohy epidural needle at L2–L3 or L3–L4 with the help of loss of resistance to air technique. Twenty milliliter of the study drug was given, sensory blockade was tested using the pinprick method, and quality of motor blockade was assessed by the modified Bromage scale.Results:In our study, demographic data comparing age and sex show no statistically significant difference among both the groups. In our study, the mean time for the onset of sensory block consider at T10 in Group B was 10.05 ± 2.1 min and in Group R was 9.8 ± 1.8 min. Moreover, the mean time duration of sensory block in Group B was 5.56 ± 0.059 h and in Group R was 5.34 ± 0.073 h. The onset of motor block in Group B was 4.98 ± 1.07 min and in Group R was 5.28 ± 1.2 min, but the duration of motor block for Group B was 4.63 ± 0.39 h and for Group R was 3.53 ± 0.23 h, which is clinically and statistically significant. The maximum level of sensory blockade for Group B was T4 and for Group R was T5. The range of block in Group B was T10–T4 and in Group R was T10–T35.Conclusion:The onset of sensory block was comparable in both the group, but the duration of sensory block is shorter with ropivacaine compared to bupivacaine. The onset of motor blockade was comparable in both the groups, but the duration of motor blockade was also shorter and the degree of motor block was less intense with ropivacaine compared to bupivacaine.

The Accuracy of a Handheld Ultrasound Device for Neuraxial Depth and Landmark Assessment: A Prospective Cohort Trial

(Anesth Analg. 2018;126:1995–1998) Widespread use of neuraxial ultrasound may be limited by technical expertise, as blocks are usually performed using body surface landmarks to guide the epidural needle insertion point. A wireless handheld ultrasound (US) device with pattern recognition software programmed to calculate depth to the epidural space and identify bony landmarks has been developed (Accuro, Rivanna Medical, Charlottesville, VA) (AU). In the present study, the authors evaluated the accuracy of this device for neuraxial depth and landmark assessment.

Color your epidural: color flow Doppler to confirm labor epidural needle position.

Labor epidural analgesia success depends on precise needle position placement within the epidural space, with reported failure rates to be as high as 32%. In this study, we describe a novel technique employing color Doppler to aid in the confirmation of the correct position of the epidural needle tip. Retrospective evaluation of 35 patients who received labor combined spinal-epidural (CSE) with confirmation of epidural needle position with color flow Doppler (CFD) ultrasonography. Demographic data, intervertebral level of insertion and dermatome sensory level were extracted. Video and image evaluation of CFD patterns were used to confirm epidural needle tip and catheter position. CFD was used to visualize intrathecal injection of local anesthetic in two patients. Three different color flow patterns were visualized after the loss of resistance technique: visualization of a red and blue mosaic adjacent to the posterior complex, a mosaic pattern enveloping the trajectory of the epidural needle, and a linear deeper mosaic color pattern during spinal injection in relation to the posterior complex. Identification of epidural needle tip and epidural catheter tip occurred in 77% and 37.1% of patients, respectively. CFD is a novel and useful technique to confirm the precise position of the epidural needle tip in the context of labor analgesia. Identification of the epidural catheter with CFD is difficult despite an adequate CSE technique.

Incidence of Persistent Headache at 18 Months Following Accidental Dural Puncture in the Obstetric Population: A Prospective Service Evaluation in 45 Patients.

The aim of the prospective longitudinal service evaluation was to reveal the incidence of persistent headache at 18 months following accidental dural puncture with a 16-gauge Tuohy needle. This followed an observation that a subset of female patients was presenting to the local pain medicine clinic with persistent headache following an accidental dural puncture. Two thirds of patients with an accidental dural puncture develop post dural puncture headache that is believed to be a self-limiting condition. There is emerging evidence from retrospective studies that post dural puncture headache can result in persistent headache. Prospective longitudinal service evaluation in obstetric patients who suffered an accidental dural puncture headache. Patients provided written consent for telephone follow-up at 6, 12, and 18 months. Patients reporting persistent headache were reviewed at a pain medicine clinic for further investigations and management. Over an 18-month period, 45 patients suffered accidental dural puncture. Five patients declined consent. One patient was lost to follow-up. Of the 39 patients who completed follow-up, 12 patients (30%) reported persistent headache at 18 months. Six patients reported new onset headache while 6 patients reported worsening of pre-existing headache. Post dural puncture headache from an accidental dural puncture can no longer be considered a self-limiting condition. Current evidence probably mandates the addition of persistent headache as one of the potential complications of an epidural insertion during informed consent process.

Double Assurance of Epidural Space Detection Using Fiberoptics-Based Needle Design and Autofluorescence Technologies for Epidural Blockade in Painless Labor.

Purpose: Technology of reflectance spectroscopy incorporated with auto-fluorescence spectroscopy were employed to increase the safety of epidural placement in regional anesthesia which is generally used for surgery, epidural anesthesia, post-operative pain control and painless childbirth. Method: Ex vivo study of auto-fluorescence spectroscopy was performed for the para-vertebral tissues contained fat, interspinous ligament, supraspinous ligament and ligamentumflavum by multimode microplate reader at wavelength 405 nm for the purpose of tissue differentiation. A specially designed optic-fiber-embedded needle was employed to incorporate with both reflectance and autofluorescence spectroscopies in order to probe the epidural space as double assurance demands. In vivo study was carried out in a Chinese native swine weighted about 30 kg under intubated general anesthesia with ventilation support. The reflective (405 nm) and autofluorescence signals (λ and λ*) were recorded at 5 different sites by an oscilloscope during the needle puncture procedure from skin to epidural space in the back of the swine. Results: Study of either autofluorescence spectroscopy for tissue samples or ex vivo needle puncture in porcine trunk tissues indicates that ligmentumflavum has at least 10-fold higher fluorescence intensity than the other tissues. In the in vivo study, ligamentumflavum shows a double-peak character for both reflectance and autofluorescence signals. The epidural space is located right after the drop from the double-peak. Both peaks of reflectance and fluorescence are coincident which ensures that the epidural space is correctly detected. Conclusions: The fiber-optical technologies of double-assurance demands for tissue discrimination during epidural needle puncture can not only provide an objective visual information in a real-time fashion but also it can help the operator to achieve much higher success rate in this anesthesia procedure.

Analysis of caudal epidurogram in single center: A preliminary study of lumbar radiculopathy management.

A caudal epidural block involves placing a needle through the sacral hiatus and delivering medication into the epidural space. The procedure is safe and simple, but failure rates can be as high as 25%. The purpose of this study was to investigate the success rate of caudal epidural block by analyzing needle placement and dye flow pattern.We retrospectively analyzed the medical records of patients who underwent caudal epidural block under spinal stenosis. A case was defined as a failure if it met at least one of the following four criteria: the epidural needle was not placed correctly inside the caudal canal; blood regurgitation or aspiration in the needle was observed; the contrast dye was injected into a blood vessel; or a large amount of the dye leaked into the sacral foramen or did not reach the L5-S1 level.At least 1 failure criterion was observed in 14 cases (17.7%), while none of the failure criteria were satisfied in 65 successful cases (82.3%).No matter how experienced the anesthesiologist may be, delivery of adequate therapeutic agent is not achieved in approximately 20% of cases. Therefore, we recommend fluoroscopy-guided needle placement and confirmation by radio-contrast epidurograpy as the best choice.

Fiber-Optic Distributed Strain Sensing Needle for Real-Time Guidance in Epidural Anesthesia

Epidural anesthesia is a pain relief treatment mainly used for pregnant women during delivery. The procedure is described as an injection of anesthetic fluid into an epidural space using a hemodynamic Tuohy needle. The correct identification of epidural space is crucial for successful anesthesia, but due to the blindness of the procedure, the existing methods can fail with potentially severe consequences for patients. Since the tissue preceding the epidural space has high density, the strain significantly changes when the needle reaches the proximity of the epidural space, and this change can be used as an indicator. Distributed fiber optic sensors, working with an optical backscatter reflectometer, can improve the scenario by measuring the strain along each section of the epidural needle. This work goes beyond the epidural space identification: distributed strain data detect strain events leading to a potential failure to reach the epidural space before the procedure is finalized. The experiments have shown that the penetrations along different paths (with different speeds, with misalignment, and with rotation) result in different strain patterns. The proposed method has been validated on phantoms reproducing the epidural space, in different insertion conditions.

Comparing low-dose bupivacaine with epidural volume extension to standard bupivacaine dosing for short obstetric procedures: a prospective, randomized study

Intrathecal bupivacaine's long duration of action can unnecessarily increase the time to meet Postanesthesia Care Unit (PACU) discharge criteria for patients undergoing short obstetric procedures. We sought to use a technique known as epidural volume extension (EVE) to determine if we could provide an adequate surgical block while significantly decreasing the time required to meet PACU discharge criteria for patients undergoing short obstetric procedures. Fifty participants were randomized into two groups. The control group received a 10 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space via a combined spinal-epidural technique. The EVE group received a 5 mg of 0.5% isobaric bupivacaine plus 15 µg of fentanyl injection in the intrathecal space followed immediately by a 10 mL injection of sterile saline through the epidural needle for the EVE. Data were analyzed on 45 of the 50 patients. Time to meet PACU discharge criteria was significantly reduced in the EVE group when compared to the control group (50 vs. 135 minutes, P<0.001). The EVE group had a faster time to complete motor recovery when compared to the control group (66 vs. 181 minutes, P<0.001). Peak block height was similar in both groups at the time of surgery start (T5 vs. T5, P=0.44). The use of low-dose isobaric bupivacaine in combination with 10 mL of saline EVE allows for faster motor recovery and time to meet PACU discharge criteria in patients undergoing short obstetric procedures.

Real-Time Ultrasound-Assisted Thoracic Epidural Placement: A Feasibility Study of a Novel Technique.

The placement of thoracic epidural catheters is complicated by the layering of the vertebral lamina. Therefore, traditional blind palpation techniques require insertion of an epidural needle with likely contact of lamina with redirections into the epidural space. We discuss a safe and consistent technique using true real-time ultrasound visualization of the needle with a paramedian sagittal oblique view to improve the consistency of placing an epidural in the thoracic spine for postoperative analgesia. Successful epidural placement was achieved in every patient. All catheters were found to be effective for use in the postoperative phase.