CSE vs. DPE vs. Epidural experience

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dabears505 said:
Curious, how deep do you guys insert touhy before attaching syringe? Also do people do intermittent or continuous pressure?
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2cm, but average LOR depth at my shop is right about 4cm. If I’ve got a biggun (or at my previous gig where LOR was closer to 8cm, then I’ll insert 3-4cm. (Remember Salty’s Law). You can tell when the tip is in interspinous ligament. Waiting till you’re in flavum to put on the syringe is asking for wet taps since a good chunk of people have soft mush burger ligaments with poor feel.


abolt18 said:
Only have experience with doing small advances and checking after each move.
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Intermittent technique is amateur hour. A) it takes longer, and B) you’re advancing without checking so wet tap risk increases. Continuous with a little bounce if you must (that’s why I leave 1/2-1 mL of air in the syringe - for a little bounce and squish that feels oh so good). You need to master continuous technique to move into the big leagues.
 
SaltyDog said:
2cm, but average LOR depth at my shop is right about 4cm. If I’ve got a biggun (or at my previous gig where LOR was closer to 8cm, then I’ll insert 3-4cm. (Remember Salty’s Law). You can tell when the tip is in interspinous ligament. Waiting till you’re in flavum to put on the syringe is asking for wet taps since a good chunk of people have soft mush burger ligaments with poor feel.




Intermittent technique is amateur hour. A) it takes longer, and B) you’re advancing without checking so wet tap risk increases. Continuous with a little bounce if you must (that’s why I leave 1/2-1 mL of air in the syringe - for a little bounce and squish that feels oh so good). You need to master continuous technique to move into the big leagues.
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Will consider trying this, definitely.
 
SaltyDog said:
Intermittent technique is amateur hour. A) it takes longer, and B) you’re advancing without checking so wet tap risk increases. Continuous with a little bounce if you must (that’s why I leave 1/2-1 mL of air in the syringe - for a little bounce and squish that feels oh so good). You need to master continuous technique to move into the big leagues.
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Ive never tried it... Last tap was 2014 but id like to try. Is there a video or technique you recommend?
 
SaltyDog said:
2cm, but average LOR depth at my shop is right about 4cm. If I’ve got a biggun (or at my previous gig where LOR was closer to 8cm, then I’ll insert 3-4cm. (Remember Salty’s Law). You can tell when the tip is in interspinous ligament. Waiting till you’re in flavum to put on the syringe is asking for wet taps since a good chunk of people have soft mush burger ligaments with poor feel.




Intermittent technique is amateur hour. A) it takes longer, and B) you’re advancing without checking so wet tap risk increases. Continuous with a little bounce if you must (that’s why I leave 1/2-1 mL of air in the syringe - for a little bounce and squish that feels oh so good). You need to master continuous technique to move into the big leagues.
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I push it in around 3 for normal bmi. 2 for tiny ladies. I do bounces with an air filled syringe in my right while pushing continuously on the needle with my left. <30 seconds from tuohy entry to threading catheter on a normal bmi lady.
 
I put the toughy in until I feel something ligamenty, and then attach the syringe,continuous. Key is to still advance the toughy very gingerly and try and feel everything at the begining, and check yourself, in a thin patient I would never advance past 3.5 cm or so without checking for LOR.
 
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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Are you a man or a woman?
And I suppose you are being sarcastic?
 
Arch Guillotti said:
Sounds like a really good guy.
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Oh yeah. The one who’s at the top of the list for women to call upon when they are in the agony of bringing life into the world. They are asking for more torture on top of it all.
What a prick. Please don’t be that guy. And don’t learn how to be callous from that guy.
 
chocomorsel said:
Oh yeah. The one who’s at the top of the list for women to call upon when they are in the agony of bringing life into the world. They are asking for more torture on top of it all.
What a prick. Please don’t be that guy. And don’t learn how to be callous from that guy.
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I don't use lido for a 16g catheter and patients don't flinch. Why would it be worse with an 18g tuohy?
 
dhb said:
I don't use lido for a 16g catheter and patients don't flinch. Why would it be worse with an 18g tuohy?
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notsure-1.jpg
 
chocomorsel said:
Well, I would really appreciate some
Lidocaine for a big ass 16G IV. I have had IVs. Much smaller ones. And those things hurt a lot. Much worse than a blood draw.
I try to be nice.
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Just like sometimes a small kidney stone hurts more than delivering a baby, a 16g can be less painful than a 22. #sizedontmatter
If people complained i wouldn't do it but the fact is that they don't.
 
dhb said:
Just like sometimes a small kidney stone hurts more than delivering a baby, a 16g can be less painful than a 22. #sizedontmatter
If people complained i wouldn't do it but the fact is that they don't.
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dude...
have you researched any of this?
last time i checked there was a significant reduction in pain scores from some subcut lido for 18s and bigger... 20s and smaller no benefit afaik

bonuses. .. if you use nitrocaine to numb the vein or even the artery it dilates to twice its size and never spasms so you have a much bigger target and better first pass success. very nice trick
 
personally i think the 10 seconds it takes to freeze the skin is so worth it in terms of patient trust, nitro dilation, more patient tolerance of missed ivs etc.


i just dont wanna be the guy patients remember as the only dude that hurt them during their stay.

i like that im the bringer of pain relief. my wife had surgery and she still remembers and complains about the 'needles'. mother****ers didnt give her midaz or freezing or anything prior to regional block. why the absolute **** like...

if im a patient grand, i can take it, i grew up on a farm on the atlantic coast chasing off wolves and mad bulls. but most people cant, dont and shouldn't have to put up with that
 
Newtwo said:
dude...
have you researched any of this?
last time i checked there was a significant reduction in pain scores from some subcut lido for 18s and bigger... 20s and smaller no benefit afaik

bonuses. .. if you use nitrocaine to numb the vein or even the artery it dilates to twice its size and never spasms so you have a much bigger target and better first pass success. very nice trick
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Nitrocaine? What’s that? Never heard of it. You guys often have stuff we donr
I am guessing in many European countries they don’t have anything similar to Press Ganey scores so people like @dhb could really care less.
But poking a giant 16g without lido seems unintentionally cruel.

Just because they don’t complain doesn’t mean it doesn’t hurt.
 
chocomorsel said:
Never had either to compare. Have you?
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So I've had everything from 18's to 22's letting med students try. I've also had 14 Ga straight needles for double red blood cell donation.

Location and operator skill matters more than size.

Edit: For IV's. I've never shove a 17ga touhy in without local. Especially after bony contact, it's amazing how much duller the some touhy's can be after even one or two light bony contacts.
 
chocomorsel said:
Nitrocaine? What’s that? Never heard of it. You guys often have stuff we donr
I am guessing in many European countries they don’t have anything similar to Press Ganey scores so people like @dhb could really care less.
But poking a giant 16g without lido seems unintentionally cruel.

Just because they don’t complain doesn’t mean it doesn’t hurt.
Click to expand...
nitrocaine isabout 300mcg GTN mixed with 2mls of 2% lidocaine. it was actually in A&A last month for peds art line but wed been doing it for years back home for adult ivs and art lines. doubles first pass success rate at best conservative estimate
 
I like the nitrocaine idea. Just so I'm clear, 300mcg of NTG..? Seems like a big dose...? Must be very little systemic absorption?

Just to play devils advocate...a couple years ago I stopped using lidocaine for local with nerve blocks. it seemed like patients reacted alot to the burn of the lidocaine even with versed, so since it was a 21g needle for the block I just stopped using lido and seems like patients react less to the naked needle.

For epidurals, I still use lido, but they also react a lot and have considered not using it simply because sometimes I'm not sure I'm gaining a whole lot with Lido. Burn vs sharp pain. Thoughts?
 
Add half a mil of bicarb. lido is acidic. that hurts. lido with epi is more acidic and hurts even more

A private practice plastic surgeon was telling me hes being doing that for years and had much better online reviews since. Also bought a second boat. Hardly paid for by NaBic but we can dream

Google the nitrocaine. They were using 4 to 5mcg/kg. no sequelae iirc. Ive certainly not seen any. Its almost so good, its harming patients to not use it i sometimes think
 
Newtwo said:
Add half a mil of bicarb. lido is acidic. that hurts. lido with epi is more acidic and hurts even more

A private practice plastic surgeon was telling me hes being doing that for years and had much better online reviews since. Also bought a second boat. Hardly paid for by NaBic but we can dream

Google the nitrocaine. They were using 4 to 5mcg/kg. no sequelae iirc. Ive certainly not seen any. Its almost so good, its harming patients to not use it i sometimes think
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I will have to try the nitrocaine. I do agree the 300 mcg seems like a big dose, but I geuss your injecting a cc or less with the local anyway.

I will second the bicarbonate for lidocaine. Also helps if it’s warmed up, I usually carry the lido ampule in my pocket to warm it up.
 
So I'm doing another OB month right now and every single epidural I've placed, I've used Lido with the little 25g needle and every single woman has jumped when I placed that tiny little needle in her back....that's whether I go slowly and just barely enter the skin or go deep right away to a half inch or so and then back out. I don't know how the hell anyone shoves a tuohy into someone's back and expects them to be fine with it. That's all well and good if you do it, you'll never hear me claim that it's impossible or that your lying or any BS like that. Personally, I just don't need to save that 10 seconds it takes to pop the vial, draw up the med and stick it in her back.
 
Not an anesthesiologist... But with my second epidural the resident didn't give more lidocaine when she changed levels and it hurt so much more. I also didn't complain because my options were endure the pain of the epidural or go through childbirth unmedicated. But if she hadn't gotten it on that first poke at the second level I was asking her to call her attending to come do it because the pain was so much worse. And she had already been poking for half an hour.
 
MirrorTodd said:
So I'm doing another OB month right now and every single epidural I've placed, I've used Lido with the little 25g needle and every single woman has jumped when I placed that tiny little needle in her back....that's whether I go slowly and just barely enter the skin or go deep right away to a half inch or so and then back out. I don't know how the hell anyone shoves a tuohy into someone's back and expects them to be fine with it. That's all well and good if you do it, you'll never hear me claim that it's impossible or that your lying or any BS like that. Personally, I just don't need to save that 10 seconds it takes to pop the vial, draw up the med and stick it in her back.
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You are a kind person. Child bearing women in labor who want pain relief appreciate people like you and your compassion.
 
DocVapor said:
So I've had everything from 18's to 22's letting med students try. I've also had 14 Ga straight needles for double red blood cell donation.

Location and operator skill matters more than size.

Edit: For IV's. I've never shove a 17ga touhy in without local. Especially after bony contact, it's amazing how much duller the some touhy's can be after even one or two light bony contacts.
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Was asking about kidney stones and babies.
I have had a few IVs in my time without local all over my hand and arm. Those things hurt.
 
OneFellSwoop said:
I like the nitrocaine idea. Just so I'm clear, 300mcg of NTG..? Seems like a big dose...? Must be very little systemic absorption?

Just to play devils advocate...a couple years ago I stopped using lidocaine for local with nerve blocks. it seemed like patients reacted alot to the burn of the lidocaine even with versed, so since it was a 21g needle for the block I just stopped using lido and seems like patients react less to the naked needle.

For epidurals, I still use lido, but they also react a lot and have considered not using it simply because sometimes I'm not sure I'm gaining a whole lot with Lido. Burn vs sharp pain. Thoughts?
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Don't use lido for nerve blocks either, works well.
 
chocomorsel said:
Never had either to compare. Have you?
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No on both accounts

chocomorsel said:
But poking a giant 16g without lido seems unintentionally cruel.
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See that's the point what can appear to be cruel or hurtfull isn't always so.
You know what hurts like a b..ch: a subcue weal and as said above even with a 25g. I'd rather have 1 stick with a 18 or 16g (i do use lido for 14g).
And about the tuohy i've never tried it so just playing devils advocate.
 
dhb said:
No on both accounts


See that's the point what can appear to be cruel or hurtfull isn't always so.
You know what hurts like a b..ch: a subcue weal and as said above even with a 25g. I'd rather have 1 stick with a 18 or 16g (i do use lido for 14g).
And about the tuohy i've never tried it so just playing devils advocate.
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I have had it with both. Hurts a lot less with local actually. When you start using high concentration of local then it burns more. Just need 0.5% lido is all.

Just because they don’t complain or flinch, doesn’t mean they don’t hurt. They probably just suck it up because they don’t know any better and are expecting pain.
 
chocomorsel said:
I have had it with both. Hurts a lot less with local actually. When you start using high concentration of local then it burns more. Just need 0.5% lido is all.

Just because they don’t complain or flinch, doesn’t mean they don’t hurt. They probably just suck it up because they don’t know any better and are expecting pain.
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Or i'm too stupid to see the difference.
 
This pain on injection/iv start has all been studied and discussed before hasnt it? lets leave it at that or for another thread and get back to some great tips on cse! im excited for my next locum to get to try some of your tips!
 
Newtwo said:
This pain on injection/iv start has all been studied and discussed before hasnt it? lets leave it at that or for another thread and get back to some great tips on cse! im excited for my next locum to get to try some of your tips!
Click to expand...

I’m an intermittent technique guy with LOR to air (1-2mm at a time and then check). I’ve experimented over the years and this is what seems to work best for me, I access the space quite quickly, but take my time during the critical part to avoid wet tapping. I don’t inject the entire syringe of air. I get into a zen like state and can either feel or hear my snap through the ligament and then just inject a small amount of air to confirm LOR.

I do some CSEs, usually multips progressing rapidly. Even in those who aren’t progressing rapidly I’ve never had to return to rebolus.

I’ve experimented with DPE as well and think there is some benefit as it anecdotally seems like there are fewer one sided epidurals with it.
 
There’s no one technique that is superior in all situations. In a patient of normal habitus with firm rubbery ligament, a continuous technique with saline and a bubble works well for me. For the no discernible landmarks, mushy ligament type, a gradual intermittent technique with air also works well for me. If you look at a lot of lumbar MRIs you’ll see that the flavum is usually about 3mm thick, so if you advance in increments less than this you aren’t likely push through it. A DPE is nice if you have an ambiguous situation where you suspect a false loss (loss maybe not crisp, catheter won’t thread, etc.). On the other hand, if you see CSF, it is a good opportunity to inject something in it, and make the test dose, dressing application, pump start, and whatever paperwork that needs doing more pleasant for everyone.

Since you often don’t know you’ll want/need one until you get to the space, it’s kind of helpful to just place a wrapped spinal needle on the tray along with an amp of bupi on the cart, so if you do decide you want it, you can ask the nurse to hand it to you in a sterile fashion without giving instructions to her while she roots around in the cart drawers in the dark.
 
@SaltyDog Tried your method while on call last night. Drew up 20ml of solution and squirted it into tray, used that as local and LOR fluid. Felt like the local took longer to set up as opposed to lido...maybe that's just subjective on my part. I did do a cse since the ladies called me a little late, felt like that went smooth, pretty much only used the glass lor syringe. I'm still a resident so while the technique is slick, it doesn't really save me any time since I still have to do the test dose with 1.5% lido anywhere ergo I'm cracking the vials no matter what. Will def keep it in my back pocket. Our attendings are big on dpe as well. Most of the time I open our kit and then forget to insert the spinal needle and just thread the catheter right away anyway. Subjectively haven't noticed or been told that my epidurals suck or that they are always one sided etc, so I think I will just keep doing standard epidurals with the rare cse for a lady who is further along.
 
MirrorTodd said:
[I did do a cse since the ladies called me a little late, felt like that went smooth, pretty much only used the glass lor syringe. I'm still a resident so while the technique is slick, it doesn't really save me any time since I still have to do the test dose with 1.5% lido anywhere ergo I'm cracking the vials no matter what.
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You don't need to do an epidural test dose for a labor CSE.

There are two reasons to do a test dose:

1) The local in the test dose is there to detect an intrathecal catheter. But you just gave an intrathecal dose of local deliberately, so a test dose has no utility for discerning an intrathecal vs epidural catheter.

2) The epi in the test dose is there to detect an intravascular catheter. Setting aside the odds of a soft springwound catheter actually going into a vessel (they don't), you'll detect that extraordinarily rare problem in an hour when you get called for a non working epidural. There's certainly no risk to ~10 mL of epidural mix getting infused IV over an hour. You're doing a labor CSE, not bolusing the catheter with a seizure or cardiovascular collapse dose of local, so what are you so worried about that you need to stand there doing a test dose?

Do the CSE, give the intrathecal dose, insert the catheter, tape it, hit play on the pump, declare victory, walk out.
 
pgg said:
You don't need to do an epidural test dose for a labor CSE.


1) The local in the test dose is there to detect an intrathecal catheter. But you just gave an intrathecal dose of local deliberately, so a test dose has no utility for discerning an intrathecal vs epidural catheter.


Do the CSE, give the intrathecal dose, insert the catheter, tape it, hit play on the pump, declare victory, walk out.
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I'm not an advocate for the test dose, but you will in fact discern epidural vs intrathecal catheter depending on your dose. Most spinal doses for the CSE are 2.5mg bupi or less. It's not a super fast or super dense sensory/motor block in my experience. But it does quickly relieve labor pain especially in late labor. But giving a decent test dose into the intrathecal space for what should be an epidural catheter should give notice to the discerning anesthesiologist.
 
Southpaw said:
I'm not an advocate for the test dose, but you will in fact discern epidural vs intrathecal catheter depending on your dose. Most spinal doses for the CSE are 2.5mg bupi or less. It's not a super fast or super dense sensory/motor block in my experience. But it does quickly relieve labor pain especially in late labor. But giving a decent test dose into the intrathecal space for what should be an epidural catheter should give notice to the discerning anesthesiologist.
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Probably

But then, what's the consequence of an intrathecal catheter after a CSE technique? You're not bolusing 10 mL and risking a high spinal. You'll get called an hour later for a too-numb patient, who's received 5-10 mg of bupi (1/8th % or so epidural solution) over an hour. Also not dangerous.
 
pgg said:
Probably

But then, what's the consequence of an intrathecal catheter after a CSE technique? You're not bolusing 10 mL and risking a high spinal. You'll get called an hour later for a too-numb patient, who's received 5-10 mg of bupi (1/8th % or so epidural solution) over an hour. Also not dangerous.
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That's correct. If no test dose then you'll get called later for a patient who's too numb/too hypotensive in the case of an intrathecal catheter. However I believe efficiency has its merit and I prefer tucking in that epidural as much as I possibly can when I first place it, so I'm not dealing with it/replacing it an hour later.
 
pgg said:
You don't need to do an epidural test dose for a labor CSE.

There are two reasons to do a test dose:

1) The local in the test dose is there to detect an intrathecal catheter. But you just gave an intrathecal dose of local deliberately, so a test dose has no utility for discerning an intrathecal vs epidural catheter.

2) The epi in the test dose is there to detect an intravascular catheter. Setting aside the odds of a soft springwound catheter actually going into a vessel (they don't), you'll detect that extraordinarily rare problem in an hour when you get called for a non working epidural. There's certainly no risk to ~10 mL of epidural mix getting infused IV over an hour. You're doing a labor CSE, not bolusing the catheter with a seizure or cardiovascular collapse dose of local, so what are you so worried about that you need to stand there doing a test dose?

Do the CSE, give the intrathecal dose, insert the catheter, tape it, hit play on the pump, declare victory, walk out.
Click to expand...


1.) Not true. Motor function is still decent after 1 cc of .25% marcaine. Motor function is not decent after a test dose.

2.) I have had a soft catheter go intravascular exactly once. Of course it was a patient that I really didn't want this to happen.
 
@pgg I get what your saying. I've always wondered just how effective the test dose is especially for intravascular stuff because the heart rate varies so wildly during labor. Further, I've often wondered how much ringing in the ears, numbness around the mouth etc a lady is gonna get with 45mg of lido injected intravascularly.

Keep in mind that I am still a resident so I'm not looking to rock the boat at my residency, even though I'll graduate next year. As far as I know and from what we're taught day 1 during our CA1 year of OB, you always do the test dose. I have no idea how the ob peeps would react if I just didn't do it (I'd probably get a PSR thrown my way).

Aside from what you brought up about the cse, it's standard for us to bolus up the new epidural with 5cc's of epidural mix (1/8% bup w/ 2mcg/ml fent) or straight 1/4% bup or straight 1/8% bup, then run the infusion at 6/6/15. So depending on how uncomfortable that lady is while waiting for some effect of that epidural, she could potentially get up to about 51mg of bup intrathecally or intravascularly over an hour if that catheter is in the wrong place. I know for sure I'd have a hard time defending myself if a laboring mom presented with LAST on the labor deck and the attendings ask if I did a test dose during the M/M.

Lastly, I can't remember what kit they use at NIH, but I did have one intravascular catheter during my two months there. I'll have to find out what type of catheter it is. I do remember getting frank blood back when we aspirated.

May have misread what you said earlier. I'll leave this post cause I'm lazy and post call right now.
 
MirrorTodd said:
@SaltyDog Tried your method while on call last night. Drew up 20ml of solution and squirted it into tray, used that as local and LOR fluid. Felt like the local took longer to set up as opposed to lido...maybe that's just subjective on my part. I did do a cse since the ladies called me a little late, felt like that went smooth, pretty much only used the glass lor syringe. I'm still a resident so while the technique is slick, it doesn't really save me any time since I still have to do the test dose with 1.5% lido anywhere ergo I'm cracking the vials no matter what. Will def keep it in my back pocket. Our attendings are big on dpe as well. Most of the time I open our kit and then forget to insert the spinal needle and just thread the catheter right away anyway. Subjectively haven't noticed or been told that my epidurals suck or that they are always one sided etc, so I think I will just keep doing standard epidurals with the rare cse for a lady who is further along.
Click to expand...

yeah if you have to crack the vials and do a test dose anyways it kind of defeats the purpose of this technique. If I’m doing a straight CLE, then I’ll just thread the cath and bolus with the full 5mL test dose plus the 2-3mL of 1% I didn’t use for skin local.
 
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