Injecting local through Tuohy

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requeim

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Recently came across a few MDs getting LOR and injecting ~10-20cc of local through needle for labor epidurals.

Vaguely remember LESIs being done this way but never for a labor epidural

Thoughts? Anyone else do this?
 
requeim said:
Recently came across a few MDs getting LOR and injecting ~10-20cc of local through needle for labor epidurals.

Vaguely remember LESIs being done this way but never for a labor epidural

Thoughts? Anyone else do this?
Click to expand...
This is the old way of doing things, people 50 years ago used to inject a large bolus of local anesthetics through the epidural needle, unfortunately this produced an unacceptable incidence of severe maternal hypotension and arrest of labor.
So people with some brains said: maybe we should stop doing this crazy shiit and just place the catheter then gradually administer the epidural anesthetic. But some people did not get the memo and continued to do their stupid Shiit!
 
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requeim said:
Recently came across a few MDs getting LOR and injecting ~10-20cc of local through needle for labor epidurals.

Vaguely remember LESIs being done this way but never for a labor epidural

Thoughts? Anyone else do this?
Click to expand...

You have to be sure that loss is in the epidural space. You don't want to inject 10 cc of Marcaine into a vein.

Personally, I would use the 10 cc of saline to "widen the space", thread the catheter, give a test dose, and then give a bolus from the bag or from a vial of Marcaine.
 
Planktonmd said:
It does work great as long as you don't cause severe hypotension and fetal distress!
Click to expand...

I am new school and like to do it. L&D heavy practice. I agree it dilates the space well. I get fewer one-sided blocks, faster relief (approximates cse), and contrary to what you say, little hypotension and no fetal distress. I got more fetal bradycardia with cse’s when I used to do them.

I bolus 8-12cc of 0.25% bupi depending on height through tuohy.

Patients love me, ob/gyns ask for me by name, and young hottie RNs want to take me to the call room. Give it a try. You may like it
 
Lurch said:
I am new school and like to do it. L&D heavy practice. I agree it dilates the space well. I get fewer one-sided blocks, faster relief (approximates cse), and contrary to what you say, little hypotension and no fetal distress. I got more fetal bradycardia with cse’s when I used to do them.

I bolus 8-12cc of 0.25% bupi depending on height through tuohy.

Patients love me, ob/gyns ask for me by name, and young hottie RNs want to take me to the call room. Give it a try. You may like it
Click to expand...

Last thing I'd ever want
 
I do it occasionally if the woman is really uncomfortable and a bit “screamy.” It works pretty fast. I’ll take 5cc of 0.25% and 5cc of the sterile saline in the kit. The patient is usually getting comfortable and less “screamy” as I’m taping the catheter in place. Hypotension is rare and probably no more than average.
 
dchz said:
I really don't understand what benefit this gives over bolusing the catheter after you do the test dose... What catheters are you guys using that is so hard to thread?
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There's something (theoretical) to be said about opening up the epidural space given the higher pressure exerted through the tuohy vs the tiny catheter. Also onset of relief is faster, though your incidence of hypotension will be much higher. 20cc is awfully high, but another 5-10 after a test dose makes patients comfy pretty quickly.
 
at first when i read OP i thought he meant like adding 2-3ccs of lido through the tuohy if the initial skin and injection local didn't get down to the lamina, e.g. if the patient has too much tissue in the back. THAT IS a situation where i would give lido through the tuohy, to make the patient really comfortable during the procedure. but the lido is intended to go into the connective tissue/periosteum NOT the epidural space.
 
Ronin786 said:
There's something (theoretical) to be said about opening up the epidural space given the higher pressure exerted through the tuohy vs the tiny catheter.
Click to expand...
Lido gives no advantage over saline in this aspect.

Ronin786 said:
Also onset of relief is faster.
Click to expand...
This is true. but as @Planktonmd states. I don't think the faster onset is clinically significant.
 
OB heavy practice, many colleagues do LOR with 0.25% bupi. I think ~5ml though Tuohy, potentially more.

I think that this is faster than bolusing through the catheter, though the difference isn't clinically important. See below.
I think that this is less safe than bolusing through the catheter, though if your UNRECOGNIZED inadvertent dural puncture rate is very very low then this is in the realm of safe.

Usually when I get called for epidural on normal patient I tell them they should be SIGNIFICANTLY more comfortable within 30min - position, setup, catheter placement, bolus w/ 0.125%. Don't know if I could lower that estimate much by consistently CSE'ing or bolusing LA through Tuohy.
 
dchz said:
I really don't understand what benefit this gives over bolusing the catheter after you do the test dose... What catheters are you guys using that is so hard to thread?
Click to expand...

It’s not that the catheters are hard to thread. I just get fewer call backs for one-sided blocks or hot spots. That’s what I mean by dilate or opening up the space. I think it allows the local infusion to spread more evenly. Agree saline can probably accomplish the same thing.

For, all you guys saying there’s got to be hypotension, there’s simply not at the doses I stated.

Is unrecognized dural puncture a thing? If I don’t like my LOR, I thread the catheter and bolus just like you. But I guess I’ve never been fooled by a dural puncture with a touhy.

As far as clinically insignificant differences to analgesia, do you think that cse’s for labor analgesia offer significant differences? If this technique approximates cse (which I argue it does), then I think it is worth it.

To each his own though. I think there is value to the technique and I don’t think the characterization as dangerous, old-school is a good one.
 
Lurch said:
It’s not that the catheters are hard to thread. I just get fewer call backs for one-sided blocks or hot spots. That’s what I mean by dilate or opening up the space. I think it allows the local infusion to spread more evenly. Agree saline can probably accomplish the same thing.

For, all you guys saying there’s got to be hypotension, there’s simply not at the doses I stated.

Is unrecognized dural puncture a thing? If I don’t like my LOR, I thread the catheter and bolus just like you. But I guess I’ve never been fooled by a dural puncture with a touhy.

As far as clinically insignificant differences to analgesia, do you think that cse’s for labor analgesia offer significant differences? If this technique approximates cse (which I argue it does), then I think it is worth it.

To each his own though. I think there is value to the technique and I don’t think the characterization as dangerous, old-school is a good one.
Click to expand...
This is a great technique fewer one sided blocks quicker setup. I like ropi 0.2% to dilate with about 5cc and 3cc of the saline. I dont like doing lor with ropi because its sticky like dextrose in water. This technique is more for the experienced whom are 3-4 years in practice and want to fine tune their skills.
 
Planktonmd said:
It does work great as long as you don't cause severe hypotension and fetal distress!
Click to expand...
Back in the days they were using bupivacaine 0.5 or 0.375% so that the bolus would last as long as possible. Hypotension is not an issue with a 10cc bolus of 0.2% ropivacaine.
 
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Planktonmd said:
This is the old way of doing things, people 50 years ago used to inject a large bolus of local anesthetics through the epidural needle, unfortunately this produced an unacceptable incidence of severe maternal hypotension and arrest of labor.
So people with some brains said: maybe we should stop doing this crazy shiit and just place the catheter then gradually administer the epidural anesthetic. But some people did not get the memo and continued to do their stupid Shiit!
Click to expand...
Are you seriously trying to make a deduction from something that happened 50 years ago? Did they inject halothane thru the touhy or what?

Supremely dilute ropi doesn't seem to cause too many issues
 
Lurch said:
It’s not that the catheters are hard to thread. I just get fewer call backs for one-sided blocks or hot spots. That’s what I mean by dilate or opening up the space. I think it allows the local infusion to spread more evenly. Agree saline can probably accomplish the same thing.

For, all you guys saying there’s got to be hypotension, there’s simply not at the doses I stated.

Is unrecognized dural puncture a thing? If I don’t like my LOR, I thread the catheter and bolus just like you. But I guess I’ve never been fooled by a dural puncture with a touhy.

As far as clinically insignificant differences to analgesia, do you think that cse’s for labor analgesia offer significant differences? If this technique approximates cse (which I argue it does), then I think it is worth it.

To each his own though. I think there is value to the technique and I don’t think the characterization as dangerous, old-school is a good one.
Click to expand...
My experience is exactly like yours having done a couple of thousand that way. I’m not an old timer but I think the old way is superior in this case.
 
Last edited by a moderator:
I’ve been doing this technique for years. I don’t remember the last time I had a one sided block. 10 to 15cc of 0.2 Ropi.
Works great. Never had unintentional intrathecal injection. If at all worried, i’d just try to thread the catheter (I use the floppy cse catheters) and slow bolus, but this is almost never needed.
Never had a problem with hypotension or arrest of labor either.
 
Lots of talk in this thread about "dilating the space." In residency we were taught to do this (albeit with saline not local), and that's what I did all through residency and very early in my PP career. A month or two into my first gig, I switched to a "CSE all-comers" approach and have been doing that ever since (5 years now). I do not dilate the epidural space at all in my current approach. Get LOR (I use the 1/8th bupi + 2 fent bag solution for my LOR fluid), 25g needle through the tuohy, dose, thread Cath, a few cc's thought the Cath, start infusion. I have noticed zero difference in one-sided blocks or "hot spots" since skipping the dilation step. In fact, I get fewer top off calls using my current approach than I did with a straight CLE approach. I think this whole bit about "dilating the space" is voodoo.

I will say that I don't think there's anything wrong with bolusing through the Touhy - you just have to be damn sure you are in the epidural space (I'm talkin' to all you young padawans out there).
 
SaltyDog said:
Lots of talk in this thread about "dilating the space." In residency we were taught to do this (albeit with saline not local), and that's what I did all through residency and very early in my PP career. A month or two into my first gig, I switched to a "CSE all-comers" approach and have been doing that ever since (5 years now). I do not dilate the epidural space at all in my current approach. Get LOR (I use the 1/8th bupi + 2 fent bag solution for my LOR fluid), 25g needle through the tuohy, dose, thread Cath, a few cc's thought the Cath, start infusion. I have noticed zero difference in one-sided blocks or "hot spots" since skipping the dilation step. In fact, I get fewer top off calls using my current approach than I did with a straight CLE approach. I think this whole bit about "dilating the space" is voodoo.

I will say that I don't think there's anything wrong with bolusing through the Touhy - you just have to be damn sure you are in the epidural space (I'm talkin' to all you young padawans out there).
Click to expand...

One reason I’ve been injecting saline via the touhy after LOR is that I feel fluid (any fluid) is more physiologic than air. Maybe it dilated the space some but as others have said, I feel like the medicine spreads bit better in the space. I do CSE about half the time and for just about all the “screamers” because I want them to shut it, be happy, and get some rest for pushing
 
Lurch said:
I am new school and like to do it. L&D heavy practice. I agree it dilates the space well. I get fewer one-sided blocks, faster relief (approximates cse), and contrary to what you say, little hypotension and no fetal distress. I got more fetal bradycardia with cse’s when I used to do them.

I bolus 8-12cc of 0.25% bupi depending on height through tuohy.

Patients love me, ob/gyns ask for me by name, and young hottie RNs want to take me to the call room. Give it a try. You may like it
Click to expand...
The old school way was actually a large bolus of 0.5% 0r even 0.75% and trust me they did get hypotension!
 
Newtwo said:
Are you seriously trying to make a deduction from something that happened 50 years ago? Did they inject halothane thru the touhy or what?

Supremely dilute ropi doesn't seem to cause too many issues
Click to expand...
I wasn't talking about "supremely dilute ropi"
 
I used to work with some very old school dudes. I'd see some weird stuff every now and then, but somehow it always seemed to work for them. I know when I'm in the epidural space and when I'm not, and I like to dilate the space (with saline or dilute local). Compared to an undiluted space with catheter advancement and bolus, I have fewer one-sided epidurals and fewer 'hot spots'. That's just my experience.
 
I bolus 8-10 cc of 0.125% bupiv through the Tuohy, thread the catheter, tape it, and lay patient down. Then I give test dose (3-5 cc of 1.5% lido with epi), and then I do paperwork. Lastly, 1cc fentanyl through the catheter (I add the other 4cc fentanyl to the 100cc 0.2% ropiv bag to make it 2 ug/cc fentanyl). Infusion about 10-12 cc/hr.

Haven't used ephedrine in years.
 
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Gas said:
I bolus 8-10 cc of 0.125% bupiv through the Tuohy, thread the catheter, tape it, and lay patient down. Then I give test dose (3-5 cc of 1.5% lido with epi), and then I do paperwork. Lastly, 1cc fentanyl through the catheter (I add the other 4cc fentanyl to the 100cc 0.2% ropiv bag to make it 2 ug/cc fentanyl). Infusion about 10-12 cc/hr.

Haven't used ephedrine in years.
Click to expand...

Just trolling you a bit.....

Why give a test dose after you've given 8-10 cc of the bupiv through the Tuohy? (This is just me admittedly being a jerk like the board examiners)
 
It's a cool idea that some people I worked with did. I honestly don't because I think the risks, while very unlikely, are disastrous and I would feel embarrassed trying to defend why I would do that vs. just doing a CSE if my concern was speed of comfort.
 
There is a lot of subjective BS being thrown around on this thread, I think this happens, I think that, I believe I get this, etc.
The bottom line is that dosing through the touhy is an acceptable approach to epidural placement. You just need to know exactly where you are at all times. I personally do many different approaches based on the stage of labor and the mental preparation of the mom. If she is a screaming wreck at 3cm primip then she gets a low conc initial dose that sets up slowly. I don’t want her to get complete relief instantly because she will want that again when she is at 8-9cm.
My other approach is to dose through the touhy if I have a few pts requesting epidurals all at the same time. It is the fastest way and I don’t even test the catheter. What’s the worst thing that will happen if it’s intravascular at 6cc/hr of dilute marcaine? I’ll tell you, the epidural won’t work. Never seen an unexpected intrathecal cath.
What if it’s intrathecal, then she will have a more dense block and we will turn it down to 2cc/hr. I have never seen this either.
I recommend people not be so dogmatic about everything.
 
Noyac said:
There is a lot of subjective BS being thrown around on this thread, I think this happens, I think that, I believe I get this, etc.
The bottom line is that dosing through the touhy is an acceptable approach to epidural placement. You just need to know exactly where you are at all times. I personally do many different approaches based on the stage of labor and the mental preparation of the mom. If she is a screaming wreck at 3cm primip then she gets a low conc initial dose that sets up slowly. I don’t want her to get complete relief instantly because she will want that again when she is at 8-9cm.
My other approach is to dose through the touhy if I have a few pts requesting epidurals all at the same time. It is the fastest way and I don’t even test the catheter. What’s the worst thing that will happen if it’s intravascular at 6cc/hr of dilute marcaine? I’ll tell you, the epidural won’t work. Never seen an unexpected intrathecal cath.
What if it’s intrathecal, then she will have a more dense block and we will turn it down to 2cc/hr. I have never seen this either.
I recommend people not be so dogmatic about everything.
Click to expand...

Im not quite sure it’s dogma BS more so than being cautious in a young, healthy population and not wanting to be the one that causes something bad to happen where there are plenty of other opportunities to have something bad happen. You’re mostly right. If you’re using a touhy needle you’ll know instantly when you’re in the CSF or a vessel, so if you’re not, then why not just bolus and get the lady comfortable. I think that should be reserved for hands with a bit of experience.

Also, even in my private practice full of experienced hands, at least once a year someone threads a catheter intrathecal.
 
Psai said:
Brah its 2018 we use ultrasound now
Click to expand...

Thx brah, I use US too. I’m sure you don’t get post-line X-rays bc they can’t end up elsewhere in the venous system, right?

And you also misinterpreted my post. I use US for lines and I also give saline and/or local through the tuohy bc I like my patients to be comfortable quicker with fewer one-sided epidurals/hot spots/screams post-placement waiting for an epidural to setup/callbacks from OB for nonsense.
 
Southpaw said:
Thx brah, I use US too. I’m sure you don’t get post-line X-rays bc they can’t end up elsewhere in the venous system, right?

And you also misinterpreted my post. I use US for lines and I also give saline and/or local through the tuohy bc I like my patients to be comfortable quicker with fewer one-sided epidurals/hot spots/screams post-placement waiting for an epidural to setup/callbacks from OB for nonsense.
Click to expand...

Throw down the cardiac probe on the chest, watch the bubbles in the ra and its all good
 
Twiggidy said:
Just trolling you a bit.....

Why give a test dose after you've given 8-10 cc of the bupiv through the Tuohy? (This is just me admittedly being a jerk like the board examiners)
Click to expand...

With the dilute 0.125% bupivacaine, the patients get little motor block. They get somewhat comfortable, but not 100% yet. After that 0.125% and the test dose, patients usually get quite comfortable, and they start to get some motor block if your catheter is in the right place. They can still move their legs though - just heavy. If your catheter is in a vessel, you won't notice much motor block (just the minimum from the 0.125%), and you may get the perioral numbness, tingling, tachycardia with epi, etc. If your catheter is intrathecal, you will get a profound motor block and probably hypotension too.

So the test dose is really there to test the catheter. The 0.125% is there for quick comfort, and to help prevent patchy/one-sided epidurals. In private practice, I don't have much time to spare, and a one-sided epidural is something I'd rather not deal with when they call the section. We take call from home and I have to trust that catheter is working the way it should.

Personally, it seems like 0.25% via Tuohy along with a test dose is quite a bit of local, and would be more likely to cause hypotension. Just my 2 cents on all of this.
 
Gas said:
With the dilute 0.125% bupivacaine, the patients get little motor block. They get somewhat comfortable, but not 100% yet. After that 0.125% and the test dose, patients usually get quite comfortable, and they start to get some motor block if your catheter is in the right place. They can still move their legs though - just heavy. If your catheter is in a vessel, you won't notice much motor block (just the minimum from the 0.125%), and you may get the perioral numbness, tingling, tachycardia with epi, etc. If your catheter is intrathecal, you will get a profound motor block and probably hypotension too.

So the test dose is really there to test the catheter. The 0.125% is there for quick comfort, and to help prevent patchy/one-sided epidurals. In private practice, I don't have much time to spare, and a one-sided epidural is something I'd rather not deal with when they call the section. We take call from home and I have to trust that catheter is working the way it should.

Personally, it seems like 0.25% via Tuohy along with a test dose is quite a bit of local, and would be more likely to cause hypotension. Just my 2 cents on all of this.
Click to expand...

it seems like you’d get hypotension but it doesn’t seem to happen in practice.

You don’t need to test the catheter. If you want to give the test dose to get a better block faster, just add it to your bolus through the Tuohy.
 
nolagas said:
it seems like you’d get hypotension but it doesn’t seem to happen in practice.

You don’t need to test the catheter. If you want to give the test dose to get a better block faster, just add it to your bolus through the Tuohy.
Click to expand...

I used to give 10cc’s of 0.25% Bupivicaine through the Tuohy. It set up fast, was bilateral, and I almost never had to return to the patient’s room (with a PCEA running). After a while I started doing 7-8 of 0.25% + 3-4 of test dose and it seemed even better and faster without hypotension. 10 of 0.25 + 5 of test dose was too much though based on a small N, I gave that up after having to give neo a couple of times.

Very rarely if placement just didn’t feel quite right, I’d thread a catheter, give a test dose, wait, then bolus. What a p in the a!
 
Last edited by a moderator:
I trained with those stiff nylon catheters so I try an prioritize having a catheter that works, my problem with local down the tuohy is I don't know if that catheter is going to work. I've had CSEs where the catheter is one sided or the catheter is aspiration negative but positive for IV on test dose. I don't like to come back to the room and want to know if the catheter works before I leave the room. In early labor 10mcg of IT fentanyl is an amazing thing. +1 for volume btw 16-20 ml of 0.125% bupi and lots of saline on loss seems to be my magic sauce for even blocks and long duration.
 
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