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Hey man, speak for yourself.the same 3-5 centimeters or so as anyone else
Hey man, speak for yourself.the same 3-5 centimeters or so as anyone else
5 should be the minimumthe same 3-5 centimeters or so as anyone else
I start 4 for most everyone unless they're really morbidly obese. One-sided then pull back to 3. Still one-sided then replace.5 should be the minimum
And it’s that last part that worries me most. They’re big and they start sweating and the next thing you know that catheter is sitting under the foam.I start 4 for most everyone unless they're really morbidly obese. One-sided then pull back to 3. Still one-sided then replace.
It's anecdotal, but I noticed a huge difference wrt improved efficacy and less futzing around when there's less catheter because I think there are higher odds it's midline. Of course it also means your securement method has gotta be bulletproof.
that catheter is sitting under the foam.
5 should be the minimum
Now I’m going to derail the thread......Don’t use the foam.
What’s a filter?Filter or no filter
Humble brag?I’m always leaving it in at 11 or 12
That’s what I’m talking aboutWhat’s a filter?
Indeed, the bigger they are, more catheter in the space. But if they're under ~190-210 lb (positively svelte in my neck of the woods) then 4 cm is fine.And it’s that last part that worries me most. They’re big and they start sweating and the next thing you know that catheter is sitting under the foam.
I also think since our dilution is half dilute than others have mentioned (0.0625), we run at higher volumes so there’s more spread of the solution in the space. If I get LOR at 5cm, I’m always leaving it in at 11 or 12. I’ve just experienced enough “out” catheters that needed do overs to not want to leave them so shallow.
I find the betadine to be sticky already.Indeed, the bigger they are, more catheter in the space. But if they're under ~190-210 lb (positively svelte in my neck of the woods) then 4 cm is fine.
And as Salty say the securement method matters. I like no foam, get the site bone dry, mastisol, multiple loops under the teg, and then a couple more loops as you secure the rest of the catheter to the patient's back and shoulder. The catheter is much less likely to move when multiple distal tension sites have to be broken before the catheter insertion site gets pulled on.
5 should be the minimum
The dumb filter in the epidural kit which some swear by but I throw in the trash.No filter???
I ran into a tough situation last night on call. BMI of 60, laboring all day, comfortable after a struggle-fest epidural. Of course, once they call a section 12 hours later for FTP, she tells me her epidural is “wearing off”. It’s clearly a one sided block. I pull the catheter back a bit and try bolusing with 2% lidocaine. Got her back to the OR and still one sided after 10-15 ccs lido. At this point, only 3 cm in the space. Where I trained, we would NEVER do a SAB after bolusing an epidural. I decided to pull it and just do a reduced dose SAB (1.2cc). It worked beautifully. I was obviously worried about a high spinal but I figured it was my best chance to avoid GA. I’m sure some of you guys would have pulled it to begin with before bolusing, but I was legitimately worried a spinal would be difficult; I didn’t want to give up my epidural catheter so easily. I also debated replacing the epidural and slowly obtaining levels.
Thanks for all the discussion here. Any thoughts, tips, suggestions? How would y’all have handled that?
if it's a crap epidural, pull it and place a spinal. I would at least read the procedure note from who placed it to see depth of LOR or hope they would have informed me if it was impossibly difficult. If you struggle with the spinal, can always use a CSE kit to get the spinal. I definitely don't dose up an epidural and then pull it and place a spinal.
I’m a chicken in those cases, and with a BMI 60 lady, would probably have converted to GA if the epidural bolus didn’t work. The risk of high spinal causing an emergency intubation after giving 15 mL of lido, then a spinal seems too high for me to not do a controlled setting GA.I placed it. It worked great for 12 hours. I suppose my mistake was thinking I could salvage it since it had only started being one sided in the past hour or so. I did use CSE technique to do the spinal. I regretted bolusing once I realized we weren’t making any headway.
I ran into a tough situation last night on call. BMI of 60, laboring all day, comfortable after a struggle-fest epidural. Of course, once they call a section 12 hours later for FTP, she tells me her epidural is “wearing off”. It’s clearly a one sided block. I pull the catheter back a bit and try bolusing with 2% lidocaine. Got her back to the OR and still one sided after 10-15 ccs lido. At this point, only 3 cm in the space. Where I trained, we would NEVER do a SAB after bolusing an epidural. I decided to pull it and just do a reduced dose SAB (1.2cc). It worked beautifully. I was obviously worried about a high spinal but I figured it was my best chance to avoid GA. I’m sure some of you guys would have pulled it to begin with before bolusing, but I was legitimately worried a spinal would be difficult; I didn’t want to give up my epidural catheter so easily. I also debated replacing the epidural and slowly obtaining levels.
Thanks for all the discussion here. Any thoughts, tips, suggestions? How would y’all have handled that?
I’m a chicken in those cases, and with a BMI 60 lady, would probably have converted to GA if the epidural bolus didn’t work. The risk of high spinal causing an emergency intubation after giving 15 mL of lido, then a spinal seems too high for me to not do a controlled setting GA.
I have had a number of BMI 60+ women where I do a beautiful spinal for C/S and then they can’t tolerate laying flat because they are too fat and can’t breath. Now I make them try it laying flat (tilted, but head flat) for me before I even attempt the spinal.
I also probably would have started with bolusing the epidural because of the difficulty you had placing
And what would you have done if patient developed a high spinal? Would she have been a difficult intubayion?
Now I make them try it laying flat (tilted, but head flat) for me before I even attempt the spinal.
When you initially placed the epidural what depth did you tape it? Also, what level did you insert the catheter. In my experience, when I personally have come across these "one sided" catheters the placement is too low (almost near sacral) and also not taped deep enough. If you said only 3 cm of catheter was in the space, in my book that catheter is out especially in obese patients.Probably. In retrospect, I lucked out. I think I’ll be pulling the next catheter if it even looks at me funny.
You cannot be serious! I have NEVER seen anyone do that.
When you initially placed the epidural what depth did you tape it? Also, what level did you insert the catheter. In my experience, when I personally have come across these "one sided" catheters the placement is too low (almost near sacral) and also not taped deep enough. If you said only 3 cm of catheter was in the space, in my book that catheter is out especially in obese patients.
I haven't done it but have wished I had a few times. Twice had to intubate big fat patients because of subjective dyspnea laying flat when the spinal got up to T6 or T4. They completely freaked out and were going to come off the OR table.
Why not just put the back of the table up
Also, I’d be interested in hearing people’s approach to the failed spinal for elective sections.
Also, I’d be interested in hearing people’s approach to the failed spinal for elective sections.
I've never had a failed spinal in an elective section
There was a case of failed spinal due to intrathecal digoxin in CA. Pt suffered significant disabilities.it will happen to you eventually, just gotta have your gameplan ready for when it does
Sleepytime TeaAlso, I’d be interested in hearing people’s approach to the failed spinal for elective sections.
Sleepytime Tea
I'd like to caveat this by saying I think the whole "difficult airway on OB" thing is a touch overrated, especially with glidescopes. If they test and she screams ouch then it's "good night"
Now It will happen to you tomorrow LOLI've never had a failed spinal in an elective section
Sleepytime Tea
I'd like to caveat this by saying I think the whole "difficult airway on OB" thing is a touch overrated, especially with glidescopes. If they test and she screams ouch then it's "good night"
Take down the drapes. Sit them up. Repeat spinal at lower dose, assuming partial block.
There was a case of failed spinal due to intrathecal digoxin in CA. Pt suffered significant disabilities.
I think it is really rare to have a failed spinal in young women (bupi does not work?). More likely to happen in the elderly for total joints.
There was a case of failed spinal due to intrathecal digoxin in CA. Pt suffered significant disabilities.
I think it is really rare to have a failed spinal in young women (bupi does not work?). More likely to happen in the elderly for total joints.
I'm fairly certain there's a rash of failed spinals every year in July/August at academic centers.while it is rare to have one fail in obstetric population, it is not zero. It happens. You do enough of them and you will see it. I usually assume a bad batch of drugs, but then the same batch will have other vials that work.
stuff happens and we don't always have a great reason why
I just don’t have the time nor patience to sit someone up and down just so they can be awake during a laparotomy. Unless it’s a legit contraindication, we’re going to sleep.Now you have two completely opposite answers, what will you do?
My training we have 8-10 elective sections a day. Most of my attendings would just sit them up and redo.
My job now, 3 scheduled section a day, most of the senior partners would just put them to sleep without messing anymore.
But in my training, it was MD only with selected people that would do OB.
My job now, everyone does OB and some CRNA would place spinal, some wouldn’t.
What I am trying to say is, every place and every set up is different. As long as it’s safe, until it’s not of course.
I just don’t have the time nor patience to sit someone up and down just so they can be awake during a laparotomy. Unless it’s a legit contraindication, we’re going to sleep.
Our customers, I mean patients, are babied by their obstetricians..... unless we had a very good reason, everyone gets skin to skin......
After having a few really ****ty c/s on ladies with BMIs in the 70s, yeah, I lower the head of their bed when I preop them. Takes less than a minute, and those cases left a mark.You cannot be serious! I have NEVER seen anyone do that.
After having a few really ****ty c/s on ladies with BMIs in the 70s, yeah, I lower the head of their bed when I preop them. Takes less than a minute, and those cases left a mark.