Help w epidurals, spinals etc

[gasaddict54]

I have performed my fair share but still not sure that I am very proficient at this task, esp w the obese etc. Anyone w any true advice, links or otherwise would be appreciated.

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[Noyac]

Are you serious?

All I can say is keep practicing. But if you can't do a good spinal by the time you are done with residency then you chose the wrong profession. And that's being kind. You should be able to do a spinal without much effort by the time you are a CA2.

 

[gasaddict54]

thank you that was very helpful......PRACTICE got it

 

[Jay K]

Like Noyac, I was a little bit incredulous at first, but I forget sometimes one may go through a bad rut in residency and have a spate of difficult/unsuccessful attempts which may undermine your confidence. Hard to give tips over the internet, but I hope you'll seek out some sympathetic attendings in your program who'll walk you through or give you additional tips. If you have electives in 3rd year, consider doing another OB month or more thoracic so it'll become second nature to you in placing lumbar and thoracic epidurals as well as spinals.

Regarding epidurals, I'm not certain what technique you're using, but you could try:
1. Using a plastic loss or resistance syringe - that may make the difference for you in feeling loss
2. Try doing combined spinal/epidurals to confirm location of the epidural space. If you think you've attained loss, go ahead and thread a spinal through the needle, if you get CSF then you're in the right place. Dose the spinal, remove, then thread your catheter.
3. If you advancing, then tapping, consider doing a Bromage technique with continuous pressure while advancing the epidural needle.
4. Estimate how much length of the tuohy you'll need and try to place it well into the ligament; Oftentimes residents who are hesitant won't start off with their tuohy in far enough and engaged into the ligament and try to advance w/ the LOR syringe too soon.
5. Attempt to locate the spinous process with your smaller local needle. I understand this can be hard for obese patients.
6. If you're having difficulty finding midline, try aligning C6 w/ the gluteal cleft (of course this is only fair in pt's who do not have severe scoliosus)
7. If you have them at your institution, try using reinforced flexible Arrow epidural catheters. Very difficult to thread into subcut, false loss, intrathecal or intravascular; If you're not in the epidural space, these catheters will not thread (that's my experience and my preference).
8. Positioning is KEY! Make sure they slouch and crunch over their belly well before you start; Reposition them if necessary. Remember it's not leaning, it's "bad posture" - that's what I tell the patient.

Most of these tips are for lumbar epidurals in obese/gravid patients. Part two will be thoracic epidurals.

This is what I've got for you off the top of my head. Post what you're having difficulty with in particular w/ placing epidurals and spinals, and maybe I or others can provide more tips. Good luck and you'll need to perfect your technique if you're going to provide clinical anesthesia.

 

[gasaddict54]

Like Noyac, I was a little bit incredulous at first, but I forget sometimes one may go through a bad rut in residency and have a spate of difficult/unsuccessful attempts which may undermine your confidence. Hard to give tips over the internet, but I hope you'll seek out some sympathetic attendings in your program who'll walk you through or give you additional tips. If you have electives in 3rd year, consider doing another OB month or more thoracic so it'll become second nature to you in placing lumbar and thoracic epidurals as well as spinals.

Regarding epidurals, I'm not certain what technique you're using, but you could try:
1. Using a plastic loss or resistance syringe - that may make the difference for you in feeling loss
2. Try doing combined spinal/epidurals to confirm location of the epidural space. If you think you've attained loss, go ahead and thread a spinal through the needle, if you get CSF then you're in the right place. Dose the spinal, remove, then thread your catheter.
3. If you advancing, then tapping, consider doing a Bromage technique with continuous pressure while advancing the epidural needle.
4. Estimate how much length of the tuohy you'll need and try to place it well into the ligament; Oftentimes residents who are hesitant won't start off with their tuohy in far enough and engaged into the ligament and try to advance w/ the LOR syringe too soon.
5. Attempt to locate the spinous process with your smaller local needle. I understand this can be hard for obese patients.
6. If you're having difficulty finding midline, try aligning C6 w/ the gluteal cleft (of course this is only fair in pt's who do not have severe scoliosus)
7. If you have them at your institution, try using reinforced flexible Arrow epidural catheters. Very difficult to thread into subcut, false loss, intrathecal or intravascular; If you're not in the epidural space, these catheters will not thread (that's my experience and my preference).
8. Positioning is KEY! Make sure they slouch and crunch over their belly well before you start; Reposition them if necessary. Remember it's not leaning, it's "bad posture" - that's what I tell the patient.

Most of these tips are for lumbar epidurals in obese/gravid patients. Part two will be thoracic epidurals.

This is what I've got for you off the top of my head. Post what you're having difficulty with in particular w/ placing epidurals and spinals, and maybe I or others can provide more tips. Good luck and you'll need to perfect your technique if you're going to provide clinical anesthesia.

Hey thanks for the tips, just frustrated w the obese pregos...had 450 lber yesterday for c/s and it was beyond belief much trouble it was to place a spinal. After had to summon my attending after a multiple epidural attempt on a 300 lb G9 P7 on medicaid of course. Just frustrated and looking for magic tricks that will make me great overnight.

 

[Jay K]

Hey thanks for the tips, just frustrated w the obese pregos...had 450 lber yesterday for c/s and it was beyond belief much trouble it was to place a spinal. After had to summon my attending after a multiple epidural attempt on a 300 lb G9 P7 on medicaid of course. Just frustrated and looking for magic tricks that will make me great overnight.

For presumed difficult spinal in an obese pregnant patient, I don't hesitate to use an epidural-guided technique (ie: CSE); Check Jet's tip page - he and others advocate going to a 22G to start if you anticipate difficulty. Well, hopefully you'll have multiple tricks under your belt to pull out eventually for those challenging neuraxial cases; I suppose there's always the ultrasound, although I haven't done much of that myself for neuraxial techniques. Take a look at NYSORA or USRA for tutorials if you haven't already.

 

[sevoflurane]

Continuous pressure on your syringe. If you are allingned right, once you get Sudden loss = you are there. Make sure you are engaged in ligament first = non floppy touhy.

Also, listen/feel for the ligament crunch... Means you are almost there. Don't worry. Give it time and practice.

 

[dhb]

In the fatsos (although i don't much about 400lbers) stick the needle in a back creese that's where you're vertebras bend

 

[Mman]

Unfortunately there are no magic tips that will make you great overnight at getting neuraxial blocks in the super morbidly obese patients.

I had fun last week with the 400 lber asking what was taking so long when I had the Touhy hubbed and skin tented in and basically shoving it as far as I could possibly go with continuous pressure on the hub and still wasn't far enough to get LOR. This was a total of about 5 minutes after I had put on the sterile gloves. I ended up going up a couple spaces to probably L1/2 because it seemed shallower and ended up getting it with the regular Touhy. Our epidural cart that day wasn't stocked with the big 15 cm Touhy and I wasn't feeling like waiting around for someone to bring me one.

Sometimes you just have to use the force to get the epidural in the big ones.

 

[Planktonmd]

Don't worry about it, you will get better and more confident with time and practice.
There is a thousand way to this but you need to find your favorite style and stick with it.
Also remember that It is OK to struggle once in while it keeps you humble and it happens to all of us.

 

[gasaddict54]

Unfortunately there are no magic tips that will make you great overnight at getting neuraxial blocks in the super morbidly obese patients.

I had fun last week with the 400 lber asking what was taking so long when I had the Touhy hubbed and skin tented in and basically shoving it as far as I could possibly go with continuous pressure on the hub and still wasn't far enough to get LOR. This was a total of about 5 minutes after I had put on the sterile gloves. I ended up going up a couple spaces to probably L1/2 because it seemed shallower and ended up getting it with the regular Touhy. Our epidural cart that day wasn't stocked with the big 15 cm Touhy and I wasn't feeling like waiting around for someone to bring me one.

Sometimes you just have to use the force to get the epidural in the big ones.

Ha yeah tried a CSE on my 450 beast,,,,had it hubbed, tenting etc thought i had LOR , couldnt get spinal to pass, pulled out the CSE touhy,,,,,yeah it was no lie in a Z pattern. My attending had to leave the room he was laughing so hard. About 30 mins later he finally got the spinal w the big girl needle COMPLETELY hubbed. The real question is how did this chick get pregnant? BTW the smell of crotch if it could have been bottled would be cutting edge nerve agent.

 

[Coastie]

I have performed my fair share but still not sure that I am very proficient at this task, esp w the obese etc. Anyone w any true advice, links or otherwise would be appreciated.

Wasn't there a question of you being a CRNA? After all, your first few posts talked about "MDAs" and letting CRNAs "do their own cases". In fact, most of your cases point towards a stealth CRNA account.

Anyway, dude, epidurals and spinals should be smooth as butter by this time in your training.

What year are you now?

I had to bail a 10 year + CRNA multiple times yesterday for epidurals on anorexic mothers on the labor floor (<200 lbs). Each time, she claimed it was "a tough stick" and she "used to just throw them in all the time at my previous job". Yeah, right..

 

[IN2B8R]

Ha yeah tried a CSE on my 450 beast,,,,had it hubbed, tenting etc thought i had LOR , couldnt get spinal to pass, pulled out the CSE touhy,,,,,yeah it was no lie in a Z pattern. My attending had to leave the room he was laughing so hard. About 30 mins later he finally got the spinal w the big girl needle COMPLETELY hubbed. The real question is how did this chick get pregnant? BTW the smell of crotch if it could have been bottled would be cutting edge nerve agent.

 

[gasaddict54]

Wasn't there a question of you being a CRNA? After all, your first few posts talked about "MDAs" and letting CRNAs "do their own cases". In fact, most of your cases point towards a stealth CRNA account.

Anyway, dude, epidurals and spinals should be smooth as butter by this time in your training.

What year are you now?

I had to bail a 10 year + CRNA multiple times yesterday for epidurals on anorexic mothers on the labor floor (<200 lbs). Each time, she claimed it was "a tough stick" and she "used to just throw them in all the time at my previous job". Yeah, right..

oh yeah i love it everytime someone says anything not the boards sheeple "party line" well they must obviously be a CRNA devil. Dude i have a soon to be wife CRNA and just dont have or see the problems that u guys do apparently. Ildaestro did this a while ago and was slammed only to be investigated like he shot JFK .Please have me banned if you feel simple questions like spinals/epidurals are so beneath you. Is it so hard to remember that you once struggled w something and wanted just some help? I notice that there is a glydescope thread also without these kinds of accusations. Glydescope???

 

[Coastie]

oh yeah i love it everytime someone says anything not the boards sheeple "party line" well they must obviously be a CRNA devil. Dude i have a soon to be wife CRNA and just dont have or see the problems that u guys do apparently. Ildaestro did this a while ago and was slammed only to be investigated like he shot JFK .Please have me banned if you feel simple questions like spinals/epidurals are so beneath you. Is it so hard to remember that you once struggled w something and wanted just some help? I notice that there is a glydescope thread also without these kinds of accusations. Glydescope???

So, what year are you?

Yeah, if you think CRNA = MD(A), then we don't want you in the ASA. Go ahead and check out militant-nurse.org/yeswecan if you want to cheer on the CRNA=MD(A) nonsense.

You came here in Feb 2010. Countless CRNAs have been banned for trolling/posing as physicians. Why shouldn't someone who spews the same type of rhetoric not be examined appropriately?

 

[gasaddict54]

So, what year are you?

Yeah, if you think CRNA = MD(A), then we don't want you in the ASA. Go ahead and check out militant-nurse.org/yeswecan if you want to cheer on the CRNA=MD(A) nonsense.

You came here in Feb 2010. Countless CRNAs have been banned for trolling/posing as physicians. Why shouldn't someone who spews the same type of rhetoric not be examined appropriately?

Rhetoric ?? i have never or ever will spew any kind of rhetoric and of course crna does not = MD. Where u get the idea of the above bold i have no idea as I could not feel any stronger of the opposite of this. The wife and the crnas i work w are very happy w the ACT model ( of course there are pain in the butt ones). Frankly the ones that i have conversations dont want anything to do w independence and all the downfalls that come with it. They make ~ 125K per year without any call, nights, weekends or holidays so why would they want it any other way? NOW once I get away from the educ institute way of doing things i may have a completelyt different take on this.

 

[paiute]

6. If you're having difficulty finding midline, try aligning C6 w/ the gluteal cleft .

C7 (vertebra prominans), and sometimes T1, is the bump you usually see at the base of the neck.

 

[pgg]

I had to bail a 10 year + CRNA multiple times yesterday for epidurals on anorexic mothers on the labor floor (<200 lbs). Each time, she claimed it was "a tough stick" and she "used to just throw them in all the time at my previous job". Yeah, right..

I'm not too proud to ask an experienced CRNA to help with a difficult epidural. It's a technical skill anyone can learn and do well. I've known some CRNAs who do a lot of OB and they are GOOD with the Tuohy.

It's not like you're asking them for advice on how to manage an urgent section in a 19 yo s/p Fontan ...

 

[Jay K]

C7 (vertebra prominans), and sometimes T1, is the bump you usually see at the base of the neck.

You're correct re: vertebra prominens... 70% of the time... Thanks for pointing out the mistake. 👍

 

[Jay K]

The real question is how did this chick get pregnant?

An obstetric colleague was recently discussing this very topic with us at the "lunch table," and he told me a story I wish he hadn't. In his practice, he'd seen a morbidly obese patient for infertility, and related that the patient had come to see him because she'd grown tired of having her mother and sister holding her legs open during intercourse... mental image I did NOT need...

 

[gasaddict54]

An obstetric colleague was recently discussing this very topic with us at the "lunch table," and he told me a story I wish he hadn't. In his practice, he'd seen a morbidly obese patient for infertility, and related that the patient had come to see him because she'd grown tired of having her mother and sister holding her legs open during intercourse... mental image I did NOT need...

WOW ,,,,,,,,I am , well , yeah speechless

 

[Monty Python]

An obstetric colleague was recently discussing this very topic with us at the "lunch table," and he told me a story I wish he hadn't. In his practice, he'd seen a morbidly obese patient for infertility, and related that the patient had come to see him because she'd grown tired of having her mother and sister holding her legs open during intercourse... mental image I did NOT need...

With apologies to the ladies on this thread ..... how did her sex partner keep a woodie, with his partner's MOTHER right there. Unless she was also his mother. Which would mean .................

Oh God, I need to puke.

 

[Licoricestick]

With apologies to the ladies on this thread ..... how did her sex partner keep a woodie, with his partner's MOTHER right there. Unless she was also his mother. Which would mean .................

Oh God, I need to puke.

I don't see any need for an apology - same thought had occurred to me. *shudder*

 

[pgg]

An obstetric colleague was recently discussing this very topic with us at the "lunch table," and he told me a story I wish he hadn't. In his practice, he'd seen a morbidly obese patient for infertility, and related that the patient had come to see him because she'd grown tired of having her mother and sister holding her legs open during intercourse... mental image I did NOT need...

This has got to be an urban legend.

I must've heard this mother-in-law/brother/uncle/neighbor/cousin/pulley-system/whatever fatty reproduction logistics story from 5 or 6 people now, none who ever directly encountered the patient.

Or maybe we used to work at the same institution ...

 

[GoodmanBrown]

This has got to be an urban legend.

I must've heard this mother-in-law/brother/uncle/neighbor/cousin/pulley-system/whatever fatty reproduction logistics story from 5 or 6 people now, none who ever directly encountered the patient.

Or maybe we used to work at the same institution ...

Or maybe that one person is a high-travelling doctor-shopper? 😉

 

[rsgillmd]

This has got to be an urban legend.

I must've heard this mother-in-law/brother/uncle/neighbor/cousin/pulley-system/whatever fatty reproduction logistics story from 5 or 6 people now, none who ever directly encountered the patient.

Or maybe we used to work at the same institution ...

Quite possibly. But I can tell you of an alternative method. I was talking with one of the OB residents and asked about a post-partum morbidly obese woman we were following. According to this resident the patient used something along the lines of a syringe, obviously without the needle. Apparently the husband ejaculated into a cup and then this was injected into the woman's vagina.

I can't vouch for the accuracy of the above beyond hearsay. She could have been joking with me, but if she was then she did it with a very straight look on her face/serious voice tone.

 

[Frank Rizzo]

Had a patient actually TELL ME that she used a broom stick...

Placed it under her panus, and pulled up towards her head to reveal something that must have looked and smelled something like the predator's mouth:

She claimed it was very exhausting and she was more tired than her husband when it was all done.

Interestingly enough, she had the nice cleft in her back and I lost resistance just prior to hubbing the normal Touhy needle. She tipped the scales at around 450

 

[Monty Python]

Quite possibly. But I can tell you of an alternative method. I was talking with one of the OB residents and asked about a post-partum morbidly obese woman we were following. According to this resident the patient used something along the lines of a syringe, obviously without the needle. Apparently the husband ejaculated into a cup and then this was injected into the woman's vagina.
.

Sounds like a new category of Hallmark romance cards to hit the stores soon. Maybe they'll end up on the Maury or Jerry Springer show to demonstrate the technique.

 

[Jay K]

I apologize for my role in leading this thread off tangent, but this thread has to stop... Ugh... my sincerest apologies...

 

[jetproppilot]

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[jetproppilot]

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[Coastie]

oh yeah i love it everytime someone says anything not the boards sheeple "party line" well they must obviously be a CRNA devil. Dude i have a soon to be wife CRNA and just dont have or see the problems that u guys do apparently. Ildaestro did this a while ago and was slammed only to be investigated like he shot JFK .Please have me banned if you feel simple questions like spinals/epidurals are so beneath you. Is it so hard to remember that you once struggled w something and wanted just some help? I notice that there is a glydescope thread also without these kinds of accusations. Glydescope???

LOL, good riddance militant MD wannabe. You guys are too obvious. Imitation is the greatest form of flattery...

 

[hoyden]

This has got to be an urban legend.

I must've heard this mother-in-law/brother/uncle/neighbor/cousin/pulley-system/whatever fatty reproduction logistics story from 5 or 6 people now, none who ever directly encountered the patient.

Or maybe we used to work at the same institution ...

I have heard this as well, but given the situation it is the only probability how they all get pregnant. And hey, do not forget, that getting pregnant and having a baby is a on-going for generations business, so it is not a legend 😉

Quite possibly. But I can tell you of an alternative method. I was talking with one of the OB residents and asked about a post-partum morbidly obese woman we were following. According to this resident the patient used something along the lines of a syringe, obviously without the needle. Apparently the husband ejaculated into a cup and then this was injected into the woman's vagina.