Epidural Techniques-Pros and Cons

[Disse]

Since I've been reading this forum more and more lately (it really is not only educational for all levels I think but entertaining as well) I figured I'd start a post on something I've been thinking about since reading some of the choices people made in different topics on techniques--particularly epidurals.

Jet, I believe, has stated how he only does Combined Spinal-Epidurals now (CSE) while others have stated a few pros/cons to their individual techniques. What I'd like to do is devote a post strictly to epidurals and see what everyone has to say (coming off OB call I guess I have epidurals on my mind ).

Anyway, my particular preference is fairly straight forward. Reach epidural space, thread catheter, test dose and secure catheter. Initial bolus is usually 10 cc's 0.125% bupivicaine with 1ug/cc fentanyl plus an initial 50 ug of fentanyl (so a total of 11 cc's of which the patient may or may not get the entire 11 cc's in incremental dosages), start infusion, finish charting (gives me a few bp's to watch) then leave. I rarely have hypotension I need to treat, the lipid soluble fentanyl works quickly for the patient and the nurses rarely bug me for redoses.

Other techniques:
CSE with straight bupivicaine: Epidural space Identified, 120mm 24 or 27 ga sprotte (haven't really seen a difference in HA incidence with either and the 24 ga fits the 18ga Touhy almost perfect so that if you get CSF you are almost assuredly in the epidural space with your catheter). 1/2 cc 0.25% bupivicaine intrathecal, thread catheter and quickly test dose, secure and lay patient down). Disadvantage: Hypotension and untested catheter. Also, from a resident perspective, it is not uncommon for the spinal dose to wear off for a patient who is laboring for a long time and, while the epidural is functioning fine (excellent dermatomal distribution etc. etc.) the less-dense epidural analgesia isn't the same as the dense intrathecal analgesia, less sacral nerve root coverage and more calls for a "non-functioning" epidural late in labor.

CSE with narcotic only: Same technique as above but 25 ug of fentanyl intrathecally. Pros: Less hypotension, quick onset of analgesia without dense motor blockade, nice transition to epidural with infusion (i.e. start infusion after securing catheter and rarely need to bolus). Cons: Itching and while onset of analgesia is somewhat faster, 50 ug of fentanyl in epidural space works very quickly without having to use another needle. I know some folks use other, longer-acting narcotics, in the intrathecal space and it would be interesting to hear what people have to say.

My transition for technique preference was CSE w/local, CSE/narcotic, to now essentially epidural w or w/o narcotic (unless the patient is morbidly obese and loss of resistance is questionable--then the spinal needle can be very helpful).

Comments?

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[jetproppilot]

Since I've been reading this forum more and more lately (it really is not only educational for all levels I think but entertaining as well) I figured I'd start a post on something I've been thinking about since reading some of the choices people made in different topics on techniques--particularly epidurals.

Jet, I believe, has stated how he only does Combined Spinal-Epidurals now (CSE) while others have stated a few pros/cons to their individual techniques. What I'd like to do is devote a post strictly to epidurals and see what everyone has to say (coming off OB call I guess I have epidurals on my mind ).

Anyway, my particular preference is fairly straight forward. Reach epidural space, thread catheter, test dose and secure catheter. Initial bolus is usually 10 cc's 0.125% bupivicaine with 1ug/cc fentanyl plus an initial 50 ug of fentanyl (so a total of 11 cc's of which the patient may or may not get the entire 11 cc's in incremental dosages), start infusion, finish charting (gives me a few bp's to watch) then leave. I rarely have hypotension I need to treat, the lipid soluble fentanyl works quickly for the patient and the nurses rarely bug me for redoses.

Other techniques:
CSE with straight bupivicaine: Epidural space Identified, 120mm 24 or 27 ga sprotte (haven't really seen a difference in HA incidence with either and the 24 ga fits the 18ga Touhy almost perfect so that if you get CSF you are almost assuredly in the epidural space with your catheter). 1/2 cc 0.25% bupivicaine intrathecal, thread catheter and quickly test dose, secure and lay patient down). Disadvantage: Hypotension and untested catheter. Also, from a resident perspective, it is not uncommon for the spinal dose to wear off for a patient who is laboring for a long time and, while the epidural is functioning fine (excellent dermatomal distribution etc. etc.) the less-dense epidural analgesia isn't the same as the dense intrathecal analgesia, less sacral nerve root coverage and more calls for a "non-functioning" epidural late in labor.

CSE with narcotic only: Same technique as above but 25 ug of fentanyl intrathecally. Pros: Less hypotension, quick onset of analgesia without dense motor blockade, nice transition to epidural with infusion (i.e. start infusion after securing catheter and rarely need to bolus). Cons: Itching and while onset of analgesia is somewhat faster, 50 ug of fentanyl in epidural space works very quickly without having to use another needle. I know some folks use other, longer-acting narcotics, in the intrathecal space and it would be interesting to hear what people have to say.

My transition for technique preference was CSE w/local, CSE/narcotic, to now essentially epidural w or w/o narcotic (unless the patient is morbidly obese and loss of resistance is questionable--then the spinal needle can be very helpful).

Comments?

I humbly disagree with your comment about hypotension using CSE. It is very, very uncommon, at least with the drugs that I use. I dont even break open the ephedrine amp anymore.

If you're having problems with high redose rates with CSE then I'd consider changing drugs or concentrations. Our redose rate is very, very low.

I used to use ropiv 2 mg + sufenta 5ug for intrathecal dose. The only problem with that was getting a TB syringe every time, drawing out 5 ug sufentanil, squirting it into the non-luer locked syringe, taking the syringe, draw up the ropiv, etc....point being it took a little while.
Recently changed routine...pop open ropiv .2% bottle, pop open 50ug sufentanil amp, place on table, open epidural kit, don gloves, suck up sufentanil, squirt into 100mL ropiv bottle, then suck out 2 mL. SO now instead of giving 2mg ropiv + 5ug sufentanil, I'm giving 4mg ropiv + 1ug sufentanil (2 mL)....just saves a step of getting a tb syringe which the RN usually forgets, etc.
THEN hook up infusion at 12mL/hr. Presto, George Foreman grill...set it and forget it.

I'm convinced after doing this for about 4 years on all laborers that not only is it faster and less work for me, its safer too. Why, you ask?

1)The intrathecal dose is small...have never seen a high spinal with it.
2)Rare to see sympathectomy...almost never have to give ephedrine. No more periodic 70/50 blood pressures with concominant nausea/vomiting, potential for decreased placental perfusion, etc.
3)No need for epidural bolus dramatically reduces chance of high spinal to almost zero...so you say what if your catheter goes intrathecal? (which I've never seen)...with .2% ropiv at 12mL/hr, the rising level would be insidious, not abrupt like when you dose an epidural.
4) Post-dural puncture headache incidence no higher than with regular epidural placement.

Our L&D nurses love it, I love it, and the patients love it.

Rarely do I look at some new trend in anesthesia as REALLY making a difference, since so much of this business can be done safely so many different ways. This is an exception....reduces work for RN/CRNA/MD since pats stay hemodynamically stable, no time needed to bolus catheter, hypotension is very rare so no N/V is rare, and redoses are very, very rare.

I think our combination of medicine has just as much to do with it as the technique. I think ropiv .2% + sufentanil .5ug/ml is superior to bupiv/fentanyl, or even ropiv/fentanyl.

 

[Justin4563]

I humbly disagree with your comment about hypotension using CSE. It is very, very uncommon, at least with the drugs that I use. I dont even break open the ephedrine amp anymore.

If you're having problems with high redose rates with CSE then I'd consider changing drugs or concentrations. Our redose rate is very, very low.

I used to use ropiv 2 mg + sufenta 5ug for intrathecal dose. The only problem with that was getting a TB syringe every time, drawing out 5 ug sufentanil, squirting it into the non-luer locked syringe, taking the syringe, draw up the ropiv, etc....point being it took a little while.
Recently changed routine...pop open ropiv .2% bottle, pop open 50ug sufentanil amp, place on table, open epidural kit, don gloves, suck up sufentanil, squirt into 100mL ropiv bottle, then suck out 2 mL. SO now instead of giving 2mg ropiv + 5ug sufentanil, I'm giving 4mg ropiv + 1ug sufentanil (2 mL)....just saves a step of getting a tb syringe which the RN usually forgets, etc.
THEN hook up infusion at 12mL/hr. Presto, George Foreman grill...set it and forget it.

I'm convinced after doing this for about 4 years on all laborers that not only is it faster and less work for me, its safer too. Why, you ask?

1)The intrathecal dose is small...have never seen a high spinal with it.
2)Rare to see sympathectomy...almost never have to give ephedrine. No more periodic 70/50 blood pressures with concominant nausea/vomiting, potential for decreased placental perfusion, etc.
3)No need for epidural bolus dramatically reduces chance of high spinal to almost zero...so you say what if your catheter goes intrathecal? (which I've never seen)...with .2% ropiv at 12mL/hr, the rising level would be insidious, not abrupt like when you dose an epidural.
4) Post-dural puncture headache incidence no higher than with regular epidural placement.

Our L&D nurses love it, I love it, and the patients love it.

Rarely do I look at some new trend in anesthesia as REALLY making a difference, since so much of this business can be done safely so many different ways. This is an exception....reduces work for RN/CRNA/MD since pats stay hemodynamically stable, no time needed to bolus catheter, hypotension is very rare so no N/V is rare, and redoses are very, very rare.

I think our combination of medicine has just as much to do with it as the technique. I think ropiv .2% + sufentanil .5ug/ml is superior to bupiv/fentanyl, or even ropiv/fentanyl.

I personally think cse is stupid.. just because.. waste of time and there is no reason to put a hole in someones dura when y ou dontneed to

I was pissed off today.. I was putting in a thoracic epidural with the worse kit.. the hospital ran out of the i guess husteads and i was stuck with a 17 g touy needle. with a catheter with a stylet in it.. damn i was pissed.. it took me 3 minutes more to find the space.. so i found the space in 4 minutes.. The guy from a thoracotomy woke up.. totally comfortable.. in the recovery room he is sitting up and i go up and totally push on the thoracotomy inc through the dressing and ask him how hes doin;// he stated im doing great.. didnt even fell me pushing on the incision..

 

[jetproppilot]

I personally think cse is stupid.. just because.. waste of time and there is no reason to put a hole in someones dura when y ou dontneed to

I was pissed off today.. I was putting in a thoracic epidural with the worse kit.. the hospital ran out of the i guess husteads and i was stuck with a 17 g touy needle. with a catheter with a stylet in it.. damn i was pissed.. it took me 3 minutes more to find the space.. so i found the space in 4 minutes.. The guy from a thoracotomy woke up.. totally comfortable.. in the recovery room he is sitting up and i go up and totally push on the thoracotomy inc through the dressing and ask him how hes doin;// he stated im doing great.. didnt even fell me pushing on the incision..

Whats the sequelae of puncturing the dura with a 26" spinal needle? I've heard this argument before but since I've never seen any of the concerns pan out (increased dural puncture HA incidence, a hole for the epidural catheter to somehow sneak into, blah blah blah), to me there IS a reason to put a hole in someones dura.

BTW, I love thoracic epidurals for thoracotomies.

 

[militarymd]

I think the key to all this is this....you have to put the tip of the Tuohy needle in the epidural space....after that, whatever you do doesn't matter. Patients will do well.

I have made this observation about people doing epidurals. Some have got it and some just don't. It's like some people can use the Force, and some just can't do it.

So I hope the op will be one of the those who can wield the force.

 

[jetproppilot]

I think the key to all this is this....you have to put the tip of the Tuohy needle in the epidural space....after that, whatever you do doesn't matter. Patients will do well.

I have made this observation about people doing epidurals. Some have got it and some just don't. It's like some people can use the Force, and some just can't do it.

So I hope the op will be one of the those who can wield the force.

Dude, are you trying to send UT some covert Ninja message or something? Hey UT, can you interpret Military's clandestine ORNAMENTAL message for the rest of us?...

geez, I crack myself up...

 

[zippy2u]

Speaking of epidurals, you can always tell the geeks from the studs by the way they locate the epidural space with the needle. My way, the cat's meow, is with one smooth continuous movement moving anterior until E.S. is located with continuous pumping of the syringe as you move anterior with 1/2 saline and 1/2 air. The nerds who were beat as children by the neighborhood kids locate the E.S. by that insane " go 1-2 mm, stop, then pump the syringe, go another 1-2 mm, stop and then pump the syringe.,etc." Now you greenies take heed of this most important technique and don't develope the nerd technique. ---Zippy

 

[jetproppilot]

Speaking of epidurals, you can always tell the geeks from the studs by the way they locate the epidural space with the needle. My way, the cat's meow, is with one smooth continuous movement moving anterior until E.S. is located with continuous pumping of the syringe as you move anterior with 1/2 saline and 1/2 air. The nerds who were beat as children by the neighborhood kids locate the E.S. by that insane " go 1-2 mm, stop, then pump the syringe, go another 1-2 mm, stop and then pump the syringe.,etc." Now you greenies take heed of this most important technique and don't develope the nerd technique. ---Zippy

BEAUTIFUL. EXACTLY.

Now, if you wanna enter Anesthesia Icon status, screw the saline. Unneeded. Just make sure the glass syringe plunger moves freely within the syringe B4 you start and go to work. Saves about a minute per epidural.
geez, I'm giving all my trade secrets away....

 

[zippy2u]

Back in my youth when I was full of piss and vinegar I used to routinely saunter over to the L&D area and place 3 epidurals and walk out the door in 45 minutes. That is talking to the patients, mixing up the solns. filling out all paperwork and connecting and activating the infusion pumps. ---Zippy

 

[jetproppilot]

so i found the space in 4 minutes.. .

So a minute to the ES normally? Where'd you train...the Time-Life-Anesthesia-Correspondence-Course?

just ribbin' ya bro. Don't get all riled up and invite me to the SITAY again so I can kick your...I mean you can kick my...

 

[zippy2u]

By the way Justin is spot on. Ain't no coin in placing epidurals. Homey ain't got no time for all that CSE foolishness. Them wimens callin' me God within 30 seconds when that sufenta 1 mike/cc and Rope .125% bang that epidural space. Good 'nuff for ole Zippy

 

[militarymd]

Dude, are you trying to send UT some covert Ninja message or something? Hey UT, can you interpret Military's clandestine ORNAMENTAL message for the rest of us?...

geez, I crack myself up...

 

[jetproppilot]

By the way Justin is spot on. Ain't no coin in placing epidurals. Homey ain't got no time for all that CSE foolishness. Them wimens callin' me God within 30 seconds when that sufenta 1 mike/cc and Rope .125% bang that epidural space. Good 'nuff for ole Zippy

Aint no coin, huh? At my last gig our epidurals paid a partners salary, and thats some coin.

 

[Justin4563]

Speaking of epidurals, you can always tell the geeks from the studs by the way they locate the epidural space with the needle. My way, the cat's meow, is with one smooth continuous movement moving anterior until E.S. is located with continuous pumping of the syringe as you move anterior with 1/2 saline and 1/2 air. The nerds who were beat as children by the neighborhood kids locate the E.S. by that insane " go 1-2 mm, stop, then pump the syringe, go another 1-2 mm, stop and then pump the syringe.,etc." Now you greenies take heed of this most important technique and don't develope the nerd technique. ---Zippy

what pumping of syringe with air or saline.. My way.. (the cats pajamas)is hangin' drop yo for my thoracic epidurals... soon as that drop gets sucked in... there is no question where i am..

 

[jetproppilot]

what pumping of syringe with air or saline.. My way.. (the cats pajamas)is hangin' drop yo for my thoracic epidurals... soon as that drop gets sucked in... there is no question where i am..

Hanging drop? Geez, break out the ol gas lantern to give you some light while I go tie up your horse outside the hospital...

 

[Justin4563]

you go tie up my horse jet.. thanks


hangin drop is da bomb for thoracic epidural. The ligament is too thin too realy appreciate resistance. in my opinion.. I have done like 150 thoracic epidurals yo. Not for Lumbar labar epidurals..

 

[Disse]

Nice points all.

However, what hasn't been commented on is that with a CSE you still have an untested catheter. While the catheter should be in the epidural space if CSF flows through the spinal needle it is always possible that it isn't. While this less and less likely to happen the more experience you have placing an epidural since you begin to inherently "feel" that the space has been entered it still is a possibility. Having seen an experienced practitioner's CSE "fail" intraop after the spinal dose wore off (and with appropriate dosing through the epidural catheter) I hate would to be in position where an emergency develops and proceeds to crash section with a catheter that may or may not be functioning.

I think the key to all this is this....you have to put the tip of the Tuohy needle in the epidural space....after that, whatever you do doesn't matter. Patients will do well

This I definitely think is true. CSE--patient relief extremely quickly. Well placed epidural--onset of patient relief pretty quick as well.

I humbly disagree with your comment about hypotension using CSE. It is very, very uncommon, at least with the drugs that I use. I dont even break open the ephedrine amp anymore.

We don't use ropivacaine (hospital is too cheap to buy it) but with bupivacaine hypotension seemed fairly common (however, others seem to disagree as well http://www.anesthesia-analgesia.org/cgi/content/abstract/87/3/624)

 

[jetproppilot]

Nice points all.

However, what hasn't been commented on is that with a CSE you still have an untested catheter. While the catheter should be in the epidural space if CSF flows through the spinal needle it is always possible that it isn't. While this less and less likely to happen the more experience you have placing an epidural since you begin to inherently "feel" that the space has been entered it still is a possibility. Having seen an experienced practitioner's CSE "fail" intraop after the spinal dose wore off (and with appropriate dosing through the epidural catheter) I hate would to be in position where an emergency develops and proceeds to crash section with a catheter that may or may not be functioning.



This I definitely think is true. CSE--patient relief extremely quickly. Well placed epidural--onset of patient relief pretty quick as well.



We don't use ropivacaine (hospital is too cheap to buy it) but with bupivacaine hypotension seemed fairly common (however, others seem to disagree as well http://www.anesthesia-analgesia.org/cgi/content/abstract/87/3/624)

great post.

BUT, n=48...pretty weak. P=?

I'll still provide feedback on my personal clinical experiences (albeit anecdotal) over 8 years of private practice and literally thousands of labor epidural placements.

 

[jetproppilot]

Nice points all.

However, what hasn't been commented on is that with a CSE you still have an untested catheter. While the catheter should be in the epidural space if CSF flows through the spinal needle it is always possible that it isn't. While this less and less likely to happen the more experience you have placing an epidural since you begin to inherently "feel" that the space has been entered it still is a possibility. Having seen an experienced practitioner's CSE "fail" intraop after the spinal dose wore off (and with appropriate dosing through the epidural catheter) I hate would to be in position where an emergency develops and proceeds to crash section with a catheter that may or may not be functioning.





QUOTE]

Heard this when I was a resident as well. In eight years of practice, 4 of which using CSE exclusively in L&D, with numerous crash C sections, its never been an issue. Guess it could be but I'm not gonna modify my practice for a potential pink elephant falling outta the sky. And if the pink elephant ever comes, propofol/sux/tube.
I really think residency programs groom new practioners with too much tunnel vision and amplify potential risks to the point of a clinician not even considering an anesthetic option when in fact the option is not as risky as you were lead to believe...i.e. "untested catheter", LMA on a GERD pt, etc

 

[Noyac]

Anybody doing this technique?
Place the Touhy (however you like) no CSF and you got that typical Ligamenum flavum feel and pop. Bolus thru the needle with 0.2% ropiv and narcotic of choice to the vol. of 10-20cc. Thread the cath. Vertually never get a catheter to run intrathecally or intravasc. Whole procedure lasts less than 2 mins and is performed between contractions. Pt is lying down b/4 that next contraction and that is all she feels (1 contraction). Then hook her up to PCEA and never hear from her again. NO hypotension if properly hydrated (if not, cut the dose down appropriately).
Now, I know the risks are there (intrathecal inj) but this is how we do LESI's in pain practice, w/c I have done for some time now until last year, without any intrathecal injections. I have done it this way since finishing residency and have logged hundreds (more like over a 1000)of these without one complication. If you have any doubts or if the needle didn't feel right just thread the cath and bolus after you test. I also am not a fan of the CSE. It takes to long and I can get them more comfortable in less time this way.
Ok, Fire away. But it works well for me.