CSE vs. DPE vs. Epidural experience

[nimbus]

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...... and then forget to insert the spinal needle

🤣

.......the fine art of “forgetting” to do stupid things your attending wants you to do.

 

[ButterButter]

Recently, I've had a few tough ligaments that felt like bone. After a few redirects, it was obvious that it was flavum, and I slowly pushed through with good LOR. What I didn't want to do is use too much force and end up with a syringe full of CSF. Is there a special technique that anyone uses to more easily traverse tough ligament? Does anyone twist the tuohy slightly when entering to avoid approaching it with force? Maybe a jiggle? Would this be problematic for any reason?

Edit: if this is one of those 'you're a resident, you have to feel 1000 ligaments before you're not an idiot' things, I'm cool with that

 

[IMGASMD]

Recently, I've had a few tough ligaments that felt like bone. After a few redirects, it was obvious that it was flavum, and I slowly pushed through with good LOR. What I didn't want to do is use too much force and end up with a syringe full of CSF. Is there a special technique that anyone uses to more easily traverse tough ligament? Does anyone twist the tuohy slightly when entering to avoid approaching it with force? Maybe a jiggle? Would this be problematic for any reason?

I’ve come to realization that there are different touhys. There are very sharp and very dull ones. There are ones with or without wings. 17-19G. Purple, red, silver or new.

So the short and long of it, you need to adept to the equipment or get the ones you like to prefect your technique.

 

[deleted162650]

Does anyone twist the tuohy slightly when entering to avoid approaching it with force?

Twisting/corkscrewing leads to an increased incidence of sub-dural blocks/catheters. There’s some old papers where they were studying the effects of sub-dural blocks, and the way they intentionally caused them was to rotate/twist the Tuohy.

The best way is just to brace the back of your hand against the patient’s back so you have stability/control and can advance slowly without jerking even if you need to use a good bit of force.

 

[Twiggidy]

Recently, I've had a few tough ligaments that felt like bone. After a few redirects, it was obvious that it was flavum, and I slowly pushed through with good LOR. What I didn't want to do is use too much force and end up with a syringe full of CSF. Is there a special technique that anyone uses to more easily traverse tough ligament? Does anyone twist the tuohy slightly when entering to avoid approaching it with force? Maybe a jiggle? Would this be problematic for any reason?

Edit: if this is one of those 'you're a resident, you have to feel 1000 ligaments before you're not an idiot' things, I'm cool with that

While maybe these occurrences could be “tough ligament”, I’d make the argument that you’re scraping the surface bone until you get into the epidural space.
So yes I will play the “when you’ve done enough” card and say after a few hundred you’ll know what actual ligament feels like versus “this feels harder than usual so maybe I’m not on the right spot”

 

[deleted162650]

this feels harder than usual so maybe I’m not on the right spot

That’s what she said.

 

[abolt18]

Recently, I've had a few tough ligaments that felt like bone. After a few redirects, it was obvious that it was flavum, and I slowly pushed through with good LOR. What I didn't want to do is use too much force and end up with a syringe full of CSF. Is there a special technique that anyone uses to more easily traverse tough ligament? Does anyone twist the tuohy slightly when entering to avoid approaching it with force? Maybe a jiggle? Would this be problematic for any reason?

Edit: if this is one of those 'you're a resident, you have to feel 1000 ligaments before you're not an idiot' things, I'm cool with that

I have definitely had a few REALLY tough ligaments. I found that a little twist back and forth (maybe 30° each direction) while making miniscule advancements allowed me to get through it without pushing too far.

Edit: but now that I'm reading Salty's response, everything is in question.

 

[Twiggidy]

That’s what she said.

 

[2Fast2Des]

Recently, I've had a few tough ligaments that felt like bone. After a few redirects, it was obvious that it was flavum, and I slowly pushed through with good LOR. What I didn't want to do is use too much force and end up with a syringe full of CSF. Is there a special technique that anyone uses to more easily traverse tough ligament? Does anyone twist the tuohy slightly when entering to avoid approaching it with force? Maybe a jiggle? Would this be problematic for any reason?

Edit: if this is one of those 'you're a resident, you have to feel 1000 ligaments before you're not an idiot' things, I'm cool with that

For this scenario I do the intermittent technique. I've done epidurals where I'm literally putting my whole body weight and sweating while doing continuous technique because of the very tough ligament with that sweet sweet LOR after all that hard work. Just be careful not to wet tap that lol

 

[deleted162650]

You get a nice crisp loss when you pop through lamina.

 

[Southpaw]

Twisting/corkscrewing leads to an increased incidence of sub-dural blocks/catheters. There’s some old papers where they were studying the effects of sub-dural blocks, and the way they intentionally caused them was to rotate/twist the Tuohy.

The best way is just to brace the back of your hand against the patient’s back so you have stability/control and can advance slowly without jerking even if you need to use a good bit of force.

interesting. Thanks for the info. Always learn new things here. For the past several years I’ve transitioned to slow 30 deg turn one way and back the other way while advancing when there’s a tough ligament. I also transition to intermittent. I’ll have to drop the turning technique and go straight intermittent. Generally speaking I’m a continuous advance advocate once you have the basics down.

 

[pocafx]

How do you push for continuous??? Left hand is brake holding touchy and hand against back. Right thumb is giving pressure. What is pushing?

 

[GassYous]

Right palm pushing on syringe from the back, pushing in the tuohy with constant pressure. I did it by leaning my body weight into it although I favor a quick intermittent technique. Left hand is as you described, it is for stability and braking with the medial side braced on the patient while holding the tuohy with the thumb and pointer.

When there's a tough ligament, I just muscle it in by putting body weight on it. The difference between a tough ligament and bone can be subtle but I'm not sure that you can push through bone unless you actually force it. I only turn the needle 180 if I'm already sure that I am in the space but cannot advance the catheter.

 

[deleted875186]

How do you push for continuous??? Left hand is brake holding touchy and hand against back. Right thumb is giving pressure. What is pushing?

I like to hold the toughy shaft 1cm away from the puncture site at the skin, almost as if I was holding the introducer and Whitaker needle after I did a spinal puncture for a SAB, and slowly advance the needle with my left hand, right hand is simply holding pressure on the syringe and not advancing at all.

I think the technique allows you to advance more slowly than an intermittent technique, but doesn’t allow you to get as much leverage on the needle, so I switch to intermittent with a firm ligament if I really need to push.

 

[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.

This is a much better technique than what ive been doing before. Thanks so much!

Next step is to master continuous push LOR technique. How do you hold the needle? Did someone on here push the LOR syringe with heel of their palm?

 

[woopedazz]

You can just push with your thumb, not your palm. Feels much more steady, and you really don't need that much force.

Like this:

I currently do 15-30/week using this technique.
Just be aware that you occassionally you get some ****ty little pseudo-LOR about 1-2cm away from the ED space (I assume from the interspinous ligament?).
While you're getting used to the tactile sensation of continuous pressure you'll probably fall for it a few times; you learn to just plow on through/withdraw a mm and redirect to see if it is replicatable.

My only tip for continuous technique is once you find the space; blast 2-4mL of saline into it to open it up and then sometimes advance another 0.5mm; otherwise you sometimes run into issues with threading the catheter if only the very tip of the touhy is actually in the right spot.

I've only ever used continuous pressure technique (sitting/lateral/wrapped over a ball technique). I've never used intermittent/air for advancing. I've (only) done ~200 EDB and haven't had an IT/PDPH so far. Eventually it'll come, but personally I feel this technique is very safe and reliable - and fast - from personal experience.

 

[deleted162650]

You can just push with your thumb, not your palm. Feels much more steady, and you really don't need that much force.

Like this:
View attachment 318357 View attachment 318358

I currently do 15-30/week using this technique.
Just be aware that you occassionally you get some ****ty little pseudo-LOR about 1-2cm away from the ED space (I assume from the interspinous ligament?).
While you're getting used to the tactile sensation of continuous pressure you'll probably fall for it a few times; you learn to just plow on through/withdraw a mm and redirect to see if it is replicatable.

My only tip for continuous technique is once you find the space; blast 2-4mL of saline into it to open it up and then sometimes advance another 0.5mm; otherwise you sometimes run into issues with threading the catheter if only the very tip of the touhy is actually in the right spot.

I've only ever used continuous pressure technique (sitting/lateral/wrapped over a ball technique). I've never used intermittent/air for advancing. I've (only) done ~200 EDB and haven't had an IT/PDPH so far. Eventually it'll come, but personally I feel this technique is very safe and reliable - and fast - from personal experience.

The left hand should be anchored against the patient‘s back in case they jump/flinch/move.

 

[woopedazz]

The left hand should be anchored against the patient‘s back in case they jump/flinch/move.

Yep, I use 3,4,5th digits to anchor; then the thumb and index to hold the wing and oppose the forward motion.

If you got small hands and are using a long touhy you can try gripping the needle shaft instead.

 

[DrZzZz]

You can just push with your thumb, not your palm. Feels much more steady, and you really don't need that much force.

Like this:
View attachment 318357 View attachment 318358

I currently do 15-30/week using this technique.
Just be aware that you occassionally you get some ****ty little pseudo-LOR about 1-2cm away from the ED space (I assume from the interspinous ligament?).
While you're getting used to the tactile sensation of continuous pressure you'll probably fall for it a few times; you learn to just plow on through/withdraw a mm and redirect to see if it is replicatable.

My only tip for continuous technique is once you find the space; blast 2-4mL of saline into it to open it up and then sometimes advance another 0.5mm; otherwise you sometimes run into issues with threading the catheter if only the very tip of the touhy is actually in the right spot.

I've only ever used continuous pressure technique (sitting/lateral/wrapped over a ball technique). I've never used intermittent/air for advancing. I've (only) done ~200 EDB and haven't had an IT/PDPH so far. Eventually it'll come, but personally I feel this technique is very safe and reliable - and fast - from personal experience.

I also use this technique, with a few slight differences. 1) My fingers advancing the needle are almost touching the back, not way up by the wings as in the photo. This gives me a lot more control, allowing me to advance the needle in smaller distances, and also further helps brace against patient movement. 2) I agree with dilating the space with saline from the LOR syringe, but I never "advance another 0.5mm" once I get loss. I used to do that as a resident (for the same reason of getting the needle tip more in the space to help with threading) and I had 2 wet taps that way. I stopped doing that and haven't had a wet tap since then, over roughly 750 or so epidurals. If I do struggle to pass the catheter, I adjust as necessary depending on my confidence with the loss I got.

 

[Drwine]

I have steadfastly refused to adopt CSE or DPE for labor patients. For rapidly progressing patients, I will give some local through the needle if I am confident I am in the right place before the catheter. The Cochrane report conclusion is no advantage.
There is no such thing as never. I was on call recently and they had a repeat c section on a patient who was now around 200kg when everyone else was home. For once I was grateful that CSE kits were available for the few who disagree with me and do them. Having the longer Pencan spinal needle to even reach the spinal was definitely necessary in this patient and the backup of an epidural was comforting to avoid GA if the spinal wore off if the procedure was too long. The case went fine.

 

[deleted162650]

How do you hold the needle?

My right hand is on the LOR syringe in the usual fashion, like in the pics posted by @woopedazz . My left hand is holding the hub of the Tuohy pinched in between my thumb on top and my index/middle fingers on the bottom. My first and second knuckles (MCP's) are on the patients back. This allows you to use a "rocking" motion to advance the needle with the left hand in addition to the pressure you are applying to the syringe with your right hand/thumb.

 

[gcc322]

I have steadfastly refused to adopt CSE or DPE for labor patients. For rapidly progressing patients, I will give some local through the needle if I am confident I am in the right place before the catheter. The Cochrane report conclusion is no advantage.

Purely anecdotal evidence here - I have been bolusing through the touhy for the last couple months after reading this thread. The biggest benefit I have noticed is less one sided epidurals compared with bolus through catheter.