Labo(u)r Epidural Survey

[drccw]

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I just wanted to get a feeling of what people are doing out there...

1) Sitting vs Lateral
2) Chloraprep vs Betadine
3) Hat? Mask? Gown?
4) Level
5) Midline vs Paramedian
6) Bevel up or down
7) LOR vs hanging drop?
8) If LOR then saline or air
9) Distance of catheter into epidural space
10) Bolus dose?
11) Infusion drug
12) Dose
13) PCEA


here are my answers
1) Sitting
2) Chloraprep
3) Hat and Mask
4) Try for L3-4
5) Midline
6) Bevel down
7) LOR (only read about hanging drop in a book)
8) Saline
9) 3-4 cm into epidural space
10) I bolus with our infusate (12 mL), which is
11) Bupivicaine 0.1% with Fentanyl 2 mcg/ml
12) 15 ml/hr
13) No PCEA

Just curious what every is doing out there in epidural land

drccw

 

[IlDestriero]

1) Sitting vs Lateral - sitting
2) Chloraprep vs Betadine - chloraprep
3) Hat? Mask? Gown? - hat, mask, scrubs (and not scrubs used to go outside to lunch, etc)
4) Level - L3-4
5) Midline vs Paramedian- midline
6) Bevel up or down - up
7) LOR vs hanging drop? - LOR
8) If LOR then saline or air - Saline 4cc with 1/2 cc air bubble for compression
9) Distance of catheter into epidural space - 5cm
10) Bolus dose?- 10 cc 0.2% ropiv
11) Infusion drug - 0.1% ropiv w/ fent
12) Dose- 10cc/hr
13) PCEA - yes 5cc q 10 1 hr lockout 30cc

 

[CrazyJake]

1) Sitting vs Lateral - sitting
2) Chloraprep vs Betadine - Betadine unless 'dine allergy.
3) Hat? Mask? Gown? - hat, mask. Same pair of scrubs that I put on at the start of my shift.
4) Level - L3-4
5) Midline vs Paramedian- midline
6) Bevel up or down - up
7) LOR vs hanging drop? - LOR
8) If LOR then saline or air - Saline 3-5cc with 1/2 cc air bubble for compression
9) Distance of catheter into epidural space - 5-7cm
10) Bolus dose?- 5 - 8 cc Bupivicaine 0.1% with Fentanyl 2 mcg/ml
11) Infusion drug - as above
12) Dose- 10 - 12 cc/hr - occasionally 14 cc/hour if large and in charge
13) PCEA - yes 5cc q 10 1 hr lockout 38-40cc

Also do Spinal first with 0.5 ml Fentanyl and 0.5 cc .25% Bupivacaine.

CJ

 

[bigdan]

1) Sitting
2) Betadine
3) Hat & Mask
4) Level - L3-4 unless the space above or below is better
5) Midline
6) Bevel up
7) LOR; I did my first ever "hanging drop" a coupla days ago. On chronic pain rotation - cervical & no fluoro.
8) I "wash out" the glass syringe with saline, then empty it and use air only.
9) Distance of catheter into epidural space - 3 or 4 if thin, 5 or 6 if fat.
10) Bolus dose: 8 cc of 0.08% Bupivacaine w/2 mcg/cc Fentanyl + 100 mcg Fentanyl (total amount bolused = 10 cc)
11) Infusion: 0.08% Bupivacaine w/2mcg/cc Fentanyl
12) Dose: 8 cc/hr
13) PCEA: 8 cc q 8 min, 1 hr lockout at 24 cc total

 

[OB1🤙]

drccw- why bevel down?

 

[Consigliere]

14) We have our CRNAs do 'em

 

[drccw]

drccw- why bevel down?

Someone once told me that they've had better luck avoiding sacral sparing with the bevel down. I know most of the evidence suggests that that catheter tends to go who knows where when it's threaded but I find that when I insert the needle perpendicular to the skin, bevel down, that I have had no problems with sacral sparing, saving me that I need a top off dose....

though it's probably just I've gotten lucky...

drccw

 

[drccw]

those of you who are using PCEAs-
have you audited the total avg total dose per hour?
just curious... our patient population/nurses aren't educated enough for PCEA so I usually avoid it...

drccw

 

[IlDestriero]

Someone once told me that they've had better luck avoiding sacral sparing with the bevel down. I know most of the evidence suggests that that catheter tends to go who knows where when it's threaded but I find that when I insert the needle perpendicular to the skin, bevel down, that I have had no problems with sacral sparing, saving me that I need a top off dose....

though it's probably just I've gotten lucky...

drccw

With a PCEA they top themselves off.👍

 

[drccw]

1) Sitting vs Lateral - sitting
2) Chloraprep vs Betadine - chloraprep
3) Hat? Mask? Gown? - hat, mask, scrubs (and not scrubs used to go outside to lunch, etc)
4) Level - L3-4
5) Midline vs Paramedian- midline
6) Bevel up or down - up
7) LOR vs hanging drop? - LOR
8) If LOR then saline or air - Saline 4cc with 1/2 cc air bubble for compression
9) Distance of catheter into epidural space - 5cm
10) Bolus dose?- 10 cc 0.2% ropiv
11) Infusion drug - 0.1% ropiv w/ fent
12) Dose- 10cc/hr
13) PCEA - yes 5cc q 10 1 hr lockout 30cc

does the 1 hour lockout include the 10 cc/hr infusion, or is that in addition? I guess my question is can you patients recieve 40 ml of local an hour? No wonder they don't need topping off.. 🙂

drccw

 

[PMPMD]

1) Sitting
2) Betadine
3) Hat + Mask + scrubs
4) L3-4
5) Midline
6) Bevel up
7) LOR. (saw hanging drop once - didn't work but it sounds cool)
8) LOR with 3cc saline + small air bubble
9) catheter 5 cm into epidural space
10) Bolus dose: 10 ml of 0.125% bupiv + fent
11) Infusion drug: 0.044% bupiv + epi + fent (institutional)
12) Dose: will bolus off PCEA if necessary
13) PCEA: basal 14 ml\hr, 10ml q15 min

 

[lord_jeebus]

Sitting
Duraprep (no opposition to chloraprep but we have duraprep in the OB cart)
Hat & Mask
L3-4, usually
Midline, usually
Bevel up
LOR to saline
3-5 cm
Most often bolus 8 ml 0.125% bupiv plus 100 mcg fentanyl
Infusion 0.1% bupiv with 2 mcg/ml fentanyl
10 ml/hr + 5 ml q 20min

 

[pgg]

1) Sitting
2) Betadine
3) Hat & mask
4) L3-4 ... but of course the data shows we're not all that good at guessing where we really are
5) Midline
6) Bevel up
7) LOR
8) saline
9) 5 or 6 cm in space, 7 cm in morbidly obese and I tape after they're laying down again
10) No epidural bolus but almost everyone gets a needle-through-needle CSE with 15 mcg fent + 1 mL 0.25% bupivacaine intrathecal
11) 0.125% bupivacaine + 2 mcg/mL fentanyl
12) 8 mL/hr
13) PCEA 6 mL q15min

 

[IlDestriero]

does the 1 hour lockout include the 10 cc/hr infusion, or is that in addition? I guess my question is can you patients recieve 40 ml of local an hour? No wonder they don't need topping off.. 🙂

drccw

30cc/hr max (total)
They could get 4 bolus doses in a 60 min period.
Most don't use any where near that much.

 

[IlDestriero]

1) Sitting
2) Betadine
3) Hat & mask
4) L3-4 ... but of course the data shows we're not all that good at guessing where we really are
5) Midline
6) Bevel up
7) LOR
8) saline
9) 5 or 6 cm in space, 7 cm in morbidly obese and I tape after they're laying down again
10) No epidural bolus but almost everyone gets a needle-through-needle CSE with 15 mcg fent + 1 mL 0.25% bupivacaine intrathecal
11) 0.125% bupivacaine + 2 mcg/mL fentanyl
12) 8 mL/hr
13) PCEA 6 mL q15min

You should think about adding 100 mcg clonidine to your spinal solution. It should buy you another hour or 2. One of the guys here has started doing this. Apparently it's big in Brazil.

 

[MommyMD]

1) Sitting vs Lateral - both (depends if they can sit up or not...sometimes they are more comfortable in lateral)
2) Chloraprep vs Betadine - betadine
3) Hat? Mask? Gown? - cap and mask
4) Level l3-4
5) Midline vs Paramedian - midline
6) Bevel up or down - bevel up
7) LOR vs hanging drop? - depends which ob anesthesia attending working with but do both
8) If LOR then saline or air - air
9) Distance of catheter into epidural space - 5cm
10) Bolus dose? - 10cc 0.2% ropi
11) Infusion drug -0.04%ropi/sufentanil/epi (standard in our hospital)
12) Dose - 10-12 cc/hr dependning on height 4cc bolus q5-8min
13) PCEA -yes

 

[pgg]

You should think about adding 100 mcg clonidine to your spinal solution. It should buy you another hour or 2. One of the guys here has started doing this. Apparently it's big in Brazil.

I start the epidural infusion immediately after the CSE. By the time the intrathecal dose would be wearing off an hour or so later, the epidural has kicked in. I don't know if there's much to be gained by clonidine here.


I know a guy who works at an OB hospital, who does long-acting spinals for labor. He uses (I think) 2 mL of the 0.25% bupiv + fentanyl + morphine and says he gets 2-3 hours of good analgesia out of it, plus good postpartum pain control from the morphine. I suspect it's a bit denser up front than I would like, especially if she's near pushing. They don't do epidurals there for economic reasons ... apparently not enough insurance or hospital subsidy to make it worthwhile. So they kinda guess when she's within a few hours of delivery and she gets her one shot, and that's it.


I don't put morphine in my spinals or epidurals unless it's for a section. The last time we had a thread like this I think there were a couple people who said they use morphine for post-SVD pain control.

 

[lobelsteve]

1) Sitting
2) Betadine
3) Hat & Mask
4) Level - L3-4 unless the space above or below is better
5) Midline
6) Bevel up
7) LOR; I did my first ever "hanging drop" a coupla days ago. On chronic pain rotation - cervical & no fluoro.
8) I "wash out" the glass syringe with saline, then empty it and use air only.
9) Distance of catheter into epidural space - 3 or 4 if thin, 5 or 6 if fat.
10) Bolus dose: 8 cc of 0.08% Bupivacaine w/2 mcg/cc Fentanyl + 100 mcg Fentanyl (total amount bolused = 10 cc)
11) Infusion: 0.08% Bupivacaine w/2mcg/cc Fentanyl
12) Dose: 8 cc/hr
13) PCEA: 8 cc q 8 min, 1 hr lockout at 24 cc total

Spent the day with Doris and not Nash?

 

[Idiopathic]

i think 100 mcg of clonidine is overkill. i get an hour extra with 25mcg (i think the knee literature showed 30mcg was optimal)

 

[Idiopathic]

Someone once told me that they've had better luck avoiding sacral sparing with the bevel down. I know most of the evidence suggests that that catheter tends to go who knows where when it's threaded but I find that when I insert the needle perpendicular to the skin, bevel down, that I have had no problems with sacral sparing, saving me that I need a top off dose....

though it's probably just I've gotten lucky...

drccw

i think youd have just as much likelihood of not getting good uterine coverage if this were true but whatever your experience is then its probably as valid as anything else

 

[bigdan]

Spent the day with Doris and not Nash?

(Looking around, over shoulder)

Um...yes! You are wise...

(Looks again)😏

 

[pjl]

1) Sitting vs Lateral - Patient/nurse preference, but 95% sitting. I insist on laying if they are really squirmy
2) Chloraprep vs Betadine - Chloraprep
3) Hat? Mask? Gown? - Hat, Mask. No gown
4) Level - Aim L3-4
5) Midline vs Paramedian - Midline
6) Bevel up or down - Bevel cephalad
7) LOR vs hanging drop? - LOR
8) If LOR then saline or air - Saline, why risk the pneumocephalus headache and patchy block (anecdotal)?
9) Distance of catheter into epidural space - 4-5 with a multiorifaced catheter
10) Bolus dose? - Typically 10 mL of infusion, pushed via syringe
11) Infusion drug - 0.125 % bup +2/mL fentanyl
12) Dose - 10/hour
13) PCEA - 10 q15 Our floor is closely monitored, and we rarely have high epidurals with this infusion plan

14) CSE? - If pt screaming/close, typically just fentanyl 25 mcg, no local. Then bolus epidural as appropriate
15) Test Dose? - 2% Lido w/ epi 3 mL
16) Rescue Top-off dose - 8 mL 0.25% bup w/ 100 mcg fentanyl (I personally rarely do this because I feel it masks a shoddy epidural and I would rather replace than receive a bunch of calls)

 

[sevoflurane]

1. Sitting
2. Chloraprep
3. Hat/mask
4. L3/4
5. Midline
6. Bevel up
7. LOR (Hanging drop only for cervical epidurals)
8. 2-3 cc saline + 1 cc air bubble. Glass syringe in kit. Plastic ones work great too as you don't have to prime them cuz they never stick.
9. 3-4cm into the space
10. Test dose, if negative, 100mcgs of fent + 2-3 cc's of left over lidocaine from kit.
11. .1% rop with 2mcg/ml fent
12. 10-16 ml/hr
13. No PCEA
14. All 5cc's in test dose. I used to bolus through tuohy... but I don't anymore.

Our OB nurses do a great job. They bolus if necessary (over 15 minutes) and have standing orders with strict parameters to give ephedrine if needed. They also pull our catheters and document tip intact + site C/D/I.

 

[Antigunner]

1) Sitting vs Lateral - Sitting (usually)
2) Chloraprep vs Betadine - Betadine unless allergic
3) Hat? Mask? Gown? - Hat/mask/scrubs
4) Level - L3/4 or 4/5
5) Midline vs Paramedian - midline
6) Bevel up or down - up
7) LOR vs hanging drop? - LOR
8) If LOR then saline or air - saline except with a couple attendings who like air
9) Distance of catheter into epidural space - 5-6 cm
10) Bolus dose? - 10 cc pulled from infusion bag
11) Infusion drug - 0.2% ropiv w/ 2 mcg/ml fent
12) Dose - 10 cc/hour
13) PCEA - 5 cc every 20 min.

For CSE usually just do 20-25 mcg intrathecal fent w/ no epidural bolus

 

[hivoltage]

14) We have our CRNAs do 'em

what do you do? sit and supervise them by telephone? or do you just put the blood patch in in the mornin'

 

[Mman]

1) Sitting
2) Chloraprep
3) Hat/mask
4) Level 3/4 (or so I document, but in most fatties I have no idea)
5) Midline
6) Bevel up
7) LOR
8) saline
9) 4 cm
10) 5-10 mls of 0.25% bupivicaine
11) Ropivicaine 0.2%
12) 10 ml/hr
13) I wish, but the pumps on L/D don't support it

 

[Mman]

what do you do? sit and supervise them by telephone? or do you just put the blood patch in in the mornin'

CRNAs can place labor epidurals under the supervision of the obstetrician. It isn't considered an anesthetic and this is how many small hospitals are run.

 

[pgg]

what do you do? sit and supervise them by telephone? or do you just put the blood patch in in the mornin'

CRNAs can be very proficient when it comes to needle driving. I know a few who are as technically proficient as most anesthesiologists I know. Some of those same few CRNAs may not always be able to tell the difference between a high spinal and an AFE or know how to handle either, but their monkey skills are solid.

I'm not endorsing independent practice, but they're not hamhanded wet tap machines.

 

[Consigliere]

what do you do? sit and supervise them by telephone? or do you just put the blood patch in in the mornin'

Nope. Don't supervise them at all. Stay at home in bed. OB/GYN "supervises" them. That's the way it's done in the real world, son. At least in the rural real world anyway.

 

[thegasman]

1) Sitting
2) Chloraprep
3) hat mask and scrubs
4) Level - L3-4 or l4-5
5) midline
6) Bevel up or down - up
7) LOR vs hanging drop? - LOR
8) Air but as I soon as i feel the give i stop - very little is actually injected
9) +4 cm
10) Bolus dose?- 12-14 cc ropiv 0.2% with 2mcg/cc fent
11) Infusion drug - same
12) Dose- 12 cc/hr
13) PCEA - yes 5cc q 10 1 hr lockout 33 cc

 

[dhb]

1) Sitting
2) Chloraprep
3) Hat, Mask and gloves
4) L4-L5
5) Midline
6) Bevel up
7) LOR
8) Saline
9) 4-5 cm into epidural space
10) I bolus with lidocaine that's left over from the local +- 0.75% + 10mcg sufenta 12ml
11) Ropivacaine 0.15%
12) 10-16 ml/hr
13) No PCEA

 

[dhb]

All 5cc's in test dose. I used to bolus through tuohy... but I don't anymore.

Why not?

 

[diceksox]

1) Sitting
2) Chloraprep
3) Hat and Mask. No gown?
4) Level = whatever feels best L1-4
5) Midline - 90%
6) Bevel up
7) LOR
8) air
9) 3
10) Bolus dose - depends
11) Infusion drug - bupiv/ dilaudid
12) 0.031%/ 10mcgml @12ml hr
13) No

 

[Mman]

4) Level = whatever feels best L1-4

Really? I mean I at least try to stay below the conus medullaris. I wouldn't go starting out at L1/2, at least intentionally, regardless of how good the space felt.


And I say this as someone that got a wet tap on a thoracic epidural as a resident. There were no bad outcomes for the patient, but it scared the crap out of me. It was a trauma patient with a bunch of rib fxs in the ICU. When I got loss, he decided it was a good time to cough and buck and then CSF was pouring out the touhy. We pulled it and put it at a different level.

 

[sevoflurane]

Why not?

You know... I used to bolus through the tuohy quite a bit. Never had a problem, but I just like to do anything I can do, as miniscule as it may be, to ward off evil spirits.

I prefer to bolus at a site different than that of my needle insertion. Just makes me feel better. 😉

 

[diceksox]

The diameter of the cord at the level of the conus is less than that encountered at thoracic levels. With that being said, I dont start off looking to go L1-2, but if there is a BMI of 70 and I can feel L1-2 I'm going there as opposed to the abyss below.

 

[seinfeld]

1) Sitting
2) Duraprep
3) Hat and Mask. No gown
4) Level = whatever feels best L1-4
5) Midline - 99.999%
6) Bevel up
7) LOR
8) saline
9) Depends on patient size, anymore i dont pay close attention, cather left at total distance 13-15, would rather have one sided block and have to pull back than replace it when it falls out
10) 10 ml of 0.125% bupivicaine, add fentanyl 50 mcg for the real pain intolerant one's
11) Infusion drug - 0.2% ropiv with 2mcg/ml fent at 12-14ml/hr with 10 ml bolus prn x 1 per L&D nursing


I have another question to ask, HOW much time does it take you guys to place epidural, from entering room, saying hi, charting vitals, until exit.

I have some partners who seem to take a sabbatical when sent to do an epidural.

My average 20 mins total, 5 mins after entering epidural is being bolused.

 

[pgg]

Really? I mean I at least try to stay below the conus medullaris. I wouldn't go starting out at L1/2, at least intentionally, regardless of how good the space felt.

I wouldn't start that high normally either, but mainly because you get more sacral sparing. Low thoracic labor epidurals for morbidly obese patients are described in Datta's OB anesthesia book. There's usually less back fat that high and the spinous processes are still mostly horizontal. If I struggle for even a few minutes with an obese woman I'll just go higher (without my usual CSE of course). Occasionally I'll just start high if low looks like it'll be a struggle.

 

[bigdan]

I have another question to ask, HOW much time does it take you guys to place epidural, from entering room, saying hi, charting vitals, until exit.

I have some partners who seem to take a sabbatical when sent to do an epidural.

My average 20 mins total, 5 mins after entering epidural is being bolused.

I very interested in this as well. For full disclosure, I'm a CA1 who has already completed the requisite OB rotation.

I'd say I spend 25 minutes (at best), 30-35 minutes (average) in the room doing EVERYTHING our program dictates - the last five to eight or so is prolly spent on charting and pt education in how to use PCEA.

There are others in my residency that claim near single digit door-to-door times; I cannot see how this can be done without drastically skimping on (most likely) discussion of medical history and consent or (less likely but still quite possible) safety in technique and dosing.

 

[psychbender]

I very interested in this as well. For full disclosure, I'm a CA1 who has already completed the requisite OB rotation.

I'd say I spend 25 minutes (at best), 30-35 minutes (average) in the room doing EVERYTHING our program dictates - the last five to eight or so is prolly spent on charting and pt education in how to use PCEA.

There are others in my residency that claim near single digit door-to-door times; I cannot see how this can be done without drastically skimping on (most likely) discussion of medical history and consent or (less likely but still quite possible) safety in technique and dosing.

We preop and consent everyone on admission to L&D, so when the patient requests an epidural, we just have to ensure the patient is positioned, the IV is flowing, do the procedure, and set up the pump/explain the PCEA. I usually leave the room once the patient reports some pain relief, and there hasn't been a significant drop in blood pressure (so, usually ~20min door-to-door, with at least half of that being the pump setup/teaching/waiting for some pain relief). Then, its off to the call room to write the procedure note (the one computer in the room is always in use by the nurse who is charting vitals and every single thing I do in the room), and return to the pt's room to ensure everything is working appropriately.

1) Sitting
2) Betadine, sometimes chlorprep (mostly just because the betadine is in the kits)
3) Hat, mask, gloves
4) L3/4 to start
5) Midline
6) Bevel up
7) LOR
8) Air, or saline with a compressible bubble
9) 4-6cm in the space
10) 10mL 0.125% bupivicaine with 2mcg/mL fentanyl, sometimes 5-10mL 0.25% bupivicaine instead
11) 0.125% bupivicaine with 2mch/mL fentanyl
12/13) Usually 8mL/hr, with 5mL bolus q20min

 

[Arch Guillotti]

This has been discussed a few times before on the forum. 30 minutes for a junior resident isn't unreasonable. The time in the room is variable depending on when you start timing things. Pre-op, sitting up, needle insertion, etc.

If the patient is sitting up and no weird medical problems, I think that you should have the pre-op and consent done and be dosing the epidural in 10 minutes or less usually. If you have nurses that can start the pump and give pressors then you should be out the door shortly afterwards. If you have to set up the pump, do paperwork, etc then 20 minutes total in the room isn't unreasonable. Some will be quicker, some longer. There is a lot of bravado on this forum when it comes to epidural placement times. While you are a resident focus on technique and get good at driving the needle without putting too much pressure on yourself. By the time you are a CA-3 if you push yourself you will be almost as proficient at needle driving as a few of your attendings. Also work on cutting little corners to save bits of time here and there because these tricks will help you in the future.

I very interested in this as well. For full disclosure, I'm a CA1 who has already completed the requisite OB rotation.

I'd say I spend 25 minutes (at best), 30-35 minutes (average) in the room doing EVERYTHING our program dictates - the last five to eight or so is prolly spent on charting and pt education in how to use PCEA.

There are others in my residency that claim near single digit door-to-door times; I cannot see how this can be done without drastically skimping on (most likely) discussion of medical history and consent or (less likely but still quite possible) safety in technique and dosing.

 

[CrazyJake]

I just knocked out a straightforward epidural, 20 mins. Wasn't rushing, but wasn't on sabbatical either. H+P/consent was already done, but hit the high points & started.

Psychbender - I'd write down everything you did too...but that's just me talking.

I sometimes pause during contractions, I nice perk I add at the cost of additional time.

CJ

 

[periopdoc]

There are too many variables with time. One of the hospitals I worked at was sweet, I walked into the room and the patient was already positioned with the back exposed. My epidural tray was open with the syringes filled just the way I like them. I could count on the nurses giving me a heads up on any patient medical issues, and I could count on a good fluid bolus being completely in the patient before I entered the room. When I was done, the nurse would attach the pre-programed and primed infusion pump. They were happy to administer ephedrine PRN if I handed them a premixed syringe (I always carried 3-4 syringes of ephedrine premixed.)

In that scenario, I generally had the epidural done in under ten minutes door to door time, although I would usually stick around for an additional ten minutes unless there was another epidural waiting for me. Risk benefit discussed while prepping and draping, plan discussed while epidural going in.

In my current situation, it isn't uncommon for a 30-45 minute door to door time. There are few if any time pressures outside of mom wanting to get comfortable so I am not really trying to hurry. I don't trust my nurses to tease out pertinent medical history so I have to be more meticulous. They will not push pressors. The patients are rarely positioned and the belly band is always covering T12-S2. Fluid bolus is usually in, but that is not ubiquitous. I have to open my own tray and draw up my own syringes. I have to attach the infusion set to the bag, attach it to the pump, prime it, program it, and attach it to the patient. You get the picture.


For residents, Arch is dead on. Focus on technique, not speed. You will gain speed (efficiency actually) as you progress if you have good technique.

At first, it is a good idea to set everything up ahead of time and mentally go through the process so that you know you have everything on your tray that you will need BEFORE you start your epidural.

As you progress, start to look at your efficiency. Do you save time by drawing up all of your syringes up front or by drawing them up as you use them? You will know what needs to be there and can tell at a glance if it is. For me, I like to prep and drape then give the local right away. Then I draw up anything else I might need before starting. This gives a little extra time for the local to work.

- pod

 

[periopdoc]

1) Sitting vs Lateral - whichever the patient is more comfortable with.
2) Chloraprep vs Betadine - whatever is available.
3) Hat? Mask? Gown? - Cap and mask for everyone in the room. Gloves for me.
4) Level - Start at L4-5 if possible.
5) Midline vs Paramedian - Midline for normally sized women. Paramedian for morbidly obese.
6) Bevel up or down - Up
7) LOR vs hanging drop? - LOR
8) If LOR then saline or air - Saline with air bubble
9) Distance of catheter into epidural space - 3-5 cm
10) Bolus dose? - 5cc 1.5% lido +epi plus whatever is left in the local vial after giving ~10cc saline following LOR.
11) Infusion drug - 1/10% Bupi + 2 mcg/ml fent
12) Dose - 6-10 cc/h continuous with 3-5 cc q 10 min PCEA, except for the one OB that prefers no continuous, then 10cc q15min PCEA.
13) PCEA - yes

CSE with 1cc 0.25% bupi +/- 5mcg Sufenta if patient is near to delivery and very uncomfortable.

- pod

 

[psychbender]

Psychbender - I'd write down everything you did too...but that's just me talking.

Oh, trust me, I write down everything that I did, I just put it in the procedure note, rather than the vitals section of the EMR. The other residents make fun of my notes, as I type out in full sentences exactly what I did step-by-step in the comments section (rather than just using the dropdowns and signing the note without freetexting).

 

[dA pilot]

1) Sitting
2) Betadine
3) Hat Mask Gloves
4) Level - L3-4
5) Midline vs Paramedian- midline
6) Bevel up or down - up
7) LOR vs hanging drop? - LOR
8) If LOR then saline or air - Air
9) Distance of catheter into epidural space - 3-5 cm
10) Bolus dose - 10 cc .125% Bupiv + 2 mcg/cc fentanyl
11) Infusion drug - 0.1% bupiv with 2 mcg/ml fentanyl
12) Dose- 10cc/hr
13) PCEA - yes 10cc q 15 1 hr lockout 40cc

5) Midline vs Paramedian - Midline for normally sized women. Paramedian for morbidly obese.
- pod

Is there a significant advantage to do a paramedian for moribidly obese? Biggest problem for me is finding midline in these patients and not access between spinous processes. At times, when i have a real short skinny person, i do a paramedian because the spaces are so tight.

 

[Mman]

As you progress, start to look at your efficiency. Do you save time by drawing up all of your syringes up front or by drawing them up as you use them? You will know what needs to be there and can tell at a glance if it is. For me, I like to prep and drape then give the local right away. Then I draw up anything else I might need before starting. This gives a little extra time for the local to work.

- pod

AGREE!

One of my biggest teaching points for any sterile procedure (central line, epidural, etc) for beginners is to not worry about rushing during the important parts. Don't go rushing to advance the Touhy through the ligament. Take your time. The majority of your improvement in getting faster at the procedure becomes in how quickly you can do the mindless parts of it. Opening up the kit, putting on gloves, throwing out what you don't need, opening vials, drawing up local, prepping/draping, etc. That stuff is completely mindless, but the more you do it the faster you get. Beginners tend to stumble around with the kits. They don't know what they need. They don't know where to find what they are looking for. They forget to drop something onto the kit that they needed before putting on their gloves. and on and on and on

But that just takes practice. You don't make huge strides in terms of the technical part of the procedure going faster. I mean it's a little faster, but not much. Where you really get faster is with all the little parts.

My current times for labor epidurals are around 9-15 minutes from door to door depending on how ready the patient is when I walk in (laying in piles of wrapped up cords/tubing vs sitting up ready to go). This includes about 2-3 minutes of consent. But when I was a junior resident, I was probably around 25-35 minutes in the room time.

 

[seinfeld]

I thought there was a mandatory 15minute monitoring time post epidural placement? I know for sure that our blue cross requires it in order to bill.

 

[jetproppilot]

I just wanted to get a feeling of what people are doing out there...

1) Sitting vs Lateral sitting
2) Chloraprep vs Betadine betadine since it's in the kit; either is fine
3) Hat? Mask? Gown? none of these are needed
4) LevelI go one level higher than most.
5) Midline vs Paramedianmidline unless up against a wall
6) Bevel up or downup, but probably doesn't matter
7) LOR vs hanging drop? wtf? HANGING DROP? ARE YOU SERIOUS?
8) If LOR then saline or airno need for saline. Wasted step. Air.
9) Distance of catheter into epidural space4 cm
10) Bolus dose?no bolus since I do CSE
11) Infusion drug ropiv .2%/sufent .5ug per mL/ @ 15mL per hour is the best
12) Dose just told you
13) PCEA over rated...never used




Just curious what every is doing out there in epidural land

drccw

.

 

[dhb]

Jet, don't you get a lot of motor block with 15cc of .2% ropi?