Uneven epidurals

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Just curious about other's experience here. Most of my epidurals start out with the patient experiencing a noticeable different in block density on right or left. With a good bolus of 10-12 cc 0.125% bupivicaine and positioning the patient with appropriately they pretty quickly even out.

I've read through all the posts on one-sided epidurals, but I would not consider these one-sided as they even out. I always tell the patient this is expected -- Indeed, after doing a significant amount of fluro work I see the catheters virtually always move to one gutter of the other without actively manipulating them under fluro.

Just curious if my colleagues also experience this of if I'm stuck in some bad habits. I usually leave 5 cm in space, open the space with saline before threading, try my best to hit midline of the spine (not necessarily midline of the back), etc...

Thanks.

 

[Chloroform4Life]

Stiff Braun cath with 5 cm in leads to a lot of significant one sided epidural.

I now use the springy arrow catheter and leave 3-4 cm in (since its not multi orifice like Braun). Much less problem with significant one sidedness.

 

[vector2]

When you say they even out after a good bolus and positioning, is that 10-12cc bolus on top of your initial loading dose? If you're requiring 20cc of local and positioning shenanigans, then that's definitely a one-sided epidural even if it eventually resolves to bilateral. My (initial placement) one-sided rate went significantly down when I started initially leaving 4cm in the space, re-bolusing if it was still one-sided 10 min later, and then having a low threshold to just pull it back to 3cm. If still one-sided at 3cm, just replace epidural and get it over with. There's so much hemming and hawing with bolusing and positioning considering pulling back the catheter would likely solve the problem faster (if indeed the problem is one-sided catheter direction).