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Identification of the epidural space-loss of resistance to saline: An inexpensive modification.

Dhansura T, Shaikh T, Maadoo M, Chittalwala F - Indian J Anaesth (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Anaesthesiology, Saifee Hospital, Mumbai, Maharashtra, India.

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Syringes such as the Episure Autodetect and the Epimatic syringe are designed for identification of the epidural space using saline or air, using ‘’a both hands on needle technique’’ for superior control... The loss of resistance technique is based on the fact that ligamentum flavum and interspinous ligament are relatively dense tissue, and as the tip of the epidural needle pierces the ligamentum flavum, there is an abrupt decrease in the resistance and the contents of the syringe enter the epidural space smoothly... Both air and fluid can be used as a medium for this technique and till date the debate is going on as to which medium is superior... Whereas when using air, the needle will be advanced by one hand while the finger of the other hand will be intermittently pushing the plunger to check the resistance, as the needle is advanced towards the epidural space... Air is a compressible medium, and high pressure cannot be achieved when compared to non-compressible matter-like fluid... Inadvertent dural puncture is a complication that is feared... There is a lower reported incidence of dural puncture with saline as compared to air... Studies, where saline has been used, report an incidence of 0.3–0.5%, whereas while using air, the incidence can be as high as 2%, the reason being that as the epidural space is entered the saline which enters with continuous pressure pushes the dura away thereby reducing the incidence of dural puncture... The pressures applied by the syringes were measured using the TruWave Disposable Pressure Transducer (Edwards LifeSciences), the Episure Autodetect syringe and the modified syringe exerted a comparable range of pressures at similar volumes of saline [Figure 2]... In a study using the Episure Autodetect syringe in 17 paediatric patients of 9 months to 14 years for identification of the epidural space, no inadvertent dural punctures were noted... Many other complications related to the injection of air in the epidural space are reported in literature... Since the use of air demonstrates no advantage over the use of saline, the possibility of the above complications no matter how remote speaks in favour of use of saline and abandonment of air for this valuable technique... Our modification is a simple, inexpensive technique which compares to the syringes available in the market in all aspects and would help to encourage the use of saline as the mode of loss of resistance in identification of the epidural space using ‘both hands on needle technique’ leading to better needle control and fewer complications... There are no conflicts of interest.

No MeSH data available.


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Epidural loss of resistance syringes, the Epimatic, the episure and the modified syringe
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Figure 1: Epidural loss of resistance syringes, the Epimatic, the episure and the modified syringe

Mentions: We use a regular epidural set with Touhy's needle and loss of resistance (LOR) syringe and a pair of sterile gloves and sterile scissors. Under all aseptic conditions, the wrist cuff end of the glove is cut about an inch broad and is rolled twice on to the end of the barrel of the syringe. The LOR syringe is filled with 5 ml of normal saline. After cleaning and draping the area, a local anaesthetic is infiltrated at the site of insertion. Epidural needle is inserted, and as the needle is held by the interspinous ligament, the syringe is attached to the epidural needle. One strand of the glove is rolled up to the plunger of the syringe. At this point, the tension of the rubber holds the plunger in place. Slowly, the needle is inserted inside [Figure 1]. As soon as the needle enters the epidural space the plunger moves inwards due to the tension on the band [Video 1].


Identification of the epidural space-loss of resistance to saline: An inexpensive modification.

Dhansura T, Shaikh T, Maadoo M, Chittalwala F - Indian J Anaesth (2015)

Epidural loss of resistance syringes, the Epimatic, the episure and the modified syringe
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4645360&req=5

Figure 1: Epidural loss of resistance syringes, the Epimatic, the episure and the modified syringe
Mentions: We use a regular epidural set with Touhy's needle and loss of resistance (LOR) syringe and a pair of sterile gloves and sterile scissors. Under all aseptic conditions, the wrist cuff end of the glove is cut about an inch broad and is rolled twice on to the end of the barrel of the syringe. The LOR syringe is filled with 5 ml of normal saline. After cleaning and draping the area, a local anaesthetic is infiltrated at the site of insertion. Epidural needle is inserted, and as the needle is held by the interspinous ligament, the syringe is attached to the epidural needle. One strand of the glove is rolled up to the plunger of the syringe. At this point, the tension of the rubber holds the plunger in place. Slowly, the needle is inserted inside [Figure 1]. As soon as the needle enters the epidural space the plunger moves inwards due to the tension on the band [Video 1].

View Article: PubMed Central - PubMed

Affiliation: Department of Anaesthesiology, Saifee Hospital, Mumbai, Maharashtra, India.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Syringes such as the Episure Autodetect and the Epimatic syringe are designed for identification of the epidural space using saline or air, using ‘’a both hands on needle technique’’ for superior control... The loss of resistance technique is based on the fact that ligamentum flavum and interspinous ligament are relatively dense tissue, and as the tip of the epidural needle pierces the ligamentum flavum, there is an abrupt decrease in the resistance and the contents of the syringe enter the epidural space smoothly... Both air and fluid can be used as a medium for this technique and till date the debate is going on as to which medium is superior... Whereas when using air, the needle will be advanced by one hand while the finger of the other hand will be intermittently pushing the plunger to check the resistance, as the needle is advanced towards the epidural space... Air is a compressible medium, and high pressure cannot be achieved when compared to non-compressible matter-like fluid... Inadvertent dural puncture is a complication that is feared... There is a lower reported incidence of dural puncture with saline as compared to air... Studies, where saline has been used, report an incidence of 0.3–0.5%, whereas while using air, the incidence can be as high as 2%, the reason being that as the epidural space is entered the saline which enters with continuous pressure pushes the dura away thereby reducing the incidence of dural puncture... The pressures applied by the syringes were measured using the TruWave Disposable Pressure Transducer (Edwards LifeSciences), the Episure Autodetect syringe and the modified syringe exerted a comparable range of pressures at similar volumes of saline [Figure 2]... In a study using the Episure Autodetect syringe in 17 paediatric patients of 9 months to 14 years for identification of the epidural space, no inadvertent dural punctures were noted... Many other complications related to the injection of air in the epidural space are reported in literature... Since the use of air demonstrates no advantage over the use of saline, the possibility of the above complications no matter how remote speaks in favour of use of saline and abandonment of air for this valuable technique... Our modification is a simple, inexpensive technique which compares to the syringes available in the market in all aspects and would help to encourage the use of saline as the mode of loss of resistance in identification of the epidural space using ‘both hands on needle technique’ leading to better needle control and fewer complications... There are no conflicts of interest.

No MeSH data available.


Related in: MedlinePlus