Troubleshooting

You keep hitting bone

First of all, make sure you are in the midline. Make sure the needle is at an appropriate angle for the level you are at. Make sure the patient's back is maximally flexed.

Try another space above or below.

Try paramedian.

Get somebody to help.

CSF through the needle or catheter

If you are below the level of the spinal cord, thread the catheter into the subarachnoid space. You'll be able to provide analgesia and won't have to expose the patient to a second procedure. You may also reduce the risk of post dural puncture headache if the catheter remains in situ for greater than 24 hours (need reference).

Give 1ml of 0.25% bupivacaine and 10mcg of fentanyl as required. (need regimen for infusion)

Label the catheter and the pump intrathecal. The patient will suffer if the next registrar thinks your catheter is in the epidural space.

If above the level of the spinal cord just pull out the needle or catheter and repeat the procedure one level above or below.

Either way, tell notify your consultant and make sure the patient if followed-up on the pain round.

Blood in the catheter

A relatively common problem, especially if you are off the midline.

Pull the catheter back 1cm, flush with saline. Aspirate again. Wait a few seconds. If the blood clears inject a test dose. Be worried about intravascular injection.

If the blood doesn't clear, repeat the procedure. Once the catheter is at 3cm in the epidural space you will have to re-site the epidural needle.