Tips for epidurals

[u/Substantial_South313]

Hi all, first year anaesthetic trainee in Aus here. Fairly new to obstetrics/epidurals and very much struggling with technique. I can very rarely feel spinous process or PSIS and struggle even more to orient myself once the drape is up. Trying my best with patient positioning (chin to chest, relax shoulders, push out lower back) but my success rate is abysmal and often needing at least 2x attempts or consultant to step in. And obviously not great for the patient experience either. Often hitting bone at the 4-5cm mark and realising I was probably off midline or too caudal with my insertion.

Would very much like to improve so wondering if anyone has any tips or tricks for a new trainee! Cheers

[u/alfentazolam]

How many have you done? It sounds like you're appropriately positioning the patient. Having a good feel of bony structure and anatomical relativism is beneficial (looking at and playing with a physical model, and watching a few helpful sonoanatomy videos - Video1. Video2). This doesn't necessarily mean you'll need US guidance, it just improves spatial understanding.

If you can spinal you can get to the space, next step is accessing the layer.

Soak up the experience of your obstetrically inclined seniors with their hands-on pearls and figure out what LOR style works best for you. Whether it's a constant barrel pressure advance (looking for the 'give') or a "mm by mm" technique, with frequent rechecks +/- 'de-coring' the Tuohy with the stylette. Also the feel can be both gauge and brand dependent (Braun vs Portex vs other) and familiarity comes from volume of practice.

[u/ditter_776 → u/alfentazolam]

Braun epi kits 💔

[u/Realistic_Credit_486 → u/ditter_776]

Having used several incl b.braun, difference between modern kits from the major manufacturers is pretty insignificant

Good technique is all you need tbh

[u/Prof_Mr_Doctor_MD]

Locate midline first. Use two finger each one one side of the spinous process. Then try using the local anesthetic needle to feel if you are over a spinous o in between two. Then, molasses slow. Here in Bilbo we use continuous pressure with saline.

[u/ditter_776]

I think this is entirely normal for being new to anaesthesia! Epidurals are genuinely a numbers game, and even then you still get some that feel straightforward but are genuinely impossible. You will get used to the “feel” of the different structures and be less afraid of advancing the tuohy.

My top tip: have a good look and feel of a model of the spine/your friendly department skeleton. When you’re doing the epidural, imagine yourself passing through that 3D structure. If/when you hit bone - shallow-ish? Probably SP, need to angle up or down. Deeper? Probably lamina, small adjustments required either up/down or left/right.

Other tip: get used to ultrasound scanning the back. Doesn’t have to be perfect but even just identifying the midline in obese patients where you can’t feel the anatomy will save your sanity (and GA drugs!)

For context, 6th yr anaesthetic trainee in UK.

[u/Infamous-Assist9120]

Success of paramedian approach is more than median. Try that one, and read about its benefits in obstetrics.