SpinalUltrasoundVersusPalpation

forEpiduralCatheterInsertioninLabour:ARandomized

ControlledTrial

脊柱超聲與觸診用于硬膜外導(dǎo)管插入的比較：一項(xiàng)隨機(jī)對(duì)照試驗(yàn)C.Arzola,R.Mikhael,C.Margarido,and

J.C.Carvalho

(EurJAnaesthesiol.2015;32(7):499–505)

DepartmentofAnesthesiaandPainManagement,MountSinaiHospital(CA,RM,JCAC),DepartmentofAnesthesia,

SunnybrookHealthSciencesCentre,UniversityofToronto,

Toronto,ON,Canada

Copyrightr2016WoltersKluwerHealth,Inc.Allrightsreserved.

DOI:10.1097/01.aoa.0000504749.02604.b6

Topics:LaborAnalgesia,Systems-basedPractice

Ultrasoundguidancehasgainedincreasingacceptanceamonganesthesiologistsasameanstopotentiallyimprovetheefficacyandsafetyofvariousprocedures,includingvascularaccess（血管穿刺）,peripheralnerveblockade（周圍神經(jīng)阻滯）,andneuraxialanesthesia(椎管內(nèi)穿刺).

Althoughseveralstudieshavebeenpublishedontheuseofspinalultrasound,acommonlimitationisthatasingleexpertinvestigatororselectedgroupofanesthesiologistsperformedtheultrasoundscanningwhile

anexperiencedornoviceoperatorcarriedouttheneuraxialtechnique.關(guān)于脊柱超聲的研究有些已經(jīng)發(fā)表，但是這些研究中存在明顯的局限性，這些研究中，超聲掃描操作是由一個(gè)專業(yè)超聲研究者或者一組特定麻醉醫(yī)師實(shí)施，而穿刺技術(shù)又是由另外的操作者實(shí)施。這些操作者可能是有經(jīng)驗(yàn)的醫(yī)生也可能是學(xué)習(xí)者。

Thismayaffectthegeneralizabilityoftheexistingdataandraisesthequestionofwhetherthesamebenefitswouldbeobservedifthesameclinicianperformedboththeultrasoundscanningandtheneuraxialprocedure.這有可能影響數(shù)據(jù)的普遍性，也帶來新的問題，即如果超聲掃描和穿刺技術(shù)由同一個(gè)人實(shí)施，臨床結(jié)果是否相同。Thisrandomizedcontrolledtrialinvestigated

theimpactoftheuseofpreproceduralultrasoundontheeaseofinsertionoflaborepiduralsbyamixedgroupoftraineesaftertheyparticipatedinacomprehensiveteaching

programonultrasoundassessmentofthespine.這項(xiàng)隨機(jī)對(duì)照試驗(yàn)研究了，超聲對(duì)硬膜外穿刺容易度的影響。它是將操作者隨機(jī)混合，并且這些成員都參加了全面的脊柱超聲評(píng)估程序的學(xué)習(xí)。

Theinvestigatorshypothesizedthattheuseofpreproceduralspinalultrasoundwouldimprovetheeaseofinsertionoflaborepiduralcatheterswhencomparedwiththeconventionalpalpationtechnique.與傳統(tǒng)的觸診技術(shù)比，研究者假設(shè)脊柱超聲的使用將提高硬膜外導(dǎo)管置入的容易度。

ThepresentstudytookplaceatMountSinaiHospitalinToronto,Canada,awell-establishedcenterofexcellenceinthisfield.Advanced-leveltrainees(anesthesiafellows)andresidentsintheirsecondyearoftrainingwhohadnopreviousexperienceintheuseofspinalultrasoundtofacilitateneuraxialanesthesiawereeligibletoparticipateasoperatorsinthisstudy.這些研究中，合適的操作者的既有高水平的學(xué)員（麻醉醫(yī)師），也有欠缺脊柱超聲應(yīng)用于硬膜外麻醉方面經(jīng)驗(yàn)的初級(jí)學(xué)員（第二年住院醫(yī)師）

Atotalof17residentsand5fellowswereenrolled,and128full-termparturients

witheasilypalpablelumbarspinesrequestinglaborepiduralanalgesiaagreedtoparticipate.17個(gè)住院醫(yī)師，5個(gè)研究院，128個(gè)產(chǎn)婦，產(chǎn)婦的脊柱特征容易識(shí)別并且需要硬膜外分娩鎮(zhèn)痛。

Thepatientswererandomizedeithertotheinterventiongroup（干擾組）

(preproceduralspinalultrasound)ortothecontrolgroup(conventionalpalpationtechnique).（對(duì)照組）

Anequalnumberofproceduresinthe

interventionandcontrolgroupswereplannedforeachtrainee.干擾組和對(duì)照組操作程序是一樣的

Althoughparturientscouldnotpracticallybe

blindedtotheirinterventionassignment,theywereaskednottodisclosewhethertheyhadundergonepreproceduralspinalultrasound.盡管產(chǎn)婦對(duì)干預(yù)分配是知情的，他們被要求不能透露他們是否接受術(shù)前脊髓超聲

Aresearchassistantwhowasblindedto

groupallocationcollectedtheoutcomedata.一個(gè)對(duì)如何分組不知情的研究助理收集結(jié)果數(shù)據(jù)Followingthepreproceduralspinalultrasoundinthe

ultrasoundgroup,allepiduralproceduresinbothgroupswerecarriedoutwiththepatientinthesittingposition.

在超聲組術(shù)前脊髓超聲和觸摸硬膜外組病人都是坐位Theprimaryoutcomemeasuredwastheeaseofinsertionoflaborepidurals,asdefinedbythedurationoftheepiduralprocedurenumberofinterspacelevelsatwhichtheinsertionwasattempted,andnumberofneedlepasses.主要測(cè)量以下結(jié)果：1.置入導(dǎo)管容易程度2.硬膜外操作的持續(xù)時(shí)間3.嘗試幾個(gè)節(jié)段硬膜外間隙4.打了幾針

Secondaryoutcomesmeasuredincludedtotaldurationoftheprocedure(includingultrasoundimaging),successratewiththefirstneedlepass,numberofattemptstothreadthecatheter,needtocallastaffanesthesiologistforhelp,failureofepiduralanesthesia,ratesofinadvertentduralpunctureandpostduralpunctureheadache,andpatientsatisfactionasassessedbyaquestionnairecompletedonthefirstpostpartumday.第二階段數(shù)據(jù)結(jié)果包括:1.總的時(shí)間包括超聲成像2.第一針穿刺成功率3.嘗試穿刺硬膜外的次數(shù)4.是否需要麻醉助手幫助5.硬膜外麻醉失敗率6.不慎穿破蛛網(wǎng)膜的穿刺率7.穿刺后頭痛的發(fā)生率8.患者產(chǎn)后第一天完成問卷評(píng)估的滿意度

ContinuousvariableswereanalyzedusingtheStudentttestortheWilcoxonRanksumtest,whilecategoricalvariableswereanalyzedusingthePearsonw2ortheFisherexacttest.方法：連續(xù)變量采用t檢驗(yàn)或Wilcoxon秩和檢驗(yàn)分析，而分類變量采用卡方檢驗(yàn)或fisher法測(cè)試分析

Amultivariableanalysiswasperformedtoanalyzethedurationoftheproceduresusingamixed-effects

modelthataccountedforcorrelateddataandwasadjustedforoperatoreffect(felloworresident).

多變量分析Therewerenosignificantdifferencesinthemedian(interquartilerange)epiduralinsertiontimebetweentheultrasoundandpalpationgroups,evenafteradjustmentfor

thetrainees’levelofclinicalexperience.

結(jié)果：即使調(diào)整操作者的臨床經(jīng)驗(yàn)，在超聲下硬膜外穿刺時(shí)間與傳統(tǒng)觸摸法行硬膜外穿刺的時(shí)間上是沒有統(tǒng)計(jì)學(xué)意義的

Intheultrasoundgroup,thetotaldurationoftheprocedure(includingtheultrasoundexamination)waslongerthaninthepalpation

group.（在超聲組，所有程序持續(xù)時(shí)間包括超聲檢查時(shí)間要比對(duì)照組時(shí)間更長）

The2groupsdemonstratednosignificantdifferences

inotherepiduraloutcomes(firstneedlepasssuccessrate,

numberofinterspacelevelsattempted,numberofneedle

passesatthefirstlevel,andnumberofcatheter-threading

attempts),andthepatientsatisfactionquestionnaire

showednosignificantdifferencesbetweengroups,with

mostpatientsreportingthattheyweresatisfiedwiththe

procedure.

在其他硬膜外的結(jié)果里，兩組沒有表現(xiàn)出顯著差異。包括：1.第一針通過成功率2.嘗試的間隙水平的數(shù)目3.第一針通過數(shù)4.硬膜外穿刺嘗試次數(shù)5.患者滿意度調(diào)查問卷組之間無顯著差異大多數(shù)患者報(bào)告說，他們對(duì)穿刺過程表示滿意。Asubgroupanalysisconsideringthetrainees’

levelofclinicalexperiencefoundthatresidentsshowedatrendtowardashorterepiduralproceduretimewhenperformingtheinsertionafterultrasoundassessmentascomparedwiththepalpationgroup,butthetotaldurationoftheprocedurestendedtobeprolongedwhenresidentsusedultrasoundversuspalpation.

考慮到操作者的臨床水平，一個(gè)亞組分析與觸診組對(duì)比，當(dāng)使用超聲時(shí)，硬膜外操作時(shí)間短一些，但總共使用的時(shí)間要更長

Theseresultsdemonstratethateaseofinsertionoflaborepiduralcathetersinpatientswitheasilypalpablelumbarspineswasnotimprovedbypreproceduralspinalultrasoundassessmentperformedbyagroupofanesthesiatrainees,ascomparedwiththeconventionalpalpationtechniquebasedonanatomiclandmarks.對(duì)于脊柱體表標(biāo)志明顯的病人來說，基于解剖標(biāo)志，它與傳統(tǒng)技術(shù)比較，術(shù)前脊柱超聲評(píng)估的應(yīng)用對(duì)于硬膜外導(dǎo)管置入的容易度并沒有提高。

COMMENTThisisanelegantstudythatperhapsconfirmswhatmanyanesthesiologistsalreadybelieve：inawomanwithnormallumbaranatomytheuseofpreproceduralultrasounddoesnotconferanymajoradditionalbenefitwhenperforminganepidural.

這項(xiàng)研究，也許證實(shí)了許多麻醉醫(yī)生已經(jīng)相信的：在一個(gè)有正常的腰椎解剖的人，在進(jìn)行硬膜外穿刺時(shí)，術(shù)前超聲的使用并不會(huì)產(chǎn)生額外好處。Despiteseveralpapersand2importantystematicreviewsdemonstratingthepotentialbenefitsoftheuseofultrasoundinassociationwithcentralneuraxialblockade,thereremainslittleevidencethatpreproceduralultrasoundiswidelyused.

盡管有幾篇論文和2個(gè)重要的系統(tǒng)綜述顯示超聲與中樞神經(jīng)阻滯聯(lián)合使用的潛在好處，仍然沒有證據(jù)表明，術(shù)前超聲被廣泛應(yīng)用。Centralneuraxialtechniquesforlabourarefrequentlyperformedindistressed

womeninwhomthereisatimeimperativetoprovideanalgesia.Iftheuseofultrasounddoesnotconferclearadvantageswhenperformingtheepidural,itwouldnotseemlogicaltouseitandpotentiallydelaytheprovisionofanalgesia

硬膜外麻醉技術(shù)頻繁的應(yīng)用于需要術(shù)后鎮(zhèn)痛的婦女，如果超聲在施行硬膜外麻醉時(shí)沒有明顯的優(yōu)勢(shì)，使用它似乎并不合乎邏輯，并可能延遲提供鎮(zhèn)痛Sowheredoesthatleaveus?Itwouldbefoolishtoignoretheevidenceofthebenefitsofultrasoundinrelationtocentralneuraxialblockadeandperhapsitsrolelieswith

patientswhopresentagreaterchallengetotheanesthesiologist,forexampletheobeseparturient那么留給我們思考的是什么.一味地忽略超聲引導(dǎo)下的優(yōu)勢(shì)也是不科學(xué)的，對(duì)麻醉醫(yī)生來說有巨大挑戰(zhàn)的病人，比如肥胖的產(chǎn)婦可能最適合不過超聲引導(dǎo)下硬膜外穿刺了。Levelsofobesitycontinuetoincreaseworldwide.Theuseofultrasoundintheobeseparturienthasitsownchallengesbutitbehoovestheanesthesiologisttodevelopadditionalskillstoensuretheprovisionofsafe,highqualitylaboranalgesiatothesewomen.

肥胖水平在全世界呈增長趨勢(shì)，超聲在肥胖產(chǎn)婦中的應(yīng)用具有挑戰(zhàn)。它也要求麻醉醫(yī)生發(fā)展額外的技能來確保肥胖的產(chǎn)婦可以接受安全，高質(zhì)量的麻醉技術(shù)Therehavebeensomeencouragingresultsontheuseofultrasoundfortheprovisionofepidurallaboranalgesiaintheobeseparturient.Forthisandother