CSE vs. DPE vs. Epidural experience

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Newtwo said:
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
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It’s a theoretical risk, but after tens of thousands of these done (actually likely approaching 6 figures by the study authors), I’m unaware of any infections.
 
SaltyDog said:
It’s a theoretical risk, but after tens of thousands of these done (actually likely approaching 6 figures by the study authors), I’m unaware of any infections.
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ok great thank you.
So im getting it right...
Why is the epidural bag 'under' the tray? Is that cause you draw it up with a sterile needle and gloves on?

Isnt that delicate trying to get the needle into the bag without a no sterile hand to balance the bag?
 
Newtwo said:
ok great thank you.
So im getting it right...
Why is the epidural bag 'under' the tray? Is that cause you draw it up with a sterile needle and gloves on?

Isnt that delicate trying to get the needle into the bag without a no sterile hand to balance the bag?
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Yes, you draw it up sterily with both hands gloved and one of the syringes from the tray. That’s why you put it under the sterile wrap the tray comes in. So you can stabilize it with one hand on top. If you still have trouble getting it in the hole, I feel bad for your wife.
 
SaltyDog said:
Yes, you draw it up sterily with both hands gloved and one of the syringes from the tray. That’s why you put it under the sterile wrap the tray comes in. So you can stabilize it with one hand on top. If you still have trouble getting it in the hole, I feel bad for your wife.
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I love the technique, will have to try it... you avoid wasting extra syringes and skip opening any vials
 
Benefits of DPE over CSE - (1) less fetal bradychardia after spinal dose. (2) No call back at 1 hour when spinal wears off and epidural isn’t as strong. (3) still testing the catheter by not doing a spinal.

Benefits of DPE over Epidural - (1) confirmation of correct placement with spinal fluid back. (2) Better B/l spread and less patchy blocks because of spinal entrainment.

downside of DPE: risk of spinal HA from 25G Whit. Which is nearly zero. How often do you get spinal HA with your C/S patients?
 
agammaglobulin said:
Benefits of DPE over CSE - (1) less fetal bradychardia after spinal dose. (2) No call back at 1 hour when spinal wears off and epidural isn’t as strong. (3) still testing the catheter by not doing a spinal.
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You get all those "benefits" over CSE by just doing an epidural. There is no reason to puncture the dura if you're not going to put something in the intrathecal space.


agammaglobulin said:
Benefits of DPE over Epidural - (1) confirmation of correct placement with spinal fluid back. (2) Better B/l spread and less patchy blocks because of spinal entrainment. inexperienced people put catheters in the right place more often if they probe head with a spinal needle
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Fixed that for you. 🙂

DPEs have no rational place in a non-learner's repertoire.

I'll let it go. The world seems divided into DPE believers and DPE unbelievers. If I haven't made my point by now I lack the words to communicate it.
 
IMGASMD said:
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.... 😉
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Wait... you’d give a c section dose of bupivicaine in the labor room? Like 12 mg? Would you run a phenylephrine infusion in the L&D rooms?
 
Propofool123 said:
Wait... you’d give a c section dose of bupivicaine in the labor room? Like 12 mg? Would you run a phenylephrine infusion in the L&D rooms?
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I think this person was referring to elective CS.

I rotated at another major hospital during residency and all the anesthesia residents were surprised when I did a CSE in a laboring patient, some places just never do them outside of the operating room it seems.
 
dipriMAN said:
I think this person was referring to elective CS.

I rotated at another major hospital during residency and all the anesthesia residents were surprised when I did a CSE in a laboring patient, some places just never do them outside of the operating room it seems.
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This. Thanks.
 
SaltyDog said:
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.
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They don't get headaches for the same reason patients getting a spinal for a c-section don't get headaches. You're not doing the dural puncture with a large quincke or a Tuohy during the DPE. As @pgg noted though, not sure whether the solution from the infusion into the epidural space is enough to create a gradient to push some through that dural hole. Personally, I only do a DPE if I'm replacing a spotty/one-sided epidural. I'm not convinced it adds much effect, but the literature supports it and it takes 5 extra seconds to do. And when you tell a patient that you have "confirmed" the epidural needle is in the correct spot because you got csf with the spinal needle passed beyond it, that puts it in their head that this new catheter is in the correct spot. It's all about setting expectations on L&D.
 
DrZzZz said:
They don't get headaches for the same reason patients getting a spinal for a c-section don't get headaches. You're not doing the dural puncture with a large quincke or a Tuohy during the DPE.
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Ya exactly - so I don’t buy that any epidural solution leaks in through the essentially non-existent hole you just made once the needle is out.

Why not just give them an IT dose then as well when replacing a spotty epidural? You’ve confirmed placement, and you give them instant relief since they’ve been putting up with a sketchidural.


DrZzZz said:
It's all about setting expectations on L&D.
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100% agree.
 
SaltyDog said:
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.
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Nah, DPE is fine. When it was me doing the procedure, I usually only DPE'd to confirm if it was a sketchy loss or something, because I felt like my CLEs had good efficacy. But, DPE is ideologically legitimate and you're being a bit dogmatic. The efficacy is well documented. At my current place, it's the standard and I think when you have a range of providers doing the procedure (residents, CRNAs, attending doc) the DPE is a rising tide that lifts all boats.

Also, "ret*rded"?
 
dipriMAN said:
I think this person was referring to elective CS.

I rotated at another major hospital during residency and all the anesthesia residents were surprised when I did a CSE in a laboring patient, some places just never do them outside of the operating room it seems.
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No, I routinely do CSE’s in a laboring patient. However I do not use 12 mg (full c-section dose) of bupi in the intrathecal dose. I give around 2 mg (if i remember correctly) and theN run the brew through the epidural.

Btw, what concentration do y’all run through your epidural brews?
 
I am a fan of dpe. I’ll do a regular epidural here and there if there’s no cse kit available. I seem to get less patchiness. I also very rarely get called back for additional boluses, so I sleep more. I feel like spinal dosing is overkill for labor and sets you up for higher expectations, especially if you have a needy population. Don’t hate on me bro!
 
Folsommd said:
sets you up for higher expectations, especially if you have a needy population
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This is an oft cited reason for not doing CSEs - it’s a myth. I wouldn’t do it if I got called back for boluses all the time. The guys at a super busy women’s hospital (where they routinely place 12+ epidurals on a 12 shift plus sections at night) wouldn’t do it if they got called for boluses regularly. I get called to bolus my CSEs less than I do to bolus straight CLEs places by my partners.

The same people that cite this reason for not doing a CSE have no problem loading their epidural with 1/4% bupi 😕.

I will say this though. As long as you put some local and some opioid in the epidural space, you’re going to have happy patients. The rest is just splitting chinchilla hairs (it’s fun to argue about though 😀).
 
SaltyDog said:
I think you’re missing why I think it’s a stupid technique. I understand the rationale for using it as a confirmation that you’re in the epidural space. I think that is legitimate and useful - especially when dealing with trainees or nurses or anyone who suffers from skillopenia.

What I think is stupid, is then pulling the needle out without dosing the IT space. The needle ALREADY in there! Make the most out of it. Don’t be a tease.

And sorry. I think the technique is “special”.
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Anecdotal, but I tend to get more callbacks for top-ups from patients I do CSE on because they get the unrealistic expectations that their epidural is supposed to provide relief that spinals provide, and anything less than that is torture.
 
GandalfTheWhite said:
Anecdotal, but I tend to get more callbacks for top-ups from patients I do CSE on because they get the unrealistic expectations that their epidural is supposed to provide relief that spinals provide, and anything less than that is torture.
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The key to that I find is setting expectations and tell them when it will wear off and the difference to expect. And nurses to help explain and keep mom from panicking when they have a good level.
 
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Those doing CSE for laboring women, how much bupi are you putting in there? Plus maybe 12.5-25mcg fentanyl?
 
1.25-2.5mg (if they’re advanced dilation and ready to pop). No Fentanyl. Less pruritis.
 
SaltyDog said:
I think you’re missing why I think it’s a stupid technique. I understand the rationale for using it as a confirmation that you’re in the epidural space. I think that is legitimate and useful - especially when dealing with trainees or nurses or anyone who suffers from skillopenia.

What I think is stupid, is then pulling the needle out without dosing the IT space. The needle ALREADY in there! Make the most out of it. Don’t be a tease.

And sorry. I think the technique is “special”.
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I do agree that it doesn’t make sense to do a rural puncture and than not dose some IT local and opioid. The people that claim there is no PDPH risk from a DPE are delusional, the studies from the brigham had too few patients to find any PDPHs.

I will add thatthe risk of causing fetal bradycardia is the reason I never do CSEs except in the case of immenent delivery. If your doing them routinely I think it sets you up for more fetal bradycardia, although maybe I’ve just been using too high a dose of IT fentanyl.
 
I have one goal when placing a labor epidural. Not to be called back to the room. Anecdotally, the page back to the labor room for top-ups seems to be lower with DPEs. That hole in the dura does wonders in the later stages of labor, and they don't get used to the initial density of the CSE bolus.
 
SaltyDog said:
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.
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If it's speed you are after, I suggest drawing up the "sub-Q" lidocaine in your loss of resistance syringe, hooking up the Tuohy needle to it, and eliminating the subcutaneous wheel altogether. The back is not densely innervated. Your patients will not know the difference between a 25-gauge, 22-gauge, or a 17-gauge, especially since it's the lidocaine that they feel. (And, unlike when you're starting an iv--where the skin is densely innervated and the target is very superficial (and the patient might be looking on, ready to move away at the slightest provocation), your needle shouldn't be spending a lot of time at the surface. One stick through the skin, then it's advancing through subcutaneous tissues. Taking time to infiltrate a large wheel and wait for the numbness to set up is more or less unnecessary.

I use about half of the 5 cc of lidocaine as I advance the needle. I attain a loss of resistance and push in the remaining 2-3 cc, allowing the medicine to start working immediately (and not diluting my bolus dose with saline). I then thread the catheter, test it, and am done before the nurses can believe it.

Other benefits: no need to "probe" with your local administration in heavier-set patients, as we were instructed to do in residency (when anatomic landmarks weren't readily apparent), then stick a much bigger needle in and start "probing" anew. This way, you are probing with the very need you are advancing, all the while making progress that should not have to be repeated.
 
C4C said:
If it's speed you are after, I suggest drawing up the "sub-Q" lidocaine in your loss of resistance syringe, hooking up the Tuohy needle to it, and eliminating the subcutaneous wheel altogether. The back is not densely innervated. Your patients will not know the difference between a 25-gauge, 22-gauge, or a 17-gauge, especially since it's the lidocaine that they feel. (And, unlike when you're starting an iv--where the skin is densely innervated and the target is very superficial (and the patient might be looking on, ready to move away at the slightest provocation), your needle shouldn't be spending a lot of time at the surface. One stick through the skin, then it's advancing through subcutaneous tissues. Taking time to infiltrate a large wheel and wait for the numbness to set up is more or less unnecessary.

I use about half of the 5 cc of lidocaine as I advance the needle. I attain a loss of resistance and push in the remaining 2-3 cc, allowing the medicine to start working immediately (and not diluting my bolus dose with saline). I then thread the catheter, test it, and am done before the nurses can believe it.

Other benefits: no need to "probe" with your local administration in heavier-set patients, as we were instructed to do in residency (when anatomic landmarks weren't readily apparent), then stick a much bigger needle in and start "probing" anew. This way, you are probing with the very need you are advancing, all the while making progress that should not have to be repeated.
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interesting. im all for saving time on these repetitive tasks we do 100s of times per year (sometimes even over 1000). im not so sure about there being no difference in pain felt between the various needles... do you have any data on that?

i dont really want patients to remember me as the guy that stabbed them in their spine
 
Newtwo said:
interesting. im all for saving time on these repetitive tasks we do 100s of times per year (sometimes even over 1000). im not so sure about there being no difference in pain felt between the various needles... do you have any data on that?

i dont really want patients to remember me as the guy that stabbed them in their spine
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100% agree. Patients can feel the difference between a 25G needle injecting some lidocaine, versus a 17G blunt ass toughy being shoved into their back.
 
C4C said:
If it's speed you are after, I suggest drawing up the "sub-Q" lidocaine in your loss of resistance syringe, hooking up the Tuohy needle to it, and eliminating the subcutaneous wheel altogether. The back is not densely innervated. Your patients will not know the difference between a 25-gauge, 22-gauge, or a 17-gauge, especially since it's the lidocaine that they feel. (And, unlike when you're starting an iv--where the skin is densely innervated and the target is very superficial (and the patient might be looking on, ready to move away at the slightest provocation), your needle shouldn't be spending a lot of time at the surface. One stick through the skin, then it's advancing through subcutaneous tissues. Taking time to infiltrate a large wheel and wait for the numbness to set up is more or less unnecessary.

I use about half of the 5 cc of lidocaine as I advance the needle. I attain a loss of resistance and push in the remaining 2-3 cc, allowing the medicine to start working immediately (and not diluting my bolus dose with saline). I then thread the catheter, test it, and am done before the nurses can believe it.

Other benefits: no need to "probe" with your local administration in heavier-set patients, as we were instructed to do in residency (when anatomic landmarks weren't readily apparent), then stick a much bigger needle in and start "probing" anew. This way, you are probing with the very need you are advancing, all the while making progress that should not have to be repeated.
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I disagree about the skin wheal.

I agree about not pointlessly poking all over the place with the local needle.

I’ll see your 3cc bolus and raise you 17cc (of 0.2% ropivicaine)
 
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abolt18 said:
I hear you, but I am now curious to try what was described.
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I'll save you some time. One of my attendings who, admittedly, is one of our best at placing epidurals will never re-localize if he has to go up or down a level. He just says "Sorry!" while he jams a blunt 17g needle into the patient's back. They almost always jump, many of them say expletives. It's completely needless and saves at most 10 seconds of time.
 
Mehd School said:
I'll save you some time. One of my attendings who, admittedly, is one of our best at placing epidurals will never re-localize if he has to go up or down a level. He just says "Sorry!" while he jams a blunt 17g needle into the patient's back. They almost always jump, many of them say expletives. It's completely needless and saves at most 10 seconds of time.
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Sounds like a really good guy.
 
I mean you're talking about a very powerful lobbying group on the labor floor with all the RNs and estrogen going around. They're going to figure out what you're doing (or not doing) & then you're ****ed.
You could possibly get sacked for that depending on other transgressions. I certainly do not want to risk that. ill take the extra 20 seconds there

I like being known as the guy that gives a good epidural (fast, reliable, no taps), not the back stabber (at least thats what they say to me, im sure they call me an a$$ behind my back lol)
 
Newtwo said:
I mean you're talking about a very powerful lobbying group on the labor floor with all the RNs and estrogen going around. They're going to figure out what you're doing (or not doing) & then you're ****ed.
You could possibly get sacked for that depending on other transgressions. I certainly do not want to risk that. ill take the extra 20 seconds there

I like being known as the guy that gives a good epidural (fast, reliable, no taps), not the back stabber (at least thats what they say to me, im sure they call me an a$$ behind my back lol)
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Nurse Lobbying group is a very diplomatic way of putting it.
 
Newtwo said:
im not so sure about there being no difference in pain felt between the various needles... do you have any data on that?
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Just my experience over the last year and a half.

Try it for yourself and come back and report. You aren't going to hurt my feelings, either way.

I'm not here to brag or chide people who do things a different way, but after a year and a half of doing it this way, I see no reason to go back to making multiple stabs. And--again, not to brag--but even having gotten a reputation as a fast guy, I still get nurses who simply can't help themselves and have to look over the patient's shoulder to confirm I'm finished when I say "all done." No, fast is not the primary goal. A safe, functioning epidural catheter is the goal. If she gets more comfortable more quickly with this technique in my hands that the standard, fuddy-duddy method of multiple sticks, even better.

And, as to the guy who honorably stands up for his wife and won't allow this technique on his wife: Yeah, I'm going to offer you the most favorable possible interpretation of your snark and figure that you meant to say that you won't try this on any patient at all, because you are uncomfortable trying it on your own wife. Good for you. I will counter that I treat all my patients exactly as I would want my loved ones treated, and there ain't no way in Hell I would suggest a stylistic improvement on a public forum if I didn't prefer that very same technique for my own wife.



On a separate note, is the private forum any better? I have thick skin and don't really care that internet strangers come here not for advice or suggestions but to crap all over novel advice and suggestions. I can't help but be reminded of this thread (Securing epidural) where abolt18 sketched a very helpful way of securing epidural catheters, and then everybody dumped on him because his sketch wasn't up to JAMA's editorial standards


I'd probably go check out the private forum, but last I looked into it, you had to be an ASA member, which I am not.
 
triggermaster said:
I disagree about the skin wheal.

I agree about not pointlessly poking all over the place with the local needle.

I’ll see your 3cc bolus and raise you 17cc (of 0.2% ropivicaine)
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I'm sorry if I wasn't clear. I don't mean to imply that my bolus is 3 cc of 1% or 1.5% lidocaine and nothing more. No, I get a loss of resistance with lidocaine. I then thread the catheter, and test with 5cc of lido + epi. Then I secure the catheter, ask the patient to lie back, and give 0.25% bupi, sometimes as little as 5 ccs. Sometimes as much as 10 cc. I find that without the saline in the epidural space diluting the local anesthetic, and with the ~30 second head start that the 3 cc of loss of resistance lidocaine has offered, my patients are already having to be told they are having contractions before I have finished my paperwork. And, knock wood, in the last year and a half since I've been loading with 0.25% bupi rather than 0.5% bupi (to counteract the normal saline LOR fluid), I have not yet been called back to deal with hypotension.



I'm not trying to brag, but IN MY EXERIENCE, if I warn the patient that she is going to feel a stick in her back, if I press firmly with my thumb fingernail to prepare her, and if I lead with the sharp edge of the Tuohy, that the patients do very, very well. I wouldn't have come here suggesting y'all gotsta check this out if I didn't find it remarkable how much better and easier it was for both the patient and for me.

Again, try it or don't. I don't care. The bullies who know everything are obviously going to take up more space on these forums. But people open to new ideas still benefit from hearing about new ways to skin cats.
 
So you don't invest the ten seconds it takes to draw up and place some local but you're gonna waste time stabbing her in the back with your thumbnail? I can see placing a 25 g pencan without local but the tuohy? Jesus...
 
C4C said:
Just my experience over the last year and a half.

Try it for yourself and come back and report. You aren't going to hurt my feelings, either way.

I'm not here to brag or chide people who do things a different way, but after a year and a half of doing it this way, I see no reason to go back to making multiple stabs. And--again, not to brag--but even having gotten a reputation as a fast guy, I still get nurses who simply can't help themselves and have to look over the patient's shoulder to confirm I'm finished when I say "all done." No, fast is not the primary goal. A safe, functioning epidural catheter is the goal. If she gets more comfortable more quickly with this technique in my hands that the standard, fuddy-duddy method of multiple sticks, even better.

And, as to the guy who honorably stands up for his wife and won't allow this technique on his wife: Yeah, I'm going to offer you the most favorable possible interpretation of your snark and figure that you meant to say that you won't try this on any patient at all, because you are uncomfortable trying it on your own wife. Good for you. I will counter that I treat all my patients exactly as I would want my loved ones treated, and there ain't no way in Hell I would suggest a stylistic improvement on a public forum if I didn't prefer that very same technique for my own wife.



On a separate note, is the private forum any better? I have thick skin and don't really care that internet strangers come here not for advice or suggestions but to crap all over novel advice and suggestions. I can't help but be reminded of this thread (Securing epidural) where abolt18 sketched a very helpful way of securing epidural catheters, and then everybody dumped on him because his sketch wasn't up to JAMA's editorial standards


I'd probably go check out the private forum, but last I looked into it, you had to be an ASA member, which I am not.
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hey im not trying to rag on you! if it came across that way i apologize...

im just trying to tease it out in my head. as a relatively junior staff who picks up locums in different places and an img i dont wanna upset the apple tart.

im all for efficiency though
 
C4C said:
Just my experience over the last year and a half.

Try it for yourself and come back and report. You aren't going to hurt my feelings, either way.

I'm not here to brag or chide people who do things a different way, but after a year and a half of doing it this way, I see no reason to go back to making multiple stabs. And--again, not to brag--but even having gotten a reputation as a fast guy, I still get nurses who simply can't help themselves and have to look over the patient's shoulder to confirm I'm finished when I say "all done." No, fast is not the primary goal. A safe, functioning epidural catheter is the goal. If she gets more comfortable more quickly with this technique in my hands that the standard, fuddy-duddy method of multiple sticks, even better.

And, as to the guy who honorably stands up for his wife and won't allow this technique on his wife: Yeah, I'm going to offer you the most favorable possible interpretation of your snark and figure that you meant to say that you won't try this on any patient at all, because you are uncomfortable trying it on your own wife. Good for you. I will counter that I treat all my patients exactly as I would want my loved ones treated, and there ain't no way in Hell I would suggest a stylistic improvement on a public forum if I didn't prefer that very same technique for my own wife.



On a separate note, is the private forum any better? I have thick skin and don't really care that internet strangers come here not for advice or suggestions but to crap all over novel advice and suggestions. I can't help but be reminded of this thread (Securing epidural) where abolt18 sketched a very helpful way of securing epidural catheters, and then everybody dumped on him because his sketch wasn't up to JAMA's editorial standards


I'd probably go check out the private forum, but last I looked into it, you had to be an ASA member, which I am not.
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Great discussions in the private forum. I think it's either ASA OR verified member, i.e. they confirm your identity. But I may be wrong.
 
GassYous said:
So you don't invest the ten seconds it takes to draw up and place some local but you're gonna waste time stabbing her in the back with your thumbnail? I can see placing a 25 g pencan without local but the tuohy? Jesus...
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Sometimes you have to see things with your own eyes to belive them.
I don't doubt C4Cs technique because i've see chest tubes put in smoothly with a wheal of saline at the skin.
 
Curious, how deep do you guys insert touhy before attaching syringe? Also do people do intermittent or continuous pressure?
 
Propofool123 said:
Until I feel engaged. Continuous.
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I had an attending that swore by this technique. Gave it a try for a while, seemed to work well. Then I had a patient I was 5cm deep on but felt no engagement. She was tiny and it didn’t seem right so I hooked up syringe and had LOR right where I was. I don’t do it like that anymore.
 
Beeftenderloin said:
I had an attending that swore by this technique. Gave it a try for a while, seemed to work well. Then I had a patient I was 5cm deep on but felt no engagement. She was tiny and it didn’t seem right so I hooked up syringe and had LOR right where I was. I don’t do it like that anymore.
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Same, in residency I was getting good and fast at epidurals and got burned with a super thin ligamentum that I didn't get that feel and syringe filled up quickly with clear. Since then I am more cautious and engage ever so slightly or just before ligament to avoid tapping.
 
dabears505 said:
Curious, how deep do you guys insert touhy before attaching syringe? Also do people do intermittent or continuous pressure?
Click to expand...
For midline approach (which I start with for all my labor/lumbar epidurals) I'll first consider the size of the patient and their adipose load. Skinny small person I may put the syringe on after 2.5cm (had LOR just beyond that before), but in the big ones, I may be at 7 or 8cm before I even start checking. A lot of that also depends on the tactile feedback and obviously I'll stop sooner if it feels like I'm engaged in ligament.

Thoracic epidural, I like to do paramedian now (learned midline first) and I won't put the LOR syringe on until I feel ligament.

Never done continuous. Only have experience with doing small advances and checking after each move.
 
2Fast2Des said:
Same, in residency I was getting good and fast at epidurals and got burned with a super thin ligamentum that I didn't get that feel and syringe filled up quickly with clear. Since then I am more cautious and engage ever so slightly or just before ligament to avoid tapping.
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One of my partners who has done thousands if not tens of thousands of epidurals would always say.....

“Either they’re lying or they haven’t done enough....”
 
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