Difficult case from call - what happened?

[ISoNitrous]

Does anyone else find that about 5% of epidurals are inexplicably weird?

Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.

First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.

Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.

She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).

Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.

Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.

She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.

To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.

Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.

Also - when considering local anesthetic limits, is there a statute of limitations where the ropi I gave 8 hours ago shouldn’t be counted towards my totals? I would think plasma concentrations would be pretty low by that point. Especially if some of this medication was not in the epidural space.

Any guidance or thoughts are appreciated. Thanks I’m advance for weighing in. What would you do?

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[coffeebythelake]

Does anyone else find that about 5% of epidurals are inexplicably weird?

Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.

First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.

Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.

She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).

Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.

Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.

She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.

To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.

Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.

Also - when considering local anesthetic limits, is there a statute of limitations where the ropi I gave 8 hours ago shouldn’t be counted towards my totals? I would think plasma concentrations would be pretty low by that point. Especially if some of this medication was not in the epidural space.

Any guidance or thoughts are appreciated. Thanks I’m advance for weighing in. What would you do?

What made you think there was a "highish epidural"? She was moving her arms with full strength. Did you even check a level?

 

[ISoNitrous]

What made you think there was a "highish epidural"? She was moving her arms with full strength. Did you even check a level?

Subjective breathlessness (presumed due to loss of proprioception of chest wall) and a T4 sensory level with ice bilaterally.

 

[repititionition]

I recently had a patient with b/l lower extremity motor blockade and a sensory level to T8 who was in tears with “pain” the entire labor.

Part of me loves OB but then I’ll have an experience like that and it makes me want to walk away.

 

[Volatile]

Does anyone else find that about 5% of epidurals are inexplicably weird?

Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.

First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.

Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.

She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).

Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.

Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.

She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.

To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.

Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.

Also - when considering local anesthetic limits, is there a statute of limitations where the ropi I gave 8 hours ago shouldn’t be counted towards my totals? I would think plasma concentrations would be pretty low by that point. Especially if some of this medication was not in the epidural space.

Any guidance or thoughts are appreciated. Thanks I’m advance for weighing in. What would you do?

Could have been subdural, usually has odd presentations and occasional dyspnea.
I probably wouldn’t have placed the third epidural. I usually tell them I’ll give it one more shot and you get what you get, especially if it was a straight forward placement the previous two times.
I agree with GA for the c/s. If they have a **** epidural I’ll almost always pull it and place a spinal if there’s time. if the epidural has been bolused a few times recently and they still aren’t comfortable I put them to sleep. My 2 cents

 

[coffeebythelake]

So the epidural worked at times. Bilateral, then unilateral, then bilateral, then unilateral. A few quick questions -- Any history of back problems or surgery that might lead to scaring or other anatomic issues at that level? Did you replace the epidural at different levels? Is the patient using the PCEA and demand functions appropriately? Is the PCEA programmed appropriately? Did you try adjusting the epidural catheter as it may have been directed more one sided? Did you have the patient change their position in bed (painful side down) while you were giving the redoses?

What you describe is not necessarily patchy distribution, which goes against subdural placement. Would be very unlikely to get subdural placement x2 nevermind x3

I agree w u that some pregnant patients are just weird with their epidurals. She was probably misinterpreting pressure with overt pain. And there can be quite a bit of pressure in 2nd stage of labor even with a well functioning epidural especially if not straightforward. Going to sleep for thr c-section was yhe right thing given circumstances

 

[dabears505]

Epidurals can be such nightmares.

 

[Planktonmd]

Subdural initially but then just crappy epidural. At some point you have to admit that it's time to stop trying and just do it the old fashion way : you tell her it's giving birth and it's painful. It seems that's what you did ultimately for the C Section, but 3 epidurals is too many IMHO.
My second attempt would have been some variant of CSE if I were you.

 

[pgg]

Does anyone else find that about 5% of epidurals are inexplicably weird?

Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.

There are no normal parturients. They're all at least a little bit crazy. And I mean that in a nice way.

First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.

Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.

She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).

Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.

Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.

She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.

To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.

Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.

Couple thoughts

1) I think we should keep firmly in mind that getting a needle shoved in your back and nerve-numbing juice squirted in to make half of your body feel fuzzy and numb is not a normal, everyday experience for these people. Neither is childbirth itself. It's all routine to us, there's no mystery and awe and wonder left in the 6th labor epidural of the night ... but it's all strange to them.

So it never ever surprises me when one of them tells me she's feeling weird things. Or when they can't really tell or articulate the difference between sharp pain vs pressure discomfort. We're not going for a dense surgical block with a labor epidural - they're going to feel something, and we shouldn't be surprised if they describe that something as weird.


2) Remember where the nerves come from and go. A woman can have a solid T4 level and numb legs ... yet have significant sacral sparing. Especially if the lumbar epidural you thought you put in at L3-4 is actually more like L1-L2. You can have totally numb legs and yet not much effect on S3 S4 and S5, which is exactly the region that's going to hurt when the OB goes reaching with forceps.

When you checked the legs, did you check the back of the legs (S1 and S2)? Of course you didn't, you checked the lateral thigh (L3 and L4) like everyone does.

I'm just going to guess that the reason your patient didn't tolerate a forceps delivery was because your "T4 level" was actually a T4 - L5 level with a whole lotta sacral sparing. I suspect a c-section would've gone just fine with that epidural.

 

[epidural man]

The Neuraxial and peri-neuraxial spaces are like the Bermuda Triangle. They act strange, and weird stuff happens all the time that is difficult to explain. Cardiac arrest in a healthy, 20 year old after a spinal? That's crazy - but happens.

I can completely paralyze a patient with a tiny needle in the transforaminal space, yet surgeons rip SH$T out of there with huge instruments and never seem to have problem.

Has a dural tear from surgery ever caused a central vein thrombosis that was missed post-op and caused seizures and eventually death? I doubt it. (cases of cerebral hemorrhage however).

Yet a tiny needle from me, can cause a wee-itty-bitty hole, causing diplopia, central vein thrombosis, and eventually death.

How does a tiny hole from a spinal needle, allow enough medication in from an epidural that was turned off two hours previous, cause a high spinal? (Happened to me.....)

 

[Hoya11]

Does anyone else find that about 5% of epidurals are inexplicably weird?

Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.

First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.

Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.

She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).

Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.

Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.

She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.

To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.

Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.

Also - when considering local anesthetic limits, is there a statute of limitations where the ropi I gave 8 hours ago shouldn’t be counted towards my totals? I would think plasma concentrations would be pretty low by that point. Especially if some of this medication was not in the epidural space.

Any guidance or thoughts are appreciated. Thanks I’m advance for weighing in. What would you do?

when pain returned after motor block with the second catheter, i would have bolused 10-12cc of 2% lido and looked for motor block to return 10 minutes after. if i get that motor block bilaterally after the lido i know my catheter is good.

maybe her pain was intensifying as labor progressed, she got behind after the epidural was turned off, and the bolus of 0.2% ropi just wasn't cutting it in time. so you think its not working but you just needed something quicker and stronger like lido.

i admire your commitment in doing it a third time. but before i took out the second catheter i would have exhausted all other options including pulling the catheter back, change of patient position, epidural fentanyl bolus, and lido bolus.

ga for the section is understandable if she is distressed and had enough

 

[ethilo]

I learned this gem on my first day of OB in residency and I never looked back. It helps to explain a lot of the unexplainable on the labor unit and acts to keep you grounded when all is seemingly crashing down around you:

whenever you walk onto the L&D unit the most important thing you must remember no matter what: as the anesthesiologist, you are the ONLY one who is sane.

 

[deleted875186]

wow, my thoughts

1. Subdural is a possibility. Also we use multiorifice catheters, maybe the catheter tip is subdural, or down a nerve root, or somewhere else, and the proximal hole is epidural. Sometimes I think weird s**t like this might explain some of these stories. For instance, I’ve had a few patients with a lot of parasthesias while threading catheter after excellent LOR. I always pull back catheter and bolus as my first intervention.

2. Would have tried a bolus of heavy bup (0.25%) at some point to see if density was part of the problem, can’t blame you though after the high level.

3. Whenever I replace an epidural, I more often than not will do a DPE. It confirms CSF, which isn’t in itself helpful but let’s you know your not way towards the lateral recess. The DPE also makes analgesia much better in my opinion. More importantly, if I do something and it doesn’t work, it makes sense to do something different, whether it’s technique, different proceduralist, different level. So I typically do a DPE at a different level than the initial epidural.

 

[deleted875186]

I personally like the third epidural technique. Shows confidence in what we do. Also, patient already bought into the epidural, I don’t think a third attempt poses much more risk, but has a lot of potential benefit if the epidural works.

 

[DrOwnage]

The Neuraxial and peri-neuraxial spaces are like the Bermuda Triangle. They act strange, and weird stuff happens all the time that is difficult to explain. Cardiac arrest in a healthy, 20 year old after a spinal? That's crazy - but happens.

I can completely paralyze a patient with a tiny needle in the transforaminal space, yet surgeons rip SH$T out of there with huge instruments and never seem to have problem.

Has a dural tear from surgery ever caused a central vein thrombosis that was missed post-op and caused seizures and eventually death? I doubt it. (cases of cerebral hemorrhage however).

Yet a tiny needle from me, can cause a wee-itty-bitty hole, causing diplopia, central vein thrombosis, and eventually death.

How does a tiny hole from a spinal needle, allow enough medication in from an epidural that was turned off two hours previous, cause a high spinal? (Happened to me.....)

Name checks out

 

[DrOwnage]

Epidurals make no sense sometimes brother. Good LOR, catheter feeds like butter, one sided. Weird LOR, catheter feels like I'm shoving it through a wall, patient comfortable.

 

[Volatile]

What you describe is not necessarily patchy distribution, which goes against subdural placement. Would be very unlikely to get subdural placement x2 nevermind x3

For the students in the group, be mindful that subdural placement, while often described as patchy, can have multiple presentations from profound sensory block, to odd motor blocks, to specific dermatomal spread. I think this happens due to some ports on the multiorifice catheter being intrathecal/subdural/epidural and due to odd spread within the subdural space.

Also, be aware that you are MORE likely to get a subdural block with subsequent attempts if you had a subdural block the first time.
An article from openanesthesia.org describes this.

Epidural and Combined Spinal-Epidural: Pharmacology, Technique, and Side Effects - OpenAnesthesia

www.openanesthesia.org

 

[FiO2@21]

Does anyone else find that about 5% of epidurals are inexplicably weird?

Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.

First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.

Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.

She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).

Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.

Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.

She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.

To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.

Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.

Also - when considering local anesthetic limits, is there a statute of limitations where the ropi I gave 8 hours ago shouldn’t be counted towards my totals? I would think plasma concentrations would be pretty low by that point. Especially if some of this medication was not in the epidural space.

Any guidance or thoughts are appreciated. Thanks I’m advance for weighing in. What would you do?

Some days you gotta just take the L with these... I do wonder where you poked for your 3rd epidural. Multiple studies have shown we're notoriously terrible at estimating the spinal level with physical exam. You might have been a bit too high and dealing with sacral sparing despite the higher volume.

 

[GassYous]

Just check the position with fluoro

 

[sevo00]

Just check the position with fluoro

lol

 

[2Fast2Des]

God these kind of epidurals make me hate OB and question life... 3rd epi, surprised you were able to convince her. I would have given up on the 2nd or passed the baton...

 

[MirrorTodd]

God these kind of epidurals make me hate OB and question life... 3rd epi, surprised you were able to convince her. I would have given up on the 2nd or passed the baton...

I think if I'm placing a third, I'll just go intrathecal.

 

[sevo00]

I just so DPE always on everyone now on first epidural. Haven’t got called back about pain since doing that.

 

[2Fast2Des]

I just so DPE always on everyone now on first epidural. Haven’t got called back about pain since doing that.

Same, but I have a had a run of epidurals where I get a smooth LOR but when I try the spinal needle for the DPE, I hit something hard or get nothing coming back. Even after taking out the spinal and putting more saline in still smooth LOR, and ends up being smooth threading of the catheter, I don't know what to make of that...

 

[deleted875186]

Same, but I have a had a run of epidurals where I get a smooth LOR but when I try the spinal needle for the DPE, I hit something hard or get nothing coming back. Even after taking out the spinal and putting more saline in still smooth LOR, and ends up being smooth threading of the catheter, I don't know what to make of that...

Your accessing the epidural space off midline, look at the picture below. Your hitting vertebral body or part of the foramin lateral to the the thecal sac.

 

[DrJonesss]

Same, but I have a had a run of epidurals where I get a smooth LOR but when I try the spinal needle for the DPE, I hit something hard or get nothing coming back. Even after taking out the spinal and putting more saline in still smooth LOR, and ends up being smooth threading of the catheter, I don't know what to make of that...

I had a string of these as well several months ago and after frustratingly passing the needle a few times, I gave up and just threaded the catheter. Perfectly working epidural. It started happening to another colleague too. The first 1,2x I figured I must have just been off midline but after the multiple instances I wondered if there was a manufacturer issue. No issues since.

 

[woopedazz]

I refuse to believe DPE is in any way superior to a run of the mill epidural or CSE.

My opinion can never be changed. I am that 100 year old attending who thinks halothane is unparallelled.

Don't @Me