walking epidurals

[GA8314]

Anyone doing these in L&D or for regular OR's.

One of our general surgeons asked about this for an open colectomy patient. Our policy is no ambulation with epidurals but we are running 0.1% bupivacaine +/- fentanyl 2mcg/ml (yeah an odd dose but it comes from a compounding pharmacy and that's the concentration they had available).

She's like "My patients need to ambulate". She has a point. Anyone doing this at their place?
I told her it's o.k. at that low dose and if motor involvement exists then we can lower the rate and ambulation should be with assistance of course with epidural in place, but we don't really have a policy in place.

I'll check ERAS also to see what's going on outside of our smaller community hospital.

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[psychbender]

Ambulation with a thoracic epidural should not be a huge issue at lower rates. At 6-8mL/hr, with a T8-10 insertion, there should be little, if any, leg weakness. I tell them to ambulate only with assistance, and encourage the surgical team to get them moving.

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[vector2]

Our institution thinks it's a liability nightmare, but a colectomy should probably have epidural placed at T8-10 and I'd personally have no problem letting those walk with assistance.

 

[urge]

Anyone doing these in L&D or for regular OR's.

I trained at a place that supposedly did walking epidurals for OB. I never saw anyone walking. The women kept asking for more top offs until their legs went numb.

If you insist on people walking eventually someone will fall, regardless of the epidural.

 

[OB1🤙]

We absolutely let everyone with a thoracic epidural for abdominal surgery walk (supervised).

Did in training, do in practice.

I usually run .0625% bupi with some dilaudid or fentanyl or whatever.

I let them take the Foley out too.

 

[Noyac]

Those pts need to walk thats the reason we put epidurals in them.

 

[Hoya11]

We allow walking with .0625 percent. But my own feeling is this is too weak and we are Pleasing the surgeons at the patients expense. It it were me, give me the .1 percent at least and make me comfortable as I lay in bed all day. Why do they need to walk on pod 1? Is there any evidence that it's better than pod 2 when we take the catheter out? I'd prefer in bed with heavy analgesia on pod 0 and 1 and then once the catheter is out and pain not so bad, ambulate pod 2. Surgeons just want them out of the hospital and don't care about pain control

 

[Hoya11]

We absolutely let everyone with a thoracic epidural for abdominal surgery walk (supervised).

Did in training, do in practice.

I usually run .0625% bupi with some dilaudid or fentanyl or whatever.

I let them take the Foley out too.

That's because .0625 is too weak. Great ambulation, poor pain control

 

[GA8314]

We have 0.1% bupivacaine plus/minus 2mcg/ml fentanyl on formulary from a compounder who supplies are pump cartridges.

Would you guys advocate using the narcotic or not? I see value in the narcotic because of the synergy and less need for IV narcs. However, I also see the flip side of covering our a$$ so as not to be blamed for being overly narcotized.

ERAS seems to suggest (for colorectal cases) ambulation on POD1 with epidural and without foley (pulled POD1). Transferred to PCA on POD2, and epidural pulled before 72 hours (after 48hrs).

Thoughts?

 

[OB1🤙]

That's because .0625 is too weak. Great ambulation, poor pain control

Oh OK cool. You should come out here and let my patients know they're supposed to be in pain then.

 

[GA8314]

We absolutely let everyone with a thoracic epidural for abdominal surgery walk (supervised).

Did in training, do in practice.

I usually run .0625% bupi with some dilaudid or fentanyl or whatever.

I let them take the Foley out too.

Do they get IV narcs simultaneous to epidural narcs? (I realize that's likely a bunch of dogma but just want to know).

Do you pull the foley POD1 and ambulate POD1 also?

 

[fakin' the funk]

We absolutely let everyone with a thoracic epidural for abdominal surgery walk (supervised).

Did in training, do in practice.

I usually run .0625% bupi with some dilaudid or fentanyl or whatever.

I let them take the Foley out too.

This, times a bajillion.

Dilute epidural bupivacaine +/- fentanyl in a thoracic distribution ought not to cause issues with leg weakness or urinary retention.

And if it is, get the damn thing out because the epidural is now an obstacle to recovery.

 

[fakin' the funk]

That's because .0625 is too weak. Great ambulation, poor pain control

No

At least not with a well-functioning epidural

 

[fakin' the funk]

We have 0.1% bupivacaine plus/minus 2mcg/ml fentanyl on formulary from a compounder who supplies are pump cartridges.

Would you guys advocate using the narcotic or not? I see value in the narcotic because of the synergy and less need for IV narcs. However, I also see the flip side of covering our a$$ so as not to be blamed for being overly narcotized.

Depends on how good your epidural is and if it's covering 95% of the surgical pain. If it is, I leave the fentanyl in. If there's any question someone's gonna want to give IV opioids, I take the opioid out of the epidural infusion. Not because it's physiologically mandated, but to cover your a$$ like you said.

 

[fakin' the funk]

ERAS seems to suggest (for colorectal cases) ambulation on POD1 with epidural and without foley (pulled POD1). Transferred to PCA on POD2, and epidural pulled before 72 hours (after 48hrs.

My approach with ERAS is that rah-rah, cheerleading, get your a$$ outta bed, remove obstacles to such (Foley, PCA) is the key to shortening LOS and avoiding postop complications. So I would say pull that epidural ASAP. At my place we do < 5-10% of our ERAS cases planned open so the N is super small.

 

[Urzuz]

We have 0.1% bupivacaine plus/minus 2mcg/ml fentanyl on formulary from a compounder who supplies are pump cartridges.

Would you guys advocate using the narcotic or not? I see value in the narcotic because of the synergy and less need for IV narcs. However, I also see the flip side of covering our a$$ so as not to be blamed for being overly narcotized.

ERAS seems to suggest (for colorectal cases) ambulation on POD1 with epidural and without foley (pulled POD1). Transferred to PCA on POD2, and epidural pulled before 72 hours (after 48hrs).

Thoughts?

I 100% believe you should put an adjunct into every epidural mixture unless the patient is having side effects or there is another contraindication. The data is unequivocal that pain control is better. Though there is an increased risk of oversedation, as long as the patient isn't getting slammed with other IV opioids or sedatives, there shouldn't be a problem with respiratory depression. To make sure this doesn't happen, the anesthesiologist should take the point in managing a patient's postoperative pain while the epidural is running. If the patient does require a lot of IV opioids in addition to your epidural, then your epidural isn't working correctly and should either be troubleshot or pulled.

 

[Hoya11]

Oh OK cool. You should come out here and let my patients know they're supposed to be in pain then.

You may be right, but maybe they aren't in that much pain to begin with (good surgeon technique), or maybe they are in pain at times you are not aware of. I wonder how 0.0625% would fly in OB. Does anyone use this in OB?

 

[partydoc]

I used it once in an AS patient, she got comfortable

 

[polar403]

You may be right, but maybe they aren't in that much pain to begin with (good surgeon technique), or maybe they are in pain at times you are not aware of. I wonder how 0.0625% would fly in OB. Does anyone use this in OB?

I've used 0.125% bupivacaine with no narcotic for labor epidurals successfully with no issues. It's roughly equivalent to 0.2% ropivacaine. It would stand to reason that 0.0625% bupiv with fentanyl would be fine, but why expose the laboring patient and newborn to fentanyl when plain, dilute, local anesthetic works perfectly well?

A comparison of 0.0625% bupivacaine with fentanyl and 0.1% ropivacaine with fentanyl for continuous epidural labor analgesia.
http://www.ncbi.nlm.nih.gov/pubmed/11323358

Comparison Between the Use of Ropivacaine Alone and Ropivacaine With Sufentanil in Epidural LaborAnalgesia
http://www.ncbi.nlm.nih.gov/pubmed/26512604

I realize both studies aren't perfectly applicable to what we are talking about, but it's food for thought.

 

[GA8314]

Ambulation with a thoracic epidural should not be a huge issue at lower rates. At 6-8mL/hr, with a T8-10 insertion, there should be little, if any, leg weakness. I tell them to ambulate only with assistance, and encourage the surgical team to get them moving.

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What solution do you use?

 

[GA8314]

Those pts need to walk thats the reason we put epidurals in them.

What solution do you use?

 

[Noyac]

Ropiv 0.1% with 2mcg/cc fentanyl usually.

 

[psychbender]

Bupivicaine 0.125% or ropivacaine 0.2%.

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[Laryngophed]

Ropiv 0.1% with 2mcg/cc fentanyl usually.

What he said.