Best labor epidural mix

[facted]

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

Good luck with that on the witness stand. I would be willing to bet the plaintiff will find plenty of witnesses to say that it is the standard and that you not giving it was pure laziness.

 

[deleted162650]

Good luck with that on the witness stand. I would be willing to bet the plaintiff will find plenty of witnesses to say that it is the standard and that you not giving it was pure laziness.

Not true. The busiest women’s center here locally does not test dose. The literature supporting it is very poor. If you are using a soft spring wound catheter, there’s no need. I do think you should test dose if you are using the stiff monofilament type catheters as those will poke their way into anything (giggidy).

Has anyone here ever had a “surprise” intravascular catheter using a soft spring wound cath? (i.e. no visible blood wicking up the cath or blood via the Tuohy)

 

[DocVapor]

Not true. The busiest women’s center here locally does not test dose. The literature supporting it is very poor. If you are using a soft spring wound catheter, there’s no need. I do think you should test dose if you are using the stiff monofilament type catheters as those will poke their way into anything (giggidy).

Has anyone here ever had a “surprise” intravascular catheter using a soft spring wound cath? (i.e. no visible blood wicking up the cath or blood via the Tuohy)

Yes. Arrow kit. Absolutely no blood in catheter or Touhy. 3 ml test dose, HR within seconds jumps from 80 to 140, patient says "I feel wierd." BP happens to be cycling at the time, BP jumped too, forgot the numbers.

I will always test.

 

[facted]

Not true. The busiest women’s center here locally does not test dose. The literature supporting it is very poor. If you are using a soft spring wound catheter, there’s no need. I do think you should test dose if you are using the stiff monofilament type catheters as those will poke their way into anything (giggidy).

Has anyone here ever had a “surprise” intravascular catheter using a soft spring wound cath? (i.e. no visible blood wicking up the cath or blood via the Tuohy)

Out of curiosity, what's your reason for not testing?

 

[deleted50478]

Do automated mandatory boluses of epidural medications provide superior labour pain relief than basal infusion? | Cochrane

www.cochrane.org

Epidural test dose in obstetric patients: should we still... : Current Opinion in Anesthesiology

ent guidelines do not provide clear recommendations in this regard and several recent surveys indicate a heterogeneity in clinical routine. Summary Physiological alterations during pregnancy and labour restrict the use and also the validity of traditional test agents. Epinephrine is not...

journals.lww.com

 

[Noyac]

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.

I agree. I like my Test dose. I think it adds to initial onset of the pain relief and it tells me a few things about my catheter. If I can’t aspirate blood from the catheter but the heart rate goes up with a TD then I may actually start the infusion assuming I got good pain relief after placement. I assume that the TD is absorbing into the blood stream because of a breach while placing the catheter or needle but that the catheter may not be intravascular. It usually ends up working fine. In my experience, if your catheter is in a vessel then you will be able to aspirate blood.

 

[deleted59964]

I had one the other day - could aspirate blood like the catheter was in the jugular!

 

[Hoya11]

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.

I do the traditional test dose too because why not? But think about it: if i was truly in a blood vessel and i give the test dose, the blood vessel is injected with 15mcg of epi - what heart rate change can you expect with that? If the patients heart rate increases by 10 bpm are you going to pull the catheter with a negative aspiration? what about 20bpm? 50? I typically only care that the legs still move after I give the test dose.

 

[woopedazz]

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.

What this guys says below:

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.

The recent obstetric literature agrees with it too.

 

[DrZzZz]

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'm with you. I trained with the stiff catheters. I've never had a positive test dose because every time it was intravascular, blood started filling up the catheter and I didn't even bother test dosing it. You didn't even need to aspirate. Now, my gig uses the soft spring catheters. I've yet to place one of these in a vessel. Our kit only has plain lido and that's what the group has been using for a "test dose" for years and haven't had an issue because of the lack of epi. Basically only looking for intrathecal placement.

 

[Noyac]

I had one the other day - could aspirate blood like the catheter was in the jugular!

Maybe you shouldn’t thread the catheter in so far. 😉

 

[deleted875186]

I honestly see no harm in giving the test dose with epi, makes me feel better.

Also for anyone having read any of the literature on test doses for intravascular catheters, what’s the gold standard for identifying an intravascular catheter?

 

[Noyac]

I honestly see no harm in giving the test dose with epi, makes me feel better.

Also for anyone having read any of the literature on test doses for intravascular catheters, what’s the gold standard for identifying an intravascular catheter?

You mean the air injection isnt the gold standard?

 

[Twiggidy]

I honestly see no harm in giving the test dose with epi, makes me feel better.

Also for anyone having read any of the literature on test doses for intravascular catheters, what’s the gold standard for identifying an intravascular catheter?

How about this for urban legends.......An attending of mine told the story of a lady who got a test dose with undiagnosed CAD. Epi went intravascular, HR goes sky high, enough so to case ST-elevation. Stat C/S and a trip to the cath lab later.....

Now, could it be attending wive's tale vs an actual incident? Who knows? But despite the horror story I still test dose "most" of the time.

 

[abolt18]

How about this for urban legends.......An attending of mine told the story of a lady who got a test dose with undiagnosed CAD. Epi went intravascular, HR goes sky high, enough so to case ST-elevation. Stat C/S and a trip to the cath lab later.....

Now, could it be attending wive's tale vs an actual incident? Who knows? But despite the horror story I still test dose "most" of the time.

15mcg of epi... Doesn't seem plausible! My vote is for old attending's wives tale.

 

[Twiggidy]

15mcg of epi... Doesn't seem plausible! My vote is for old attending's wives tale.

I mean if the CAD is bad enough. I mean IF true (and I tend to agree with you in that it's a big IF) the labor alone could have given her a heart attack. i've seen 10 mcg of epi have a HR go from 60 to 160 and that could easily give a positive stress test

But yes, about 70-80% of me vote's wive's tale

 

[deleted875186]

I mean if the CAD is bad enough. I mean IF true (and I tend to agree with you in that it's a big IF) the labor alone could have given her a heart attack. i've seen 10 mcg of epi have a HR go from 60 to 160 and that could easily give a positive stress test

But yes, about 70-80% of me vote's wive's tale

Risk benefit. The very low likelihood of a young-middle aged woman not tolerating a heart rate in the high 100s, versus the morbidity of an undiagnosed intravascular catheter.

 

[deleted50478]

Risk benefit. The very low likelihood of a young-middle aged woman not tolerating a heart rate in the high 100s, versus the morbidity of an undiagnosed intravascular catheter.

Risk benefit. Say it’s not intravascular it’s intrathecal. You’d rather give 3cc of 1.5% lidocaine c epi ‘test dose’ than the first 3cc of your 0.1% bupivicaine bolus?

 

[deleted875186]

Risk benefit. Say it’s not intravascular it’s intrathecal. You’d rather give 3cc of 1.5% lidocaine c epi ‘test dose’ than the first 3cc of your 0.1% bupivicaine bolus?

Don’t see a huge difference. I will catch both intrathecal injections. But yes there would be more profound changes with the test dose.

Devils advocate, you give 3 cc dilute bupi and don’t realize it’s intravascular because nothing happens. Then what?

 

[Twiggidy]

The real fact is that we use a test dose because the dose of both medicines involved are low dose enough to catch a misplaced catheter but not in a high enough dose (outside my fairy tale) to cause any real damage, whether intravascular or intrathecal.

 

[deleted59964]

I never test dose with epi ... have never had a problem, seems pretty easy to spot intravascular catheters to me.

 

[deleted162650]

Don’t see a huge difference. I will catch both intrathecal injections. But yes there would be more profound changes with the test dose.

Devils advocate, you give 3 cc dilute bupi and don’t realize it’s intravascular because nothing happens. Then what?

You go back to replace the catheter in an hour when the patient is still in pain and has no level.

 

[Twiggidy]

You go back to replace the catheter in an hour when the patient is still in pain and has no level.

Boom

 

[13merryberry]

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.

They aren’t unhappy with them at all, some just need a bonus after their water breaks or at the start of second stage. They like being able to move around and assist in their own labor instead of their legs being dead weight. We also do mostly CSEs, which gets them to a good place to start off from.

It’s fine to be skeptical but there’s certainly nothing being “misunderstood” by my division chief.

 

[BobLoblaw78]

They aren’t unhappy with them at all, some just need a bonus after their water breaks or at the start of second stage. They like being able to move around and assist in their own labor instead of their legs being dead weight. We also do mostly CSEs, which gets them to a good place to start off from.

It’s fine to be skeptical but there’s certainly nothing being “misunderstood” by my division chief.

I meant “I imagine something is getting misunderstood about your situation” by myself. But if I’m not misunderstanding it, then I would consider changing it.

It’s hard to give accurate description by writing and I assumed your group knew what it was doing.

 

[IlDestriero]

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

It’s Dame Brienne of Tharth to you, punk!