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Ultraschall Med 2012; 33(7): E132-E137
DOI: 10.1055/s-0029-1245724
Original Article

© Georg Thieme Verlag KG Stuttgart · New York

Ultrasound Guidance for Neuraxial Analgesia and Anesthesia in Obstetrics: a Quantitative Systematic Review

Ultraschallgesteuerte neuroaxiale Blockaden in der Geburtshilfe: eine quantitative systematische ÜbersichtsarbeitA. Schnabel1 , F. Schuster2 , T. Ermert1 , L. H. Eberhart3 , T. Metterlein4 , P. Kranke2
  • 1Department of Anaesthesiology and Intensive Care, University Hospital of Muenster
  • 2Department of Anaesthesia and Critical Care, University Hospital of Würzburg
  • 3Anaesthesiology and Intensive Care, University Hospital of Marburg
  • 4Anaesthesiology and Intensive Care, University Hospital of Regensburg
Further Information

Publication History

received: 12.11.2009

accepted: 6.8.2010

Publication Date:
15 November 2010 (online)

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Zusammenfassung

Ziel: Ziel dieser quantitativen, systematischen Übersichtsarbeit war es, die Effektivität der Ultraschallanwendung bei der Anlage von Epidural- und Spinalanästhesien in der Geburtshilfe zu untersuchen. Material und Methoden: Die systematische Literatursuche in MEDLINE, EMBASE, CINAHL und CENTRAL identifizierte alle randomisierten kontrollierten Studien. Als Effektivitätsmaßzahlen wurden neben dem jeweiligen Konfidenzintervall (95 %-CI) für kontinuierliche Daten (z. B. durchschnittliche Anzahl an Punktionsversuchen) die Mittlere Differenz (MD) bzw. für dichotome Größen (z. B. Anzahl an Patienten mit „blutigen“ Punktionen) das Relative Risiko (RR) berechnet. Ergebnisse: 6 Studien (publiziert zwischen 2001 – 2009) mit den Daten von 659 schwangeren Patientinnen erfüllten die Einschlusskriterien. Der Einsatz des Ultraschalls wies im Vergleich zur körperlichen Untersuchung eine geringere Gesamtanzahl an Punktionsversuchen (MD: –0,92; 95 % CI: –1,11 bis –0,74; p < 0,00001) und punktierten Wirbelkörperhöhen (MD: –0,2; 95 % CI: –0,31 bis –0,1; p = 0,0002) auf. Die Inzidenz der erfolgreichen Punktionen im ersten Versuch betrug unter Ultraschallkontrolle 71 % im Vergleich zu 20 % in der Kontrollgruppe. Auch in Bezug auf die Reduktion der Komplikationsrate in der geburtshilflichen Anästhesie erwies sich die Ultraschallanwendung als effektives Hilfsmittel (z. B. Anzahl an blutigen Punktionen; RR: 0,28; 95 % CI: 0,14 – 0,57; p = 0,0005). Schlussfolgerung: Es gibt aktuell einige Daten, die darauf hinweisen, dass der Ultraschall eine hilfreiche Ergänzung im Rahmen der geburtshilflichen Anästhesie sein könnte. Der Einsatz des Ultraschalls kann insbesondere bei Frauen mit speziellen Risiken (Adipositas, Skoliose, Dorsale Instrumentierung) zur Anlage einer zentralen Leitungsblockade empfohlen werden.

Abstract

Purpose: The aim of this quantitative systematic review was to assess the efficacy and safety of ultrasound-guided neuraxial blocks in obstetric analgesia and anesthesia. Materials and Methods: A systematic search for clinical trials investigating the efficacy and safety of ultrasound-assisted neuraxial blocks in comparison to any other technique was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. Relative risks (RR) were calculated for dichotomous data (e. g. number of patients with vascular punctures), and mean differences (MD) were calculated for continuous outcomes (e. g. number puncture attempts), along with the respective 95 % confidence intervals (95 % CI). Results: Six clinical trials (published between 2001 and 2009) including the data of 659 patients satisfied the inclusion criteria. Ultrasound-facilitated neuraxial blocks required a lower number of puncture attempts (MD: –0.92; 95 % CI: –1.11 to –0.74; p < 0.00001) and fewer puncture levels (MD: –0.2; 95 % CI: –0.31 to –0.1; p = 0.0002) in comparison with the more conventional loss of resistance. The success rate with the first attempt under ultrasound guidance in supposedly difficult patients was 71 % in comparison to 20 % using a conventional technique. Patients receiving ultrasound-assisted neuraxial blocks had a lower rate of procedure-related complications (post-dural puncture headache, spinal or vascular puncture). Conclusion: There is some evidence that ultrasound guidance may improve the efficacy and safety of neuraxial blocks in obstetrics. If technical difficulties are anticipated, ultrasound may lower the rate of procedure-related adverse events.

Key words

systematic review - epidural analgesia - ultrasound

References

  • 1 Mastroianni L J, Kelly J V, Lavietes S et al. The use of continuous epidural combined with continuous caudal anesthesia for labor and delivery.  Am J Obstet Gynecol. 1956;  71 300-303
    Google Scholar
  • 2 ACOG Committee Opinion #295: pain relief during labor.  Obstet Gynecol. 2004;  104 213
    Google Scholar
  • 3 Cook T M, Counsell D, Wildsmith J A. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists.  Br J Anaesth. 2009;  102 179-190
    Google Scholar
  • 4 Gomar C, Fernandez C. Epidural analgesia-anaesthesia in obstetrics.  Eur J Anaesthesiol. 2000;  17 542-558
    Google Scholar
  • 5 Baraz R, Collis R E. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice.  Anaesthesia. 2005;  60 673-679
    Google Scholar
  • 6 Filho G R, Gomes H P, da Fonseca M H et al. Predictors of successful neuraxial block: a prospective study.  Eur J Anaesthesiol. 2002;  19 447-451
    Google Scholar
  • 7 Schwemmer de U, Markus C K, Brederlau J et al. Use of ultrasound in peripheral nerve blocks.  Ultraschall in Med. 2009;  30 6-18
    Google Scholar
  • 8 Schwemmer U, Markus C K, Greim C A et al. Ultrasound-guided anaesthesia of the axillary brachial plexus: efficacy of multiple injection approach.  Ultraschall in Med. 2005;  26 114-119
    Google Scholar
  • 9 Currie J M. Measurement of the depth to the extradural space using ultrasound.  Br J Anaesth. 1984;  56 345-347
    Google Scholar
  • 10 Grau T, Leipold R W, Horter J et al. Colour Doppler imaging of the interspinous and epidural space.  Eur J Anaesthesiol. 2001;  18 706-712
    Google Scholar
  • 11 Grau T, Leipold R W, Horter J et al. The lumbar epidural space in pregnancy: visualization by ultrasonography.  Br J Anaesth. 2001;  86 798-804
    Google Scholar
  • 12 Moher D, Liberati A, Tetzlaff J et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.  J Clin Epidemiol. 2009;  62 1006-1012
    Google Scholar
  • 13 Jadad A R, Moore R A, Carroll D et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?.  Control Clin Trials. 1996;  17 1-12
    Google Scholar
  • 14 DerSimonian R, Laird N. Meta-analysis in clinical trials.  Control Clin Trials. 1986;  7 177-188
    Google Scholar
  • 15 Grau T, Leipold R, Conradi R et al. Ultrasonography and peridural anesthesia. Technical possibilities and limitations of ultrasonic examination of the epidural space.  Anaesthesist. 2001;  50 94-101
    Google Scholar
  • 16 Grau T, Leipold R W, Conradi R et al. Ultrasound control for presumed difficult epidural puncture.  Acta Anaesthesiol Scand. 2001;  45 766-771
    Google Scholar
  • 17 Grau T, Leipold R W, Conradi R et al. Ultrasound imaging facilitates localization of the epidural space during combined spinal and epidural anesthesia.  Reg Anesth Pain Med. 2001;  26 64-67
    Google Scholar
  • 18 Grau T, Leipold R W, Conradi R et al. Efficacy of ultrasound imaging in obstetric epidural anesthesia.  J Clin Anesth. 2002;  14 169-175
    Google Scholar
  • 19 Arzola C, Davies S, Rofaeel A et al. Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals.  Anesth Analg. 2007;  104 1188-1192
    Google Scholar
  • 20 Balki M, Lee Y, Halpern S et al. Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients.  Anesth Analg. 2009;  108 1876-1881
    Google Scholar
  • 21 Willschke H, Bosenberg A, Marhofer P et al. Epidural catheter placement in neonates: sonoanatomy and feasibility of ultrasonographic guidance in term and preterm neonates.  Reg Anesth Pain Med. 2007;  32 34-40
    Google Scholar
  • 22 Willschke H, Marhofer P, Bosenberg A et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique.  Br J Anaesth. 2006;  97 200-207
    Google Scholar
  • 23 Rapp H J, Folger A, Grau T. Ultrasound-guided epidural catheter insertion in children.  Anesth Analg. 2005;  101 333-339
    Google Scholar
  • 24 McLeod A, Roche A, Fennelly M. Case series: Ultrasonography may assist epidural insertion in scoliosis patients.  Can J Anaesth. 2005;  52 717-720
    Google Scholar
  • 25 Giebler R M, Scherer R U, Peters J. Incidence of neurologic complications related to thoracic epidural catheterization.  Anesthesiology. 1997;  86 55-63
    Google Scholar
  • 26 Lee Y, Tanaka M, Carvalho J C. Sonoanatomy of the lumbar spine in patients with previous unintentional dural punctures during labor epidurals.  Reg Anesth Pain Med. 2008;  33 266-270
    Google Scholar
  • 27 Grau T, Bartusseck E, Conradi R et al. Ultrasound imaging improves learning curves in obstetric epidural anesthesia: a preliminary study.  Can J Anaesth. 2003;  50 1047-1050
    Google Scholar
  • 28 Carvalho J C. Ultrasound-facilitated epidurals and spinals in obstetrics.  Anesthesiol Clin. 2008;  26 145-158
    Google Scholar

Dr. Alexander Schnabel

Department of Anaesthesiology and Intensive Care, University Hospital of Muenster

Albert Schweizer Str. 33

48153 Münster

Germany

Phone:  ++ 49/2 51/8 34 72 53

Fax:  ++ 49/2 51/8 34 72 53

Email: alexander_schnabel@gmx.de

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