Best labor epidural mix

[deleted875186]

What do people think? I’ve used 1/16% bupi with 2 mcg/mL fentanyl and it seems to be inadequate for a significant number of people (as in they have a block but no sense enough). I like 1/8%bupi with fentanyl, slightly higher chance of getting a motor block but this has never been significant. Do people like ropivicaine ain’t better?

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[deleted162650]

1/18th is really weak. I’ve used both 1/10th and 1/8th, and I think both work equally as well. Block is dependent on overall dose, not concentration with 10mg/hr being the sweet spot(of Bupi). Never used ropi, but seems like a waste of money to me.

 

[BobLoblaw78]

Ropiv 0.2% + Fent 2 mcg/ml.

Programmed intermittent boluses + PCA have made an obvious difference over previous baseline infusion + PCA for us. Have others noticed a big difference?

 

[Twiggidy]

What do people think? I’ve used 1/18% bupi with 2 mcg/mL fentanyl and it seems to be inadequate for a significant number of people (as in they have a block but no sense enough). I like 1/8%bupi with fentanyl, slightly higher chance of getting a motor block but this has never been significant. Do people like ropivicaine ain’t better?

I'm assuming you mean 1/8 th?

1/8 th is fine you just need to have
A) A properly placed epidural
B) Adequate volume, probably between a low of 10cc/hr up to 14 or even 16 cc if it's Brienne of Tarth

Also, some patients just don't tolerate "feeling things" as others

 

[deleted162650]

Brienne of Tarth

Look who’s Mr. GOT now.

 

[deleted875186]

I'm assuming you mean 1/8 th?

1/8 th is fine you just need to have
A) A properly placed epidural
B) Adequate volume, probably between a low of 10cc/hr up to 14 or even 16 cc if it's Brienne of Tarth

Also, some patients just don't tolerate "feeling things" as others

Sorry meant 1/16%. Much too dilute. At the hospital I’m at we use 1/8% and it seems to work very well.

 

[amp3r5and]

I don't do OB currently. Where I trained our std was 1/16th% bupi + 2mcg sufentanil if I remember correctly. People I think really liked the sufentanil

 

[deleted59964]

I think I'm out of step with most on this issue - I like to establish my block with some high concentration local (ie 0.25% bupi).

why -
It makes them very comfortable very quickly.
They get a motor block, - I see this as a hard sign that my epidural works... I just explain it will wear off in an hour or so.
I tell them to enjoy the numbness because the stuff they get from now on is less strong.

I tell them when the strong stuff wears off they should still be comfortable, but they'll feel more and be able to move better.
I very rarely hear anymore from them.

The dilute stuff for the infusion - I just use what everyone else uses. At my current gig it's 0.125% but soon apparently we're changing to 0.0625% - which I consider homeopathy. But I hate OB and will just go with the consensus on that.

 

[DM27]

We use 0.0625% Bupi with Fentanyl. If the patient is in pain I will generally do a 0.25% bolus, if they are not yet having significant discomfort I will do a 10-12mL load with the 0.0625% Bupi w/Fentanyl solution from the pump just to get things established.

 

[ghastly75]

in residency we used .125% Bup with fent (can’t remember amount) and just about everyone started at 10ml/hr up to 14, with some demand dosing. Seems to have been a fair bit of topping off. Of course most of those were placed by residents.
At my place now, we use Bup .0833 with fent 2mcg/ml and most women do great. It’s all attending placing and managing epidurals, not sure if related. i was skeptical but seems to do trick.

 

[deleted162650]

At my current gig it's 0.125% but soon apparently we're changing to 0.0625% - which I consider homeopathy.

Just run it at double the rate for the same end result.

 

[Block-Buster]

0.15% ropivacaine w/ 2mcg/ml fentanyl @ 10ml/hr. works great. I place the catheter then test dose with the full 5ml of 1.5% lido w/ epi, then bolus off pump with 5ml once I get it all hooked up. Sets up quickly & rarely get called back.

 

[MirrorTodd]

Eighth percent bup with 2mcg/ml fent running at 6/6/15. Course we're also at an academic center so there's room/time to play. We've also been taught to perform DPE's as well although I would frequently forget as soon as I got loss.

 

[narcusprince]

Ropi 0.2%. Bolus 5-10cc through the Tuouhy needle. 7/4/15/4. Rarely get calls on OB I don’t do OB much anymore. But that was my cocktail when I was busier.

 

[deleted59964]

Eighth percent bup with 2mcg/ml fent running at 6/6/15. Course we're also at an academic center so there's room/time to play. We've also been taught to perform DPE's as well although I would frequently forget as soon as I got loss.

what does 6/6/15 mean? not common nomenclature here - thanks

 

[MirrorTodd]

what does 6/6/15 mean? not common nomenclature here - thanks

Rate of 6ml/hr, 6ml pcea bolus, every 15 minutes

 

[deleted59964]

Rate of 6ml/hr, 6ml pcea bolus, every 15 minutes

thank you

 

[Noyac]

We use 0.1% ropiv with 2mcg/cc fent at 6cc/hr with PCEA. I’m not saying it’s the best but it works well for us.

But my favorite thoracic concoction is 0.1% ropiv or bupiv with Demerol 100mcg/cc. The Demerol is awesome in epidural because it adds to the local anesthetic effect without motor block and it has analgesia on top of that.

 

[epidural man]

Does anyone find it strange that we have all decided to use long acting local anesthetic for infusions?

What if there was a remi-like local anesthetic? That would be a great infusion drug that could take away the need for a bolus.

What would be cool is a differential pump that could run a short acting local infusion with a long acting bolus.

 

[Hoya11]

Does anyone find it strange that we have all decided to use long acting local anesthetic for infusions?

What if there was a remi-like local anesthetic? That would be a great infusion drug that could take away the need for a bolus.

What would be cool is a differential pump that could run a short acting local infusion with a long acting bolus.

im not following you, yes it makes sense that we use long acting local anesthetic, why would you want a remi-like local anesthetic ( like lido or cpc) ?

 

[deleted162650]

Take home point:

As long as there is some local with a little bit of opioid it really doesn’t matter.

 

[facted]

We use 0.1% bupi with 2mcg/fent and run it at 12ml/hr. We are working on switching our pumps to PIEB.

I load with 14ml of .07% bupi (10 saline, 4 0.25%). I very rarely get called back. But agree with the others that it really depends on who's doing the epidural and that there are a lot of ways to skin a cat.

But I'm a strong believer in less dilute local and more volume, and most importantly, setting the proper expectations. You load with heavy local or a CSE and pts will expect that level of comfort throughout and you're setting yourself up for trouble IMO.

 

[Twiggidy]

Does anyone find it strange that we have all decided to use long acting local anesthetic for infusions?

What if there was a remi-like local anesthetic? That would be a great infusion drug that could take away the need for a bolus.

What would be cool is a differential pump that could run a short acting local infusion with a long acting bolus.

It's not so much the duration of action as it is the anesthetic profile, ie, low dose bupiv gives a sensory block. While Bupivacaine is long acting , per se, if you turn off that infusion or it's disconnected for some reason, they'll be hurting within a half hour.

 

[Noyac]

Is anyone using the PIEB technique ( programmed intermittent epidural bolus) rather than the continuous infusion?

 

[Twiggidy]

Is anyone using the PIEB technique ( programmed intermittent epidural bolus) rather than the continuous infusion?

Not here but I’ve read some papers where they claim patients get increased pain relief

 

[deleted162650]

I'd like to try it, but I've never been at a facility with pumps that were able to do PIEB.

 

[facted]

Is anyone using the PIEB technique ( programmed intermittent epidural bolus) rather than the continuous infusion?

We are moving to it. Have to upgrade the pumps...

 

[Noyac]

We are moving to it. Have to upgrade the pumps...

Can you elaborate? Why are you going this route? What is your current epidural potion and what are you trying to remedy?

 

[facted]

Can you elaborate? Why are you going this route? What is your current epidural potion and what are you trying to remedy?

See above for our current protocol. I think it works pretty well, actually. But there is a pretty good evidence that PIEB is a superior technique which is why we're gonna implement it.

 

[13merryberry]

We use 0.04% bupi with 1.6 mcg/cc fentanyl. Run it at 15 cc/hr with PCEA for 10 cc bolus q20 min. We also do like 80% CSEs. About 1/3-1/2 of women need a single bolus of 1/8 with 100 mcg fentanyl during an intense part of labor or for sacral sparing, but we have a 24 hour dedicated OB service so this can easily be accommodated. Other than that it works great for the vast majority with no motor block at all and no fetal bradycardia.

 

[narcotics999]

We use 0.04% bupi with 1.6 mcg/cc fentanyl. Run it at 15 cc/hr with PCEA for 10 cc bolus q20 min. We also do like 80% CSEs. About 1/3-1/2 of women need a single bolus of 1/8 with 100 mcg fentanyl during an intense part of labor or for sacral sparing, but we have a 24 hour dedicated OB service so this can easily be accommodated. Other than that it works great for the vast majority with no motor block at all and no fetal bradycardia.

We use 0.04% bupi with 1.6 mcg/cc fentanyl. Run it at 15 cc/hr with PCEA for 10 cc bolus q20 min. We also do like 80% CSEs. About 1/3-1/2 of women need a single bolus of 1/8 with 100 mcg fentanyl during an intense part of labor or for sacral sparing, but we have a 24 hour dedicated OB service so this can easily be accommodated. Other than that it works great for the vast majority with no motor block at all and no fetal bradycardia.

That is the lowest bupi I have ever seen.

1/3 - 1/2 needs bolus makes my head spin. 24 hours availability does not mean the ob anesthesiologist has to wake up to give a bolus at 3am.

 

[facted]

That is the lowest bupi I have ever seen.

1/3 - 1/2 needs bolus makes my head spin. 24 hours availability does not mean the ob anesthesiologist has to wake up to give a bolus at 3am.

50% of pts need a top-up? You guys should re-examine your infusion, no matter how many people you have on call to do said top-ups.

 

[deleted875186]

50% of pts need a top-up? You guys should re-examine your infusion, no matter how many people you have on call to do said top-ups.

Agreed, my experience with 1/16th % is that many people will need a stronger concentration at some point during labor. Running 1/8%, there are less tip offs and many more people that just coast on the PIEB setting without any intervention.

 

[woopedazz]

Where I am we just use 0.2% Ropivacaine for epidurals:
Test dose with it, then load them up with 15-20mL and get them comfy and go through how a PCEA works, then put them on a PCEA with 7mL bolus and 15min lockout. No continuous infusion. No opioid. Works well.
Extremely rare to need to go see the patients once it's in unless... it isn't actually in.

 

[okayplayer]

Where I am we just use 0.2% Ropivacaine for epidurals:
Test dose with it, then load them up with 15-20mL and get them comfy and go through how a PCEA works, then put them on a PCEA with 7mL bolus and 15min lockout. No continuous infusion. No opioid. Works well.
Extremely rare to need to go see the patients once it's in unless... it isn't actually in.

No hypotension with that loading dose?

 

[woopedazz]

No hypotension with that loading dose?

Nope. Also the test dose is included in the 15-20mL.

 

[Block-Buster]

A test dose should have epi, otherwise what's positive test for intravascular? neurologic symptoms? seems weird.

 

[BobLoblaw78]

Is anyone using the PIEB technique ( programmed intermittent epidural bolus) rather than the continuous infusion?

I’ve been using PIEB for several years. It makes an obvious difference. I run 0.2% ropiv with fent. 6 ml every 30 min. Plus pca of 5 ml. Do it. You’ll love it!!

 

[narcotics999]

I’ve been using PIEB for several years. It makes an obvious difference. I run 0.2% ropiv with fent. 6 ml every 30 min. Plus pca of 5 ml. Do it. You’ll love it!!

How is this superior to 12cc/hr continuous infusion with 5cc pcea?

 

[13merryberry]

"1/3 - 1/2 needs bolus makes my head spin. 24 hours availability does not mean the ob anesthesiologist has to wake up to give a bolus at 3am."

"50% of pts need a top-up? You guys should re-examine your infusion, no matter how many people you have on call to do said top-ups."

--------

The thinking of my division chief is that the low concentration/high volume is adequate for >50% of women, so using a higher concentration would be overdosing over half our patients. The patients never get too numb to move around and could definitely walk if we let them. I've never had an epidural myself but from talking with patients, most women really love the light touch with the medication since a lot of them are scared of "being too numb" and find any degree of motor block unnerving and uncomfortable.

Yeah our solution is very dilute, and yes while most women who need top ups only need one, it can add up on the busy floor. That being said, when I was a resident I only occasionally got woken up at night to give a bolus, and even then usually only one time. I think due to the high infusion rate and high volume allowed for the PCEA boluses the solution works better than you'd expect, and I actually don't know the real numbers on how many patients need boluses, and how many...I could be overestimating.

But I mean yeah I agree, it is more labor intensive, just not really as much as a lot of people are imagining haha.

 

[woopedazz]

A test dose should have epi, otherwise what's positive test for intravascular? neurologic symptoms? seems weird.

The hospitals I've worked at haven't used epi in test doses for over a decade. I understand it's a big thing in the US; and I'm not sure what the rest of this country does.

 

[BobLoblaw78]

How is this superior to 12cc/hr continuous infusion with 5cc pcea?

Because it gives 6 ml over a couple of seconds, every 30 min. Where 12 ml per hour drips in slowly with a continuous infusion.

Ask yourself why it works when you go top off a patient with a bolus. The medicine is under higher pressure and is forced into every area of the spinal cord/nerve roots. A slow infusion goes slowly and takes the path of least resistance, likely one or two directions. Think of it as a river with tributaries. Big bolus floods all tributaries. Slow flow never gets pushed to the tributaries/nerve roots.

 

[BobLoblaw78]

"50% of pts need a top-up? You guys should re-examine your infusion, no matter how many people you have on call to do said top-ups."

--------

The thinking of my division chief is that the low concentration/high volume is adequate for >50% of women, so using a higher concentration would be overdosing over half our patients.

Women love epidurals. If only 50% are loving their epidural and the other 50% are asking for a top-up (ie not satisfied) something is wrong. That would be like giving light anesthesia and 50% love not being as groggy afterwards. But the other 50% are waking up during surgery and asking for more anesthesia! Lol

I imagine something is getting misunderstood about your situation but it is something to consider if not.

 

[facted]

The hospitals I've worked at haven't used epi in test doses for over a decade. I understand it's a big thing in the US; and I'm not sure what the rest of this country does.

It's not a test dose without epi, as said above. 1 or 2 ml intravascular lido won't necessarily give pts neuro symptoms but the epi in there will certainly increase the HR.

What's the rationale for no epi? It's pretty much standard of care in the US.

 

[facted]

"1/3 - 1/2 needs bolus makes my head spin. 24 hours availability does not mean the ob anesthesiologist has to wake up to give a bolus at 3am."

"50% of pts need a top-up? You guys should re-examine your infusion, no matter how many people you have on call to do said top-ups."

--------

The thinking of my division chief is that the low concentration/high volume is adequate for >50% of women, so using a higher concentration would be overdosing over half our patients. The patients never get too numb to move around and could definitely walk if we let them. I've never had an epidural myself but from talking with patients, most women really love the light touch with the medication since a lot of them are scared of "being too numb" and find any degree of motor block unnerving and uncomfortable.

Yeah our solution is very dilute, and yes while most women who need top ups only need one, it can add up on the busy floor. That being said, when I was a resident I only occasionally got woken up at night to give a bolus, and even then usually only one time. I think due to the high infusion rate and high volume allowed for the PCEA boluses the solution works better than you'd expect, and I actually don't know the real numbers on how many patients need boluses, and how many...I could be overestimating.

But I mean yeah I agree, it is more labor intensive, just not really as much as a lot of people are imagining haha.

Do you let your patients walk? If not, what's the point of such a light epidural? There's a huge area between your dilute solution and something so strong that patients are routinely numb in their legs. We use .1% and our pts don't typically complain of numbness and they're very happy with their epidural. I say maybe 10 or 20% need a top-up (in a very demanding population).

Check the literature, your solution and top up rates seem very unusual.

 

[Hoya11]

A test dose should have epi, otherwise what's positive test for intravascular? neurologic symptoms? seems weird.

There are some who believe that the test dose is only intended to rule out an intrathecal placement. And that if you were truly intravascular "you would see blood" when you aspirate or out of the needle. I think there is a lot of truth to that.

 

[deleted875186]

There are some who believe that the test dose is only intended to rule out an intrathecal placement. And that if you were truly intravascular "you would see blood" when you aspirate or out of the needle. I think there is a lot of truth to that.

I disagree, the catheter is tiny. How many times have you placed a small gauge IV and been able to aspirate blood from it?

 

[deleted50478]

It's not a test dose without epi, as said above. 1 or 2 ml intravascular lido won't necessarily give pts neuro symptoms but the epi in there will certainly increase the HR.

What's the rationale for no epi? It's pretty much standard of care in the US.

False. You don’t need a test dose at all. It certainly isn’t standard of care.

 

[deleted50478]

How is this superior to 12cc/hr continuous infusion with 5cc pcea?

You get better spread with intermittent bolus vs slow continuous infusion. Not only do you get a better epidural from the same dose, you can even end up needing fewer boluses (hand or pcea) because better spread -> less pain -> fewer boluses.

 

[Block-Buster]

There are some who believe that the test dose is only intended to rule out an intrathecal placement. And that if you were truly intravascular "you would see blood" when you aspirate or out of the needle. I think there is a lot of truth to that.

By that logic, wouldnt you also always aspirate csf if it was intrathecal? I agree that most of the time you will be able to aspirate blood or csf but not ALWAYS. If it's good enough for Chestnut, it's good enough for me. I'll stick with the 3ml lido 1.5% w/ 5mcg/ml epi.