How do you do your Epidurals?

Started by Russell Coupland, January 26, 2005, 02:13:20 AM

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How do you do your Epidurals

Loss of resistance to air
42 (62.7%)
Loss of resistance to saline
18 (26.9%)
Hanging Drop
7 (10.4%)
Other
0 (0%)

Total Members Voted: 67

dramitshah

Quote from: yogenbhatt1 on May 24, 2007, 02:16:33 AM
In an elderly  or severly malnourished patient, try using a running saline drip for locating the epidural space. Just connect a saline drip after entering the skin. keep advancing. In htese patients generally no FEELs are felt. The drip does not go till you enter the space and here the drip starts running. Even the onlookers are amazed.

dear  dr yogenbhai,
is your technique possible in all patients or only very old malnourished patient and if only for this group of patients than can you explain possible mechanisam for this ?

amarkatira

we are doing regularly in sitting position with loss of resistance to air.

yogenbhatt1

Dear Dr. Amit Shah,
   When we use NS in a LOR syringe, no matter how much you try, the pressure exerted on the piston can never be the same. Even after a  feel developed over 25 years of practice, I have entered dura. The tissue resistance in poorly nourished or elderly or cachectic patients is so low, that at every level you will be able to push the piston of LOR syringe, even when filled with NS.
    When you use a saline drip set with a NS bottle, the height where it is hanged from remains same, and the gravitational force will remain same throughout the whole procedure. This is how it works by exerting a steady pressure due to gravity. The moment you are in epidural space the NS drip starts running at a steady and good speed.
Note: I have manaed to  puncture dura once even by this method. I was sure that I am in space , but there was no flow from drip, so I pushed further and there was dura puncture. But the raitio of success is very good.
Try it a couple of times with a 100 ml NS bottle and see.

yogenbhatt1

Dear Amarkatira '
Hi , read your note about using air in all Epidurals. I attended a CME lecture some time back, and was shocked to hear a statement made by the speaker. She mentioned about a study conducted with air, and it was proved that when they placed Transe Esophagial Probe of ultra sound, they realised that almost 90 % patients had air embolism. In a small child even 5 ml of Air can be very dangerous, if this study is anywhere near right.
The speaker was Dr. Laxmi Vaz, a very famous Paediatric Anaesthesiologist, now only in pain management in Mumbai. I really  do not know the refference of the article, but if it is true, I think, you start using NS. You will get used to it in the first case only.

jafo1964

Just a case report
We tried this technique of saline infusion - gravitational flow to identify space

Once space is identified the NS infusion is removed and catheter threaded. During this time the saline flows back through the catheter and scarily could also be CSF tap due to the advancing catheter
So you need a definitve methid to tell the difference between the two

One of our resident assumed the back flow to be NS, and  as usual proceeded to dose the patient. He ended up with a total spinal with patient in cardiovascular collapse and apnoea

I fully agree with Dr. Vaz's statistics
But  LOR air syringe still survives as a technique.
Also air deposited into epidural space can form pockets around nerve roots and prevent LA from coming in contact with it thus producing patchy blocks.

I use Lor air syringe and what technique you train in and gain experience with you are comfortable performing
Hope all the youngsters switch to LOR saline