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- Herve Schlotterbeck, W.A. Dow, P. Diemunsch (1 March 2008)
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Ultrasound technique for neuraxial procedures
- Thillaiampalam Kathirgamanathan (18 February 2008)
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Herve Schlotterbeck CHU de Hautepierre, Strasbourg, W.A. Dow, P. Diemunsch
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We thank Dr Kathirgamanathan for his interesting comments on our article [1]. He raises the fact that the technique used in our study, performed in an overweight population (mean BMI = 28 kg/m˛), might minimise the frequency of errors in identification of the intervertebral level punctured. It is well known that morbidity and mortality increases in correlation with pre-pregnancy BMI [2], and we agree that a BMI of 30 kg/m˛ does not represent a validated cut-off value for the definition of obesity in the obstetric population. Nevertheless, this value is generally accepted as the threshold value for the definition of obesity in the general population. The definition of obesity in the pregnant patient is not clear and the two factors usually evaluated are the pre-pregnancy BMI and the weight gain during the pregnancy [3]. We did not aim to address the issue of body weight and BMI in terms of being overweight or obese, however we are not convinced that a BMI over 25 kg/m˛ in pregnant women at term truly represents being overweight. Nevertheless, we looked for possible confounding factors during the determination of the lumbar puncture level and arbitrarily took the cut- off value for the definition of obesity in the general population as a surrogate for an “overweight threshold” in the obstetric population at term. We completely agree with Dr Kathirgamanathan about the growing place for the use of ultrasound in anaesthesia practice, and in particular for spinal procedures. Our study aimed to use the ultrasound technique to demonstrate that the usual anatomical landmarks are frequently misleading in the obstetric population. This, of course, highlights the possible advantages of using ultrasound for the performance of epidurals and spinals in both easy and difficult cases [4, 5]. 1. Schlotterbeck H, Schaeffer R, Dow WA, Touret Y, Bailey S, Diemunsch P. Ultrasonographic control of the puncture level for lumbar neuraxial block on obstetric anaesthesia. Br J Anaesth 2008; 100: 230-4 2. Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S. Effect of Body Mass Index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Public Health 2007; 7: 168 3. DeVader SR, Neeley HL, Myles TD, Leet TL. Evaluation of gestational weight gain guidelines for women with normal prepregnancy body mass index. Obstet Gynecol 2007; 110: 745-51 4. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult epidural puncture. Acta Anaesthesiol Scand 2001; 25: 766-71 5. Kawaguchi R, Yamauch M, Sugino S, Tsukigase N, Omote K, Namiki A. Two cases of epidural anesthesia using ultrasound imaging. Masui 2007; 56: 702 -5 Conflict of Interest:None declared |
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Thillaiampalam Kathirgamanathan, Consultant Anaesthetist
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I have read with interest the article about Ultrasonic control of the puncture level for neuraxial block in obstetric anaesthesia by Schlotterbeck and others(1). They should be congratulated for the timely publication of this article. However I would like to make one comment about the study. In their discussion they mentioned that they did not find increased BMI was not a significant factor to influence the frequency of errors. To my knowledge the arbitary cut off of more than 30 BMI is not evidence based in terms of anaesthetic morbidity. If the BMI is more than 25, it is classified as overweight. The mean BMI in this study was 28. Therefore it would not be wrong to say that this study was carried out in overweight patients. If the study had been done in patients less than BMI of 25, the frequency of errors might have been even higher than this study. The overweight patients are in the increase in the reproductive age group. The last CEMACH report has made recommendations to have local guidelines in the management of obese pregnant women (2). In this context, the NICE guidelines have recommended to use ultrasound technique during epidural procedure(3). Therefore it is time to consider this reliable easy to use technique to be included in the local guidelines and equipments in the management of obese patients while facilitating the training in the use of this technique in obstetric anaesthesia. 1 Schlotterbeck H, Schaeffer R et al Ultrasonographic control of the puncture level for lumbar neuraxial block on obstetric anaesthesia: Br J Anaesth 2008; 100: 230-234 2 the confidential enquiry into maternal and child health (CEMACH) : Savings Mothers Lives ; reviewing maternal death to make motherhood safe 2003-2005 National Institute for Health and Clinical excellence; Ultrasound guided catheterisation of the epidural space January 2008 Conflict of Interest:None declared |
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