Anesth Pain Med.  2021 Oct;16(4):368-376. 10.17085/apm.21035.

Comparison of landmark and real-time ultrasound-guided epidural catheter placement in the pediatric population: a prospective randomized comparative trial

Affiliations
  • 1Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, India
  • 2Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
  • 3Department of Anesthesiology and Critical Care, Dr S N Medical College, Jodhpur, India

Abstract

Background
Epidural block placement in pediatric patients is technically challenging for anesthesiologists. The use of ultrasound (US) for the placement of an epidural catheter has shown promise. We compared landmark-guided and US-guided lumbar or lower thoracic epidural needle placement in pediatric patients.
Methods
This prospective, randomized, comparative trial involved children aged 1–6 years who underwent abdominal and thoracic surgeries. Forty-five children were randomly divided into two groups using a computer-generated random number table, and group allocation was performed by the sealed opaque method into either landmark-guided (group LT) or real-time ultrasound-guided (group UT) epidural placement. The primary outcome was a comparison of the procedure time (excluding US probe preparation). Secondary outcomes were the number of attempts (re-insertion of the needle), bone contacts, needle redirection, skin-to-epidural distance using the US in both groups, success rate, and complications.
Results
The median (interquartile range [IQR]) time to reach epidural space was 105.5 (297.0) seconds in group LT and 143.0 (150) seconds in group UT; P = 0.407). While the first attempt success rate was higher in the UT group (87.0% in UT vs. 40.9% in LT; P = 0.004), the number of bone contacts, needle redirections, and procedure-related complications were significantly lower.
Conclusions
The use of US significantly reduced needle redirection, number of attempts, bone contact, and complications. There was no statistically significant difference in the time to access the epidural space between the US and landmark technique groups.

Keyword

Acute pain; Anesthesia; Epidural; Pediatrics; Ultrasound

Figure

  • Fig. 1. Consort flow diagram. AIIMS: All India Institute of Medical Sciences, ASA: American Society of Anesthesiologists.

  • Fig. 2. Orientation of the ultrasound probe in paramedian longitudinal plane.

  • Fig. 3. Structures visualized on an ultrasound scan for epidural catheter placement.

  • Fig. 4. Displacement of posterior dura complex on the US on saline injection.

  • Fig. 5. Scatter plot showing the linear correlation between the body weight and the skin-epidural distance as measured on ultrasound.


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