Epidural Techniques

[Lefty]

I'm a CA-1 doing my OB month right now. I have several attendings that all have different methods of placing epidurals. In particular I have one who uses a continuous, rather than an intermittent, method of looking for LOR. He is the only one I see doing this, but it looks really smooth and a little quicker than the other methods.

Are a lot of you out there using a continuous technique? If so do you use air or saline? In my text it says that continuous technique is normally done with saline (in case you wet tap--so as to avoid causing pneumocephalus), but my attending still uses air in the syringe. Anyone using continuous technique have any thoughts on that--risk vs advantages?

While it looks smoother and faster I think it also looks more difficult to control the needle and keep it midline with my left hand in the position described by my text (with volar surface of left hand against back). I'm thinking about trying a few epidurals that way this week. I'd love feedback from anyone who uses that technique or who has tried it and doesn't like it.

Thanks

---

Members don't see this ad.

 

[Monty Python]

I'm a CA-1 doing my OB month right now. I have several attendings that all have different methods of placing epidurals. In particular I have one who uses a continuous, rather than an intermittent, method of looking for LOR. He is the only one I see doing this, but it looks really smooth and a little quicker than the other methods....................

One partner where I used to work did it this way. He had a noticeably higher incidence rate of wet taps.

 

[apma77]

initially , you should do the intermittent technique until u get more exp
im a ca-3 now and feel very comfortable with the continuous technique and have not had any wet taps with it- plus its quicker

theres no one right way

One partner where I used to work did it this way. He had a noticeably higher incidence rate of wet taps.

 

[Laryngospasm]

initially , you should do the intermittent technique until u get more exp
im a ca-3 now and feel very comfortable with the continuous technique and have not had any wet taps with it- plus its quicker

theres no one right way

Agree with that, many people change to the continuous technique with more experience.

 

[Gern Blansten]

I use continuous once I find good resistance with the ligament. I do most of the pushing with my thumb on the plunger, using my left(non-syringe) hand as a guide and brace. Once the epidural space is found, the plunger drops instead of the needle advancing any further. I have done many this way over the years and this technique has not caused any wet taps for me. I do not condone this technique for beginners. Probably would not try it until you have a couple hundred under your belt. It is true though that it is much faster.

 

[Carm]

This is only based on my experience. Have done about 45 epidurals so far as a CA-1 (so obviously I am at the very beginning of the experience curve). The other night my attending had me try the continuous technique. I am at the perfect level in my training to echo the above sentiments. It felt like I did not have enough control at my current experience level. Plan on continuing the intermittant method for now. The more I am doing the more I can "feel" the anatomy as I advance the needle.

My attending said he uses this method at the pain clinic. I will probably keep it in my holster until I have significantly more experience.

 

[ReefTiger]

I started using this technique on like my 5th epidural and I've never looked back. It is, in my opinion, much easier and more reliable. I always use saline as well and make sure that the glass syringe moves with minimal to no resistance prior to beginning. The keys to doing it correctly are to make sure that the tuohy needle is in the midline of the interspinous ligament before attaching the glass syringe. From there I place my left hand against the patient's back with the index finger and thumb against the tuohy flanges.

I use my thumb to push against the plunger (which should have firm resistance against the ligament) which will place pressure against my index finger and thumb. The needle advances as I allow less resistance from the thumb and index finger of my left hand. I go very slowly, but you always know when you get LOR as the plunger immediately pushes in saline.

I just never get cocky and go fast with advancement. I've yet to have a wet tap this way, and see no advantage to not using continuous pressure.

 

[dr_bigmac]

During my anesthesia rotations I've been tought to use the hanging drop technique from day one. It also lets you use two hands to guide the needle. You use the pinkies to stablize the needle on the back and advance the needle using a pincet grip on both the touhy flanges.

 

[Monty Python]

I'm a CA-1 doing my OB month right now. I have several attendings that all have different methods of placing epidurals. In particular I have one who uses a continuous, rather than an intermittent, method of looking for LOR. He is the only one I see doing this, but it looks really smooth and a little quicker than the other methods.

Are a lot of you out there using a continuous technique? If so do you use air or saline? In my text it says that continuous technique is normally done with saline (in case you wet tap--so as to avoid causing pneumocephalus), but my attending still uses air in the syringe. Anyone using continuous technique have any thoughts on that--risk vs advantages?

While it looks smoother and faster I think it also looks more difficult to control the needle and keep it midline with my left hand in the position described by my text (with volar surface of left hand against back). I'm thinking about trying a few epidurals that way this week. I'd love feedback from anyone who uses that technique or who has tried it and doesn't like it.

Thanks

On a tangent here: you'll notice several brands of epidural trays, with slight differences between them (usually cost-savings). Hopefully in your training you'll have the opportunity to see all of them.

My favorite is the kit from Arrow. The Tuohy has cm graduations on it, the cath is very soft yet easy to thread, and I've never seen one puncture a vein.

Some other kits don't have the flanges attached to the Tuohy, there's no graduation markings on the Tuohy, and the cath is much stiffer.

Most (all?) kits still include a glass syringe. The Portex plastic syringe is very user-friendly. It's available as a separate sterile item from the manufacturer if not already in your particular epidural tray.

 

[fval28]

I started using this technique on like my 5th epidural and I've never looked back. It is, in my opinion, much easier and more reliable. I always use saline as well and make sure that the glass syringe moves with minimal to no resistance prior to beginning. The keys to doing it correctly are to make sure that the tuohy needle is in the midline of the interspinous ligament before attaching the glass syringe. From there I place my left hand against the patient's back with the index finger and thumb against the tuohy flanges.

I use my thumb to push against the plunger (which should have firm resistance against the ligament) which will place pressure against my index finger and thumb. The needle advances as I allow less resistance from the thumb and index finger of my left hand. I go very slowly, but you always know when you get LOR as the plunger immediately pushes in saline.

I just never get cocky and go fast with advancement. I've yet to have a wet tap this way, and see no advantage to not using continuous pressure.

Agree with above- I've been using it exclusively for a while now and have yet to wet-tap anyone. (Now that I said that I will probably have about 10 wet-taps in a row) 🙂

I want to stress the importance of using saline with this approach- IMHO- the feel of the saline is different (more sensitive) than with just air and the saline has the (theoretical) advantage of opening up the epidural space and allowing easier catheter placement.

 

[bubalus]

the saline has the (theoretical) advantage of opening up the epidural space and allowing easier catheter placement.

I seem to recall reading something about using saline to open up the epidural space, but that it took something like 20 ml--quite a bit more than is a plastic or glass LOR syringe.

 

[seattledoc]

one of the problems with using air is if you plunge too much air into the epidural space, there's more risk of a patchy block. Not the end of the world but annoying for all. And there is the pneumocephalus. I notice more older docs using air, and very few younger docs doing it. It must have been "the way to do it" in the 70's and 80's.

 

[Lefty]

Lots of good responses here. Thanks for your input.

For those of you using saline for LOR, I assume you use the saline in the same glass syringe that usually comes in the epidural kits. Is that true? Also, are you leaving an air bubble in the saline to check for compressability as well?

 

[jetproppilot]

I'm a CA-1 doing my OB month right now. I have several attendings that all have different methods of placing epidurals. In particular I have one who uses a continuous, rather than an intermittent, method of looking for LOR. He is the only one I see doing this, but it looks really smooth and a little quicker than the other methods.

Are a lot of you out there using a continuous technique? If so do you use air or saline? In my text it says that continuous technique is normally done with saline (in case you wet tap--so as to avoid causing pneumocephalus), but my attending still uses air in the syringe. Anyone using continuous technique have any thoughts on that--risk vs advantages?

While it looks smoother and faster I think it also looks more difficult to control the needle and keep it midline with my left hand in the position described by my text (with volar surface of left hand against back). I'm thinking about trying a few epidurals that way this week. I'd love feedback from anyone who uses that technique or who has tried it and doesn't like it.

Thanks

I think you'll find, dude, that the longer you are in this business the quicker you are at procedures...and that has to do with being more comfortable with the procedure/anatomy, and just as importantly, being able to eliminate steps that arent really needed.

I use the continuous technique you mention. The saline is not needed IMHO.

Take the glass syringe and make sure the plunger moves back and forth freely. Realize that after a while, finding the epidural space is more tactile than visual . I pull the plunger back to 2 mL for every epidural I place...maybe it would be 3 or 4 for you, but make it constant.

I push forward slowly but continuously, popping the plunger continuously...since I've used 2mL forever I know exactly what it feels like to hit the ES...

....and heres a salient tip....

after you get to the point where you know when it feels right, don't settle.

Get a little LOR but you're not really sure? Don't settle. Pull the Tuohy back and redirect. Hit the ES. Settle only when youre sure it feels absolutely right.

SO, pick a way you like to do epidurals. And do it that way. Every single time. It'll pay dividends when you're up against a hard one.