Comparative efficacy of ultrasound guidance or conventional anatomical landmarks for neuraxial puncture in adult patients: a systematic review and network meta-analysis

Anaesthesia for caesarean delivery in women with class 3 obesity: a retrospective cohort study from the north-west of England (2022-2023)

BACKGROUND

The Royal College of Anaesthetists (RCOA) and the Royal College of Obstetricians and Gynaecologists (RCOG) have recommended standards for pregnant women with a body mass index (BMI) ≥40 kg/m2. These include achieving specified rates for neuraxial anaesthesia and conversion from neuraxial to general anaesthesia (GA) during caesarean delivery (CD), 100% attendance at the anaesthesia antenatal clinic, re-weighing in the third trimester, and anaesthesia provision by a specialty trainee year 6 (ST6) or above.

METHODS

Records of 760 women with BMI ranging from 40.0-49.99 kg/m2 (89.7%), 50.0-59.99 kg/m2 (8.9%) and ≥ 60 kg/m2 (1.4%) undergoing a CD were reviewed across nine maternity units in the north-west of England. We aimed to analyse the variations in anaesthetic technique across the BMI cohorts, assess adherence with the proposed standards and explore the documented incidence of pain during CD (PDCD).

RESULTS

Neuraxial anaesthesia was successfully utilised in 92.6% women. Spinal anaesthesia rates declined as BMI increased from ≥40-49.99 kg/m2 (81.1%) to ≥50-59.99 kg/m2 (67.2%) to ≥60 kg/m2 (45.5%), (P =0.0001), whilst combined spinal epidural (CSE) use increased (4% vs 19.4% vs 45.5%, P <0.0001). No differences were observed in the primary GA (3.7%; P =0.12) or the neuraxial to GA conversion rates (3.8%; P =0.54) across the BMI cohorts. The neuraxial anaesthesia standards for all CD categories were met by at least 66.7% of all hospitals, whilst the neuraxial to GA conversion standards for elective CD were met by only 33.3%. PDCD was documented in 6.1% and only 24.9% of women were re-weighed in the third trimester. Anaesthetic clinic attendance was recorded in 57% whilst a ST6 or above provided anaesthesia to 87.1% of women.

CONCLUSION

As BMI increases, anaesthetists tend to favour a CSE technique over spinal anaesthesia. Maternity units found it challenging to comply with the specified RCOA/RCOG standards.

Point-of-care ultrasound in obstetric anesthesia clinical practice

PURPOSE OF THE REVIEW

Point-of-care ultrasound (POCUS) is increasingly recognized as a valuable tool in obstetric anesthesia. This review synthesizes key studies and reviews published within the last 2 years on its application in clinical practice with relevant supporting literature.

RECENT FINDINGS

Handheld ultrasound-assisted neuraxial block placement modestly reduces periprocedure time compared with landmark-based techniques. Devices with integrated three-dimensional or artificial intelligence-guided software may improve first-attempt success, particularly in obese patients. Focused cardiac ultrasound has gained interest as a potential tool for predicting postspinal hypotension through predelivery inferior vena cava collapsibility assessment. POCUS is also valuable for evaluating shock and cardiovascular compromise, aiding in the diagnosis and clinical management of amniotic fluid embolism and maternal cardiomyopathy. Gastric ultrasound can be performed qualitatively, aids aspiration risk assessment, and can be used in studies evaluating drug effects on gastric contents and antral cross-sectional area. Robust training programs are essential to equip obstetric anesthesiologists with sustainable POCUS skill sets.

SUMMARY

POCUS is associated with reduced neuraxial block placement times, provides critical hemodynamic data in patients with amniotic fluid embolism and cardiomyopathy, and allows gastric content evaluation for aspiration risk assessment. Expanding structured training and research is crucial to maximizing its clinical utility.

Papilledema

OBJECTIVE

This article describes the recognition, investigation, and management of papilledema.

LATEST DEVELOPMENTS

Papilledema describes optic disc swelling (usually bilateral) arising from raised intracranial pressure. Due to the serious nature of papilledema, there is a fear of underdiagnosis and hence one of the major stumbling points is the correct identification of papilledema. While there has been a stepwise increase in the incidence and prevalence of idiopathic intracranial hypertension due to the worldwide epidemic of people living with obesity, secondary causes such as cerebral venous sinus thrombosis, intracranial masses, and infections must not be missed. Our ability to image the optic nerve has been greatly enhanced by the directed use of optical coherence tomography, with recent studies observing novel imaging findings that can help distinguish pseudopapilledema from papilledema. The structured investigation of papilledema is now routine and research into the management of CSF disorders is finding new avenues for targeted treatments.

ESSENTIAL POINTS

Confirmation of papilledema typically requires a thorough ocular examination including visual field testing. Ocular imaging such as color fundus photographs and optical coherence tomography are useful. Joint care between ophthalmologists and neurologists is key to treating the underlying condition and managing any visual dysfunction and headache.

Ultrasound-guided spinal anaesthesia for a patient with severe scoliosis

Ultrasound (US) guided spinal anaesthesia is gaining recognition for its ability to minimise technical difficulties encountered in patients with atypical spinal anatomy. Spinal anaesthesia is administered during a surgical procedure lithotripsy in patients with respiratory complications that can result from severe scoliosis or cerebral palsy. Here, we report a case in which US-guided spinal anaesthesia proved feasible and advantageous in a patient with cerebral paralysis and severe scoliosis. A man in his 60s with cerebral paralysis and severe scoliosis was scheduled for spinal anaesthesia because of his nocturnal SpO2 drops and need for nasal high flow. Using US guidance, we confirmed that the needle entry angle was consistent with the rotating spinous process. The spinal needle was then advanced successfully, and spinal anaesthesia was administered without issue. The US technique for detecting the rotation of the vertebrae and puncturing them is useful in patients with severe scoliosis.

Cervical-Level Regional Paraspinal Nerve Block in Cervical Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Regional paraspinal nerve block techniques have shown promise in cervical spine surgery pain relief and opioid reduction. The study aims to evaluate cervical-level regional paraspinal nerve block techniques in cervical spine surgery.

METHODS

Systematic randomized controlled trial (RCT) searches in ScienceDirect, PubMed, Embase, and Cochrane was conducted until March 2024. Key outcome measures included postoperative pain scores and postoperative opioid utilization. Techniques assessed were erector spinae plane block (ESPB), inter-semispinal plane block (ISPB), and superficial cervical plexus block (CPB).

RESULTS

The study included 6 RCTs and 648 participants. Regional paraspinal nerve block significantly reduced postoperative pain scores at 4, 6, 8, 12, and 24 hours. Postoperative opioid usage was lower in the block group (mean difference [MD]: -1.68; 95% CI: -3.14 to -0.21; P = 0.02), with fewer complications (odds ratio: 0.51; 95% CI: 0.40-0.66; P = 0.001). Patients using fentanyl as postoperative opioid had significantly lower opioid usage with the block (MD: -1.39; 95% CI: -1.76 to -1.01; P < 0.001). Dosage >10 mL correlated with decreased opioid usage (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001). ESPB (MD: -1.37; 95% CI: -1.83 to -0.90; P < 0.001) and ISPB (MD: -3.52; 95% CI: -7.09-0.00; P = 0.05) effectively reduced opioid consumption. Posterior approach (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001), bilateral administration (MD: -2.14; 95% CI: -4.26 to -0.03; P < 0.001), and ultrasound-guided intervention (MD: -2.68; 95% CI: -5.24 to -0.12; P < 0.001) resulted in a significant reduction of opioid usage.

CONCLUSIONS

Cervical-level regional paraspinal nerve block effectively reduces postoperative pain and opioid usage, particularly with a dosage exceeding 10 mL, utilizing ESPB and ISPB techniques, administered posteriorly, bilaterally, and under ultrasound guidance.

Efficacy of Computer-Aided Three-Dimensional Ultrasound Guidance for Neuraxial Anesthesia in Adult Patients: A Systematic Review and Meta-Analysis

Artificial intelligence for ultrasound scanning in regional anesthesia is a rapidly developing interdisciplinary field. This study aimed to evaluate the efficacy of computer-aided three-dimensional ultrasound (C-aided US) guidance for neuraxial anesthesia in adult patients. We searched all randomized controlled trials (RCTs) of adult patients who required neuraxial anesthesia in the MEDLINE, CENTRAL, Embase, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases on June 19, 2023. The primary outcomes were first-pass success, procedure time, and incidence of procedure-related adverse events. We used the Risk of Bias 2 to evaluate the risk of bias for each outcome, a random-effects model to conduct a meta-analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to evaluate the certainty of evidence. Seven RCTs (594 patients) were included. The C-aided US guidance results were as follows: first-pass success (risk ratio = 1.39, 95% confidence interval (CI) = 0.89 to 2.16; low certainty) and total procedure time (mean difference = 0.85 minutes, 95% CI = -0.81 to 2.5; low certainty). Four RCTs reported procedure-related adverse events (e.g., paresthesia, back pain, hemorrhagic events) in both groups (low certainty). The updated meta-analysis showed that there might be no differences in the first-pass success rates and total procedure times between C-aided US guidance and anatomical landmark guidance for neuraxial punctures.

Point-of-Care Ultrasound: A Vital Tool for Anesthesiologists in the Perioperative and Critical Care Settings

Point-of-care ultrasound (POCUS) is an essential skill in various specialties like anesthesiology, critical care, and emergency medicine. Anesthesiologists utilize POCUS for quick diagnosis and procedural guidance in perioperative and critical care settings. Key applications include vascular ultrasound for challenging venous and arterial catheter placements, gastric ultrasound for aspiration risk assessment, airway ultrasound, diaphragm ultrasound, and lung ultrasound for respiratory assessment. Additional utilities of POCUS can include multi-organ POCUS evaluation for undifferentiated shock or cardiac arrest, ultrasound-guided central neuraxial and peripheral nerve blocks, focused cardiac ultrasound, and novel applications such as venous excess ultrasound. This review highlights these POCUS applications in perioperative and intensive care and summarizes the latest evidence of their accuracy and limitations.

Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials

BACKGROUND

Data suggest that preprocedural ultrasound may improve the efficacy of central neuraxial puncture. However, it remains uncertain whether these findings can be extended to various clinical scenarios, including diverse patient populations and the application of real-time ultrasound guidance. Additionally, it is unclear whether ultrasound-guided techniques improve safety and patient-centered outcomes.

METHODS

We searched six databases for randomized trials of adult patients undergoing neuraxial puncture, comparing real-time ultrasound, preprocedural ultrasound, and landmark palpation for efficacy, safety and patient-centered outcomes. Our primary outcome was a failed first-attempt neuraxial puncture. After two-person screening and data extraction, meta-analyses were conducted and the Grading of Recommendations Assessment, Development and Evaluation approach was applied to assess the certainty of evidence.

RESULTS

Analysis of 71 studies involving 7153 patients, both real-time ultrasound (OR 0.30; 95% credible interval (CrI) 0.15 to 0.58; low certainty) and preprocedural ultrasound (OR 0.33; 95% CrI 0.24 to 0.44; moderate certainty) showed a significant reduction in the risk of a failed first neuraxial puncture. Real-time ultrasound had the best performance for preventing first-attempt failures (low certainty evidence). Although real-time ultrasound was also the leading method for reducing the risk of complete neuraxial puncture failure, the results did not show a statistically significant difference when compared with landmark palpation. Preprocedural ultrasound, however, significantly reduced the odds of complete puncture failure (OR 0.29; 95% CrI 0.11 to 0.61). These ultrasound-guided approaches also contributed to a reduction in certain complications and increased patient satisfaction without any other significant differences in additional outcomes. Trial sequential analysis confirmed that sufficient information was achieved for our primary outcome.

CONCLUSIONS

Ultrasound-guided neuraxial puncture improves efficacy, reduces puncture attempts and needle redirections, reduces complication risks, and increases patient satisfaction, with low to moderate certainty of evidence. Despite real-time ultrasound's high ranking, a clear superiority over preprocedural ultrasound is not established. These results could prompt anesthesiologists and other clinicians to reassess their neuraxial puncture techniques.

Celebrating the state of the art and innovations in regional anaesthesia in the British Journal of Anaesthesia

To coincide with the annual scientific meeting of Regional Anaesthesia UK in London 2024, where there is a joint scientific session with the British Journal of Anaesthesia, a special regional anaesthesia edition of the journal has been produced. This editorial offers some highlights from the manuscripts contained within the special edition.