bevel direction

8/10/2019 Bevel direction

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Bevel direction of epidural needles

reliably predicts of catheter

placement and contrast in human

cadavers: results of a pilot study

Presented By:

Amri Mubarrok

DEPARTMENT OF ANESTESIOLOGY AND INTENSIVE CARE

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ DR. MOHAMMAD HOESIN GENERAL HOSPITAL2014

Journal Reading

Preceptor:

Based on: Shaparin N, Jeffrey B, White RS, Kaufman AK. Bevel direction of epidural needles reliably predicts of catheter placement and

contrast in human cadavers: results of a pilot study. Jour of Clin Anestesia (2014) p1-4


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NAVIGATION KEY

Discussion

IntroductionMaterial &

Method

Result


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INTRODUCTION

In lower extremity surgery, direction of catheterinsertion influences the efficacy of epiduralanesthesia

Bevel direction in epidural spaces correlates

with the directional spread of injectate

When catheter placed bevel of needle facingcephalad direction in the mid thoracic & low-thoracicspine : injected contrast spread preferentially incephalad direction

There are still limited data assessing thedirection flow on injectate

In this cadaver study, radiopaque contrast used toconfirm relationship between bevel orientation,catheter direction and radiopaque contrast spread inthe lumbar region


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MATERIALS & METHODS

Gambar 1. Pengaruh tekanan terhadap jaringan.2

8 human cadavers divided

randomly

Group 1

4 cadavers; needle beveldirectioncephaled

Group 2

4 cadavers; needle beveldirectioncaudad

Location: University of Medicine and Dentistry of New

Jersey


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MATERIALS & METHODSContinued

Gambar 2.Gayagesekyang dihasilkan saat pasien berada di tempat tidur

(A) pada pinggul (B) pada tumit.2

Inject 2 ml radiopage contrast (Omnipaque 300 GE Heathcare Inc. Priceton USA) &obtain lumbar posteroanterior radiograph

Obtained direction of spread by remaining 1,8 mL contrast

Insert 18-gauge touhy epidural needle into laminar space

After epidural space entered, threaded single orifice catheter 4 cm into epiduralspace

Place proned to eliminate gravitational effects

Identifed L4-L5 interspace using posterior/superoir iliac creast as landmarkCut down with 11 blade scapel until supraspinous ligament reached at L4-L5

interspace

8 cadavers divided randomly

Group 1: cephaled Group 2: caudad


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RESULT

Catheter tip direction according to the radiograph corresponded directly with bevel

direction

8 cadavers

Group 2: Caudad

No excluded

Excluded 1

cadaver due to

inability to access

epidural space

Group 1: Cephaled

3 of 3 (100%)

flowed primarily

cephaled

direction

3 cadavers flowed primarily

caudad

1 cadaver equally caudad &

cephalad


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DISCUSSION

Epidural

analgesia

Advantage

Better outcome thanGA for total hip

replacement surgery

Improve earlyrehabilitation after

mayor knee surgeries

Preferred for patientselderly/multiplecomorbidities

Disadvantage

Sparring effect forsurgery involving

ankle & foot


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DISCUSSION

Bevel orientation of

epidural needle

Catheter placement

directionConflicting

result

Tiso et al

28 patients, 3 cm lumbarepidural anestesia

80% concordance catheter

directioncephaled group

46% concordancecaudad

group

Choi et al

106 patients, 5 cm thoracicepidural anestesia

63% concordancecephaled

group

22% concordancecaudad

group

Narrow posterior depth of epidural space

in thoracic regionincreased resistance

thoracic epidural require greater

angulationaffect catheter direction

Continued


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epidural needle

Direction of spread

of the injectate

Hasntbeen

absolute &

conclusive

Yokohama et al

Lumbar epiduralanalgesia

Method: needle bevel only

directed in cephaladdirection

Result: more cephalad

spread than caudad

Park et al 3rdlumbar intervertebral

space anesthesia

correlate in patients >40

yo compared with 2039yo patients

No significant differences

in cephaled spread

between cephalad &

caudad group

Liu et al

20 patients for anklesurgery/hemorhoidectomy

No significant differences

between groups in

characteristics of epidural

anesthesia (onset time,

duration, & anesthetic

level)

Touhy needle direction has minor effect on injectate

spread

Young patients have soft &

loose dura & aerolar tissue

when anestetic given,

dura & aerolar tissue

pushed away allow tospread in both cephalad &

caudad direction

Older group firm & thick

dura & aerolar tissue

produced dominant

spread in direction of bevelepidural needle

DISCUSSION

Continued


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epidural needle

Achieving effective

epidural analgesia

Dependinglevel of

epidural

injection

DISCUSSION

Continued

Huffnangle et al

Bevel directioncranial, caudal,

90right, 90left

lumbar region

Cephaled oriented

needle had

greatest success of

epidural analgesia

For sacral region,

mix cephaled &

caudad direction

preferable

Asato et al Initial partial injcaudad region &

cephalad inj

remainded

greater sacral

spread Onset of sacral

dermatomal

coverage more

rapid when split

cephalad & caudad

direction inj

Chou et al

Caudaddirection

resulted faster

onset & greater

anestesia

Excluded 15%catheter due to

poor placement

This study

Caudal planedirection allow

decreased

volume of local

anestesia


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LIMITATION OF STUDY

May influence catheterdirection

Not feasible to placecadavers sit/lateral decubitusposition

No study compared patients

position with ability threadcatheter & influence the

Dead human: fibroticchanges of surroundingtissue & epidural spacemaintain catheterdirection

Live human: less rigid

tissue structure & epiduralfat padsallow catheterplacement change easily

7 subjects

Smallsample size Use humancadavers

Prone

position

Discussion


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THANK YOU

bevel direction

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