Ultrasound Guided Midline vs Landmark Paramedian Continous Spinal Anesthesia in the Elderly
NCT ID: NCT06740994
Last Updated: 2024-12-18
Study Results
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Basic Information
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RECRUITING
NA
110 participants
INTERVENTIONAL
2024-04-29
2025-08-31
Brief Summary
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The aim of this study will be to compare the conventional "blind" landmark paramedian approach to the ultrasound "modern" guided midline approach for the continuous spinal anesthesia in the elderly with hip fractures.
Patients will randomly divided into two groups:
Group(PML): will undergo conventional landmark guided paramedian continuous spinal anesthesia Group (MUS): will undergo ultrasound guided midline continuous spinal anesthesia
Detailed Description
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Patients will randomly divided into two groups by using random number generating software (Research Randomizer Version 4.0) Group(PML): will undergo conventional landmark guided paramedian continuous spinal anesthesia Group(MUS) : will undergo ultrasound guided midline continuous spinal anesthesia A written informed consent will be obtained from all participants, who will be blinded as to their allocated group.
After establishing a baseline monitoring (3 lead ECG, pulse oximetry and non-invasive blood pressure) and an intravenous access, a fascia-iliaca ultrasound guided block at the fractured hip will be performed for all patients by the injection of 20 ml of 1.5 % lidocaine.
15 minutes later with the aid of an assistant, the patient will be positioned at the edge of the operating table in an arched back posture.
In both groups the continuous spinal anesthesia(CSA) will be performed with one of three anesthesiologists (two residents in their fourth year of training anesthesia and one associate professor), each have sufficient experience in performing neuraxial ultrasound scans prior to the study. To fulfill this they will use an 18 gauge Tuohy needle with a 22 gauge intrathecal catheter.
In group PML:
The anesthesiologist will star by drawing the 10th rib line then he will by palpation identify the most prominent spinous process beneath. At this level he will mark on the patient skin the point of injection which will be1 cm lateral and 1 cm caudal to the caudal edge of the spinous process chosen.
After infiltration of the skin with 3 ml of 1% lidocaine at the marked site, the anesthesiologist will introduce the tuohy needle in a cephalomedial direction 10 to 15° off the sagittal plane.
when cerebrospinal fluid will be obtained, the CSA (continuous spinal anesthesia) catheter will be advanced 3 cm cephalad to the intrathecal space and taped to the skin.
The patient will be then returned to dorsal position and a volume of 30 ug of fentanyl and 3 ml of 0.1% isobar bupivacaine will be injected intrathecally via the catheter.
The intervertebral level at which the injection will be done,will be scanned with ultrasound at the end of the surgery, before CSA catheter withdrawal.
In group MUS:
The anesthesiologist will use a portable ultrasonography with a curved 2-5 MHz (Mega Hertz) probe to detect the sacrum in the paramedian sagittal oblique view (PSO) of the neuroaxis.
Than the transducer will be moved cephalad to scan the quality of interspinous spaces from L5/S1 to L2/L3. The interlaminar space that will have the best PSO quality i.e the clearest and largest ultrasound image of the posterior complex ( ligamentum flavum and posterior dura) and anterior complex ( posterior longitudinal ligament and anterior dura) will be chosen as the interspace for injection.
At this level a skin marker will be used to mark the midpoint of the short borders of the probe. Following this the probe will be rotated by 90° to obtain the transverse median view (TM) and by the same way the midpoint of the short borders of the probe will be marked.
The intersection of these two marks will be used as the point of injection. Similarly skin will be infiltrated with lidocaine and the tuohy needle will be inserted in the cephalomedial plane with a cephalad angle estimated by the probe inclination in the TM view.In this group, the anesthesiologist will not palpate the landmarks except he changing technique.For the rest of the procedure, the same steps will be followed.
In both groups, an alternative technique would be used if unsuccessful after 3 attempts( landmark/ultrasound guided paramedian approach for MUS Group ; landmark/ultrasound midline approach for PML Group).
For all participants strict asepsis will be respected throughout all the procedure, The distance needed to reach the intrathecal space from the skin will be recorded and the quality of the interspinous spaces chosen will be noted in the PSO and TM ultrasound views using a predefined scale (good = both posterior and anterior complex visible ; intermediate = posterior or anterior complex visible ; poor = neither complex visible)
Conditions
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Study Design
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RANDOMIZED
PARALLEL
TREATMENT
SINGLE
Study Groups
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paramedian landmark group
conventional landmark paramedian approach will be performed. isobar bupivacaine will be injected for continuous spinal anesthesia.
conventional landmark paramedian technique
a blind landmark scanning will be done and skin marking of the best palpable spinous process will be made.
the site of injection will be determined by palpation. continuous spinal anesthesia will be performed via paramedian approach.
Midline ultrasound group
preprocedural ultrasound guided midline approach will be performed. isobar bupivacaine will be injected for continuous spinal anesthesia.
preprocedural ultrasound guided midline technique
a preprocedural ultrasound scanning will be done, and skin marking of the best quality space will be made.
the site of injection and the insertion angle of the needle will be determined by ultrasound.
continuous spinal anesthesia will be performed via midline approach.
Interventions
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conventional landmark paramedian technique
a blind landmark scanning will be done and skin marking of the best palpable spinous process will be made.
the site of injection will be determined by palpation. continuous spinal anesthesia will be performed via paramedian approach.
preprocedural ultrasound guided midline technique
a preprocedural ultrasound scanning will be done, and skin marking of the best quality space will be made.
the site of injection and the insertion angle of the needle will be determined by ultrasound.
continuous spinal anesthesia will be performed via midline approach.
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
Exclusion Criteria
* previous history of lumbar spine surgery
* per operative severe complication with conversion to general anesthesia
65 Years
ALL
No
Sponsors
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University Tunis El Manar
OTHER
Responsible Party
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Sameh Ben Ahmed
Associate professor
Principal Investigators
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MECHAAL BEN ALI, Professor
Role: PRINCIPAL_INVESTIGATOR
university manar Tunis, Tunisia
Locations
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BEN ALI MECHAAL, Professor
Nabeul, Mrazga, Tunisia
Countries
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Central Contacts
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Facility Contacts
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MECHAAL BEN ALI, Professor
Role: primary
SAMEH BEN AHMED, Doctor
Role: backup
Other Identifiers
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UTEM USSA
Identifier Type: -
Identifier Source: org_study_id