Interlam. Glass/plastic; saline/air What do you use?

[mille125]

i agree with mille, but you must be making a lot of money to incur that risk. PM me if you quit, cuz i'll take your job jk

you cant spend your money as well when you are in the slammer with no medical license

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[DigableCat]

The fact that our practice discourages the use of dye for epidurals was another one...

When I first arrived at my hospital, the group of anesthesiologists that have been doing ESIs looked at me rather strangely when I told them that I used contrast for ALL of my ESIs(whether interlaminar or transforaminal). The chest thumping of "We know what we are doing and we know when we are in the epidural space" was evident from the first day. Sure, my procedure make take a few moments more, but it's my medical ass on the line. The arbitrary cost of Isovue will not make me change my mind about that. And besides, when I'm teaching the residents/fellows, I hope they appreciate the new approach to an old procedure. They also hardly ever get laterals views for interlaminars, only for transforaminals. I can count too many times, I've had them tell me "I think I've engaged the ligament", only to get a lateral and show them that they still have a ways to go.

Do what makes you comfortable. And do what's best for the patient.

 

[Jcm800]

When I first arrived at my hospital, the group of anesthesiologists that have been doing ESIs looked at me rather strangely when I told them that I used contrast for ALL of my ESIs(whether interlaminar or transforaminal). The chest thumping of "We know what we are doing and we know when we are in the epidural space" was evident from the first day. Sure, my procedure make take a few moments more, but it's my medical ass on the line. The arbitrary cost of Isovue will not make me change my mind about that. And besides, when I'm teaching the residents/fellows, I hope they appreciate the new approach to an old procedure. They also hardly ever get laterals views for interlaminars, only for transforaminals. I can count too many times, I've had them tell me "I think I've engaged the ligament", only to get a lateral and show them that they still have a ways to go.

Do what makes you comfortable. And do what's best for the patient.

i dont understand the fear of laterals...i could only choose one image, it would be a lateral most of the time. Especially with Cervicals...

 

[powermd]

i say this with all seriousness....you need to get a new job....this guy is going to take you down.....why on earth are you continuing to work with him??????

No dye, neuroaxial blocks on patients with plavix, .....come on

I hear you. When I learned of these things I seriously thought I was going to have to quit. Turns out my boss (however cavalier) is a very reasonable guy, and the other partner in the practice is supportive of my viewpoints. We will be going 100% ASRA from here on out. The back of our old referral pads says we'll do Plavix with a 5 day wait, and exceptions were made in the past for certain patients. The new pads will require a full 10 day wait. The balk about dye was based on the notion that I would use one bottle of Omnipaque per epidural/snrb ($50-70). I can split up one bottle of Omni over multiple patients, or go to Isopaque. What I'm worried about now is my exposure to risks that he may take on his own if I become a partner in the practice (in two years). Suffice to say this practice is otherwise very much worth sticking with.

 

[mille125]

I hear you. When I learned of these things I seriously thought I was going to have to quit. Turns out my boss (however cavalier) is a very reasonable guy, and the other partner in the practice is supportive of my viewpoints. We will be going 100% ASRA from here on out. The back of our old referral pads says we'll do Plavix with a 5 day wait, and exceptions were made in the past for certain patients. The new pads will require a full 10 day wait. The balk about dye was based on the notion that I would use one bottle of Omnipaque per epidural/snrb ($50-70). I can split up one bottle of Omni over multiple patients, or go to Isopaque. What I'm worried about now is my exposure to risks that he may take on his own if I become a partner in the practice (in two years). Suffice to say this practice is otherwise very much worth sticking with.[/QUOTE]




I hope so for your sake. Usually when docs are talking about doing epidurals on plavix patients, there are also other serious deficiencies. Remember you can be liable for a partner's/associates mistake.

 

[PMR 4 MSK]

I hear you. When I learned of these things I seriously thought I was going to have to quit. Turns out my boss (however cavalier) is a very reasonable guy, and the other partner in the practice is supportive of my viewpoints. We will be going 100% ASRA from here on out. The back of our old referral pads says we'll do Plavix with a 5 day wait, and exceptions were made in the past for certain patients. The new pads will require a full 10 day wait. The balk about dye was based on the notion that I would use one bottle of Omnipaque per epidural/snrb ($50-70). I can split up one bottle of Omni over multiple patients, or go to Isopaque. What I'm worried about now is my exposure to risks that he may take on his own if I become a partner in the practice (in two years). Suffice to say this practice is otherwise very much worth sticking with.

We use Isovue at about $30/bottle.

If you become a partner, you take on their risks, no matter where you go. That's why you use the first coupleyears to determine if you are compatible. Sorta like dating your collegues before you marry them in practice.

 

[Jcm800]

I used the el cheapo 5 cc srynge with saline loaded it, and it was...GREAT!

i did it twice, one for an blood patch (i figured what better place to start, if i wet tap, so what) and one for an epidural catheter for a pump trial...

both i look on lateral and im pushing and watching, once i got nervous as i thought it looked close so i put on the LOR srynge, and verified no loss, then went back to the regular syringe...

both times the loss was very distinct, much better than with the glass LOR.

I am going to buy an island on all the money i will save on LOR syringes...or maybe just a happy meal. either way, i like it.

 

[SSdoc33]

i think most people train on the LOR syringes, so they just stick with them. maybe make a donation to SDN so you can get as many icons as russo over there....

 

[powermd]

We use Isovue at about $30/bottle.

If you become a partner, you take on their risks, no matter where you go. That's why you use the first coupleyears to determine if you are compatible. Sorta like dating your collegues before you marry them in practice.

Which Isovue concentration gives the equivalent opacity to Omni 180? I would assume they would be very similar.

Who do you buy it from?

The Bracco pricing sheet lists 10 mL bottles of Isovue-M 200 for about $62/bottle if you order 10.

 

[Jcm800]

Which Isovue concentration gives the equivalent opacity to Omni 180? I would assume they would be very similar.

Who do you buy it from?

The Bracco pricing sheet lists 10 mL bottles of Isovue-M 200 for about $62/bottle if you order 10.

why isovue over omnipaque. I have always used omnipaque, is Isovue much chaeper. Omnipaque is okay for intrathecal, case you get an oops...

 

[Jcm800]

ok, i have now done the plastic syringe thing with cervical and thoracic.

I am a believer.

thanks

 

[lovebailey2001]

I was trained with the normal, cheap plastic syringes with air for LOR, but then I used Glass syringes (5 ml) with air or saline during my senior residency, and I really found them superior to any other thing. the glass syringe plunger gives back the slightest resistance, ie even .25 ml when I check them in pre-procedural period to make them smooth with a drop of saline! yes, b.brawn LOR syringes are also good but are costly and with glass you can get them autoclaved and reuse!

 

[GasEmDee]

Thread necromancy:

I found this interesting. Anyone using a common plastic syringe as a LOR syringe? How does it compare to the plastic B.Braun LOR syringe?

Thanks!

 

[emd123]

Thread necromancy:

I found this interesting. Anyone using a common plastic syringe as a LOR syringe? How does it compare to the plastic B.Braun LOR syringe?

Thanks!

No. Too sticky.

 

[lobelsteve]

Plastic 10cc. No issues. That's how I trained. Now it seems like a waste of money to use glass or epilor.

 

[pmrmd]

Plastic 6cc. "LOR" with contrast under CLO watching it travel from substance of LF to epidural space, the Ligament technique. Totally agree its a waste of money to get special syringe.

 

[emd123]

Plastic 6cc. "LOR" with contrast under CLO watching it travel from substance of LF to epidural space, the Ligament technique. Totally agree its a waste of money to get special syringe.

Plastic 10cc. No issues. That's how I trained. Now it seems like a waste of money to use glass or epilor.

Plastic lor syringe from an epi kit or a la carte?

 

[lobelsteve]

Plastic lor syringe from an epi kit or a la carte?

I use 10cc plastic. No kits. All individual parts dropped on tray.

 

[pmrmd]

Plastic lor syringe from an epi kit or a la carte?

Not an LOR syringe. The usual cheap, plastic syringe you would use to inject anywhere else. I guarantee you can feel the difference between LF and epidural space even with a 25-g spinal needle.

 

[GasEmDee]

I trained and got used to using the B.Braun plastic LOR syringe for years. Now we have kits with the B.Braun glass syringe. I am not doing pain procedures, only labor and surgical epidurals. I find that the glass syringe occasionally and unpredictably sticks, and thats when i get the wet taps. I tried using it with air, but air is too compressible. Debating whether I want to try to throw a regular syringe onto the kit.

Any comments on how the regular plastic syringe compares to the specialized B.Braun plastic LOR syringe?

Thanks guys!

 

[hyperalgesia]

In order of stickiness (with saline and properly primed):
glass < plastic LOR < regular plastic < bamboo pole
I was using regular plastic for a few years but had a sticky experience with CESI so I stopped. The difference in static friction is minimal but I think, when LOR syringes are produced, there is at least some attention to precision. A jury would undoubtedly hear that the standard of care is with a specially designed LOR syringe. I don't buy my own equipment so I don't care about cost.

 

[Ligament]

Plastic 6cc. "LOR" with contrast under CLO watching it travel from substance of LF to epidural space, the Ligament technique. Totally agree its a waste of money to get special syringe.

hehe I was going to say "thats exactly how I do it" but then I read further and this is indeed EXACTLY how I do it. LOL.

 

[Ligament]

hehe I was going to say "thats exactly how I do it" but then I read further and this is indeed EXACTLY how I do it. LOL.

Plastic 6cc. "LOR" with contrast under CLO watching it travel from substance of LF to epidural space, the Ligament technique. Totally agree its a waste of money to get special syringe.

If you iris collimate VERY tightly and run live fluoro while advancing through LF it will minimize radiation.

 

[ampaphb]

Plastic 3cc syringe.

Given that the vast majority on this board don't use glass, you would be hard pressed to claim that as the community standard.

 

[lobelsteve]

Plastic 3cc syringe.

Given that the vast majority on this board don't use glass, you would be hard pressed to claim that as the community standard.

Heck, i could argue LOR is worthless when we have live CONTRAST CLO techniques.

 

[Ducttape]

community standard doesnt necessarily translate to "industry" standard, unfortunately. however, i do not know of any organization of physicians that specifically states the type of syringe necessary for LOR...

 

[geauxg8rs]

community standard doesnt necessarily translate to "industry" standard, unfortunately. however, i do not know of any organization of physicians that specifically states the type of syringe necessary for LOR...

Until someone makes their own "proprietary system" and then claims it is Standard of Care.

 

[H2H]

Plastic LOR with Saline

 

[emd123]

So, I guess I'm completely wasting tons of money buying ESI trays to get that nice little glass syringe wrapped up with a few syringes and lidocaine. Am I the only one still doing this?

 

[lobelsteve]

So, I guess I'm completely wasting tons of money buying ESI trays to get that nice little glass syringe wrapped up with a few syringes and lidocaine. Am I the only one still doing this?

Surely not, but now you can bill the NDC code and make $500 off the tray. And those glass syringes are re-usable.