caligas

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who likes to use the long epidural needle more routinely on really big patients?

I've started using it routinely when the BMI is above 50 (~3% of our OB). I've noticed that there is a learning curve to developing feel and little tricks with it and using it little more often is very helpful. Also you avoid that frustration of being on a great track and having the needle hub out and then have to switch out to the long needle. Also, I've never really liked having to get my LOR with the skin indented.
 

pgg

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In those really big patients, if I think the 9 cm Tuohy might not reach, I'll sometimes just move up to the L1 or T12 space. There's often a fat shelf / recess above the buttocks and the spine isn't as deep. I haven't used a long needle in a long time.

Low thoracic epidurals for labor analgesia work just fine. A little more sacral sparing, sometimes. But they work and they're usually easier than the standard L3-4 in the super morbid obese.
 

Laryngophed

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I'm just a CA2, but I only reach for Excalibur when I'm doing a mid-thoracic epidural on someone with >9 cm of fat pad between me and ligament.

Edit - I usually move up when I'm placing a lumbar epidural and there is some good distance Aron's the lower midsection.
 

anes121508

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who likes to use the long epidural needle more routinely on really big patients?

I've started using it routinely when the BMI is above 50 (~3% of our OB). I've noticed that there is a learning curve to developing feel and little tricks with it and using it little more often is very helpful. Also you avoid that frustration of being on a great track and having the needle hub out and then have to switch out to the long needle. Also, I've never really liked having to get my LOR with the skin indented.

Man I feel, ya.........In residency we had a low volume high risk place. So inevitably that mean ridiculous BMI patients were deemed high risk and sent to us. So frustrating when you know you are just engaged in ligament and hubbed all the way. I used to just try and push the fat in a little more and create some room for myself. Then I started pulling out the harpoon from the get go to avoid this. Then I started scanning people with the ultrasound to get an idea of depth and midline. Works great and takes no time at all. Then you know what type of needle you will need. Ill even try to do it on admission and use the surgical marker. When they call, I already have a mark for idea of midline and a number of how deep I estimated the space based on US.
 
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pgg

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That's a lot of work. :)
 

GravelRider

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I like to get the harpoon out for demonstration purposes during consent if I have a particularly histrionic parturient. It usually gets them to sit still for a few minutes when they think about that sword entering their spine.
 

narcusprince

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I rarely use the long Thouy needle. I think in my 4 years of practice I may have had to resort to the harpoon once or twice. I come from the school of doing low thoracic epidurals. Also for those really large people sometimes I will pass an epidural intrathecally I have done this maybe 1-2 times in 4 years. Any value in seeing the morbidly obese pregnant patient population in the preoperative clinic? At the ASA they had this machine that looked like a tricorder(hand held this size of a gameboy) but it was an ultrasound machine for locating the epidural space. I could see a process where you scan the patient in clinic, document the depth of the epidural space then when you see the patient on the labor deck you know what to bring.
 

B-Bone

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I do about 100-200 epidurals a year, and I have only used the big dog once. In retrospect, I didn't need it that time. I live in the great white north where they grow 'em large and in charge. It's not like these ladies' backs are constructed of solid muscle; just gotta compress that fat, son.


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lobelsteve

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I like using 6" 14G Tuohy for scs cases at T12-L1. Lets me enter at under 30 degree angle and allows for easier lead steering and less migration. Sometimes 1" remaining on needle when in epidural space, sometimes 3". But i get to cheat with AP and lateral fluoro.
 
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anes121508

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I do about 100-200 epidurals a year, and I have only used the big dog once. In retrospect, I didn't need it that time. I live in the great white north where they grow 'em large and in charge. It's not like these ladies' backs are constructed of solid muscle; just gotta compress that fat, son.


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Haha I know....compressing the fat has saved me 4-5 times, but it's much easier if u have more real estate because if u let up the compression u come out of the space.

Obviously you have done tons more than me...maybe I've just had bad luck : 8-9 in 3 years with the harpoon
 

anes121508

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That's a lot of work. :)
Mainly for practice sine I'm no expert yet, but I've grown to like it for the large people. I know I'm midline and it's just a matter of north or south.

Also have found quite a few cases where the back crack definitely was not midline and would have thrown me off in the 400+ lb patient
 

Laryngophed

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When I'm not sure, I just use my pen (before prep) and push on the back of the patient. And then I ask if I am midline, left, or right. And let her guide me.