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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?
 

SaltyDog

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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.
 
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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

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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.
 

JobsFan

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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 :laugh:

* edit inspired by Yoda
 

vector2

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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.
 
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BLADEMDA

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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.
 
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agolden1

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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.
 
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DrZzZz

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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.
 
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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.
 
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SaltyDog

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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.
 

GAnoAW

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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.
 
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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.
 

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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.
 

SaltyDog

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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

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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

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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.
 

ragnathor

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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.