Ultrasound-guided Spinal Anesthesia Research Articles

Continuing medical education for attending physicians in anesthesia: Feasibility of an innovative blended learning approach.

Continuing medical education plays a pivotal role in fostering and upholding the standard of excellence in medicine. Both SPOC (small private online course) and BOPPPS (bridge-in, learning objective, pretest, participatory learning, posttest, and summary) methodologies are rooted in the same educational and learning theories, emphasizing active student engagement, interaction, and feedback. Using ultrasound-guided spinal anesthesia as an exemplar, we aimed to investigate the feasibility of blended teaching (combination of BOPPPS and SPOC) for anesthesiology clinicians and explore trainees' and trainers' perspectives towards the innovative method. Twenty-seven attending anesthesiologists were randomly divided into experimental group (n = 14, blended teaching method) and control group (n = 13, traditional teaching method). The questionnaire was administered before and a week post-training. Their operative skills (measured by operation time) were assessed. The students' cognitive evaluation of the blended teaching mode was conducted in the experimental group. The experimental group demonstrated notably higher theoretical scores compared to the control group [(46.42 ± 5.345) vs (41.92 ± 5.219), t = 2.213, P < .05]. The operation time in the experimental group was significantly shorter than that in the control group [(84.79 ± 28.450) seconds vs (114.23 ± 35.607) seconds, t = -2.383, P < .05]. Most participants preferred blended learning as it was more effective than traditional learning. Suggestions for enhancement included enhanced online interactivity with trainers and the inclusion of case analysis. Integration of blended teaching incorporating BOPPPS and SPOC methodologies holds promise for enhancing the efficiency of skill training among anesthesiologists. Blended learning may become a viable and well-received option among anesthesia clinicians in China.

A Case of a Dwarf Patient with Kyphoscoliosis with Severe Restrictive Airway Disease for Bilateral Tibia Nailing under Ultrasound-guided Spinal Anesthesia

A Case of a Dwarf Patient with Kyphoscoliosis with Severe Restrictive Airway Disease for Bilateral Tibia Nailing under Ultrasound-guided Spinal Anesthesia

Role of Ultrasound-Guided Spinal Anesthesia for Elder Patients Going Through Surgeries of Lower Limb: Review Article

Role of Ultrasound-Guided Spinal Anesthesia for Elder Patients Going Through Surgeries of Lower Limb: Review Article

Comparing the minimum local anesthetic dose of ropivacaine in real-time ultrasound-guided spinal anesthesia and traditional landmark-guided spinal anesthesia: a randomized controlled trial of knee surgery patients.

BackgroundThrough previous studies and clinical practice, we have found that real-time ultrasound-guided (UG) spinal anesthesia (SA) and traditional landmark-guided (LG) SA each require a different minimum local anesthetic dose (MLAD) of ropivacaine. For this study, we used Dixon’s up-and-down sequential method to analyze and compare the MLAD of different ropivacaine concentrations required for the UG and LG SA methods.MethodsA total of 120 patients undergoing knee surgery were consecutively recruited and randomly divided into four groups (30 patients per group). These groups were categorized as follows: Group I: high ropivacaine ultrasound-guided (HRUG), Group II: low ropivacaine ultrasound-guided (LRUG), Group III: high ropivacaine landmark-guided (HRLG), and Group IV: low ropivacaine landmark-guided (LRLG). SA was established by a bolus administration of up-and-down doses of 0.75% or 0.5% plain ropivacaine. Initial doses of 16, 18, 12, and 14 mg were administered to groups I–IV, and after that, increased or decreased by 1.5 mg according to dose effectiveness. Upon identifying the intervertebral puncture level, a lumbar X-ray was performed with metal markers, and actual radiographic findings were identified and compared to the initial markings.ResultsFor UG groups, the MLAD in the LRUG group was significantly higher than in the HRUG group [20.192 mg (95% CI, 19.256–21.174) versus 17.176 mg (95% CI, 16.276–18.124), respectively; P<0.001]. For LG groups, the MLAD in the LRLG group was significantly higher than in the HLRG group [14.478 mg (95% CI, 13.364–15.500) versus 13.201 mg (95% CI, 11.959–14.571), respectively; P=0.047]. When comparing both high ropivacaine groups (HRGs: I/III) to the low ropivacaine groups (LRGs: II/IV), we found that both UG subgroups (I/II) had a significantly higher MLAD than LG subgroups (III/IV) (P<0.001). US identified L4–5 in up to 90% of cases. Comparatively, palpation was successful in only 33.3% of patients. The rates of cephalad localization by US and palpation were 6.67% vs. 66.67%, respectively (P=0.002).ConclusionsWe found a higher MLAD of ropivacaine was required for UG SA at the L4–5 level due to the method providing a more accurate (less cephalad) localization than traditional LG SA.Trial RegistrationChinese Clinical Trial Registry ChiCTR2000033158.

Use of Three-Dimensional Computed Tomography Reconstruction and RealTime Ultrasound-Guided Spinal Anaesthesia in a Patient with Ankylosing Spondylitis: A Case Report

Use of Three-Dimensional Computed Tomography Reconstruction and RealTime Ultrasound-Guided Spinal Anaesthesia in a Patient with Ankylosing Spondylitis: A Case Report

Comparison of the time taken for subarachnoid block using ultrasound-guided method versus landmark technique for cesarean section - A randomized controlled study.

Background and Aims:Spinal anesthesia is the regional technique preferred for cesarean section and is usually administered using the traditional landmark technique. Ultrasonography of the spine appears to be helpful in locating the puncture site and increasing the success rate. The primary objective of this study was to assess the use of ultrasonogram in locating the lumbar interspinous space for spinal anesthesia in laboring parturients brought for elective cesarean section.Material and Methods:Sixty parturients scheduled to undergo elective cesarean section under spinal anesthesia were included in this prospective randomized controlled trial, after obtaining the institutional ethical clearance. In Group I, 30 patients received spinal anesthesia by landmark technique and in Group II, 30 patients underwent ultrasound-guided spinal anesthesia. The statistical analysis was done using SPSS software version 17 (SPSS Inc., Chicago, Illinois, USA) for Microsoft windows.Results:The time taken for spinal in Group I was longer than in Group II (62 ± 18s; 41 ± 11s; P = 0.0001). The number of attempts of needle insertion was significantly less in Group II (group I 1.86 ± 1.04: group II 1.06 ± 0.25). However, the total preparation time (28 8.30 ± 92 vs 804.73 ± 77; P = 0.0001) was more in the ultrasound-guided than in the landmark group. The patients had better satisfaction in group II.Conclusion:Preprocedural ultrasound is a useful tool for successful lumbar puncture in parturients as it minimizes the number of attempts of needle insertion and provides better patient satisfaction.

Real-time ultrasound-guided spinal anaesthesia vs pre- procedural ultrasound-guided spinal anaesthesia in obese patients.

Background and Aims:Spinal anaesthesia is conventionally performed using a landmark-guided midline approach. These surface landmarks may be absent, indistinct or distorted in the presence of obesity, previous spinal surgeries, deformities, or degenerative changes associated with ageing. In the present study, we compared the efficacy of real-time ultrasound (RUS)-guided paramedian approach, and pre-procedure ultrasound (PUS) landmark-guided paramedian approach in obese patients.Methods:Eighty patients with body mass index (BMI) >30 kg/m2 were included in the study. The participants were randomly assigned to two intervention groups, i.e., RUS and PUS approach. The primary end point was to attain a successful lumbar puncture. Variables like the number of attempts, the number of passes, the time taken for identifying landmark(s), and time for a successful lumbar puncture(s) were secondary end points and were recorded in both the groups.Results:The median number of attempts were 4 (IQR 2-4) and 2 (IQR 1-2), respectively, in the PUS and RUS group (P-value < 0.001). The median number of passes, the median time for identifying space, and the time for successful lumbar puncture was statistically significantly less in the RUS group, than the PUS group.Conclusion:The time taken for the identification of the space, the number of attempts, number of passes, and the time taken for successful lumbar puncture was more in the PUS group as compared to the RUS group.

Influence of age, laterality, patient position, and spinal level on the interlamina space for spinal puncture

Background and objectivesThe lumbar interlamina space height is an important determinant of successful spinal puncture. We aimed to evaluate the influence of age, laterality, patient position, and spinal level on...

Feasibility of Real-time Ultrasound-guided Spinal Anesthesia Using Dynamic Needle Tip Positioning

Feasibility of Real-time Ultrasound-guided Spinal Anesthesia Using Dynamic Needle Tip Positioning

Minimum Effective Dose of 0.5% Bupivacaine for Ultrasound-guided Spinal Anesthesia Using Taylor's Approach

Minimum Effective Dose of 0.5% Bupivacaine for Ultrasound-guided Spinal Anesthesia Using Taylor's Approach

Real-time ultrasound-guided spinal anesthesia for cesarean section in patient with severe kyphoscoliosis and Duchenne’s muscular dystrophy - A case report -

Real-time ultrasound-guided spinal anesthesia for cesarean section in patient with severe kyphoscoliosis and Duchenne’s muscular dystrophy - A case report -

Real-time Ultrasound-guided Spinal Anesthesia Using a New Paramedian Transverse Approach.

Ultrasound-guided spinal anesthesia is an attracting and advanced technique. We developed a new paramedian transverse approach for real-time ultrasound-guided spinal anesthesia. Using this approach, the block can be performed with the dominant hand whether in right or left lateral decubitus or sitting position. Our preliminary experience in 42 orthopedic and obstetric patients showed it could achieve high first pass success rate with acceptable procedure time. The effectiveness and safety of this approach need further investigation by comparing it with blind technique and other ultrasound-guided techniques with well-designed randomized controlled trials.

Ultrasound to Identify the Lumbar Space in Women With Impalpable Bony Landmarks Presenting for Elective Caesarean Delivery Under Spinal Anaesthesia: A Randomized Trial

(Int J Obstet Anesth. 2016;28:12–16) The use of ultrasound-guided spinal anesthesia for cesarean delivery in patients with spinous processes that are difficult or impossible to palpate is gaining in popularity. The main aim of this study was to determine whether preprocedural ultrasound scanning would make it easier to locate an appropriate needle insertion point and thereby improve the performance of spinal anesthesia for elective cesarean delivery in patients with impalpable bony landmarks.

Real-time ultrasound-guided spinal anesthesia in patients with predicted difficult anatomy.

There are limited reports of lumbar neuraxial blocks using real-time US in patients with predicted difficulties. We compared the number of attempts to perform spinal anesthesia using real-time US guidance versus landmark technique in patients meeting predefined criteria for difficult spinal anesthesia. We also compared procedure time, block success, patient satisfaction and difficulty scores between groups. Following institutional review board approval patients scheduled for total hip or knee arthroplasty with expected difficulty to perform spinal anesthesia were included. Number of attempts, block time, success rate, patient satisfaction and difficulty scores were recorded and we conducted the Kruskal-Wallis non-parametric test of difference between the groups. Thirty-eight patients were enrolled and a total of 32 data sets was analyzed. For number of attempts, we observed no difference between the groups (P<0.83). The US group resulted in marginally higher time to block compared to the control (P<0.0653). The US group resulted in marginally higher satisfaction compared to the control group (P<0.09). The block success rate was 100% in both groups. Anesthesiologists rated the US group procedure more difficult than the control group (χ2=10.85, P<0.0010). This trial suggests that real-time US guidance for spinal anesthesia in challenging patients in comparison to the controlled group was completed in longer time, with lower needle insertion attempts, and higher patient satisfaction scores but without statistically significant differences.

The use of ultrasound in planned cesarean delivery under spinal anesthesia for patients having nonprominent anatomic landmarks

Study objectiveThe aim of the study was to compare conventional landmark method with ultrasound-guided spinal anesthesia in cesarean delivery cases where spinous processes and interspinous spaces were not prominent on physical examination. DesignRandomized controlled clinical trial. SettingOperating rooms of university hospital of Erzurum, Turkey. PatientsSixty-four 18- to 45-year-old American Society of Anesthesiologists I-II patients scheduled for cesarean delivery under spinal anesthesia having hardly palpated anatomic landmarks on vertebral column. InterventionsPalpation difficulty of vertebral column landmarks was scored as 0, 1, 2, or 3 from easy to difficult for all patients in sitting position. The patients with score 2 or 3 were randomly allocated into 2 groups as group C (conventional, n=32) and group U (ultrasound, n=32) in which ultrasound guidance was used. MeasurementsThe number of skin punctures, the number of needle steering, the number of puncture tried vertebral levels, and procedure time were all recorded. Main resultsThe number of skin punctures was significantly lower in group U (P<.001). Successful subarachnoid puncture on first attempt was also significantly higher in group U (P<.01). The duration of procedure in the patients with score 2 was determined to be significantly longer in the ultrasound-guided group (P<.001). ConclusionsUltrasound guidance is an effective and safe method to reduce the number of puncture attempts, improve the success rate of subarachnoid access on the first attempt, and reduce the need to puncture multiple levels, although it prolongs procedure time in patients with score 2 according to our scoring system designed for this current study.

The Infiniti Plus ultrasound needle guidance system improves needle visualization during the placement of spinal anesthesia.

The Infiniti Plus ultrasound needle guidance system improves needle visualization during the placement of spinal anesthesia.

Ultrasound-guided spinal anaesthesia in obstetrics

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Ultrasound-guided spinal anaesthesia in obstetrics: is there an advantage over the landmark technique in patients with easily palpable spines?

BackgroundData are scarce on the advantage of ultrasound-guided spinal anaesthesia in patients with easily identifiable bony landmarks. In this study, we compared the use of ultrasound to the landmark method in patients with no anticipated technical difficulty, presenting for caesarean delivery under spinal anaesthesia. MethodsA total of 150 pregnant women were recruited in this randomized, controlled study. Ultrasound examination and spinal anaesthesia were performed by three anaesthetists with experience in ultrasound-guided neuraxial block. Patients were randomized to either the Ultrasound Group (n=75) or the Landmark Group (n=75). In both groups the level of L3–4 or L4–5 was identified by ultrasound (transverse and longitudinal approach) or palpation. The primary outcome was the procedure time, measured from the time of skin puncture by the introducer to the time of viewing cerebrospinal fluid at the hub of the spinal needle. Secondary outcomes were the number of skin punctures, number of passes, and incidence of successful spinal blockade. ResultsThe average procedure time, number of skin punctures and needle passes, were similar in both groups. The number of patients with successful spinal anaesthesia after one puncture was not statistically different between the groups. ConclusionThe present results indicate that when performed by anaesthetists experienced in both ultrasound and landmark techniques, the use of ultrasound does not appear to increase the success rate of spinal anaesthesia, or reduce the procedure time or number of attempts in obstetric patients with easily palpable spines.

Single-operator real-time ultrasound-guided spinal injection using SonixGPS™: a case series

The SonixGPS™ is a novel needle tracking system that has recently been approved in Canada for ultrasound-guided needle interventions. It allows optimization of needle-beam alignment by providing a real-time display of current and predicted needle tip position. Currently, there is limited evidence on the effectiveness of this technique for performance of real-time spinal anesthesia. This case series reports performance of the SonixGPS system for real-time ultrasound-guided spinal anesthesia in elective patients scheduled for joint arthroplasty. In this single-centre case series, 20 American Society of Anesthesiologists' class I-II patients scheduled for lower limb joint arthroplasty were recruited to undergo real-time ultrasound-guided spinal anesthesia with the SonixGPS after written informed consent. The primary outcome for this clinical cases series was the success rate of spinal anesthesia, and the main secondary outcome was time required to perform spinal anesthesia. Successful spinal anesthesia for joint arthroplasty was achieved in 18/20 patients, and 17 of these required only a single skin puncture. In 7/20 (35%) patients, dural puncture was achieved on the first needle pass, and in 11/20 (55%) patients, dural puncture was achieved with two or three needle redirections. Median (range) time taken to perform the block was 8 (5-14) min. The study procedure was aborted in two cases because our clinical protocol dictated using a standard approach if spinal anesthesia was unsuccessful after three ultrasound-guided insertion attempts. These two cases were classified as failures. No complications, including paresthesia, were observed during the procedure. All patients with successful spinal anesthesia found the technique acceptable and were willing to undergo a repeat procedure if deemed necessary. This case series shows that real-time ultrasound-guided spinal anesthesia with the SonixGPS system is possible within an acceptable time frame. It proved effective with a low rate of failure and a low rate of complications. Our clinical experience suggests that a randomized trial is warranted to compare the SonixGPS with a standard block technique.

Methodological considerations of ultrasound-guided spinal anesthesia using the Ultrasonix GPS™ needle tracking system

To the Editor, We read with interest the recent case report on ultrasound-guided spinal anesthesia with the Ultrasonix GPS needle tracking system. Based on our recent experience with this technique, we suggest that this report merits further discussion on certain methodological considerations. We recently described our preliminary experience with this system on spinal anesthesia in two cadavers in the prone position, and we have subsequently used the technique in several patients in the sitting position. In our cadaver study, a 2-5 MHz convex transducer was used in a parasagittal oblique plane. A 19G SonixGPS needle was inserted out-of-plane using the needle guidance technology and coloured dye was injected. The spinal needles were left in situ, and 16 injections between T2/3 and L4/5 were completed. All 16 attempts required only a single skin puncture. An anatomist carried out a post-procedural dissection, revealing successful needle and dye placement in the neuraxial space in 100% of attempts. In the case report by Wong et al., it is unclear which needle trajectory was employed relative to the ultrasound plane. Based on their Fig. 2, it appears that they utilized an in-plane approach directed cephalad. The position of the needle relative to the probe is indicated at the bottom right of the screen shot. For our cadaver study, we used both in-plane and out-of-plane approaches with the SonixGPS system. We found that the in-plane approach was technically difficult because of the size of the transducer head, the acute angle required, and the narrow interlaminar space. This approach also increased the skin-to-target distance travelled by the needle. The approach facilitating easiest access to the neuraxial space without encountering the lamina was the medially angled paramedian view with the needle entering out-of-plane at the medial aspect of the transducer (Figure). Needle tracking using the SonixGPS system with an in-plane approach helps to align the needle with the transducer and to identify the position of the needle shaft and tip. Nevertheless, the needle entry point is confined to the midline on either the caudal or cephalad edge of the transducer. Due to the length of the curvilinear probe, an in-plane approach greatly increases the required needle length to reach the subarachnoid space. An out-of-plane approach, however, maximizes the benefit of a needle tracking system. The system extrapolates where the needle tip will intersect the ultrasound plane based on the needle trajectory. This allows for unlimited needle entry starting points along the long edge of the transducer with a shorter distance to the dura and, in the case of neuraxial blocks, helps avoid laminae. The needle trajectory does not need to line up with the plane of the ultrasound beam and, therefore, this constraint is eliminated. Based on our experience with real-time ultrasoundguided neuraxial techniques using the SonixGPS in the prone and sitting positions, we also consider the sitting position to be more familiar and more ergonomic for the anesthesiologist. We agree with the authors that the SonixGPS system is a technological advance that may be helpful with difficult spinal anesthetics and needs further evaluation in the clinical setting. Editor’s Note: The authors of the article: Can J Anesth 2012; DOI: 10.1007/s12630-012-9809-2 respectfully declined an invitation to submit a reply to the above Letter to the Editor.