CSE vs. DPE vs. Epidural experience

[osoprop28]

I know it's somewhat of a personal preference, but any opinion on CSE vs. DPE (dural puncture confirmation epidural) vs. Epidural?

After reading the A&A study comparing the three, it seems like DPE is the best option (obviously depends on each individual), but wanted to hear what you guys thought on this forum.

Also, this might not be totally related, but is there ever an instance where it's OK to do an epidural but intrathecal access (CSE) is contraindicated? Someone asked me and I couldn't think of any answers. I figured if intrathecal access is contraindicated, epidural is contraindicated due to the risk of wet-tap. Is that right?

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[deleted162650]

Also, this might not be totally related, but is there ever an instance where it's OK to do an epidural but intrathecal access (CSE) is contraindicated?

Yeah, anywhere above L2.

DPE is f***ing r***rded. If you're going to access the IT space then for God's sake, put some drug in there.

CSE v. CLE is personal preference with pros and cons for each and has been discussed ad nauseam on this board in the past. Do both and figure out which works better for you.

 

[Guillemot]

Recommend this video. The later part talks about how ****ty we are at assessing spinal level.

 

[nimbus]

I’ve never done a DPE on purpose.

 

[Iso4ane]

I’ve never done a DPE on purpose.

Until you accidentally get a wet tap, then it is?

 

[nimbus]

Until you accidentally get a wet tap, then it is?

Exactly

 

[deleted875186]

I would not want a DPE if it were my body. I do CSEs on fast moving multifarious women that I think will deliver in the next hour or two, otherwise everyone is an epidural.

 

[AdmiralChz]

Never done a DPE and don’t plan to, my partners have been less than impressed with the technique though. I rarely do CSEs these days, we don’t reliably have the correct needles and I’ve been finding myself having to dose the catheter anyways with some frequency.

 

[deleted59964]

help you I will ...

want to be comfortable faster, ask for your epidural earlier.
by putting some 0.25% to load, epidural gives fast onset profound analgesia ... I don't dabble in these new fangled techniques

* edit inspired by Yoda

 

[deleted59964]

Recommend this video. The later part talks about how ****ty we are at assessing spinal level.

thanks Yoda.

 

[vector2]

Recommend this video. The later part talks about how ****ty we are at assessing spinal level.

I’d be more impressed if the model he was using to make those pretty ultrasound pictures weighed about 200% more. Then it would be a bit more relevant to my difficult epidural population.

 

[BLADEMDA]

I don’t puncture the dura if possible when doing an epidural. I like the old fashioned way of simply dosing up the epidural after injecting some local through the epidural needle (0.25 percent). With experience this technique will almost match the onset of analgesia of a CSE (but still slower by about 2-3 minutes).

But, I respect those who choose to do a CSE over a standard epidural. I’ve read the studies and agree that technique is the fastest way to achieve analgesia and the block is slightly denser.

 

[agolden1]

Resident experience:

Multiple OB attendings at my program are big on DPE including a couple of rather curmudgeonly ones who you wouldn't think would be convinced by the data, but have been. We all start out learning regular epidural, but are encouraged to do DPE with after gaining proficiency with standard epidural technique. I'd say 80% of the residents at my shop do a DPE with every epidural they place. Anecdotally I've found that since I started doing DPEs, I've had waaaaayyyyy fewer one sided blocks with a slightly faster onset time. Peak analgesia seems about the same. If you're still mastering the feel of loss of resistance, its also a great confirmatory test to make sure you're in the right place.

We do CSEs under three circumstances. Fast moving multiparous (as dipriman mentioned above), replacement of a failed epidural in patient who is completely miserable, and for repeat cesarean sections in morbidly obese when we know we have slow residents/attendings.

 

[DrZzZz]

Resident experience:

Multiple OB attendings at my program are big on DPE including a couple of rather curmudgeonly ones who you wouldn't think would be convinced by the data, but have been. We all start out learning regular epidural, but are encouraged to do DPE with after gaining proficiency with standard epidural technique. I'd say 80% of the residents at my shop do a DPE with every epidural they place. Anecdotally I've found that since I started doing DPEs, I've had waaaaayyyyy fewer one sided blocks with a slightly faster onset time. Peak analgesia seems about the same. If you're still mastering the feel of loss of resistance, its also a great confirmatory test to make sure you're in the right place.

We do CSEs under three circumstances. Fast moving multiparous (as dipriman mentioned above), replacement of a failed epidural in patient who is completely miserable, and for repeat cesarean sections in morbidly obese when we know we have slow residents/attendings.

I had one attending who was a big fan of DPE when I trained. He was an OB fellowship trained guy (please, hold back your laughter at the poor soul who did an OB fellowship) who liked to do CSE for just about everyone. Then he got into DPE and fell in love with it. In my practice, I only use it for replacement of a non-functioning or one-sided epidural. I personally don't find the CSE that valuable, especially given the extra work of getting the meds for it, the need to draw it up sterile, etc. And we don't have any OB's slow enough where I work to warrant anything more than a spinal for a C-section. I've done maybe 2 DPE's in the past year and both patients were much happier than they had been with their original epidural.

 

[UscGhost]

The extra amount of time it takes to do a CSE (draw up meds...procedure itself) likely eats up most of the benefit of faster onset time.

The patient has been in pain for awhile..a minute or two wont make much difference.

And if you have skiddish nurses or OB...then do a CSE and off to c section you go with the first decel.

 

[deleted162650]

The extra amount of time it takes to do a CSE (draw up meds...procedure itself) likely eats up most of the benefit of faster onset time.

You need to think outside the box a lil’ bit. Doing a CSE doesn’t have to involve drawing up/preparing any extra meds.

 

[AdmiralChz]

And if you have skiddish nurses or OB...then do a CSE and off to c section you go with the first decel.

Preach! So true.

 

[deleted875186]

You need to think outside the box a lil’ bit. Doing a CSE doesn’t have to involve drawing up/preparing any extra meds.

Agreed. Fastest way is probably just squirting some epidural bag mix on your tray and using it.

 

[deleted162650]

Agreed. Fastest way is probably just squirting some epidural bag mix on your tray and using it.

That’s the only fluid I use start to finish for the whole damn procedure.

 

[MoMoGesiologist]

It’s all elective who cares?

 

[GAnoAW]

That’s the only fluid I use start to finish for the whole damn procedure.

For those using this technique, what dose are you using and how quickly does your spinal set up?

In general, I am an epidural purist, though there are occasional situations where I’ll do a CSE. The times I most want it are when the women are jumping all over the place and can’t sit still for even the 1 minute I need them to, from the time I’m in ligament to threading catheter. For these infrequent times, I became a fan of placing a quick single shot spinal to get them to stay still so that I could then place epidural to follow. When I was taught this technique, I did it with 2.5 mg bupi + 10-20 mcg fent. It started to set up within about 2 minutes, which was about as long as it took me to finish setting up my epidural kit so that all in the procedure took only a few minutes longer than the straight epidural. In an effort to simplify and not have to take out the extra meds, after reading other threads here, I’ve now tried this several times with 2.5 cc of our bag mixes. The dose has varied at different sites due to different solutions, but is generally around 2-2.5mg bupi + 5mcg fent, and it seems to do absolutely nothing for me. In line with what I was taught, it seems the fast set up relies on more fentanyl than the bag mix has to offer, but I’m interested in what others’ experiences have been using the mix for spinal and how I can use this more successfully.

 

[deleted875186]

For those using this technique, what dose are you using and how quickly does your spinal set up?

In general, I am an epidural purist, though there are occasional situations where I’ll do a CSE. The times I most want it are when the women are jumping all over the place and can’t sit still for even the 1 minute I need them to, from the time I’m in ligament to threading catheter. For these infrequent times, I became a fan of placing a quick single shot spinal to get them to stay still so that I could then place epidural to follow. When I was taught this technique, I did it with 2.5 mg bupi + 10-20 mcg fent. It started to set up within about 2 minutes, which was about as long as it took me to finish setting up my epidural kit so that all in the procedure took only a few minutes longer than the straight epidural. In an effort to simplify and not have to take out the extra meds, after reading other threads here, I’ve now tried this several times with 2.5 cc of our bag mixes. The dose has varied at different sites due to different solutions, but is generally around 2-2.5mg bupi + 5mcg fent, and it seems to do absolutely nothing for me. In line with what I was taught, it seems the fast set up relies on more fentanyl than the bag mix has to offer, but I’m interested in what others’ experiences have been using the mix for spinal and how I can use this more successfully.

I was taught the same thing, and with such a small dose of fentanyl there occasionally is a woman who doesn’t really get that much relief from a CSE.

 

[pgg]

I have always wondered if the reason studies show DPEs result in more reliable blocks is because those studies are done in academic institutions. Naturally that means the procedures are being done by residents who are just learning now to place epidurals. They benefit from the poke-ahead depth-gauging CSF-seeking spinal needle and it helps them avoid false losses or very lateral epidural catheters.

There's probably something to the faster onset and reduced sacral sparing from the dural puncture, but I suspect the claimed benefits are not as large when the person driving the needle has done it 500 or 1000 times before.

 

[deleted162650]

For those using this technique, what dose are you using and how quickly does your spinal set up?

In general, I am an epidural purist, though there are occasional situations where I’ll do a CSE. The times I most want it are when the women are jumping all over the place and can’t sit still for even the 1 minute I need them to, from the time I’m in ligament to threading catheter. For these infrequent times, I became a fan of placing a quick single shot spinal to get them to stay still so that I could then place epidural to follow. When I was taught this technique, I did it with 2.5 mg bupi + 10-20 mcg fent. It started to set up within about 2 minutes, which was about as long as it took me to finish setting up my epidural kit so that all in the procedure took only a few minutes longer than the straight epidural. In an effort to simplify and not have to take out the extra meds, after reading other threads here, I’ve now tried this several times with 2.5 cc of our bag mixes. The dose has varied at different sites due to different solutions, but is generally around 2-2.5mg bupi + 5mcg fent, and it seems to do absolutely nothing for me. In line with what I was taught, it seems the fast set up relies on more fentanyl than the bag mix has to offer, but I’m interested in what others’ experiences have been using the mix for spinal and how I can use this more successfully.

I use 2.5mL of our bag solution (1/8th% bupi + fent 2/mL). While I'm not sure if I'd say it's instant, it's still faster than when I do a straight CLE (I bolus my CLE's with the full 5mL Lido test dose plus the remaining 2.5mL 1% Lido I didn't use for skin local). Using a bigger IT dose (especially a bigger opioid dose) is when you will start to see more fetal brady issues. I don't really do the CSE for the onset time though. I do it because it's faster for me to squirt bag solution into the tray than to open the three little glass vials, set them into their little wells, and then draw stuff up from them through the filter needle/straw. Actually doing the CSE portion is maybe 7 seconds more than if I just thread the Cath. I get fewer top off requests on CSE patients than CLE patients = a more pleasant OB call experience. The OB nurses are a big fan of my technique as well (coming from unsolicited feedback) so that's why I do what I do.

Figure out what you like and go for it. As I said earlier (I think in this thread), as long as you put some opioid and local in the neuraxial vicinity it works.

 

[bellevueperson]

Usually do straight LEs but will do a DPE if replacing a one-sided epidural, trying to get a multip quickly comfortable, or placing an epidural I think will be difficult and want confirmation that I'm in and won't have to come back to replace it. Anecdotally, it sets up faster than a straight LE with fewer top-offs and haven't had the pruritis and hypotension you can see with a CSE.

 

[Mman]

I have always wondered if the reason studies show DPEs result in more reliable blocks is because those studies are done in academic institutions. Naturally that means the procedures are being done by residents who are just learning now to place epidurals. They benefit from the poke-ahead depth-gauging CSF-seeking spinal needle and it helps them avoid false losses or very lateral epidural catheters.

There's probably something to the faster onset and reduced sacral sparing from the dural puncture, but I suspect the claimed benefits are not as large when the person driving the needle has done it 500 or 1000 times before.

One of the big academic names on a study of DPE admitted to me that was probably much of the reason they have shown success.

 

[deleted131481]

I don’t puncture the dura if possible when doing an epidural. I like the old fashioned way of simply dosing up the epidural after injecting some local through the epidural needle (0.25 percent). With experience this technique will almost match the onset of analgesia of a CSE (but still slower by about 2-3 minutes).

So just to clarify, you get your loss, inject local, then thread your catheter? And if so how much initial volume? I haven't done this in practice but thought this would result in more even/symmetric spread to start that will hopefully continue with the catheter placement.

 

[deleted697535]

Sorry for bumping an old thread but for you guys doing DPE, how do you bill it?
Our billing codes only have CSE or Epidural, no dpe.
Would billing it as CSE be overkill?

 

[nimbus]

So just to clarify, you get your loss, inject local, then thread your catheter? And if so how much initial volume? I haven't done this in practice but thought this would result in more even/symmetric spread to start that will hopefully continue with the catheter placement.

It does and it makes the catheter thread easier. I used to use 10ml when I did OB.

 

[deleted162650]

Sorry for bumping an old thread but for you guys doing DPE, how do you bill it?
Our billing codes only have CSE or Epidural, no dpe.
Would billing it as CSE be overkill?

In the US, there’s no difference in reimbursement. Same code for either.

 

[DrOwnage]

We do CSEs under three circumstances. Fast moving multiparous (as dipriman mentioned above), replacement of a failed epidural in patient who is completely miserable, and for repeat cesarean sections in morbidly obese when we know we have slow residents/attendings.

You do CSEs in someone who's had a failed epidural and likely a decent amount of bolus anesthestic with that still sitting in the space? It thought this was treason punishable by death.

 

[2Fast2Des]

I do cse with 1ml of 0.25 bupi with epi from the vial from our cart. It doesn't add any time to draw up as I just squirt it into one of the wells in the kit. Usually do it if they are progressing quickly or in lot of discomfort so they get done quick relief. I also counsel them about expectations when the spinal wears off so I don't get paged because analgesia is less. So far so good

 

[deleted697535]

In the US, there’s no difference in reimbursement. Same code for either.

Its not where i work ;-) Considerably not!

 

[pgg]

DPE is f***ing r***rded. If you're going to access the IT space then for God's sake, put some drug in there.

As long as we're bumping the thread I thought I'd quote this for emphasis.

 

[deleted697535]

I do cse with 1ml of 0.25 bupi with epi from the vial from our cart. It doesn't add any time to draw up as I just squirt it into one of the wells in the kit. Usually do it if they are progressing quickly or in lot of discomfort so they get done quick relief. I also counsel them about expectations when the spinal wears off so I don't get paged because analgesia is less. So far so good

Do you use a cse kit, or just push a long 27 thru the regular touhy?
Have you seen any problems like hypotension etc with that?
I only did a handful in residency and only in the OR and i kinda regret that now

 

[deleted162650]

Do you use a cse kit, or just push a long 27 thru the regular touhy?
Have you seen any problems like hypotension etc with that?
I only did a handful in residency and only in the OR and i kinda regret that now

Here’s how I do it.

Technique stolen from the guys at Mary Birch Women’s Hospital - one of if not the busiest LD units in CA. They’ve published a couple papers on it. Lead author Gambling if you want to read up.

Take epidural bag and pull the stopper like you’re going to spike it, then lay it on the top of the cart facing you with the opening right at the edge. Open the (standard) epidural tray on top of the cart with the sterile wrap covering the epidural bag except for the opening. Drop a 25 (or 27) x 120mm Whitacre onto the tray. Use the 20mL syringe to suck 15-20mLs of epidural solution (1/8th bupi + 2 fent) and squirt it into the large well in the tray. Suck up 3-4mLs with the LOR syringe, attach the 25g needle and use for skin local/wheal. Remove 25g needle. Insert Tuohy 2ish cms. Suck up 3-4 more mLs solution in LOR syringe and access epidural space. Remove LOR syringe and insert Whit through Tuohy. Draw up 2.5mLs bag solution in the 3mL syringe and inject into IT space. Remove syringe/Whit. Thread cath. Draw up 3-5mLs bag solution with LOR syringe. Inject through cath. Tape. Done.

 

[IMGASMD]

During residency, very very rarely we’d do a cse. So it was always very exciting to do them. After a few, I don’t really see the big deal. We give the same dose as a c-section dose in the needle, leave the catheter in and hoping we won’t have to use it. Heavy bupi, 1.2ml + little fent. Sometimes more, sometimes less....

At my current job, senior partners don’t really believe in cse. So we don’t even have the needle for it. I’ve tried to push a 27g with the touhy we have. Can’t get it. So did a few single shots epidural and hoping it’ll last long enough.......

 

[Status Sciaticus]

why is DPE ******ed? hasnt it been shown to more reliably lead to correct epidural placement and better pain satisfaction scores?

 

[deleted697127]

During residency, very very rarely we’d do a cse. So it was always very exciting to do them. After a few, I don’t really see the big deal. We give the same dose as a c-section dose in the needle, leave the catheter in and hoping we won’t have to use it. Heavy bupi, 1.2ml + little fent. Sometimes more, sometimes less....

This is dumb.

 

[IMGASMD]

This is dumb.

Hey. I didn’t criticize your techniques!

I guess I should have clarified, we don’t routinely place cse, unless in the OR for c-section for super big size parturient.....

 

[deleted697127]

Hey. I didn’t criticize your techniques!

haha sorry. For some reason i assumed you were saying you were giving c section dose for labor epidural.

 

[deleted162650]

why is DPE ******ed? hasnt it been shown to more reliably lead to correct epidural placement and better pain satisfaction scores?

Because if you’re going to poke a hole in the dura, you should be putting some drug in there to achieve maximum benefit for the added step.

Unless you’re a “just the tip, just to see how it feels” kinda guy.

 

[pgg]

why is DPE ******ed? hasnt it been shown to more reliably lead to correct epidural placement and better pain satisfaction scores?

Because the study that showed the technique to be more reliable had CA1s pushing the Tuohy.

I don't believe there's any place for DPEs in the practice of people who are even somewhat good at placing epidurals. Which is basically everyone who isn't an inexperienced resident.

 

[2Fast2Des]

Do you use a cse kit, or just push a long 27 thru the regular touhy?
Have you seen any problems like hypotension etc with that?
I only did a handful in residency and only in the OR and i kinda regret that now

Our kits are epidural cse kits so the long spinal needle comes with. Alternatively we have cse needle kit with tuohy and spinal needle separately you can throw in if you have a regular epidural kit. Haven't seen any issues quite yet, but it gives me time to start analgesia and not rush getting the catheter in, taping, then bolusing, etc. Plus for a difficult epi feel better that I'm in the right spot. If I get called for mom who's just started induction or not much discomfort I'll just do dpe or regular epi, depending on how I feel. Always good to have different tricks up your sleeve so keep up the practice, never know which situation may call for it. As long as no harm is done, and potential benefit can be had, I don't see why not

 

[Status Sciaticus]

Because if you’re going to poke a hole in the dura, you should be putting some drug in there to achieve maximum benefit for the added step.

Unless you’re a “just the tip, just to see how it feels” kinda guy.

Isnt the epidural drug continuously going in by virtue of the hole your tip created? I get CSEs for laboring patients, but for those that are opting for early epidurals, whats the point of giving spinal meds just to give it?

Because the study that showed the technique to be more reliable had CA1s pushing the Tuohy.

I don't believe there's any place for DPEs in the practice of people who are even somewhat good at placing epidurals. Which is basically everyone who isn't an inexperienced resident.

So if the study had attendings doing the epidurals and showed the same results, would you then believe that DPE is the superior choice?

 

[deleted697535]

Here’s how I do it.

Technique stolen from the guys at Mary Birch Women’s Hospital - one of if not the busiest LD units in CA. They’ve published a couple papers on it. Lead author Gambling if you want to read up.

Take epidural bag and pull the stopper like you’re going to spike it, then lay it on the top of the cart facing you with the opening right at the edge. Open the (standard) epidural tray on top of the cart with the sterile wrap covering the epidural bag except for the opening. Drop a 25 (or 27) x 120mm Whitacre onto the tray. Use the 20mL syringe to suck 15-20mLs of epidural solution (1/8th bupi + 2 fent) and squirt it into the large well in the tray. Suck up 3-4mLs with the LOR syringe, attach the 25g needle and use for skin local/wheal. Remove 25g needle. Insert Tuohy 2ish cms. Suck up 3-4 more mLs solution in LOR syringe and access epidural space. Remove LOR syringe and insert Whit through Tuohy. Draw up 2.5mLs bag solution in the 3mL syringe and inject into IT space. Remove syringe/Whit. Thread cath. Draw up 3-5mLs bag solution with LOR syringe. Inject through cath. Tape. Done.

Oh wow
So they do their LOR not to saline, but to the local solution itself? So then you dont obviously need any normal saline and that saves a step which i like. And they also use that same local for the skin wheal which also saves another step!

Then use 3mls of that bupi/fent for the spinal and 3mls for the epidural catheter.

Any concerns ever raised about injecting something from those bags into the IT space? Re sterility etc?
Sorry im talking and typing this out in my head so i dont screw it up

Now our standard labour bag has 0.8% bupi with fent 2mcg/ml. I guess i can still just use the same volumes and it should still be fine right? Just a bit slower onset

 

[MirrorTodd]

Maybe I'm missing something, but is it REALLY that much easier to open the epidural bag by pulling the stopper and then carefully inserting a needle to draw off a couple of cc's, then squirting it onto the tray, rather than just opening a couple of vials that come with the tray and drawing up the meds? Perhaps I have to experience it but it doesn't seem like it's that much easier. Don't you all still use the test dose of lido with epi?

 

[deleted162650]

Isnt the epidural drug continuously going in by virtue of the hole your tip created? I

I really don’t think so. They don’t get headaches so CSF isn’t leaking out - so I don’t believe epidural solution is leaking in.

 

[deleted162650]

Maybe I'm missing something, but is it REALLY that much easier to open the epidural bag by pulling the stopper and then carefully inserting a needle to draw off a couple of cc's, then squirting it onto the tray, rather than just opening a couple of vials that come with the tray and drawing up the meds? Perhaps I have to experience it but it doesn't seem like it's that much easier. Don't you all still use the test dose of lido with epi?

I find it easier/quicker, but your mileage may vary.

No test dose. Test doses are for p*ssies.
And the literature supporting them is shaky at best.

 

[pgg]

Isnt the epidural drug continuously going in by virtue of the hole your tip created?

Some may be going in through the hole. Maybe. I guess. It might account for the marginally "reduced sacral sparing" these studies report, which may or may not actually exist.

Why do people with wet taps get headaches? Because CSF is continuously escaping from the hole that was accidentally made. Kind of makes me wonder how much drug is really going to "flow" against the current of CSF escaping the hole you made in your DPE. Perhaps if your epidural infusion is set to intermittent boluses.

Diffusion across the dura works too. I mean, that's what epidurals relied on before DPEs were cool.

I get CSEs for laboring patients, but for those that are opting for early epidurals, whats the point of giving spinal meds just to give it?

There is no point. Doing a CSE for an "early epidural" makes no sense.

So if the study had attendings doing the epidurals and showed the same results, would you then believe that DPE is the superior choice?

Probably not -

1) "Superior" is a subjective thing. Even if the analgesia actually is "superior" it comes with the cost of elevated PDPH risk - which isn't zero, and is almost certainly greatly underestimated in our OB patients because we simply don't follow up on them 48h+ out, and mild PDPHs are probably just endured by new mothers and attributed to lack of sleep inflicted by their new bundles of joy.

2) Most published research that shows a small/modest effect is bull****.


DPEs are a silly thing to do. You're adding PDPH risk for (probably) no benefit or (at best) a marginal benefit. If a person's still-improving technique in finding the epidural space, or an unusually difficult patient presents herself, I might be convinced there's some benefit (to the anesthesiologist) from DPEs as a probe-ahead crutch.