Development and Evaluation of a Score to Predict Difficult Epidural Placement During Labor

Jean Guglielminotti, France Mentré, Ennoufous Bedairia, Philippe Montravers, Dan Longrois
2013 Regional anesthesia and pain medicine  
Phone number: 33 1 40 25 83 55 Fax number: 33 1 40 25 63 09 2 Abstract Background and Objectives: Difficult epidural placement (DEP) during labor may be distressing for the patient and may increase the risk of dural puncture. A score predicting DEP based on the combination of individual risk factors could identify high-risk patients. Therefore, this study aimed to identify risk factors for DEP and build a prediction score. Methods: 330 patients were prospectively included. More than one skin
more » ... re than one skin puncture with Tuohy needle defined DEP. Dura puncture occurrence was recorded. The population was randomly split into a training (Tra) and a validation (Val) sets. In Tra, risk factors were identified with logistic regression and used to build a score defining 3 risk-groups. Model and score discrimination was assessed with the c-index and clinical usefulness of the score with decision curves. Results : DEP frequency was 30% (95%CI: 25-35). Dural puncture was more frequent in DEP patients (4% versus 0%, p=0.007). Three independent risk factors for DEP were identified: difficult interspinous space palpation (OR 6.1; 2.8-13.9), spinal deformity (OR 2.4; 1.1-5.3) and inability to flex the back (OR 3.0; 1.2-7.8). C-index of the model was 0.81 (0.74-0.88) in Tra and 0.78 (0.70-0.86) in Val. A 5-point score was created defining a low-(score 0), intermediate-(score 1-2) and high-risk groups (score 3-4) with predicted rates of DEP of 9.7%, 30.3% and 68.9%, respectively. The c-index of the score was 0.79 (0.72-0.86) in Tra and 0.76 (0.69-0.84) in Val. Decision curves support the clinical usefulness of the score. Conclusions: This study confirms risk factors for DEP and proposes a score predicting DEP. The score identifies high-risk patients that may benefit from an intervention to decrease DEP. This hypothesis should be evaluated in an impact study.
doi:10.1097/aap.0b013e31828887a6 pmid:23518864 fatcat:6rw7tgi36jhfvlkbnmrhtzfmvy