why are 70% of my epidurals a bit 1 sided?

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turnupthevapor

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I've been around the block for some time now but I have been noticing my epidurals are predominately one sided to some degree! Usually get both feet numb but one leg is usually more heavy than the other leg and pain is one sided to a degree...... I place 5 cm of catheter in the space and load with roughly 3 ml TD and 12 ml .125-.2 bupi.

Is 5 cm to much? I have been taught 3-5 but always head to 5 for fear of dislodgment, maybe 3 in the future..... any thoughts?
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That's the most likely explanation. Also, do you ask the patient whether they feel the needle in the midline, during placement?
 
FFP said:
That's the most likely explanation. Also, do you ask the patient whether they feel the needle in the midline, during placement?
Click to expand...


I have periodically maybe I will make that routine....thanks Brofessor
 
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Which cath you using? Braun certainly more likely to track off to one side than arrow.
 
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i used to believe the catheter migrating to one side thing.
but when you do epidural steroid injections under II and you use contrast injected straight from the touhy ... it very frequently goes all on one side
 
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When I got into private practice several years ago, I noted the same thing with many of my epidurals. I was inserting them at L4-5 with 5cm in the space. My partners all place theirs higher and L2-3 and only 3cm in. When I started using that technique, I had much better results. I agree with Braun needles tracking more, and have learned to adjust to that during placement as well.
 
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How hard do you inject by hand through the catheter when you load the patient? I think that you can get better spread by injecting HARD and breaking up some of the midline fenestrations in the plica mediana dorsalis. Literature shows >80% parturients have some element of the PMD.
 
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We do a test dose, wait, then dose through the needle, then place the catheter.
 
Arrow kit. Spring wound catheter (don't say anything NOY--- :poke:---;)). :thumbup:

Also, don't be afraid to turn up the rate of your catheter or use the full 5cc test dose + some left over lido do dilate/fill the epidural space .
It's a rarity when I actually use 12 ml/hr. It's not like they are going to be getting off the bed and doing yoga any time soon.
I usually use a higher rate so long as they can still feel their contractions and coordinate pushing when the time comes.
 
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Lastly... don't hesitate to just REPLACE the catheter. Fussing around with it over hours is just not worth it--> neither for the patient or for you.
 
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Prolly just bad luck. We use the Braun kit and I always thread 4-5 cm. Can't remember the last one sided epidural I've had. I do inject the test dose forcefully thru the catheter.
 
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I try and get the patient to describe more of what they are feeling, both as the needle is going in, but also as I am threading the catheter. It doesn't take very long to readjust the needle a few millimeters the other direction.

Also, I explain realistic expectations to the patients. There is a lot that can be explained while performing the procedure and setting up the pump. It also keeps the patients' minds occupied.
 
I dilate the space with 5ml of 0.25% bupi through the thouy and dread 7-8cm into space and pull back to 4-6 cm inside epidural space. Rarely do my patients complain of unilateral blockade.
 
Are you using a multiorifice catheter? Maybe that matters. I'm sure there's studies supporting it. That's what we use.
I go in at L2-3 and thread in 5 and take the needle out and pull back to 4. 6 to 5 if they're quite obese.
It usually works great. I also dilate the space with 5cc of saline with needle placement.
Of note I don't query the patient, check a level, etc. It works or it doesn't. If it doesn't I might try to do something, but usually I just replace it.
 
ZzzPlz said:
How hard do you inject by hand through the catheter when you load the patient? I think that you can get better spread by injecting HARD and breaking up some of the midline fenestrations in the plica mediana dorsalis. Literature shows >80% parturients have some element of the PMD.
Click to expand...
I'm pretty sure this is not true. But I can't provide anything to support my stance. So if you like this then go for it.

But if you are truly injecting very slowly then the local usually just exist through the distal orifice. So maybe ZzzPlz has a point.

Or is it the proximal port? I don't remember.
 
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sevoflurane said:
Arrow kit. Spring wound catheter (don't say anything NOY--- :poke:---;)). :thumbup:

Also, don't be afraid to turn up the rate of your catheter or use the full 5cc test dose + some left over lido do dilate/fill the epidural space .
It's a rarity when I actually use 12 ml/hr. It's not like they are going to be getting off the bed and doing yoga any time soon.
I usually use a higher rate so long as they can still feel their contractions and coordinate pushing when the time comes.
Click to expand...
Yeah those catheters suck balls!!!!!
 
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Ezekiel2517 said:
Prolly just bad luck. We use the Braun kit and I always thread 4-5 cm. Can't remember the last one sided epidural I've had. I do inject the test dose forcefully thru the catheter.
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At 70%, you can't call it bad luck.
 
Turnup, as you can tell there are many approaches and many ideas. Everyone think their way is best. That why they do'it that way. I can't believe you are getting 70% one sided. That's crazy percentage. Unheard of number.

But I give you props for admitting it and coming here to try to fix it. However, I think you are probably exaggerating your numbers.

Well, I don't have any great cures for your issue.

Also, are you talking about labor epidurals only. Because those suggesting to use the L2/3 space don't help if you are also talking about thoracic as well.

Btw, I always advance at least 5cm unless I meet resistance at which pint I suspect something isn't right.
 
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Noyac said:
I'm pretty sure this is not true. But I can't provide anything to support my stance. So if you like this then go for it.

But if you are truly injecting very slowly then the local usually just exist through the distal orifice. So maybe ZzzPlz has a point.

Or is it the proximal port? I don't remember.
Click to expand...

You don't find that you get better spread when you ram some in by hand vs give a bolus off a pump? I do.
 
ZzzPlz said:
You don't find that you get better spread when you ram some in by hand vs give a bolus off a pump? I do.
Click to expand...
Slow: Proximal port

Bolus yields better block because use of all orifices and also cause a lot of local is introduced at once causing a denser block to those really thick nerve roots. Especially the l5 and s1

For the uninitiated:
http://www.ncbi.nlm.nih.gov/pubmed/8694379
 
I know this sounds like common sense, but are you sure you're midline? I push/palate fairly hard to try and find a spinous process if they're not terribly obese. Then I rock my thumb back and forth until it's exactly centered and then place the needle midline to my thumb. I also pay close attention to my trajectory so I remain perpendicular to the back.

Knock on wood, I've never had a wet tap in over 300 epidurals. But I have placed a number of blood patches in residency. Sometimes the resident(s) had tried multiple attempts and the patient would warn me that she was "difficult" yet I'd place the blood patch first pass. I'm not a neuraxial ninja. When I'd look at where the previous attempts were made they were upwards of 1-2cm off midline from where I placed the blood patch.

I also like the wire wound catheters that Sevo mentioned. Haven't had a single intravascular puncture with those compared to the crappy stiff braun catheters.
 
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I wonder how much of it is bias? The OP is looking for a differential, so is finding it. He/she isn't saying that they are completely one sided, just a bit stronger on one side than the other. If that is it, then maybe it is more common than we realize if we aren't actively looking for it.

On the other hand, if the OP does mean that they are so one sided that they are constantly called down for redoses, then 70% does seem quite high.
 
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Noyac said:
Yeah those catheters suck balls!!!!!
Click to expand...

Hey hey now Nooooooo yac :vomit: .... Check out what kazuma said. I know this rokkstar personally, he's right on the money.

kazuma said:
I also like the wire wound catheters that Sevo mentioned. Haven't had a single intravascular puncture with those compared to the crappy stiff braun catheters.
Click to expand...

:smuggrin:
 
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sevoflurane said:
Hey hey now Nooooooo yac :vomit: .... Check out what kazuma said. I know this rokkstar personally, he's right on the money.



:smuggrin:
Click to expand...
I know. I'm just busting your chops as you know. I assume those catheters are better but I still prefer the old stiffer ones.
 
The PMD is certainly present in most patients. Thread any catheter very far and it will fall in the lateral gutter. Lessons learned in the fluoro suite. Overcome the PMD with volume (saline bolus is helpful) and don't thread your catheters a mile in.
 
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BobBarker said:
The PMD is certainly present in most patients. Thread any catheter very far and it will fall in the lateral gutter. Lessons learned in the fluoro suite. Overcome the PMD with volume (saline bolus is helpful) and don't thread your catheters a mile in.
Click to expand...
This may be true but it isn't a absolute.
I just got called to address a unilateral epidural that a partner placed. This is actually the fort one of these I've seen in a long time. We just don't get this very often. I I thought I would just pull it back a bit a bolus. Well it was only at 9cm at the skin. So there goes your theory BobBarker.the bolus didn't work and I replaced it.
 
I try to place my labor epidurals absolutely midline as most here have been describing and thread cath 4-5 cm into epidural space with LOR to air. I'd say probably 1/30 have clinically significant one sided block requiring intervention. It used to be 1/5-10 until I started blousing 4-5 cc saline after my loss and before threading the catheter. This has made a huuuuge difference and is the only change in practice I had at the time so while not completely scientific, it has strong anecdotal repeatable effects.

One thing I've been curious about is when we perform paramedian technique we intentionally enter at an oblique, off midline trajectory and while it's been hammered home in this thread and others about staying midline to avoid one sided blocks, there is still this perfectly acceptable alternative approach and I don't remember hearing anything about frequent one sided blocks related to this approach. I typically only do paramedian for thoracic epidurals and never get one sided blocks with those, but the space also tends to be cleaner at that level. Anyone have experience doing lots of paramedian approach for Lumbar labor epidurals?
 
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Probably simplistic but OP, are they one-sided to the side that the pt is leaning? I've had an awful lot of "one-sided" epidurals that magically improved by having the pt no longer positioned with that side down...
 
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OP what are you using to locate the epidural space, air or saline?

There is well confirmed data that if air is injected into the epidural space it can cause a spotty block which could be interpreted as one-sided.
 
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Noyac said:
OP what are you using to locate the epidural space, air or saline?

There is well confirmed data that if air is injected into the epidural space it can cause a spotty block which could be interpreted as one-sided.
Click to expand...

I use Air, point noted, thanks!
 
How much air being injected would cause a problem? I use 2cc air in the syringe and use it to feel LOR but don't actually inject much of any, maybe 0.5cc at most when I get LOR.
 
teeva said:
How much air being injected would cause a problem? I use 2cc air in the syringe and use it to feel LOR but don't actually inject much of any, maybe 0.5cc at most when I get LOR.
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I'm not sure how much will cause the issue of a spotty block. Maybe someone smarter than me will chime in here. Sevo?
 
turnupthevapor said:
I've been around the block for some time now but I have been noticing my epidurals are predominately one sided to some degree! Usually get both feet numb but one leg is usually more heavy than the other leg and pain is one sided to a degree...... I place 5 cm of catheter in the space and load with roughly 3 ml TD and 12 ml .125-.2 bupi.
Click to expand...

Dude you do LOR with air and are confused why your blocks are one sided?

5cm is not too much. I do 4-6cm. Very low rate of laterality, even lower rate of dislodgement.
 
Having done thousands of ESIs I can tell you 1) it's really hard to place the needle dead in the midline and not run into the spinous process or tough ligamentous obstructions, 2) even if you do, spread only very rarely goes bilateral. Volume is the way to overcome this problem. I would recommend a solid 10 mL bolus to flood the space. Use 0.25% bupi if you're being aggressive, 0.125% if you have time to tinker.
 
Huh?

Doing zillions of epidurals under fluoro for years and playing around with dye and volume has given me some insight I wanted to share. Take my recommendations with a grain of salt.
 
soorg said:
Thread it 4 cm, unless obese-then it's 5 cm.
Click to expand...

This. Have had to replace a lot of one-sided epidurals where colleagues threaded it to 6-7 cm, regardless of patient size. 4 cm in a regular size patient, 5 cm in a patient where you feel like the back fat will help the catheter slide out over a little time. The catheter only needs to be 3 cm in the space to work properly.
 
OneFellSwoop said:
I try to place my labor epidurals absolutely midline as most here have been describing and thread cath 4-5 cm into epidural space with LOR to air. I'd say probably 1/30 have clinically significant one sided block requiring intervention. It used to be 1/5-10 until I started blousing 4-5 cc saline after my loss and before threading the catheter. This has made a huuuuge difference and is the only change in practice I had at the time so while not completely scientific, it has strong anecdotal repeatable effects.

One thing I've been curious about is when we perform paramedian technique we intentionally enter at an oblique, off midline trajectory and while it's been hammered home in this thread and others about staying midline to avoid one sided blocks, there is still this perfectly acceptable alternative approach and I don't remember hearing anything about frequent one sided blocks related to this approach. I typically only do paramedian for thoracic epidurals and never get one sided blocks with those, but the space also tends to be cleaner at that level. Anyone have experience doing lots of paramedian approach for Lumbar labor epidurals?
Click to expand...

I used to do paramedian approach all the time, I'd do a high lumbar, around L2/L3 or L3/L4, worked great. A lot of times posture and positioning is key and those "difficult" epidurals were a piece of cake. Also, never had issues with unilateral blocks.
 
polar403 said:
This. Have had to replace a lot of one-sided epidurals where colleagues threaded it to 6-7 cm, regardless of patient size. 4 cm in a regular size patient, 5 cm in a patient where you feel like the back fat will help the catheter slide out over a little time. The catheter only needs to be 3 cm in the space to work properly.
Click to expand...
Why replace the epidural and not just pull it back a bit?
 
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