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Discussion in 'Anesthesiology' started by Jeff05, May 6, 2008.
does anyone do combined frequently - if so, why?
does anyone rarerly/never do combined - f so, why?
We do them frequently at my hospital for L&D. Some people claim they like the confirmation that CSF gives them. My main reason is for the quick relief, because we have a lot of women who ask for epidural late.
Also for big women for mult. repeat C/S -- epidural as backup.
I'm just a resident, but I generally try not to do them for laboring women because I think it obscurs (well, delays) my ability to determine how well the catheter is working. If the lady ultimately needs a c/s, it's nice to know ahead of time if I can count on the catheter (since they all are fat and have dicey airways).
Ditto. It's a way to get a 100% effaced, 8-9 cm, 0 station late presenter comfortable quickly. We end-up doing about 1:10 CSE to regular epidural.
my collegues do them a lot. I almost never. matter of fact i only do it when it is the middle of the night and i have to replace a catheter that one of my co residents put in that isn't working or if the patient asks for it because there labor nurse has told them how great it is. i feel that i can get a women very comfortable in almost the same time frame as a cse if i give the 3 cc test dose of 1.3% lido and then 5 or 6 cc ( or whatever is left of the local for the skin in the tray)of 2% lido and then tape her up and put her on her back. I just think why nic the dura if you dont have to. and for the nay sayers i have yet to get called back for a low bp when i do it this way and i have done 120 so far.
Been doing them exclusively for labor analgesia for about 8 years. Have posted extensively on reasoning.
Understand the concern of is my catheter good? but pragmatically it hasnt been an issue. Replacing catheters is very rare in my humble experience. This is another one of those anesthesia dogmas propegated by our teaching institutions........like the fear put in residents of putting a parturient to sleep for a C section. Both are something you have to keep awareness of but in experienced hands both can be done very safely.
Regardless of initial technique (CSE vs epidural) on very rare occasion surgical analgesia will not be obtained after dosing the catheter. I think its silly to rule out CSE on this possibility happening since it can happen on a perfectly functioning labor epidural done in the traditional way as well.
Fast onset, cant remember the last time I had to use ephedrine, near-zero-chance of a high spinal since you dont haffta put in the initial 10-15 mL in the epidural space, its fast for me to do, the patients love them, the L&D nurses love'm, and I love'm.......are the main reasons I've been doing them for so long.
Another propegated academic anesthesia dogma.
I don't know how many epidurals I've done....thousands I'm sure. Don't know how many thousands.
In my experience doing the technique exclusively for years and years, PDPH incidence isnt increased by using a small SN thru the Tuohy, so saying you're not doing them because you don't want to nic the dura is not a reason to avoid the technique.
what do you put into the spinal for CSE?
we use fent 25mcg +/- 0.5mL of 0.25% bupi
Thats sad if this is some institution's dogma. There's no evidence that CSEs cause more PDPH.
I draw up 1mL .25% bupiv and squirt out just a little so I've got about .8mL + 25 mikes fentanyl.
Followed by eighth percent bupiv with fentanyl 2ug/mL at 16mL/hr.
Ropiv .2% 1mL + a cuppla mikes sufentanil for the spinal dose followed by an infusion of .2% ropiv with sufentanil .5 ug/mL ran at 12 mL/hr is the absolute bomb but unfortunately we dont have that at my current gig.
Hundreds of CSE - one reason is that you're sure that the placement of the cath. is in the perfect place..I wouldn't spoil your pleasure to read my study soon.
In the study you'll see that for thoracic epidurals is extremely safe to do CSE - sounds crazy, right?
So you actually powered the study to detect a difference in the safety outcome (I ask because this is almost never done)? People power the study for some effect outcome, but then count up adverse events on the side and, finding no difference, declare the technique is safe, when their study was probably dramatically underpowered to detect that particular difference.
Not only safety - the results - 0 failed epidurals, no complications, patient satisfaction, time to accomplish the procedure.
Of course I am subjective. The statistic guru is looking over - we'll see.
No it's been studied already.
I don't do CSE maybe i should do more.
10 min for the epidural to set in isn't that bad? or is it?
This has been discussed b/4. I do exactly as Jet described (once again).
I do them for a couple of reasons but the biggest reason is b/c I am not in-house even after placing an epidural in OB. I feel it is safer to do a very small intrathecal dose and let the epidural load by infusion over an hour while the IT dose is working then to load a large epidural dose and wait around to see if there are problems. It gets me in and out of the hospital the fastest with the least risk. Never had a PDPH with a CSE either.
Other reason is that we get called late in labor b/c most women here "want to go natural". This gets them comfy fast. 10 minutes to wait for the epidural to kick in is a long time in my book. Sometimes I'll just give them a spinal and say, OK are you comfy? Then sit still for a minute while I place your epidural.
Wow Jet, you have my attention. Compared to you, I'm way underdosing my patients when it comes to the epidural. I tend to run them at the institutional rate of 10 ml/hr. Our infusion comes premixed as Bupi 0.1% + Fentanyl 2 mcg/ml. Since I have to take a fentanyl out for the spinal, I toss in the remaining 85 mcg either into the infusion, or occasionally push it through the epidural.
However, I see your situation of coming from home. We can program our pumps to act as PCEAs, so we rarely get called to bolus the catheter, but it does happen occasionally. We are in house, so it is not a big deal. It would probably be very annoying if you had to bolus.
As you can calculate I tend to use 15 mcg Fentanyl for my CSE. I was tempted to go higher, but I was afraid of causing too much itching. How do your patients tolerate it?
One of my pet peeves is being called for a hypotensive patient (rarely happens, but still does occur) and I arrive to find the nursing staff are usually not instituting basic measures. I'm the one who has to tell them to turn the patient to her left, and to open up the IVF. I have to prod them to tell me if there are any changes in fetal heart rate since the onset of the hypotension. If I wasn't doing the initial resuscitation I might actually have time to look at the tracing myself.
How do you deal with hypotension in your hospital? Do you have written protocols? Do you have to come in for every episode?
Sorry for hijacking this thread, but you struck a curiosity nerve.
Come on cchoukal, humility is good, but be proud of your status as an anesthesiology resident. By prefacing with "just" you make it sound like you didn't have to accomplish anything to get to where you are.
I'm a resident also, a CA-3. My experience agrees with Jet's and Noyac's -- you rarely have to replace a catheter. In fact there was a abstract of a study presented at this month's SOAP conference which showed that catheters rarely have to be replaced. No significant difference between whether catheter was placed via epidural or via CSE technqiue. In fact faulty catheters placed via CSE technique tended to be replaced earlier. Perhaps this is because there was no pressure to "will" your catheter to work by trying different maneuvers. So you could argue it is probably better to do a CSE technique because you'll find out about fix any problems sooner.
Additionally, you can make the argument that if you do a CSE, you can be absolutely certain your catheter was in the right place at least at the time you placed it. What happens hours later is independent of how the catheter was placed -- if it's going to migrate, there's not much you can do about it. I just tape it up well and tell patients to avoid sliding, but rather lift their backs if they change positions.
I've been lucky so far -- I've only had to replace 2 catheters in the 3 years I've been an anesthesia resident. Both happened to be on the same night. Both were for patchy blocks.
This was discussed in a previous thread.
I do CSE's almost always. The only time I will put in an epidural is if they are super morbidley obese and/or have an exceptionally crummy airway. I will do CSE in VBAC's, preeclamptics, etc as long as their airway is reasonable.
We use 15 mcg of fentanyl as well but still a lot of women itch and end up asking for benadryl (I know it doesn't do any good) or nubain.
I actually think that bad epidurals from CSE's are recognized earlier because after the spinal dose wears off the woman is miserable iand t is obvious the epidural ain't working whereas with crappy epidurals the women get redosed continually and the catheter maybe pulled back some before someone bites the bullet and replaces it. I think I have had one or two catheters placed via CSE technique that have sucked eggs and had to be replaced 60-90 minutes later.
16 ml/hour also seems high to me, but my sample reference of residency is n=1. Most peopel seem to start out at 10/6/35, whereas I'll go 12/6/35. I don't know that I've ever seen one run over 14 cc/hr. I think that some would argue that if the woman requires that much local then it might be a crappy epidural and need to be replaced. I don't really know the answer to that one.
So if you get a squirrel at 8+ cm you will pop in a low dose spinal, then wait a few minutes and put a catheter in?
Almost. I pop in a spinal and then immediately begin to place an epidural. They get comfy so fast that i don't really wait in between.
Almost everybody gets a CSE at our institution . Mostly for institutional preference but reasoning is as follows.
1. Positive endpoint (especially helpful since this is a training program so the attending knows that the resident is in the right place.)
2. Instant gratification (also important since we're all anesthesiologists)
3. walking epidural, etc, etc, time efficient, etc, nurses are happier, don't cause as much hypotension etc.
I will consider a plain epidural in somebody who has a high chance of c-section. will also consider intrathecal catheter when I absolutely have to have a working catheter(500 pounder MP 4)
well, I just meant that I wasn't trying to pass my experience off as that of some seasoned person, but thanks for the nod...
I think the spinal catheter that someone mentioned above is intriguing when, as the poster put it, you have to have a working catheter... which is why I do the straight up epidural with no narcs. If it's in the right place, local should be sufficient, right?
Sure are a lot of you guys using the epidurals for c/s. I don't. Not even my own epidural. I pull it and put in a spinal even if they have had a CSE. Better block, no questions. It either works or it doesn't.
25 mikes is tolerated very well.
You're getting me mixed up with Noy on the home thing....I come in to place the epidural, then leave (if at nite, weekend, etc)....we have a CRNA in house at all times for redosing, hypotension, etc so I dont have to come in again for that specific epidural unless theres a C section..
Dealing with an unhelpful nursing staff is another issue. You (or someone) needs to have an eloquent talk with the head of the L&D nursing staff to see if a little more proactivity can be accomplished.
Our nursing staff in L&D receives alotta complaints about lack of support too...but I've never had a problem with them.
10mL/hr isnt enough for a .1% bupiv infusion IMHO.
I dont like the PCEA mode for labor epidurals. If you were the parturient, would you wanna haffta wake up from well needed rest every 30 minutes to push the button?
Great concept if during the day and mom is well rested but not patient friendly if she needs to sleep.
Again, my humble opinion.
Nice post that brings up another suggestion of mine:
In the rare event that a catheter isnt providing adequate analgesia, don't f uk around with it. Dont reposition the patient, pull it out a cuppla cm and retape, etc in an effort to make it work better.
Pull it ALL the way out...i.e. DC it...and place a new one.
Will save you alotta headaches and time.
Absolutely....but not as good.
Like you, I didnt use opiods either for my first few years out.
But then I saw the light.
Analgesia is definitely better with a little dope-du-jour added to your local.
In the case of one-sided blocks or poor catheters I will usually give 5 cc then pull back a couple of cm and dose some more. If that doesn't fix it, then I offer to replace it. I think it is much easier in the long run to just replace it rather than monkeying around with a crappy catheter for hours on end. Unfortunately a small percentage of women aren't gonna be happy no matter what you do, those I treat on a case by case basis and sometimes just gimp along because I know that if I replace it there will be no real difference.
Interesting. Do you do this for stat or urgent sections as well as the failure to progress/CPD sections? What dose are you giving of bupi?
I am pretty leery of this at this point in my career for the sole reason that the one time I did this and gave only 10 mg of bupi it resulted in a high spinal and had to intubate the pt. Great learning case though.
Agree, opiods soup things up quite a bit. Of course I've never used straight local.
Yes, especially for stat c/s. I don't want to be f*cking around with a questionable epidural in a stat case. I pull it and pop in a spinal. It works faster than the epidural even when I am dosing the epidural while rolling the pt to the OR.
I typically give full dose. About 13mg bupiv and 200mcg PFMS. If I am worried about a high spinal I cut the bupiv to 10mg and add some fentanyl withthe PFMS. Seems to work well, OB's like my way better or so they say and i am aware of the high spinal risk after epidural has been in place but never seen it, yet.
Had a similar case (a long time ago) where epidural put in by someone else was dosed for a C section.....inadequate surgical analgesia.....DCed it, used a lower dose of HB bupiv just like you did....high spinal.....intubated.
I'll never do that again.
Inadequate analgesia after dosing the epidural means MOMMA GETS A SNORKEL.
Any other problems? Did you wake her up after the case? What if we give isobaric bupiv? Seems like it wouldn't matter but maybe it will, anyone doing this?
Nahhh, she did fine, Noy. She woke up 45 minutes later normally.
Maybe it was unrelated but I modified the way I handle this specific situation after that.
Your approach isnt the same since your ladies are getting the (low dose) infusion for labor analgesia and you pop in a spinal.
This lady received a surgical dosing thru the epidural and enough time went by that it was obvious it wasnt gonna work....and of course she had been on an epidural infusion prior....
....so I thought I could tailor my intrathecal dose by reducing it....
didnt work so well.
I don't normally change something I do on a bad situation of n=1, but I'd rather just put momma to sleep after a full epidural dose fails to provide adequate surgical analgesia.
Put another way, I don't redo regionals that dont work.
ABSOLUTELY RIGHT! for the fat ones - when I expect a long case...(depends of the OB guy and patient previous abdominal surgeries) - I place without any problem a spinal cath. Headache - well - we have the magic for this..
Anecdotally, the really BIG parturients.....nahhhh...not referring to the 180 pounders.....I'm referring to the 280, 290,.....GASP.....300...320 pounders......blow spout care necessary....
Don't get spinal headaches.
If I hear the species-specific Orca sounds when I walk in the room for a C section I dont putz around with the 25".
I pull out the 22" spinal needle with the cutting edge...not the blunt one....which one is which? Whittacre is cutting or blunt? I can never remember...
Have yet to haffta put in a blood patch in the Free Willy group of parturients who got the big spinal needle in the back for a C section.
Interesting enough that if I was an academic dude I'd do a study and publish the results, but....uhhhhh.....my center console fishing machine is in the shop getting a sound system installed....I'd rather be in Cocodrie, Louisiana navigating my Robalo to a BULL RED hot-spot, now being able to FEEL THE GROOVE of the new sound system blurting out ARRRREE YOU READYYYYYYY!!!! (Korn) while we reel in DA FISH........over publishing.......ANY DAY OF DA WEEK!!!!
Over the next ten years of your career, Arch, you'll probably gain one full month of sleep not monkeying with this stuff in the middla the nite, and replacing it in the first place.
Please! 300 lbs is our starting point! it is RARE to have anyone below 250... We stock the 15cm "harpoon" in all our carts...
Just last night, at 4:30am, I placed an epidural in a primip who was so scared she was shaking and her husband was watching every move I made like a prison guard. Here the pts are often anti medicine but this guys weren't that bad. I did my usual CSE and placed the cath and was charting when she looked up at me from the bed and said, "Did you put some dope in there?"
I said, YEP
Talking about epidurals,
What do you do when the anesthesiologist who rounds on epidural tells you "you should order an MRI" after telling him that one pt on an epidural cannot move his legs?
Me-"Must be the local"
MD-"No I have never seen a motor block from an epidural infusion."
Me-"You know what, forget it."
To diagnose an epidural hematoma you must always maintain a high index of suspicion and any unexpected neurological finding should be taken seriously.
The most common presentation for an epidural hematoma is severe back pain but progressive weakness of the lower extremities is certainly a possible presentation.
So, if the block is too good for the amount and/or concentration of local you are using, it's not crazy to think it might be something bad.
When I pain service rounds we have had a couple of pts. with thoracic epidurals who couldn't move their legs at all. I guess neither the pt. nor the nurse (if they noticed) thought anything was weird about this. We would stop the infusion for an hour then restart at a lower rate and nobody ever had any problems.
Sometimes it is a waste of time, but there have been many times when a gimpy catheter can turn into a good one with a little volume and adjusting the catheter. i don't spend more than 15 minutes fooling with it. Since it takes me one minute to site a new one I don't worry about wasting time too much.
Here's the discussion section from a 2007 ASA abstract:
"Spinal anesthesia after failed epidural anesthesia is associated with an increased incidence of high spinal anesthesia and decreased umbilical artery pH compared to repeat epidural anesthesia. Based on these findings, when time permits repeat epidural anesthesia should be initiated after failed epidural conversion rather than spinal anesthesia. Further study is required to determine if a smaller intrathecal local anesthetic dose is associated with a decreased risk of high spinal anesthesia."
Spinal vs. Epidural Anesthesia after Failed Epidural Anesthesia for Cesarean Delivery
Alexander M. DeLeon, M.D., Cynthia A. Wong, M.D., Nicole Higgins, M.D., Robert A. McCarthy, Pharm.D.
Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
I'm not saying it's right or wrong, I'm just saying.
What do you use, a cc of 1/4% bupi or so? And do you keep them seated the whole time or do it in the lateral postition?
I assume you are doing this for squirrels that you might wet tap otherwise because they can't hold still.
You are right.
But "you should order an MRI" shouldn't be the first thing to come out of your mouth. Chances are infusion is too high. Stopping the infusion for a while should be your first thought.
Sitting the whole time.
i give 5-10 mcg sufenta + 1 ml 0.25% bupivicaine in my cse. after the sab dose, one girl said, "holy sh!t, that feels just like heroin."