Epidural and one sided block

[Jacads]

I have heard two theories on this one that that the catheter is inserted too far and goes to one side, the other is that some people have a natural "septa" separating the two sides of the dura? They both sound plausible is there another reason? How far do you advance your catheters for a labor epidural?

Thanks,

Jacads

---

Members don't see this ad.

 

[militarymd]

I have heard two theories on this one that that the catheter is inserted too far and goes to one side, the other is that some people have a natural "septa" separating the two sides of the dura? They both sound plausible is there another reason? How far do you advance your catheters for a labor epidural?

Thanks,

Jacads

4 cm into space...there is actually a study looking at this...

 

[bubalus]

Beilin Y, Bernstein HH, Zucker-Pinchoff B. Related Articles, Links
The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space.
Anesth Analg. 1995 Aug;81(2):301-4.

This one says 5 cm.

FWIW, I had a patient who had at least 5 different epidural catheters placed for a variety of indications and NEVER had a satisfactory block. I figured it was probably the way she was built.

 

[Laryngospasm]

I have heard two theories on this one that that the catheter is inserted too far and goes to one side, the other is that some people have a natural "septa" separating the two sides of the dura? They both sound plausible is there another reason? How far do you advance your catheters for a labor epidural?

Thanks,

Jacads

Most references say 3-5 cm, any shorter and you risk it coming out, especially in the "larger" patients. longer and you risk going of to one side or in a nerve root. As far as I know there are anatomical studies that point both toward and away from the plica medialis or however the f its spelled.

 

[Noyac]

I have heard two theories on this one that that the catheter is inserted too far and goes to one side, the other is that some people have a natural "septa" separating the two sides of the dura? They both sound plausible is there another reason? How far do you advance your catheters for a labor epidural?

Thanks,

Jacads

I really doubt that the spta can prevent spread of the local that effectively. I heard that arguement while I was in residency and I gave it some credence than but I have changed my views since. I believe that in the majority of on sided blocks there is a false loss of resistance as the needle passes away from midline. The practitioner feels like this is the epidural space and threads the catheter. This paramedian space is actually outside of the epidural space and will easily accept a catheter and a large bolus of local. The block becomes one sided and people want to blame the anatomy of the pt. I don't buy it. Now I know htat there are studies looking at all of this and stating all types of theories which may or may not be real but I feel it is more common for the epidural to be paramedian and not actually in the epidural space.

 

[militarymd]

I really doubt that the spta can prevent spread of the local that effectively. I heard that arguement while I was in residency and I gave it some credence than but I have changed my views since. I believe that in the majority of on sided blocks there is a false loss of resistance as the needle passes away from midline. The practitioner feels like this is the epidural space and threads the catheter. This paramedian space is actually outside of the epidural space and will easily accept a catheter and a large bolus of local. The block becomes one sided and people want to blame the anatomy of the pt. I don't buy it. Now I know htat there are studies looking at all of this and stating all types of theories which may or may not be real but I feel it is more common for the epidural to be paramedian and not actually in the epidural space.

I know that over time, my one sided blocks have decreased significantly to almost none......

either the my patient population has changed....or I'm learning to put the catheters in the middle.

 

[Noyac]

I know that over time, my one sided blocks have decreased significantly to almost none......

either the my patient population has changed....or I'm learning to put the catheters in the middle.

Ditto Mil Ditto

I think it is that the more you put in the better able you are in recognizing when that LOR just doesn't feel right.

 

[jetproppilot]

I know that over time, my one sided blocks have decreased significantly to almost none......

I'm learning to put the catheters in the middle.

This is the key IMHO.

 

[jetproppilot]

I know that over time, my one sided blocks have decreased significantly to almost none......

either the my patient population has changed....or I'm learning to put the catheters in the middle.

And if you and Noy would consider trying CSE

1) the "almost none" would become "none"

2)for labor analgesia, its faster, you dont have to dose the catheter, and the risk of a high level is almost nonexistent

3)if you use ropivicaine/sufentanil for parturient-epidural-infusions your epidurals will become George-Foreman-Grill-Like ...i.e. Set-It-And-Forget-It...

just me, jet, trying to take you rokkstars to the next level......

 

[jetproppilot]

I'm learning to put the catheters in the middle.

One more clinical tidbit for my budding colleagues:

IN THE MIDDLE IS NOT ALWAYS IN THE MIDDLE.

Since, at first glance, that makes no f uk k ing sense at all, lemme explain.

This is why I'm a big proponent of identifying with your thumb, by pushing hard on the parturient's back, the spinous process your Tuohy is gonna fly, superiorly, over.

We all learned in residency to palpate the posterior-superior iliac crest, go midline-medial, etc.

Waste of time.

Sit'er-up. Position her optimally.

Eyeball where you think it is, then let your thumb do the walking.

I always feel for the spinous process one level above where I think the PSIC is.....anecdotally going one level higher is technically easier.....

but heres my point....its not uncommon to feel the spinous process slightly right-or-left of midline.....a little subclinical-scoliosis manifesting...

so make a mark with your thumbnail at the top of the spinous process, EVEN IF ITS A LITTLE LEFT OR RIGHT OF MIDLINE.

Case-in-point: not uncommon for an inexperienced clinician to fire-the-Tuohy at true-midline, even though they palpated a spinous process slightly off midline.

So you're gonna fire your Tuohy in the middle of your designated thumbnail-spot, even if its not midline.

So like I said.

The middle is not always the middle.

But if your middle is appropriately designated, then it truly is the middle....so shoot for the modified middle.

Don't be afraid to shoot wide right or wide left. After all, you're not an FSU field-goal kicker.

hahahhahahhhahahaha.....thats some funny, albeit very true s h i t.

 

[Monty Python]

IN THE MIDDLE IS NOT ALWAYS IN THE MIDDLE.


Eyeball where you think it is, then let your thumb do the walking.

]

My most bizarre epidural was on a gravid 14 year old with horrible, untreated scoliosis. Her L3-4 interspace was about 12 inches down from her scapula.

Through trial and error and taking the best from lots of books I put 2-3 cm of catheter in skinny/normal folks, and 4-5 cm in biscuit-poisoned pts short of ideal body height. One key is learning a good taping/securing technique for the catheter on obese backs, with all those fat rolls.

 

[Noyac]

And if you and Noy would consider trying CSE

1) the "almost none" would become "none"

2)for labor analgesia, its faster, you dont have to dose the catheter, and the risk of a high level is almost nonexistent

3)if you use ropivicaine/sufentanil for parturient-epidural-infusions your epidurals will become George-Foreman-Grill-Like ...i.e. Set-It-And-Forget-It...

just me, jet, trying to take you rokkstars to the next level......

No worries Jet. I am doing CSE's for labor now. I started doing them when I changed jobs. I my old gig I had a crna in house babysitting the epidural but now, no crna's (both good and bad for me) so I put in the epidural and go home. The CSE is safer in this situation for the reasons you mentioned.