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BJA Advance Access originally published online on April 27, 2009
British Journal of Anaesthesia 2009 102(6):845-854; doi:10.1093/bja/aep079
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© The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org

Real-time ultrasound-guided paramedian epidural access: evaluation of a novel in-plane technique

M. K. Karmakar*, X. Li, A. M.-H. Ho, W. H. Kwok and P. T. Chui

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, SAR, People's Republic of China

* Corresponding author. E-mail: karmakar{at}cuhk.edu.hk

Background: Current methods of locating the epidural space rely on surface anatomical landmarks and loss-of-resistance (LOR). We are not aware of any data describing real-time ultrasound (US)-guided epidural access in adults.

Methods: We evaluated the feasibility of performing real-time US-guided paramedian epidural access with the epidural needle inserted in the plane of the US beam in 15 adults who were undergoing groin or lower limb surgery under an epidural or combined spinal–epidural anaesthesia.

Results: The epidural space was successfully identified in 14 of 15 (93.3%) patients in 1 (1–3) attempt using the technique described. There was a failure to locate the epidural space in one elderly man. In 8 of 15 (53.3%) patients, studied neuraxial changes, that is, anterior displacement of the posterior dura and widening of the posterior epidural space, were seen immediately after entry of the Tuohy needle and expulsion of the pressurized saline from the LOR syringe into the epidural space at the level of needle insertion. Compression of the thecal sac was also seen in two of these patients. There were no inadvertent dural punctures or complications directly related to the technique described. Anaesthesia adequate for surgery developed in all patients after the initial spinal or epidural injection and recovery from the epidural or spinal anaesthesia was also uneventful.

Conclusions: We have demonstrated the successful use of real-time US guidance in combination with LOR to saline for paramedian epidural access with the epidural needle inserted in the plane of the US beam.

Keywords: anaesthetic techniques, epidural; analgesic technique, subarachroid; spinal cord, extradural space; monitoring, ultrasound


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