lumbar epidural in PP

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Hey y'all - I was wondering how some of you private guys like to place / dose labor epidurals? Specifically CSE vs traditional epidural.

In my residency we almost exclusively do CSE with spinal narcs for pts early in labor and will add spinal bupivicaine / fent if dosing for a patient further along. The technique seems to quicken onset to analgesia, improve pt satisfaction and maybe provides better sacral analgesia. To me, it also clouds how well the actual catheter works especially when adding local to the spinal dose.

I am taking on a private job soon and was thinking of reducing / restricting CSE dosing solely for really advanced parturients to help ensure functioning catheters in patients who may be more likely to end up with a C/S. If not using the CSE technique, do you tend to bolus with local (maybe 20mg bupivicaine or so) before starting your catheter infusion?

Thanks for any advice and wisdom!
 
1. Straight epidural
2. Thread catheter
3. Test dose 3 mL 1.5% lido+epi
4. Tape catheter
5. 10 mL bolus 0.125% bup-2mcg/ml fentanyl mix
6. Start 10 mL/hour infusion with 5 mL bolus q 20 min with 20 mL/hr lockout.

Time from in room to bolus is average 8 minutes, I leave after charting~5-7 min later with them feeling substantially better (second or third contraction after dose). Block continues to set up after I leave.

In my hands, with my kits, it takes me an extra 2 minutes of set up to do CSE, but the comfort is faster. I found my out of room time was ~same, and their comfort was only 1-2 contractions faster. When I stopped doing those routinely, I got a lot less calls at the 1.5-2.5 hour mark for top off doses.



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1. Straight epidural
2. Thread catheter
3. Test dose 3 mL 1.5% lido+epi
4. Tape catheter
5. 10 mL bolus 0.25% bup + 100 mcg fentanyl
6. Start 10 mL/hour infusion with 4 mL bolus q 15 min with 20 mL/hr lockout.

pt usually comfortable by the time I finish charting and leave the room
 
I go straight epidural, give the test dose, and usually 5cc bolus off the pump. Anything else depends on the whether the pt's BP can tolerate it. If they are in a lot of pain, I'll give a little lido. 0.25% bupi for topoffs if needed. Seems as if the majority of our pts request an epidural early, before even having any significant pain. I play it very conservative in OB and go slow with dosing. I don't want to be blamed for hypotension leading to any adverse outcomes. I guess you can call it defensive medicine. From what I have seen and experienced in PP, I just think the OB setting is the highest risk setting for us for lawsuits. This is just me, obviously there are others in our group who do things differently i/e: prefer cse's
 
Similar to previous posts. I don't like cse either, takes longer to set up and not enough difference in analgesia onset time to justify potential complications including setting the pt up for unrealistic expectations once the spinal wears off.

I use saline with continuous pressure for LOR (faster, and safer IMO than incremental advancement and checking for loss)

Thread catheter (spiral wound soft catheters are the bomb and virtually eliminate intravascular puncture):banana:

Test dose 3ml 1.5%lido/epi

6-7ml 0.25% bupivacaine +100 mcg Fent

Usually in and out of the room within 15 min and the patient is usually calm and resting comfortably by then.
 
0. No IV fentanyl
1. Straight epidural
2. Thread catheter
3. Test dose 3 mL 1.5% lido+epi
4. Tape catheter
5. 12-15ml bolus 0.125% bupi
6. Start infusion

I do CSE < 5% of the time. It is maybe just a couple minutes faster (< 5 minutes) than loading the epidural catheter. And it takes a couple minutes to get the extra meds and needle and syringe on the field.

I do a confirmatory dural puncture (no intrathecal dose) < 2% of the time, if I have a doubt about my LOR. There is some data that doing this results in better analgesia / less manual doses.

We have the Braun kits, so those catheters can end up anywhere. At least 5% of the time the catheter threads into a vein and there is frank blood per catheter.
 
1. Straight epidural
2. Bolus 5ml of 0.25 through thouy
3. tread catheter 7 cm into space pull back to 5cm
4. Test dose
5.bolus 2nd 5ml 0.25% bupi
6. Ropi 0.2% 8/4/15/4
Sets up as fast as a cse. Rarely, never had a unilateral block with this technique.
 
What do y'all think about Braun vs Arrow kit? I was trained with the Braun and think i can "feel" the touhy better. Like going through ligamentum flavum, the Braun touhy consistently gives you a crunchy sensation whereas I don't feel the same with the Arrow touhy. I do like how soft the Arrow's catheter is though and how I've never threaded one of those intravascular. One time, I keep getting heme back with 3 attempts using the Braun's catheter, then I switched to Arrow and no problem.
 
Chloroform4Life said:
What do y'all think about Braun vs Arrow kit? I was trained with the Braun and think i can "feel" the touhy better. Like going through ligamentum flavum, the Braun touhy consistently gives you a crunchy sensation whereas I don't feel the same with the Arrow touhy. I do like how soft the Arrow's catheter is though and how I've never threaded one of those intravascular. One time, I keep getting heme back with 3 attempts using the Braun's catheter, then I switched to Arrow and no problem.
Click to expand...

Arrow cath far superior. Braun makes a soft spring wound cath now too though so maybe see if your guys can get Braun kits with those caths. With regards to the OP:

Plan A: CSE All comers
1. Squirt 15-20cc of the infusion solution (Bupi 1/8% + Fent 2/mL) into the epidural tray
2. Use above solution for skin local and LOR fluid
3. IT dose w/ 2-3 cc of above solution
4. Thread cath
5. Bolus 2-5cc of above solution through cath
6. Tape Cath
7. Start infusion
8. Chart

Plan B: (When we run out of CSE needles which seems to happen at least once a month)
1. Straight epidural
2. Thread cath (Arrow)
3. Bolus/test dose w/ all 5 cc 1.5% Lido w/ Epi
4. Bolus w/ remaining 2-3 cc 1% Lido left over from skin local
5. Tape Cath
6. Start infusion
7. Chart

Anecdotally, the CSE pts are comfortably slightly faster (duh), but not terribly significantly. More importantly, I think they have a higher quality of analgesia throughout their labor and I get less calls for top-offs. There is at least 1 good size well conducted study that supports these anecdotal observations.
 
Chloroform4Life said:
What do y'all think about Braun vs Arrow kit? I was trained with the Braun and think i can "feel" the touhy better. Like going through ligamentum flavum, the Braun touhy consistently gives you a crunchy sensation whereas I don't feel the same with the Arrow touhy. I do like how soft the Arrow's catheter is though and how I've never threaded one of those intravascular. One time, I keep getting heme back with 3 attempts using the Braun's catheter, then I switched to Arrow and no problem.
Click to expand...
I've used both kits and now that you mention it, i agree that I prefer the braun tuohy more and that the feedback is better. Perhaps it's b/c it's an 18g , isnt the arrow a 17? I cannot remember ever having the braun cath going intravascular.
 
For those of you doing CSE frequently... Do you have to do your own blood patches? What is your headache rate? Do you use fluoro for patches? I am 8 years out and do about 190 epidurals a year. I haven't done a CSE since residency. I have had one wet tap. She got a headache. Blood patch didn't make her better. I know its anecdotal, but I am not going to intentionally puncture any dura that I can avoid. For spinal, in my group of 20, we have a 1/200 headache rate using 25g pencil point needles. Interestingly enough our group (epidural) wet tap rate/head ache rate is right at 1/200. If we did CSE for every epidural our blood patch rate would go way up. We have a labor epidural rate of 87% and a C/S rate of 29%. So adding a dural puncture to every epidural would lead to a lot more headaches...
 
johncunningham said:
For those of you doing CSE frequently... Do you have to do your own blood patches? What is your headache rate? Do you use fluoro for patches? I am 8 years out and do about 190 epidurals a year. I haven't done a CSE since residency. I have had one wet tap. She got a headache. Blood patch didn't make her better. I know its anecdotal, but I am not going to intentionally puncture any dura that I can avoid. For spinal, in my group of 20, we have a 1/200 headache rate using 25g pencil point needles. Interestingly enough our group (epidural) wet tap rate/head ache rate is right at 1/200. If we did CSE for every epidural our blood patch rate would go way up. We have a labor epidural rate of 87% and a C/S rate of 29%. So adding a dural puncture to every epidural would lead to a lot more headaches...
Click to expand...

I'd performed a number of CSEs and never did I have to deal with pdph related issues. I had colleagues who would cause a wet tap and then move to a different level to place an epidural. Those were the ones who I had to do blood patches for when I was on call the following day. There really is something to placing a spinal cath and providing anesthetic through it as a spinal catheter. In a same way, I feel CSEs help reduce the likelihood of pdph. Yes, I always asked my colleagues on call the day after me to check in and see if these pts I did CSEs for had pdph issues.
 
johncunningham said:
For those of you doing CSE frequently... Do you have to do your own blood patches? What is your headache rate?
Click to expand...
I gave my opinions on this at length in this thread:

http://forums.studentdoctor.net/threads/ob-anesthesia-hot-topics.1158592/

Short version - I do blood patches after CSEs for labor about as often as I do them after spinals for c sections: never.

I don't doubt that somewhere around 2% of 25-27g dural punctures get "headaches" if the person doing the study asks enough leading questions. I also don't doubt that there's a world of difference between a 17g Tuohy hole or a 22g cutting hole (from an ER LP) ... and the 25-27g pencil point holes we make for CSEs and spinals.
 
I think I remember reading somewhere that the chance of headache with 25G pencil needle is about 1 in 500. This is the number I quote patients when I explain a spinal to them. The thing is though, even if they get a headache from such needle, the hole is so small that it will most likely resolve on its own as oppose to an 18G touhy's hole, which likely needs a blood patch.
 
lane said:
1. Straight epidural
2. Thread catheter
3. Test dose 3 mL 1.5% lido+epi
4. Tape catheter
5. 10 mL bolus 0.25% bup + 100 mcg fentanyl
6. Start 10 mL/hour infusion with 4 mL bolus q 15 min with 20 mL/hr lockout.

pt usually comfortable by the time I finish charting and leave the room
Click to expand...

This, but I use 1/16th strength bupi for infusion. Same bolus though. I will cse if they are progressing fast. Sometimes I only get intrathecal narcs in before they have to push.
 
I do an epidural with LOR to saline, thread the catheter, test dose, tape it up, and then bolus 5-10 mls of 0.25% bupivicaine depending on patient pain level and baseline BP. Short, sweet, and works great. If the patient is getting close to delivering and having trouble holding still in position, I will occasionally just drop a 25 g spinal needle on to the epidural tray and do a spinal with 1 ml of 0.25% bupivicaine, let that kick in, and then do an epidural after they are more comfortable. I'd rather be stabbing their back with a 25 g needle than an 18 g Tuohy if they are wiggling all over the place.

Once in a blue moon I will have patient that is close enough to delivering that a spinal might be all they need but still relaxed and positioned well and I'll just do a traditional CSE with that kit.

And yes, CSE patients still get PDPH. If anyone says they don't it's a lie or they don't do enough. We have plenty of literature on the matter.
 
Chloroform4Life said:
I think I remember reading somewhere that the chance of headache with 25G pencil needle is about 1 in 500. This is the number I quote patients when I explain a spinal to them. The thing is though, even if they get a headache from such needle, the hole is so small that it will most likely resolve on its own as oppose to an 18G touhy's hole, which likely needs a blood patch.
Click to expand...

I quote 1/100 for any epidural or spinal or CSE. They all have about the same risk. Now that doesn't mean a 25 g needle has a 1/100 chance of you getting a blood patch for the headache. Most PDPH patients do not end up needing a blood patch, but about 1/100 do get a headache. I mean maybe it's a little less, but not a ton (at least in the OB population, old ortho/urology patients risk is much less).
 
Random Resident said:
This, but I use 1/16th strength bupi for infusion. Same bolus though. I will cse if they are progressing fast. Sometimes I only get intrathecal narcs in before they have to push.
Click to expand...
The infusion we use is ropi 0.2% with fentanyl 2 mcg/cc. I realized that I didn't specify that afterwards.
 
I like the technique of bolusing the Tuohy prior to threading the catheter (then testing the catheter). Pt's get comfortable while I'm threading the catheter, securing in place, etc. When you use a little lido through the Tuohy, the onset time seems to be very close to CSE onset.
 
Mman said:
And yes, CSE patients still get PDPH. If anyone says they don't it's a lie or they don't do enough. We have plenty of literature on the matter.
Click to expand...

There may be loads of literature on it but I still see 0%.
 
Arch Guillotti said:
There may be loads of literature on it but I still see 0%.
Click to expand...

either you don't do enough, don't follow up enough to see it, or do something differently than the rest of the world. A 25 g hole in the dura with any needle out there will lead to some PDPH. No way around it.
 
Mman said:
either you don't do enough, don't follow up enough to see it, or do something differently than the rest of the world. A 25 g hole in the dura with any needle out there will lead to some PDPH. No way around it.
Click to expand...
None of the above, sorry.
 
Mman said:
either you don't do enough, don't follow up enough to see it, or do something differently than the rest of the world. A 25 g hole in the dura with any needle out there will lead to some PDPH. No way around it.
Click to expand...
How about this:

25 g holes in the dura generally don't produce clinically significant PDPHs. I'll just arbitrarily define "clinically significant" as "bad enough for the patient to seek treatment."

It's certainly not the 2%+ rate reported in the literature. No way. We do postop checks prior to discharge on 100% of new mothers. As I've written before, I'll start caring about these alleged headaches when the patients do.


The study I want to do is go around the postpartum ward asking all the women who delivered au naturale if they have headaches or not. Bet I get a lot more than 2% ... hospitals are lousy hotels, even without screaming newborns and and relatives crowding around with balloons and cameras. If I phrase it just right, I bet they'll agree to a positional component too! 🙂
 
Mman said:
then why are you so unique and special and why can nobody reproduce your results?
Click to expand...

He's not. There are at least 5 people on this forum that routinely CSE and we all share the same results. Why are you so close minded that you can't accept that our way to skin the cat is just as good as yours.
 
Wasnt there some paper by the guys at Brigham a few years ago stating that the PDPH rate for CSE was actually LOWER than straight epidurals?

I will buy that the guys on here saying their rates of PDPH needing a EBP after CSE is near 0. for a PP guy, you would have to do ~250 epidurals to statistically see one if you are average, and we all know that everyone posting here is above average.

Blade, show us some papers?


Either way, PDPH risk would not be my reason to do, or not to do a CSE. For me it is the time/hassle (in my hands), and the rare-but-still-common-enough fetal bradycardia after intrathecal narcotics. The bradycardia doesnt matter clinically, but it sure does waste some time.

If I start having a bunch of spotty, failed, or otherwise inadequate epidurals, I will probably try a few more CSEs, just for the change of pace.
As it is, the OB nurses I work with tend to ask me to do their personal epidurals a fair amount of the time, and I take that as a sign that I dont need to change my practice. When that changes, so will I.


Sent from my iPad using SDN mobile app
 
SaltyDog said:
He's not. There are at least 5 people on this forum that routinely CSE and we all share the same results. Why are you so close minded that you can't accept that our way to skin the cat is just as good as yours.
Click to expand...

"as good as yours"? Unlike him, I admit that some of my patients get a PDPH. That's why I counsel them on the risk. It happens. There is no way to prevent it. It happens with spinals, it happens with CSEs, it happens with epidurals. It happens. When someone claims it never happens to them, call me suspicious.

I'm trying to figure out what awesome method he has that can't be replicated in a study to prevent PDPH. I mean it'd be on the cover of Anesthesiology. No more headaches!!!!!!!
 
Mman said:
then why are you so unique and special and why can nobody reproduce your results?
Click to expand...

A recent Cochrane review of 14 randomized controlled trials comparing CSE with epidural analgesia in labour confirmed that CSE provides faster onset of effective pain relief along with a higher incidence of maternal satisfaction. However, the review found no difference between CSE and epidural techniques with regards to maternal mobility, the incidence of post-dural puncture headache, the rate of forceps delivery, or the rate of caesarean section.
 
Mman said:
then why are you so unique and special and why can nobody reproduce your results?
Click to expand...
U mad? 🙂

I counsel all of my laboring patients on the risk of PDPH, about 1:200, which is probably close to the risk of a frank or unrecognized dural puncture from the Tuohy.


On the reported 2%+ rate of PDPH from 25g dural punctures:

http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124

Asking postpartum women if their heads hurt 24-48 hours after delivery could be a case study in poorly done research and publication bias.


pjl said:
Wasnt there some paper by the guys at Brigham a few years ago stating that the PDPH rate for CSE was actually LOWER than straight epidurals?
Click to expand...

Yes, Cappiello: http://www.ncbi.nlm.nih.gov/pubmed/18931227

If have some quibbles with that study though. I don't think their results can be honestly generalized to the non-academic world at large.

I suspect there are two main reasons they had fewer PDPHs with the dural puncture technique:
1) The study was underpowered. 80 patients are not enough to ascertain the difference in incidence of a rare event.
2) It was done at an academic hospital, so the procedures were being done by residents, including CA-1s. When you're just learning how to place an epidural, and you're uncertain if that was a real LOR or false LOR, the "probe ahead" method with the spinal needle will reduce the incidence of 17g Tuohy punctures. No CSF back? OK, I can advance the Tuohy more. CSF back? OK, the Tuohy must be in the right place. Attendings don't need that crutch to avoid 17g wet taps.

I do believe that the DPE technique probably has the other advantages they talk about, namely faster onset and reduced sacral sparing.
 
Arch Guillotti said:
A recent Cochrane review of 14 randomized controlled trials comparing CSE with epidural analgesia in labour confirmed that CSE provides faster onset of effective pain relief along with a higher incidence of maternal satisfaction. However, the review found no difference between CSE and epidural techniques with regards to maternal mobility, the incidence of post-dural puncture headache, the rate of forceps delivery, or the rate of caesarean section.
Click to expand...

huh? To what are you referring? You said you don't get PDPH with your spinals. I'm wondering how. Of course there is no difference in CSE and epidural in terms of PDPH. I've said that many times. They both get headaches somewhere slightly less than 1% of the time. You said yours never get a headache.

So why are you quoting a study showing similar rates of PDPH? That means the rate is >0, yet you quoted your own person rate at "0%".

Like I said, if you can teach us all how to never get a PDPH, you'd be world famous.
 
Last edited:
Mman said:
huh? To what are you referring? You said you don't get PDPH with your spinals. I'm wondering how. Of course there is no difference in CSE and epidural in terms of PDPH. I've said that many times. They both get headaches somewhere slightly less than 1% of the time. You said yours never get a headache.

So why are you quoting a study showing similar rates of PDPH? That means the rate is >0, yet you quoted your own person rate at "0%".

Like I said, if you can teach us all how to never get a PDPH, you'd be world famous.
Click to expand...

You also stated more than once that CSE's are more likely to cause a PDPH than straight epidural. That is false with both anecdotal and research evidence showing there is no difference. Of course any time you are poking needles near or through dura, PDPH is a risk and I counsel my pts as such as well.
 
SaltyDog said:
You also stated more than once that CSE's are more likely to cause a PDPH than straight epidural. That is false with both anecdotal and research evidence showing there is no difference. Of course any time you are poking needles near or through dura, PDPH is a risk and I counsel my pts as such as well.
Click to expand...

link please?

What I've said in the past on other threads is if there is no hole in the dura you can't get a PDPH, that's simply how the process works. I've also repeatedly said that the incidence is roughly the same between all the procedures. I've said it before. I've said in this thread. I'll say it again.

But I'm not the one claiming a "0%" incidence of PDPH.
 
Mman said:
link please?

What I've said in the past on other threads is if there is no hole in the dura you can't get a PDPH, that's simply how the process works. I've also repeatedly said that the incidence is roughly the same between all the procedures. I've said it before. I've said in this thread. I'll say it again.

But I'm not the one claiming a "0%" incidence of PDPH.
Click to expand...

Mman said:
Statistically the incidence of PDPH with CSE is similar to just epidural, or somewhere around 1%. But count me in the category that says if I never poke a hole in your dura you can't get a headache whereas if I do even with a small needle you might.
Click to expand...

What are you saying? If you poke a hole in the dura you can't get a headache, except when you do get a headache?

All I am saying is that I have never blood patched someone after a routine CSE.
 
Mman said:
link please?

What I've said in the past on other threads is if there is no hole in the dura you can't get a PDPH, that's simply how the process works. I've also repeatedly said that the incidence is roughly the same between all the procedures. I've said it before. I've said in this thread. I'll say it again.

But I'm not the one claiming a "0%" incidence of PDPH.
Click to expand...

Arch and PGG already posted a couple of studies. I'll post another one tomorrow from work where I have better access to the lit.
 
Arch Guillotti said:
What are you saying? If you poke a hole in the dura you can't get a headache, except when you do get a headache?

All I am saying is that I have never blood patched someone after a routine CSE.
Click to expand...

I'm saying if you never poke a hole in the dura you can't get a headache. Is it that hard to understand? PDPH during routine epidurals is from unintentional dural puncture. And I say if you've never needed to do a blood patch after a CSE, well then you don't follow up or are lying. The literature is clear. If you can prove otherwise, you will be world famous.
 
SaltyDog said:
Arch and PGG already posted a couple of studies. I'll post another one tomorrow from work where I have better access to the lit.
Click to expand...

There is ZERO reputable literature suggesting no chance of PDPH after a CSE which is what Arch is explicitly stating.
 
Mman said:
There is ZERO reputable literature suggesting no chance of PDPH after a CSE which is what Arch is explicitly stating.
Click to expand...

I am saying that I do a lot of CSE's and that my rate of post dural puncture headache requiring blood patch is 0%. I never said you couldn't get one. I guess I am lying though:prof::prof::prof:


stripes_lighten_up_francis.jpg
 
which is why you should help us all learn how to get better. All I do is make a single pass with a needle. After several thousand I've seen some PDPHs. I'd like to learn how to make the incidence zero. I doubt you've done 5,000 without a headache, though.

Help us all get better. Teach us the ways of the force.
 
Last edited:
Well the study I was thinking of:

A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery
Gambling, David MB, BS*; Berkowitz, Jonathan PhD†; Farrell, Thomas R. MD‡; Pue, Alex MD*; Shay, Dennis MD*

actually doesn't address PDPH rates unfortunately. It is a nice paper with a large sample size in a PP setting. Perhaps someone will dig through the references and see if any of those studies address PDPH.

Mman, you're moving the goal posts here (as PGG would say). You initially argued against CSE on the basis of increased PDPH risk. That has been shown to not be the case so now you zero in on one statement by Arch, and getting all huffy putting words in his mouth that there is zero risk of PDPH after CSE. All he said was he hasn't had one. His rate is 0% (as is mine), but I think we'll all agree that if you do enough then sure, you'll probably get one.

Bottom line is that CSE carries no increased risk of PDPH so don't cite that as a reason not to do them. If you prefer straight epidural then cool. They are essentially equivalent with any differences amounting to split hairs. I like CSE's because I can do it faster than straight CLE they way I do them and the way my kits come. If we're missing the needles then I go CLE without hesitation. I do notice that *in my hands*, The pts who get CSE's are more comfortable both faster and throughout their labor, and I get less calls for boluses. If my wife were in labor I'd CSE her (not that I recommend poking your own wife with needles).
 
SaltyDog said:
Mman, you're moving the goal posts here (as PGG would say). You initially argued against CSE on the basis of increased PDPH risk. That has been shown to not be the case so now you zero in on one statement by Arch, and getting all huffy putting words in his mouth that there is zero risk of PDPH after CSE. All he said was he hasn't had one. His rate is 0% (as is mine), but I think we'll all agree that if you do enough then sure, you'll probably get one.
Click to expand...

I think you need to reread the thread. What I initially said had no argument against a CSE. I said I do them on occasion. The last line said that CSE patients still get PDPH. That's it. My contention was when I said that anybody that hasn't seen a PDPH either hasn't done enough or hasn't followed up close enough, but Arch shot that down. You basically completely agree with me. CSE has similar rate of PDPH to epidural. You and I both agree that if you do enough you'll eventually get one.

I have never once cited an INCREASED risk of PDPH as a reason to not to CSE. In fact, I've over and over and over again said the risk of PDPH is about the same for epidural and CSE.
 
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