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deleted875186
Keep wet tapping away until you get it. And keep your head high...., because your patients can not.
This made my day. I just started laughing in front of random people on the subway.
Keep wet tapping away until you get it. And keep your head high...., because your patients can not.
Couple of things.
Don't worry about a lumbar wet tap. A headache isn't the worst thing in the world and it rarely is dangerous.
Second thing - use better control.
Thirdly, think about the anatomy a little bit. I suggest moving up a level from where you think you are at. Look at this MRI T1 Sagital (fat is bright) I pulled off the internet - but this is very typically of everyone. The bright signal next to the arrow is the epidural fat. The black lines on each side are the ligament (posterior) and the dura (anterior). The epidural space at L5/S1 is very thin, and in most, not even visible on MRI. The epidural space increases as you move up and is often the widest at L3/4, maybe L2/3. However, notice that the space in a single level varies dramatically to almost non-existent to very wide (3-5mm). The widest epidural space is in the middle of the space (in a caudal-cephelad direction), so try and do your best to be in the middle of the space.
View attachment 244287
Couple of things.
Don't worry about a lumbar wet tap. A headache isn't the worst thing in the world and it rarely is dangerous.
Second thing - use better control.
Thirdly, think about the anatomy a little bit. I suggest moving up a level from where you think you are at. Look at this MRI T1 Sagital (fat is bright) I pulled off the internet - but this is very typically of everyone. The bright signal next to the arrow is the epidural fat. The black lines on each side are the ligament (posterior) and the dura (anterior). The epidural space at L5/S1 is very thin, and in most, not even visible on MRI. The epidural space increases as you move up and is often the widest at L3/4, maybe L2/3. However, notice that the space in a single level varies dramatically to almost non-existent to very wide (3-5mm). The widest epidural space is in the middle of the space (in a caudal-cephelad direction), so try and do your best to be in the middle of the space.
View attachment 244287
Have you tried using an ultrasound to get an estimate of the distance to the epidural space?
I couldn’t disagree more. The OP needs lots and lots of reps doing this procedure in the standard way until he/she develops a system and it clicks. In the community practice where most of you are headed, there is no time to grab an ultrasound from another floor, bring it to OB, etc. If you did this at my group, you would be a huge outlier. Your partner would have been called and come up, assessed, and placed epidural by the time you had the ultrasound ready to go. You need to be on/off the labor floor in 30 min or less 95% of the time in my practice (and many others like ours).This was my first thought. Use it to help find midline and level as well
This was my first thought. Use it to help find midline and level as well
there is no time to grab an ultrasound from another floor, bring it to OB, etc.
I couldn’t disagree more. The OP needs lots and lots of reps doing this procedure in the standard way until he/she develops a system and it clicks. In the community practice where most of you are headed, there is no time to grab an ultrasound from another floor, bring it to OB, etc. If you did this at my group, you would be a huge outlier. Your partner would have been called and come up, assessed, and placed epidural by the time you had the ultrasound ready to go. You need to be on/off the labor floor in 30 min or less 95% of the time in my practice (and many others like ours).
Sorry if you guys don’t want to hear it, but this is the real world perspective.
I’m not saying use it for life, but as a tool to learn until her gets comfortable. US removes some variables and could help get him started. He’s also not in charge of a busy OB practice. Later likely not practical
If he had problems US would solve he wouldn’t be getting wet taps, he’d be hitting bone.
It's a skill that I know that they teach in OB anesthesia fellowships so it couldn't hurt to at least try it . You don't have to actually perform it using U/S, just get an appreciation for the anatomy so you know what you're looking at.I have yet to use ultrasound for epidurals during residency, do you guys think it’s a skill I should go out my way to learn? As others have said, it does take more time and effort.
I have yet to use ultrasound for epidurals during residency, do you guys think it’s a skill I should go out my way to learn? As others have said, it does take more time and effort.
don't do it
I bet the odds of U/S speeding the placement of an epidural for an experienced person are less than 1 in 1000.
Of course it doesn’t speed the process. But on that one or two patients per year when you run into a wall of bone it can be an asset.
The ones that aren't easy are the ones ultrasound is least useful on.
So at this point I'm at a loss. Clearly I suck at epidurals.....
FML
Why do you say that? Example? To me an example where U/S comes in handy would be the BMI 40 with some scoli that you can’t appreciate because it’s buried under 3” of fat. You can’t feel anything, and what is midline on the surface is actually 2” off from where the spine is.
And yes, I agree that 99% of labor epidurals are easy. If you say 100% are easy you’re full of sheet.
If he had problems US would solve he wouldn’t be getting wet taps, he’d be hitting bone.
placed an epidural on a lady that had scoliosis s/p Harrington rods, used the US to map out where the rods were and where the epidural space was.. it can be very helpful in the rare occasion
That’s great but be careful, some surgeons leave no epidural space at the lumbar level even for scoliosis repair, and for fusions almost definitely no remaining epidural space.
It could help tell him the depth of flavum. But whatever you’re right I’m wrong.
I personally think an epidural attempt is contraindicated in this situation if you can’t go belownor above the surgery site. What do others think?placed an epidural on a lady that had scoliosis s/p Harrington rods, used the US to map out where the rods were and where the epidural space was.. it can be very helpful in the rare occasion
I personally think an epidural attempt is contraindicated in this situation if you can’t go belownor above the surgery site. What do others think?
glass syringe and intermittent FTW. Continuous saline BTFO
Don't lose faith, someday you'll be among the best and use hanging drop.Once he’s good he’ll switch to continuous. 😉
Don't lose faith, someday you'll be among the best and use hanging drop.
I want your life!Coolest sh** ever.