Dural puncture avoidance

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bedrock said:
Most of the time I just skip contrast for patients with reported contrast allergies.

I will premedicate for most CESI. However, since I do my CESI with catheter, I can skip contrast even on those if needed.
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How do you afford catheters in PP?
 
MitchLevi said:
Extension tubing for all epidurals under all circumstances. That is the single most important safety step in the procedure. Not worried about standard of care because loss of resistance lies.
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You keep extension tubing connected at all times during an epidural? Safety step for who? The patient?
 
po_boy said:
You keep extension tubing connected at all times during an epidural? Safety step for who? The patient?
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As soon as the 25g is on target I attach the purged cath ext tubing and inject contrast. All adjustments made from that point have the tubing in place.
 
po_boy said:
You keep extension tubing connected at all times during an epidural? Safety step for who? The patient?
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It’s the only step that is considered mandatory by SIS.

Once my needle is near my target and I have another one or two little adjustments to make I attach the tubing.

If you put contrast in the patient, then remove the tubing and attach just a syringe of your steroid, you’re increasing the likelihood you wet tap that pt or end up in a vessel.
 
MitchLevi said:
It’s the only step that is considered mandatory by SIS.

Once my needle is near my target and I have another one or two little adjustments to make I attach the tubing.

If you put contrast in the patient, then remove the tubing and attach just a syringe of your steroid, you’re increasing the likelihood you wet tap that pt or end up in a vessel.
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​

You would do this with even LOR technique?

Why not just attach contrast then steroid syringe directly to epidural needle?

How does the absence of tubing or removing tubing increase the likelihood you wet tap or end up in a vessel?
 
po_boy said:

​

You would do this with even LOR technique?

Why not just attach contrast then steroid syringe directly to epidural needle?

How does the absence of tubing or removing tubing increase the likelihood you wet tap or end up in a vessel?
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Touching the needle moves the needle.
Changing syringe on tubing eliminates this.
 
po_boy said:

​

You would do this with even LOR technique?

Why not just attach contrast then steroid syringe directly to epidural needle?

How does the absence of tubing or removing tubing increase the likelihood you wet tap or end up in a vessel?
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As S said, you're moving the needle in an uncontrolled manner, and if you think depressing the plunger doesn't move the syringe you're not paying attention. All of these movements can put you IT, vascular, posterior and out of the target area, etc.

It matters quite a bit.
 
I'm really not trying to be argumentative; just trying to understand.

Are you holding the needle in place with your non-dominant hand while you push the contrast or steroid through the tubing?

If I'm anchoring the needle with my non-dominant hand and not using tubing, I don't see how the needle would move enough to cause in issue.

I trained with tubing during fellowship for all ILESI and TFESI, but we were also going live with fluoro.

I do not use live fluoro for ILESI currently. Are y'all going live for either ILESI or TFESI?
 
po_boy said:
I'm really not trying to be argumentative; just trying to understand.

Are you holding the needle in place with your non-dominant hand while you push the contrast or steroid through the tubing?

If I'm anchoring the needle with my non-dominant hand and not using tubing, I don't see how the needle would move enough to cause in issue.

I trained with tubing during fellowship for all ILESI and TFESI, but we were also going live with fluoro.

I do not use live fluoro for ILESI currently. Are y'all going live for either ILESI or TFESI?
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I don’t think anyone is arguing man. You’re good.

Why use contrast if you’re not live? You can have vascular flow that you’ll miss.

The tubing is the ONLY step in a spine procedure that is “mandatory.” It is clearly safer and IMO you’re practicing outside what I would consider appropriate care.

No live contrast isn’t great either, but the tubing is a legit issue man. I would recommend you use it.
 
MitchLevi said:
I don’t think anyone is arguing man. You’re good.

Why use contrast if you’re not live? You can have vascular flow that you’ll miss.

The tubing is the ONLY step in a spine procedure that is “mandatory.” It is clearly safer and IMO you’re practicing outside what I would consider appropriate care.

No live contrast isn’t great either, but the tubing is a legit issue man. I would recommend you use it.
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Just to be clear: you're advocating for tubing and live fluoro for both CESI and LESI?
 
i advocate for tubing but live fluoro for interlaminars is probably not as necessary if you are seeing contrast appropriately on static images.

saves on radiation. yes maybe only a second or two, but each second is 15-30 seconds per day less radiation to your corneas and gonads...

now tfesi is different and live fluoro is important.
 
No live fluoro for me except cervical TFESI (which I do very rarely) and no tubing except that one. Maybe it’s an anesthesia thing? We just hold the needle all the time for labor epidurals. As long as it’s a luer lok, I have no problem holding the needle still. Just have to stabilize your grip correctly.
 
callmeanesthesia said:
No live fluoro for me except cervical TFESI (which I do very rarely) and no tubing except that one. Maybe it’s an anesthesia thing? We just hold the needle all the time for labor epidurals. As long as it’s a luer lok, I have no problem holding the needle still. Just have to stabilize your grip correctly.
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Holding the needle has worked without fail since day one.

I’m open to new ideas and techniques. However, I fail to see how tubing adds anything to safety. If anything, there’s more of a chance of tugging on the tube and moving the needle IMO.
 
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po_boy said:
Holding the needle has worked without fail since day one.

I’m open to new ideas and techniques. However, I fail to see how tubing ads anything to safety. If anything, there’s more of a chance of tugging on the tube and moving the needle IMO.
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People way smarter and more experienced than anyone in this forum disagree.

Dude, if you do a TFESI anywhere in the spine, use tubing. Less important in the ILESI bc of the LF, and especially if you’re a caveman using an 18 or 20 Tuohy, but if you do a TF use the tubing bc it matters. You’ll also spare your hand radiation.
 
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MitchLevi said:
People way smarter and more experienced than anyone in this forum disagree.

Dude, if you do a TFESI anywhere in the spine, use tubing. Less important in the ILESI bc of the LF, and especially if you’re a caveman using an 18 or 20 Tuohy, but if you do a TF use the tubing bc it matters. You’ll also spare your hand radiation.
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I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
 
callmeanesthesia said:
I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
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Right. Is anyone not using dex for TF?
 
callmeanesthesia said:
I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
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I wouldn’t begrudge you doing that if you’re using dex
 
callmeanesthesia said:
I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
Click to expand...

Agree. I don't do live flouro on anything besides SCS trials, sympathetic blocks, and S1 TFESIs with depo (all other TFESI levels with dex).
 
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