Influence of Lumbar Ultrasound on Resident Learning Curve for Lateral Labor Epidural Placement

Pre-insertion Ultrasound Guidance for Labor Epidural Placement in the Lateral Position: A Randomized Controlled Trial of Image Reproducibility During Labor and Impact on Resident Learning Curve

The aim of this study is to evaluate the impact of lumbar spine ultrasound on the success rate and efficiency of labor epidural placement in the lateral position. The investigators hypothesize that ultrasound imaging of the lumbar spine of women in early labor will yield similar ultrasound results when done immediately prior to epidural placement. The investigators also hypothesize that the use of ultrasound with landmarks marked and depth to the epidural space estimated will facilitate epidural placement in terms of both efficiency (time required for placement) and efficacy of pain relief.

Study Overview

• Status: Terminated
• Conditions: Lumbar Ultrasound; Labor Epidural
• Intervention / Treatment: Other: Ultrasound

Detailed Description

Several studies have demonstrated a significant benefit in pre-procedural ultrasound for epidural placement by anesthesia residents, particularly when performed in the obese population. To the investigators knowledge, however, no studies have evaluated this teaching modality for the lumber epidural technique in the lateral position. Formalizing the educational process for this less frequently performed, highly technical and critical skill may have a profound impact on trainee learning curves, and may enhance the overall success and efficiency of epidural placement, quality of analgesia provided, and safety of the procedure.

• Study Type: Interventional
• Enrollment (Actual): 28
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Brigham and Women's Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

Pregnant Subjects

Inclusion Criteria:

• pregnant women
• 18 years or older
• in early labor (cervix dilated < 5 cm
• pain visual analog score (VAS) < 3, or both) requesting consultation by the anesthesia team for anticipated epidural pain relief.

Exclusion Criteria:

• absolute contraindications of neuraxial anesthesia including patient refusal
• uncorrected coagulopathy
• infection at the skin site of epidural placement
• increased intracranial pressure, or untreated hemodynamic instability.
• In addition, patients with a history of scoliosis or spine surgery
• body mass index (BMI) >40 kg/m2
• allergy to local anesthetic, or allergy to opioids will be excluded.

Anesthesiologists

Inclusion criteria:

• Anesthesia residents or fellows who are performing the epidural technique in pregnant subjects who agree to be part of the study.
• Anesthesia residents or fellows with prior experience in the lumbar epidural technique, defined as having placed 20 or greater lumbar epidurals during their residency and prior to enrollment.

Exclusion criteria:

• individuals who do not want to participate in the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control; Baseline ultrasound only, with no markings placed. No ultrasound prior to epidural placement.
Experimental: Ultrasound; Baseline and pre-puncture ultrasound with markings placed.	Other: Ultrasound; A baseline lumbar ultrasound in a standardized lateral position (by bed markings) will be performed with the midline and L3-L4 interspace marked, and estimated depth to the epidural space recorded. A second lateral lumbar ultrasound will be performed immediately prior to placement at the time of epidural request. The bed position will be standardized with lines drawn down the back, at the flexion of the knee, and heel of the foot. The sonographic measurements will include the midline, the L3-4 interspace, (both marked at the skin surface), and the measured depth to the ligamentum flavum (in centimeters).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Depth to the epidural space (cm) from baseline ultrasound compared to pre-placement ultrasound.	Measured depth to the epidural space (cm) from baseline ultrasound compared to pre-placement ultrasound, measured with a 2-5 MHz curvilinear ultrasound probe at the lumbar spine, midline, at level L3-4.	From enrollment to time of epidural placement, approximately 5 hours
Time required for epidural placement	Time required for placement (T0 = insertion of needle for subcutaneous lidocaine infusion prior to epidural needle placement). Tfinal = time at complete removal of Weiss epidural needle after catheter is threaded into the epidural space.	From enrollment to time of epidural placement, approximately 5 hours
Need for assistance from additional anesthesiologist	Need for assistance from additional anesthesiologist	From enrollment to time of epidural placement, approximately 5 hours
Number of attempts at epidural placement	defined as number of times the Weiss epidural needle enters the skin	From enrollment to time of epidural placement, approximately 5 hours
Incidence of paresthesias	Paresthesia defined as pain with needle or catheter insertion	From enrollment to time of epidural placement, approximately 5 hours
Labor pain at time of 30 minutes after placement is complete.	Labor pain rated on a visual analog scale (VAS)	From enrollment to time of epidural placement, approximately 5 hours, plus 30 minutes.
Rate of epidural replacement for inadequate analgesia	Inadequate analgesia determined as VAS >3 despite catheter adjustment and/or epidural dose adjustment.	From enrollment to time of epidural placement, approximately 5 hours
Rate of inadvertent dural puncture at the time of placement.	Defined as cerebrospinal fluid aspiration through needle or catheter.	From enrollment to time of epidural placement, approximately 5 hours
Midline measurement from baseline ultrasound compared to pre-placement ultrasound.	Measured midline (anatomical marking) from baseline ultrasound compared to pre-placement ultrasound, measured with a 2-5 MHz curvilinear ultrasound probe at the lumbar spine, midline.	From enrollment to time of epidural placement, approximately 5 hours
L3-L4 lumbar spine level measured from baseline ultrasound compared to pre-placement ultrasound.	Measured L3-L4 lumbar spine level from baseline ultrasound compared to pre-placement ultrasound, measured with a 2-5 MHz curvilinear ultrasound probe at the lumbar spine, paramedic.	From enrollment to time of epidural placement, approximately 5 hours

Collaborators and Investigators

• Sponsor: Brigham and Women's Hospital
• Investigators: Principal Investigator: Michaela K Farber, MD MS, Brigham and Women's Hospital

Publications and helpful links

General Publications

• Sahin T, Balaban O, Sahin L, Solak M, Toker K. A randomized controlled trial of preinsertion ultrasound guidance for spinal anaesthesia in pregnancy: outcomes among obese and lean parturients: ultrasound for spinal anesthesia in pregnancy. J Anesth. 2014 Jun;28(3):413-9. doi: 10.1007/s00540-013-1726-1. Epub 2013 Oct 20.
• Vallejo MC, Phelps AL, Singh S, Orebaugh SL, Sah N. Ultrasound decreases the failed labor epidural rate in resident trainees. Int J Obstet Anesth. 2010 Oct;19(4):373-8. doi: 10.1016/j.ijoa.2010.04.002. Epub 2010 Aug 8.
• Carvalho JC. Ultrasound-facilitated epidurals and spinals in obstetrics. Anesthesiol Clin. 2008 Mar;26(1):145-58, vii-viii. doi: 10.1016/j.anclin.2007.11.007.
• Grau T, Bartusseck E, Conradi R, Martin E, Motsch J. Ultrasound imaging improves learning curves in obstetric epidural anesthesia: a preliminary study. Can J Anaesth. 2003 Dec;50(10):1047-50. doi: 10.1007/BF03018371.
• Mhyre JM, Greenfield ML, Tsen LC, Polley LS. A systematic review of randomized controlled trials that evaluate strategies to avoid epidural vein cannulation during obstetric epidural catheter placement. Anesth Analg. 2009 Apr;108(4):1232-42. doi: 10.1213/ane.0b013e318198f85e.
• Harney D, Moran CA, Whitty R, Harte S, Geary M, Gardiner J. Influence of posture on the incidence of vein cannulation during epidural catheter placement. Eur J Anaesthesiol. 2005 Feb;22(2):103-6. doi: 10.1017/s0265021505000190.
• Balki M. Locating the epidural space in obstetric patients-ultrasound a useful tool: continuing professional development. Can J Anaesth. 2010 Dec;57(12):1111-26. doi: 10.1007/s12630-010-9397-y. Epub 2010 Nov 11. English, French.
• Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. Eur J Anaesthesiol. 2004 Jan;21(1):25-31. doi: 10.1017/s026502150400105x.

Study record dates

Study Major Dates

• Study Start: June 1, 2014
• Primary Completion (Actual): March 1, 2021
• Study Completion (Actual): March 1, 2021

Study Registration Dates

• First Submitted: June 26, 2016
• First Submitted That Met QC Criteria: July 7, 2016
• First Posted (Estimated): July 11, 2016

Study Record Updates

• Last Update Posted (Actual): October 1, 2024
• Last Update Submitted That Met QC Criteria: September 27, 2024
• Last Verified: September 1, 2024

More Information

Terms related to this study

• Other Study ID Numbers: 2013P002510

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO