ESI in pregnancy

[Bostonredsox]

I did a quick search and saw an old stem on this. Looking for insight on what you guys have seen. And to clarify, I am not looking for advice, just experiences. My wife is 31 weeks pregnant, really bad LB pain, had two herniated discs on MRI 5 years ago (and several pregnancies ago). Popped it 2 weeks ago, pain is debilitating. She cant stand or even hold our one year old, cant walk without staggering in pain. Severe radiculopathy with it too. I took a few days off to help but I have to be back on nights in a week. Spoke with her OB and she spoke with our anesthesia PM guy who is gonna see her tomorrow and from what I can tell, talk about bupiv/betameth ESI, hoping it buys her 6 weeks til she can deliver safely.

Do you guys see this alot? Do you have patients that actually get a good amount of benefit from it? The other option is opiates which she will probably refuse, my wife hates pills. Just wondering if you guys see women respond to the ESI's well enough to make it to delivery and hopefully avoid a section. thanks guys.

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[dhb]

my wife hates pills

Hence her current state? 😉

Sorry can't help much on this subject

 

[Bostonredsox]

Hence her current state? 😉

Sorry can't help much on this subject

Well its not as if her thoughts arent without reason, narc withdrawl can be a tough cookie when it comes time for delivery of the baby. Anyway, had MRI today PM going to try an US guided ESI tomorrow as he didnt want to use flouro. MRI showed the L5-S1 culprit and it looks like he should be able to get a needle in there. Hopefully her pain improves its hard seeing your spouse in this much pain.

 

[WholeLottaGame7]

Well its not as if her thoughts arent without reason, narc withdrawl can be a tough cookie when it comes time for delivery of the baby. Anyway, had MRI today PM going to try an US guided ESI tomorrow as he didnt want to use flouro. MRI showed the L5-S1 culprit and it looks like he should be able to get a needle in there. Hopefully her pain improves its hard seeing your spouse in this much pain.

By "current state," I'm 99.6% sure he's referring to "pregnant," and not "in pain."

Also don't have experience with this, best of luck to you both.

 

[Mman]

U/S guided? Why not just a good old fashioned blind technique? There have been probably tens of millions of labor epidurals placed without ultrasound guidance. While not using fluoro is less than ideal, if you give enough volume it'll spread at least 2 levels even if you miss on your guess of what level you are at. Can't imagine success rate with ultrasound guidance is any better than blind.

 

[IlDestriero]

I hope that they're not going to try a transforaminal approach with ultrasound.

 

[OB1🤙]

U/S guided? Why not just a good old fashioned blind technique? There have been probably tens of millions of labor epidurals placed without ultrasound guidance. While not using fluoro is less than ideal, if you give enough volume it'll spread at least 2 levels even if you miss on your guess of what level you are at. Can't imagine success rate with ultrasound guidance is any better than blind.

Seriously, this. I can see if it's a PM&R or other non-anesthesia pain guy who hasn't done a gazillion "blind" epidurals, but c'mon. U/S guided ESI? I like billing for ultrasound-guided thisnthat as much as the next guy, but I also like for it to add some degree of anything positive to the procedure.

That being said, good luck with it and I hope your wife gets better.

 

[pastafan]

I hope that they're not going to try a transforaminal approach with ultrasound.

+1
I have done these with the interlaminar approach utilizing Marcaine 0.25% or Lidocaine 1% plus Kenalog 80 mg with great success over the past 20 years. The results have been surprisingly good but of course it helps if you put the medication in the right place. 😉
I'm sorry that your wife is suffering. I know first hand what it is like to be in your shoes. Hopefully this will help.

 

[Arch Guillotti]

I would do it blind. I know plenty of guys that do this.

 

[IlDestriero]

I would do it blind. I know plenty of guys that do this.

I would do it blind, but use the ultrasound to identify the 12th rib and count spaces down to where I needed to inject.

 

[Bostonredsox]

I know she cannot read this forum or atleast doesnt know how to login to it, so i think were safe.....she has quite a bit of pregnancy weight from 3 preganancies in just over 3 years. My guess is he thinks her landmarks wont be the easiest to see and US may increase his yield of hitting the right spot. I know he has done a million blind epidurals (30+ year gas attending), but the US cant hurt right? I can hit the IJ fine without US, but I still use it as frankly, it doesnt hurt and can only help (and that whole standard of care thing lol). anyway thanks for the support, I am hoping this ameilorates her pain so she wont need to be sectioned. Last baby woo!!

 

[EdPierce]

use the iliac crest as l4 and go below it blind midline maybe off to the worse side

 

[Mman]

I know she cannot read this forum or atleast doesnt know how to login to it, so i think were safe.....she has quite a bit of pregnancy weight from 3 preganancies in just over 3 years. My guess is he thinks her landmarks wont be the easiest to see and US may increase his yield of hitting the right spot. I know he has done a million blind epidurals (30+ year gas attending), but the US cant hurt right? I can hit the IJ fine without US, but I still use it as frankly, it doesnt hurt and can only help (and that whole standard of care thing lol). anyway thanks for the support, I am hoping this ameilorates her pain so she wont need to be sectioned. Last baby woo!!

You can assure her that lots of women at term pregnancy manage to get labor epidurals despite carrying extra weight. And unless she's 400+ lbs, it's unlikely to be terribly difficult. She'll even have an easier time positioning herself because she isn't in contracting in labor.

 

[dhb]

By "current state," I'm 99.6% sure he's referring to "pregnant," and not "in pain."

yes

 

[Bostonredsox]

I hope that they're not going to try a transforaminal approach with ultrasound.

No, the space is tight. He is going intralaminar. Going to localize with US then complete it blind. Wants to minimize palpation as she is so exquistely tender to touch in the areas of the injury. looked at MR myself today, lot of edema near the cord. I feel horrible for her she is miserable. The guy offered to taeke me onto his service next month and then just let me 'work from home'. I thought that was nice. anyway shes having it monday.

 

[powermd]

You could do an ultrasound guided caudal with 10 mL of volume. That should get you to L4. Very easy to do. Just visualize the sacral cornue (like a set of bunny ears). Drop a 25g needle in between them (perpendicular to the skin), when you feel the "ka-dunk" of the needle dropping into place, you're there. You don't need local for this. If you turn on the doppler, you should see all of the injectate stay below the sacral ligaments, and injection should be smooth and steady. If you don't get the "ka-dunk" or injection meets a lot of resistance, you're not in the right place. Keep in mind most people have two sets of bones that look like the sacral cornue. You want the more superior of the two, ideally just below the most caudad sacral spinous process. Just look for the bunny ears with a ligament spanning between them. It's usually right at the top of the natal cleft. The patient will feel a great deal of pressure at the site of injection, and eventually in the low back, or extremity associated with the HNP.

I usually do this with patients prone, but it works just as well with the patient standing, and bent forward supporting their weight on the exam table. In fact, when there's a lot of redundant tissue, this position helps pull it away from the site of injection.

 

[Mman]

You could do an ultrasound guided caudal with 10 mL of volume. That should get you to L4. Very easy to do. Just visualize the sacral cornue (like a set of bunny ears). Drop a 25g needle in between them (perpendicular to the skin), when you feel the "ka-dunk" of the needle dropping into place, you're there. You don't need local for this. If you turn on the doppler, you should see all of the injectate stay below the sacral ligaments, and injection should be smooth and steady. If you don't get the "ka-dunk" or injection meets a lot of resistance, you're not in the right place. Keep in mind most people have two sets of bones that look like the sacral cornue. You want the more superior of the two, ideally just below the most caudad sacral spinous process. Just look for the bunny ears with a ligament spanning between them. It's usually right at the top of the natal cleft. The patient will feel a great deal of pressure at the site of injection, and eventually in the low back, or extremity associated with the HNP.

I usually do this with patients prone, but it works just as well with the patient standing, and bent forward supporting their weight on the exam table. In fact, when there's a lot of redundant tissue, this position helps pull it away from the site of injection.

I suppose you COULD do that, but is that any easier than the 11 seconds it takes to just do a blind LOR technique in the lower lumbar spine?

 

[powermd]

I suppose you COULD do that, but is that any easier than the 11 seconds it takes to just do a blind LOR technique in the lower lumbar spine?

If you have the equipment, I would say yes, easier (for me anyway, since I do these all the time in 80 year olds with spinal stenosis on anticoagulation).

Also, no risk of wet tap, or intrathecal particulate steroids. Almost negligible risk of intravascular injection. Greater certainty you were actually epidural.

 

[lobelsteve]

If you have the equipment, I would say yes, easier (for me anyway, since I do these all the time in 80 year olds with spinal stenosis on anticoagulation).

Also, no risk of wet tap, or intrathecal particulate steroids. Almost negligible risk of intravascular injection. Greater certainty you were actually epidural.

ESI on anticoagulation? No thanks.

http://www.asra.com/publications-anticoagulation-3rd-edition-2010.php

 

[powermd]

We've talked about this before.

http://forums.studentdoctor.net/showpost.php?p=11403563&postcount=81

Our technique is fundamentally different from a classical caudal, so it's risk profile w/r/t anticoagulation is different. Thousands of injections so far and not a single symptomatic hematoma. The risk of thrombosis from stopping anticoagulation on everyone is probably greater than the risk of a single epidural hematoma from our technique.

ESI on anticoagulation? No thanks.

http://www.asra.com/publications-anticoagulation-3rd-edition-2010.php

 

[lobelsteve]

We've talked about this before.

http://forums.studentdoctor.net/showpost.php?p=11403563&postcount=81

Our technique is fundamentally different from a classical caudal, so it's risk profile w/r/t anticoagulation is different. Thousands of injections so far and not a single symptomatic hematoma. The risk of thrombosis from stopping anticoagulation on everyone is probably greater than the risk of a single epidural hematoma from our technique.

I agree the risk is not greater than 1:3000.

But if you were to ever realize the risk......screwed in court.

 

[Bostonredsox]

Feedback. Procedure went fine, it just didn't help her. Shes pretty miserable and her weakness has worsened. they are looking at sectioning her at 34 wks