@#^%@!@ labor epidurals...

[leaverus]

Why do such a high percentage of my labor epidurals turn out to be one-sided?? Someone help me out here...i don't know what i'm doing wrong but it seems like one out of every four or five that i put in the woman gets a unilateral block. I typically do CSE because it gets 'em comfortable fast, and i don't have to waste time sticking around bolusing up the epidural, and it give me extra reassurance that my tuohy tip is in the right place (and i don't buy that nonsense about "untested" catheter); normally tape the catheter at 4 - 6 cm in the space. One of my attendings suggested maybe taping at 3 - 4cm but that didn't seem to work. So is my estimate of midline just that bad?? Anybody have any suggestions?

---

Members don't see this ad.

 

[Jeff05]

max 5 cm into space.
the key for labor epidurals is volume volume volume.
even most one sided epidurals can be overcome with 15mL.
otherwise, pull back 1-2cm and try again.

 

[aredoubleyou]

max 5 cm into space.
the key for labor epidurals is volume volume volume.
even most one sided epidurals can be overcome with 15mL.
otherwise, pull back 1-2cm and try again.

Agree on all points. Probably the less distance the catheter is in the better.

Also important is the ob nurse - motivated ones will get the lady in position for good spread to the weaker side - the lazy ones will just page the crap out of you until you put another one in. Also think PCEA can help overcome a one sided epidural with frequent boluses, but many places dont have this.

My guess is your doing nothing wrong and have had an unlucky streak.

 

[thegasman]

max 5 cm into space.
the key for labor epidurals is volume volume volume.
even most one sided epidurals can be overcome with 15mL.
otherwise, pull back 1-2cm and try again.

This is absolutely the key. You state you are doing cse so you don't have to bolus the epidural. Are you eventually giving an epidural bolus or just starting an infusion? If not bolusing the epidural then you are probably not getting enough volume into the space to spread throughout. I have had great success with a total of 15-20 cc initial epidural bolus then infusion of 10 cc/hr. I was previously giving lower volume and had more one sided blocks. If I do get a block that is a little one sided I bolus 10-15 cc and it resolves.

 

[TrustMe]

I usually bolus 10-15cc after the test dose and before starting the infusion. We run our infusions at 14cc/hr. I can count on one hand the number of one-sided epidurals I have had in the last year. Although now that I have said that my next 10 will probably be one sided. I also agree with the diligence of the OB nurse to reposition pt.'s with one sided blocks before calling.

 

[Bertelman]

Agree with what everyone else has said.

However, I remember a similar streak I had last year. Eventually, I realized even though I was palpating and inserting midline, my trajectory was off. Midway through insertion, if I let go of the needle, it would rebound to several degress off midline. I can't remember having many unilateral blocks as I much as I just had difficulty placing the catheter.

My .02 says do everything you can to make sure you begin midline, and check during needle advancement to make sure you stay midline. I think I was pushing more vigorously with one of my fingers on the needle wing, thus mine always had a rightward tilt.

 

[Gern Blansten]

(and i don't buy that nonsense about "untested" catheter);

It sounds as if what you are describing is an "untested catheter." Once the CSE has worn off, 1/5 of the time, you are left with a one sided block and a catheter that would not provide optimal anesthesia if a c-section is required. Therefore, the catheter is untested as to whether or not it will provide adequate analgesia/anesthesia. Maybe my idea of an untested catheter is different than yours.

I agree with the others, the most common reason for one-sided blocks in my experience is that the catheter is in too far. Threading it too far can also lead to a knotted catheter which is no fun.

 

[jwk]

Volume is key, but so is some speed with injection.

After the test dose, are you giving the bulk of your bolus through the needle, or placing the catheter and then finishing your bolus?

Test dose, bolus through needle, place catheter, small test dose to confirm cath not in the bad places, and done.

 

[Noyac]

Volume is key, but so is some speed with injection.

After the test dose, are you giving the bulk of your bolus through the needle, or placing the catheter and then finishing your bolus?

Test dose, bolus through needle, place catheter, small test dose to confirm cath not in the bad places, and done.

JWK, you are a practicing with the force here.

I never learned to do the bolus thru the needle until I was in PP, although I had done many epidurals, even cervicals in residency. Something about tutoring that prevents attendings from giving the whole picture.

Leaverus, I don't presume to have the answer but you might want to try bolusing thru your toughy b/4 threading your catheter to see if that helps. Honestly, I believe that one-sided epidurals are just epidurals that are not in the epidural space.

Good Luck

 

[dhb]

I agree with what everyone has said.
For strait epidurals i go 10cc through the needle 5 through the catheter and run 10cc/h.
For CSE when setting the pump i give a 5cc bolus and run at 10cc/h

One attending tought me this: when you are inserting the catheter go to the 20cm mark more or less then pull back to your desired mark (less than 5cm in) his reasoning was that if you insert further then pull back your catheter will straiten out... don't knonw how much value this has..

 

[urge]

I'm seriously considering a movement to stop ob epidurals. The pt satisfaction ratio to problems related to epidurals is pretty low.

Who is with me?

Stop labor epidurals!!

Damn Gertie Marx!!

 

[urge]

One attending tought me this: when you are inserting the catheter go to the 20cm mark more or less then pull back to your desired mark (less than 5cm in) his reasoning was that if you insert further then pull back your catheter will straiten out... don't knonw how much value this has..

Sounds reasonable. However, I'm concerned about the catheter knotting itself in the epidural space. Then it will break when you pull it out. Slim chance, I know. But, I guess it can happen.

 

[thegasman]

JWK, you are a practicing with the force here.

I never learned to do the bolus thru the needle until I was in PP, although I had done many epidurals, even cervicals in residency. Something about tutoring that prevents attendings from giving the whole picture.

Leaverus, I don't presume to have the answer but you might want to try bolusing thru your toughy b/4 threading your catheter to see if that helps. Honestly, I believe that one-sided epidurals are just epidurals that are not in the epidural space.

Good Luck

Agree again. In residency we were taught that a bolus through the needle was a no-no. Now in PP I give 10 cc through the needle, place the catheter, test dose, then 5-10cc more bolus and start infusion.

 

[leaverus]

Thanks for the replies, guys. Of course i've pretty much already tried the stuff mentioned. Gern, i suppose you're right about the untested catheter thing, but since my incidence of unilateral block is about the same whether i do a straight epidural or CSE, i can't blame the technique of CSE for leading to "untested" catheter. Also, i usually do thread up to 20 and then pull back to my usual 4-6cm in the space. In general after giving my spinal dose, i just start the infusion and don't bolus the epidural. Noyac, i used to bolus through the tuohy before threading the catheter and that didn't seem to make a difference either so i switched back to CSE. My guess is either 1) not enough volume as many have suggested, 2) my estimate of midline is way off, or 3) maybe it's our catheters? we use those lousy stiff ones that maintain their curve, and the soft Arrow ones with the coiled spring in 'em are so much nicer....

 

[SleepIsGood]

Thanks for the replies, guys. Of course i've pretty much already tried the stuff mentioned. Gern, i suppose you're right about the untested catheter thing, but since my incidence of unilateral block is about the same whether i do a straight epidural or CSE, i can't blame the technique of CSE for leading to "untested" catheter. Also, i usually do thread up to 20 and then pull back to my usual 4-6cm in the space. In general after giving my spinal dose, i just start the infusion and don't bolus the epidural. Noyac, i used to bolus through the tuohy before threading the catheter and that didn't seem to make a difference either so i switched back to CSE. My guess is either 1) not enough volume as many have suggested, 2) my estimate of midline is way off, or 3) maybe it's our catheters? we use those lousy stiff ones that maintain their curve, and the soft Arrow ones with the coiled spring in 'em are so much nicer....

My suggestion is this.

Stop doing CSE.

You want 'fast' relief. Well, get LORTA using the Toughy. Then take some lidocaine and push it through the toughy. Then thread the cath to 5cm past where you got LOR. Do a test dose with your 1.5%lido with epi.

Done.

Havent had a unilat epidural after doing this. Obviously this is just my way. I personally dont like CSE. I know you are using only a 25G needle to do the spinal part. My thought though is....highest rates of PDPH is with a Spinal Needle (cuz spinals are more often done)...and the age range in which these LnD pts fall in, is 'high risk' for PDPH (younger, female). So why do the spinal. I prefer just giving a fast acting drug like Lido (3 mls) or so.

 

[2ndyear]

I agree with what everyone has said.
For strait epidurals i go 10cc through the needle 5 through the catheter and run 10cc/h.
For CSE when setting the pump i give a 5cc bolus and run at 10cc/h

One attending tought me this: when you are inserting the catheter go to the 20cm mark more or less then pull back to your desired mark (less than 5cm in) his reasoning was that if you insert further then pull back your catheter will straiten out... don't knonw how much value this has..

Personally I find that if I go in that far I get into a vessel. I generally thread to about 5-6 and pull back to 3-4 cm in. I have seen a seizure from an epidural bolused for a section that was intravascular. Treatable, yes. Did it result in a settlement? Also yes.

 

[Gaseous Clay]

Excuse my ignorance, but what type of solution are you guys using for this 10-15 ml bolus? We have pre-made syringes of bupi (0.125%), fent (7-8 mcgs/ml), and epi that we bolus. To my knowledge, everyone (including myself) starts with a 5 ml bolus after the test dose (some do through the needle, I sometimes will depending on my Attending). This works well in usually 5-10 mins and then we start the infusion at 10-14 ml/hr.

 

[Bertelman]

Thanks for the replies, guys. Of course i've pretty much already tried the stuff mentioned. Gern, i suppose you're right about the untested catheter thing, but since my incidence of unilateral block is about the same whether i do a straight epidural or CSE, i can't blame the technique of CSE for leading to "untested" catheter. Also, i usually do thread up to 20 and then pull back to my usual 4-6cm in the space. In general after giving my spinal dose, i just start the infusion and don't bolus the epidural. Noyac, i used to bolus through the tuohy before threading the catheter and that didn't seem to make a difference either so i switched back to CSE. My guess is either 1) not enough volume as many have suggested, 2) my estimate of midline is way off, or 3) maybe it's our catheters? we use those lousy stiff ones that maintain their curve, and the soft Arrow ones with the coiled spring in 'em are so much nicer....

We use the lousy stiff ones, too. My rate of unilateral block is WAY lower than yours. Are you doing PCEA? Are your nurses supportive, and aggressive in managing unilateral block?

 

[Noyac]

My suggestion is this.

Stop doing CSE.

You want 'fast' relief. Well, get LORTA using the Toughy. Then take some lidocaine and push it through the toughy. Then thread the cath to 5cm past where you got LOR. Do a test dose with your 1.5%lido with epi.

Done.

Havent had a unilat epidural after doing this. Obviously this is just my way. I personally dont like CSE. I know you are using only a 25G needle to do the spinal part. My thought though is....highest rates of PDPH is with a Spinal Needle (cuz spinals are more often done)...and the age range in which these LnD pts fall in, is 'high risk' for PDPH (younger, female). So why do the spinal. I prefer just giving a fast acting drug like Lido (3 mls) or so.

I'm going to have to disagree here. I've been doing CSE's for over 5 yrs now and I have "never" had a PDPH from one. THe spinal needle is also a 27g in our CSE trays. I also don't remember ever having a one sided block with the CSE technique.

I think we all have our own way of doing things that works for us. For me, the CSE has been exceptional.

 

[Noyac]

Excuse my ignorance, but what type of solution are you guys using for this 10-15 ml bolus? We have pre-made syringes of bupi (0.125%), fent (7-8 mcgs/ml), and epi that we bolus. To my knowledge, everyone (including myself) starts with a 5 ml bolus after the test dose (some do through the needle, I sometimes will depending on my Attending). This works well in usually 5-10 mins and then we start the infusion at 10-14 ml/hr.

That's a lot of fentanyl.

Our mixture is 0.1% bupiv with 2 mcg/cc fentanyl.

 

[SleepIsGood]

I'm going to have to disagree here. I've been doing CSE's for over 5 yrs now and I have "never" had a PDPH from one. THe spinal needle is also a 27g in our CSE trays. I also don't remember ever having a one sided block with the CSE technique.

I think we all have our own way of doing things that works for us. For me, the CSE has been exceptional.

Totally reasonable to disagree.

Question though. Do you guys all run your infusions at 10-15 ml/hr ? with or w/o a demand dose?

I know attendings get on our tail for running stuff at 8-9 ml/hr. I usually like to go 9ml/hr with 3ml pcea bolus q 15min. When I was a CA1, people would tell us to run only at 5-6ml/hr with deman6d doses. I definitely found out after multiple calls for 'boluses' from nurses that 5-6 ml/hr was too low. Havent had any trouble at 8-9 though. An attending once told me if you have to run an epidural at 10 ml/hr or more, it's likely NOT in the epidural space or something is wrong with it.

I know there's no 'solid' number. everyone's different, blah blah....

 

[proman]

Rarely have unilateral blocks:

Arrow epidural catheters, LOR + 4-5 cm, bolus 8-10 cc of 0.125% bupi plain through catheter, infulsion at 12-14 cc/hr bupi 0.1% + fent 2mcg/cc. Only do CSEs when the patient's pain warrants it.

Yeah it's boring but it works.

 

[Bertelman]

Interesting how different the protocols are. I bolus with 10 cc of .125 bupiv with 100 mcg fent (10/cc). Run solutions of .125 % with some volume of fentanyl (not sure what right now). Rn my rates at standard 12/hr, with demand doses.

I wonder if it also depends on your population. Obviously, I'm still in academics, with no shortage of 17 y/os and suboxone users.

 

[SleepIsGood]

wow...nice to hear that you guys run your rates at 10-12 ml/hr.

Yes, i know you arent anywhere close to 'toxic' doses. But, jeez, we would LITERALLY get reemed for this type of stuff.

Needless to say, I'm sure your patients are comfy as hell.

 

[dhb]

Excuse my ignorance, but what type of solution are you guys using for this 10-15 ml bolus?

10cc ropi 0.2% with 2cc sufenta (10mcg) and 3cc saline = 15cc. Then i run the epidural at 10ml/h with plain ropi 0.125%

 

[cchoukal]

putting the word never in quotes really inspires confidence in the answer.

 

[Noyac]

Totally reasonable to disagree.

Question though. Do you guys all run your infusions at 10-15 ml/hr ? with or w/o a demand dose?

I know attendings get on our tail for running stuff at 8-9 ml/hr. I usually like to go 9ml/hr with 3ml pcea bolus q 15min. When I was a CA1, people would tell us to run only at 5-6ml/hr with deman6d doses. I definitely found out after multiple calls for 'boluses' from nurses that 5-6 ml/hr was too low. Havent had any trouble at 8-9 though. An attending once told me if you have to run an epidural at 10 ml/hr or more, it's likely NOT in the epidural space or something is wrong with it.

I know there's no 'solid' number. everyone's different, blah blah....

We all use PCEA rate of 6ml/hr and a demand dose of 5ml q 15 min. I don't know how often the pts push the bolus button but I get the impression from the nurses that it isn't all that frequent.

I have used 8ml/hr with a 3ml q 15 demand and it works the same.

We rarely get calls for a bolus. Usually, if the pt needs a bolus, the are nearing complete dilation and the nurses just tell them its time to push. A lot of the headaches with OB anesthesia are nurse generated and therefore, can be eliminated with good nursing care.

Pt education can go a long way as well. I tell pts that their contractions will return and as they get more intense they are nearing complete dilation.

As far as not being in the epidural space if you run at 10ml/hr. Thats tough to swallow.

 

[Noyac]

putting the word never in quotes really inspires confidence in the answer.

 

[Frank Rizzo]

Pt education can go a long way as well. I tell pts that their contractions will return and as they get more intense they are nearing complete dilation.

This point can't be over-emphasized. I give my same little speil to all of them... It will take away SOME of the pain... intense pressure towards the end that the epidural will not help with... blah blah blah.

 

[dA pilot]

If you are doing a CSE and you get CSF with your spinal, you are most likely not off midline by much if at all. I agree with Gern that you are overthreading the catheter or you change the direction of your epidural needle when you take out the spinal needle.

 

[USAnesthesiaDoc]

I've been out of residency for 4 years in private practice and do lots of OB. Have tried lots of different combos of local and fentanyl both via needle and catheter. I currently bolus 7 mls bupi 0.25% with epi via needle, then additional 3 mls same solution via catheter for test dose. Run infusion of bupi 0.0625% with sufentanil 1 mcg/ml at 10 ml/hr with demand dose 3 ml q 15 min. Usually leave catheter 3-5 cm into epi space. Works very well, patients usually comfortable after tape job is done, definitely by the time my paperwork is finished. I also like local via the needle b/c fewer paresthesias with catheter insertion and fewer intravascular catheters. Occasionally I give some additional 1.5% lido with epi via catheter (3-5 mls) if they are progressing quickly/ruptured/multip. Used to give lido via needle and then catheter, but found they were comfortable SO quickly that I saw more FHR decels and need for ephedrine. With my current regimen, sets up quickly, rarely need ephedrine, (almost) never get unilateral blocks. Patients stay comfortable for a good hour in case there is a delay from pharmacy or nursing getting the infusion hung.

 

[pgg]

Where I trained the usual protocol for a straight epidural was 10 ml/hr of .125% bupiv + 2 mcg/ml fent, or straight .2% ropiv (which was favored by certain providers who seemed to prefer the "I can't move my legs" level of blockade). 5 ml PCEA demand with a 15 minute lockout. Up front bolusing wasn't standardized at all. I usually used about 10 ml of the mix after giving the remainder of the ~5.5 ml lido/epi test dose.

Another hospital where I did some OB as a resident used .125% bupiv + 2 mcg/ml fent, but with a 6 ml/hr rate and 6 ml bolus with a 15 min lockout. I did a lot more topping off there - I don't think 6/hr of .125%+fent is really enough for most patients. They were also fans of CSEs, or even "dural puncture epidurals" in which they deliberately puncture the dura with a 25 g pencil point needle but give no drug through it ... just note CSF return and proceed with the epidural catheter placement and dosing. They put out a study in A&A in late 2008 claiming faster onset, better sacral spread, and fewer one-sided blocks, with no increase in PDPH. Kind of an interesting technique, though I think their results are substantially skewed by the fact that trainees did most of the study placements. I suspect that the technique probably doesn't have much to offer more experienced hands.

Anyway, since I've been free to do what I want, I finish off the test dose through the catheter (including what's left over in the ampule), put in about 5 of the .125% bupiv 2/ml fent mix, tape the catheter, lay them down, give 5 ml more while I do the paperwork, set the pump at 8/hr with a 6q15 bolus/lockout, and leave it. I rarely get called back.

I can't remember the last time I had a one-sided block that wasn't fixed with either patient position changing (helps to have a good nurse) or pulling the catheter back a cm or so.

 

[Gaseous Clay]

That's a lot of fentanyl.

Our mixture is 0.1% bupiv with 2 mcg/cc fentanyl.

The bolus syringe has a lot of fentanyl, the infusion bag is the same as yours.

 

[leaverus]

I can't remember the last time I had a one-sided block that wasn't fixed with either patient position changing (helps to have a good nurse) or pulling the catheter back a cm or so.

Seriously?? I've never thought that gravity affected epidural spread and whenever i've tried positioned a woman to one side or the other it hasn't worked. Also, pulling back on the catheter has rarely converted a unilateral catheter to a good one. BTW, we don't have PCEA just the continuous infusion because i dont think our nurses know how to program the pumps for PCEA and i dont think they want to learn either.

 

[Bertelman]

Seriously?? I've never thought that gravity affected epidural spread and whenever i've tried positioned a woman to one side or the other it hasn't worked. Also, pulling back on the catheter has rarely converted a unilateral catheter to a good one. BTW, we don't have PCEA just the continuous infusion because i dont think our nurses know how to program the pumps for PCEA and i dont think they want to learn either.

Oh, it works. I will say that if you have a truly "unilateral block", as in they feel nearly everything on one side, you're probably out of luck (or are they out of luck?). If they have a little window covering a couple dermatomes, then dropping that side down and giving them a stiff bolus can often work things out.

 

[proman]

One thing that I've learned with troubleshooting epidurals: I give it one shot. If it doesn't work then, replace it. Less pain for everyone involved.

 

[Noyac]

I always bolus through the needle with 5cc of saline b/4 threading the catheter. It decreases the chance of an intravascular cath and it decreases the chance of dermatome sparing (hot spots and unilateral blocks).

Reference:
Evron S, Gladkov V, Sessler DI, et al. Predistention of the epidural space before catheter insertion reduces the incidence of intravascular epidural catheter insertion. Anesth Analg. 2007; 105:460-464.

 

[dhb]

One thing that I've learned with troubleshooting epidurals: I give it one shot. If it doesn't work then, replace it. Less pain for everyone involved.

Last night on call, was called at 5am for an epidural. Placement went fine, go back to sleep and i get a call 1/2h later from the OB nurse because the pump is beeping and she can't fix it. I told her to change the pump.
15 min later calls back for the same problem so i go donw to check it out. I bolus 5cc through the cath and i get this chewy coil like feel and i get a 1cc back flow in the syringe but the patient felt the bolus in her back.
So i'm like wtf i check the cath to see if it was bent at the skin but everthing looked fine i pull back 1cm and ret-ape.
Re-bolus but still the same feel.

All said and done it's now 7am and i'm like F*@# A! One of the rare night i could've had a nice sleep on call i get F@#~! by this little guy

Threw it away and got a regular feel...

 

[Trisomy13]

I always bolus through the needle with 5cc of saline b/4 threading the catheter. It decreases the chance of an intravascular cath and it decreases the chance of dermatome sparing (hot spots and unilateral blocks).

Reference:
Evron S, Gladkov V, Sessler DI, et al. Predistention of the epidural space before catheter insertion reduces the incidence of intravascular epidural catheter insertion. Anesth Analg. 2007; 105:460-464.

i'm a big fan of this technique as well. i can't say i do it 100% of the time, but if i have any trouble threading the catheter, in goes the saline, and the trouble usually is gone.

 

[leaverus]

i'm a big fan of this technique as well. i can't say i do it 100% of the time, but if i have any trouble threading the catheter, in goes the saline, and the trouble usually is gone.

Well i do that too so why am i getting so many unilateral blocks? OK, my exact technique is: LOR of resistance to 3cc saline in the glass syringe. As soon as i get loss, i put my spinal needle in and give 1cc 0.25%bup+25mcg fentanyl. Then give the rest of the saline through the tuohy to a total of 5cc and thread my catheter up to 4 - 6cm in the epidural space. Give test dose (i know i'm not really testing for IT since the spinal has been given), tape catheter, lay patient down, and start infusion at 10cc/hr.

 

[thegasman]

Well i do that too so why am i getting so many unilateral blocks? OK, my exact technique is: LOR of resistance to 3cc saline in the glass syringe. As soon as i get loss, i put my spinal needle in and give 1cc 0.25%bup+25mcg fentanyl. Then give the rest of the saline through the tuohy to a total of 5cc and thread my catheter up to 4 - 6cm in the epidural space. Give test dose (i know i'm not really testing for IT since the spinal has been given), tape catheter, lay patient down, and start infusion at 10cc/hr.

in my opinion as stated before, you are not putting enough volume in the epidural space. I would personally give a total of 10 cc NS through the tuohy with your technique, thread the catheter to +4 cm, then I would probably give a small epidural bolus of 4-5 cc local and start infusion. More volume in the epidural space equals greater spread equals less unilateral block.

That being said, I usually don't do cse so I give 10 cc 0.2ropiv with fent 2mcg/ml through the needle with another 5-10 through the catheter after a test dose. The l+d nurses comment on how well this works.

 

[deleted21609]

I'm not convinced that too much length of catheter in the space is contributing to one sided blocks. With one of my attendings we put a good 8cm in the space routinely and have no problem with one-sided blocks. This is after injecting 15cc through the needle though.
The attending has done this thousands of times apparently with no apparent difference in the block and no knots forming in the catheter in the space.
(When I do them on my own I put 4-5cm.)
Where I am now we inject 10-15cc of 0.2% plus 100mcg of fentanyl initially then run 0.2% with 3mcg/cc fentanyl at a constant rate of 10-15cc/hr, no pcea. The catheters are in the epidural space.