Epidural placement on obese pts.

[soorg]

Anybody have any help on how to place epidurals (thoracic and lumbar) on someone who is gargantuan? Better yet, how does one avoid a second wet tap on someone who presents for a blood patch?

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[cchoukal]

Since our OB population averages around 250 lbs (and regularly gets near 400), I've got some experience with this population.

1) Discussion of risks and benefits and that the risks of pretty much everything (difficult placement, WT, predominantly) are higher because of their size.

2) Finding midline is my key and can be hard to do without palpable landmarks. I do the following:

a) Between about 175 and 300 pounds, the lovehandles and the spine make a nice cross right at about T11-L1 roughly. This is usually a great place to start.
b) above 300 lbs, though, for whatever reason, the physical and architectural integrity of their largesse breaks down, so you sort of just have to eyeball it.
c) I really try to find spinous process and map it out with my local needle. If I can't reach it with my local needle, I'll use a 20g or 18g spinal needle just to find the process to approximate midline. I know people say that spinous processes can be off kilter and be really misleading, but I think that's pretty rare. All I can say for sure is that if I have a good, reliable contact with the spinous process by one of these methods, I have a really high success rate hitting ligamentum flavum and, ultimately, getting a good epidural.

3) beyond that, it's a matter of keeping the catheter in. In the gorillas, there's a lot of "skin" between the surface and where that catheter is anchored by LF and lots of movement by the patient can supposedly really torque on it. I can't think of the last time I had a laboring patient work their catheter out, though.

4) we have a decent number of patients who ultimately require more than the 10 cm Hustead needle, so we stock what I believe are 15 or 17cm needles, and the accompanying longer spinal needles for CSE. It's really something to watch the babydaddy's eyes widen when they see us whip that badboy out.

Anyway, that's what I do, and it seems to work a high percentage of the time.

As for the bloodpatches, I almost never do them. I've had 4 or 5 wet taps in the last 2 years and left the catheter in the intrathecal space in 4 of them for 24 hrs and none developed headaches.

 

[huktonfonix]

learn to differentiate the tissue by feel. it should be an almost entirely tactile procedure. Ligament is still gonna feel like ligament even in a fatty. If it doesnt feel right, dont just keep shoving the needle blindly. thats how you wet tap. Figure out where you are (hit bone with something if you need to ) and redirect. You should always (midline anyway) feel subQ ,supraspinous, interspinous, flavum, LOR. If you dont, then youre not midline and who knows where youre needle is going.

 

[militarymd]

fluoroscopy

 

[huktonfonix]

fluoroscopy

Touche. Ultrasound may help also.

 

[coprolalia]

Sometimes I just want to know how some of these fat f*cks got pregnant in the first place. Actually... scratch that... I don't really want to know.

-copro

 

[pgg]

Sometimes I just want to know how some of these fat f*cks got pregnant in the first place. Actually... scratch that... I don't really want to know.

-copro

You said it yourself in the fanny pack thread ...

Something about mopeds.

 

[coprolalia]

HAHAHAHA!!!


-copro

 

[cchoukal]

Sometimes I just want to know how some of these fat f*cks got pregnant in the first place. Actually... scratch that... I don't really want to know.

-copro

And the babydaddies (or, "boo," as they're being called now) are always really thin... I'll never figure it.

 

[militarymd]

And the babydaddies (or, "boo," as they're being called now) are always really thin... I'll never figure it.

if you're fat and the chick is fat, you can't get in close enough to do the deed....unless you are only 2 inches...............

..........................







..........from the floor.

 

[Teillard]

\
As for the bloodpatches, I almost never do them. I've had 4 or 5 wet taps in the last 2 years and left the catheter in the intrathecal space in 4 of them for 24 hrs and none developed headaches.

That you heard about.

 

[cchoukal]

These folks stick around at least 3 days post c/s or 2 post vag delivery. We see them every day, have close communication with the rounding ob service, and give them specific instructions to call us if they have headache. It's still possible, I suppose, despite this follow up that they have a headache and don't tell us, but I doubt it.

 

[Laurel123]

I find that sometime with the fatties, their fat folds will form a christmas tree the peaks in the midline. Then put in the needle and ask the patient if they feel any 'pinches' on the left or the right and redirect accordingly. Once you are in ligament, it will feel like ligament. otherwise it just feels like soft squishy fat.

And to answer the question of how the pregnancy occurs, I had that same question in residency. So some of us did a little research and found a nasty porn video for 'chubby chasers' and ordered it for our residency lounge collection so any new resident could see how it was done. It is not to be watched on a full stomach. But it is doggy style with the fatty braced against something and the fatty chaser uses his hands to spread the cheeks while he does the deed. And the dude does need to be of at least average in size.

 

[soorg]

I don't get it either. How does someone that big get pregnant? Forget about just simple physical attraction; I'm talking logistics. Is it physically possible? Guess so. And yer right, the guy is always a toothpick, like 140lbs. Nature is gross.

My favorite is when the gastric bypass patients come in with B-hCGs. Guess even the obese need/get love.

 

[milrisome]

My friend in med school actually asked one of these types how it happened. I won't gross you out with all the details but let's just say there were multiple people and implements involved.