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Background and Aims Thoracic epidural analgesia is the gold standard for major thoracic and upper abdominal surgeries. To effectively perform epidural analgesia, the epidural space should be localised accurately. Various techniques have been described the facilitate accurate needle insertion; including surface landmark and ultrasound-assisted techniques. Practitioners have relied on the surface palpation landmark method and loss extensively. However, this technique can sometimes be challenging to access the thoracic epidural area and carries substantial failure rates, especially in obese patients or those with oedema on the back This meta-analysis compares the efficacy of the US-assisted versus landmark-based thoracic epidural insertion via the paramedian route.
Methods Randomized controlled trials were sought in six databases for a systematic review and meta-analysis. With a 95% confidence interval, a fixed-effects model calculated Risk Ratio or Mean Difference. Cochrane Risk of Bias assessed bias. Four RCTs were examined. The study was registered with PROSPERO with the identifying code CRD42022360527.
Results Preprocedural ultrasound increased thoracic epidural placement first puncture success rate (RR= 1.28, 95% CI [1.05 to 1.56], P value= 0.02) and decreased the need for two or more skin punctures (MD= -2.41, 95% CI [-3.34 to -1.47], P value= 0.00001). The ultrasound group reduced needle redirections (RR= 0.6, 95% CI [0.38 to 0.94], P value= 0.02). The epidural block success rate was equal in both groups (RR= 1.02, 95% CI [0.96 to 1.07], P value= 0.6).
Conclusions Thoracic epidural insertion is improved by ultrasound but not the success rate. Quality research with larger samples is needed to emphasise that.
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