CSE and spinal headache

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gagyekum

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New attending and recently I've been switching to doing CSE for my labor epidural. Unfortunately lately I've had a significant increase in spinal headaches. When i pull the spinal needle, no CSF from the tuohy, cathether passess easily and no response to the test dose. No sign of inadvertent dural puncture. I typically use a 25g spinal needle but now im thinking of switching to a27g. My understanding is that CSE should actually decrease the risk of PDPH but maybe I've been unlucky.

Any advice or tips should be greatly appreciated
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That's what I was thinking. Initially with the 27g, I was never getting enough flow of csf to comfortably give medicine. I just might only do 27g or completely forgot CSE and go back to traditional epidurals
 
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gagyekum said:
That's what I was thinking. Initially with the 27g, I was never getting enough flow of csf to comfortably give medicine. I just might only do 27g or completely forgot CSE and go back to traditional epidurals
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Have given many doses through a 27 gauge needle without issue. If csf comes back in the hub its fine to give the med. forget aspirating altogether.
 
Interesting. I do CSEs more often then not and never had an issue but I think our kit has a 27g.

Yea I never aspirate on these either. I just inject when I get flow.
 
gagyekum said:
My understanding is that CSE should actually decrease the risk of PDPH but maybe I've been unlucky.
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Help me out… why in the world would an intentional dural puncture decrease the risk of PDPH? 27G is appropriate for labor… no real reason to go larger. Doesn’t really matter how much flow you have, or even your ability to aspirate… it’s a low dose spinal for labor… just dose it and move on. I’ve been doing DPEs with 27G whitacre needles for 3 years… don’t think I’ve had a single PDPH from it yet.
 
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We use 27g for CSEs in my group. Agree with others, don’t expect to be able to aspirate it. Won’t necessarily even free flow back at you in most patients. You’ll feel the pop through dura and see a drop of CSF appear in the lure lock injection port, that’s about all the “confirmation” you get with a 27g most of the time.
 
patriot6 said:
Help me out… why in the world would an intentional dural puncture decrease the risk of PDPH? 27G is appropriate for labor… no real reason to go larger. Doesn’t really matter how much flow you have, or even your ability to aspirate… it’s a low dose spinal for labor… just dose it and move on. I’ve been doing DPEs with 27G whitacre needles for 3 years… don’t think I’ve had a single PDPH from it yet.
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Yeah, I dunno why CSE would be lower, but I can understand the rate being similar. Presumably CSE reduces the incidence of tuohy wet taps in the occasional difficult epidural (because one can confirm questionable LOR by just doing a dural puncture instead of advancing), and this is balanced out by the incidence of the rare PDPH that comes from that intentional 25 or 27g DP.
 
gagyekum said:
New attending and recently I've been switching to doing CSE for my labor epidural. Unfortunately lately I've had a significant increase in spinal headaches. When i pull the spinal needle, no CSF from the tuohy, cathether passess easily and no response to the test dose. No sign of inadvertent dural puncture. I typically use a 25g spinal needle but now im thinking of switching to a27g. My understanding is that CSE should actually decrease the risk of PDPH but maybe I've been unlucky.

Any advice or tips should be greatly appreciated
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What kind of 25 are you using? I do exclusively CSEs and I do a lot of them. Have never had a PDPH from the 25g pencil point hole I create. I also will use a 27g sometimes as there have been times over the years where our hospital has run out of 25g pencil points. I’m wondering if you’re using a cutting 25.

There’s no risk difference with PDPH whether is a spinal or CSE. It’s still a 25g hole in the dura. I think something is up here. It’s either a cutting tip or it’s not really a 25g.
 
PDPH gauge difference is negligible when using 22/24/25/27g non-cutting needle. I use 24/25 pencan or whitacre. Big difference between 25 and 27 if it’s a cutting needle though.
 
Beeftenderloin said:
We use 27g for CSEs in my group. Agree with others, don’t expect to be able to aspirate it. Won’t necessarily even free flow back at you in most patients. You’ll feel the pop through dura and see a drop of CSF appear in the lure lock injection port, that’s about all the “confirmation” you get with a 27g most of the time.
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I feel a pop whether it’s 25 or 27g pencil point. I am also able to aspirate in most instances. Yes, csf flow is slower though the 27g, but provided that you’re roughly midline and feel a good dural pop, you should be able to aspirate.
 
Southpaw said:
I feel a pop whether it’s 25 or 27g pencil point. I am also able to aspirate in most instances. Yes, csf flow is slower though the 27g, but provided that you’re roughly midline and feel a good dural pop, you should be able to aspirate.
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Aspirating takes too much time and I am going to inject anyway if I see csf.
 
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dannyboy1 said:
Why is everyone doing CSE’s? What is the benefit? I have found that the onset of pain relief is pretty rapid if you just give the entire 5 cc test dose epidural.
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I’ve been in a practice that did epidurals. The practice I’m with now does CSEs. I much prefer CSEs. The quality of the epidural is better and there’s certainly less one-sidedness/bolusing/replacing of epidural issues that I deal with.
 
Southpaw said:
I’ve been in a practice that did epidurals. The practice I’m with now does CSEs. I much prefer CSEs. The quality of the epidural is better and there’s certainly less one-sidedness/bolusing/replacing of epidural issues that I deal with.
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I do plain epidural and bolus through the touhy. Rapid relief and significantly less one sided blocks than bolus through cath. No extra meds to draw up/waste and no dural puncture.
 
gcc322 said:
I do plain epidural and bolus through the touhy. Rapid relief and significantly less one sided blocks than bolus through cath. No extra meds to draw up/waste and no dural puncture.
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I’m glad. I agree bolusing through the tuohy before threading decreases the one-sidedness.

All of us think what we do is best. I prefer CSEs. Nothing on OB is perfect.
 
Southpaw said:
I’ve been in a practice that did epidurals. The practice I’m with now does CSEs. I much prefer CSEs. The quality of the epidural is better and there’s certainly less one-sidedness/bolusing/replacing of epidural issues that I deal with.
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Why do you think CSEs have less epidural issues? It makes sense initially maybe more complete pain relief but once the initial spinal dose wears off why would the epidural be any better? If anything I could see it being worse given the small possibility the epidural catheter migrated somewhere funny and it’s not discovered until later
 
LaryngoSpazz said:
If anything I could see it being worse given the small possibility the epidural catheter migrated somewhere funny and it’s not discovered until later
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The catheter is larger than the 25g durotomy. I’ve never seen migration but I have heard of it. I’m less worried about catheter migration than I am about consequences of bupiv (or any local really) through the tuohy in the case of dural rent/tear that isn’t obvious until it’s too late. Of course no one thinks it’ll happen to them until it does.

Analgesic onset is quicker with CSE. CSE is safer than bolusing local through the tuohy. I feel the block is more even and less one sided than when I did straight epidurals. It could be the small 25g/27g hole in the dura. It does make sense that as a pressure gradient builds in the epidural space (over time with infusion + PCEA) that some medicine seeps spinal.

Anecdotally (and some studies show CSE superiority and some show no difference) we run lower bupi concentration (0.1%) than we did in my last job but I feel the analgesia is superior. Moms maintain more motor control of their lower extremities with lower bupi concentration, which they appreciate.

Certainly one can see hypotension/pruritis/fetal brady with CSE but it’s relatively rare, temporary, and easily dealt with in places that routinely do CSE. I see less hypotension now than when I bolused bupi through the tuohy which I did to speed onset and decrease one sided catheters.

Anyway, just my opinion. I do a lot of OB.
 
Southpaw said:
The catheter is larger than the 25g durotomy. I’ve never seen migration but I have heard of it. I’m less worried about catheter migration than I am about consequences of bupiv (or any local really) through the tuohy in the case of dural rent/tear that isn’t obvious until it’s too late. Of course no one thinks it’ll happen to them until it does.

Analgesic onset is quicker with CSE. CSE is safer than bolusing local through the tuohy. I feel the block is more even and less one sided than when I did straight epidurals. It could be the small 25g/27g hole in the dura. It does make sense that as a pressure gradient builds in the epidural space (over time with infusion + PCEA) that some medicine seeps spinal.

Anecdotally (and some studies show CSE superiority and some show no difference) we run lower bupi concentration (0.1%) than we did in my last job but I feel the analgesia is superior. Moms maintain more motor control of their lower extremities with lower bupi concentration, which they appreciate.

Certainly one can see hypotension/pruritis/fetal brady with CSE but it’s relatively rare, temporary, and easily dealt with in places that routinely do CSE. I see less hypotension now than when I bolused bupi through the tuohy which I did to speed onset and decrease one sided catheters.

Anyway, just my opinion. I do a lot of OB.
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I wasn’t necessarily thinking catheter ends up intrathecal, just that it’s not in the epidural space. I don’t do CSEs now but in residency I remember a fair amount of times having to replace co-residents CSE epidurals after the initial spinal dose wore off and it became clear the epidural catheter did not work. Probably happens less in PP than academics. I have a slight preference for straight epidurals cause I don’t violate the dura and I bolus through the catheter so I know it works. I do LOR with saline and give a few ccs of saline before threading the catheter so I think that reduces one sidedness a bit although it certainly can happen.

I’m always looking to do things better so I was just curious why you thought cse was superior.
 
LaryngoSpazz said:
I wasn’t necessarily thinking catheter ends up intrathecal, just that it’s not in the epidural space. I don’t do CSEs now but in residency I remember a fair amount of times having to replace co-residents CSE epidurals after the initial spinal dose wore off and it became clear the epidural catheter did not work. Probably happens less in PP than academics. I have a slight preference for straight epidurals cause I don’t violate the dura and I bolus through the catheter so I know it works. I do LOR with saline and give a few ccs of saline before threading the catheter so I think that reduces one sidedness a bit although it certainly can happen.

I’m always looking to do things better so I was just curious why you thought cse was superior.
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It does happen less in PP. But it does happen. Again nothing is perfect in OB. There are times when I don’t get CSF and I know my tuohy is sitting in the epidural space. I just must be much more off midline than I thought or my tuohy is going in at some weird angle. There are times when ligament is super soft and I don’t feel much at all pre-epidural space, and the CSE is nice for confirmation. And of course there are times when my epidural fails.

I work in a large group with diverse experience. I think all of us would agree the CSE is worth the extra step. That said, there’s nothing at all wrong with those who choose to do epidurals. There are times when for various reasons we choose to do an epidural with no CSE. And yeah it works fine.
 
DPE for the best of both worlds 😁

Confirmation of midline and LOR being epidural, slightly faster onset, maybe less one-sided, and still find out right away if your catheter is going to work or not.
 
I hate working with residents that do CSEs. In PP I get it. But in teaching hospitals it drives me insane.
 
Arch Guillotti said:
Why?
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They think their epidural is working great, but once the spinal wears off it reveals itself as not so great.
I feel like most of the blood patches I do are caused by CSEs, but it could be confirmation bias.
But my main gripe is when the junior residents don't get the best education about the effects of rapid analgesia on foetal heart rate. And the completely avoidable urgent sections that get booked for iatrogenic reasons.
 
patriot6 said:
Help me out… why in the world would an intentional dural puncture decrease the risk of PDPH?
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patriot6 said:
I’ve been doing DPEs with 27G whitacre needles for 3 years… don’t think I’ve had a single PDPH from it yet.
Click to expand...

Heh, sorry to poke fun, but I think it's funny that you've been doing DPEs for years but don't know why some people think these dural punctures decrease the PDPH risk. 🙂

The original article touting the virtues of DPEs was ridiculous. For readers who haven't been exposed to this nonsense yet, I'm sorry. DPEs are "dural puncture epidurals" or what's more commonly referred to as magical thinking. The scheme is to get LOR with a Tuohy as usual, then poke a hole in the dura with a spinal needle-through-needle technique, not give any intrathecal drugs, remove the spinal needle, thread the epidural catheter, and dose it like a regular epidural.

They reported faster onset of blockade and less sacral sparing, and also made the outlandish claim that DPEs reduced the risk of PDPH.

Of course, anyone who read the study while sober immediately understood that the observe lower PDPH rate was because they did the study in an academic hospital where trainees were pushing the needles, and a CSE/DPE technique helps newbies effectively probe ahead of the Tuohy if they get an equivocal LOR. Thus ... reducing the incidence of both frank wet taps and subclinical dural tears caused by hamfisted Tuohy drivers.

IMNSHO the very fact that the authors actually tried to make the claim of reduced PDPH incidence with DPEs marks them as wide-eyed gullible doofuses, and throws the rest of the study in doubt.

Stop doing DPEs, guys. You're being silly. If you're going to poke a hole in the dura, make the journey worthwhile and squirt some drugs in there.
 
pgg said:
Heh, sorry to poke fun, but I think it's funny that you've been doing DPEs for years but don't know why some people think these dural punctures decrease the PDPH risk. 🙂

The original article touting the virtues of DPEs was ridiculous. For readers who haven't been exposed to this nonsense yet, I'm sorry. DPEs are "dural puncture epidurals" or what's more commonly referred to as magical thinking. The scheme is to get LOR with a Tuohy as usual, then poke a hole in the dura with a spinal needle-through-needle technique, not give any intrathecal drugs, remove the spinal needle, thread the epidural catheter, and dose it like a regular epidural.

They reported faster onset of blockade and less sacral sparing, and also made the outlandish claim that DPEs reduced the risk of PDPH.

Of course, anyone who read the study while sober immediately understood that the observe lower PDPH rate was because they did the study in an academic hospital where trainees were pushing the needles, and a CSE/DPE technique helps newbies effectively probe ahead of the Tuohy if they get an equivocal LOR. Thus ... reducing the incidence of both frank wet taps and subclinical dural tears caused by hamfisted Tuohy drivers.

IMNSHO the very fact that the authors actually tried to make the claim of reduced PDPH incidence with DPEs marks them as wide-eyed gullible doofuses, and throws the rest of the study in doubt.

Stop doing DPEs, guys. You're being silly. If you're going to poke a hole in the dura, make the journey worthwhile and squirt some drugs in there.
Click to expand...

You’ve channeled Salty Dog. In training institutions I believe that DPEs would reduce the incidence of PDPH vs epidural. I also believe DPE would lead to faster onset and less sacral sparring, though I’m less apt to believe to latter. There’s a lot of sacral sparring in any labor epidural, though I do believe putting a hole in the dura can potentially help with that.

There have been plenty of epidurals in my BMI > 60 ladies where I’m thrilled to be putting a hole in the dura simply for confirmation.
 
Add me to the list of those not a fan of CSE or DPE. My rare exception to my statement is doing an elective cesarian section on a very morbidly obese patient especially with a slow surgeon. I give the surgical anesthesia through the spinal needle and have the catheter for backup. Pencil point needles are much easier to bend than an epidural needle with bone contact and the 6 inch "harpoon needles" are harder to direct and a larger gauge one is going to give the patient a headache.
 
I have no issues with CSE but I am old school with just the traditional Epidural. I won't rehash my technique on this thread but any good epidural bolused with 0.25% Bup provides great initial pain relief followed by an infusion of your choice. These days the cocktail is fairly weak vs what we used to run through the catheters but the motor block is substantially less. Anyone using Ropivacaine these days? I really liked 0.20% Rop for great sensory analgesia but these days the typical stuff is 0.125% Bup. When I made up my own solution I used 0.15% Bup which was superior IMHO.
 
Straight2eight said:
DPE for the best of both worlds 😁

Confirmation of midline and LOR being epidural, slightly faster onset, maybe less one-sided, and still find out right away if your catheter is going to work or not.
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Agreed. DPE is my go to. I don't do it for confirmation. I know I am in the epidural space. I do it for better analgesia that sets up quicker. Anecdotally, that small hole in the dura also seems to help with LA spread in the later stages of pregnancy. I hate being called back to bolus an epidural at 8-9cm with LA or fentanyl. I also hate when the spinal portion of a CSE wears off, and they start feeling a little more and you get paged back to assess. There is also some degree of truth to CSEs infrequently being associated with uterine hypertonicity (the dense, abrupt sympathectomy they experience is no bueno for me). I have seen it multiple times and everyone freaks out and rushes to the OR with scalpels in hand. I have no interest in that. My goal is to achieve a steady state and never step foot in the labor room again. No peaks, no valleys. Not too numb, not too sensate.
 
Maz777 said:
Agreed. DPE is my go to. I don't do it for confirmation. I know I am in the epidural space. I do it for better analgesia that sets up quicker. Anecdotally, that small hole in the dura also seems to help with LA spread in the later stages of pregnancy. I hate being called back to bolus an epidural at 8-9cm with LA or fentanyl. I also hate when the spinal portion of a CSE wears off, and they start feeling a little more and you get paged back to assess. There is also some degree of truth to CSEs infrequently being associated with uterine hypertonicity (the dense, abrupt sympathectomy they experience is no bueno for me). I have seen it multiple times and everyone freaks out and rushes to the OR with scalpels in hand. I have no interest in that. My goal is to achieve a steady state and never step foot in the labor room again. No peaks, no valleys. Not too numb, not too sensate.
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DPE is fine. I’ve not one single time gone to the OR from fetal brady post CSE. Does it happen? Yes occasionally, and it’s temporary. If you work in an institution that is on board with CSEs (RNs and OBs know what to expect) then this is a non issue.

I won’t argue your other points, as to each their own. Whether I’m called back to assess/bolus is largely dependent on which RN is taking care of the patient.
 
I think trainees should do DPEs to start. Maybe the first 25-50. +/- an intrathecal dose to gain some familiarity with it. I got this advice as an intern and it helped me distinguish faster which pops and textures were normal and which were abnormal. I still like to have a CSE kit available in case I have a questionable loss of resistance.

As for onset time, I don’t like that the task falls to us. I can and will place a quick intrathecal dose when it’s indicated, but being called to a room and getting significant relief in about 30 minutes is more a very reasonable expectation and it drives me nuts when L&D nurses start requesting CSEs. I’m friendlier than most with these nurses, but many of them need to drop the outdated thinking that an epidural shouldn’t be placed “too early.”
 
abolt18 said:
What??? Please expound because this, to me, is not common sense.
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I said that CSE is safer than bolusing through the tuohy. I’d like you to consider whether or not it’s safer, over 1,000 epidurals, for a resident to push 8-10cc 0.25% bupi through the tuohy to dilate the space/decrease onset time/decrease one-sidedness vs those same residents pushing 1cc of CSE solution (say 0.25% bupi w 15mcg fent) as a CSE dose.

What is the likelihood of unintended dural rent/tear among those trainees prior to the epidural bolus through the tuohy? What would be the consequences?

Or do you only want to discuss attending placed epidurals? Even then I maintain CSE is safer than bolusing through the tuohy, again based on common sense. CSE is less local for faster onset and proven benefit as I’ve already stated vs bolusing though the tuohy. In my opinion it’s better and safer.
 
Southpaw said:
You’ve channeled Salty Dog.
Click to expand...
That might be one of the nicest things anyone's said about me here.

I agree with your point that CSEs or even DPEs have some value to learners. And I confess, maybe me sometimes too. I had my first wet tap in ages a month or two ago - hospital supply chain kept switching kits on us, and I think the Tuohy in the kit-o-the-day was just sharper than what I was used to. I felt what I thought was a false loss, thought nah, kept going, gush. If I'd tried putting a spinal needle through the Tuohy there and got CSF back then maybe I wouldn't have wet tapped her.
 
I don't really get the whole bolus through Tuohy vs CSE debate? In all likelihood one of you are right, but I do neither.

It takes <30 seconds from LOR --> thread/check catheter --> bolus down the catheter. CSE makes that process longer overall and adds a confounder to the mix. Bolus down Tuohy provides the local maybe 20sec earlier... But I'm not sure that benefit is carried forward to less time in room... You still have to thread the catheter, secure, do documentation/education, orders, etc. If anything it adds an extra 2 seconds in the room because you had to do an additional step.

Maybe I'm just a slow writer
 
pgg said:
Heh, sorry to poke fun, but I think it's funny that you've been doing DPEs for years but don't know why some people think these dural punctures decrease the PDPH risk. 🙂

The original article touting the virtues of DPEs was ridiculous. For readers who haven't been exposed to this nonsense yet, I'm sorry. DPEs are "dural puncture epidurals" or what's more commonly referred to as magical thinking. The scheme is to get LOR with a Tuohy as usual, then poke a hole in the dura with a spinal needle-through-needle technique, not give any intrathecal drugs, remove the spinal needle, thread the epidural catheter, and dose it like a regular epidural.

They reported faster onset of blockade and less sacral sparing, and also made the outlandish claim that DPEs reduced the risk of PDPH.

Of course, anyone who read the study while sober immediately understood that the observe lower PDPH rate was because they did the study in an academic hospital where trainees were pushing the needles, and a CSE/DPE technique helps newbies effectively probe ahead of the Tuohy if they get an equivocal LOR. Thus ... reducing the incidence of both frank wet taps and subclinical dural tears caused by hamfisted Tuohy drivers.

IMNSHO the very fact that the authors actually tried to make the claim of reduced PDPH incidence with DPEs marks them as wide-eyed gullible doofuses, and throws the rest of the study in doubt.

Stop doing DPEs, guys. You're being silly. If you're going to poke a hole in the dura, make the journey worthwhile and squirt some drugs in there.
Click to expand...
DPE, for me, is just when I have a questionable LOR, especially in a morbid obese woman who already caused me to struggle to get in. I see it as another tool in the toolbox.

I'm not a fan of the inappropriate expectations that can be set by the CSE, unless the delivery is moments away, so I'm a straight epidural guy, except in the above circumstances. Also don't like the fact that I don't actually know if my epidural is going to work or not until that spinal wears off. I have not had major issues with one-sided or patchy epidurals since our hospital switched our pumps to intermittent mandatory boluses.
 
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woopedazz said:
I don't really get the whole bolus through Tuohy vs CSE debate? In all likelihood one of you are right, but I do neither.

It takes <30 seconds from LOR --> thread/check catheter --> bolus down the catheter. CSE makes that process longer overall and adds a confounder to the mix. Bolus down Tuohy provides the local maybe 20sec earlier... But I'm not sure that benefit is carried forward to less time in room... You still have to thread the catheter, secure, do documentation/education, orders, etc. If anything it adds an extra 2 seconds in the room because you had to do an additional step.

Maybe I'm just a slow writer
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Maybe you’re just better at epidurals? Maybe your patient population (AU/NZ?) is easier to please? I mean, it’s not really debatable that either dilating the epidural space or poking a hole in the dura leads to a decrease in one-sided epidurals. But we are talking small % difference, so one only notices differences when either their personal, or their departmental, volume is high.
 
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nimbus said:
I felt the catheters were more likely to thread smoothly after a big bolus through the tuohy, but it could have been my imagination.
Click to expand...

This is absolutely true- fewer one sided blooks and less incidence of trauma to adjacent blood vessels combined with a faster onset of the block.
 
What do you all think for labor CSE just giving something like 25mcg of fentanyl intrathecal alone instead of something like dilute LA+opioid 1cc of pump solution? Getting the immmedidiate analgesia without significant motor blockade? I give 5cc test dose and then run the pump infusion. I think I can tell if the catheter is working well or not quicker as the analgesia from fentanyl alone isn’t as dense as pump solution.

I like DPE generally if I’m unsure of the LOR. I do think it’s best we have so far to help confirm placement. I just hate to poke the dura and not give anything. Not too sure as well if I believe the DPE papers about it being so magical. Could be wrong…
 
gagyekum said:
New attending and recently I've been switching to doing CSE for my labor epidural. Unfortunately lately I've had a significant increase in spinal headaches. When i pull the spinal needle, no CSF from the tuohy, cathether passess easily and no response to the test dose. No sign of inadvertent dural puncture. I typically use a 25g spinal needle but now im thinking of switching to a27g. My understanding is that CSE should actually decrease the risk of PDPH but maybe I've been unlucky.

Any advice or tips should be greatly appreciated
Click to expand...
How does CSE decrease risk of PDPH? Compared to what? I haven’t heard that before. Do you have papers about that?

Maybe it’s the type of spinal needle you’re using at your new attending job? Hopefully it’s a pencil point like whiticare/pencan 25G. I remember reading that needle gauge matters really most with cutting needles like quickne needles. Gauge not as important for pencil point.
 
I don’t routinely do CSE, only if epidural requested and delivery is likely to be very quick. DPE is stupid, only would do it in case of difficult epidural, say maybe if replacing one that is not working and it seemed to feel good upon placement.

Let’s be honest, if any of us were a patient in this situation, you would ask for a straight epidural, no dural puncture, lowest risk of complications.
 
I do almost entirely traditional epidurals for labor (DPE occasionally for questionable LoR to avoid a 17G dural puncture). The onset is very fast with an appropriate loading dose. One-sided and misplaced epidurals are still pretty rare in my hands.

For specifics, I leave 5cm of catheter in the epidural space starting the catheter bend facing straight down (not sure if that makes a difference).

Our mix is 0.2% ropivicaine with 2mcg/mL fentanyl which I bolus initially through the catheter with a syringe with the aim of better spread. We don't currently have lidocaine test doses in our kits due to shortage, so I use 3mL of the loading dose as the test dose to make sure it's not intrathecal. I end up giving 11-22 mL total from a syringe including the test dose in divided doses while setting up the pump and they get comfortable real quickly. It's custom practice for patients to be preloaded with 1L of LR to make sure nobody is hypovolemic, but I'll start cautiously before it's finished usually. Always with phenylephrine on me.
 
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