Subdural anesthesia needle placement

[plea]

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In my rotation, I noticed that most anesthesiologist has hard time in subdural anesthesia needle placement. I watched at least 10 plus procedures and almost all of them takes over 25 minutes to finish the procedure. Off course this procedure is difficult but do you think this can be improved with experience or it is common to any one even with experience? What if the surgeon’s requested that but you can’t make it..is there any other approach something lie to use ultra sound? I think this procedure is frustrating especially when the patient is angry and not cooperative.
Thanks

 

[rsgillmd]

In my rotation, I noticed that most anesthesiologist has hard time in subdural anesthesia needle placement. I watched at least 10 plus procedures and almost all of them takes over 25 minutes to finish the procedure. Off course this procedure is difficult but do you think this can be improved with experience or it is common to any one even with experience? What if the surgeon's requested that but you can't make it..is there any other approach something lie to use ultra sound? I think this procedure is frustrating especially when the patient is angry and not cooperative.
Thanks

Subdural? I don't think so. You are probably observing either an epidural or a spinal (subarachnoid). The subdural space is more of a potential space and inadvertent administration of medication into the subdural space is characterized by uneven levels of block (one side may be significantly higher than the other), and unusually high levels for what would be expected if the medication had been given into the epidural space. Very rare. I've only seen 2 cases so far.

Epidurals and spinals are a technical procedure dependent upon the skill of the practitioner, the patient's anatomy, positioning of the patient, and sometimes just luck. A couple of days ago I put a morbidly obese woman to sleep because neither I nor the CRNA I was working with could get a spinal in her. I managed to get a loss of resistance after burying the long Tuohy needle at L5-S1, but no CSF. Dosing through the needle resulted in no evidence of block, so off to sleep she went.

Epidurals/spinals should not really be painful if you have infiltrated the skin and are in midline. If the patient is having pain, then usually you are off midline and need to redirect your needle. Some patients perceive pressure as pain, but that's another story.

Discuss with the anesthesiologist what problems he/she encountered and what they did to address them. You can sometimes learn more from a difficult procedure than you can from one that went smoothly.

Ultrasound can be used. It takes practice to get used to recognizing the structures. For me it is more a waste of time. I can do one faster without it.

 

[nap$ter]

:troll:

In my rotation, I noticed that most anesthesiologist has hard time in subdural anesthesia needle placement. I watched at least 10 plus procedures and almost all of them takes over 25 minutes to finish the procedure. Off course this procedure is difficult but do you think this can be improved with experience or it is common to any one even with experience? What if the surgeon’s requested that but you can’t make it..is there any other approach something lie to use ultra sound? I think this procedure is frustrating especially when the patient is angry and not cooperative.
Thanks

 

[plea]

I am sorry, it is Epidural not subdural. I saw this procedure in OB rotation and unfortunately it was not easy . I think most procedures lasts over 25 min.

 

[IlDestriero]

It's a 5 minute procedure, maybe 10 if they're morbidly obese and you've got to get the ultrasound to rough out some landmarks and find the harpoon. If momma can't sit still after 100mcg of fentanyl, she can enjoy natural childbirth, like God intended.

 

[bigdan]

How fast is a "fast" epidural ?(serious question)

I'm completing my OB subspecialty months, and from getting the call for the epidural to leaving the room with pt happy AND safe, my fastest time is probably about 25 minutes, but normal is around 35 min. Super-fatties and crazy patients are a different story.

What do you guys do to speed things up?

 

[Idiopathic]

probably if you leave the room before 30 minutes from when you entered you arent monitoring your patients long enough. it takes me 5-8 minutes to sit a patient up, place an epidural and lay them back down, assuming no complications. i consider myself fast.

where i see many people losing time is by attaching LOR syringe before truly being in the ligament and inefficient advancement of the needle. i use a continuous LOR technique with one hand on the wings and one hand on the plunger...no stopping until the epidural space.

 

[jwk]

I am sorry, it is Epidural not subdural. I saw this procedure in OB rotation and unfortunately it was not easy . I think most procedures lasts over 25 min.

Here's how ours works. MD gets the call. When he/she walks in the patient's room, the patient is sitting up in the bed with their legs in a chair, fluid bolus already in, BP cuff and SaO2 probe on, fentanyl already out of the Pyxis if that particular doc uses it, and epidural pump with pre-loaded syringe from pharmacy already set up, programmed, and ready to go. Look at pre-op questionaire, labs, and signed consent which were all done when the patient walked or rolled in from the street. Needle in, test dose and bolus through the needle, catheter in, test dose through catheter, dressing on, done. Nurse hooks up and starts pump while paperwork being done. Total time in room - 10 minutes tops and usually half that. Hypotension is rare with our labor epidurals, but nurse is quick to call and we're quick to be there if there is a problem because we have dedicated OB anesthesia staff 24/7.

Practice makes perfect, both in speed and patient comfort. If you're rooting around in someone's back for 25 minutes, no wonder they're screaming.

 

[Jeff05]

for me - average time to pop in a spinal - 60 seconds from finder needle to meds going in.

average time for OB epidural 2 min from finder needle until catheter going in.

thoracics take an extra min since i don't use continuous LOR to saline like i do in OB.

it is extremely rare not to be able to get a spinal or epidural in. in that case, just put em to sleep.


25 minutes to do anything in anesthesia is way too long.

 

[lord_jeebus]

I spend 5-7 minutes placing a typical OB epidural, from prepping to lying the patient back down...and 20 minutes on hospital nonsense ranging in appropriateness from consent and anesthesia documentation (appropriate but could be made more efficient), to a long set of epidural-related orders (Pharmacy finds ways to make this take longer and longer), to programming the infusion pump (why can't the nurses do this??)

 

[pgg]

probably if you leave the room before 30 minutes from when you entered you arent monitoring your patients long enough.

I do CSEs with intrathecal narcotics nearly 100% of the time now. They never get hypotensive, and since I'm not bolusing the epidural, I don't stick around long. After taping the catheter and laying her down again, it takes me 6 or 8 minutes to prime/program the pump and explain the button to her. 2 or 3 minutes to write the note (I have templates to cut & paste that fit most of the time). I'm usually in the room about 20 minutes. Our nurses are pretty good about getting the patients sitting and positioned.

25 minutes as the OP wrote seems way to long for the procedure but if that includes the talk, consent, procedure, pump setup, and a few minutes of monitoring, it doesn't seem unreasonable.

 

[ssmallz]

Here's how ours works. MD gets the call. When he/she walks in the patient's room, the patient is sitting up in the bed with their legs in a chair, fluid bolus already in, BP cuff and SaO2 probe on, fentanyl already out of the Pyxis if that particular doc uses it, and epidural pump with pre-loaded syringe from pharmacy already set up, programmed, and ready to go. Look at pre-op questionaire, labs, and signed consent which were all done when the patient walked or rolled in from the street. Needle in, test dose and bolus through the needle, catheter in, test dose through catheter, dressing on, done. Nurse hooks up and starts pump while paperwork being done. Total time in room - 10 minutes tops and usually half that. Hypotension is rare with our labor epidurals, but nurse is quick to call and we're quick to be there if there is a problem because we have dedicated OB anesthesia staff 24/7.

Practice makes perfect, both in speed and patient comfort. If you're rooting around in someone's back for 25 minutes, no wonder they're screaming.

I'm jealous. Typical Epidural for me: Get a call from nursing "Dr. We need an epidural". I arrive in the room to find the patient w/no nurse. Page nurse to room, as nurse arrives, pt needs to go to bathroom. Nurse walks pt to and from bathroom 5 minutes wasted. Pt finally gets into bed and I do my breif preop. Pt starting to sit up, nurse scrambling for the monitors and the inevitable missing BP cuff. At that point I ask the nurse for the epidural bag and nurse rings out another nurse to bring one in. Prep, Drape, numb, LOR to saline, epidural in ~3-5 mins. At this point I have to attach the epirual bag to the tubing, flush it through, and program the pump. All this and I can usually go 15-20 minutes door to door. The worst part is that god forbid there's a pump issue, I need to personally come up and trouble shoot it. Nothing better than waking up at 2:30am to reprogram a pump b/c "it's beeping". I can't wait for PP

 

[Idiopathic]

Here's how ours works. MD gets the call. When he/she walks in the patient's room, the patient is sitting up in the bed with their legs in a chair, fluid bolus already in, BP cuff and SaO2 probe on, fentanyl already out of the Pyxis if that particular doc uses it, and epidural pump with pre-loaded syringe from pharmacy already set up, programmed, and ready to go. Look at pre-op questionaire, labs, and signed consent which were all done when the patient walked or rolled in from the street. Needle in, test dose and bolus through the needle, catheter in, test dose through catheter, dressing on, done. Nurse hooks up and starts pump while paperwork being done. Total time in room - 10 minutes tops and usually half that. Hypotension is rare with our labor epidurals, but nurse is quick to call and we're quick to be there if there is a problem because we have dedicated OB anesthesia staff 24/7.

Practice makes perfect, both in speed and patient comfort. If you're rooting around in someone's back for 25 minutes, no wonder they're screaming.

let me just say that unless you have somewhere else to be urgently, its important to stick around, monitor the patient (get two blood pressures after the block), bolus the catheter, get a level, etc. yes, its good to be efficient, i would argue its not always good to be "fast". i would never, ever, allow a trainee to stay in a room only 5 minutes (10, "tops").

i dont know what shape your OB patients are when you get to them, but ours are usually already on pitocin and are usually miserable with labor pains. we also have an almost exclusively high-risk population, so maybe we are a little more high strung than most PP groups.

 

[Monty Python]

I spend 5-7 minutes placing a typical OB epidural, from prepping to lying the patient back down...and 20 minutes on hospital nonsense ranging in appropriateness from consent and anesthesia documentation (appropriate but could be made more efficient), to a long set of epidural-related orders (Pharmacy finds ways to make this take longer and longer), to programming the infusion pump (why can't the nurses do this??)

At least in my state, RNs are not allowed due to specific wording in the Nurse Practice Act section on local anesthetics.

 

[Idiopathic]

I spend 5-7 minutes placing a typical OB epidural, from prepping to lying the patient back down...and 20 minutes on hospital nonsense ranging in appropriateness from consent and anesthesia documentation (appropriate but could be made more efficient), to a long set of epidural-related orders (Pharmacy finds ways to make this take longer and longer), to programming the infusion pump (why can't the nurses do this??)

this is not the way to own the profession, by the way.

 

[sevoflurane]

let me just say that unless you have somewhere else to be urgently, its important to stick around, monitor the patient (get two blood pressures after the block), bolus the catheter, get a level, etc. yes, its good to be efficient, i would argue its not always good to be "fast". i would never, ever, allow a trainee to stay in a room only 5 minutes (10, "tops").

i dont know what shape your OB patients are when you get to them, but ours are usually already on pitocin and are usually miserable with labor pains. we also have an almost exclusively high-risk population, so maybe we are a little more high strung than most PP groups.

Agree 100%. How are they going to learn? You need to do a couple hundred 20-30 min. epidurals, IMO. You can’t just jump into 5-10 minute epidurals. Some people tape in their epidurals at the 12cm mark no matter what... You need to learn why this is a bad idea and if you stick around for a couple hundred, do a proper level check, etc, these sort of things become very apparent + you start to build a lot of confidence after that many. I’ve had 2 wet taps in my career. Both of them happened during the first 200 epidurals.

During my CA-2 year I got shipped out to a high volume private practice OB facility. 15-20 epidurals per shift + 4-8 c/s per day. Busy, busy, busy.... It was there I learned how to do a 5 minute epidural, but I already had 150+ epidurals under my belt. 20 minutes turned into 5-10 minutes after a couple of days with those guys. CRNA’s charted vitals and stayed with the patient as I went on to the next room.

Fast forward 5 years:

In my group, the patient has read the consent, is in sitting position, has had 1 liter of fluids + I have a tray that is pulled and placed on top of a table right next to the patient.... all before I hit the room. All necessary equipment is w/in arms reach.

As I walk into the OB floor, the H&P is handed to me. I enter the patient room and I ask all the questions I need to ask and explain what will happen + risks. While I do this, I'm prepping my tray (which is the longest part of the procedure. I open and prep the tray the same way every single time...). Within 5 minutes of entering the room I'm done with the procedure with test dose on board. While I'm writing my note I'm checking vitals. I do a little chit-chat for a minute or two before I leave the room constantly assessing the situation (vitals, FHR, patient color etc..). The last thing I do before leaving the room is to shake the patient's hand while palpating a radial and confirm this with the last BP. I also ask the patient to move their toes.

Total time is always under 10 minutes... and 5 minutes of this is after the test dose.

BTW, we have excellent nurses, which is key.

 

[sevoflurane]

I'm jealous. Typical Epidural for me: Get a call from nursing "Dr. We need an epidural". I arrive in the room to find the patient w/no nurse. Page nurse to room, as nurse arrives, pt needs to go to bathroom. Nurse walks pt to and from bathroom 5 minutes wasted. Pt finally gets into bed and I do my breif preop. Pt starting to sit up, nurse scrambling for the monitors and the inevitable missing BP cuff. At that point I ask the nurse for the epidural bag and nurse rings out another nurse to bring one in. Prep, Drape, numb, LOR to saline, epidural in ~3-5 mins. At this point I have to attach the epirual bag to the tubing, flush it through, and program the pump. All this and I can usually go 15-20 minutes door to door. The worst part is that god forbid there's a pump issue, I need to personally come up and trouble shoot it. Nothing better than waking up at 2:30am to reprogram a pump b/c "it's beeping". I can't wait for PP

I hated those calls..... 🙁

 

[sevoflurane]

Here's how ours works. MD gets the call. When he/she walks in the patient's room, the patient is sitting up in the bed with their legs in a chair, fluid bolus already in, BP cuff and SaO2 probe on, fentanyl already out of the Pyxis if that particular doc uses it, and epidural pump with pre-loaded syringe from pharmacy already set up, programmed, and ready to go. Look at pre-op questionaire, labs, and signed consent which were all done when the patient walked or rolled in from the street. Needle in, test dose and bolus through the needle, catheter in, test dose through catheter, dressing on, done. Nurse hooks up and starts pump while paperwork being done. Total time in room - 10 minutes tops and usually half that. Hypotension is rare with our labor epidurals, but nurse is quick to call and we're quick to be there if there is a problem because we have dedicated OB anesthesia staff 24/7.

Practice makes perfect, both in speed and patient comfort. If you're rooting around in someone's back for 25 minutes, no wonder they're screaming.

Good post. I imagine most efficient groups work like this. Having good nursing really helps things move along. 👍

 

[Dogdaze]

I find the time required for an epidural to be an interesting topic. Ever since I was a resident there has been (what I perceive as) a disconnect between stated times to perform an epidural and the "actual" time. I had a colleague in residency who claimed to take no more than 15 minutes... well we all had the same nursing "help" as he did, and most residents took 40-50 minutes, or even more. So what was the difference? Well, one night we were on call together and he got the assignment, and he was gone for? 42 minutes! He later "clarified" that his previous reported timing was for local anesthetic to taping. He conveniently forgot all of the other bulls&#t such as patient interview, postioning, level determination, order entry, etc.

So now, I see people reporting the "no more than 5-10 minutes" for an epidural, I have to think that is needle time, not time away from the OR.

Just now I was called to go do an epidural between OR cases. The call came at 8:54 and I was back down to the OR at 9:30. When I'm called to this is what I have to do:
1) Chart review/patient interview
2) explain an epidural/written consent
3) open up kit, prep skin
4) don gloves, set up kit, draw up local and inject
5) Find eipdural space with Toughy/thread cath/test dose
6) tape/secure
7) draw up bolus/give 1/2 of it
8) complete required paperwork: finish H&P, billing slip, orders
9) confirm with nursing pump settings
10) a few kind words before departing

5-10 minutes? Not a chance.


of course, #5 is where the money's at. Little skinnys vs. big fat fatties can make you or break you. Also, I find the younger the patient (esp teenagers), the less likely they are to be cooperative with positioning. Againg affecting timing for step 5.

Maybe I'm just envious of all of you you have the "table set" when you get there, but in our work environment , 30ish minutes is the minimum from leaving the OR to returning for the next case

 

[bigdan]

Guys -

Thanks for all the great responses!!!! I'm a CA1, so I'm not trying to break any land-speed records, but I do realize that efficiency is important when moving through my training. My worry with being "fast" is the only way I see that you can leave the room much quicker than 20-30 minutes is to cut corners on monitoring or intro/eval stuff...and that's where I feel I could get burned.

ssmallz - your set up is EXACTLY like every single day I have spent on OB. It's almost like the nurses are allergic to suggesting the pt should go to the bathroom BEFORE they call us for the epidural...like it would cause them to anaphylax if the pt were to pee before I came in the room. WTF.

Dogdaze - Thanks for your comments as well. Your list of steps is my process (after the pt goes to the potty, that is). I cannot get this much under 30 minutes WHILE STILL MONITORING THE PT APPROPRIATELY. It's nice to hear that people do this out in the real world.

 

[IlDestriero]

I was referring to time standing behind the patient, not charting, etc. That's the 5-10 min part. I prep quickly and while it's drying I get everything else ready. Than local and I give it a minute to work while I pull out the catheter and confirm good pt position. LOR, catheter, test, tape. I than go over and start the chart. Quick check for evidence of spinal a few min later and than bolus over a few minutes in aliquots while charting. Hook up PCEA and a quick explanation while they're repositioning her. Out the door. Get a cup of tea and check the vitals again in a few more minutes. I don't check a level. If it doesn't set up, they'll call before long and I tell the pt to not use the PCEA until it sets up. We don't do high risk women, so the likelihood of crashing back is more infrequent. We also have no trainee OBs so no hemming and hawing over the strips and overreacting, with the running and the screaming. I also don't like to move the needle during a contraction if they're really hurting, so sometimes that adds another minute while I wait to start or reposition the needle.
You'll get faster with experience, but 10 minutes door to door is probably impossible and evidence of poor consent, charting, or monitoring. There's no avoiding that and each step takes a few minutes. Even if they already have a signed consent, I still cover the key R/B/A, and note the discussion. If you were working with a CRNA and only needle jockeying, you could probably be door to door in 5 minutes.😉 I've never seen that type of practice.

 

[Idiopathic]

I was referring to time standing behind the patient, not charting, etc. That's the 5-10 min part. I prep quickly and while it's drying I get everything else ready. Than local and I give it a minute to work while I pull out the catheter and confirm good pt position. LOR, catheter, test, tape. I than go over and start the chart. Quick check for evidence of spinal a few min later and than bolus over a few minutes in aliquots while charting. Hook up PCEA and a quick explanation while they're repositioning her. Out the door. Get a cup of tea and check the vitals again in a few more minutes. I don't check a level. If it doesn't set up, they'll call before long and I tell the pt to not use the PCEA until it sets up. We don't do high risk women, so the likelihood of crashing back is more infrequent. We also have no trainee OBs so no hemming and hawing over the strips and overreacting, with the running and the screaming. I also don't like to move the needle during a contraction if they're really hurting, so sometimes that adds another minute while I wait to start or reposition the needle.
You'll get faster with experience, but 10 minutes door to door is probably impossible and evidence of poor consent, charting, or monitoring. There's no avoiding that and each step takes a few minutes. Even if they already have a signed consent, I still cover the key R/B/A, and note the discussion. If you were working with a CRNA and only needle jockeying, you could probably be door to door in 5 minutes.😉 I've never seen that type of practice.

i think the lesson here is that pretty much all attendings who do some OB are capable of doing b+b epidurals in no time flat (like, 3 minutes), but any variable can affect your time (outside influences as described above, intravascular catheter, etc.)

The things I would recommend to a new trainee in how to improve efficiency:

1) i will make maybe one pass with my thumb to find midline. I dont go mashing on backs to try and locate a spinous process in a woman who is already edematous from preeclampsia/normal pregnancy. if you find midline in the lumbar region, you can work from there.

2) numb the skin before you draw everything else up (saline, test dose, etc) and get your catheter/touhy ready. this shaves 90-120 seconds off your time.

3) make sure the patient is positioned correctly from the start, especially larger women. you will get so caught up in your touhy that by the time you step back, you realize the patient is sitting straight up (or even extended) andt here is probably no way you are slipping a touhy between the processes.

other tricks too, but these are good efficiency-boosters

 

[24858]

I'm with dogdaze on this one. There ate always cocky guys who claim to do an epidural in thirty seconds. I don't care how long it takes as long as the thing works. I usually take about thirty to forty minutes with paperwork and monitoring and pump setup. Sure some epidurals go in on the first shot and it is quick but there are the ones that take a few attempts. What can I say? There are some fatties out there. I an competent at putting epidurals in and competent at treating reactions that occur afterwards. I like to be in the room with phenylephrone ready to go at the first signs of trouble. Rather than in the call room sitting down waiting for a nurse to page me about decels due to hypotension.

 

[IlDestriero]

One new source of delay is that the nurses have to have the orders in the computer before they can get the epidural PCEA for me. They used to override it in the Pyxis. Sometimes I forget to order it before I start. That slows things down by several minutes.😡

It's not a race, but I do hate the labor deck, so efficiency will get me out faster. Find a system that works for you and your set up, look for ways to save time, and try to not deviate. X10 epidurals and you're looking at an extra hour doing something else. The frequent small inefficiencies add up over the course of the day.

 

[sevoflurane]

I'm with dogdaze on this one. There ate always cocky guys who claim to do an epidural in thirty seconds. I don't care how long it takes as long as the thing works. I usually take about thirty to forty minutes with paperwork and monitoring and pump setup. Sure some epidurals go in on the first shot and it is quick but there are the ones that take a few attempts. What can I say? There are some fatties out there. I an competent at putting epidurals in and competent at treating reactions that occur afterwards. I like to be in the room with phenylephrone ready to go at the first signs of trouble. Rather than in the call room sitting down waiting for a nurse to page me about decels due to hypotension.

30-40 minutes seems a bit long to me. But the difference may be that:

• Everything is set up and ready to go when I get there. Consent, patient in sitting position with full monitors, etc..
• My pumps are programed by the nurses under my instruction. They also know how to trouble shoot an epidural pump. Continuous rate, no PCEA over here.
• My population is mostly skinny females ages 18-30. The larger BMI’s certainly can take longer. LOR is rarely > 6.5cm.
• We have early epidural placement. Not when they are dilated to 8cm and ready to jump off the bed. So they are calm, display understanding and only get a test dose. No bolus unless necessary.
• Our notes consist of checking boxes and writing down LOR, catheter depth, infusion rate. Less than a minute to fill out. Literally.

Again, proper nurse training goes a long way. They really help move things along.

 

[Idiopathic]

30-40 minutes seems a bit long to me. But the difference may be that:

• 
  [*]Everything is set up and ready to go when I get there. Consent, patient in sitting position with full monitors, etc..
  [*]My pumps are programed by the nurses under my instruction. They also know how to trouble shoot an epidural pump. Continuous rate, no PCEA over here.
  [*]My population is mostly skinny females ages 18-30. The larger BMI’s certainly can take longer. LOR is rarely > 6.5cm.
  [*]We have early epidural placement. Not when they are dilated to 8cm and ready to jump off the bed. So they are calm, display understanding and only get a test dose. No bolus unless necessary.
  [*]Our notes consist of checking boxes and writing down LOR, catheter depth, infusion rate. Less than a minute to fill out. Literally.

Again, proper nurse training goes a long way. They really help move things along.

further delineating the differences between PP anesthesia and academic anesthesia

 

[Idiopathic]

i was the third provider on a 45 minute CSE the other night, lost at 11.5 cm. felt good to get it, but didnt like the thought of nobody else i could call, since i was the attending. of course it was semi-urgent, 2AM, 325lb, just ate on the way into the hospital...

what are you gonna do

 

[Dogdaze]

Idio, We're in PP here, no residents, nor med students. Still takes 30ish minutes from the time you leave the OR until you return. Nobody "sets the table" for us, which granted takes more time than the "needle jockeying".

Just my 2 cents, but it seems like the "oh yeah, my epidural time is faster than yours" kind of bragging goes hand in hand with with the my #@#& is bigger than yours mentality

 

[IlDestriero]

Idio, We're in PP here, no residents, nor med students. Still takes 30ish minutes from the time you leave the OR until you return. Nobody "sets the table" for us, which granted takes more time than the "needle jockeying".

Just my 2 cents, but it seems like the "oh yeah, my epidural time is faster than yours" kind of bragging goes hand in hand with with the my #@#& is bigger than yours mentality

I'm the guy that the other guys call when they can't get the epidural, but I probably don't have the biggest &$@*!. I'm cool with that. The former is probably more useful than the latter, especially when you're just trying to get back to your call room at 2am.

 

[sevoflurane]

I hope you don't take my posts as "bragging". That is not my point at all and if it came through that way, well then I apologize.

All I am saying is that the discrepancy is not with the person driving the tuohy needle but with the HELP you may or may not get when placing one. Pretty simple actually. Train your nurses to help you do your job. These are all simple tasks that can be delegated to get you moving faster. How long does it take to get a patient in position, prime the pump, enter the rate, get an epidural tray out of the anesthesia labor cart, etc, etc. These steps do save time and what it does is let you focus on the procedure at hand... without spending 1/2 an hour or more per epidural.

My 2cents.

 

[dhb]

My fastest was probably 7-8min and i barely had the time to say hi, so consistently under 10min seems a tad unrealistic but yes with the perfect set up you can do less than 15min.

Funny how we always b!tch about nurses but i think we an all agree that the true good ones are worth their weight in gold (if they stay away from the doughnut tray).

 

[pgg]

I don't check a level because I do CSEs with intrathecal fentanyl on just about everybody and they're comfortable before I'm done taping the catheter.

I don't bolus the catheter because they're already comfortable. They don't ever get hypotensive so I don't really feel a need to stay very long. I watch the fetal tracing and vitals as I'm typing in the note (99% cut & paste) and order set.

If only the nurses could prime, program, and plug in the pump I think I could be safely out of the room less than 5 minutes after laying her down again.


I'm a big fan of CSEs. The patients get comfortable faster and I just never have to mess around with bolusing the catheter and waiting and checking a level and maybe bolusing some more and waiting and maybe giving ephedrine for some hypotension or nausea ...