剖腹产术前使用超声引导增加硬膜外导管的首次置入成功率？
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Does Preprocedural Ultrasound Increase the First-Pass Success Rate of Epidural Catheterization Before Cesarean Delivery? A Randomized Controlled Trial
背景与目的
术前超声引导可以提高硬膜外导管置入的有效性和安全性，特别是在困难的情况下。大多数产科病人中超声辅助硬膜外导管置入的研究已经过时且设计不一致的非盲试验。这项双盲，随机对照研究旨在比较剖宫产术前超声辅助置管与传统触诊技术置管的差异。我们假设使用术前超声引导可以增加首次穿刺成功后的硬膜外导管置管成功率。
方 法
合格的试验对象为ASAⅡ级的足月单胎产妇， 选择腰硬联合下剖宫产术。排除标准为年龄＜19岁或＞ 40岁，体重指数≥35kg/m2，临产妇女或对椎管内麻醉有禁忌症，脊柱明显畸形，以前有过脊柱手术或异常的解剖标志。一百一十例患者随机分为2组（触诊组和超声组）。一个经验丰富的麻醉医生执行所有的步骤。试验者和受试者均不知道分组情况。在硬膜外导管置入管前，分别在超声和触诊组中对脊柱行系统性超声评估和对照。主要的结果为首次穿刺成功后硬膜外导管置管成功率。次要结果是在第一次穿刺时硬膜外导管置管成功率，硬膜外针穿刺成功次数和皮肤穿刺次数，穿刺时间，穿刺过程中病人的满意度，穿刺过程中的并发症（无意的硬脑膜和血管穿破、阻滞无效、单侧或区域阻滞和背痛发生率）
结 果
对108例患者（触诊组55例，超声组53例）进行了分析。首次穿刺后导管置入，触诊组和超声组的成功率分别为60％和58.5％（两组差异的置信区间为−18.5%到21.6%；P＞0.99）。硬膜外导管置管成功率，硬膜外针穿刺成功次数和皮肤穿刺次数，穿刺过程中病人的满意度两组比较无显著差异。两组的穿刺持续时间分别为超声组185（57-680）s，触诊组215（114-720）s（P = 0.036，两独立样本非参数检验和P = 0.083， t检验无差异）。两组穿刺过程中的并发症发生率均较低。
结 论
对于经验丰富的麻醉医生不清楚术前超声引导是否改善了解剖标志清晰的临产剖宫产病人的硬膜外置管术。
原始文献摘要
Mohamed Mohamed Tawfk, Magdy Mamdouh Atallah, Walaa Safaa Elkharboutly, Nasser Sameh Allakkany, and Mostafa Abdelkhalek.Does Preprocedural Ultrasound Increase the First-Pass Success Rate of Epidural Catheterization Before Cesarean Delivery? A Randomized Controlled Trial. Anesth Analg 2017;124:851–6
BACKGROUND: Preprocedural ultrasound may improve the effcacy and safety of epidural catheterization, especially in diffcult cases. Most studies of ultrasound-assisted epidural catheterization in the obstetric population are dated and nonblinded with inconsistent designs. This double-blind, randomized controlled study aimed to compare the ultrasound-assisted with the conventional palpation techniques for epidural catheterization in parturients undergoing cesarean delivery. We hypothesized that the use of preprocedural ultrasound would increase the success rate of epidural catheterization at the frst needle pass
METHODS: Eligible subjects were American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancy undergoing elective cesarean delivery using doubleinterspace combined spinal–epidural anesthesia. Exclusion criteria were age <19 or >40 years, body mass index ≥35 kg/m2, women presenting in labor or having any contraindication to neuraxial anesthesia, marked spinal deformity, previous spinal surgery, or impalpable anatomical landmarks. One hundred ten patients were randomly allocated into 2 equal groups (palpation and ultrasound groups). All procedures were performed by a single experienced anesthesiologist. Patients and investigators assessing the outcome data were blinded to group allocation. A systematic spinal ultrasound assessment and a sham procedure were performed in the ultrasound and palpation groups, respectively, before attempting epidural catheterization. The primary outcome was the rate of successful epidural catheterization at the frst needle pass. Secondary outcomes were the rate of successful epidural catheterization at the frst skin puncture, number of performed needle passes and skin punctures, duration of the epidural procedure, patient satisfaction from the procedure, and complications of the procedure (incidence of unintentional dural and vascular punctures, failed block, unilateral or patchy block, and backache).
RESULTS: Data from 108 patients (55 patients in the palpation group and 53 patients in the ultrasound group) were analyzed. The rate of successful epidural catheterization at the frst needle pass was 60% in the palpation group and 58.5% in the ultrasound group (95% confdence interval of the difference in proportions between groups is -18.5% to 21.6%; P > 0.99). There were no signifcant differences between the 2 groups in the success rate at the frst skin puncture, the number of needle passes and skin punctures, or patient satisfaction. The median (range) duration of the epidural procedure was 185 (57–680) seconds in the ultrasound group and 215 (114–720) seconds in the palpation group (P = 0.036 with the Mann-Whitney U test and P = 0.083 with the Student t test with unequal variances). The overall rate of complications of the procedure was low in both groups
CONCLUSIONS: For experienced anesthesiologists, it remains unclear whether preprocedural ultrasound improves the epidural catheterization technique in parturients with palpable anatomical landmarks undergoing cesarean delivery.
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