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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Ultrasound-guided regional anesthesia and analgesia: a qualitative systematic review

SS Liu, JE Ngeow, and JT YaDeau.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

The authors concluded that, compared with most other techniques, use of ultrasound for peripheral nerve blocks hastened block performance and onset of block, but it did not show significant benefits for the onset of surgical anaesthesia and conversion to general anaesthesia. Without further details on study quality and given the other methodological concerns, it is difficult to judge their reliability.

Authors' objectives

To compare the efficacy and safety of ultrasound guidance with other techniques for regional anaesthesia and analgesia.

Searching

MEDLINE was searched from inception to November 2007. Search terms were reported. Reference lists of retrieved publications were screened. The authors' personal bibliographical files were checked.

Study selection

Randomised controlled trials (RCTs) that compared ultrasound guidance with an alternative technique in patients undergoing regional anaesthesia and analgesia were eligible for inclusion. Large prospective case series (more than 100 patients) evaluating ultrasound-guided blocks were also eligible for inclusion. The efficacy outcome was success rate of regional anaesthesia and analgesia, which was defined as not requiring conversion to an alternative anaesthetic technique (e.g. general anaesthesia). The safety outcome was complication rate.

Included studies evaluated either ultrasound-guided peripheral nerve blocks or ultrasound-guided central neuraxial blocks. The majority of included studies were RCTs. The control arm of the majority of RCTs was nerve stimulation. The majority of included patients were adults.

The authors did not state how many reviewers performed the study selection.

Assessment of study quality

The authors did not state that they assessed validity.

Data extraction

Where possible, for dichotomous outcomes, data were extracted on the proportion of patients experiencing an event. For continuous outcomes, data were extracted on mean or median values of the outcomes of interest.

The authors did not state how many reviewers performed the data extraction.

Methods of synthesis

The studies were combined in a narrative synthesis, supported by accompanying data tables.

Results of the review

Twenty RCTs and three case series were included in the review (n=2,649 patients).

Peripheral nerve blocks (11 RCTs of adults, three RCTs of children and two case series): Seven RCTs of adults for upper extremity blocks reported a non-significant difference in failed block between ultrasound-guided blocks and controls. Four RCTs reported a non-significance difference in onset of surgical anaesthesia. Four RCTs of adults for lower extremity and low body blocks reported no difference in failed blocks between ultrasound-guided blocks and controls. One RCT of children reported that ultrasound-guided blocks were significantly associated with a longer duration of analgesia compared with controls. Two RCTs of children reported a significant lower volume of local anaesthetic needed for ultrasound-guided blocks in comparison with controls. Two case series reported greater than 98% success rate in ultrasound-guided peripheral nerve blocks.

Central neuraxial blocks (six RCTs and one case series): Two RCTs reported that there were no differences in failed blocks between ultrasound-guided blocks and controls. One RCT reported that ultrasound-guided blocks were significantly associated with a lower rate of postpartum headache and backache compared with controls. One case series reported that the epidural space was located with the first puncture attempt for almost all patients.

No serious complications were reported in any study.

Authors' conclusions

Compared with most other techniques, use of ultrasound for peripheral nerve blocks hastened block performance and onset of block, but it did not show significant benefits for the onset of surgical anaesthesia and conversion to general anaesthesia.

CRD commentary

The inclusion criteria were clear. Relevant sources were searched, but the search strategy appeared to be limited. Efforts were made to find published studies but there were no apparent efforts to retrieve unpublished studies, introducing the potential for publication bias. The authors did not state whether language restrictions were applied in the search, which made it difficult to assess the risk of language bias. It was also unclear whether steps were taken to minimise bias and error in the review process. A formal validity assessment was not carried out.

The authors did not assess the level of clinical heterogeneity between the included studies; it was difficult to assess whether the decision to adopt a narrative synthesis was appropriate. The authors' conclusion reflected the evidence presented. However, without further details on study quality and given the other methodological concerns, it is difficult to judge their reliability.

Implications of the review for practice and research

Practice: The authors stated that, although ultrasound does not improve the success of regional anaesthesia compared with most other techniques, its efficacy was not inferior and it did not increase risk. Ultrasound may therefore offer potential patient-oriented benefits.

Research: The authors stated that further well designed RCTs with a sufficient power are required to examine the efficacy for conventional techniques. Further epidural RCTs with meaningful primary outcomes (e.g. improved analgesia or fewer failures) are needed in all patient populations. Large prospective case series are required to evaluate the efficacy and complication of the use of ultrasound guidance. Further studies are also required to use validated instruments to examine and quantify the potential patient-oriented benefits with ultrasound (e.g. faster block performance and fewer needle passes).

Funding

Not stated.

Bibliographic details

Liu SS, Ngeow JE, YaDeau JT. Ultrasound-guided regional anesthesia and analgesia: a qualitative systematic review. Regional Anesthesia and Pain Medicine 2009; 34(1): 47-59. [PubMed: 19258988]

Indexing Status

Subject indexing assigned by NLM

MeSH

Analgesia /adverse effects /methods; Anesthesia, Conduction /adverse effects /methods; Evidence-Based Medicine; Humans; Nerve Block /adverse effects; Randomized Controlled Trials as Topic; Risk Assessment; Trauma, Nervous System /etiology /prevention & control; Treatment Outcome; Ultrasonography, Interventional

AccessionNumber

12009105305

Database entry date

09/12/2009

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19258988

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