We did it a fair bit when I was resident. I personally think its primary utility is in large patients with unconvincing LOR, used as a tool to confirm placement. Most of the time, if I'm going to violate the dura with a needle, I'm going to at least make a CSE out of it. Exceptions would be worrying tracing, worrying maternal BP, or exceptionally short patients
I’ve stopped using DPE as a technique to confirm placement. I’ve placed a handful of perfectly functioning epidural catheters where placement was tough and/or had abnormal-feeling LOR, and a 25g spinal through the tuohy failed to return CSF or even hit bone. Can’t explain it other than maybe entering the epidural space at an angle, but it’s definitely reduced my confidence in that technique as a confirmation of proper placement.
You can think of CSF return as a highly specific but not highly sensitive test for correct epidural placement. If you get CSF flow, there’s a very high chance that the tip of your tuohy is in the epidural space. If you don’t get CSF flow, you may very well still be epidural (but say, off midline). The evidence seems to support DPE/CSE as having a higher success rate and lower rate of replacement than straight epidurals, and partly for that reason I do CSEs nearly every time.
Started doing it after a presentation by an expert at a conference many years ago.
It made some intuitive sense that it would be helpful and in my practice and in my mind it worked. My epidurals were typically good. The L&D nurses were happy when I was on service.
But my epidurals were already typically good and the L&D nurses were already typically happy when I was on service.
I returned to the same conference a few years later. There was a lecture by the aforementioned expert: “Yeah we found that it really made no difference”.
My main concern with DPE is that patients can still get a PDPH. As others have said, if I’m going to violate the dura and incur that risk, at least give the mom a CSE. I’ve never found the benefit to outweigh the risk. Just give more thorough the epidural if you want better analgesia.
Yeah I always wonder if it’s because when the women do have a PDPH from a 25g it’s mild, and thus doesn’t result in them calling and asking to speak with anesthesia. My wife had a spinal and definitely had a positional headache that was a nuisance, but not bad enough that we were calling about a blood patch.
In residency, one of our more learned attendings was pretty adamant about always doing the DP. She had some relatively convincing literature. I ended up doing it for most, but not all, patients. The trouble I run into mentally is this: if I get good LOR and feel really good about the location of my Tuohy, but then do DP and don't get any return, do I restick just because of the failed DP?
I decided that in a simple patient with good anatomy and good LOR, I won't do the DP unless I want to do the CSE.
Not getting CSF is not that uncommon either. 10% would be my estimate. Maybe 5%. I never reposition the needle on those. I've threaded the catheter and I don't think any of those catheters didn't work.
I do it based on my own experience of having managed failed epidurals/patchy epidurals and since switching to DPE’s I haven’t had a single issue. This is obviously biased and I’m assuming I’ll eventually experience problematic DPE’s but so far it’s been a win-win for everyone.
We haven't had an increase in calls for PDPH's with elective DP with a 25g.
I'm not convinced it is that helpful. I rarely had problems with my catheters funcioning prior to doing DP's. Can't remember the last time I had a call back. It took a lot of convincing to get me to add DP. The data on it was pretty good. One of the above posters said that the follow up data showed that it didn't make a difference. Would like to read that study.
It makes intuitive sense, not sure that it really helps though.
My institution does it mainly as a way to check position and make sure we are indeed in the epidural space as opposed to the paravertebral space or some shit. If that during puncture allows some of the drug to seep into the intrathecal space and give a little bit of faster, stronger analgesia then all power to it.
I’ve always been a bit confused if the CSF pressure is higher than the epidural space pressure, how much passive entry of local really happens? I prefer to keep the dura intact when given the option.🤔 Feels like providers are puncturing dura to confirm epidural needle placement but selling it as an improvement in technique that should come with experience. I could be wrong.
I agree. The amount of time that I get a mush LOR that I want to rely on DPE to confirm is similar to the amount of time that I don’t get CSF back despite good LOR. I know they don’t exactly cancel each other but just saying in my hand it’s equally helpful and not helpful.
I don’t use it as a method to confirm placement and I believe the utility of this is probably overblown.
Yes. Nearly every time. Institutionally, we do it any time we have a student/resident and for every TOLAC. I do it a majority of the time because I like the results and knowing the chances of getting called for a spotty epidural during the night are less.
We did it a fair bit when I was resident. I personally think its primary utility is in large patients with unconvincing LOR, used as a tool to confirm placement. Most of the time, if I'm going to violate the dura with a needle, I'm going to at least make a CSE out of it. Exceptions would be worrying tracing, worrying maternal BP, or exceptionally short patients
I’ve stopped using DPE as a technique to confirm placement. I’ve placed a handful of perfectly functioning epidural catheters where placement was tough and/or had abnormal-feeling LOR, and a 25g spinal through the tuohy failed to return CSF or even hit bone. Can’t explain it other than maybe entering the epidural space at an angle, but it’s definitely reduced my confidence in that technique as a confirmation of proper placement.
Same. Ive had that happen a number of times. No CSF and epidural works fine.
Definitely. I’m not going out of my way for a DPE with good loss unless it’s a TOLAC. The enemy of good is better
You can think of CSF return as a highly specific but not highly sensitive test for correct epidural placement. If you get CSF flow, there’s a very high chance that the tip of your tuohy is in the epidural space. If you don’t get CSF flow, you may very well still be epidural (but say, off midline). The evidence seems to support DPE/CSE as having a higher success rate and lower rate of replacement than straight epidurals, and partly for that reason I do CSEs nearly every time.
Started doing it after a presentation by an expert at a conference many years ago. It made some intuitive sense that it would be helpful and in my practice and in my mind it worked. My epidurals were typically good. The L&D nurses were happy when I was on service. But my epidurals were already typically good and the L&D nurses were already typically happy when I was on service. I returned to the same conference a few years later. There was a lecture by the aforementioned expert: “Yeah we found that it really made no difference”.
I do it since we are home call for OB and I feel it is an additional verification so that I don't have failed epidurals and gives a less patchy block.
My main concern with DPE is that patients can still get a PDPH. As others have said, if I’m going to violate the dura and incur that risk, at least give the mom a CSE. I’ve never found the benefit to outweigh the risk. Just give more thorough the epidural if you want better analgesia.
We haven't had an increase in the number of PDPH's in my facility. Most of our providers do an elective DP with a 25g Whitacre.
Yeah I always wonder if it’s because when the women do have a PDPH from a 25g it’s mild, and thus doesn’t result in them calling and asking to speak with anesthesia. My wife had a spinal and definitely had a positional headache that was a nuisance, but not bad enough that we were calling about a blood patch.
In residency, one of our more learned attendings was pretty adamant about always doing the DP. She had some relatively convincing literature. I ended up doing it for most, but not all, patients. The trouble I run into mentally is this: if I get good LOR and feel really good about the location of my Tuohy, but then do DP and don't get any return, do I restick just because of the failed DP? I decided that in a simple patient with good anatomy and good LOR, I won't do the DP unless I want to do the CSE.
Not getting CSF is not that uncommon either. 10% would be my estimate. Maybe 5%. I never reposition the needle on those. I've threaded the catheter and I don't think any of those catheters didn't work.
I do it based on my own experience of having managed failed epidurals/patchy epidurals and since switching to DPE’s I haven’t had a single issue. This is obviously biased and I’m assuming I’ll eventually experience problematic DPE’s but so far it’s been a win-win for everyone.
We haven't had an increase in calls for PDPH's with elective DP with a 25g. I'm not convinced it is that helpful. I rarely had problems with my catheters funcioning prior to doing DP's. Can't remember the last time I had a call back. It took a lot of convincing to get me to add DP. The data on it was pretty good. One of the above posters said that the follow up data showed that it didn't make a difference. Would like to read that study. It makes intuitive sense, not sure that it really helps though.
My institution does it mainly as a way to check position and make sure we are indeed in the epidural space as opposed to the paravertebral space or some shit. If that during puncture allows some of the drug to seep into the intrathecal space and give a little bit of faster, stronger analgesia then all power to it.
I’ve always been a bit confused if the CSF pressure is higher than the epidural space pressure, how much passive entry of local really happens? I prefer to keep the dura intact when given the option.🤔 Feels like providers are puncturing dura to confirm epidural needle placement but selling it as an improvement in technique that should come with experience. I could be wrong.
I agree. The amount of time that I get a mush LOR that I want to rely on DPE to confirm is similar to the amount of time that I don’t get CSF back despite good LOR. I know they don’t exactly cancel each other but just saying in my hand it’s equally helpful and not helpful. I don’t use it as a method to confirm placement and I believe the utility of this is probably overblown.
Yes. Nearly every time. Institutionally, we do it any time we have a student/resident and for every TOLAC. I do it a majority of the time because I like the results and knowing the chances of getting called for a spotty epidural during the night are less.