D
deleted875186
Anyone have any good stories?
- Joined
- Jan 24, 2017
- Messages
- 3,748
- Reaction score
- 4,305
Largest? How do you define that?
- Joined
- Sep 25, 2012
- Messages
- 1,624
- Reaction score
- 2,365
It's gonna be someone from the south. Once the BMI gets above 65, their fat just start organizing into shelves.
The epidural experience of a BMI 70 lady is about the same as BMI 60, but the 70 lady has a nice shelf for your things. Then it matters which level you tried. If you're at L4-L5, it's gonna be more than 10. But they hardly get post puncture headaches so being slightly aggressive at L2-3 isn't a huge deal.
My biggest LOR is around 10, the long 15cm touhy had about 5 cm left. But the LOR woulda been 9ish if I pressed down on the fat.
The epidural experience of a BMI 70 lady is about the same as BMI 60, but the 70 lady has a nice shelf for your things. Then it matters which level you tried. If you're at L4-L5, it's gonna be more than 10. But they hardly get post puncture headaches so being slightly aggressive at L2-3 isn't a huge deal.
My biggest LOR is around 10, the long 15cm touhy had about 5 cm left. But the LOR woulda been 9ish if I pressed down on the fat.
- Joined
- Sep 20, 2010
- Messages
- 1,074
- Reaction score
- 495
To paraphrase Shamuel Shem from House of God - "There is nobody cavity that cannot be reached with a 14 gauge needle Tuohy and a good strong arm".
Even on the biggest ladies I rarely need to get the long harpoon out... just use the 9cm one in the kit, hub it, and compress the fat ("good strong arm") until I get in. Wet taps very rare, but in event that I do I just put a catheter in anyway for a continuous low-dose spinal and tell her she's gonna have really good analgesia.
Even on the biggest ladies I rarely need to get the long harpoon out... just use the 9cm one in the kit, hub it, and compress the fat ("good strong arm") until I get in. Wet taps very rare, but in event that I do I just put a catheter in anyway for a continuous low-dose spinal and tell her she's gonna have really good analgesia.
Correct- these distances are a bit relative- so a bit more fat compression or better ‘slouching’ position will shorten the LOR distance...
- Joined
- Apr 24, 2012
- Messages
- 4,483
- Reaction score
- 5,021
Personally, BMI 77 using harpoon, I got to 10cm hitting zero landmarks before I started feeling freaked out (doing this epidural moments after my first wet tap). I asked my attending to take over. He advanced only 1 more cm and got LOR at 11cm. Epidural worked perfectly.
I have definitely taken the 9cm needle to the skin and had to tent the skin pretty aggressively to get LOR, the above noted strong arm.
Another attending at my hospital has a claim to fame, verified by witnesses, of 15cm. The harpoon all the way to the hub. Reportedly had excellent analgesia.
- Joined
- Mar 27, 2011
- Messages
- 1,993
- Reaction score
- 2,651
Not an epidural, but I had a 99 BMI for a spinal that I buried with the longest tuohy we could find and got nothing. We went to sleep.
Legend has it that she still has excellent analgesia to this very day.
So I got paged to a patient's room one day. I won't lie to you boys, I was terrified! 34F, 38wk, 82 bmi, 8cm 90%.
But I pressed on, and as I made my way to the patient's door, a strange calm came over me. I don't know if it was divine intervention or the kinship of all living things but I tell you at that moment I was an OB anesthesiologist!
The patients (and nurses!) had been angry all day my friends, like a group of old men returning sandwiches at a deli. I got past the patient's threshold and then suddenly the great beast appeared before me. I tell ya she was ten stories wide if she was a foot. As if sensing my presence she gave out a big bellow. I said, "Easy big girl!" And then as I watched her struggling I realized something had to be put into her backside.
Then from out of nowhere, the kids' father tossed me like a cork and I found myself on top of her, face to face with her moldy lower back. I could barely see from all of the rolls of fat over her shelf, but I knew something was there. I pushed the harpoon in as far as it could go. A perfect LOR and placement at 14cm.
- Joined
- Jan 14, 2006
- Messages
- 11,894
- Reaction score
- 20,960
What’s a labor epidural?
- Joined
- Jan 21, 2005
- Messages
- 1,205
- Reaction score
- 2,066
12 cm
D
deleted162650
Salty’s Law:
Blended unit value is inversely proportional to mean LOR depth.
Blended unit value is inversely proportional to mean LOR depth.
D
deleted126335
I've had to just get to the hub on the harpoon which I think is 15 cm. Never had to tent the skin in with it. Fortunately that is not a frequent occurrence for me. I feel like 7-8 cm is about the average depth of LOR in my patient population but can still almost always get it with the regular needle by tenting the skin in.
- Joined
- Feb 19, 2014
- Messages
- 321
- Reaction score
- 302
BMI 70. Loss @ 14 . Catheter came out overnight and had to be replaced by coressident with similar loss.
D
deleted875186
I myself have had 12 LOR on a BMI 70 patient.
I prefer not to compress the skin looking for loss. If you compress and go an extra 2 cm with the needle, how much do you thread the catheter and where do you leave it at the skin?
I prefer not to compress the skin looking for loss. If you compress and go an extra 2 cm with the needle, how much do you thread the catheter and where do you leave it at the skin?
Once needle is in the space, have an assistant thread the catheter in. Once at appropriate depth, withdraw needle while maintaining forward pressure on catheter. Once needle is out, skin pressure can be released. The fat will act as a lubricant and allow the skin to relax without altering the catheter location.
You won't be able to really know depth later, which is why I always over thread by 2-4cm, just to make sure I have some tolerance. You can always pull back later.
D
deleted875186
I’ve noticed this sucking in of the catheter from the skin is a very reliable sign that the catheter is in place. I’ll admit I’m never sure of where it should be at the skin in these cases.
- Joined
- May 3, 2005
- Messages
- 4,238
- Reaction score
- 2,293
Cervical patient for fluoroscopically directed interlaminar ESI midline approach. A 5" needle did not reach the spinous processes on this morbidly obese patient- required a 7" Tuohy to reach the epidural space
- Joined
- Apr 7, 2005
- Messages
- 311
- Reaction score
- 391
Does anyone tunnel these catheters? For some of the larger BMI pts where it was a real challenge and position is critical what I used to do was after removing the needle numb skin 2 cm above catheter reintroduce touhy through skin and puncture at the point where catheter is exiting skin and then back thread catheter and then withdraw needle.
Yeah I agree, the ligaments will hold the catheter in place pretty well.
Put a couple of tension loops under a piece of gauze, then large tegaderm on top of everything. Do whatever you can to prevent the tegaderm/skin/catheter combo from directly acting on and pulling the catheter out after extreme patient movement.
If you're tunneling in the dermis, I think you're more likely to have the catheter dislodge with the patient's spine twisting. Perpendicular fastening has the least shear movement (draw it out on paper, and imagine rotation of the spine, and what that would do to the skin folds in the lower back.
Tunneling up or down might be better than lateral tunneling, but I don't think there's an advantage over straight on fastening, so no reason to waste time doing it.
- Joined
- Apr 7, 2005
- Messages
- 311
- Reaction score
- 391
And for regional?
Amazing. Tears in my eyes from laughing so hard
- Joined
- Dec 12, 2006
- Messages
- 2,985
- Reaction score
- 3,484
As a pain guy, I've hubbed the big Touhy with indenting the skin. I've hubbed the smaller one with indentation doing a cervical ESI. Luckily in the pain world I've got flouro and contrast to ensure proper location though. 
- Joined
- Aug 22, 2011
- Messages
- 456
- Reaction score
- 701
I had a BMI 76 for C/S. Nothing with long spinal (surprise surprise) but got lucky with the harpoon @ 12cm for an epidural and dosed it up with Lidocaine. Was very happy to see the epidural working, no way that lady was getting a GA...not really sure what my plan B was. Just walk out and quit my job, maybe. I have a picture of the BMI w scheduled procedure on my phone for bragging rights. You know its bad when fluid makes a little pool on top of their 'shelf' when they're sitting down.
For big patients I just leave a lot of catheter in the space assuming some gets pulled out when they lay down. Something like LOR @ 8cm (regular tuohy hubbed and pushed in) leave catheter at 15.
For big patients I just leave a lot of catheter in the space assuming some gets pulled out when they lay down. Something like LOR @ 8cm (regular tuohy hubbed and pushed in) leave catheter at 15.
why wouldn't you do a GA? I've put a perfect spinal in a patient like that and had to convert to GA because they were unable to breathe even with the bed in some decent reverse t-burg. BMI isn't a contraindication to sticking a tube down their trachea.
- Joined
- Feb 8, 2015
- Messages
- 506
- Reaction score
- 799
My current obstetric training/public hospital is the "big mamma's" hospital for the state. Nearly everyone with a BMI over 50 comes our way - and some get quite large. It's also located right in the heart of the low socio-economic region with the associated issues you come to expect.
I've seen things you people wouldn't believe. Midwives on fire off the shoulder of Orion. I watched C-Sections booked to avoid instrumenting the Tannhäuser Gate. All those moments will be lost in time, like tears in rain.
I've seen things you people wouldn't believe. Midwives on fire off the shoulder of Orion. I watched C-Sections booked to avoid instrumenting the Tannhäuser Gate. All those moments will be lost in time, like tears in rain.
- Joined
- Sep 27, 2015
- Messages
- 10
- Reaction score
- 8
BMI 77, LOR with 6" needle at 10 cm.
BMI 69, LOR with 6" needle 14 cm.
BMI 69, LOR with 6" needle 14 cm.
D
deleted697127
1 attempting a large BMI is undoubtedly impressive but hearing ca1s brag about deep LOR kinda comes across as bragging about not understanding geometry. I swear some of the numbers I’ve heard and seen charted it’s a surprise someone hasnt pushed one out a patients belly button.
Some of the deepest LORs I've gotten have not been in the fattest patients. It just depends how they carry it. I've seen plenty that have very little fat in their lower back while most of it is in their abdomen and thighs.
