OB epidural tip

[anbuitachi]

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.

Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol | Trauma Surgery & Acute Care Open

i find it funny you think we collect units for any blocks. we do blocks out of the goodness of our heart.

the issue is that we dont have the staff to go do epidurals in ICU and have someone follow these patients. but we are trying to set up a pain service 24/7 who can follow these patients so hopefully in the next decade.. but i guess right now we are having ICU team do the intercostal or whatever to help with the pain

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[anbuitachi]

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.

Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol | Trauma Surgery & Acute Care Open

not really, just that ultrasound is very expensive. if i need emergency access i can always place a fem line. in emergencies i can ask them to bring the OB ultrasound but honestly, itd be faster probably just to have a colleague bring one up from main OR since i'd need 2nd hand anyway. I can imagine the OB nurse taking their sweet time looking for this ultrasound and coming back 20 mins later saying they cant find it

 

[Status Sciaticus]

i find it funny you think we collect units for any blocks. we do blocks out of the goodness of our heart.

the issue is that we dont have the staff to go do epidurals in ICU and have someone follow these patients. but we are trying to set up a pain service 24/7 who can follow these patients so hopefully in the next decade.. but i guess right now we are having ICU team do the intercostal or whatever to help with the pain

not really, just that ultrasound is very expensive. if i need emergency access i can always place a fem line. in emergencies i can ask them to bring the OB ultrasound but honestly, itd be faster probably just to have a colleague bring one up from main OR since i'd need 2nd hand anyway. I can imagine the OB nurse taking their sweet time looking for this ultrasound and coming back 20 mins later saying they cant find it

Apologies. I thought you were in a production based practice.

 

[zizzer]

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.

That seems extreme. I'm sure somebody using an ultrasound routinely is still fine at them and just likes using technology, despite it being an extra step that adds a minute or so to each one they do.

 

[pgg]

Also, while a lower thoracic epidural works fine, don't forget where the largest interspace(s) are in patients.

The T10-11 and T11-12 spinous processes are about as horizontal, and the interspaces just as big, as the L1-3 area. Give or take. Generally T11-12 and the upper lumbar spaces are bigger than L4-5.

The biggest downside to a low thoracic epidural for labor is you sometimes get more sacral sparing and need large bolus doses or a higher infusion rate.

 

[Ezekiel2517]

The T10-11 and T11-12 spinous processes are about as horizontal, and the interspaces just as big, as the L1-3 area. Give or take. Generally T11-12 and the upper lumbar spaces are bigger than L4-5.

The biggest downside to a low thoracic epidural for labor is you sometimes get more sacral sparing and need large bolus doses or a higher infusion rate.

View attachment 347230

In my experience, w the patient in the flexed position, it feels like the lower lumbar spaces create a larger interspace. (IIRC, the L4-5 space is typically the largest space when the patient is flexed). I've done a lot of epidurals. In most patients, you can choose whatever you want and place the epidural. In those rare really tough or very high BMI patients where my needle has been hitting nothing but os, going lower has more often than not been what ended up being successful when other spaces haven't worked.

 

[DrZzZz]

That seems extreme. I'm sure somebody using an ultrasound routinely is still fine at them and just likes using technology, despite it being an extra step that adds a minute or so to each one they do.

Fair, but I'm sticking to it. If an anesthesiologist is using ultrasound to do an epidural on every patient, I'm definitely presuming he/she is a novice holding a tuohy and is not someone I would want taking care of anyone I care about on L&D.

 

[DrAmir0078]

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.

How about if you do it as a research and comparison attempts (spinal vs epidural) and see the P value if any!

Everyone knows his body better, like in placing IV, many patients direct you to the right arm, right vein and many times I failed if I didn't listen (happened most when I was a EDTech back in the US, in my first years), and I got that stigma like lol, I do listen to the patient, he knows which vein works.

Now a neuraxial and that is interesting Pal!

 

[nimbus]

Fair, but I'm sticking to it. If an anesthesiologist is using ultrasound to do an epidural on every patient, I'm definitely presuming he/she is a novice holding a tuohy and is not someone I would want taking care of anyone I care about on L&D.

He’s been doing primarily OB anesthesia for 30 yrs, exclusively OB anesthesia for >10 yrs. Hes more experienced than 98% of people I know, definitely not a novice. He’s spent the majority of his career not using ultrasound but believes it’s better/easier with ultrasound.

 

[pastafan]

How about if you do it as a research and comparison attempts (spinal vs epidural) and see the P value if any!

I'm retired and haven't done an OB epidural in almost a decade.

This might make a nice study if someone has a couple of anesthesiology residents. Ask patient to identify midline and then use US to compare results. Quantify the delta and then publish results.

 

[DrZzZz]

He’s been doing primarily OB anesthesia for 30 yrs, exclusively OB anesthesia for >10 yrs. Hes more experienced than 98% of people I know, definitely not a novice. He’s spent the majority of his career not using ultrasound but believes it’s better/easier with ultrasound.

That honestly blows my mind. Still can't fathom how using an ultrasound on EVERY epidural is better or easier. If you said he just uses it from the getgo for our larger ladies, sure, I can concede that may help. But every patient, no.

 

[deleted875186]

The T10-11 and T11-12 spinous processes are about as horizontal, and the interspaces just as big, as the L1-3 area. Give or take. Generally T11-12 and the upper lumbar spaces are bigger than L4-5.

The biggest downside to a low thoracic epidural for labor is you sometimes get more sacral sparing and need large bolus doses or a higher infusion rate.

View attachment 347230

This is not true in my experience in the pain clinic, thoracic spaces are always tighter. And as mentioned above, with a patient flexing at their lumbar spine the space is ginormous. The L5-S1 followed by the L4-5 space are always the biggest. If I have a young patient in the pain clinic for an injection it is even more obvious, the 5-1 or 4-5 space is giant.

 

[Mman]

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.

I use the 5 inch tuohy about 1 out of every 1000 epidurals. The overwhelming majority of BMI 50 and 60 patients have LOR at 7-8 cm, maybe 9 cm on a few where you gotta tent the skin a little bit with the needle.

I actually find the little skinny BMI 20 patients to take me longer to place an epidural than a BMI of 50 because I am far more worried about getting a wet tap.

 

[ethilo]

I use the 5 inch tuohy about 1 out of every 1000 epidurals. The overwhelming majority of BMI 50 and 60 patients have LOR at 7-8 cm, maybe 9 cm on a few where you gotta tent the skin a little bit with the needle.

I actually find the little skinny BMI 20 patients to take me longer to place an epidural than a BMI of 50 because I am far more worried about getting a wet tap.

I agree, sometimes the skinnier ones end up being more challenging.

 

[BLADEMDA]

I agree, sometimes the skinnier ones end up being more challenging.

1. More likely to wet tap a thin patient. The epidural space is narrower
2. More likely to get a post dural punture headache requiring a blood patch on a thin patient vs obese
3. More likely to require a second blood patch on a thin patient vs a obese one
4. The interspace between lumbar vertebral bodies is wider for obese patients
5. I tend to do my epidurals at L2-L3 for obese patients so I can find my landmarks better


More likely to require multiple attempts to obtain an epidural in an obese patient
More likely to get a patchy block on an obese patient
More likely to get a failed epidural on an obese patient

 

[BLADEMDA]

This is not true in my experience in the pain clinic, thoracic spaces are always tighter. And as mentioned above, with a patient flexing at their lumbar spine the space is ginormous. The L5-S1 followed by the L4-5 space are always the biggest. If I have a young patient in the pain clinic for an injection it is even more obvious, the 5-1 or 4-5 space is giant.

Here is my typical obese OB patient: BMI 45

I have them sitting up. Their fat is enormous at the lower lumbar levels. I find an extra 2" of fat at L4-L5 vs L2-L3. Second, they tend not to flex well when pregnant and in labor negating much of the bigger interspace of L4-L5 vs L2-L3. Third, my one sided block or patchy block rate is much lower at L2-L3 because the catheter is better secured and less likely dislodged. I also tend to place the catheter at least 5cm into the space.

I am not arguing about the success or safety of L4-L5 but rather what works for me in my real world setting. If you are struggling at L4-L5 then disregard the academics and give my technique a try because it has worked quite well for decades. YMMV, so L4-L5 is just fine if your success rate is high at 98% or so.

I also encourage new graduates to improve their techniques and develop a pattern of success in the real world. Many times I have rescued others trying to place an epidural at L4-L5 simply by moving up 2-3 interspaces where you don't have to travel through layers and layers of fat to engage the ligament.

 

[Status Sciaticus]

Here is my typical obese OB patient: BMI 45

I have them sitting up. Their fat is enormous at the lower lumbar levels. I find an extra 2" of fat at L4-L5 vs L2-L3. Second, they tend not to flex well when pregnant and in labor negating much of the bigger interspace of L4-L5 vs L2-L3. Third, my one sided block or patchy block rate is much lower at L2-L3 because the catheter is better secured and less likely dislodged. I also tend to place the catheter at least 5cm into the space.

I am not arguing about the success or safety of L4-L5 but rather what works for me in my real world setting. If you are struggling at L4-L5 then disregard the academics and give my technique a try because it has worked quite well for decades. YMMV, so L4-L5 is just fine if your success rate is high at 98% or so.

I also encourage new graduates to improve their techniques and develop a pattern of success in the real world. Many times I have rescued others trying to place an epidural at L4-L5 simply by moving up 2-3 interspaces where you don't have to travel through layers and layers of fat to engage the ligament.

Do you manage it the same way you would an epidural at the L4/5 or do you adjust the rate to account for the spread to ensure a sufficiently dense block?

 

[Mman]

Do you manage it the same way you would an epidural at the L4/5 or do you adjust the rate to account for the spread to ensure a sufficiently dense block?

the only change when you go up higher is you end up blocking different levels. Seems obvious, but worth remembering. Higher placement is more likely to have sacral sparing and complaints of pain later in labor as baby descends, though higher level also more reliable at getting abdomen numb higher up.

 

[Lecithin5]

1. More likely to wet tap a thin patient. The epidural space is narrower
2. More likely to get a post dural punture headache requiring a blood patch on a thin patient vs obese
3. More likely to require a second blood patch on a thin patient vs a obese one
4. The interspace between lumbar vertebral bodies is wider for obese patients
5. I tend to do my epidurals at L2-L3 for obese patients so I can find my landmarks better


More likely to require multiple attempts to obtain an epidural in an obese patient
More likely to get a patchy block on an obese patient
More likely to get a failed epidural on an obese patient

Only thing I disagree with is patchy blocks with obese- in my experience, patchiness/one-sidedness happens far more in thinner folks than obese folks.

 

[Status Sciaticus]

the only change when you go up higher is you end up blocking different levels. Seems obvious, but worth remembering. Higher placement is more likely to have sacral sparing and complaints of pain later in labor as baby descends, though higher level also more reliable at getting abdomen numb higher up.

Right, thats why I was asking him/her if he/she changes the rate or perhaps a different concentration to account for the sacral sparing.

 

[ethilo]

5cm of catheter in the space can go anywhere, including straight down, so the PCEA will adapt to wherever the situation brings. Some will click it more to avoid sacral sparing, some will need to click it less.

Educating your patient how to use the PCEA appropriately is the best way to avoid rebolus calls.

 

[anbuitachi]

5cm of catheter in the space can go anywhere, including straight down, so the PCEA will adapt to wherever the situation brings. Some will click it more to avoid sacral sparing, some will need to click it less.

Educating your patient how to use the PCEA appropriately is the best way to avoid rebolus calls.

true.

also helps IMO to set it at a high infusion rate

 

[Twiggidy]

This could be why I'm not a great OB anesthesiologist but one of my primary techniques is being brutally honest:
"Ma'am this could take long"
"Ma'am this local does sting and I'm going to use a lot of it"
"You'll feel me moving the needle around and it may be uncomfortable"
"If you bare with me and we get through this, despite this 15-20 minutes of discomfortable you will feel much better than your labor pain"

This sounds wild, but I feel like setting the bar low so they don't expect Superman, then when I am Superman they are pleasantly surprised or if it is hard it's exactly what I tell them. That's just me.

 

[vector2]

This could be why I'm not a great OB anesthesiologist but one of my primary techniques is being brutally honest:
"Ma'am this could take long"
"Ma'am this local does sting and I'm going to use a lot of it"
"You'll feel me moving the needle around and it may be uncomfortable"
"If you bare with me and we get through this, despite this 15-20 minutes of discomfortable you will feel much better than your labor pain"

This sounds wild, but I feel like setting the bar low so they don't expect Superman, then when I am Superman they are pleasantly surprised or if it is hard it's exactly what I tell them. That's just me.

100.

I don't sugarcoat it anytime I give local (or propofol for that matter) with that "just a little pinch / spicy in the IV" nonsense. All it does is make the pt not trust you.

 

[Status Sciaticus]

This could be why I'm not a great OB anesthesiologist but one of my primary techniques is being brutally honest:
"Ma'am this could take long"
"Ma'am this local does sting and I'm going to use a lot of it"
"You'll feel me moving the needle around and it may be uncomfortable"
"If you bare with me and we get through this, despite this 15-20 minutes of discomfortable you will feel much better than your labor pain"

This sounds wild, but I feel like setting the bar low so they don't expect Superman, then when I am Superman they are pleasantly surprised or if it is hard it's exactly what I tell them. That's just me.

“But last time it only took 2 minutes and I didn’t feel nothing!” 🙄🙄

 

[Twiggidy]

“But last time it only took 2 minutes and I didn’t feel nothing!” 🙄🙄

"Well heck ma'am. We should hire that guy"

 

[OptionOffense]

Here is my typical obese OB patient: BMI 45

I have them sitting up. Their fat is enormous at the lower lumbar levels. I find an extra 2" of fat at L4-L5 vs L2-L3. Second, they tend not to flex well when pregnant and in labor negating much of the bigger interspace of L4-L5 vs L2-L3. Third, my one sided block or patchy block rate is much lower at L2-L3 because the catheter is better secured and less likely dislodged. I also tend to place the catheter at least 5cm into the space.

I am not arguing about the success or safety of L4-L5 but rather what works for me in my real world setting. If you are struggling at L4-L5 then disregard the academics and give my technique a try because it has worked quite well for decades. YMMV, so L4-L5 is just fine if your success rate is high at 98% or so.

I also encourage new graduates to improve their techniques and develop a pattern of success in the real world. Many times I have rescued others trying to place an epidural at L4-L5 simply by moving up 2-3 interspaces where you don't have to travel through layers and layers of fat to engage the ligament.

you are correct, you have greater success at L1, or L2, however, later stages of labor requires S1 they are howling in pain when it gets to that level? Do you find that?

 

[dannyboy1]

“But last time it only took 2 minutes and I didn’t feel nothing!” 🙄🙄

This is an epidural maam. Not the conception 😉

 

[hiyaman]

If ultrasound is handheld then might not take very much additional time to mark midline and level. At my training institution we had a hand held ultrasound we used for this purpose for challenging (scoliotic or massively obese) patients.

 

[DrZzZz]

This sounds wild, but I feel like setting the bar low so they don't expect Superman, then when I am Superman they are pleasantly surprised or if it is hard it's exactly what I tell them. That's just me.

I do the same but maybe to a lesser extent. I emphasize that the epidural is only intended to take away some of the sharp pain they're having, but the pressure will get worse as labor progresses and the epidural won't help with that. Then when it actually does make labor (at lease close to) painless, they think I'm a miracle worker. And if/when they do have some pain as baby descends, they don't think the epidural is suddenly failing because expectations were already set at the beginning.

 

[OptionOffense]

I do the same but maybe to a lesser extent. I emphasize that the epidural is only intended to take away some of the sharp pain they're having, but the pressure will get worse as labor progresses and the epidural won't help with that. Then when it actually does make labor (at lease close to) painless, they think I'm a miracle worker. And if/when they do have some pain as baby descends, they don't think the epidural is suddenly failing because expectations were already set at the beginning.

Tell them:: 50 % chance it doesnt work 50% chance youll get a headache 5 % chance epidural hematoma.. Any questions?

 

[Status Sciaticus]

Tell them:: 50 % chance it doesnt work 50% chance youll get a headache 5 % chance epidural hematoma.. Any questions?

How about the chance of my baby goin full autistic doctor?

 

[patriot6]

How about the chance of my baby goin full autistic doctor?

"Mam, judging by the length of your allergy list, it's close to 100%."

 

[icristi58]

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.