Catheterisation, Education, Epidural Anesthesia, Graduate Medical Education, Medical, Postoperative Pain
Conditions
Keywords
epidural catheter, loss of resistance, hanging drop, procedural training, epidural space identification
Brief summary
This prospective observational study aims to evaluate the impact of epidural catheter placement techniques - loss of resistance (LOR) and hanging drop (HD) - on first-attempt success rates and procedural complications among anesthesia residents. Residents with at least two years of training will perform epidural catheterization under supervision for patients scheduled for elective surgery requiring perioperative epidural analgesia. An independent observer will record procedural details, complications, and postoperative pain scores. The study will enroll 440 patients aged 18-80 with ASA I-III classification.
Detailed description
Epidural catheterization is a cornerstone technique in perioperative and obstetric pain management. Two established methods are commonly used to identify the epidural space: the loss of resistance (LOR) technique, using air or normal saline, and the hanging drop (HD) technique. Although both are widely employed, comparative data on their performance by residents in training are limited. This study prospectively observes which technique the resident chooses, records procedural parameters (depth of epidural space, number of attempts, level of insertion), and documents immediate complications (dural puncture, intravascular placement, paresthesia, hypotension) and postoperative outcomes (NRS scores at 0, 6, 12, and 24 hours; PDPH). Cases in which a resident is unable to complete the procedure are documented separately, including the reason for failure and subsequent management by a supervising specialist. All procedures are performed using an 18G Tuohy needle and standard catheter set. A test dose is administered to all patients following catheter placement. Data are recorded by an independent observer using a standardized data collection form.
Interventions
PROCEDUREepidural catheter placement
Epidural catheterization performed using an 18G Tuohy needle and standard catheter set by anesthesia residents with a minimum of two years of training, under specialist supervision. Technique selection (LOR or HD) is at the discretion of the performing resident and is not randomized.
Sponsors
Marmara University Pendik Training and Research Hospital
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
* Age 18-80 years * ASA physical status I, II, or III * Scheduled for elective surgery requiring perioperative epidural analgesia or anesthesia (lumbar or thoracic approach) * Epidural catheter to be placed by a resident with ≥ 2 years of anesthesia training
Exclusion criteria
* Spinal deformity (scoliosis, kyphosis, or prior spinal surgery at the target level) * Coagulopathy or anticoagulant therapy precluding neuraxial blockade * Active infection at the insertion site or systemic infection * Pre-existing neurological disease affecting the spinal cord or nerve roots * Emergency surgery * History of prior failed epidural catheterization * Patient refusal or inability to provide written informed consent * Local anatomical pathology precluding safe epidural access
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| First-attempt success rate | Time Frame: Immediately upon procedure completion | Defined as successful epidural space identification and catheter placement in a single Tuohy needle insertion attempt, without redirecting the needle. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Dural puncture rate | Intraoperative | Inadvertent dural puncture defined as free flow of cerebrospinal fluid through the Tuohy needle or epidural catheter, confirmed by visual inspection. Recorded as yes/no by the independent observer at the time of the procedure |
| Catheter Advancement Failure Rate | intraoperative | Inability to thread the epidural catheter beyond 3 cm into the epidural space despite confirmed needle placement, necessitating needle repositioning or procedure abandonment. Recorded as yes/no by the independent observer. |
| Operator-Assessed Difficulty Score | Immediately after procedure completion | The performing resident rates the overall technical difficulty of the procedure immediately upon completion using a 5-point Likert scale: 1 = very easy, 2 = easy, 3 = moderate, 4 = difficult, 5 = very difficult. Recorded on the standardized data collection form |
| Intravascular catheter placement rate | intraoperative | Unintentional intravascular placement defined as aspiration of blood through the epidural catheter prior to test dose administration. Recorded as yes/no by the independent observer immediately following catheter advancement |
| Postoperative Pain Scores | 0, 6, 12, and 24 hours postoperatively | Pain intensity assessed using the Numerical Rating Scale (NRS), where 0 = no pain and 10 = worst imaginable pain. Recorded at four time points: immediately upon arrival to the recovery unit (0 hours), and at 6, 12, and 24 hours postoperatively by the independent observer. |
| Rate and Type of Assistance Required During Catheter Placement | Intraoperative | The level of assistance received by the performing resident is recorded in three categories: (1) No assistance - procedure completed independently; (2) Verbal guidance only - supervising specialist provides verbal instructions without physical intervention; (3) Physical assistance - supervising specialist takes over needle or catheter manipulation partially or completely. Recorded by the independent observer at the time of the procedure. |
| First-Attempt Success Rate Stratified by Resident Seniority Level | Intraoperative | First-attempt success rates are compared across three seniority strata defined by duration of anesthesia training: junior residents (2-3 years), intermediate residents (3-4 years), and senior residents (4 years and above). Seniority is determined by the total duration of anesthesia specialty training at the time of the procedure. |
Countries
Turkey (Türkiye)
Contacts
CONTACTDilara Göçmen, asst prof
Outcome results
None listed