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Background: The traditional loss-of-resistance (LOR) technique for thoracic epidural catheter placement can be associated with a high primary failure rate. In this study, we compared the traditional LOR technique and dynamic pressure-sensing (DPS) technology for primary success rate and secondary outcomes pertinent to identifying the thoracic epidural space., Methods: This pragmatic, randomized, patient- and assessor-blinded superiority trial enrolled patients ages 18 to 75 years, scheduled for major thoracic or abdominal surgeries at a tertiary care teaching hospital. Anesthesiology trainees (residents and fellows) placed thoracic epidural catheters under faculty supervision and rescue. The primary outcome was the success rate of thoracic epidural catheter placement, evaluated by the loss of cold sensation in the thoracic dermatomes 20 minutes after injecting the epidural test dose. Secondary outcomes included procedural time, ease of catheter placement, the presence of a positive falling meniscus sign, early hemodynamic changes, and unintended dural punctures. Additionally, we explored outcomes that included number of attempts, needle depth to epidural space, need for faculty to rescue the procedure from the trainee, patient-rated procedural discomfort, pain at the epidural insertion site, postoperative pain scores, and opioid consumption over 48 hours., Results: Between March 2019 and June 2020, 133 patients were enrolled; 117 were included in the final analysis (n = 57 for the LOR group; n = 60 for the DPS group). The primary success rate of epidural catheter placement was 91.2% (52 of 57) in the LOR group and 96.7% (58 of 60) in the DPS group (95% confidence interval [CI] of difference in proportions: -0.054 [-0.14 to 0.03]; P = .264). No difference was observed in procedural time between the 2 groups (median interquartile range [IQR] in minutes: LOR 5.0 [7.0], DPS 5.5 [7.0]; P = .982). The number of patients with epidural analgesia onset at 10 minutes was 49.1% (28 of 57) in the LOR group compared to 31.7% (19 of 60) in the DPS group ( P = .062). There were 2 cases of unintended dural punctures in each group. Other secondary or exploratory outcomes were not significantly different between the groups., Conclusions: Our trial did not establish the superiority of the DPS technique over the traditional LOR method for identifying the thoracic epidural space ( Clinicaltrials.gov identifier: NCT03826186)., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Introduction: In anesthesia, a medication error would occur every 20 to 133 anesthesia procedures, and 14% is related to a route administration error. To secure neuraxial route, ISO group published a norm in 2016 to develop specific connectors, the "NRFit® connector". The main objective of this work, is to develop a risk mapping related to neuraxial medication errors therefore prepare the NRFit® implementation in anesthesia units in a French Universitary Hospital., Methods: Failure modes, effects and criticality analysis (FMECA) methodology was used for our risk mapping which was divided in 3 anesthesia specialities. For each, the analysis was performed for accidental neuraxial administration of intravenous drugs, and its opposite error. Secondly, NRFit® devices were tested for 1 month by 3 experimented anesthetists., Results: The majority of reported errors concerns epidural and intrathecal anesthesia, and more frequently in the field of obstetrics. Opioids and tranexamic acid, administered in neuraxial route, are drugs with the highest criticality. The tests were rather conclusive and made it possible to highlight the additional needs in medical devices., Discussion: Obstetrics is the riskiest area due to the frequency of epidural anesthesia, the administration of critical drugs in intravenous and neuraxial route. This work increased the awareness of our group, improved the measure of this risk and harmonized practices., Conclusion: This work is the first step of the project to prevent administration route error in anesthesia during patient's drug management. The next step will be the NRFit® implementation for epidural and combined spinal-epidural anesthesia in our hospital., (Copyright © 2024 Académie Nationale de Pharmacie. Published by Elsevier Masson SAS. All rights reserved.)

If an accidental dural puncture occurs, one option is to insert a catheter and use it as an intrathecal catheter. This avoids the need for a further injection and can rapidly provide labour analgesia and anaesthesia for caesarean section. However, there are no recommendations for managing intrathecal catheters and, therefore, significant variation in clinical practice exists. Mismanagement of the intrathecal catheter can lead to increased motor block, high spinal anaesthesia, drug error, hypotension and fetal bradycardia. Care must be taken with an intrathecal catheter to adhere to strict aseptic technique, meticulous labelling, cautious administration of medications and good communication with the patient and other staff. Every institution considering the use of intrathecal catheters should establish a protocol. For labour analgesia, we recommend the use of dilute local anaesthetic agents and opioids. For caesarean section anaesthesia, gradual titration to the level of the fourth thoracic dermatome, with full monitoring, in a facility equipped to manage complications, should be performed using local anaesthetics combined with lipophilic opioids and morphine or diamorphine. Although evidence of the presence and duration of intrathecal catheters on the development of post-dural puncture headache and need for epidural blood patch is limited, we suggest considering leaving the intrathecal catheter in for 24 hours to reduce the chance of developing a post-dural puncture headache while maintaining precautions to avoid drug error and cerebrospinal fluid leakage. Injection of sterile normal saline into the intrathecal catheter may reduce post-dural puncture headache. The level of evidence for these recommendations was low., (© 2021 Association of Anaesthetists.)

Background: Neuraxial anesthesia can be challenging in obstetric patients due to the gravid uterus interfering with patient positioning. Ultrasound is commonly used in obstetric anesthesia to facilitate neuraxial needle placement. Some positioning maneuvers facilitate the ultrasound visualization of structures and the placement of neuraxial needles, but the Epidural Positioning Device (EPD) has yet to be evaluated., Objectives: Our goal was to evaluate whether the use of the EPD increased the acoustic target window in the lumbar area of pregnant patients. We hypothesized that the application of the EPD would increase the measured lengths of the paravertebral longitudinal ligament (PLL), the interlaminar distance (ILD) and the ligamentum flavum (LF)., Methods: Lumbar ultrasonography was performed on 29 pregnant women having an elective cesarean delivery. Two anesthesiologists independently scanned the L3-4 right paramedian space, using a curvilinear ultrasound transducer, in two positions for each patient: traditional sitting with lumbar flexion and sitting with use of the EPD for lumbar flexion. The PLL, ILD and LF lengths were measured using the ultrasound caliper software and recorded, with the anesthesiologists blinded to the results. Patients were asked to rate their comfort in both positions., Results: There were no significant differences between the measured lengths of the PLL, ILD and LF in the two positions. Patient comfort was significantly higher with use of the EPD (OR 10, 95% CI 2.4 to 88)., Conclusion: Although the application of an EPD did not improve the paramedian acoustic target area in term parturients, greater patient comfort might facilitate needle placement., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The standard of care for neuraxial procedures is landmark palpation to determine the site of placement. This research study aimed to test the primary feasibility of VerTouch™, a force-sensing resistor device, to identify landmarks for the initiation of neuraxial procedures. Patients were recruited at the time of labour epidural, or when consenting for spinal anaesthesia for caesarean delivery at a single centre. The clinical team used the device to create a pressure map image of the bony spine. If they felt confident, they used the device guide to make a mark on the patient's back. If the mark was used, total insertions and redirections, combined as passes, of the needle during the procedure were counted for secondary outcome analysis. A total of 101 parturients were recruited, and the provider felt confident making a mark based on the imaging in 96.9% of cases. Device success (completion using the mark and ≤4 total passes) occurred in 91.4% of cases. This feasibility study showed that the primary outcome, the provider using the device to make a mark, was successful. In addition, based on comparing passes with historical data, the Vertouch™ device showed promise for future use to minimise needle manipulation in neuraxial procedures.

Percutaneous epidural neuroplasty (PEN) is an effective interventional treatment for radicular pain. However, in some cases, contrast runoff to the spinal nerve root does not occur. We investigated whether contrast runoff to the spinal nerve root affects the success rate of PEN and whether additional transforaminal epidural blocks for intentional contrast runoff affect the success rate of PEN in cases in which contrast runoff is absent.This study was registered at ClinicalTrials.gov (Identifier: NCT03867630) in March 2019. We reviewed the medical records of 112 patients who underwent PEN with a wire-type catheter from May 2016 to August 2018. Patients were divided in 3 groups (Runoff group, Non-runoff group, Transforaminal group).Patients with low back pain and leg radicular pain who did not respond to lumbar epidural steroid injectionsPEN was performed in 112 patients with a wire-type catheter in target segment. We compared the success rate of PEN betweenThe success rate was significantly different between the Runoff group and the Non-runoff group (P < .0007) and between the Non-runoff group and the Transforaminal group (P = .0047), but not between the Runoff group and the Transforaminal group (P = .57).Contrast runoff influenced the success rate of PEN. In cases without contrast runoff, additional transforaminal epidural blocks for intentional contrast runoff increased the success rate of PEN with a wire-type catheter.

Anesthesiologists commonly perform the loss of resistance technique in order to identify the epidural space during neuraxial procedures; however, this technique is subjective and lacks reliability in certain cases. The so-called CompuFlo® technology provides objective information about the position of the epidural needle by means of a pressure curve and acoustic signals. The technology was introduced several years ago and was evaluated in several trials, which showed promising results. The purpose of the present publication is to report on the first experiences with the CompuFlo® technology in German-speaking countries. A series of 24 epidural procedures using the CompuFlo® device was carried out in routine daily practice. The epidural space was successfully identified in 23 cases. Conversion to the conventional loss of resistance technique was performed during the initial cases in a prolonged procedure. The CompuFlo® technique is considered to be a promising technology, which might help to reduce complications after epidural anesthesia, e.g. postdural puncture headache.

Background: The migration of pediatric thoracic epidural catheters via a thoracic insertion site has been described. We assessed the migration of caudally threaded thoracic epidural catheters in neonates and infants at our institution., Methods: The anesthesia records and diagnostic imaging studies of neonates and infants who had caudal epidural catheters placed during a 26-month period at our hospital were analyzed. Imaging studies were reviewed for changes in epidural catheter tip position., Results: Eighty-five patients 1-325 days of age (median, 51 days; interquartile range, 39-78 days) and weights of 2.5-9.5 kg (median, 5 kg; interquartile range, 4.3-5.8 kg) met the study criteria. Fifty-four (64%) of the patients (95% CI, 52%-73%) experienced catheter migration of 1 or more vertebral levels (range, 3 levels caudad [outward] to 3 levels cephalad [inward]), and 23 (27%) of the patients (95% CI, 18%-38%) experienced catheter migration to the T4 level or higher. Migration of 2 or more vertebral levels occurred only in children who weighed <6 kg and were under 73 days of age., Conclusions: Epidural catheter migration occurs commonly in neonates and infants. Postoperative imaging is crucial to confirm catheter tip location after epidural catheter placement, as failure to assess catheter migration might result in suboptimal analgesia or other undesirable outcomes.

Background: Insufficient fixation of an epidural catheter may result in migration of the catheter and eventual catheter failure. However, the best fixation method remains to be established. Aron Alpha A (2-ethyl cyanoacrylate) adhesive is approved for clinical use and can be used for surgical adhesion to both skin and blood vessels. We hypothesized that the addition of Aron Alpha A adhesive to film dressing would result in consistent and dependable catheter fixation., Methods: In this study, 58 women who were scheduled for cesarean delivery under spinal and epidural anesthesia were recruited. Patients were randomly assigned to a control or treatment group. In the control group, the catheter was fixed solely by film dressing. In the treatment group, a small amount of Aron Alpha A was applied at 2 sites along the catheter. The fixation area was then covered by film dressing. The catheter insertion length was recorded after fixation (T0), immediately postoperatively (T1), on postoperative day 1 (T2), and when the catheter was removed (T3). The change in insertion length from T0 to T3 between the 2 groups was the primary outcome measure. The incidence of catheter failure was also recorded. For all comparisons, P < .05 was considered statistically significant., Results: Initially, 58 women were enrolled; however, 3 patients were excluded. From the remaining 55 patients, 27 and 28 were assigned to the control and treatment groups, respectively, and were evaluated. The change in insertion length from T0 to T3 was significantly more in the control group compared with the treatment group (-1.9 ± 2.2 vs 0 ± 0 cm, respectively; P < .001). In the control group, 11 catheters (41%) failed; in the treatment group, all catheters provided effective analgesia throughout the study (P < .001)., Conclusions: Epidural catheter fixation using film dressing combined with 2-ethyl cyanoacrylate adhesive application at 2 sites along the catheter resulted in secure fixation in patients receiving postoperative epidural analgesia for cesarean delivery.

Purpose of Review: Low-dose combined spinal epidural (CSE) anesthesia is a common technique to anesthetize women for cesarean section. It is used to reduce the incidence of hypotension while providing excellent anesthetic conditions., Recent Findings: Low spinal doses produce effective anesthesia but of limited duration. Therefore, an epidural catheter (and thus CSE) is required to guarantee pain-free surgery. Recent work confirmed that lower spinal doses can reduce significantly hypotension., Summary: Low-dose CSE is a valuable strategy to anesthetize pregnant women for cesarean section but requires attention and training.

Purpose of Review: Central neuraxial blockade is increasingly the anaesthetic management of choice for parturients, including in higher risk pregnancies. Although they are usually effective and safe, there are potentially devastating neurological complications that may present either overtly or insidiously. A thorough understanding of the variety of potential neurological complications is essential to adequately consent patients in addition to diagnosing and managing complications following neuraxial anaesthesia. This review aims to describe a number of potential neurological injuries that may occur and suggested management based on available evidence., Recent Findings: Current evidence supports neuraxial anaesthesia as a safe management strategy in low and many higher risk pregnancies, with a low overall incidence of neurological complications. Neuraxial blockade is safe in patients with platelet counts greater than 70 000/μl and the risk of infective complications secondary to epidural catheterization remains low until day five post procedure. There is also some early evidence supporting the use of transnasal local anaesthetic as a strategy for managing postdural puncture headache., Summary: Difficulty remains in establishing absolute risk of complications and optimal management strategies given the low overall number of patients affected and heterogeneity of therapy. There may be a role for centralized registration of postneuraxial complications in obstetric patients to further develop our collective understanding of these conditions.

Background: Physician educators must balance the need for resident procedural education with clinical time pressures as well as patient safety and comfort. Alternative educational strategies, including e-learning tools, may be beneficial to orient novice learners to new procedures and speed proficiency. We created an e-learning tool (computer-enhanced visual learning [CEVL] neuraxial) to enhance trainee proficiency in combined spinal-epidural catheter placement in obstetric patients and performed a randomized controlled 2-center trial to test the hypothesis that use of the tool improved the initial procedure performed by the anesthesiology residents., Methods: Anesthesiology residents completing their first obstetric anesthesiology rotation were randomized to receive online access to the neuraxial module (CEVL group) or no access (control) 2 weeks before the rotation. On the first day of the rotation, residents completed a neuraxial procedure self-confidence scale and an open-ended medical knowledge test. Blinded raters observed residents performing combined spinal-epidural catheter techniques in laboring parturients using a procedural checklist (0-49 pts); the time required to perform the procedure was recorded. The primary outcome was the duration of the procedure., Results: The CEVL group had significantly shorter mean (±standard deviation) procedure time compared to the control group 22.5 ± 4.9 vs 39.5 ± 7.1 minutes (P < .001) and had higher scores on the overall performance checklist 36.4 ± 6.6 vs 28.8 ± 7.1 (P = .012). The intervention group also had higher scores on the open-ended medical knowledge test (27.83 ± 3.07 vs 22.25 ± 4.67; P = .002), but self-confidence scores were not different between groups (P = .64)., Conclusions: CEVL neuraxial is a novel prerotation teaching tool that may enhance the traditional initial teaching of combined spinal-epidural procedures in obstetric anesthesiology. Future research should examine whether the use of web-based learning tools impacts long-term provider performance or patient outcomes.

Background: Cervical transforaminal epidural block (CTEB) is a useful option in the diagnosis and treatment of cervical radicular pain. However, inadvertent intravascular injection can lead to severe neurologic complications. Blunt needles are considered to displace instead of penetrate vessels because of their dull needle tip., Objectives: To investigate whether there is a difference between blunt and sharp needles in intravascular injection rates during CTEB., Study Design: Prospective, randomized, clinical trial., Setting: A tertiary hospital in South Korea., Methods: After institutional review board approval, 108 patients undergoing CTEB for treatment of radicular pain resulting from spinal stenosis and herniated nucleus pulposus were randomly assigned to one of 2 needle groups (blunt needle or sharp needle). The needle position was confirmed using biplanar fluoroscopy, and 2 mL of nonionic contrast medium was injected to detect intravascular injection. Intravascular injection was defined as the contrast medium spreading out through the vascular channel during injection under real-time fluoroscopy. This study was registered in ClinicalTrials.gov., Results: The intravascular injection rate was not significantly different between the blunt needle and sharp needle groups (35.2% vs. 33.3%, P > 0.05). The procedure time was longer in the blunt needle group than in the sharp needle group (101.00 ± 12.4 seconds vs. 56.67 ± 8.3 seconds, P < 0.001)., Limitations: This was a single-center study. Additionally, the physicians could not be blinded to the type of needle used., Conclusions: In the present study, use of a blunt needle did not reduce the rate of intravascular injection during CTEB compared to use of a sharp needle. In addition, procedure time significantly increased with blunt needle use compared to sharp needle use., Key Words: Analgesia, bleeding, blunt needle, cervical spine, clinical trials, complications, intravascular injection, radiculopathy, sharp needle, transforaminal epidural block.

This study investigates the safety and efficacy of a large-dose, needle-based epidural technique in obstetric anesthesia. The technique differs from a standard, catheter-based approach in that the anesthetic dose is administered through an epidural needle prior to insertion of the epidural catheter. Using a data-driven informatics and machine learning approach, our findings show that the needle-based technique is faster and more dose-effective in achieving sensory level. We also find that injecting large doses in the epidural space through the epidural needle is safe, with complication rates similar to those reported in published literature for catheter-based technique. Further, machine learning reveals that if the needle dose is kept under 18 ml, the resulting hypotension rate will be significantly lower than published results. The machine learning framework can predict the incidence of hypotension with 85% accuracy. The findings from this investigation facilitate delivery improvement and establish an improved clinical practice guideline for training and for dissemination of safe practice.

Background: Dural puncture, paraesthesia and vascular puncture are the most common complications of epidural catheter insertion. Their association with variation in midline needle insertion depth is unknown., Objective: This study evaluated the risk of dural and vascular punctures and the unwanted events paraesthesia and multiple skin punctures related to midline needle insertion depth., Material and Methods: A total of 14,503 epidural catheter insertions including lumbar (L1-L5; n = 5367), low thoracic (T7-T12, n = 8234) and upper thoracic (T1-T6, n = 902) insertions, were extracted from the German Network for Regional Anaesthesia registry between 2007 and 2015. The primary outcomes were compared with logistic regression and adjusted (adj) for confounders to determine the risk of complications/events. Results are presented as odds ratios (OR, [95% confidence interval])., Main Results: Midline insertion depth depended on body mass index, sex, and spinal level. After adjusting for confounders increased puncture depth (cm) remained an independent risk factor for vascular puncture (adjOR 1.27 [1.09-1.47], p = 0.002) and multiple skin punctures (adjOR 1.25 [1.21-1.29], p < 0.001). In contrast, dural punctures occurred at significantly shallower depths (adjOR 0.73 [0.60-0.89], p = 0.002). Paraesthesia was unrelated to insertion depth. Body mass index and sex had no influence on paraesthesia, dural and vascular punctures. Thoracic epidural insertion was associated with a lower risk of vascular puncture than at lumbar sites (adjOR 0.39 [0.18-0.84], p = 0.02)., Conclusion: Variation in midline insertion depth is an independent risk factor for epidural complications; however, variability precludes use of depth as a reliable guide to insertion in individual patients.

Background: There is no clear consensus about how best to prevent post-dural puncture headache (PDPH) following an accidental dural puncture in parturients. Our primary objective was to investigate whether the insertion of an intrathecal catheter following accidental dural puncture reduces the incidence of PDPH and therapeutic epidural blood patch., Methods: Anaesthetic records from January 2009 to December 2015 were reviewed retrospectively and parturients who had an accidental dural puncture and/or PDPH were identified. Data from those with a recognised dural puncture in whom an intrathecal catheter was inserted at the time of accidental dural puncture (ITC group) were compared to those without an intrathecal catheter (non-ITC group), as were outcomes of patients with an intrathecal catheter for ≥24 hours compared to <24 hours., Results: Of 94 recognised accidental dural punctures, 66 were in the ITC group (37 for ≥24 h) and 28 in the non-ITC group. In the ITC group, 22 (33.3%) required an epidural blood patch in comparison to 19 (67.9%) in the non-ITC group (P <0.01, 95% CI 12.5 to 52.0). In the ITC group, 62 (93.9%) developed PDPH in comparison to 28 (100%) in the non-ITC group (P=0.186, 95% CI -6.55 to 14.57). Intrathecal catheter insertion for ≥24 h obviated the need for an epidural blood patch in 28 (75.7%) parturients, compared to 13 (59.1%) if <24 h (P=0.184, 95% CI -7.08 to 39.72)., Conclusion: Inserting an intrathecal catheter after a recognised accidental dural puncture significantly reduced the need for an epidural blood patch., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

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.

Background: Thoracic epidural anesthesia (TEA) is one of the pillars of perioperative pain care. Particularly for spine surgery which causes significant postoperative pain TEA seems like an appealing option. However, beneficial effects of a TEA are questionable when the catheter is not used intraoperatively, a decision that is usually based on the surgeon's wish to perform immediate neurological examination postoperatively., Methods: Forty patients undergoing transforaminal lumbar interbody fusion surgery (TLIF) were randomized into two groups. Patients received preoperative insertion of a TEA. For patients in the intraoperative group an epidural infusion was started preoperatively and maintained throughout. For patients in the postoperative group the epidural infusion was started once neurological examination had been performed. The primary outcome measure in this study was postoperative requirements of piritramide during the first two postoperative hours. Secondary outcomes involved postoperative pain numeric rating scale (NRS) scores, intraoperative opioid requirements, side effects and ability to perform direct postoperative neurological examination., Results: Postoperative group patients required significantly more opioids both intra- and postoperatively (P=0.036 and P=0.039) and NRS scores were significantly higher on admission to recovery, at 30 and 60 min as compared to patients in the intraoperative group (P=0.013; P=0.004 and P=0.012). Early postoperative neurological examination was feasible in all patients in both groups., Conclusions: Epidural catheters used intraoperatively during TLIF are feasible, significantly reduce pain, intra- and postoperative use of opioids and do not influence the quality of neurological tests directly after the surgical procedure.

Placing the needle inside the epidural space for locoregional anesthesia is a challenging procedure, which even today is left to the expertise of the operator. Recently, we have demonstrated that the use of optically sensorized needles significantly improves the effectiveness of this procedure. Here, we propose an optimized configuration, where the optical fiber strain sensor is directly integrated inside the epidural catheter. The new design allows the solving of the biocompatibility issues and increases the versatility of the former configuration. Through an in vivo study carried out on a porcine model, we confirm the reliability of our approach, which also opens the way to catheter monitoring during insertion inside biological spaces.

Purpose: We propose a novel framework for enhancement and localization of steeply inserted hand-held needles under in-plane 2D ultrasound guidance., Methods: Depth-dependent attenuation and non-axial specular reflection hinder visibility of steeply inserted needles. Here, we model signal transmission maps representative of the attenuation probability within the image domain. The maps are employed in a contextual regularization framework to recover needle shaft and tip information. The needle tip is automatically localized by line-fitting along the local-phase-directed trajectory, followed by statistical optimization., Results: The proposed method was tested on 300 ex vivo ultrasound scans collected during insertion of an epidural needle into freshly excised porcine and bovine tissue. A tip localization accuracy of [Formula: see text] was achieved., Conclusion: The proposed method could be useful in challenging procedures where needle shaft and tip are inconspicuous. Improved needle localization results compared to previously proposed methods suggest that the proposed method is promising for further clinical evaluation.

Although there are reports of iatrogenic Horner syndrome in the adult population, pediatric cases are rare. The current report presents a case of acquired Horner syndrome that occurred after an epidural catheter was placed for pain control. Horner syndrome completely resolved after removing the catheter and no imaging or further work-up was necessary. [J Pediatr Ophthalmol Strabismus. 2018;55:e1-e3.]., (Copyright 2018, SLACK Incorporated.)

Background: Caudo-lumbar and caudo-thoracic epidural anesthesia is an established technique that carries a low risk of dural puncture or spinal cord trauma in infants. Traditionally catheter advancement is based on external measurements. However, malpositioning of catheters are known to occur. We hypothesized that caudal-epidural catheters inserted under real-time ultrasound guidance may be more accurate than the accuracy of the measurements traditionally used for their placement., Methods: We studied 25 patients, aged 2 days to 5 months, posted for abdominal or thoracic surgery, receiving general anesthesia followed by caudo-epidural continuous block. External measurement defined as the distance from the caudal space and the surgically congruent vertebral level was measured in centimeters with the back gently flexed. Subsequently, a caudo-epidural block was performed in the same position. The epidural catheter insertion was followed under real-time ultrasound guidance till the predetermined vertebral level was reached. The actual length placed under real-time ultrasound scan was defined as the actual length. The high-frequency probe was placed longitudinal and paramedian to the spine. The vertebral level was determined by identifying the lumbosacral junction in longitudinal saggital view and counting the vertebrae up from L5. The catheter length at the skin was compared with the length recorded by external measurement., Results: The actual length placed under real-time ultrasound scan were consistently longer than the external distance between the caudal space and selected vertebral level. The mean values of ultrasound were higher than the mean values of external measurement with a difference of 4.28 cm. Accuracy was not affected by age or affected by the selected vertebral level in the age group we studied., Conclusion: We conclude that catheters placed under ultrasound guidance are more accurate than the traditional method developed before the advent of ultrasound in young infants., (© 2017 John Wiley & Sons Ltd.)

Background: Detecting loss of resistance (LOR) can either be taught with dedicated simulators, with a cost ranging from &OV0556;1500 to 3000, or with the 'Greengrocer's Model', requiring simply a banana., Objectives: The purpose of this study was to compare three dedicated epidural puncture training simulators and a banana in their ability to simulate LOR. Our hypothesis was that there was a difference between the four simulators when comparing the detection of LOR., Design: Single-blinded, randomised, controlled study., Setting: Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Switzerland., Participants: Fifty-five consultant anaesthesiologists., Interventions: The participants were asked to insert an epidural catheter in four different epidural puncture training simulators: Lumbar Puncture Simulator II (Kyoto Kagaku, Kyoto, Japan), Lumbar Epidural Injection Trainer (Erler-Zimmer, Lauf, Germany), Normal Adult Lumbar Puncture/Epidural Tissue (Simulab Corp., Seattle, Washington, USA) and a banana. The simulators were placed in identical boxes to blind the participants., Main Outcome Measures: The primary outcome was the detection of LOR rated on a 100-mm visual analogue scale, in which 0 mm represented 'completely unrealistic' and 100 mm represented 'indistinguishable from a real patient'., Results: The mean visual analogue scale scores for LOR in the four simulators were significantly different: 60 ± 25 mm [95% confidence interval (CI), 55 to 65 mm], 50 ± 29 mm (95% CI, 44 to 55 mm), 64 ± 24 mm (95% CI, 58 to 69 mm) and 49 ± 32 mm (95% CI, 44 to 54 mm); P less than 0.001, Friedman test., Conclusion: Two of the three dedicated epidural simulators were rated more realistic in detecting LOR than the banana, but some participants preferred the banana to the other three simulators. Given the relative cost of a banana compared with a dedicated simulator, we suggest that a banana be used to teach the technique of LOR for epidural puncture., Trial Registration: KEK Nr: Req-2015-z087.

Background: Identifying the epidural space is essential during epidural anesthesia (EA). Pressure of the epidural space in pregnancy is higher than that in nonpregnant woman. Loss of resistance (LOR) method is the most commonly preferred method for identifying the epidural space. Epidrum and Epi-Jet are recently innovated supporting devices that facilitate identifying process for epidural space. In this study we aimed to compare Epidrum, Epi-Jet, and LOR methods in identifying the epidural space, feasibility of technique., Methods: Two hundred and forty pregnant women who were scheduled for caesarian section surgery under lumbar EA or combined spinal epidural anesthesia (CSEA) were randomized into three groups (Group I Epidrum, n = 80), Group II (Epi-Jet, n = 80), and Group III (LOR, n = 80). We recorded the time required to identify the epidural space and deflation of Epidrum balloon and Epi-Jet syringe, number of attempts, additional methods used to identify epidural space, usefulness of methods, accuracy of identification of epidural space, and outcomes of epidural catheterization., Results: There were no significant differences between the groups with respect to demographic data, duration of deflation of Epidrum balloon and Epi-Jet syringe and distance between skin and epidural space. The mean time required to enter epidural space in Group I was shorter than that in Group II (P = 0.031). Feasibility of Epi-Jet was easier than that of Epidrum (P = 0.015). Number of uncertainties of epidural space identification was higher in Group I than that in Group II (P = 0.009). Also, the requirement for LOR to confirm epidural space and failure rates was higher in Group I than Group II (P < 0.001)., Conclusion: We suggest that Epi-Jet is superior to Epidrum in pregnant patients in terms of clarity of epidural space identification, usefulness, and success rates of EA or CSEA.

A 71-year-old woman on aspirin presented for a distal pancreatectomy, splenectomy, and partial colectomy with a T8/9 epidural catheter placed preoperatively in 3 attempts. Prophylactic 5000 units of subcutaneous heparin were given before the procedure. After catheter removal on postoperative day 2, the patient developed transient bilateral lower extremity paralysis, with near complete recovery within 30 minutes. An urgent MRI revealed a T4-T8 epidural hematoma prompting an emergent T3-T8 laminectomy. This case presentation highlights the need for heightened awareness regarding complications related to neuraxial analgesia in patients receiving unfractionated heparin for thromboembolism prophylaxis with concurrent aspirin use.

Background and Objectives: Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis., Methods: We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications., Results: Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas., Conclusions: Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia.

Objective: To compare the running-drip and hanging-drop techniques for locating the epidural space in dogs., Study Design: Prospective, randomized, clinical trial., Animals: Forty-five healthy dogs requiring epidural anaesthesia., Methods: Dogs were randomized into four groups and administered epidural anaesthesia in sternal (S) or lateral (L) recumbency. All blocks were performed by the same person using Tuohy needles with either a fluid-prefilled hub (HDo) or connected to a drip set attached to a fluid bag elevated 60 cm (RDi). The number of attempts, 'pop' sensation, clear drop aspiration or fluid dripping, time to locate the epidural space (TTLES) and presence of cerebrospinal fluid (CSF) were recorded. A morphine-bupivacaine combination was injected after positive identification. The success of the block was assessed by experienced observers based on perioperative usage of rescue analgesia. Data were checked for normality. Binomial variables were analysed with the chi-squared or Fisher's exact test as appropriate. Non-parametric data were analysed using Kruskal-Wallis and Mann-Whitney tests. Normal data were studied with an anova followed by a Tukey's means comparison for groups of the same size. A p-value of < 0.05 was considered to indicate statistical significance., Results: Lateral recumbency HDo required more attempts (six of 11 dogs required more than one attempt) than SRDi (none of 11 dogs) (p = 0.0062). Drop aspiration was observed more often in SHDo (nine of 11 dogs) than in LHDo (two of 11 dogs) (p = 0.045). Mean (range) TTLES was longer in LHDo [47 (18-82) seconds] than in SHDo [20 (14-79) seconds] (p = 0.006) and SRDi [(34 (17-53) seconds] (p = 0.038). There were no differences in 'pop' sensation, presence of CSF, rescue analgesia or pain scores between the groups., Conclusion and Clinical Relevance: The running-drip method is a useful and fast alternative technique for identifying the epidural space in dogs. The hanging-drop technique in lateral recumbency was more difficult to perform than the other methods, requiring more time and attempts., (Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Objectives: Perioperative epidural analgesia in liver resection provides optimal dynamic pain relief. Coagulation disorders occurring in the postoperative period can lead to greater risk of complications during epidural catheter removal. The aim of this study is to evaluate the effectiveness and complications of epidural analgesia and delayed epidural catheter removal due to postoperative coagulopathy., Methods: A retrospective study of 114 patients undergoing open liver resection and epidural analgesia, from March 2012 to February 2015. Postoperative course of pain intensity, coagulation parameters and delayed catheter removal was analyzed RESULTS: Of the 114 operated patients, 73 met the inclusion criteria. 59% of patients received major hepatectomy (resection ≥ 3 segments) and 15% had Child's Class A cirrhosis (11/73). 96% of catheters functioned properly. 89% of patients had controlled pain (numerical rate scale <3) at rest and 8.2% (6 patients) had severe pain (numerical rate scale > 6) with movement. The INR peaked on postoperative day 2, 1.41 [0.99-2.30], and gradually returned to normal values in most patients by postoperative day 4, 1.26 [0.90 - 2.20]. The catheters were left in place 3.6 (± 1.1) days. In 6 patients (8%), catheter removal was postponed due to coagulation disorders., Conclusions: Epidural analgesia for liver resection was a safe practice, which produced optimal control of postoperative pain. The percentage of delayed catheter removal due to postoperative coagulopathy was low, not requiring transfusion of blood products., (Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Study Objective: Obese parturients both greatly benefit from neuraxial techniques, and may represent a technical challenge to obstetric anesthesiologists. Several studies address the topic of obesity and neuraxial analgesia in general, but few offer well described definitions or rates of "difficulty" and "failure" of labor epidural analgesia. Providing those definitions, we hypothesized that increasing body mass index (BMI) is associated with negative outcomes in both categories and increased time needed for epidural placement., Design: Single center retrospective chart review., Setting: Labor and Delivery Unit of an inner city academic teaching hospital., Patients: 2485 parturients, ASA status 2 to 4, receiving labor epidural analgesia for anticipated vaginal delivery., Interventions: None., Measurements: We reviewed quality assurance and anesthesia records over a 12-month period. "Failure" was defined as either inadequate analgesia or a positive test dose, requiring replacement, and/or when the anesthesia record stated they failed. "Difficulty" was defined as six or more needle redirections or a note indicating difficulty in the anesthesia record., Main Results: Overall epidural failure and difficulty rates were 4.3% and 3.0%, respectively. Patients with a BMI of 30kg/m 2 or higher had a higher chance of both failure and difficulty with two and almost three fold increases, respectively. Regression analysis indicated that failure was best predicted by BMI and less provider training while difficulty was best predicted by BMI. Additionally, increased BMI was associated with increased time of discovery of epidural catheter failure., Conclusions: Obesity is associated with increasing technical difficulty and failure of neuraxial analgesia for labor. Practitioners should consider allotting extra time for obese parturients in order to manage potential problems., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Current 2-D ultrasound technology is unable to perform a midline neuraxial needle insertion under real-time ultrasound guidance using a standard needle and without an assistant. The aim of the work described here was to determine the feasibility of a new technology providing such capability, starting with a study evaluating the selected puncture site. A novel 3-D ultrasound imaging technique was designed using thick-slice rendering in conjunction with a custom needle guide (3DUS + Epiguide). A clinical feasibility study evaluated the ability of 3DUS + Epiguide to identify the epidural needle puncture site for a midline insertion in the lumbar spine. We hypothesized that (i) the puncture site identified by 3DUS + Epiguide was within a 5-mm radius from the site chosen by standard palpation, and (ii) the difference between the two puncture sites was not correlated to the patient characteristics age, weight, height, body mass index and gestational age. The mean (±standard deviation) distances between puncture sites determined by 3DUS + Epiguide and palpation were 3.1 (±1.7) mm and 2.8 (±1.3) mm, for the L2-3 and L3-4 interspaces of 20 patients, respectively. Distances were comparable to intra-observer variability, indicating the potential for a thick-slice rendering of 3-D ultrasound along the Epiguide trajectory to select the puncture site of a midline neuraxial needle insertion. The long-term potential benefits of this system include increased efficiency and use of anesthesia, and a reduction in the frequency and severity of the complications from incorrect needle insertions. Epidural success in the most difficult cases (e.g., the obese) will be the focus of future work., (Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Spinal needle injections are guided by fluoroscopy or palpation, resulting in radiation exposure and/or multiple needle re-insertions. Consequently, guiding these procedures with live ultrasound has become more popular, but images are still challenging to interpret. We introduce a guidance system based on augmentation of ultrasound images with a patient-specific 3-D surface model of the lumbar spine. We assessed the feasibility of the system in a study on 12 patients. The system could accurately provide augmentations of the epidural space and the facet joint for all subjects. Following conventional, fluoroscopy-guided needle placement, augmentation accuracy was determined according to the electromagnetically tracked final position of the needle. In 9 of 12 cases, the accuracy was considered sufficient for successfully delivering anesthesia. The unsuccessful cases can be attributed to errors in the electromagnetic tracking reference, which can be avoided by a setup reducing the influence of the metal C-arm., (Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Study Objective: Elderly patients with degenerative knee disease may have accompanying degenerative spine conditions. There are no studies on lumbar epidural catheter withdrawal forces in these patients. The aim of this study was to investigate withdrawal forces and possible associated risk factors in patients undergoing total knee arthroplasty (TKA)., Design: Prospective randomized trial., Setting: Operating room and ward in a university hospital., Patients: Seventy-eight patients aged 65 to 80years who were undergoing TKA and combined spinal epidural anesthesia were enrolled., Interventions: Lumbar epidural catheterization was performed in a lateral position before surgery and the patients were randomly allocated to one of 3 positions for removal: flexed lateral (L), prone (P), and sitting (S). On the third postoperative day, the lumbar epidural catheters were removed by a single investigator with the patient in the assigned position., Measurements: We measured the peak tension during catheter withdrawal and evaluated the factors affecting peak tension., Main Results: The forces required to remove the catheters were considerably greater in the sitting and prone than in the flexed lateral position: group P (3.9N [0.28-10.36]), group S (4.1N [0.04-11.57]), and group L (1.3N [0.07-3.65]) (P<.001). There was a positive correlation between the length of catheter in the epidural space and peak tension (P=.0026, β coefficient=.223)., Conclusions: For ease of removal of catheters from the lumbar epidural space, the flexed lateral position is recommended for elderly patients undergoing TKA. When placing the epidural catheter, the physician should be careful not to insert a catheter that is excessively long., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Neuraxial anesthesia and epidural steroid injection techniques require precise anatomical targeting to ensure successful and safe analgesia. Previous studies suggest that only some of the tissues encountered during these procedures can be identified by spectroscopic methods, and no previous study has investigated the use of Raman, diffuse reflectance, and fluorescence spectroscopies. The authors hypothesized that real-time needle-tip spectroscopy may aid epidural needle placement and tested the ability of spectroscopy to distinguish each of the tissues in the path of neuraxial needles., Methods: For comparison of detection methods, the spectra of individual, dissected ex vivo paravertebral and neuraxial porcine tissues were collected using Raman spectroscopy (RS), diffuse reflectance spectroscopy, and fluorescence spectroscopy. Real-time spectral guidance was tested using a 2-mm inner-diameter fiber-optic probe-in-needle device. Raman spectra were collected during the needle's passage through intact paravertebral and neuraxial porcine tissue and analyzed afterward. The RS tissue signatures were verified as mapping to individual tissue layers using histochemical staining and widefield microscopy., Results: RS revealed a unique spectrum for all ex vivo paravertebral and neuraxial tissue layers; diffuse reflectance spectroscopy and fluorescence spectroscopy were not distinct for all tissues. Moreover, when accounting for the expected order of tissues, real-time Raman spectra recorded during needle insertion also permitted identification of each paravertebral and neuraxial porcine tissue., Conclusions: This study demonstrates that RS can distinguish the tissues encountered during epidural needle insertion. This technology may prove useful during needle placement by providing evidence of its anatomical localization.

Introduction: The adoption of regional and epidural analgesia in UK military personnel injured in action during Op HERRICK increased from 2008, in line with structural and environmental developments in the UK medical treatment facility. Historically, there have been concerns that invasive analgesic techniques could carry an increased risk of infection, due to the mechanism of injury and the environmental conditions in which the injuries were sustained. Consequently, the epidural and continuous peripheral nerve blockade (CPNB) catheters that were inserted in UK military personnel during a 33-month period of Op HERRICK were clinically and microbiologically examined, after subsequent admission to the University Hospitals Birmingham (UHB) NHS Trust., Methods: Data on epidural and CPNB insertions were collected via the specialist pain service at UHB over the study period, including de novo and replacement insertions performed in both Afghanistan and the UK. Patients were regularly reviewed and relevant clinical concerns were documented in patients' case notes as necessary. The anatomical site, duration of placement and the results of microbiological culture of the epidural and CPNB catheter tips were all recorded., Results: Overall, 236 catheters were assessed, of which 151 catheter tips (64%) were cultured (85 epidural, 66 CPNB). Of these, 48 grew bacteria (34% of cultured epidurals and 29% of cultured CPNB). There was no difference between the colonisation rates of epidurals inserted in Afghanistan and the UK. Only one infection related to a misplaced epidural catheter was confirmed., Conclusions: With the exception of the epidural (34%) and proximal sciatic (42%) catheters, these figures, in a military cohort characterised by significant injury scores, are consistent with those reported for civilian surgical patients. The results strongly support the expansion of regional analgesia during Op HERRICK from 2008 onwards. The outcomes suggest a possible translation into civilian major trauma practice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: The aims of this study were to determine the utility of transesophageal echocardiography (TEE) for identifying spinal canal structures and epidural catheter position and to assess the effect of catheter position on intraoperative hemodynamics and quality of postoperative analgesia., Methods: Twenty-six adult patients undergoing thoracic surgery were included in this prospective, observational study. An epidural catheter was inserted 7.5 cm or more into the thoracic epidural space using a midline approach and a loss-of-resistance technique. A pediatric TEE probe was inserted after induction of general anesthesia. It was used to identify the spinal canal structures, the catheter tip position in the epidural space, and the spread of injected local anesthetic. Intraoperative hemodynamics, postoperative visual analogue scale (VAS) pain scores, and the need for rescue epidural doses were recorded and compared between groups determined by their catheter position., Results: Two subjects were excluded from the study because of an intrathecally positioned epidural catheter. The remaining 24 subjects were divided into two groups based on TEE-determined epidural catheter position: posterior (Gr-P) or lateral (Gr-L). Spinal canal structures and the epidural catheter was successfully identified in all patients. The epidural catheter was located posteriorly in 20 (83%) patients and laterally in four (17%) patients. The spread of the local anesthetic was bilateral in all Gr-P patients, whereas it was unilateral in all but one of the Gr-L patients. Compared to Gr-P patients, Gr-L patients had higher heart rates and blood pressures at various time points after local anesthetic administration until the end of surgery (P = 0.02 to < 0.001). Postoperative VAS scores (P = 0.02) and the median number of rescue analgesic doses required during the intraoperative and postoperative periods were also higher in Gr-L patients (P < 0.001)., Conclusion: Transesophageal echocardiography reliably identified spinal canal structures and the position of epidural catheters in the epidural space in adult patients. Posteriorly located epidural catheters appear to provide better epidural analgesia than laterally situated catheters.