Predictors of difficult epidural placement in pregnant women: A trainees' perspective

Suman Rajagopalan, Krishna Shah, Danielle Guffey, Connie Tran, Maya Suresh, Ashutosh Wali, Suman Rajagopalan, Krishna Shah, Danielle Guffey, Connie Tran, Maya Suresh, Ashutosh Wali

Abstract

Background and aims: Epidural analgesia is believed to be the most difficult technique to learn for a trainee. The reason for this is not only inexperience of the provider and the complexity of the technique but also patient factors like obesity, spinal deformity and others which makes the epidural placement difficult. The aim of this study was to evaluate some of the common risk factors for difficult epidural placement as perceived by the anesthesia providers during training, with varying level of experience.

Material and methods: This prospective observational study includes patients who received epidural placement for labor analgesia. Data recorded on these patients included age, height, weight, body mass index (BMI), ease of palpation of the spinous process, level of epidural placement, number of attempts, time taken for epidural placement and experience of the provider. The association between the variables were assessed using logistic regression for first attempt success and Cox proportional hazard ratio for time to epidural placement.

Results: A total of 373 patients received epidural placement for labor analgesia. The mean BMI at the time of placement was 34. The first attempt success rate for the placement of epidural was 67% (n = 273). Women with well palpable spinous process were 3.3 times more likely to have a successful first attempt placement irrespective of the provider experience or BMI [3.39 (1.77-6.51), P < 0.001]. The time to placement was shorter in patients with good anatomical landmarks [1.58 (1.20-2.07), P < 0.001) and when performed by a trainee who had performed a minimum of 20 epidural procedures [1.57 (1.26-1.94), P < 0.001).

Conclusion: Inability to palpate the spinous process contributes to multiple attempts at epidural placement when performed by a trainee.

Keywords: Difficult epidural; epidural analgesia; obstetric analgesia; predictors.

Conflict of interest statement

There are no conflicts of interest.

Copyright: © 2019 Journal of Anaesthesiology Clinical Pharmacology.

Figures

Figure 1
Figure 1
Kaplan-Meier curve that indicates the time to placement of the epidural catheter. The median time to placement was 13 minutes (95% CI = 12,14)
Figure 2
Figure 2
Kaplan-Meier curve showing the time to placement of epidural by palpation of spinous process and provider experience. The curves indicate that the time to placement of the epidural was significantly longer when the spinous process was not well palpable when compared to those that were well palpable (P < 0.001). Also, the trainees took longer time for placement if they had not performed at least 20 prior epidurals (P < 0.001)

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