Posted: May 12th, 2022

Use of Ultrasound for Neuraxial Anesthesia

Use of Ultrasound for Neuraxial Anesthesia

Author Note:
No conflicts of interest to disclose.

Abstract
Abstract here; left-aligned. 150-200 words. Significance of problem. Key findings in literature.
Keywords: Ultrasound, neuraxial anesthesia, epidural, spinal

Use of Ultrasound for Neuraxial Anesthesia
Introduction of topic.
Milieu of Problem
Significance of topic.
Problem Magnitude
Significance of topic.
Problem Magnitude = There are X amount of laboring moms that are seen at UHTMC; we have the ability to improve SRNA comfort using ultrasound for neuraxial anesthesia, increasing utilization of ultrasound for neuraxial blocks, reducing the number of attempts for successful neuraxial anesthesia, and ultimately increasing patient satisfaction. Strong evidence from current literature supports the use of ultrasound for neuraxial anesthesia in reducing the number of attempts for successful neuraxial anesthesia.
IOM 6 Aims – Efficient, equitable (obese, patients with structural spinal cord abnormalities (scoliosis) ), and patient-centered.
This can improve the efficiency of anesthesia care by reducing the amount of time required for neuraxial anesthesia, reducing the number of attempts in obese patients; together resulting in increased patient satisfaction.
Problem statement = The use of ultrasound for neuraxial anesthesia is under-utilized at University Health-Truman Medical Center.
Add literature support.
Measurable problem =
Secondary problems =
Plan =
Impact =
University Health Truman Medical Center
Mission: University Health is an academic health center providing accessible, state-of-the-art quality healthcare to our community regardless of the ability to pay. (meet the mission statement by the state-of-the-art quality healthcare through implementation of US for neuraxial anesthesia; which is at the forefront of anesthesia practice. Nearly ½ of all babies born in KC annually are at UH-TMC; by implementing US for neuraxial we have the opportunity to improve the quality of care provided to these patients with fewer attempts. University Health Truman Medical Center School of Nurse Anesthesia (UH-TMCSONA).

Drivers and Stakeholders
Drivers and stakeholders are the individual, group of individuals, or organizations that support implementation of this project both inside and outside of the University Health Truman Medical Center School of Nurse Anesthesia. Internal drivers for this project include the extensive literature support for neuraxial anesthesia, anesthesia department leadership, and education leadership within the school of nurse anesthesia, which has pushed for further implementation of ultrasound training or utilization. External drivers include the Council of Accreditation (COA), which has recently implemented a minimum requirement for the number of cases utilizing ultrasound for vascular access (venous, arterial, or central) and regional anesthesia (neuraxial, truncal, and peripheral blocks) to maintain Student Registered Nurse Anesthetist (SRNA) education with current anesthesia practice. Key stakeholders include the educational leadership in the anesthesia department, anesthesia department leadership, anesthesia department staff, and SRNAs.
Purpose
The purpose of this project is to improve the knowledge of SRNAs regarding the use of ultrasound to perform neuraxial anesthesia, maintain education with current anesthesia practice, and improve the delivery of care through a reduction of attempts for neuraxial anesthesia. The scholarly project was guided by the PICOT: In SRNAs, does the education of neuraxial ultrasound technique compared to baseline knowledge increase knowledge, comfort, and utilization of ultrasound for neuraxial anesthesia within three months? Project outcomes include increased SRNA comfort utilizing ultrasound for neuraxial anesthesia, increased utilization of ultrasound for neuraxial anesthesia at University Health Truman Medical Center, and decreased number of attempts for neuraxial anesthesia.
Search Method
A review of literature was completed utilizing PubMed, EBSCO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar exploring the use of ultrasound for neuraxial anesthesia. A detailed chart was completed to explain the different searches and articles that were discovered (see Appendix A). MeSH search terms that were utilized for PubMed include: neuraxial anesthesia and ultrasound with the following filters: English language, age adult 19+, research article, human species, and published within ten years. A search of EBSCO was conducted using the general search terms: ultrasound, epidural anesthesia, spinal anesthesia, and neuraxial anesthesia; search limiters include anesthesia, spinal anesthesia, spinal, epidural anesthesia, epidural, academic journals, English language, and published within five years. General search terms utilized for the CINAHL database include ultrasound, epidural anesthesia, spinal anesthesia, neuraxial anesthesia; search limiters include: academic journals, evidenced-based, spinal anesthesia, epidural anesthesia, ultrasonography, anesthesia, English language, and published within ten years. A search of Google Scholar was conducted utilizing the general search terms ultrasound, neuraxial anesthesia, epidural anesthesia, spinal anesthesia. Search limiters include within last five years and search terms included in the article title. Articles were excluded if they were not pertinent to ultrasound, spinal anesthesia, epidural anesthesia, adult population, and full-text was not available. Use of a PRISMA flow diagram (see Appendix B) was completed to explain the selection process for the articles that were included into the literature review.
Review of Literature
Supporting Evidence
First Theme
First theme discussion.
Second Theme
Second theme discussion.
Third Theme
Third theme discussion.
Major Gaps in Knowledge
Discussion of major gaps in knowledge that were discovered.
Conclusion
Conclusion and summarization of topic

References
Chin, A., Crooke, B., Heywood, L., Brijball, R., Pelecanos, A. M., & Abeypala, W. (2018). A randomised controlled trial comparing needle movements during combined spinal-epidural anaesthesia with and without ultrasound Helpance. Anaesthesia, 73(4), 466-473. https://doi.org/10.1111/anae.14206
Chin, K. J. (2018). Recent developments in ultrasound imaging for neuraxial blockade. Curr Opin Anaesthesiol, 31(5), 608-613. https://doi.org/10.1097/aco.0000000000000634
Elsharkawy, H., Saasouh, W., Babazade, R., Soliman, L. M., Horn, J. L., & Zaky, S. (2019). Real-time ultrasound-guided lumbar epidural with transverse interlaminar view: Assessment of an in-plane technique [Article]. Pain Medicine (United States), 20(9), 1750-1755. https://doi.org/10.1093/pm/pnz026
Gaur, A., Dedhia, J., & Bouazza‑Marouf, K. (2018). Ultrasound and central neuraxial blocks [Editorial]. Saudi Journal of Anaesthesia, 12(2), 175-177. https://doi.org/10.4103/sja.SJA_768_17
In Chan, J. J., Ma, J., Leng, Y., Tan, K. K., Tan, C. W., Sultana, R., Sia, A. T. H., & Sng, B. L. (2021). Machine learning approach to needle insertion site identification for spinal anesthesia in obese patients. BMC Anesthesiology, 21(1). https://doi.org/10.1186/s12871-021-01466-8
Jatuporn, P., Kanthida, T., Nalinee, K., Suttasinee, P., Pannawit, B., Kwanruthai, N., Somrutai, B., & Manoj Kumar, K. (2022). Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: A prospective, randomized, superiority trial. BMC Anesthesiology, 22(1), 1-11. https://doi.org/10.1186/s12871-022-01730-5
Jiang, L., Zhang, F., Wei, N., Lv, J., Chen, W., & Dai, Z. (2020). Could preprocedural ultrasound increase the first-pass success rate of neuraxial anesthesia in obstetrics? A systematic review and meta-analysis of randomized controlled trials. Journal of Anesthesia, 34(3), 434-444. https://doi.org/10.1007/s00540-020-02750-6
Kalagara, H., Nair, H., Kolli, S., Thota, G., & Uppal, V. (2021). Ultrasound imaging of the spine for central neuraxial blockade: A technical description and evidence update. Current Anesthesiology Reports, 11(3), 326-339. https://doi.org/10.1007/s40140-021-00456-3
Khan, M., Gupta, M., Sharma, S., & Kasaudhan, S. (2022). A comparative study of ultrasound Helped versus landmark technique for combined spinal-epidural anaesthesia in patients undergoing lower limb orthopaedic surgery. Indian Journal of Anaesthesia, 66(4), 272-277. https://doi.org/10.4103/ija.ija_775_21
Lee, J.-H., Kim, D.-H., & Koh, W. U. (2021). Real-time ultrasound guided thoracic epidural catheterization: A technical review. Anesthesia and Pain Medicine, 16(4), 322-328. https://doi.org/10.17085/apm.21060
Li, J., Krishna, R., Zhang, Y., Lam, D., & Nalini, V. (2020). Ultrasound-guided neuraxial anesthesia. Current Pain and Headache Reports, 24. https://doi.org/10.1007/s11916-020-00895-3
Oh, T. T., Ikhsan, M., Tan, K. K., Rehena, S., Han, N.-L. R., Sia, A. T. H., & Sng, B. L. (2019). A novel approach to neuraxial anesthesia: Application of an automated ultrasound spinal landmark identification. BMC Anesthesiology, 19(1). https://doi.org/10.1186/s12871-019-0726-6
Park, S. K., Bae, J., Yoo, S., Kim, W. H., Lim, Y. J., Bahk, J. H., & Kim, J. T. (2020). Ultrasound-Helped versus landmark-guided spinal anesthesia in patients with abnormal spinal anatomy: A randomized controlled trial. Anesth Analg, 130(3), 787-795. https://doi.org/10.1213/ane.0000000000004600
Ravi, P., Naik, S., Joshi, M., & Singh, S. (2021). Real-time ultrasound-guided spinal anaesthesia vs pre- procedural ultrasound-guided spinal anaesthesia in obese patients. Indian Journal of Anaesthesia, 65(5), 356-361. https://doi.org/10.4103/ija.IJA_446_20
Sadeghi, A., Patel, R., & Carvalho, J. C. A. (2021). Ultrasound-facilitated neuraxial anaesthesia in obstetrics. BJA Education, 21(10), 369-375. https://doi.org/10.1016/j.bjae.2021.06.003
Shaylor, R., Saifi, F., Davidson, E., & Weiniger, C. F. (2016). High success rates using ultrasound for neuraxial block in obese patients. Isr Med Assoc J, 18(1), 36-39. https://www.ima.org.il/MedicineIMAJ/viewarticle.aspx?year=2016&month=01&page=36
Sidiropoulou, T., Christodoulaki, K., & Siristatidis, C. (2021). Pre-procedural lumbar neuraxial ultrasound—a systematic review of randomized controlled trials and meta-analysis. Healthcare, 9(4), 479. https://doi.org/10.3390/healthcare9040479
Tubinis, M. D., Lester, S. A., Schlitz, C. N., Morgan, C. J., Sakawi, Y., & Powell, M. F. (2019). Utility of ultrasonography in identification of midline and epidural placement in severely obese parturients. Minerva Anestesiol, 85(10), 1089-1096. https://doi.org/10.23736/s0375-9393.19.13617-6
Urfalioğlu, A., Bilal, B., Öksüz, G., Bakacak, M., Boran, Ö. F., & Öksüz, H. (2017). Comparison of the landmark and ultrasound methods in cesarean sections performed under spinal anesthesia on obese pregnants. Journal of Maternal-Fetal & Neonatal Medicine, 30(9), 1051-1056. https://doi.org/10.1080/14767058.2016.1199677
Uyel, Y., & Kilicaslan, A. (2021). Preprocedural ultrasonography versus landmark-guided spinal anesthesia in geriatric patients with difficult anatomy: A prospective randomized trial [Article]. Eurasian Journal of Medicine, 53(1), 9-14. https://doi.org/10.5152/eurasianjmed.2020.20215
Vadhanan, P., Rajendran, I., & Rajasekar, P. (2020). Ultrasound-guided caudal epidural anesthesia in adults for anorectal procedures. Anesthesia: Essays & Researches, 14(2), 239-242. https://doi.org/10.4103/aer.AER_60_20
Vallejo, M. C. (2018). Pre-procedure neuraxial ultrasound in obstetric anesthesia. Journal of Anesthesia and Perioperative Medicine (JAPM), 5(2), 85-91. https://doi.org/https://doi.org/10.24015/JAPM.2017.0050
Young, B., Onwochei, D., & Desai, N. (2021). Conventional landmark palpation vs. preprocedural ultrasound for neuraxial analgesia and anaesthesia in obstetrics – a systematic review and meta‐analysis with trial sequential analyses. Anaesthesia, 76(6), 818-831. https://doi.org/10.1111/anae.15255

Appendix A

Search Methods

Database Search terms used Number of articles Number of included articles Number of excluded articles Search term years
PubMed MeSH: Neuraxial Anesthesia AND Ultrasound

39

7

32

2012-2022

EBSCO General
Ultrasound, Epidural Anesthesia OR Spinal Anesthesia OR Neuraxial Anesthesia

189
11
178

2017-2023
CINAHL General:
Ultrasound, Epidural Anesthesia OR Spinal Anesthesia
121

3

118

2012-2022

Google Scholar General:
Ultrasound AND Neuraxial Anesthesia OR Epidural Anesthesia OR Spinal Anesthesia

150
8
142
2017-2022

Appendix B

Figure 1: PRISMA Flow Diagram of the Review of Literature: describes databases utilized and searched, number of abstracts screened, and full text articles included

Appendix C Theoretical Framework

Appendix D Literature Matrix
# Study Variable Strengths Limitations Implications/
Recommendations
1. Article reference in APA format:
Chin, A., Crooke, B., Heywood, L., Brijball, R., Pelecanos, A. M., & Abeypala, W. (2018). A randomised controlled trial comparing needle movements during combined spinal-epidural anaesthesia with and without ultrasound Helpance. Anaesthesia, 73(4), 466-473. https://doi.org/10.1111/anae.14206

Type of Evidence: Randomized controlled trial

Design: Prospective, Randomized controlled trial

Level and Quality of Evidence: Level II
Independent Variable:
Utilization of ultrasound for CSE
Dependent Variable:
First-pass success (a single needle insertion with no redirections) and procedure difficulty.

Demographics:
Two-hundred and eighteen women were included in the random allocation, and 215 included in the final analysis.

:
Reliability/Precision:
Sample size was calculated based on data from Grau et al. [13]. Using a 5% level of significance, 90% power and a pooled standard deviation of 0.69, a total of 215 women were required for a difference of 0.3puncture attempts between groups.

Validity/
Accuracy:
Association between categorical variables was examined using Pearson Chi-squared tests of association. Fischer’s exact test was used when the assumptions of the Chi-square test were not met. Student’s t-test was used to show the differences between groups for para-metric continuous variables. Mann–Whitney U-tests were used for non-parametric continuous variables. To account for analyzing multiple outcomes, we corrected using the Benjamini–Yekutieli method (four tests). Binary logistic regression was used to model first-pass success. Use of ultrasound, ease of spinous process palpation, ease of iliac crest palpation, body mass index and seniority of anesthetist were included in the initial model, and variables removed using backwards elimination. Use of ultrasound was forced to remain in the model. Tests were declared statistically significant data<0.05 (two-sided)
Bias:
Not listed
Methodology:
Pre-specified sub-group analyses included the effect of ability to palpate landmarks on technical performance (24 tests), and the effect of BMI on the difficulty of CSE (four tests). Post hoc sub-group analyses included association between composite landmark sand technical performance (12 tests), satisfaction and needle movements (six tests), VNRS and needle movements (three tests), technical performance and seniority of anesthetist (eight tests), interspace difference and palpating difficulty (one test), palpation difficulty and image quality (one test), and spinous process palpation and paresthesia (two tests).
Reliability/Precision:
The anesthetists did not perform the ultrasound themselves.
Validity/
Accuracy:
The anesthetists did not perform the ultrasound themselves.
Bias:
They did not control for whether a consultant or registrar performed the CSE, which may have added bias incase selection according to anticipated difficulty.

Methodology: Recruited women aged>18 years and>37 weeks’ gestation who were scheduled for elective caesarean section under CSE anesthesia. We did not recruit women who were unable to provide fully informed consent

There were no significant differences between the groups with respect to the secondary outcomes of block quality, patient pain, satisfaction, or procedural complications.

Article reference in APA format:
Chin, K. J. (2018). Recent developments in ultrasound imaging for neuraxial blockade. Curr Opin Anaesthesiol, 31(5), 608-613. https://doi.org/10.1097/aco.0000000000000634

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

2. Article reference in APA format:
Elsharkawy, H., Saasouh, W., Babazade, R., Soliman, L. M., Horn, J. L., & Zaky, S. (Aberra et al.). Real-time Ultrasound-Guided Lumbar Epidural with Transverse Interlaminar View: Assessment of an In-Plane Technique [Article]. Pain Medicine (United States), 20(9), 1750-1755-1755. https://doi.org/10.1093/pm/pnz026

Type of Evidence: Descriptive

Design: Prospective Observational Pilot Trial

Level and Quality of Evidence: Level IV Independent Variable:
Use of Ultrasound for epidural placement using in-plane approach

Dependent Variable:
Epidural placement success

Demographics:
ASA physical status, Age, sex, height, and weight: Reliability/Precision:
Providers had extensive experience with ultrasonography

Validity/Accuracy:
Utilized 95% CI

Bias:
Not identified in the study

Methodology:
Acknowledgement of limitations of the study Reliability/Precision:
Lack of reliability tools utilized

Validity/Accuracy:
Small sample size of 22

Power factor was not calculated to determine sample size

Bias:
Bias could have been introduced by the provider regarding difficulty of epidural placement

Methodology:
Lack of randomization or controlled trial

Only able to descriptively analyze the study
All providers had previous experience and training with ultrasonography

63.6% of patients found the technique satisfactory or very satisfactory

Success rate was 95% with the epidural space being identified in 100% of patients
3. Article reference in APA format:
Gaur, A., Dedhia, J., & Bouazza‑Marouf, K. (2018). Ultrasound and central neuraxial blocks [Editorial]. Saudi Journal of Anaesthesia, 12(2), 175-177. https://doi.org/10.4103/sja.SJA_768_17

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

4. Article reference in APA format:
In Chan, J. J., Ma, J., Leng, Y., Tan, K. K., Tan, C. W., Sultana, R., Sia, A. T. H., & Sng, B. L. (2021). Machine learning approach to needle insertion site identification for spinal anesthesia in obese patients. BMC Anesthesiology, 21(1). https://doi.org/10.1186/s12871-021-01466-8

Type of Evidence: Prospective Cohort Study

Design: Cohort Study

Level and Quality of Evidence: Level IV
Independent Variable:
Ultrasound for determining needle insertion/landmarks.

Dependent Variable:
Success rate for spinal anesthesia.
Demographics:
Female patients above 21 years old who required spinal anesthesia for Cesarean section with a BMI of more than 30 kg/m2. Reliability/Precision:
Thirty-eight patients (79.1, 95% CI 65.0 – 89.5%) had successful dural puncture at first attempt (‘First-attempt group’), whereas the rest were successful only after two (n = 6 or 12.5%), three (n = 2 or 4.2%), and four (n = 2 or 4.2%) puncture attempts (‘Not at first attempt group’). The BMIs between successful first attempt group and ‘not at first attempt group’ did not show significant difference.

Validity/
Accuracy: The scanning duration of L3/4 interspinous space and the posterior complex were 21.0 [IQR: 17.0, 32.0] secs and 11.0 [IQR: 5.0, 22.0] secs respectively. With that, the average number of puncture attempts was 1.3, with a standard deviation of 0.75. The Pearson’s correlation coefficient and Cronbach’s alpha between the program recorded depth of the skin to posterior complex and the clinician measured depth was 0.915 and 0.956, respectively

Bias: No bias discussed in the article.

Methodology: The mean age of patients was 32.3 ± 4.8 (ranged 22 – 44) years, with an average BMI of 35.0 ± 4.5 kg/m2.
Reliability/Precision:
Not discussed in the article.

Validity/
Accuracy:
1. The study aimed to recruit obese patients with BMI above 30 kg/m2. As compared with previous study on obstetric women with BMI below 30 kg/m2 [19], the difference in BMI resulted in a lower first attempt success rate, probably due to the lower image quality of ultrasound images in obese patients.
2.

Bias: n/a

Methodology: The exclusion criteria were a history of scoliosis or spinal instrumentation, allergy to ultrasound transmission gel, and patients with visible wound or injury to the lumbar spine.

5. Article reference in APA format:
Jatuporn, P., Kanthida, T., Nalinee, K., Suttasinee, P., Pannawit, B., Kwanruthai, N., Somrutai, B., & Manoj Kumar, K. (2022). Real-time ultrasound-guided versus anatomic landmark-based thoracic epidural placement: a prospective, randomized, superiority trial [article]. BMC Anesthesiology, 22(1), 1-11. https://doi.org/10.1186/s12871-022-01730-5

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

Article reference in APA format:
Jiang, L., Zhang, F., Wei, N., Lv, J., Chen, W., & Dai, Z. (2020). Could preprocedural ultrasound increase the first-pass success rate of neuraxial anesthesia in obstetrics? A systematic review and meta-analysis of randomized controlled trials. Journal of Anesthesia, 34(3), 434-444. https://doi.org/10.1007/s00540-020-02750-6

Type of Evidence:

Design:

Level and Quality of Evidence: Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

Article reference in APA format:
Kalagara, H., Nair, H., Kolli, S., Thota, G., & Uppal, V. (2021). Ultrasound imaging of the spine for central neuraxial blockade: A technical description and evidence update. Current Anesthesiology Reports, 11(3), 326-339. https://doi.org/10.1007/s40140-021-00456-3

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

6. Article reference in APA format:
Khan, M., Gupta, M., Sharma, S., & Kasaudhan, S. (2022). A comparative study of ultrasound Helped versus landmark technique for combined spinal-epidural anaesthesia in patients undergoing lower limb orthopaedic surgery [Article]. Indian Journal of Anaesthesia, 66(4), 272-277. https://doi.org/10.4103/ija.ija_775_21

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

Article reference in APA format:
Lee, J.-H., Kim, D.-H., & Koh, W. U. (2021). Real-time ultrasound guided thoracic epidural catheterization: a technical review. Anesthesia and Pain Medicine, 16(4), 322-328. https://doi.org/10.17085/apm.21060

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

7. Article reference in APA format:
Li, J., Krishna, R., Zhang, Y., Lam, D., & Nalini, V. (2020). Ultrasound-guided neuraxial anesthesia. Current Pain and Headache Reports, 24. https://doi.org/10.1007/s11916-020-00895-3

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

8. Article reference in APA format:
Oh, T. T., Ikhsan, M., Tan, K. K., Rehena, S., Han, N.-L. R., Sia, A. T. H., & Sng, B. L. (2019). A novel approach to neuraxial anesthesia: application of an automated ultrasound spinal landmark identification. BMC Anesthesiology, 19(1). https://doi.org/10.1186/s12871-019-0726-6

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

Article reference in APA format:
Park, S. K., Bae, J., Yoo, S., Kim, W. H., Lim, Y. J., Bahk, J. H., & Kim, J. T. (2020). Ultrasound-Helped versus landmark-guided spinal anesthesia in patients with abnormal spinal anatomy: A randomized controlled trial. Anesth Analg, 130(3), 787-795. https://doi.org/10.1213/ane.0000000000004600

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

9. Article reference in APA format:
Ravi, P., Naik, S., Joshi, M., & Singh, S. (2021). Real-time ultrasound-guided spinal anaesthesia vs pre- procedural ultrasound-guided spinal anaesthesia in obese patients [Article]. Indian Journal of Anaesthesia, 65(5), 356-361. https://doi.org/10.4103/ija.IJA_446_20

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

Article reference in APA format:
Sadeghi, A., Patel, R., & Carvalho, J. C. A. (2021). Ultrasound-facilitated neuraxial anaesthesia in obstetrics. BJA Education, 21(10), 369-375. https://doi.org/10.1016/j.bjae.2021.06.003

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

10. Article reference in APA format:
Shaylor, R., Saifi, F., Davidson, E., & Weiniger, C. F. (2016). High Success Rates Using Ultrasound for Neuraxial Block in Obese Patients. Isr Med Assoc J, 18(1), 36-39.

Type of Evidence: Cohort study

Design: Cohort Study

Level and Quality of Evidence: Level IV
Independent Variable:
Utilization of ultrasound for spinal anesthesia
Dependent Variable: First-pass success (a single needle insertion with no redirections) and procedure difficulty.
Demographics: Patients that were scheduled for ESWL
under neuraxial block, were ASA physical status I-III and were
over 18 years old. Reliability/Precision:
An overall success rate at the first attempt of 90.5% (CI 0.8–0.95) was achieved using ultrasound-guided neuraxial block. This block placement success rate was similar for all patients, regardless of BMI above versus below 30 kg/m2.

Validity/Accuracy:
The ease of palpation of anatomic landmarks, P = 0.001, and the ease of palpation of iliac crest, P < 0.001, differed significantly between the patients above versus below 30 kg/m2. The reported verbal pain scores (VPS) due to block insertion was similar among all patients regardless of BMI category (above versus below 30 kg/m2).

Bias:
n/a

Methodology:
n/a

Reliability/Precision:
Not discussed in article.
Validity/
Accuracy:
The study had one experienced operator performing both ultrasound and spinal blocks.

Bias:
Bias could be introduced as the data were recorded by the practitioner.

Methodology: Excluded patients with coagulopathy, thrombocytopenia, previous spine surgery or trauma, suspected or known neurological disease or anatomic malformation of neuraxial structures, or on anticoagulation drugs.

11. Article reference in APA format:
Sidiropoulou, T., Christodoulaki, K., & Siristatidis, C. (2021). Pre-Procedural Lumbar Neuraxial Ultrasound—A Systematic Review of Randomized Controlled Trials and Meta-Analysis. Healthcare, 9(4), 479. https://doi.org/10.3390/healthcare9040479

Type of Evidence:

Design:

Level and Quality of Evidence:
Independent Variable:

Dependent Variable:

Demographics: Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:
Reliability/Precision:

Validity/Accuracy:

Bias:

Methodology:

12. Article reference in APA format:
Tubinis, M. D., Lester, S. A., Schlitz, C. N., Morgan, C. J., Sakawi, Y., & Powell, M. F. (2019). Utility of ultrasonography in identification of midline and epidural placement in severely obese parturients. Minerva Anestesiol, 85(10), 1089-1096. https://doi.org/10.23736/s0375-9393.19.13617-6

Type of Evidence: Randomized Controlled Trial

Design: Randomized Controlled Trial

Level and Quality of Evidence: Level II
Independent Variable:
Utilization of ultrasound

Dependent Variable:
Time for detection of midline

Demographics: Severely obese parturients whose anatomic landmarks are difficult to palpate. “Severe obesity” as class II obesity (BMI 35 to 35.9 kg/m2) and above.
Reliability/Precision:
Data were summarized using either mean and standard deviation (SD) (for continuous outcomes) or counts and percentages (for categorical outcomes). Two-sample t-test was used to compare the ultrasonography and palpation groups on the primary endpoint. Linear regression was then used to test the relationship between midline identification method and time required for epidural placement, while controlling for provider experience (i.e., junior vs. senior resident) as well as interaction between experience and method. To assess whether the success of each midline identification method varied with patient BMI, linear regression was also used to test for an interaction between midline identification method and patient BMI. This model included main effects for method and patient BMI and controlled for provider level of experience.

Validity/Accuracy: Compared to palpation, ultrasonography required less time to place the epidural (6.2 minutes vs. 9.0 minutes; P<0.01), more time to locate midline (44.5 seconds vs. 30.9 seconds; P<0.01), and less total time for epidural placement (6.9 minutes vs. 9.5 minutes; P<0.01) (Table II, Figure 2). Patients in the ultrasonography group also required fewer needle passes (2.1 vs. 2.8; P=0.02). The epidural failure rates when the ultrasonography group was compared to the palpation group were not significantly different (4.0% vs. 9.3%; P=0.19)

Bias: n/a

Methodology:
All patients gave informed written consent to participate in this study. All severely obese patients admitted to our labor and delivery unit for expected vaginal delivery and requesting a labor epidural who did not meet the exclusion criteria were eligible for the study. Exclusion criteria were: 1) age less than 19 years old; 2) Body Mass Index (BMI) <35 kg/m2; 3) diagnosis of coagulopathy or platelet count <80,000; 4) history of lumbar spine surgery; 5) diagnosis of scoliosis; 6) diagnosis of intracranial or spinal mass.
Reliability/Precision:
Not discussed in the article.
Bias: The residents performing the epidural placement were aware of the study and the study group in which the patient was randomized. This knowledge might have affected the speed at which the epidural was placed.
They did not require a full ultrasound examination of the lumbar spine, including measuring the depth from skin to epidural space.
Methodology: Only located spinous process in the transverse plane to determine midline for two reasons: 1) the spinous process is an easily identifiable landmarks with minimal ultrasonography experience, as proven by the success of our trainees; 2) locating midline is often seen as one of the more challenging aspects of lumbar epidural placement in severely obese parturients

13. Article reference in APA format:
Urfalioğlu, A., Bilal, B., Öksüz, G., Bakacak, M., Boran, Ö. F., & Öksüz, H. (2017). Comparison of the landmark and ultrasound methods in cesarean sections performed under spinal anesthesia on obese pregnants. Journal of Maternal-Fetal & Neonatal Medicine, 30(9), 1051-1056. https://doi.org/10.1080/14767058.2016.1199677

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14. Article reference in APA format:
Uyel, Y., & Kilicaslan, A. (2021). Preprocedural Ultrasonography Versus Landmark-Guided Spinal Anesthesia in Geriatric Patients with Difficult Anatomy: A Prospective Randomized Trial [Article]. Eurasian Journal of Medicine, 53(1), 9-14. https://doi.org/10.5152/eurasianjmed.2020.20215

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15. Article reference in APA format:
Vadhanan, P., Rajendran, I., & Rajasekar, P. (2020). Ultrasound-guided caudal epidural anesthesia in adults for anorectal procedures. Anesthesia: Essays & Researches, 14(2), 239-242. https://doi.org/10.4103/aer.AER_60_20

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Article reference in APA format:
Vallejo, M. C. (2018). Pre-procedure neuraxial ultrasound in obstetric anesthesia. Journal of Anesthesia and Perioperative Medicine (JAPM), 5(2), 85-91. https://doi.org/https://doi.org/10.24015/JAPM.2017.0050

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Article reference in APA format:
Young, B., Onwochei, D., & Desai, N. (2021). Conventional landmark palpation vs. preprocedural ultrasound for neuraxial analgesia and anaesthesia in obstetrics – a systematic review and meta‐analysis with trial sequential analyses. Anaesthesia, 76(6), 818-831. https://doi.org/10.1111/anae.15255

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