Trouble with Epidurals...

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arkantoz2004

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I'm having the weirdest problem that has been haunting me for a while now. Almost 60-70% of my epidural catheters go intravascular while placing them. I have no problem in identifying the space with air/saline. But when i gently push the catheter in... I very often get a nice blood flow back. What am I doing wrong technically? Or am I totally jinxed? :confused:
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arkantoz2004 said:
I'm having the weirdest problem that has been haunting me for a while now. Almost 60-70% of my epidural catheters go intravascular while placing them. I have no problem in identifying the space with air/saline. But when i gently push the catheter in... I very often get a nice blood flow back. What am I doing wrong technically? Or am I totally jinxed? :confused:
Click to expand...

Dont know what to say. Even with a styleted catheter 60-70% is a very high number. Only rec I can make is to "open up" the epidural space with either 5-10 ml of saline or local prior to catheter
 
arkantoz2004 said:
I'm having the weirdest problem that has been haunting me for a while now. Almost 60-70% of my epidural catheters go intravascular while placing them. I have no problem in identifying the space with air/saline. But when i gently push the catheter in... I very often get a nice blood flow back. What am I doing wrong technically? Or am I totally jinxed? :confused:
Click to expand...

BEING THIS IS YOUR FIRST POST here I'm doubting your credibility already.

There isnt an anesthesia resident ON EARTH that gets a 70% incidence of intravascular catheters.

So GO BACK to whatever website you originated from,

SLIM.

nice try.
 
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jetproppilot said:
BEING THIS IS YOUR FIRST POST here I'm doubting your credibility already.

There isnt an anesthesia resident ON EARTH that gets a 70% incidence of intravascular catheters.

So GO BACK to whatever website you originated from,

SLIM.

nice try.
Click to expand...



is there a pre-requisite number of posts about scotch and obama that one has to achieve before posting a clinical question?
 
arkantoz2004 said:
I'm having the weirdest problem that has been haunting me for a while now. Almost 60-70% of my epidural catheters go intravascular while placing them. I have no problem in identifying the space with air/saline. But when i gently push the catheter in... I very often get a nice blood flow back. What am I doing wrong technically? Or am I totally jinxed? :confused:
Click to expand...


Assuming you are new with epidurals, are you being supervised by anyone? What advice are they giving you? What depth are you typically achieving LOR? Perhaps you are trying to thread at a false loss space and are essentially subcutaneous rather than epidural, or are straying from midline, either from the beginning or while you are directing the needle. just some thoughts.

I'd try hukton's advice about "opening up" the potential space with some saline prior to threading.
 
If these attempts result from a bunch of redirections and bouncing around structures, then you'll see some heme.

If you're getting blood after a silky smooth insertion 60-70% of the time, then you need to stop practicing at the Hemophiliacs' Hospital for Women and Children.
 
huktonfonix said:
Dont know what to say. Even with a styleted catheter 60-70% is a very high number. Only rec I can make is to "open up" the epidural space with either 5-10 ml of saline or local prior to catheter
Click to expand...


Agree. Use saline to dilate the space, use a non-styleted catheter and limit the insertion of the catheter to 5-6 cm.
 
BLADEMDA said:
Agree. Use saline to dilate the space, use a non-styleted catheter and limit the insertion of the catheter to 5-6 cm.
Click to expand...

For the med students, blade is referring 5-6 cm on top of the skin to epidural space distance.

It's a hard habit to force beginning CA-1's to break because some attendings tell them to just put every catheter to 12 cm. They look at me like I have 2 heads when I walk in the room and ask what the S-E distance was.

P.S. I agree with Jet on this one -- 60-70% is way out of the ballpark. Either this person is a troll or is really lousy at identifying and staying in the midline.
 
how many epidurals did you do?


did you consider the barometric pressure at the time of the day at the floor of the hospital vs the patient's surgical considerations and vital signs to help the children because they are your future?

damn, i need to turn off my beauty queen brains now.
 
rsgillmd said:
Either this person is a troll or is really lousy at identifying and staying in the midline.
Click to expand...

Ive heard that the further youre from mid line the more likely you are to hit a vein - I just figgured it was BS, but maybe not.

But if youre batting 70% you should bet your attendings money that you can hit a vein - you'd make a killing
 
rsgillmd said:
For the med students, blade is referring 5-6 cm on top of the skin to epidural space distance.

It's a hard habit to force beginning CA-1's to break because some attendings tell them to just put every catheter to 12 cm. They look at me like I have 2 heads when I walk in the room and ask what the S-E distance was.

P.S. I agree with Jet on this one -- 60-70% is way out of the ballpark. Either this person is a troll or is really lousy at identifying and staying in the midline.
Click to expand...

if your needle is 8-9 cm long and you thread the catheter to 12 cm you have 3-4 cm in the space, the number which is textbook. this never changes. your LOR, the epidural space, is always at the tip of your needle, regardless. the skin-to-epidural space is irrelevant, except as a guide if you need to pull your catheter back and want to avoid coming out of the space altogether. we have several attendings that always document the S-E number, and a couple of OB-fellowship trained attendings who don't bother.

now if you mean the end result of always ending up with the 12cm mark at the skin, then sure, that's silly.
 
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Trisomy13 said:
if your needle is 8-9 cm long and you thread the catheter to 12 cm you have 3-4 cm in the space, the number which is textbook. this never changes. your LOR, the epidural space, is always at the tip of your needle, regardless. the skin-to-epidural space is irrelevant, except as a guide if you need to pull your catheter back and want to avoid coming out of the space altogether. we have several attendings that always document the S-E number, and a couple of OB-fellowship trained attendings who don't bother.

now if you mean the end result of always ending up with the 12cm mark at the skin, then sure, that's silly.
Click to expand...

We've got 9 cm needles, but it's 12 cm before the cath sees the light of the epidural space. I insert mine to 17 @ the hub, then compare the skin mark to my memory of LOR. Aim for 4-5 in space.

OP, I would question how you confirm you are intravascular. I often have hit a small vessel on the way in with the needle, but thread cleanly into the space. On the way out, the blood in the needle tracks along the epidural catheter, giving the appearance of blood return. It's quite easy to differentiate, though, by either wiping the catheter or trying to aspirate for free flow.

If you are actually intravascular 70% of the time, I'd stop doing them until you get some very good feedback from a trusted source, and maybe watch them do a few. That's quite inexcusable. You're like 4 standard deviations from the mean.
 
I would agree with the above, but in my almost 1 year, 200 or so epidural experience your advancing the catheter too far in the space. I have had relatively few intravascular catheters, but is has always been when the cather goes past 4-5cm in the space. I feel putting excess saline in the space helps alot with smooth passage of the catheter w/o paresthesia, but that catheter starts to wander into blood vessels once it starts to get in farther than 5 cm. Surprisingly have not had this trouble with thoracic epidurals which we routinely put at 5-6 in the space. The veins must just be less engourged in the non preggers patient and I have not done nearly as many. You need to be really mindful in the "skinny" or at least "not morbidly obese" OB patient because it easy to just keep threading that catheter until u get a parathesia or see red, just stop at 3-4cm and you'll be fine.:thumbup:
 
Thanks for all the answers guys. From all the suggestions told I think what i'm doing is pushing the catheter a little too deep inside. I have been doing the saline thingy lately and the numbers are better, but I have been in a vessel that way too ! So i'm gonna narrow it down to sticking the catheter too deep inside as my problem. I've been pushing it up to the 20 mark before withdrawing.

When I mean i've been inside a vessel... umm... its like I can draw a blood sample from the epidural catheter :p


Jetpropilot & some of you others : Don't be so paranoid. This is a genuine post and I am asking for advice here, and I appreciate all the suggestions given. I truly hope you don't believe that some things in medicine just cant happen.

Thanks guys!
 
arkantoz2004 said:
Thanks for all the answers guys. From all the suggestions told I think what i'm doing is pushing the catheter a little too deep inside. I have been doing the saline thingy lately and the numbers are better, but I have been in a vessel that way too ! So i'm gonna narrow it down to sticking the catheter too deep inside as my problem. I've been pushing it up to the 20 mark before withdrawing.

When I mean i've been inside a vessel... umm... its like I can draw a blood sample from the epidural catheter :p


Jetpropilot & some of you others : Don't be so paranoid. This is a genuine post and I am asking for advice here, and I appreciate all the suggestions given. I truly hope you don't believe that some things in medicine just cant happen.

Thanks guys!
Click to expand...

I tend to push the catheter too deep and w/drawl until im at the cm mark I want to be at...and rarely get blood in the catheter.
 
if you hit pipes, its also likely you're off midline. try to stay midline. this might solve your problem.
 
Are other residents at your program having the same problem? I'm assuming that you're using a 17 ga Tuohy? Multiple attempts on 250+lb women? If you are going too deep, I would assume that the fluid you get back will often be clear and not red. There is something very very wrong if you're getting a 60-70% intravascular occurence. Definitely something your attendings should be watching closely. As a CA-1 with 200+ epidurals under my belt, I have had ONE intravascular. That is not saying I'm awesome but I would assume that would be closer to the normal incidence.
 
jetproppilot said:
BEING THIS IS YOUR FIRST POST here I'm doubting your credibility already.

There isnt an anesthesia resident ON EARTH that gets a 70% incidence of intravascular catheters.

So GO BACK to whatever website you originated from,

SLIM.

nice try.
Click to expand...

I agree, very suspicious.
 
ill echo this, many epidural catheters need a little saline flush to clear blood from them but when you are in a vein you are in a vein and you will get steady blood flow back. i have also put the fetal doppler on the mom before and injected 3 cc of air into the catheter and listened for the whoosh on the doppler and then hoped they didnt have a PFO. this was in the case of a BMI 50, difficult epidural who we absolutely would not have wanted to put to sleep for crash section so we really wanted a working epidural

sadly we heard the whoosh of intracardiac air, and we had to replace it
 
Idiopathic said:
ill echo this, many epidural catheters need a little saline flush to clear blood from them but when you are in a vein you are in a vein and you will get steady blood flow back. i have also put the fetal doppler on the mom before and injected 3 cc of air into the catheter and listened for the whoosh on the doppler and then hoped they didnt have a PFO. this was in the case of a BMI 50, difficult epidural who we absolutely would not have wanted to put to sleep for crash section so we really wanted a working epidural

sadly we heard the whoosh of intracardiac air, and we had to replace it
Click to expand...

If aspirating blood were so reliable we wouldn't put epi in the test dose.
 
proman said:
If aspirating blood were so reliable we wouldn't put epi in the test dose.
Click to expand...

We don't use epi in our labor epidural test dose. Explaination (pro/con opinions welcome) - we don't have an EKG to look for changes, and with contractions the patient's B/P and heart rate go up and you are wondering...were those extra ten-twenty heartbeats because of the epi or the contraction? For epidurals for surgery, since they usually don't have that confounding factor, we always test with epi. ...:xf:
 
MD/TX2006 said:
We don't use epi in our labor epidural test dose. Explaination (pro/con opinions welcome) - we don't have an EKG to look for changes, and with contractions the patient's B/P and heart rate go up and you are wondering...were those extra ten-twenty heartbeats because of the epi or the contraction? For epidurals for surgery, since they usually don't have that confounding factor, we always test with epi. ...:xf:
Click to expand...

I would recommend that you use the epi. Have seen the HR increase with an intravascular dose of epi? It's very easy to distinguish. It's a 20-30 beat increase instantly. It ain't that way with a contraction.

It's just too easy to ignore.
 
Noyac said:
I would recommend that you use the epi. Have seen the HR increase with an intravascular dose of epi? It's very easy to distinguish. It's a 20-30 beat increase instantly. It ain't that way with a contraction.

It's just too easy to ignore.
Click to expand...

agreed. Its pretty distinctive when it happens.
 
Careful incremental dosing of the initial epidural bolus appears to be just as safe as using an epi-containing test dose. At one institution where I've rotated as a resident, it's been all but abandoned. They just give their ~15 cc or so of 1/8% bupiv + fent 2/ml in 4-5 cc increments over 15 minutes. You'll know if the catheter isn't epidural well before they seize or get a high spinal.

Besides, not using a "traditional" test dose freaks out some of our protocol-zombie labor nurses, so it's got that going for it.

Every bolus dose of anything, epi-containing or not, should be viewed as a test dose.
 
pgg said:
Careful incremental dosing of the initial epidural bolus appears to be just as safe as using an epi-containing test dose. At one institution where I've rotated as a resident, it's been all but abandoned. They just give their ~15 cc or so of 1/8% bupiv + fent 2/ml in 4-5 cc increments over 15 minutes. You'll know if the catheter isn't epidural well before they seize or get a high spinal.

Besides, not using a "traditional" test dose freaks out some of our protocol-zombie labor nurses, so it's got that going for it.

Every bolus dose of anything, epi-containing or not, should be viewed as a test dose.
Click to expand...

How can you tell the catheter is venous?
 
dhb said:
Do you always test with epi? I don't unless i have a doubt.
Click to expand...

Pretty much. Unless tachycardia is a problem for the pt. Then I may use air.

I also use the 5cc vial of 1.5%lido with epi as a small loading dose for most epidurals. I give the 3cc TD and then after I see no tachy I finish off the vial. Not in OB though, I just start the pump after the CSE.
 
pgg said:
Careful incremental dosing of the initial epidural bolus appears to be just as safe as using an epi-containing test dose. At one institution where I've rotated as a resident, it's been all but abandoned. They just give their ~15 cc or so of 1/8% bupiv + fent 2/ml in 4-5 cc increments over 15 minutes. You'll know if the catheter isn't epidural well before they seize or get a high spinal.

Besides, not using a "traditional" test dose freaks out some of our protocol-zombie labor nurses, so it's got that going for it.

Every bolus dose of anything, epi-containing or not, should be viewed as a test dose.
Click to expand...

Thats fine and with dilute solutions some argue against the need for the test dose. However, who has 15 extra minutes to sit around and dose the epidural? I plan to be done and gone in 15 minutes.
 
you could just load your patients with vitamin K beforehand

or just say screw it, do spinal catheter
 
Bertelman said:
How can you tell the catheter is venous?
Click to expand...

They don't get numb.

huktonfonix said:
Thats fine and with dilute solutions some argue against the need for the test dose. However, who has 15 extra minutes to sit around and dose the epidural? I plan to be done and gone in 15 minutes.
Click to expand...

Efficiency is not prized 'round these or those academic parts.

I usually end up giving all of the lido/epi test dose in the kits. The block sets up a bit while the dressing goes on, she lays down, I give about 5 cc of the bupiv/fent mix, program the pump, chart, and leave.

I'm also becoming a fan of CSEs where the intrathecal dose is only fentanyl. Test dose the epidural, start the infusion, chart, leave. They never have any hypotension, they get comfortable fast, I don't have to sit there and incrementally bolus the epidural to get a level. They do itch a bit though, and it's an extra step to get and account for the fentanyl.
 
pgg said:
I'm also becoming a fan of CSEs where the intrathecal dose is only fentanyl. Test dose the epidural, start the infusion, chart, leave. They never have any hypotension, they get comfortable fast, I don't have to sit there and incrementally bolus the epidural to get a level. They do itch a bit though, and it's an extra step to get and account for the fentanyl.
Click to expand...

I like the CSE as well. But I use 2.5mg bupiv with my fent. In the past I would just use fent for the pts that were in early labor and I would add bupiv if they were >5cm dilated. I noticed that when I just put fent in, they itched much more than when I combined the two. I now give everyone some bupiv with the fent. I notice less itching with this combination.

Try it and let me know if you see a difference.
 
Noyac said:
I like the CSE as well. But I use 2.5mg bupiv with my fent. In the past I would just use fent for the pts that were in early labor and I would add bupiv if they were >5cm dilated. I noticed that when I just put fent in, they itched much more than when I combined the two. I now give everyone some bupiv with the fent. I notice less itching with this combination.

Try it and let me know if you see a difference.
Click to expand...

I've noticed that too. The standard concoction I grew up using (CA1-2) was a cc of .25% bupiv with 15 mcg fent. Works very nicely but still had the occasional bit of hypotension, and the post-CSE decels, though almost invariably transient, still got some people worked up.

Then I tried using just fentanyl and I agree, the itching is the major downside. I wonder if a 20 or 40 mcg prophylactic Narcan chaser in the IV would help that without reversing the pain relief. But now I'm just complicating what should be a simple, easy task ...
 
pgg said:
I've noticed that too. The standard concoction I grew up using (CA1-2) was a cc of .25% bupiv with 15 mcg fent. Works very nicely but still had the occasional bit of hypotension, and the post-CSE decels, though almost invariably transient, still got some people worked up.

Then I tried using just fentanyl and I agree, the itching is the major downside. I wonder if a 20 or 40 mcg prophylactic Narcan chaser in the IV would help that without reversing the pain relief. But now I'm just complicating what should be a simple, easy task ...
Click to expand...

I personally paid close attention to the Fetal brady and hypotension when doing a CSE. It is my opinion that the incidence of these two is the same whether you use narc/local vs just narc. I'm sure I willsee one or both of these soon after saying this but I haven't seen it in quite a while (maybe more than a year).
 
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