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[Epidural catheterization dose not meet our expectation]
M Miyazaki1, K Takeda, H Ohsumi
1Department of Anesthesia, Osaka National Hospital.
Insights
Accurate epidural catheter placement relies on landmark selection. Counting from the closest landmark improves accuracy, and early ambulation increases dislodgement risk, especially in abdominal surgery patients.
Area of Science:
- Anesthesiology
- Spinal Procedures
- Surgical Navigation
Background:
- Epidural catheter placement accuracy is crucial for effective anesthesia and pain management.
- Landmark identification for thoracic and lumbar epidural placement can be challenging.
- Variability exists between palpated and radiographically confirmed intervertebral spaces.
Purpose of the Study:
- To evaluate the accuracy of landmark-based epidural catheter placement.
- To compare different counting methods for identifying target intervertebral spaces.
- To assess postoperative epidural catheter migration and dislodgement rates.
Main Methods:
- 241 patients undergoing abdominal or orthopedic hip surgery were divided into three groups based on epidural catheterization level (Th7-10, Th10-L1, L1-4).
- Comparison of anesthesiologist-identified intervertebral space with radiographically confirmed space.
- Assessment of catheter movement and dislodgement during the postoperative period.
Main Results:
- Low agreement between palpated and confirmed intervertebral spaces, ranging from 33% to 55% depending on the landmark and group.
- Counting from the iliac crest (L3-4 landmark) showed increasing agreement from Group A (33%) to C (55%).
- Counting from the C7 landmark showed better agreement in Group A (55%) than Group C (33%).
- Higher rates of catheter dislodgement were observed in Groups A and B compared to Group C, linked to early ambulation in abdominal surgery patients.
Conclusions:
- Epidural catheter placement accuracy is influenced by the chosen landmark and counting method.
- Starting landmark identification from a point closer to the target intervertebral space improves accuracy.
- Postoperative catheter dislodgement is a concern in patients with early ambulation, necessitating careful monitoring.
Abstract:
According to the roentgenographically confirmed intervertebral space at which an epidural catheter was placed, 241 patients who underwent abdominal or orthopedic hip surgery were allocated into 3 groups. Groups A, B, and C received epidural catheterization at Th7-10, Th10-L1, and L1-4, respectively. In each group, we examined the intervertebral space, which the anesthesiologist who had placed epidural catheter had determined, and the one which had been confirmed roentgenographically. We also investigated the catheter movement during the postoperative period. Catheters were barely placed at the same intervertebral space which had been confirmed roentgenographically. Considering the iliac crest as a landmark of L3-4 intervertebral space, the puncture point agreed with the roentgenographically confirmed intervertebral space with a percentage of 33 in group A. The extent of agreement increased up to 47 and 55 percent, in groups B and C, respectively. In contrast, when we counted down from the cervical prominent vertebra, a landmark of C7, the agreement was better in group A (55%) than in group C (33%). In the postoperative period, catheters came out more frequently in groups A and B than in group C, resulting from the early ambulation in abdominal surgery groups. There results suggest that, to place the epidural catheter more properly, (1) we should start to count from the landmark which is close to the puncture point and (2) we should keep it in mind that catheters come out accidently in patients who are encouraged to ambulate in the early postoperative period.