dosing thru the epidural needle

[redfish reeler]

Is it ok to dose thru the needle with a dilute solution of local anesthetic in OB.? I have heard it is done all the time in "the real world" . It seems like if you are sure of where u r then pts will get relief faster.

---

Members don't see this ad.

 

[Hockeyguy]

Is it ok to dose thru the needle with a dilute solution of local anesthetic in OB.? I have heard it is done all the time in "the real world" . It seems like if you are sure of where u r then pts will get relief faster.

We do it on occasion depending on the attending. It is very variable. If a patient is uncomfterable I just do a CSE. It works like a charm. Just use 3cc of CAD solution. Easy reliable and gives the patients what they want- relief.

 

[pgg]

Is it ok to dose thru the needle with a dilute solution of local anesthetic in OB.? I have heard it is done all the time in "the real world" . It seems like if you are sure of where u r then pts will get relief faster.

It's OK and a matter of personal preference. Some do it to expand the epidural space to ease passing the catheter. I don't see much advantage in terms of speed of onset (how long does it really take to put in a catheter?) but I'll sometime use some saline to expand the space if the catheter doesn't go easily.

Another downside is that (like CSEs) you may not detect a misplaced catheter until later if your first dose isn't through the catheter.

IMO if it's fast relief you're after a CSE is a better choice.

 

[militarymd]

I always load through the needle. 10cc 1.5 % lidocaine.

I inject 2 cc first....ask patient if they feel more pressure on one side or the other....if there is more sensation on one side or another, I'll re-position the needle a little....then the next 8 cc of local.

I haven't had a one sided block in 3 years.

I don't do cse's....the time difference is negligible.

 

[tucker27705]

I give my initial doses via the touhy. I use saline for loss of resistance, others use the bup. Most of us dose with 1/4 bup, roughly 15ml. I do 3-4 mL for my first dose, wait 30 sec and look for a response that would indicate I'm not in the right place, during this time I remove the 20cc syringe. I look at fluid return, nothing to a very slow trickle is acceptable. Then I repeat with 2 more times for a total of 10mL. I then thread the catheter. It is very rare to thread intravascularly with this technique (1/50?). Then finish with 5 mL via the catheter to help verify it is not intra vasc/thecal.
This works very well for me.
You have to have done enough to feel very comfortable with where the needle tip is. And you have to be careful and not cocky and assume you are incorrect as to needle placement until you don't have a reaction to your test dose. On one occasion I had no fluid return via the needle, and yet gave an intrathecal dose. Of course she did not speak english and I didn't speak her language. But something didn't seem right, so I stopped after about 8mL of 1/4%. (spidey sense kicking in, did anyone read Blink?) She was very comfortable up to her shoulders and required no further dosing prior to delivery of her baby.
So the answer is, yes, we do it in the real world. Very helpful if you have 30 deliveries during your shift. Saving a few mins with each epidural can add up. I've been in and out of a room in 15mins with paperwork completed. Dosing via the catheter would add a bit to that.
T

 

[Mofeen]

It's OK and a matter of personal preference. Some do it to expand the epidural space to ease passing the catheter. I don't see much advantage in terms of speed of onset (how long does it really take to put in a catheter?) but I'll sometime use some saline to expand the space if the catheter doesn't go easily.

Another downside is that (like CSEs) you may not detect a misplaced catheter until later if your first dose isn't through the catheter.

IMO if it's fast relief you're after a CSE is a better choice.

If the catheter doesn't thread easily, do you pull the catheter back through the Toughy, or the Toughy and catheter in tandem?

 

[Bertelman]

It is very rare to thread intravascularly with this technique (1/50?).

That seems to be more often than I would expect.

If the catheter doesn't thread easily, do you pull the catheter back through the Toughy, or the Toughy and catheter in tanderm?

...also, I like the "toughy" needle reference above. Toughy indeed, though I think the spelling would be tuffy. Those are the garbage bags I used to use cleaning up the yard.

 

[aredoubleyou]

I'll re-position the needle a little..

.

Can you be more specific...roate clockwise/ counterclockwise a little, or push in/out a little?

 

[Mofeen]

That seems to be more often than I would expect.



...also, I like the "toughy" needle reference above. Toughy indeed, though I think the spelling would be tuffy. Those are the garbage bags I used to use cleaning up the yard.

My bad. Meant Touhy. Haha.

 

[militarymd]

Can you be more specific...roate clockwise/ counterclockwise a little, or push in/out a little?

when I inject the initial 1 to 2 cc of lidocaine....almost always, the patient will feel some pressure....either in the right or left hip, or in the middle.

If they say right hip, I will pull the tuohy back and redirect to the contralateral side with the LOR syringe again.

The folks who do this under fluoro will attest to how poorly we all judge level AND midline.

 

[Bertelman]

Depends on your epidural kit. Sounds like you use the spring-loaded catheters. That's what we use. They rarely go intravascular. The other kind (don't know what they are called, but used them as a resident), go intravascular a lot more.

Nope. No spring-loaded. I remember my first month or two having a rash of 3 or 4 intravasculars. Maybe has happened once in the last year for me.

 

[pgg]

If the catheter doesn't thread easily, do you pull the catheter back through the Toughy, or the Toughy and catheter in tandem?

By "doesn't thread easily" I mean it doesn't get hung up as the tip exits the Tuohy. If there is resistance at that point I just pull the catheter back and reassess the Tuohy postition by pushing some saline through the LOR syringe.

I wouldn't pull the catheter back through the needle if it was already past the tip, but that happens rarely. It's usually obvious before that much gets in ... it's like starting lines, if you have to fight to thread the wire in you're probably screwing it up and should just start again.

 

[Bertelman]

What's your secret?

I think it was the B Braun nylon catheter we used in residency. About 1 in 25 would go intravascular. I saw this with senior residents (when I was a junior), with junior residents (when I was a senior), and attendings.

We use this where I work now:
http://www.arrowintl.com/documents/pdf/literature/epd-s0407.pdf
I've seen about 1 in 300 go intravascular so far.

I dunno. Flood the field with 10 cc saline (or LA if you wish) with LOR. My approach angle is typically close to horizontal. I usually bump another mm or two after LOR. Never thread during contractions. Go gently. Stop at 4-5 cm.

Most importantly, I probably insert 1 or 2 per month now.

But seriously, when I was still doing 20 or 30 a month I would say it is closer to 1 in 100.

 

[Bertelman]

You guys ever get written up on OB?

Honestly, it seemed so innocent when I first posted. A few more additions, then your snarkiness, led to unbridled laughter.

 

[xjohns1]

Is it ok to dose thru the needle with a dilute solution of local anesthetic in OB.? I have heard it is done all the time in "the real world" . It seems like if you are sure of where u r then pts will get relief faster.

i think doing this adds some risk (how much, who knows) without a defensible benefit to the pt. i would argue a test dose of dilute la+epi is the standard of care for epidural catheterization. not only are you not doing a true test dose before dosing the epidural by touhy, you also are foregoing a test dose after the final placement of the catheter because you may not be able to rely on loss of motor or sensory function were there to be inadvertent intrathecal placement of the catheter even after proper epidural placement of your bolus dose through the touhy. when i was a resident i asked my program director (who coauthors a definitive ob anesthesia text) about this scenario. although the risk of a dangerous situation is low, there is a nonzero risk of an accident which you would be hard-pressed to justify in court. it is experts such as my program director who are called upon by the plaintiff's counsel to evaluate the appropriateness of the defendant's actions. again, although the risks seem small, they are potentially life-threatening, and it seems to me a major part of what we do is anticipating, preventing, and treating even the rarest (but potentially dangerous) complications of perioperative care.

 

[Intubate]

when I inject the initial 1 to 2 cc of lidocaine....almost always, the patient will feel some pressure....either in the right or left hip, or in the middle.

If they say right hip, I will pull the tuohy back and redirect to the contralateral side with the LOR syringe again.

The folks who do this under fluoro will attest to how poorly we all judge level AND midline.

I agree that we can't blindly judge midline or level, but you also can't control the direction your catheter goes. Even when you needle is dead center, the catheter will usually go to one side or the other (seen it under fluoro many times). It seems like your extra needle manipulation is just extra risk.

 

[Noyac]

My first 3 years out of residency I would bolus through the Touhy needle using 15-20cc of 1.25% Bupiv with 50-100 mcg Fentanyl. I was also doing pain management back then and we always bolused through the needle since we rarely threaded a catheter. Back then I thought the CSE could increase the risk of PDPH's. I had crna's in-house as well so I didn't need to stick around to watch the pt so much.

Now I have no crna's and I started to do the CSE b/c I felt it was safer (I could leave sooner ). No large bolus of LA. I just place the CSE dose it, thread the catheter and start the PCEA and leave within 5 minutes of placing the whole thing. I will also say that the pts get comfy about 1-2 ctx's faster with a CSE which is pretty insignificant. And I have not had a PDPH with a CSE either and it's been 5 yrs. So I guess I was wrong about that one.

I also never gave a TD when I was blusing thru the needle. I just gave the whole thing. Then tested the catheter after.

 

[militarymd]

I agree that we can't blindly judge midline or level, but you also can't control the direction your catheter goes. Even when you needle is dead center, the catheter will usually go to one side or the other (seen it under fluoro many times). It seems like your extra needle manipulation is just extra risk.

correct...so why start with the needle tip off midline...and multiorifice catheters mitigate the migration.

the "extra risk" of dural puncture? is worth it to me to not have to replace catheters that don't work or leave patients with hot spots. n

 

[Bertelman]

My first 3 years out of residency I would bolus through the Touhy needle using 15-20cc of 1.25% Bupiv with 50-100 mcg Fentanyl.

You like to give 250 mg bupiv?

 

[thegasman]

You like to give 250 mg bupiv?

i'm sure he means 0.125%

 

[Noyac]

You like to give 250 mg bupiv?

Sorry,

0.125%

 

[MTGas2B]

Is it ok to dose thru the needle with a dilute solution of local anesthetic in OB.? I have heard it is done all the time in "the real world" . It seems like if you are sure of where u r then pts will get relief faster.

For a month of residency I did OB at a private hospital. This was quick paced high volume OB place. One of the attending would always get his loss with 2% lidocaine instead of saline. His theory was quick relief, even at worst case (wet tap) a couple ml of IT lidocaine will still help.

Can't say I will do this one on my own, but it was a very effective. Personally, I became of fan of the mini-CSE.

 

[Bertelman]

i'm sure he means 0.125%

I know, but it was fun.

 

[Noyac]

I know, but it was fun.

That's understandable. I give enough grief here. I had better be able to take some.

 

[dhb]

I became of fan of the mini-CSE.

Can you explain this?

 

[MDEntropy]

And I have not had a PDPH with a CSE either and it's been 5 yrs. So I guess I was wrong about that one.

Noy,
What size and type of spinal needle are you using for your cse? No pdph in 5 years is great, given almost any volume of OB practice. I assume you never see pdph after c-sections either. IF you have eliminated this problem from your practice, except for the occasional wet tap, this is great.

As for the original post,
I test dose through the catheter for reasons mentioned above. I once asked a patient down to lie down after the cath was placed, after much trouble shooting, needed to remove a multi-orifice catheter that never worked. I want to make sure my catheter is in the right place and working before my patient gets back on her back.

 

[Noyac]

Noy,
What size and type of spinal needle are you using for your cse? No pdph in 5 years is great, given almost any volume of OB practice. I assume you never see pdph after c-sections either. IF you have eliminated this problem from your practice, except for the occasional wet tap, this is great.

CSE kits have a 27g Pencan. For c/s I use a 25g pencan. And I was wrong when I said 5 yrs. I have not had a PDPH from a CSE or spinal in 8 yrs. But I have had one from a Touhy. It happened last week. First one I can remember since residency. I had a very large pt about 250-300lbs with that flabby back area where you can't feel ****. No biggy, been there b/4 I though. I started to advance the Touhy (am I spelling this right) and I ran into some resistance but I was still advancing so I continued. I got to 9cm. I haven't had to go that far in forever. Then she says her butt is burning, Awh ****. I pulled the touhy out and put the stylet back in. I got a 3mm core of boney ligamentous material out of the end. NO wonder I never had a LOR. What a *******. I went in about 1/2 an inch higher and got LOR at 8.5cm. Partner had to do a EBP the next day.

I have had a wet tap since residency but no PDPH with the 1, 2 or 3 that I had. This was the first one that I didn't notice until I had already pulled out of the csf.

 

[MTGas2B]

Can you explain this?

We would mix up 1 ml of isobaric 0.25% bupi plus about 10-12.5 mcg of fentanyl, and a inject it intrathecally before placing the epidural.

The relief is quick. Downside is you can't really test for an inadvertant intrathecal catheter, so I would make sure I tested it before using it for a bolus. I would generally reserve it for patients a bit further along who I expected would deliver pretty quick. I tried to avoid it in the first timer at 4 cm.

 

[Noyac]

We would mix up 1 ml of isobaric 0.25% bupi plus about 10-12.5 mcg of fentanyl, and a inject it intrathecally before placing the epidural.

The relief is quick. Downside is you can't really test for an inadvertant intrathecal catheter, so I would make sure I tested it before using it for a bolus. I would generally reserve it for patients a bit further along who I expected would deliver pretty quick. I tried to avoid it in the first timer at 4 cm.

Sorry but you lost me. Why is 2.5mg bupiv and some fentanyl a "mini cse"?

And why can you not test for intrathecal placement of the catheter?

 

[huktonfonix]

I've never seen anyone get a spinal level from the 0.5-1 ml of 0.25 bupiv + fentanyl that would compare to the level from an intrathecal catheter dosed with 45mg of lidocaine. I CSE just about everyone for labor epidurals for the same reasons Noyac mentioned. Studies have not shown an increased PDPH or misplaced catheter incidence. In fact I would argue that in the occasional patient with "soft" ligaments and a questionable LOR, the finding of CSF with the spinal needle helps to confirm your position of the Tuohy in the epidural space.

 

[SleepIsGood]

I dont think I've done a CSE for a laboring epidural in ages.

What I do is similar I believe to what people are saying here. Get LORTA at X cm. Then inject about 5 mL of Saline (another test confirming you are in the epidural space if the saline goes in nice and smoothly). Then I inject the rest of the 1% lido (usually after you make your skin wheal there's about 2 mL) and about 2 mL of 1.5% lido with the epi (the stuff in the test dose). I inject this through the Toughy.

Next I thread the cath to 20 cm, but then pull back where I need (5 cm in the epidural space past the LORTA ). Next I use the 3 mL of the test dose I have left and test the catheter.

I think dosing all that lido before threading the cath will get the patient nice and comfy by the time you thread the catheter, place the tegaderm, and taped the epidural and started the infusion.

It's easy. No additional needles (spinal needles) or fentanyl, etc to grab from places as when you are doing a CSE. No fentanyl to check out means no unnecesary botherations from the pharmacy people, no concerns about PDPH, unless you wet tap....You are good to go.

I like to keep things simple.

I run the infusions at around 11-12 ml/hr with q 10-15 min lockouts and 3 mL boluses. I've not really gotten called to 'bolus'.

 

[Bertelman]

CSE kits have a 27g Pencan. For c/s I use a 25g pencan. And I was wrong when I said 5 yrs. I have not had a PDPH from a CSE or spinal in 8 yrs. But I have had one from a Touhy. It happened last week. First one I can remember since residency. I had a very large pt about 250-300lbs with that flabby back area where you can't feel ****. No biggy, been there b/4 I though. I started to advance the Touhy (am I spelling this right) and I ran into some resistance but I was still advancing so I continued. I got to 9cm. I haven't had to go that far in forever. Then she says her butt is burning, Awh ****. I pulled the touhy out and put the stylet back in. I got a 3mm core of boney ligamentous material out of the end. NO wonder I never had a LOR. What a *******. I went in about 1/2 an inch higher and got LOR at 8.5cm. Partner had to do a EBP the next day.

I have had a wet tap since residency but no PDPH with the 1, 2 or 3 that I had. This was the first one that I didn't notice until I had already pulled out of the csf.

I've come close to that before. A little resistance on the way in, felt a clear pop, but couldn't push saline. Inserted the stylet, then tried- easy to push saline.

Since then, I frequently reload the stylet briefly after hitting bone or any significant resistance.

 

[Arch Guillotti]

What I do is similar I believe to what people are saying here. Get LORTA at X cm. Then inject about 5 mL of Saline (another test confirming you are in the epidural space if the saline goes in nice and smoothly). Then I inject the rest of the 1% lido (usually after you make your skin wheal there's about 2 mL) and about 2 mL of 1.5% lido with the epi (the stuff in the test dose). I inject this through the Toughy.

Next I thread the cath to 20 cm, but then pull back where I need (5 cm in the epidural space past the LORTA ). Next I use the 3 mL of the test dose I have left and test the catheter.

I think dosing all that lido before threading the cath will get the patient nice and comfy by the time you thread the catheter, place the tegaderm, and taped the epidural and started the infusion.

I am a little confused here.

You give 2 ml of 1% lido through the needle (20 mg). Then you give 2 ml of 1.5% lido w/epi thru the needle (30 mg). That's a total of 50 mg.

Then after the catheter is in you give the rest of the test dose. What exactly are you testing once the cath is in? IV placement? Isn't that what you are doing with the initial (albeit small) dose of lido w/epi? And why would you mix lido 1% w/1.5%? I am just trying to understand your rationale here.

 

[Licoricestick]

I've come close to that before. A little resistance on the way in, felt a clear pop, but couldn't push saline. Inserted the stylet, then tried- easy to push saline.

Since then, I frequently reload the stylet briefly after hitting bone or any significant resistance.

So whatever was in the tip of your needle ended up in the epidural space?

 

[Noyac]

So whatever was in the tip of your needle ended up in the epidural space?

What happens if this material gets seeded into the epidural space?

 

[pgg]

What happens if this material gets seeded into the epidural space?

Nothing, I would think.

 

[Noyac]

Nothing, I would think.

Are you sure? I don't think I want to transplant some tissue into the epidural space.

 

[dhb]

Now I have no crna's and I started to do the CSE b/c I felt it was safer (I could leave sooner ).

Are you still doing the 5mcg sufenta CSE? Since you and Jet advocated the CSE i've tried to do them as much as possible but i've had a hard time getting good pain relief.

I started with 2.5mg bupi 2.5 sufenta which was insufficient so i'm now using 5-6mg bupi with 2mcg sufenta = 1.5cc which i dilute up to 2cc with CSF and inject that rapidly. I'm still not getting 100% relief although that might be in women who are in advanced stage of labor.

I feel i can't go higher with the doses without calling it a full spinal... comments?

 

[proman]

I've never given opiate with the 2.5mg of bupi in my CSE (no mixing, just 1cc of 0.25% bupi). All have been comfortable for 45min-1hour. Never wanted to give more.

 

[dhb]

I've never given opiate with the 2.5mg of bupi in my CSE (no mixing, just 1cc of 0.25% bupi). All have been comfortable for 45min-1hour. Never wanted to give more.

heavy? in my experience i don't cover enough dermatomes with such a low dose: sometimes they feel pain at the thoracic level sometimes at the sacral level...

 

[proman]

No, just plain isobaric. What's the goal of your CSE? I'm talking of covering contraction pain, not for surgical anesthesia. I've just found 1cc is enough.

 

[Noyac]

Are you still doing the 5mcg sufenta CSE? Since you and Jet advocated the CSE i've tried to do them as much as possible but i've had a hard time getting good pain relief.

I started with 2.5mg bupi 2.5 sufenta which was insufficient so i'm now using 5-6mg bupi with 2mcg sufenta = 1.5cc which i dilute up to 2cc with CSF and inject that rapidly. I'm still not getting 100% relief although that might be in women who are in advanced stage of labor.

I feel i can't go higher with the doses without calling it a full spinal... comments?

I use 20 mcg fentanyl (its easier to get from the nurses) and 1 cc isobaric bupiv. I don't think the problem is that the pts are farther along in labor in your case b/c we frequently get called when the pt is 7, 8 or even 9 cm as they decide they now want an epidural. Even if they are far along in labor the relief is almost instant and it lasts 1-1 1/2 hrs. The only problem with the cse is that later on when the cse dose has worn off and they are on the epidural infusion they occasionally think that the epidural has stopped working. In reality its just that the epidural is not quite as strong as the spinal dose. And they are further along in their labor.

 

[MTGas2B]

Sorry but you lost me. Why is 2.5mg bupiv and some fentanyl a "mini cse"?

And why can you not test for intrathecal placement of the catheter?

Its such a small dose of bupi you don't a big spinal, but its enough to get them pretty comfortable.


So, problem is now that they have a (kind of) dense block from the spinal, an intrathecal test bolus would be masked if the catheter was intrathecal.

 

[Noyac]

Its such a small dose of bupi you don't a big spinal, but its enough to get them pretty comfortable.


So, problem is now that they have a (kind of) dense block from the spinal, an intrathecal test bolus would be masked if the catheter was intrathecal.

I've never had a dense block with the cse. Their legs are warm, feet tingle, but they can move them well. That's not dense to me. Now if I were to give 45 mg Lido intrathecal I would notice a big difference.

 

[dhb]

I don't think the problem is that the pts are farther along in labor in your case b/c we frequently get called when the pt is 7, 8 or even 9 cm as they decide they now want an epidural. Even if they are far along in labor the relief is almost instant and it lasts 1-1 1/2 hrs.

Well then i don't understand why with my higher doses i haven't reliably had the instant relief...??
I use heavy bupi because that's what's available

 

[Noyac]

Well then i don't understand why with my higher doses i haven't reliably had the instant relief...??
I use heavy bupi because that's what's available

I have no idea.

 

[SleepIsGood]

I am a little confused here.

You give 2 ml of 1% lido through the needle (20 mg). Then you give 2 ml of 1.5% lido w/epi thru the needle (30 mg). That's a total of 50 mg.

Then after the catheter is in you give the rest of the test dose. What exactly are you testing once the cath is in? IV placement? Isn't that what you are doing with the initial (albeit small) dose of lido w/epi? And why would you mix lido 1% w/1.5%? I am just trying to understand your rationale here.

Sorry for the delay in answering.

well here's the rationale...the first 2 mL of 1% and the 2mL of 1.5% lido with epi is through the Toughy. This is my 'bolus' dose, so that before I'm done threading my catheter the pt will have some sort of analgesia.

Next I thread the catheter. I then give the test dose 3 ml of 1.5% lido with epi (the usual 45 mg of lido that would result in a spinal if intrathecal or tachycardia if vascular). I do this because although I had no problems with the Toughy, you can still accidentally thread the catheter into a vein or even intrathecally, so I believe its prudent to check where you are before you start your infusion.

Again, the reason I bolus through the Toughy, is because clinically, with that 50mg of lido I have found pts no matter how far along they are (4 or even 9 cm) get some quick relief. I dont like CSE, just because it's more work. I've seen this to be equivalent and just as efficacious CLINICALLY. Everything you need is in the kit and you dont have to go open other packages and get fentanyl and get a spinal needle,etc.

 

[Bertelman]

So whatever was in the tip of your needle ended up in the epidural space?

Yes, some small piece of ligament or bone was displaced into the epidural space.

I'm not sure why that is any more alarming than the plastic catheters we routinely insert.

Have you ever seen a lumbar lami? Our spine surgeons don't seem to be too worried about rasping bone all over the f'ing place

 

[MTGas2B]

I've never seen anyone get a spinal level from the 0.5-1 ml of 0.25 bupiv + fentanyl that would compare to the level from an intrathecal catheter dosed with 45mg of lidocaine. I CSE just about everyone for labor epidurals for the same reasons Noyac mentioned. Studies have not shown an increased PDPH or misplaced catheter incidence. In fact I would argue that in the occasional patient with "soft" ligaments and a questionable LOR, the finding of CSF with the spinal needle helps to confirm your position of the Tuohy in the epidural space.

I agree I think the chances are low, but it still muddies the water for intrathecal testing. Doesn't mean I don't do it.

 

[thegasman]

Well then i don't understand why with my higher doses i haven't reliably had the instant relief...??
I use heavy bupi because that's what's available

It is because you are using hyperbaric marcaine in the sitting position and getting a saddle block - not adequate for contractions. Try using 1 cc isobaric 0.25 marcaine with a little bit of fentanyl and this will be much more effective than your hyperbaric.