OB Anesthesia Hot Topics

[DreamLover]

After just reading a thread here about whether or not do redo a failed spinal, I've become more curious about people's OB practice in comparison to mine. I feel like OB anesthesia practice doesn't seem to change very quickly.

I would be leery to redo a spinal as well, but there are always extenuating circumstances.

What are some of your current practices?

Do you regularly pretreat for aspiration?
- I do Zantac +/- Bicitra but not Reglan regularly because I feel it can make my already anxious pt's a little nutty...some of my partners don't pretreat at all

Do you place labor epidurals early or wait until "X" time?

Do you routinely do a CSE Vs Epidural?
- if CSE, are you just dosing opioids?

What are people running in their epidural bags? At what rate?
- I usually start .1% Marcaine /2mcg Fent at 10ml/hr and go up but one of my partners always starts at 15 and like .125%/5mcg

Any changes in people's comfort about platelet count Vs "function" (via TEG or ROTEM) for epidural placement?

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[Mman]

--bicitra for c-sections
--labor epidural whenever patient is deemed in labor by OB and patient requests epidural
--usually just regular old epidural
--0.2% ropivicaine @ 10 ml/hr
--platelet count > 100K and stable for me in otherwise healthy patient, between 80K to 100K depends on the patient, <80K too low for me

 

[BLADEMDA]

--bicitra for c-sections
--labor epidural whenever patient is deemed in labor by OB and patient requests epidural
--usually just regular old epidural
--0.2% ropivicaine @ 10 ml/hr
--platelet count > 100K and stable for me in otherwise healthy patient, between 80K to 100K depends on the patient, <80K too low for me

Agree but I use Bupivacaine 0.125% with Fentanyl at 10-12 mls per hour (it's cheaper).

 

[IlDestriero]

After just reading a thread here about whether or not do redo a failed spinal, I've become more curious about people's OB practice in comparison to mine. I feel like OB anesthesia practice doesn't seem to change very quickly.

I would be leery to redo a spinal as well, but there are always extenuating circumstances.

What are some of your current practices?

Do you regularly pretreat for aspiration?
- I do Zantac +/- Bicitra but not Reglan regularly because I feel it can make my already anxious pt's a little nutty...some of my partners don't pretreat at all

Do you place labor epidurals early or wait until "X" time?

Do you routinely do a CSE Vs Epidural?
- if CSE, are you just dosing opioids?

What are people running in their epidural bags? At what rate?
- I usually start .1% Marcaine /2mcg Fent at 10ml/hr and go up but one of my partners always starts at 15 and like .125%/5mcg

Any changes in people's comfort about platelet count Vs "function" (via TEG or ROTEM) for epidural placement?

Zantac and bicitra.
we place one when called, don't care when, though they won't call until they're in active labor and committed to delivery.
Used to do 100% CSE when I could go home for a few hours after dosing the spinal, now I'm in house and don't care, so 0% CSE. Though I might place one for some patient specific reason. A few of my partners place them for expected complex c sections, I just do an epidural.
1/8% Bupiv w/ 2mcg/cc fent. PCEA 10ml/hr, 5ml bolus, 10min lock out, 30cc/hr max.
We just go with platelet count. I think everyone uses 75k for an epidural. I know that there is no set number in any policy.
We are getting a new teg machine or something similar for cardiac, maybe we will get all academic and run some tests prior to placement.

 

[narcusprince]

My practice
Labor epidural whenever the patient wants one and the obstetrician declares the patient in labor. I will place them earlier in the day for obese or possible difficult epidural placement due to staffing changes during call shifts.
Rate depends on height of patient but usually ropi 0.2% pcea 8/4/15/4 I bolus up front with 5-10ml of .25% bupi.
Cse I do not do them for laboring moms. I can get a level in 5-7 minutes with most moms.
Pretreatment for c/s ondansetron and bicitra +_ zantac if facility has it I use it.
Platelet count 80 thousand and holding place epidural. Spinals 60k and holding I will place them.
TEG takes too long to be useful maybe the new quick tegs are faster. I have used TEG/Sonoclot with patients with isolated factor deficiencies to guide pull/placement of cle.

 

[IlDestriero]

Oh, forgot the bolus, 10cc .2% ropi.

 

[teeva]

Bicitra for all c/s
Epidural whenever they ask for it
No CSE
0.2% bupi 10ml/hr, 5-7ml on demand
I don't necessarily wait for plt count before doing epirual or spinal unless there's previous history of coagulopathy or thrombocytopenia. That said, 95% of the time lab results are back already when I get called, and if not then prenatal labs from past 90 days is available most of the time. I'm comfortable with plt consistently (like on prenatal and on admission labs and sometimes they check another one right before they call me for epidural) above 80 for epidural. I haven't had to deal with any plt below 70 for c/s, but assuming easy airway I would just explain to pt why GA may be less risky.

 

[pgg]

CSE for everyone. Patients love them, nurses do too. Hit play on the pump, no bolus, out the door seconds later. I spend less time in the room. Everyone wins.

 

[loveumms]

Bicitra for all - zofran for some (if high risk for nausea ... not a pretreatment for aspiration obviously). I personally put everyone on a prophylactic phenylephrine drip. They get 500mcg in their IVF bag right before spinal goes in. Hardly ever get nausea anymore.

Epidural once in active labor - we have had a few where we were asked to put in epidural and then the patient wasn't actually in labor (ridiculous, I know!)
Have not done a CSE in years. I personally want to know that my epidural is working. If I want fast relief, I put in extra lidocaine after the test dose (4-5ml of 2% lido on top of the 5ml 1.5%).

Stable platelets at 80k for epidural, 60-70K for spinal (depending on how scary their airway looks and whether they ate five big macs on the way in for their 'urgent' c-section)

we run 1/16th bupi with fentanyl - usually at 8ml an hour, 4ml q15 min for max of 20ml an hour

So, I tell all my residents this personal story and it changed the way I practice. I've had three kiddos ... each one had a wonderful epidural! The second one, I came in at 7cm and got my epidural. I was very comfy however I started to get some pain so I asked the resident to bolus me (after the self bolus didn't work). She did with 6ml of 0.25% bupi and I delivered two hours later. Problem was I couldn't move my legs for at least 4 hours after ... my husband had to carry me to the bathroom and I couldn't walk. It was AWFUL! So I personally don't bolus any lady who is >7cm with 0.25% bupi - they all get lidocaine. Now, some will say "oh well then you are going to have a patient calling you over and over for another bolus because they were so comfortable". Well, I kinda think that's my job anyway (to make patients comfortable ... yes, getting called a few times stinks but if that makes the patient more comfortable then so be it). Or you might say "oh no can't give repeated boluses of lido b/c pt may get tachycphylactic with the lidocaine" - that might be true but I've not done too many c-sections for failure to progress past 7cm so usually I only get paged once or twice for this. Or you might say "well, then the patient won't be able to push because you made the block so dense" - well don't give 8ml of 2% lido. I usually use 5mL of 1% and have not had any problems with patients not being able to push. Anyway, the patient usually can push if they put their hands on their abdomen and feel the contractions and push with them.

 

[inflamesdjk02]

CSE for everyone. Patients love them, nurses do too. Hit play on the pump, no bolus, out the door seconds later. I spend less time in the room. Everyone wins.

What's been your rate of spinal headache? I agree patients and nurses both love them. But I have a partner who routinely does them for everyone and he's had 2 patients in the last couple of months come back with spinal headaches necessitating epidural blood patch. If I can bolus an epidural with 15 - 20 mL of 0.0625% bupi and get a level in 5 minutes, then I don't feel it necessary to put a hole in the dura. Also, if your patient then needs a C/S for whatever reason, how do you know if your epidural will work? For those reasons I prefer to simply place and dose the epidural.

 

[BLADEMDA]

My practice
Labor epidural whenever the patient wants one and the obstetrician declares the patient in labor. I will place them earlier in the day for obese or possible difficult epidural placement due to staffing changes during call shifts.
Rate depends on height of patient but usually ropi 0.2% pcea 8/4/15/4 I bolus up front with 5-10ml of .25% bupi.
Cse I do not do them for laboring moms. I can get a level in 5-7 minutes with most moms.
Pretreatment for c/s ondansetron and bicitra +_ zantac if facility has it I use it.
Platelet count 80 thousand and holding place epidural. Spinals 60k and holding I will place them.
TEG takes too long to be useful maybe the new quick tegs are faster. I have used TEG/Sonoclot with patients with isolated factor deficiencies to guide pull/placement of cle.

Nice. I routinely bolus through the needle to dilate the space which is why I rarely ever get a one-sided block or a bloody catheter. In addition, the epidural sets up quickly (3-5 minutes) after the bolus so no CSE needed in my hands. Now, I'm not advocating that residents or attendings (new ones at least) adapt my technique but after you've been at this gig for 5 years or so I expect you have developed your "spidey sense" to keep you out of trouble.

 

[inflamesdjk02]

Nice. I routinely bolus through the needle to dilate the space which is why I rarely ever get a one-sided block or a bloody catheter. In addition, the epidural sets up quickly (3-5 minutes) after the bolus so no CSE needed in my hands. Now, I'm not advocating that residents or attendings (new ones at least) adapt my technique but after you've been at this gig for 5 years or so I expect you have developed your "spidey sense" to keep you out of trouble.

Specifically, what do you bolus? Volume? Concentration? How do you know that your epidural works after doing this?

 

[BLADEMDA]

Specifically, what do you bolus? Volume? Concentration? How do you know that your epidural works after doing this?

8mls of 0.25% Bup with 100 ug Fentanyl. I place the catheter. I secure it. By the time I finish my note the patient is comfortable. All I can say is that I can feel when something isn't quite right. I know by "feel" whether there is even a possible dural "rent" or the catheter isn't going in smoothly. When in doubt (1/20 or so) I resort to the "standard" technique of Epidural placement and utilize 5-6 mls of saline instead of the bolus dose of 0.25% Bup.
I'd say after 300 or so Epidurals you probably have a good sense of what I'm talking about here. After 1,000 you definitely know what I'm talking about.

 

[vector2]

-Bicitra, reglan, pepcid for C/S. Nothing for laborers
-They can have an epidural whenever they want after the OB has admitted them. I encourage them to ask for it sooner rather than later while pre-op'ing so I don't have to deal with a screaming pt who can't sit still or follow commands
-Straight epidural for 95% of laborers (10-15cc of bupiv 0.125% bolus). CSE if they're extremely uncomfortably upon admission, i.e. delivery is imminent. CSE is 1ml of 0.25% bupiv, 20mcg fent then start the standard epidural infusion (bup 0.1%, fent 2mcg/ml, 10/5/10/40)
-plt..stable 80 for epidural. stable 60 for spinal. probably somewhat negotiable depending on habitus and expected ease of placement. won't wait for labs if they've had some labs within the last 3 months that looked good and their clinical picture hasn't changed

 

[waterhammer]

Attending for 1 year now! Been doing a lot of OB recently.
-Bicitra for all sections. Would give H2 blocker if we had it.
-Epidural when they ask.
-Rarely place CSEs. .7-1.0 ml of 0.25% bupiv when I do. Had a partner who gave everyone CSEs with fentanyl. Seemed to work well, but I usually want to know my epidural is working so I hopefully don't get called back (it's a 24h shift!)
-Hospital infusiom is 0.08% bupiv with 2mcg/ml fent. Cannot get a tailor made infusion. Start at 12 ml/hr and increase by 4 at a time if needed. Load with4-5 ml of 0.25% bupiv. Pt bolus 5 ml q15.
-No TEG available. >100 plt sure, 80-100 probably, <80 probably not.

Seems like we have at least 1 section a day for failure to progress/arrest of descent.

 

[sleepallday]

-stopped using bicitra for C/S. I personally felt it made the patients more likely to throw up.
-we place the epidurals whenever the patient wants it
-I like placing a CSE for just about everyone for the same reason PGG mentioned above. I'll use 0.25% bupi 0.6cc. No narcs, I've found that many will complain about the itching. The only issue with a CSE is that my catheter is unproven. So if the lady has an absolutely horrible airway or an increased chance of going for a section, i'll just place an epidural to give myself some peace of mind.
-epidural infusion 0.1% bupi + 2mcg fentanyl @10-14/5/30/20-24. We just got new infusion pumps that can program bolus intervals as opposed to a basal rate. I haven't tried it yet but there are a few papers showing that patients are more comfortable with this setting. (sorry to lazy to look it up now but i believe its out of northwestern)
-my threshold for platelets is similar to everyone else, 75-100 and like to see the trend.

 

[Mman]

Would give H2 blocker if we had it.

huh? Don't have it???

 

[pgg]

What's been your rate of spinal headache? I agree patients and nurses both love them.

I believe my PDPH rate is 0% ... though I admit our only follow up is a post-delivery check the next day. It's possible they develop them later and don't come back.

It's a 25 or 27 g pencil point needle so the risk's low.

7 or 8 years ago there was a study out of B&W about "dural puncture epidurals" where they routinely put a 25 g hole in the dura for every epidural, but didn't give an intrathecal dose. They had better functioning epidurals, and a lower rate of PDPH. There were some quirks to that study that make me not 100% buy off on their conclusions (namely, trainees were placing all the epidurals) but I don't really worry about PDPH with these needles.

Also, if your patient then needs a C/S for whatever reason, how do you know if your epidural will work?

They work because I place them.

More seriously, the mere fact that a needle-through-needle CSE gets CSF back is compelling evidence that the tip of the Tuohy is in the correct place.

If the catheter doesn't work, you'll know in an hour or so.

And if it doesn't work and the section gets called sooner, well, GA isn't that big a deal.


Excluding the rare high risk patient, the whole procedure is solely indicated for patient satisfaction, so I find that the speed (both onset of relief and my total time in room) make CSEs worth doing routinely.

 

[pgg]

I am also a fan of the prophylactic phenylephrine infusion via 500-1000 mcg added to the IV bag after a csection spinal. Credit to Noyac for mentioning that on this forum years ago.

 

[okayplayer]

I am also a fan of the prophylactic phenylephrine infusion via 500-1000 mcg added to the IV bag after a csection spinal. Credit to Noyac for mentioning that on this forum years ago.

Do you guys ever see bradycardia with this? I've been surprised by the reflex bradycardia elicited by even 100 mcg phenylephrine bolus in this population.

 

[pgg]

Do you guys ever see bradycardia with this? I've been surprised by the reflex bradycardia elicited by even 100 mcg phenylephrine bolus in this population.

No. The beauty of the technique is they get a true infusion, not intermittent boluses. No highs or lows in BP or HR. It's especially nice with the labile pre-E crowd.

With the NIBP only going q3min, I find the HR is a early and reliable sign of where her BP is going, so I just titrate her heart rate with the wheel thingy on the IV tubing, aiming for 70-80. If it gets down toward 60ish, I slow the drip. If it gets above 100, I open it up further or bolus another 50 or 100 with a syringe.

If I'm in hands-off mode with a resident, when the HR passes 120, I reach for the suction and the puke bag, because it's coming.

 

[loveumms]

Do you guys ever see bradycardia with this? I've been surprised by the reflex bradycardia elicited by even 100 mcg phenylephrine bolus in this population.

Nope - just like pg. said - it's beautiful and I've not seen bradycardia unless the resident gives a bolus.

 

[deleted162650]

1) Scheduled C/S w/ NPO pt will get Pepcid but no Bicitra. Bicitra just contributes to nausea for these pts. If patient is not NPO or has been laboring they get Pepcid + Bicitra. (Remember that labor slows gastric emptying, pregnancy itself does not)

2) Epidural any time pt wants it provided they have declared themselves to be in active labor. I also don't have a cutoff time. As long as pt can sit for it and OB is OK with it, I'll place it however close to delivery they are.

3) CSE for all comers for all the same reasons that PGG eloquently outlined above. I think those that have reservation with regards to the technique are basing their opinions off dogmatic arguments with little to no personal experience. To those that don't CSE regularly I challenge you to CSE your next 25 labor epidurals, and I bet you'll never go back. I use the infusion solution for everything (1/8th% Bupi + Fent 2/mL or 1/10% Bupi + Fent 2/mL) depending which hospital I'm at. I squirt 20cc into the tray and use 3-5cc for skin local, 3-5cc for LOR fluid, 2.5-3cc for IT dose via 26g Gertie Marx, thread cath and then 3-5cc via Arrow flex-tip after negative aspiration. No PDPH yet in 2 years of using this technique. Much lower rates of top offs/bolus requests than when I did straight epidurals.

4) Infusion at hosp A: Bupi 1/8% + Fent 2/mL = 8mL/hr w/ bolus dose of 6 q5min to max of 30/hr.
Infusion at hosp B: Bupi 1/10% + Fent 2/mL = 10mL/hr w/ bolus dose of 5 q5min to max of 25/hr.
Literature and anecdotal experience would suggest that 10mg of Bupi/hr is the magic number regardless of infusion concentration. Honestly though I don't
think it matters much as long as you're putting some local and some narcotic in there.

5) PLT cutoff of 75 in the absence of any clinical signs of coagulopathy. Could probably talk me into going a little lower for an SAB in the right pt. At 2am-5am cutoff is closer to 100 .

 

[inflamesdjk02]

8mls of 0.25% Bup with 100 ug Fentanyl. I place the catheter. I secure it. By the time I finish my note the patient is comfortable. All I can say is that I can feel when something isn't quite right. I know by "feel" whether there is even a possible dural "rent" or the catheter isn't going in smoothly. When in doubt (1/20 or so) I resort to the "standard" technique of Epidural placement and utilize 5-6 mls of saline instead of the bolus dose of 0.25% Bup.
I'd say after 300 or so Epidurals you probably have a good sense of what I'm talking about here. After 1,000 you definitely know what I'm talking about.

Great information, thanks!

Excluding the rare high risk patient, the whole procedure is solely indicated for patient satisfaction, so I find that the speed (both onset of relief and my total time in room) make CSEs worth doing routinely.

I'm starting to think about my technique...

To those that don't CSE regularly I challenge you to CSE your next 25 labor epidurals, and I bet you'll never go back.

I will do my next 25 with CSE and get back to you all! I've probably done about n=100 straight epidurals in the past year (as an attending). And maybe another 100 during residency.

 

[BLADEMDA]

The problem with CSE is that 50-60% of my laboring patients are obese or morbidly obese. Hence, I perform the Epidural at L1-L2 much of the time in that subgroup. I wouldn't want to puncture the dura at that level on purpose. EVen PGG has posted previously that in obese patients he prefers high lumbar or low thoracic epidurals which rules out the CSE technique.

So, rather than puncture the dura and risk a PDPH I simply bolus through the needle to obtain a very fast onset. Will it match the CSE in terms of onset? No. It takes about 3 minutes longer to get pain relief (setting up much more slowly as well than a CSE) compared to a CSE.

Too each his own as far as technique but with obesity on the rise I caution against high lumbar CSEs in these patients as it is very easy to be off by 1 or even 2 levels in these types of patients.

 

[BLADEMDA]

When preparing for spinal anesthetic blockade, it is important to find landmarks on the patient. The iliac crests usually mark the interspace between the fourth and fifth lumbar vertebrae, and a line can be drawn between them to help locate this interspace. Care must be taken to feel for the soft area between the spinous processes to locate the interspace. Depending on the level of anesthesia necessary for the surgery and the ability to feel for the interspace, the L3-4 interspace or the L4-5 interspace can be used to introduce the spinal needle. Because the spinal cord ends at the L1 to L2 level, it would not be wise to attempt spinal anesthesia at or above this level.

http://www.nysora.com/techniques/ne...es/landmark-based/3423-spinal-anesthesia.html

 

[pgg]

The problem with CSE is that 50-60% of my laboring patients are obese or morbidly obese. Hence, I perform the Epidural at L1-L2 much of the time in that subgroup. I wouldn't want to puncture the dura at that level on purpose.

You are right of course, I wouldn't do a CSE if I was going high lumbar or low thoracic.

That doesn't happen often though. As much as we gripe about obesity at my hospital, I have to admit our patient population isn't that obese. If I had to make a wild guess, probably 10% or less top 100 kg.

 

[PainDrain]

Do you guys ever see bradycardia with this? I've been surprised by the reflex bradycardia elicited by even 100 mcg phenylephrine bolus in this population.

I have seen some profound bradycardia in OB patients in response to phenylephrine bolus. I had one go down to the 20s with long pauses. I was actually worried it was impending cardiovascular collapse it was so profound.

Also, I always get a bit nervous when the HR begins to hit the 50s; specially when they get that grey-green look and start getting a bit anxious. I tend to use a few prophylactic doses of ephedrine right after the spinal is in and then use phenylephrine boluses if needed.

 

[PainDrain]

I have to admit our patient population isn't that obese. If I had to make a wild guess, probably 10% or less top 100 kg.

Really, only 10%? It's a good day when my patients are less than 100kg. Recently we have had a run of very large women. Our typical patient is 5'2" and 200 with several pushing 300-375.

 

[BLADEMDA]

Really, only 10%? It's a good day when my patients are less than 100kg. Recently we have had a run of very large women. Our typical patient is 5'2" and 200 with several pushing 300-375.

Which is why I prefer the "high epidural" approach most of the time without a dural puncture. It's my routine and I don't blink at placing Epidurals in the 120-130kg population with my approach.

 

[waterhammer]

huh? Don't have it???

Not in our cart, and most of our sections are not scheduled.

 

[waterhammer]

I am also a fan of the prophylactic phenylephrine infusion via 500-1000 mcg added to the IV bag after a csection spinal. Credit to Noyac for mentioning that on this forum years ago.

Yes, I stole this idea and works great. Have worked it into other situations, too.

 

[jwk]

Not in our cart, and most of our sections are not scheduled.

We have these wonderful people called "nurses" who get us anything we need out of the drug machine. Lots of sections aren't scheduled, but most aren't emergent.

 

[cowbydoc]

I'm a new attending and I just had a horrific day on OB. I had one problem epidural and I thought this would be a good place to do an anonymous M&M.
Healthy lady about 250# with GDM. First epidural attempt I couldn't thread the catheter with good LOR and significant midline pain when I tried to thread the catheter. So, I try again at a different interspace. Attempt #2 goes intravascular. Tachy with test dose, definitely intravascular. After an hour or two break to let the mother rest she wants me to try again. This time I'm paranoid and go very slowly with frequent checks and get a wet tap. I'm confused at the wet tap, I couldn't have been more careful and I checked for LOR very frequently. At this point I apologize and pack it in.
Any suggestions? I'm no guru but I am not bad with epidurals either. I tend to be an "overchecker" with my LOR and she might have had a very tight space but I have hardly ever had one complication, much less three. Maybe the first attempt the catheter was hitting the flavum? Thanks for the help SDN'ers.

 

[Noyac]

I'm a new attending and I just had a horrific day on OB. I had one problem epidural and I thought this would be a good place to do an anonymous M&M.
Healthy lady about 250# with GDM. First epidural attempt I couldn't thread the catheter with good LOR and significant midline pain when I tried to thread the catheter. So, I try again at a different interspace. Attempt #2 goes intravascular. Tachy with test dose, definitely intravascular. After an hour or two break to let the mother rest she wants me to try again. This time I'm paranoid and go very slowly with frequent checks and get a wet tap. I'm confused at the wet tap, I couldn't have been more careful and I checked for LOR very frequently. At this point I apologize and pack it in.
Any suggestions? I'm no guru but I am not bad with epidurals either. I tend to be an "overchecker" with my LOR and she might have had a very tight space but I have hardly ever had one complication, much less three. Maybe the first attempt the catheter was hitting the flavum? Thanks for the help SDN'ers.

Just keep plugging away. Some pts just don't get an epidural.

However, when you do get a "wet tap" inject the 10cc of NS that comes in the kit intrathecally. It will cut down the PDPH incidence way down. Not to zero but way better than without.

 

[Hoya11]

I'm a new attending and I just had a horrific day on OB. I had one problem epidural and I thought this would be a good place to do an anonymous M&M.
Healthy lady about 250# with GDM. First epidural attempt I couldn't thread the catheter with good LOR and significant midline pain when I tried to thread the catheter. So, I try again at a different interspace. Attempt #2 goes intravascular. Tachy with test dose, definitely intravascular. After an hour or two break to let the mother rest she wants me to try again. This time I'm paranoid and go very slowly with frequent checks and get a wet tap. I'm confused at the wet tap, I couldn't have been more careful and I checked for LOR very frequently. At this point I apologize and pack it in.
Any suggestions? I'm no guru but I am not bad with epidurals either. I tend to be an "overchecker" with my LOR and she might have had a very tight space but I have hardly ever had one complication, much less three. Maybe the first attempt the catheter was hitting the flavum? Thanks for the help SDN'ers.

maybe you created a hematoma with the first attempt, catheter gets into it on the second attempt, it makes the ligament harder to feel and wet tap...

 

[Noyac]

maybe you created a hematoma with the first attempt, catheter gets into it on the second attempt, it makes the ligament harder to feel and wet tap...

Now that one is new to me.

 

[PainDrain]

Here is my take on this one. First attempt you were off midline or had a false loss. Being off midline and hitting the foramen or the lamina edge can cause a loss without being able to thread the cath. Were you using a stiff cath or a flexible cath? I have threaded stiff caths into the subQ tissue and it causes the pain you are talking about. Flexible caths almost never thread into subQ tissues.

Second attempt was intravascular and it's pretty obvious. Again, a flexible cath is less likely to venture into a vessel.

Third attempt, was it a frank wet tap or just a little fluid? If it was a wet tap it would be a gush. A little fluid, like a drop, could be a pocket of local or a small amount of saline left over from your last attempt.

 

[Maverikk]

Anyone do intrathecal catheters for wet taps? Heard this was very common at select places where staffed were trained. Had a patient with a big lumbar fusion who we knew the epidural wouldn't work, did a CSE, about 1 hour later went for stat C section, epidural not working, convert to GA, mom not happy. A lot of things went wrong here. But when I think back on it wish I had done an intrathecal catheter

 

[Colba55o]

I've only had 1 wet tap so far on OB as an attending and did an intrathecal catheter. Mom was elated and said it was the best epidural she'd had. Not so happy when PDPH set in the next day

 

[narcusprince]

So, I am trying something different. I just started bolusing through the thuoy needle. From n=2 the time to adequate pain control is much decreased. Blade do you do your LOR with local or just saline?

 

[BLADEMDA]

So, I am trying something different. I just started bolusing through the thuoy needle. From n=2 the time to adequate pain control is much decreased. Blade do you do your LOR with local or just saline?

Saline- 3 mls LOR. If everything goes smoothly and the "feel" is just right I'll bolus through the needle. My technique is based on very important fact: You are experienced (N over 300 preferably 1,000) before attempting this technique as one must be able to notice subtle things during the procedure prior to the bolus.

If you think there is any chance of intravascular injection or dural rent/puncture revert to the standard "textbook" technique.

 

[IlDestriero]

I used to bolus 100 mcg of Fent through the needle before threading the catheter. It seemed to work pretty well/quickly. However that was at the old job where many women foolishly believed that they could deliver without an epidural and waited until they were dying in pain and exhausted. Sometimes I'd give it IV to chill them out.

 

[narcusprince]

I have placed close to 400 epodurals between residency and staff practicing for 4 years as staff. The interesting thing is last night I had 2 of the toughest epidurals each 20 minutes a piece. They both did quite well by the time I treaded the catheter both were happy. Almost as fast as a cse.

 

[Mman]

This time I'm paranoid and go very slowly with frequent checks and get a wet tap. I'm confused at the wet tap, I couldn't have been more careful and I checked for LOR very frequently. At this point I apologize and pack it in.
Any suggestions? I'm no guru but I am not bad with epidurals either. I tend to be an "overchecker" with my LOR and she might have had a very tight space but I have hardly ever had one complication, much less three. Maybe the first attempt the catheter was hitting the flavum? Thanks for the help SDN'ers.

Some patients have a midline ligamentous connection between their ligamentum flavum and dura at some levels of their back. It's possible in those to never actually get a LOR. You just move through one continuous ligamentous structure into their CSF. It isn't common, but my colleagues in the pain clinic notice it when injecting contrast under fluoro on some patients.

Mostly just bad luck if that happens. Not every spine has normal anatomy. On L&D we are just going blind so we never know.

I once wet tapped a lady at 4 cm depth of my needle (and she weighed 200+ lbs). She came back for a blood patch under fluoro and they noted the depth from her skin to epidural space on fluoro was only 2 cm. She had teeny tiny spinous processes.

 

[Noyac]

So, I am trying something different. I just started bolusing through the thuoy needle. From n=2 the time to adequate pain control is much decreased. Blade do you do your LOR with local or just saline?

I did it this way in the past when I had a crna in house to manage the epidural. Now I place them and go home, so I just do CSE's since I think they are safer for me to leave right after placement. How much trouble can one get into with 1cc of marcaince and 20mcg of fentanyl?

 

[Arch Guillotti]

What's been your rate of spinal headache? I agree patients and nurses both love them. But I have a partner who routinely does them for everyone and he's had 2 patients in the last couple of months come back with spinal headaches necessitating epidural blood patch. If I can bolus an epidural with 15 - 20 mL of 0.0625% bupi and get a level in 5 minutes, then I don't feel it necessary to put a hole in the dura. Also, if your patient then needs a C/S for whatever reason, how do you know if your epidural will work? For those reasons I prefer to simply place and dose the epidural.

I do a fair amount of CSE's and have never had anyone complain of pdph.

I haven't had any issues with the epidurals working for c/s either.

 

[Arch Guillotti]

Saline- 3 mls LOR. If everything goes smoothly and the "feel" is just right I'll bolus through the needle. My technique is based on very important fact: You are experienced (N over 300 preferably 1,000) before attempting this technique as one must be able to notice subtle things during the procedure prior to the bolus.

Agree with this technique only when very experienced.

 

[Arch Guillotti]

Now that one is new to me.

Me too.

 

[oldguy55]

Interesting discussion.

1. Bicitra for all C-sections. I don't like it because I think it contributes to intra-op nausea, but the group feels it is "standard of care" so we all do it.

2. Epidurals go in whenever it is clear the patient is in active labor and we are committed to delivery, or whenever the nurse is tired of dealing with her. I would like them to have at least some discomfort with contractions; the women who want an epidural "in case it hurts later" tend to believe their epidural has failed when they get to 5cm and the contractions get intense. I try hard to manage expectations by repeatedly telling them the epidural will make the contractions "less uncomfortable". Needless to say, some of them still wonder why they can feel their legs when I am finished.

3. Everyone gets a CSE.

I was a late convert to this technique, compared to my partners, i.e. just for the last 15-18 years; before that all straight epidurals. Like PGG, I finally realized that the gentle bounce of the spinal needle on the dura, followed by the slight pop through the dura, was excellent confirmation that my epidural needle was indeed in the epidural space. This reassured me that my LOR was true and I was not off the midline (easy to do when you can't feel any landmarks whatsoever). My spinal dose is 2.5mg bupivacaine and 25mcg fentanyl. After the spinal dose I inject 5ml of saline; I think it dilates the space, making intravascular catheters less likely. No data, just experience. Of course, staying in the midline would help, too, but that's not always so easy. No epidural bolus, obviously. My epidurals work; at least 500/year, 31 years. Not to say there aren't failures, but they are quite rare. I don't feel the need to wait for an epidural dose to work. I am in and out of the room in 15-20 minutes, patient loves me, nurse is happy, I am back to the OR where I belong. Many patients begin to feel numbness before I remove the spinal needle, and often don't notice the contractions anymore, by the time the catheter is in.
BTW, my PDPH rate, over approximately 8,000 CSEs, is zero, to the best of my knowledge.
Our OB population is mostly obese. Under 100kg is a treat. I use L3-4 or L2-3, or at least that's where I think I am. We are notoriously bad at judging this. L1-2 is too high for me.

4. Infusion of 0.125% bupivacaine + 2mcg/ml fentanyl at 6ml/hr, PCEA bolus of 6ml available q 20 minutes, one hour limit 18ml.
BTW, my PDPH rate, over approximately 8,000 CSEs, is zero, to the best of my knowledge.

5. My platelet cut-off for epidurals and spinals is 100k. For a really sick hip fracture I might go lower, but for elective labor epidurals I am pretty conservative.