Securing epidurals

[izzygoer]

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Would appreciate suggestions for securing epidurals in obstetric patients. Do you use the yellow sponge that comes in kits, tegaderms, do u put mastidol at the insertion site?

Looking for Any good methods of taping for induction pts who are in for the long haul that reduces dislodgement thanks

 

[Depakote]

I'm sure there are more time-tested techniques than mine but I haven't had any issues.

I leave just enough space that I can see some marking on the catheter so whoever looks at the dressing can tell how deep it is... then I thread the catheter through the little foam pad north of the insertion site. I then circle the catheter in a wide loop around the insertion site and up to the right shoulder. Tegaderm on top. 2 inch tape holding the edges of the tegaderm down and a long strip of tape going up to the shoulder.

 

[pjl]

Have patient sit up tall (will frequently suck catheter in a bit in the bigger ones), then just a tegaderm, with 2" transpore tape around it and up the back. If they are really sweaty or just out of hot tub that is the only time this method fails. I have lost 1 in the last 3 years.

 

[Infexious]

.

 

[fakin' the funk]

Would appreciate suggestions for securing epidurals in obstetric patients. Do you use the yellow sponge that comes in kits, tegaderms, do u put mastidol at the insertion site?

Looking for Any good methods of taping for induction pts who are in for the long haul that reduces dislodgement thanks

I use 4-5 of the "big" tegaderms, the ones that are about 4"x5" in size. One over the catheter exit site then another 3-4 to tape up to the shoulder depending on how tall she is. Tegaderms, if laid down carefully, tend not to get snagged and curl up at the edges the way the 2" pink tape does. My N is around 200-300 for labor epidurals, and no catheters lost.

 

[Ezekiel2517]

quick tip - when placing the catheter on the back, secure it with tape or tegaderm in the groove in the middle of the pt's back instead of on the shoulder blades. That way when the pt is shifting around in bed, there is minimal contact with the catheter.

 

[somedumbDO]

Why tape up the back most pts hate it when it's removed and half time u have to negotiate the bra that the ob nurse neglected to inform the pt about. 2x2 inch thermaphore tape to the side if the epidural pump. Pts happy catheter secured... Boom

 

[ranvier]

I like the yellow foam. Small loop then tegaderm. I have them sit tall before tape. If you have removed catheters you realize paper tape turns into concrete and is pretty secure. A small loop at the end other of the catheter (pump side) can save the occasional night calls as the friction fit can fail. I use the yellow epidural only labels to create this. I also counsel them that if they wiggle too much we may have to replace it....if there is time. Kinda mean I guess but rarely have to....

 

[Vaporized]

I am currently on OB and had something weird happen. I start my shift get sign out on the list, there is a lady who is obese had gastric bypass lost 100 lb with working epidural. In a CS get called that Pt is very uncomfortable. Attending goes to bolus epidural and I go see her after CS , still uncomfortable. I check get back, catheter pulled to 7 at the skin. At this time they wheel someone back for urgent CS so we go start that, attending says he will start that epidural. Goes and puts it in, waits while he gets good analgesia, life is good. She is near delivery, in a lot of pain, failure to progress, take back for CS , start to bolus with lido to no effect. Think about spinal vs GA, attending decides GA. Case goes smooth, at the end I go to take out epidural and it is 7 cm at skin. Weird.
We pretty much secure them all by making a loop at the skin site so there isn't tension, tegraderm, then secure that with rectangle of thick tape and secure it up the back with tape. Attending says 25 years hadn't had a problem. For this patient, however, she had lost so much weight, but her skin was SUPER floppy and saggy. Our hypothesis was the when sitting up for epidural the catheter would go through skin to epidural space just fine. Then when she went on her back the skin would move significantly and pull catheter from epidural space. When I checked them both times. The tape on the back and securing the catheter was in place, not pulled. The catcher was sort of "pushed out" from the puncture site into the tergraderm.
I don't know. Kind of weird.

 

[jwk]

Why tape up the back most pts hate it when it's removed and half time u have to negotiate the bra that the ob nurse neglected to inform the pt about. 2x2 inch thermaphore tape to the side if the epidural pump. Pts happy catheter secured... Boom

Hard to re-dose in the middle of a C/S if it's down under the sterile field.

 

[somedumbDO]

Hard to re-dose in the middle of a C/S if it's down under the sterile field.

You got plenty of length for that bad boy at head of bed. I save time and pts are happier without that waxing job at the end.

 

[painstop]

I am currently on OB and had something weird happen. I start my shift get sign out on the list, there is a lady who is obese had gastric bypass lost 100 lb with working epidural. In a CS get called that Pt is very uncomfortable. Attending goes to bolus epidural and I go see her after CS , still uncomfortable. I check get back, catheter pulled to 7 at the skin. At this time they wheel someone back for urgent CS so we go start that, attending says he will start that epidural. Goes and puts it in, waits while he gets good analgesia, life is good. She is near delivery, in a lot of pain, failure to progress, take back for CS , start to bolus with lido to no effect. Think about spinal vs GA, attending decides GA. Case goes smooth, at the end I go to take out epidural and it is 7 cm at skin. Weird.
We pretty much secure them all by making a loop at the skin site so there isn't tension, tegraderm, then secure that with rectangle of thick tape and secure it up the back with tape. Attending says 25 years hadn't had a problem. For this patient, however, she had lost so much weight, but her skin was SUPER floppy and saggy. Our hypothesis was the when sitting up for epidural the catheter would go through skin to epidural space just fine. Then when she went on her back the skin would move significantly and pull catheter from epidural space. When I checked them both times. The tape on the back and securing the catheter was in place, not pulled. The catcher was sort of "pushed out" from the puncture site into the tergraderm.
I don't know. Kind of weird.

I'm curious what people do under these circumstances where you are dealing with a patchy epidural at the time of the clamp test. Every option has a positive and negative and I have tried it all ways. If you bolus the epidural and then proceed to spinal intraop, there is about a 10% chance of a high spinal. If you decide on GA, the significant other will not be able to come into the room for delivery and there are issues with airway edema (overblown in my opinion) and possible aspiration (also overblown since they routinely do GA with LMAs in these pts in other countries). My preferred method (unless this is an extremely hypertensive patient) is to actually do room air general with 50 mg Ketamine (and 2 mg Midazolam to avoid/minimize dysphoria). The patient is usually asleep within 10 seconds so the incision is able to be made slightly faster than the GA route (not significantly different) and spinal (probably more significant different time difference). More importantly, the significant other is able to be in the OR when the baby comes out. I usually just tell the dad that the pt received some pain medications for discomfort and will be sleepy for about an hour. I have found the overall stress level of the room is less when I do this method as well because it is much closer to the normal modus operandi of their C-Sections.

Any thoughts?

 

[okayplayer]

I'm curious what people do under these circumstances where you are dealing with a patchy epidural at the time of the clamp test. Every option has a positive and negative and I have tried it all ways. If you bolus the epidural and then proceed to spinal intraop, there is about a 10% chance of a high spinal. If you decide on GA, the significant other will not be able to come into the room for delivery and there are issues with airway edema (overblown in my opinion) and possible aspiration (also overblown since they routinely do GA with LMAs in these pts in other countries). My preferred method (unless this is an extremely hypertensive patient) is to actually do room air general with 50 mg Ketamine (and 2 mg Midazolam to avoid/minimize dysphoria). The patient is usually asleep within 10 seconds so the incision is able to be made slightly faster than the GA route (not significantly different) and spinal (probably more significant different time difference). More importantly, the significant other is able to be in the OR when the baby comes out. I usually just tell the dad that the pt received some pain medications for discomfort and will be sleepy for about an hour. I have found the overall stress level of the room is less when I do this method as well because it is much closer to the normal modus operandi of their C-Sections.

Any thoughts?

To me it depends if it is patchy or no block whatsoever. If it is a small area that isn't as numb on the Allis test sometimes all you need is more time/local or the surgeon can use local and you give some ketamine.

If there is no block whatsoever, the options are sit them up and do a spinal or put them to sleep and I think the answer depends on the urgency of the section and how difficult the airway might be. If I had just put 10-20 ml lido in the epidural space I would more conservatively dose my spinal (1.2-1.4ml 0.75% bupi vs 1.6ml) and of course be ready for a possible high spinal.

 

[Libertas]

if its a take back for failure to progress, I don't let the surgeons drape until we're sure the block is working. If its an emergency, the circumstances are obviously different.

 

[DrN2O]

Or a spinal catheter

 

[Mman]

I'm curious what people do under these circumstances where you are dealing with a patchy epidural at the time of the clamp test. Every option has a positive and negative and I have tried it all ways. If you bolus the epidural and then proceed to spinal intraop, there is about a 10% chance of a high spinal.

1) If the epidural is iffy before rolling in the room, they either get a spinal or a GA depending on the time I have.
2) If I do a spinal with a patient that has an epidural running they get a very small dose (usually 0.8 ml of hyperbaric bupiv) and the chances of a high spinal are tiny
3) I only use the epidural for the c-section if they are really numb from the baseline continuous infusion running. Any question and it's coming out.
4) If for whatever reason I'm still iffy with patient draped or after starting, I'll usually try to get by with some adjuncts. Nitrous is my first choice. I'll add some others like fentanyl or ketamine or versed if needed. Relatively low threshold for just going to sleep and intubating, though.

 

[fakin' the funk]

I'm curious what people do under these circumstances where you are dealing with a patchy epidural at the time of the clamp test. Every option has a positive and negative and I have tried it all ways.

I've said this before on this forum, but if you are deciding what to do with a patchy epidural / "sketchidural" at the time of skin incision you are WAYYYYY too late.

When the OB makes the call to go to C-section you have to answer the question: "Will this epidural provide surgical anesthesia for a C-section?"
(Really, you should answer this question 20-30 minutes after you place the epidural)
If the answer is NO then you either pull and replace the epidural (slow), spinal (preferred), or GETA (if crash or other options suboptimal).
If the answer is YES, but then somehow in the process of transport and prep, your epidural has become patchy or hasn't topped up with a decent volume of 2% lido/epi/bicarb, I would do GETA.

(Secondly, if you have a sketchidural on a laboring patient, why are you not getting calls from the RNs to evaluate a patient with an epidural who has a lot of pain?)

 

[periopdoc]

As for the original question, too much mental masturbation on this topic.

Put it in. Foam or not. Make a loop near insertion site. Medium Tegaderm over this. Plastic tape around edges of Tegaderm. Catheter up the middle of the back and over the left shoulder. If bra present, great. It holds the catheter in place while I tape. One to two layers of plastic tape up the back and to the shoulder. Tape a loop of the epidural pump tubing to the shoulder so if there is any pulling between the pump and the patient, it is on the epidural tubing, not the catheter. Paper tape sux coming off.

Do the same for OB or pain epidurals. Haven't lost an epidural in 5 plus years.

-pod

 

[IHatePikeys]

Keep it simple. Yellow foam, one loop, medium tegaderm, then 2 inch silk tape 12-18 inches across low back, 3-4 strips, depending on size of patient, then one strip up the back and over the shoulder. I'll add that I choose the shoulder on which side the pump is located. It gives more slack for the catheter. I've never had one come out in 5+ years.

Also, scaring your patient by telling them that wiggling will cause their catheter to dislodge is uncool. They're giving birth, and may be there awhile, they're going to move around a bit. A well secured catheter shouldn't come out.

 

[oldguy55]

Keep it simple. Yellow foam, one loop, medium tegaderm, then 2 inch silk tape 12-18 inches across low back, 3-4 strips, depending on size of patient, then one strip up the back and over the shoulder. I'll add that I choose the shoulder on which side the pump is located. It gives more slack for the catheter. I've never had one come out in 5+ years.

Also, scaring your patient by telling them that wiggling will cause their catheter to dislodge is uncool. They're giving birth, and may be there awhile, they're going to move around a bit. A well secured catheter shouldn't come out.

Even simpler: one half-loop then straight up the back. Benzoin. One tegaderm over the loop and insertion site. One strip of 1" plastic tape up the back. Done. A smooth, flat dressing.

The yellow foam and the extra tape around the edges add nothing except bulk that will roll up as the patient (inevitably) moves around.

For those patients with, to be nice, a generous amount of tissue between the spine and the skin, apply the tegaderm after the patient lies down onto her side. At that time the primary anchor is in ligamentum. After tegaderm it is anchored at the skin and shifting tissue will cause it to pull out of the epidural space.

Worked for me for >30 years.