I tend to get one sided epidural more than half of my patients any thoughts?
One sided epidurals?
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More than 4cm into the space increases your chances of one sided blocks.
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Lumbar plexus catheter. Blaz
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Are your patients complaining of one sided pain as proceed with your epidural needle, or of unilateral paraesthesias when you insert the epidural catheter?
If you are truly in the midline, they certainly shouldn't have unilateral complaints as you progress towards the epidural space, and generally shouldn't complain of paraesthesias when the epidural catheter is inserted (less of a big deal than previous part).
Basically, what I'm trying to say is make sure you are in the midline before you even get to the epidural space. It's not a guarantee, but it's better than the alternative. 1/2 of your patients with unilateral block is just too much. Whenever I'm struggling or not sure what to do, I go back to the basics.
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What kind of catheters are you using? I find that the mono perforated flextip have a higher incidence of one-sided blocks.
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What others have alluded to is that if you're off midline or if you push the catheter in too far, the catheter tip is more likely to lean off to one side or the other. This will push your local anesthetic off to one side, theoretically, and give you a one-sided block.
Ways to prevent or fix that include the following:
1) try to be midline (what about the paramedian approach? Are there more one-sided blocks w/ this technique?)
2) Take meticulous measurements of your catheter length. If you get a one-sided block, pull your catheter back a cm or 2 (you should know how much catheter is left in the epidural space after you do this).
3) Plow huge volumes of dilute local anesthetic into the existing catheter, in the hopes that some of the large volume will push to the contralateral side.
Ways to prevent or fix that include the following:
1) try to be midline (what about the paramedian approach? Are there more one-sided blocks w/ this technique?)
2) Take meticulous measurements of your catheter length. If you get a one-sided block, pull your catheter back a cm or 2 (you should know how much catheter is left in the epidural space after you do this).
3) Plow huge volumes of dilute local anesthetic into the existing catheter, in the hopes that some of the large volume will push to the contralateral side.
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Other thoughts -
The LOR to air technique can cause patchy or one-sided blocks too if you inadvertently inject air into the epidural space. I've seen a couple people routinely get patchy blocks despite otherwise good technique, and I blame the air-pocket-over-the-nerve-root phenomenon.
Patient position during bolusing/infusion affects distribution. I had to fix one OB nurses' habit of encouraging the lateral position after being called for a lot of one-sided-blocks.
You probably just have too much catheter in the space though.
The LOR to air technique can cause patchy or one-sided blocks too if you inadvertently inject air into the epidural space. I've seen a couple people routinely get patchy blocks despite otherwise good technique, and I blame the air-pocket-over-the-nerve-root phenomenon.
Patient position during bolusing/infusion affects distribution. I had to fix one OB nurses' habit of encouraging the lateral position after being called for a lot of one-sided-blocks.
You probably just have too much catheter in the space though.
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For some reason, people are very good at detecting sidedness in their lower back.
As you are advancing the needle, make it a point to ask frequently "what side do you feel that on?" Then adjust the needle accordingly.
Agree with above, don't thread the catheter more than 3 to 4 cm. I hate the practice of threading like 7 to 8cm with the idea of pulling the catheter back after the needle is out. That makes no sense. If the catheter has gone to the gutter, it will stay there even with pulling 3 cm out.
Also, if you are worried that 3 or 4 cm is going to migrate out, then you haven't pulled enough post-op catheters. I know they will and do migrate, but I think that is a function of something else, not length in the epidural space.
The real answer is just keep doing them. You will get better and being absolutely midline and you will see your success rate going up.
As you are advancing the needle, make it a point to ask frequently "what side do you feel that on?" Then adjust the needle accordingly.
Agree with above, don't thread the catheter more than 3 to 4 cm. I hate the practice of threading like 7 to 8cm with the idea of pulling the catheter back after the needle is out. That makes no sense. If the catheter has gone to the gutter, it will stay there even with pulling 3 cm out.
Also, if you are worried that 3 or 4 cm is going to migrate out, then you haven't pulled enough post-op catheters. I know they will and do migrate, but I think that is a function of something else, not length in the epidural space.
The real answer is just keep doing them. You will get better and being absolutely midline and you will see your success rate going up.
