For those who put anesthetic in their epidurals, why?

[Doctodd]

injecting a tight foramen hurts. but it is the injection of choice. i do the same -- add a little more lido in those cases

and severe NF stenosis in a LOL can indeed cause motor block with 1 mL of 1% lido. really not the end of the world (especially in the lumbar spine)

The 0.5cc of contrast was agonizing. And I still had to push through the contrast that was in the needle before the ropivacaine reached the target. It hurt me too.

---

Members don't see this ad.

 

[nopain1234]

(sincere question following the TX paralysis case.)

Seems like excluding local may help with earlier identification of nerve/cord injury post-procedure in patients who reports numbness/weakness.

What Texas paralysis case?

 

[Laryngospasm]

Probably referring to the recent one with the huge settlement. I believe it was in texas. There’s a recent thread on it.

 

[drrosenrosen]

What Texas paralysis case?

Woman wins $10M suit over epidural hematoma

The time course on this sounds very weird. She had an ESI and had numbness in the legs immediately after (don't put local in your epidurals, kids!). She was monitored for about 90 minutes in the pain clinic. This apparently was found as negligent in the case, although if I'd put lidocaine in...

forums.studentdoctor.net

 

[SC Tian]

I overheard people do S1 tf esi using depomedrol, vascular uptake with S1 tf is lower? If I remember correctly, S1>L5 caudal>Interlaminar.

 

[MD87]

I overheard people do S1 tf esi using depomedrol, vascular uptake with S1 tf is lower? If I remember correctly, S1>L5 caudal>Interlaminar.

The issue isn't "vascular" uptake, it's arterial uptake. Interlaminar is safe. Lower levels for TFESI are safer than higher levels, but radiculomedullary arteries have been noted as low as S1, so theoretically it would be possible to cause an infarct with particulate steroid at any level from S1 and up. Not sure anyone has actually looked at the foramen caudad to S1, as typically this wouldn't be clinically relevant since canal stenosis at S1-S2 or foraminal stenosis at S2 aren't exactly common.

 

[oreosandsake]

too many opinions, stopped reading

steroids
1) no evidence that 80mg is better than 40mg
just like eating 3 pizzas when you could have been full at 4 slices.
studies show 8 vs 4mg dex lumbar TFESI also same efficacy. I use 5mg a level

anesthetics in the cervical epidurals can cause issues and create larger ddx when issues arise

1-2 ml of 1% PF lido in lumbar epidurals is nice for the patient. i cut it with PFNS for volume. if you get classic contrast flow, proceed should usually be fine. if your contrast looks funny and you suspect anything, get a new syringe and take out the lido, or else start over until it looks right.
dont put bupi in epidurals. it's chronic pain. the extra 6-8 hours anesthetic effect is the good deed that comes back to punish you

 

[Baron Samedi]

The issue isn't "vascular" uptake, it's arterial uptake. Interlaminar is safe. Lower levels for TFESI are safer than higher levels, but radiculomedullary arteries have been noted as low as S1, so theoretically it would be possible to cause an infarct with particulate steroid at any level from S1 and up. Not sure anyone has actually looked at the foramen caudad to S1, as typically this wouldn't be clinically relevant since canal stenosis at S1-S2 or foraminal stenosis at S2 aren't exactly common.

Comparison of Incidences of Intravascular Injection between Medial and Lateral Side Approaches during Traditional S1 Transforaminal Epidural Steroid Injection

Purpose. Intravascular injection rates are higher during traditional S1 transforaminal epidural steroid injection (TFESI) compared with lumbar transforaminal injection. We compared the incidences of intravascular injection between the medial and lateral ...

www.ncbi.nlm.nih.gov

Been doing more of a medial S1 approach since I read this article and it has cut down a fair amount of my own vascular contrast patterns.

 

[Ducttape]

too many opinions, stopped reading

steroids
1) no evidence that 80mg is better than 40mg
just like eating 3 pizzas when you could have been full at 4 slices.
studies show 8 vs 4mg dex lumbar TFESI also same efficacy. I use 5mg a level

anesthetics in the cervical epidurals can cause issues and create larger ddx when issues arise

1-2 ml of 1% PF lido in lumbar epidurals is nice for the patient. i cut it with PFNS for volume. if you get classic contrast flow, proceed should usually be fine. if your contrast looks funny and you suspect anything, get a new syringe and take out the lido, or else start over until it looks right.
dont put bupi in epidurals. it's chronic pain. the extra 6-8 hours anesthetic effect is the good deed that comes back to punish you

instead of using a separate syringe, after appropriate looking contrast pattern, for select patients (ie screaming), ill instill 0.5 ml of 1% lido prior to injecting steroid. instill slowly, let that sit for a min, then inject steroid.

 

[Painologist]

I use 0.5% lido in all my epidurals. For cervical I use 1-2 ml of 0.5% PF lido. For IL, about 3 ml and for TF I will use 1 ml per side. Patients do great. Occasionally their legs feel slightly numb but they’re always able to walk out on their own with no issues. It is nice when patients start to feel some relief immediately afterwards. To be honest, this is how we did it in fellowship which is why I continue to do so. I trained with some well known and highly published physicians and all the faculty did it this way.

 

[lobelsteve]

I use 0.5% lido in all my epidurals. For cervical I use 1-2 ml of 0.5% PF lido. For IL, about 3 ml and for TF I will use 1 ml per side. Patients do great. Occasionally their legs feel slightly numb but they’re always able to walk out on their own with no issues. It is nice when patients start to feel some relief immediately afterwards. To be honest, this is how we did it in fellowship which is why I continue to do so. I trained with some well known and highly published physicians and all the faculty did it this way.

Legs numb.
Ticking time bomb.
Wait til your first fall outside your office or out of car when they get home.
Or they drive and crash.

 

[SC Tian]

Comparison of Incidences of Intravascular Injection between Medial and Lateral Side Approaches during Traditional S1 Transforaminal Epidural Steroid Injection

Purpose. Intravascular injection rates are higher during traditional S1 transforaminal epidural steroid injection (TFESI) compared with lumbar transforaminal injection. We compared the incidences of intravascular injection between the medial and lateral ...

www.ncbi.nlm.nih.gov

Been doing more of a medial S1 approach since I read this article and it has cut down a fair amount of my own vascular contrast patterns.

Thanks for sharing, this still does not support a particulate steroid injection in high vascular spinal region like this.

 

[Ferrismonk]

too many opinions, stopped reading

steroids
1) no evidence that 80mg is better than 40mg
just like eating 3 pizzas when you could have been full at 4 slices.
studies show 8 vs 4mg dex lumbar TFESI also same efficacy. I use 5mg a level

anesthetics in the cervical epidurals can cause issues and create larger ddx when issues arise

1-2 ml of 1% PF lido in lumbar epidurals is nice for the patient. i cut it with PFNS for volume. if you get classic contrast flow, proceed should usually be fine. if your contrast looks funny and you suspect anything, get a new syringe and take out the lido, or else start over until it looks right.
dont put bupi in epidurals. it's chronic pain. the extra 6-8 hours anesthetic effect is the good deed that comes back to punish you

I agree with most of this, but I use 0.25% bupi because there is usually less motor block than with lidocaine. Saline for anyone who is driving themselves home.

 

[SSdoc33]

I use 0.5% lido in all my epidurals. For cervical I use 1-2 ml of 0.5% PF lido. For IL, about 3 ml and for TF I will use 1 ml per side. Patients do great. Occasionally their legs feel slightly numb but they’re always able to walk out on their own with no issues. It is nice when patients start to feel some relief immediately afterwards. To be honest, this is how we did it in fellowship which is why I continue to do so. I trained with some well known and highly published physicians and all the faculty did it this way.

dont use local in the neck

for lumbar, +/-

 

[Baron Samedi]

Thanks for sharing, this still does not support a particulate steroid injection in high vascular spinal region like this.

Of course. I use dex for any epidural regardless of region.

Even if it's 1/1000000, the risk is not worth it for 3 months of 50% relief of an entirely subjective symptom.

 

[clubdeac]

I agree with most of this, but I use 0.25% bupi because there is usually less motor block than with lidocaine. Saline for anyone who is driving themselves home.

How is there less motor block with bupiv? This goes against the science

 

[epidural man]

Of course. I use dex for any epidural regardless of region.

Even if it's 1/1000000, the risk is not worth it for 3 months of 50% relief of an entirely subjective symptom.

Can you explain this reasoning?

I don't understand this at all. Many of my partners will only use DEX as well - but I can't understand the reasoning.

Here is why I think it is important. I believe particulate works much better than non-particulate. (this assumption could be wrong and we have had MANY discussions about his).

However, I want to know why people are nervous about placing particulate steroid in a place that has ZERO percent chance of ending up in an artery (ILESI or Caudal).

 

[Ferrismonk]

Can you explain this reasoning?

I don't understand this at all. Many of my partners will only use DEX as well - but I can't understand the reasoning.

Here is why I think it is important. I believe particulate works much better than non-particulate. (this assumption could be wrong and we have had MANY discussions about his).

However, I want to know why people are nervous about placing particulate steroid in a place that has ZERO percent chance of ending up in an artery (ILESI or Caudal).

Simple, because there isn't a zero chance.


I do lumbar ILESI all the time for labor. We do a test dose through the catheter before the bolus to ensure we're not intrathecal or intravascular. I've had a positive test dose for intravascular spread.

 

[SC Tian]

S1 tf, caudal esi and interlaminar esi have extremely low chance of arterial injection that can cause cord infarcts, but the risk of vascular injection is there, actually S1 almost 25%, what is consequence of putting particles in venous system of spine if not arterial?

 

[Ferrismonk]

How is there less motor block with bupiv? This goes against the science

So I can't find any good studies for this, but anecdotally in the anesthesia world Bupi and Ropi are more selective for sensory fibers than Lido and therefore are useful in producing a differential blockade. This is concentration and volume dependent.

In the OB world, I always get more motor block with lidocaine than bupivacaine, although this may also be concentration dependent.

 

[Baron Samedi]

Can you explain this reasoning?

I don't understand this at all. Many of my partners will only use DEX as well - but I can't understand the reasoning.

Here is why I think it is important. I believe particulate works much better than non-particulate. (this assumption could be wrong and we have had MANY discussions about his).

However, I want to know why people are nervous about placing particulate steroid in a place that has ZERO percent chance of ending up in an artery (ILESI or Caudal).

Particulate and non-particulate steroids in spinal epidurals: a systematic review and meta-analysis - PubMed

Particulate steroids are not demonstrably better in relieving pain compared to their non-particulate counterparts. In view of the concerns over the safety profile of particulate steroids, it may be prudent to switch to non particulates, or at the very least the dangers and alternatives should be...

pubmed.ncbi.nlm.nih.gov

I've never seen any compelling data that particulate outperforms nonparticulate steroids. If you have some high quality reference supporting use, please let me know. My practice is always evolving and I don't claim to know everything, or even most things.

 

[RoloTomassi]

Particulate and non-particulate steroids in spinal epidurals: a systematic review and meta-analysis - PubMed

Particulate steroids are not demonstrably better in relieving pain compared to their non-particulate counterparts. In view of the concerns over the safety profile of particulate steroids, it may be prudent to switch to non particulates, or at the very least the dangers and alternatives should be...

pubmed.ncbi.nlm.nih.gov

I've never seen any compelling data that particulate outperforms nonparticulate steroids. If you have some high quality reference supporting use, please let me know. My practice is always evolving and I don't claim to know everything, or even most things.

I don't think the data that they're equal is that great either. Lack of data either way. Relying on my own anecdotal experience and that of other experienced docs who have used both for an unofficial aggregate n of tens of thousands, seems like particulate is better. Would estimate 90% docs agree.

 

[Baron Samedi]

I don't think the data that they're equal is that great either. Lack of data either way. Relying on my own anecdotal experience and that of other experienced docs who have used both for an unofficial aggregate n of tens of thousands, seems like particulate is better. Would estimate 90% docs agree.

But how much of that experience is bias just because how we were trained and practiced for so many years?

It's just confirmation bias on a large scale.

I can anecdotally say that once I switched to nonparticulate steroids I noticed zero difference whatsoever in efficacy, response rate, or duration.

 

[RoloTomassi]

Simple, because there isn't a zero chance.


I do lumbar ILESI all the time for labor. We do a test dose through the catheter before the bolus to ensure we're not intrathecal or intravascular. I've had a positive test dose for intravascular spread.

For IL particulate complication it would require:

Vascular epidural space + that vascular is arterial + artery going somewhere dangerous + missed during contrast injection + particulate actually clots

Non-zero risk but low enough for me.

 

[RoloTomassi]

But how much of that experience is bias just because how we were trained and practiced for so many years?

It's just confirmation bias on a large scale.

I can anecdotally say that once I switched to nonparticulate steroids I noticed zero difference whatsoever in efficacy, response rate, or duration.

Could very well be. I am biased towards wanting dex to be equal or better. Cheaper, more available, PF, safer. Might be confirmation bias still. Wish I had your experience then I wouldn't feel bad about going all dex.

 

[RoloTomassi]

Comparison of Incidences of Intravascular Injection between Medial and Lateral Side Approaches during Traditional S1 Transforaminal Epidural Steroid Injection

Purpose. Intravascular injection rates are higher during traditional S1 transforaminal epidural steroid injection (TFESI) compared with lumbar transforaminal injection. We compared the incidences of intravascular injection between the medial and lateral ...

www.ncbi.nlm.nih.gov

Been doing more of a medial S1 approach since I read this article and it has cut down a fair amount of my own vascular contrast patterns.

I don't know how you do S1 but I trained in AP approach mostly, got vascular frequently. In practice, I only do oblique approach (same view as L5-S1 TF) any almost never get vascular. Not sure how this makes sense anatomically

 

[epidural man]

Simple, because there isn't a zero chance.


I do lumbar ILESI all the time for labor. We do a test dose through the catheter before the bolus to ensure we're not intrathecal or intravascular. I've had a positive test dose for intravascular spread.

Okay.

It is true. I can’t disprove the existence of dragons, but it seems pretty clear they don’t exist.

In the same way, there has never been a single case of arterial injection causing severe nerve damage from particulate with an inter laminar approach. And there have been MANY injections.

Here is a question.
No anatomical study has ever shown arteries (large enough to be cannulated) in the posterior epidural space. No report (of the billions of inter laminar injections) has shown arterial injection with particulate causing nerve damage. If this data isn’t enough for you to say “okay, risk of this complication is essentially zero”, what data would you need to see to make that statement?

 

[SSdoc33]

Okay.

It is true. I can’t disprove the existence of dragons, but it seems pretty clear they don’t exist.

In the same way, there has never been a single case of arterial injection causing severe nerve damage from particulate with an inter laminar approach. And there have been MANY injections.

Here is a question.
No anatomical study has ever shown arteries (large enough to be cannulated) in the posterior epidural space. No report (of the billions of inter laminar injections) has shown arterial injection with particulate causing nerve damage. If this data isn’t enough for you to say “okay, risk of this complication is essentially zero”, what data would you need to see to make that statement?

 

[SSdoc33]

Simple, because there isn't a zero chance.


I do lumbar ILESI all the time for labor. We do a test dose through the catheter before the bolus to ensure we're not intrathecal or intravascular. I've had a positive test dose for intravascular spread.

intravascular does not necessarily equal intra-arterial

 

[bedrock]

I don't know how you do S1 but I trained in AP approach mostly, got vascular frequently. In practice, I only do oblique approach (same view as L5-S1 TF) any almost never get vascular. Not sure how this makes sense anatomically

I do the same. Not quite L5-S1 TFESI view, but halfway there, plus a touch inferior, before walking superior and quite medial into foramen. Final position of needle tip is quite medial in the S1 foramen and I get great superior epidural spread and almost never get vascular uptake at S1.

 

[bedrock]

But how much of that experience is bias just because how we were trained and practiced for so many years?

It's just confirmation bias on a large scale.

I can anecdotally say that once I switched to nonparticulate steroids I noticed zero difference whatsoever in efficacy, response rate, or duration.

Not trying to start a fight here, but I don't think you're paying attention if you don't notice a difference.

I certainly don't always see a big difference between dex and depo, but I very frequently do. However, the big disclaimer as I've shared on this forum a few times, is that stenosis is physiologically different from a disc herniation.

If for someone has radiculopathy from an acute lumbar disc herniation and someone wants to do two TFESI with dex and then refer to surgeon if neurologic deficit/severe persisent pain, I have no problem with them skipping particulate steroid ESI. However every single study comparing steroids in LESI are only for acute disc herniations, There are NO studies comparing dex vs particulate steroid for the chronic lumbar stenosis/radicular issues we see in the pain world.

In over a decade of chronic pain practice, acute lumbar radiculopathy comprise less than 5% of my patients. Most lumbar patients (without facet issues) have stenosis with neurogenic claudication, recurrent radiculopathy from persistent lateral recess/foraminal stenosis after laminectomty/previous discetomy, or adjacent segment stenosis s/p lumbar fusion, etc.

And for all of those diagnoses, depomedrol works much longer and better than dex, 60% of the time. Not always but very frequently.

Key thing is you have to compare apples to apples. epidural spread is different between ILESI and TFESI. It won't be enough to convince you if you do ILESI with depo compared to TFESI with dex.

You work in the VA and have no lawsuit concerns. Do an L5-S1 or S1 lumbar TFESI with dex on your next 30 patients who have L4-L5, L5-S1 pathologies that I listed in the fourth paragraph. For each of those patients who get less than 4 weeks of relief, repeat the same TFESI but this time with kenalog or depomedrol. Do that on 30 patients and then tell me if none of those patients who initially had less than 4 weeks of relief, suddenly have 4 months or more of relief after switching to depomedrol/kenlog.

 

[Baron Samedi]

Not trying to start a fight here, but I don't think you're paying attention if you don't notice a difference.

I certainly don't always see a big difference between dex and depo, but I very frequently do. However, the big disclaimer as I've shared on this forum a few times, is that stenosis is physiologically different from a disc herniation.

If for someone has radiculopathy from an acute lumbar disc herniation and someone wants to do two TFESI with dex and then refer to surgeon if neurologic deficit/severe persisent pain, I have no problem with them skipping particulate steroid ESI. However every single study comparing steroids in LESI are only for acute disc herniations, There are NO studies comparing dex vs particulate steroid for the chronic lumbar stenosis/radicular issues we see in the pain world.

In over a decade of chronic pain practice, acute lumbar radiculopathy comprise less than 5% of my patients. Most lumbar patients (without facet issues) have stenosis with neurogenic claudication, recurrent radiculopathy from persistent lateral recess/foraminal stenosis after laminectomty/previous discetomy, or adjacent segment stenosis s/p lumbar fusion, etc.

And for all of those diagnoses, depomedrol works much longer and better than dex, 60% of the time. Not always but very frequently.

Key thing is you have to compare apples to apples. epidural spread is different between ILESI and TFESI. It won't be enough to convince you if you do ILESI with depo compared to TFESI with dex.

You work in the VA and have no lawsuit concerns. Do an L5-S1 or S1 lumbar TFESI with dex on your next 30 patients who have L4-L5, L5-S1 pathologies that I listed in the fourth paragraph. For each of those patients who get less than 4 weeks of relief, repeat the same TFESI but this time with kenalog or depomedrol. Do that on 30 patients and then tell me if none of those patients who initially had less than 4 weeks of relief, suddenly have 4 months or more of relief after switching to depomedrol/kenlog.

I don't get in fights, so don't sweat it.

I honestly believe you could inject normal saline and the results would probably be the same for chronic pain. Or you could inject a particulate steroid first and those who fail, bring back and inject with dex and some of them will suddenly respond.

 

[bedrock]

I don't get in fights, so don't sweat it.

I honestly believe you could inject normal saline and the results would probably be the same for chronic pain. Or you could inject a particulate steroid first and those who fail, bring back and inject with dex and some of them will suddenly respond.

Until you try what I recommended, you’ll never know.

 

[MitchLevi]

The ESI homeruns I hit are more commonly seen with Depo. I get them with dexamethasone, but it doesn't seem to be as frequent.

As stated above, stenosis isn't the same as an HNP.

In my hands (geriatric pts with multilevel spinal, lateral recess and foraminal stenosis), ILESI with Depo works better than an ILESI with dex.

In ESI that result in zero relief, it is almost never Depo. I've had those too, but not as commonly.

 

[Ferrismonk]

Okay.

It is true. I can’t disprove the existence of dragons, but it seems pretty clear they don’t exist.

In the same way, there has never been a single case of arterial injection causing severe nerve damage from particulate with an inter laminar approach. And there have been MANY injections.

Here is a question.
No anatomical study has ever shown arteries (large enough to be cannulated) in the posterior epidural space. No report (of the billions of inter laminar injections) has shown arterial injection with particulate causing nerve damage. If this data isn’t enough for you to say “okay, risk of this complication is essentially zero”, what data would you need to see to make that statement?

The kind of data I would like to see is a high-profile case where a physician injected particulate steroid, the patient had a catastrophic neurological outcome for whatever reason, and the jury recognized this wasn't the particulate's fault and let the doctor go.

 

[PinchandBurn]

Triamcinolone has black box warning for epidural use.

Yes

But the new medicare LCD does not allow for methylprednisolone.

I used to only use methylprednisolone but now converted to triamcinolone

 

[bedrock]

Yes

But the new medicare LCD does not allow for methylprednisolone.

I used to only use methylprednisolone but now converted to triamcinolone

This has been discussed. Everyone is still getting paid on Medicare patients if using depo.

 

[PinchandBurn]

This has been discussed. Everyone is still getting paid on Medicare patients if using depo.

It's medicare

You may get paid. Question is will they use the language in the LCd and clawback. Trust me I think it's BS but it's on there

 

[HyperSonic]

Legs numb.
Ticking time bomb.
Wait til your first fall outside your office or out of car when they get home.
Or they drive and crash.

Do you use any local for your ESIs/TFESIs Steve?

 

[epidural man]

The kind of data I would like to see is a high-profile case where a physician injected particulate steroid, the patient had a catastrophic neurological outcome for whatever reason, and the jury recognized this wasn't the particulate's fault and let the doctor go.

I get that.

Risk adverse is the best way to be.

However, why do you think it is even a possibility to happen?

 

[lobelsteve]

Do you use any local for your ESIs/TFESIs Steve?

Earlier in this thread I mentioned the crying test. If patient has a driver and is crying in pain from an acute hnp, i replace my 2cc nss with 2cc 2% lidocaine.

 

[SSdoc33]

Earlier in this thread I mentioned the crying test. If patient has a driver and is crying in pain from an acute hnp, i replace my 2cc nss with 2cc 2% lidocaine.

Funny how you use lido on an injection that you claim is "not painful"

Ive heard people say that before. That TFESIs don't hurt. Not true

 

[lobelsteve]

Funny how you use lido on an injection that you claim is "not painful"

Ive heard people say that before. That TFESIs don't hurt. Not true

The injection is not painful. They are crying from the acutely herniated disc before the procedure.
I can make them stop crying with 2cc 1% PF lidocaine.

 

[clubdeac]

So I can't find any good studies for this, but anecdotally in the anesthesia world Bupi and Ropi are more selective for sensory fibers than Lido and therefore are useful in producing a differential blockade. This is concentration and volume dependent.

In the OB world, I always get more motor block with lidocaine than bupivacaine, although this may also be concentration dependent.

You’re absolutely right. I’m going to redact my statement. I was thinking of cardiac toxicity which is greater with bupiv. Had a brain fart

 

[interjectionreflection]

I agree with most of this, but I use 0.25% bupi because there is usually less motor block than with lidocaine. Saline for anyone who is driving themselves home.

I've had a couple of patients whose ride fell through after the Injection and they refuse to cab home. Do you make them wait around a certain amount of time prior to discharge? Also, do you know if we are liable if they drive and get into an accident? Edit: I've just been documenting that I asked them to bring a driver and that their insurance may not cover them in this situation

 

[Laryngospasm]

make them wait an hour.. if no weakness by them you should be pretty safe. Hospital policy is that they have a driver though and we ask and document before procedure.

 

[Asclepius186]

There have been studies that local anesthetic alone compared to steroid + local in an ESI are equally effective. I believe that the local anesthetic may have benefit in both the short term immediately after the epidural and potentially longer term. I believe these possible benefits of local outweigh risks for low volume, low concentration (1-2cc of 0.25% bupi for LESI).

What are the real risks?

Cord stick and certainly cord injection should be a never event, and as Steve said, even saline in the cord could be catastrophic.

Possible unrecognized intrathecal injection? Still should pretty much never happen, but even if it does, patient will have mild weakness for an hour or 2 with no lasting consequences.

Epidural injection of that amount is very unlikely to cause weakness. Certainly if you’re using 4-5ccs of local it would be more likely, but I never use more than 1-2ccs.

I never use local in CESI due to risk of high spinal.

If I’m the one getting the epidural, I would want a bit of local in my injectate.

 

[RoloTomassi]

I've had a couple of patients whose ride fell through after the Injection and they refuse to cab home. Do you make them wait around a certain amount of time prior to discharge? Also, do you know if we are liable if they drive and get into an accident? Edit: I've just been documenting that I asked them to bring a driver and that their insurance may not cover them in this situation

Don't DC until normal neuro status--mental status, sensory/motor function, balance. Document normal pre-DC PE. If they leave AMA document that.

 

[Baron Samedi]

There have been studies that local anesthetic alone compared to steroid + local in an ESI are equally effective. I believe that the local anesthetic may have benefit in both the short term immediately after the epidural and potentially longer term. I believe these possible benefits of local outweigh risks for low volume, low concentration (1-2cc of 0.25% bupi for LESI).

What are the real risks?

Cord stick and certainly cord injection should be a never event, and as Steve said, even saline in the cord could be catastrophic.

Possible unrecognized intrathecal injection? Still should pretty much never happen, but even if it does, patient will have mild weakness for an hour or 2 with no lasting consequences.

Epidural injection of that amount is very unlikely to cause weakness. Certainly if you’re using 4-5ccs of local it would be more likely, but I never use more than 1-2ccs.

I never use local in CESI due to risk of high spinal.

If I’m the one getting the epidural, I would want a bit of local in my injectate.

Subdural is the real risk.