OB epidural tip

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pastafan

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On another forum I saw a thread that mentioned unsuccessful attempts to place an epidural in OB due to being off center. When you get an extremely obese patient where you are unable to palpate or see any landmarks I always found it useful to ask the patient to point to the center of their back. They would unerringly point to the midline. Hope this helps someone at 4 a.m.
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pastafan said:
On another forum I saw a thread that mentioned unsuccessful attempts to place an epidural in OB due to being off center. When you get an extremely obese patient where you are unable to palpate or see any landmarks I always found it useful to ask the patient to point to the center of their back. They would unerringly point to the midline. Hope this helps someone at 4 a.m.
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Interesting.

I frequently found if I get deep enough that I think I should be nearing the epidural space, but no loss, or you encounter bone, I will ask them does it feel left or right, and use that as my guide to direct left or right. Of course I also redirect superior or inferior as well.
 
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I just aim north of the butt crack and then when I am banging into bone ask them if it feels left or right and aim accordingly. Patients can almost unerringly tell which side of their spine you are missing on.
 
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I never do OB but I have a partner who does 100% OB and he has been using ultrasound for every single epidural. He marks midline and notes depth before ever touching the patient with a needle.
 
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nimbus said:
I never do OB but I have a partner who does 100% OB and he has been using ultrasound for every single epidural. He marks midline and notes depth before ever touching the patient with a needle.
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I did this in residency on anybody with less than ideal landmarks and will do it to get back up to speed if I ever start doing OB again. Just used the machine with curvilinear probe they had for the OBs and it took two seconds. The depth is of course not a precise measurement secondary to pressure from the probe etc but usually gives you a general idea +/- a cm.
 
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nimbus said:
I never do OB but I have a partner who does 100% OB and he has been using ultrasound for every single epidural. He marks midline and notes depth before ever touching the patient with a needle.
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I just don't get it. I love ultrasounds and use them all the time. I never use it for a labor epidural. Have never needed it, ever. Median duration of time from the tuohy needle breaking the skin to LOR is what, 10 seconds? 15 seconds? I mean 30 seconds feels like an eternity. I get for trainees that have no experience it might be useful, but once you have done thousands it is just so easy 99% of the time.
 
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Mman said:
I just don't get it. I love ultrasounds and use them all the time. I never use it for a labor epidural. Have never needed it, ever. Median duration of time from the tuohy needle breaking the skin to LOR is what, 10 seconds? 15 seconds? I mean 30 seconds feels like an eternity. I get for trainees that have no experience it might be useful, but once you have done thousands it is just so easy 99% of the time.
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I am a little more careful.. I got mm at a time because I lose sleep for weeks after a wet tap.
 
OptionOffense said:
I am a little more careful.. I got mm at a time because I lose sleep for weeks after a wet tap.
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I use continuous pressure so it is continually advancing. Depending on how large the patient is, you can just push the needle in 3-6 cm to get it anchored in ligament before you even bother checking for LOR. I probably average 1 wet tap every 500-1000 attempts (it's too rare to narrow down any closer than that).
 
maybe you guys have a different population...it's easy sure on healthy young females, but the BMI 50+ I think can be hard.
 
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Mman said:
I just don't get it. I love ultrasounds and use them all the time. I never use it for a labor epidural. Have never needed it, ever. Median duration of time from the tuohy needle breaking the skin to LOR is what, 10 seconds? 15 seconds? I mean 30 seconds feels like an eternity. I get for trainees that have no experience it might be useful, but once you have done thousands it is just so easy 99% of the time.
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Yea but you can bill for the us
 
nimbus said:
I never do OB but I have a partner who does 100% OB and he has been using ultrasound for every single epidural. He marks midline and notes depth before ever touching the patient with a needle.
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I can't imagine using ultrasound for routine epidurals. Even in a practice where the patients' BMI is always over 50 ... if they're gigantic and the usual L3-4 doesn't look easy, just go up above the butt fat shelf to T12 or so. Don't even need the long needle. Low thoracic epidurals work fine for labor.


Also ... in before someone pops in asking When Will Ultrasound For Labor Epidurals Become Standard Of Care?
 
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pgg said:
I can't imagine using ultrasound for routine epidurals. Even in a practice where the patients' BMI is always over 50 ... if they're gigantic and the usual L3-4 doesn't look easy, just go up above the butt fat shelf to T12 or so. Don't even need the long needle. Low thoracic epidurals work fine for labor.


Also ... in before someone pops in asking When Will Ultrasound For Labor Epidurals Become Standard Of Care?
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That’s his routine. We’ve talked about it many times in the lounge.
 
Everyone saying epidurals are easy is this on healthy bmi under 30 patients? If thats the case i definitely agree. However, im in the deep south where bmi of 40 is probably the average. Will have a bmi of 50 at least once a shift. These usually end up being difficult because there are no landmarks. My first pass is almost just to have a feel of where im at. Im actually on planning using ultrasound to see if it improves my techinique
 
james775 said:
Everyone saying epidurals are easy is this on healthy bmi under 30 patients? If thats the case i definitely agree. However, im in the deep south where bmi of 40 is probably the average. Will have a bmi of 50 at least once a shift. These usually end up being difficult because there are no landmarks. My first pass is almost just to have a feel of where im at. Im actually on planning using ultrasound to see if it improves my techinique
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Also in the south, regularly taking care of bmi >50. Still easy probably 90% off the time. Like pgg said, go atop the shelf and that's usually a good spot. And if you hit bone on first pass, great, you've got a landmark to work off with your next redirect. I'm not saying there's zero use for an US guided epidural, but to use it for every single patient like nimbus's partner is a joke. That dude should probably not do OB anymore. It's not comparable to people saying you should use US every time for an A-line, or hell, even the VL for every intubation crowd. Those are more reasonable positions.
 
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spinal3.jpg


probe is positioned in the longitudinal paramedian plane. Top right: sacrum is seen as a continuous hyperechoic line parallel to the skin, approximately 5 cm deep continuing as "cracks" (interspaces) alternating with "lumps" (lamina of different vertebrae). Bottom: close up at a lumbar "crack" (interspace), with lamina of two different vertebrae on the right (caudad) and on the left (cephalad). The elements of the interspace can be easily identified, including distinct images of the posterior dura mater, the epidural space and the ligamentum flavum. The vertebral body-posterior longitudinal ligament-anterior dura mater is seen as a single unit.
 
interspace in transverse plane

Figure 5. Typical sonogram of an interspace in the transverse plane, showing very symmetric images of transverse and articular processes on each side, in addition to the ligamentum flavum-posterior dura mater and the vertebral body-posterior longitudinal ligament-anterior dura mater.
 
If I was going to use U/S for OB (never have and doubt ever will) I would likely go with the longitudinal approach (probe vertical, straight up and down on back) to find the interspace.
 
Ultrasound is a great tool. I havent necessarily used it for OB epidurals but it was mainly because we didn't have that many patients who would need it and it wasn't typically easy to get the ultrasound machine up to OB.

It's very useful for arterial lines, IVs, and of course..nerve blocks. Old school guys often question it's use and say it's not "necessary". However, I am an advocate of using the best equipment if available...because why not?

Being able to visualize the important structures will always be superior to blind or tactile approach when controlling for individual physician skill
 
james775 said:
Everyone saying epidurals are easy is this on healthy bmi under 30 patients? If thats the case i definitely agree. However, im in the deep south where bmi of 40 is probably the average. Will have a bmi of 50 at least once a shift. These usually end up being difficult because there are no landmarks. My first pass is almost just to have a feel of where im at. Im actually on planning using ultrasound to see if it improves my techinique
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Let us know what you think of U/S in Ob. You need to use the U/S at least 10 times in OB before posting so you get enough experience with it as part of your technique.

I do not think "live" U/S for epidural placement will replace LORT anytime soon. But, if you need it to find the interspace and "guess" at the epidural depth then by all means use it. IMHO, once you find the interspace the rest is good technique based on experience.
 
BLADEMDA said:


I probably could do 3 epidurals before this guy does one.
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Well..Given that it takes him about 30 seconds to identify midline and mark it (which 90% of the value of ultrasound in this scenario)..its fine
 
UscGhost said:
Ultrasound is a great tool. I havent necessarily used it for OB epidurals but it was mainly because we didn't have that many patients who would need it and it wasn't typically easy to get the ultrasound machine up to OB.

It's very useful for arterial lines, IVs, and of course..nerve blocks. Old school guys often question it's use and say it's not "necessary". However, I am an advocate of using the best equipment if available...because why not?

Being able to visualize the important structures will always be superior to blind or tactile approach when controlling for individual physician skill
Click to expand...

Why would it be hard to get an ultrasound machine up to ob?
 
DrZzZz said:
Also in the south, regularly taking care of bmi >50. Still easy probably 90% off the time. Like pgg said, go atop the shelf and that's usually a good spot. And if you hit bone on first pass, great, you've got a landmark to work off with your next redirect. I'm not saying there's zero use for an US guided epidural, but to use it for every single patient like nimbus's partner is a joke. That dude should probably not do OB anymore. It's not comparable to people saying you should use US every time for an A-line, or hell, even the VL for every intubation crowd. Those are more reasonable positions.
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Why do we take such extreme positions? Never do OB just because he likes to use US? Geez.

OB is by nature a crazy patient pop. Any edge you can take to ensure success, take it. If US ensures he stays midline and reduces his one-sided rate, or whatever, then by all means do it. To each their own.
 
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I used US to determine depth 3 times this year. Really useful in a certain patient population: those exposed to learner trainees.

All were night shifts where I was handed over multiple "patchy" (failed) epidurals in each of them. Trainee says LOR @ ~6cm consistently; easy thread, etc.

They'd bolused another 20ml of 0.2% ropiv into God knows what plane as i walk in. So get the US out, see the huge fluid deposit at 6-8cm depth, see the space a solid 0.5cm - 1cm beyond that. Insert needle to 6cm --> get lor, comfortably push straight through it until hitting ligament again --> second lor --> successful placement.

I wouldn't have the balls to push beyond 8cm with no resistance if i hadn't confirmed the trainee was creating their own space beforehand with the US. I think it is a really useful tool in obs
 
woopedazz said:
I used US to determine depth 3 times this year. Really useful in a certain patient population: those exposed to learner trainees.

All were night shifts where I was handed over multiple "patchy" (failed) epidurals in each of them. Trainee says LOR @ ~6cm consistently; easy thread, etc.

They'd bolused another 20ml of 0.2% ropiv into God knows what plane as i walk in. So get the US out, see the huge fluid deposit at 6-8cm depth, see the space a solid 0.5cm - 1cm beyond that. Insert needle to 6cm --> get lor, comfortably push straight through it until hitting ligament again --> second lor --> successful placement.

I wouldn't have the balls to push beyond 8cm with no resistance if i hadn't confirmed the trainee was creating their own space beforehand with the US. I think it is a really useful tool in obs
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In this situation I would place the epidural at a different level, and use a dural puncture to confirm as I noted above.
 
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woopedazz said:
I used US to determine depth 3 times this year. Really useful in a certain patient population: those exposed to learner trainees.

All were night shifts where I was handed over multiple "patchy" (failed) epidurals in each of them. Trainee says LOR @ ~6cm consistently; easy thread, etc.

They'd bolused another 20ml of 0.2% ropiv into God knows what plane as i walk in. So get the US out, see the huge fluid deposit at 6-8cm depth, see the space a solid 0.5cm - 1cm beyond that. Insert needle to 6cm --> get lor, comfortably push straight through it until hitting ligament again --> second lor --> successful placement.

I wouldn't have the balls to push beyond 8cm with no resistance if i hadn't confirmed the trainee was creating their own space beforehand with the US. I think it is a really useful tool in obs
Click to expand...
Also, I will say this probably only happens with trainees. If a seasoned person gets a LOR but never felt ligament they know something is up.
 
I do something similar. On patients where you can't feel the landmarks, I will press my finger into the spot where I feel like the midline is and ask the patient if it feels like it's exact middle or if it's off to the left or right. They usually have a very good sense of it, down to millimeters. Also, while a lower thoracic epidural works fine, don't forget where the largest interspace(s) are in patients.
 
Ezekiel2517 said:
I do something similar. On patients where you can't feel the landmarks, I will press my finger into the spot where I feel like the midline is and ask the patient if it feels like it's exact middle or if it's off to the left or right. They usually have a very good sense of it, down to millimeters. Also, while a lower thoracic epidural works fine, don't forget where the largest interspace(s) are in patients.
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I can barely get patients in labor to telll me if what they are feeling is sharp or dull Im surprised they are able to localize the middle for you down to millimeters
 
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OptionOffense said:
I can barely get patients in labor to telll me if what they are feeling is sharp or dull Im surprised they are able to localize the middle for you down to millimeters
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Very rarely has failed me. I do and have done a lot of epidurals/spinals, and obviously have gotten my fair share of 50, 60+ BMI. Had a 65 BMI epidural just this past week. You can try it on yourself. Even if you're just a little bit off midline, you know. The OP's observation supports this as well
 
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anbuitachi said:
which magical hospital is this?! none of the hospitals i went to had this
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what if you need emergency access for a hemorrhaging or DIC patient and cant see/palpate venous access? What if you want to do TAP blocks post C/S?
seems that your department is cutting corners.
 
GandalfTheWhite said:
what if you need emergency access for a hemorrhaging or DIC patient and cant see/palpate venous access? What if you want to do TAP blocks post C/S?
seems that your department is cutting corners.
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what if i want to ecmo??? we dont have that either

we dont do tap blocks post C/S. dont have enough staff. we can give pain meds though =). Also OB can infiltrate the incision. incision is so small...

remind me of those calls i get in the middle of night on call from ICU, asking us to do intercostal blocks on their rib fracture patients... we dont do that either
 
Southpaw said:
Why do we take such extreme positions? Never do OB just because he likes to use US? Geez.

OB is by nature a crazy patient pop. Any edge you can take to ensure success, take it. If US ensures he stays midline and reduces his one-sided rate, or whatever, then by all means do it. To each their own.
Click to expand...

All I'm saying is that if my wife was pregnant and the doc pulled in an ultrasound to do her epidural, I'd absolutely ask if there was someone else available. If you want to use it on a BMI 50+, by all means. But if you're using it on everyone, I think that's very odd and suggests you're incompetent at placing epidurals. He might be the one I want in a sick heart or disaster airway case...but clearly he's weak in OB. I have partners like that. Everyone has their strengths, and someone who uses an ultrasound for every epidural clearly is weak on the L&D floor.
 
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anbuitachi said:
what if i want to ecmo??? we dont have that either

we dont do tap blocks post C/S. dont have enough staff. we can give pain meds though =). Also OB can infiltrate the incision. incision is so small...

remind me of those calls i get in the middle of night on call from ICU, asking us to do intercostal blocks on their rib fracture patients... we dont do that either
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you really equivocating US guided access placement with ECMO???
Yeah OB can infiltrate the wound, but then you wont collect the bilateral TAP units, and their infiltration is shoddy at best.
You could just do a thoracic epidural for the rib fractures. Data neither here nor there, but several studies show a mortality benefit.
 
While I use ultrasound for every arterial line, I agree its ridiculous to use an U/S to place every epidural.
 
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I once had a patient with BMI in 50’s where I could not feel anything on her back. Tried for 10 min asking the patient “does this feel midline, left, right”, couldnt get it. Used US to scan the back. Turns out, the patient had mild scoliosis when I mapped out the spinous process, and she was actually misguiding me the entire time. Once the spinous process was mapped out, it was an easy placement.

Also, one time, the interpreter got left/right confused so flipped patient’s answers. Thank god that the ob nurse spoke some spanish and corrected it for me. I would’ve kept trying going the wrong way otherwise. 😂

I definitely would not use it on every patient, but there is no denying that US can be useful in certain cases.
 
anbuitachi said:
dont want to owe them for using their equipment. my department has a strict no other department can use our equipment policy, so i dont use other departments equipment either
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What kind of policy is that?
 
We are a high risk OB center, avg 4-5000 births a year (~14 births q24h), and are distinguished as a "bariatric OB center of excellence."

I have used a long Touhy a grand total of 0 times in the 3+ years out of residency in this setting. I think I used one maybe twice in residency and retrospectively it was probably unnecessary even then.

We have no ultrasound on OB. Would be nice for lines and blocks, but oh well.


There are landmarks on the large patients. Some have mentioned the fat folds which had some symmetry in some patients. I tend to step back and look at their head and shoulders and sometimes things are visible in the thoracic spine. It's all about symmetry. If all else fails, take their width divide by 2, and ask them for feedback on laterality as you poke around.
 
OptionOffense said:
What kind of policy is that?
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started because other departments keep using our ultrasound and leaving it in terrible shape.. and often we dont know where they take it because they dont return it to the right place. they just leave it there in the room after their case, with blood or whatever on it without being cleaned. they are too used to having a scrub tech/circulator/house keeping cleaning up their crap. then the anesthesiologist who needs it has to find it and clean it up.
 
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