A randomized trial to investigate needle redirections/re-insertions using a handheld ultrasound device versus traditional palpation for spinal anesthesia in obese women undergoing cesarean delivery

Spinal Anesthesia for Cesarean Section in a Class III Obese Parturient: A Case Report

The rising prevalence of obesity, including among pregnant patients, presents challenges for anesthetic management during cesarean sections. We report the case of a parturient with class III obesity (BMI > 60) undergoing elective cesarean section successfully managed with single-shot spinal anesthesia. This case report supports the feasibility of single-shot spinal anesthesia in parturients with class III obesity and emphasizes the importance of rapid recognition and management of potential complications.

Ultrasound-based Accuro system versus traditional palpation technique for neuraxial anaesthesia: A systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

This review evaluates the efficacy and safety of Accuro, a handheld ultrasound device, compared to the palpation technique for neuraxial anaesthesia. Accuro provides real-time imaging guidance, potentially improving accuracy and efficiency.

METHODS

A comprehensive search across six electronic databases identified randomised clinical trials comparing Accuro with palpation for neuraxial anaesthesia. Risk ratios or mean differences with 95% confidence intervals (CIs) were calculated using a random-effects model. Bias risk was evaluated using the Cochrane Risk of Bias tool.

RESULTS

Five studies (n=369) met the inclusion criteria. Accuro showed a favourable risk ratio for first insertion success (1.44 [95% CI [1.01, 2.05], p=0.05]). It significantly reduced needle skin passes (MD -0.63; 95% CI [-1.05, -0.21]; p<0.01), but not needle redirection (MD -1.31; 95% CI [-2.71, 0.11]; p=0.07). Procedure time was shorter in palpation (MD 127.82; 95% CI [8.68, -246.97]; p=0.04). Four studies had a low risk of bias; one had some concerns.

CONCLUSION

Accuro can potentially improve success rates and reduce skin passes in neuraxial anaesthesia. Further trials with larger samples are needed, especially in patients with anticipated difficulties.

Advances in Epidural Labor Analgesia for Obese Parturients

With the development of society and economy, and the improvement of people's living standards, obesity has gradually become a significant issue not only in China but globally. Epidural anesthesia, being the most commonly used method for labor analgesia in clinical practice, has significantly reduced the pain experienced by parturients during childbirth and decreased the cesarean delivery rate. However, due to the anatomical and physiological differences between obese and non-obese parturients, the effectiveness and techniques of labor analgesia may vary. This review focuses on the anatomical characteristics and drug differences in obese parturients, the methods of epidural labor analgesia in this population, the application of ultrasound in epidural puncture for obese parturients, and the complications associated with labor analgesia. The goal is to provide a guidance for clinical practice.

Does preprocedural ultrasound prior to lumbar neuraxial anesthesia or analgesia increase first-pass success in adults with obesity? A systematic review

Background and Aims

Preprocedural ultrasound (PPU) reduces the risk of technical failure in non-obese patients and when technical difficulty is predicted. We conducted this review to determine if PPU improves first-pass needle insertion success for neuraxial anesthesia in patients with obesity.

Methods

We conducted a systematic review without meta-analysis, due to the small number of included studies. The study protocol was registered (PROSPERO: CRD42022368271). We conducted searches in MEDLINE, Embase, PubMed, and Cochrane Library from January 1, 1980 to October 1, 2022 for peer-reviewed randomized controlled or observational studies comparing PPU versus landmark techniques in patients with body mass index >30 kg/m2. The quality of evidence was assessed using the revised Cochrane risk-of-bias tool for randomized trials and Grading of Recommendations Assessment, Development, and Evaluation approach.

Results

There were nine randomized controlled studies, comprising 866 patients having lumbo-sacral neuraxial techniques. Three studies utilized a small handheld ultrasound device called Accuro™ and six utilized non-handheld ultrasound devices. Certainty of evidence was low for improving the first-pass success rate. There was evidence (moderate certainty) that PPU decreased number of passes, increased first insertion attempt success, and reduced number of insertion attempts. There was no evidence that PPU affected identifying time, needling time, or overall procedural time. There was no evidence that PPU influenced procedural failure rate (very low certainty evidence) and insufficient evidence to suggest that artificial intelligence-supported handheld devices were superior to conventional ultrasound devices.

Conclusions

In patients with obesity, there is evidence of very-low to moderate certainty that PPU improves markers of insertion success, with no indication of increased adverse effects. PPU should be used to reduce attempts. Further studies adhering to standardized outcome definitions are required for definitive recommendations.

Registration

The study protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022368271).

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.

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.

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

BACKGROUND

Preprocedural, real-time, and computer-aided three-dimensional ultrasound has been widely used for neuraxial puncture; however, the optimal guidance is unclear. We examined the comparative efficacy of three ultrasound guidance and anatomical landmarks for neuraxial puncture in adults.

METHODS

We searched for randomised controlled studies comparing the efficacy of ultrasound guidance and anatomical landmarks for neuraxial puncture in adults using electronic databases and unpublished studies. The primary outcomes were first-pass success and patient satisfaction. A random-effects network meta-analysis (NMA) was used.

RESULTS

We identified 74 eligible studies (7090 patients). Preprocedural ultrasound and real-time ultrasound-guided neuraxial puncture improved first-pass success compared with anatomical landmarks (risk ratio [RR] 1.6; 95% credible interval [CrI] 1.3-1.9; RR 1.9; 95% CrI 1.3-2.9, respectively, moderate confidence). Computer-aided ultrasound-guided neuraxial puncture also increased first-pass success (RR 1.8; 95% CrI 0.97-3.3, low confidence), although estimates were imprecise. However, real-time ultrasound-guided neuraxial puncture resulted in minimal difference in first-pass success compared with preprocedural ultrasound (RR 1.2; 95% CrI 0.8-1.8, moderate confidence). Preprocedural ultrasound improved patient satisfaction slightly compared with anatomical landmark use (standardised mean differences 0.28; 95% CrI 0.092-0.47, low confidence).

CONCLUSIONS

This NMA provides evidence supporting ultrasound-guided neuraxial puncture compared with use of anatomical landmarks, including indirect comparisons. Among the three ultrasound guidance methods, preprocedural ultrasound appears to be a better adjunctive option.

A Prospective Cohort Study to Evaluate Needle Passes Using a Portable Ultrasound Device versus Traditional Landmark Approach for Epidural Anesthesia in a Busy Obstetric Tertiary Care Center

Despite its many cited benefits, ultrasound guidance for neuraxial procedures is not widespread in anesthesiology. Some cited limitations include device cost and accessibility. We test the hypothesis that a handheld and relatively inexpensive ultrasound can improve neuraxial proficiency (e.g., decreased needle manipulations and block time). This prospective study compared the number of needle passes, redirections, and procedural time between epidural placed with a handheld ultrasound versus landmarks. Needle passes and attempts were defined as the number of times the Tuhoy needle was redirected, and the times skin was punctured (re-insertion). Procedural time was defined as the time from local anesthetic infiltration until loss of resistance was obtained. The impact of level of training and accuracy of the device were also analyzed. 302 patients receiving labor epidural were included in the study. No difference in body mass index (BMI) nor distribution of level of training was noted between the groups. Regression analysis adjusted for BMI demonstrated a decrease in needle passes (-1.75 (95% CI -2.62, -0.89), p < 0.001), needle attempts (-0.51 (95% CI -0.97, -0.04), p = 0.032) and procedural time (-154.67s 95% CI -303.49s, -5.85s), p = 0.042) when a handheld ultrasound was utilized. The mean (95% Confidence interval) difference between needle depth and ultrasound depth was 0.39 cm (0.32, 0.46), p < 0.001. The use of a handheld device resulted in statistically significant decrease of needle manipulations and block time. More research is needed to evaluate the impact of and increase in accessibility of ultrasound technology.