Preprocedural Ultrasound Guidance for Combined Spinal-Epidural Anesthesia Results in Better Success Rates in Elderly Patients with Hip Fracture: A Randomized Controlled Trial

Background: Combined spinal-epidural (CSE) anesthesia is considerably challenging for elderly patients with hip fractures. This study aimed to investigate the ability of a modified preprocedural ultrasound-guided technique to improve the success rate and efficacy of CSE anesthesia for elderly patients with hip fractures. Methods: This prospective, single-blind, parallel-group randomized controlled trial included 80 patients (aged ≥ 65 years) who were scheduled for elective hip fracture surgery with CSE anesthesia. Patients were randomly allocated into either the landmark group (n = 40) or the ultrasound group (n = 40). The primary outcome was first-pass success rate. Secondary outcomes included first-attempt success rate; number of needle insertion attempts; number of needle passes; locating, puncture, and total time; level of block; procedural adverse reactions and postoperative complications; and patient satisfaction score. Patients were blinded to group allocation.Results: All patients,40 in each group, completed the study and were included in the final analysis. The first-pass success rates for the landmark and ultrasound groups were 20% and 70%, respectively (P < 0.001). The first-attempt success rates in the landmark and ultrasound groups were 42.5% and 85%, respectively (P < 0.001). The number of needle insertion attempts and passes in the landmark group were 2 (1, 2) and 3 (2, 4), respectively; values of 1 (1, 1) and 1 (1, 2) were documented for the ultrasound group (median [interquartile range], all P < 0.001). The locating time (P < 0.001) and total time (P = 0.001) were longer in the ultrasound group, while puncture time was shorter (P = 0.003). No significant difference was found regarding the incidence of adverse reactions and complications. More patients in the ultrasound group had a satisfaction score of 4–5 (P = 0.007). Subgroup analysis demonstrated benefits for ultrasound in patients with scoliosis.Conclusions: Modified ultrasound-assisted CSE anesthesia increases first-pass and first-attempt success rates, and reduces needle insertion attempts, passes, and puncture time for elderly patients with hip fracture, especially those with scoliosis. This technique improves patient satisfaction and warrants consideration for application in clinical practice.Trial registration: Chinese Clinical Trial Register, ChiCTR1900020819. Registered January 20, 2019, http://www.chictr.org.cn/showprojen.aspx?proj=34634