CSE for labor analgesia, dosing?

[acidbase1]

typically the only time I administer an intrathecal dose is if patient is near complete, progressing quickly, or extreme discomfort. I use hyperbaric bupivicaine @ 7.5 mg. My question is how do you dose your epidural thereafter?

My typical standard epidural dosing (no intrathecal) is 8cc 0.125% marcaine throughly the tuohy then another 8cc 0.125% through the epidural catheter plus 100mcg of fentanyl.

After performing CSE with the 7.5mg intrathecal, I give 8cc (0.125%) through the catheter with 100mcg of fentanyl. I worry about over dosing with the intrathecal dose, would doing another 8cc through the tuohy be excessive?

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[Noyac]

I think your initial 8cc after the intrathecal dose is unnecessary, much less the 8cc through the catheter.

I give 3/4cc of 0.25% marcaine with 20mcg fent intrathecal and just start the pump once attached to the catheter.

 

[pgg]

7.5 mg is a really large intrathecal dose for labor analgesia. I mean, you're most of the way to a surgical block with that. I'm surprised your patients who are near complete can push with that dose.

With a fast surgeon I'll do 1.2 mL of 0.75% bupivacaine + 15 mcg fentanyl, which is only 9 mg. For a c-section.

For labor analgesia, I think most of the people I know are using things like
- 1 mL of 0.25% (2.5 mg) maybe with 15-25 mcg of fentanyl
- 0.5 mL of 0.5% (2.5 mg) maybe with 15-25 mcg of fentanyl
- 2 mL of the 0.125% bupiv + 2 mcg/mL fent infusion mix (2.5 mg)
or thereabouts.

 

[deleted162650]

2.5cc of the 1/8th bupi + 2mcg/mL fent bag solution IT and another 3-5cc through the cath. Set pump. Leave.

 

[Twiggidy]

2.5cc of the 1/8th bupi + 2mcg/mL fent bag solution IT and another 3-5cc through the cath. Set pump. Leave.

Ditto this.

The doses in the OP are way too high.

 

[acidbase1]

Much appreciated. That was my thought. Interestingly enough it’s worked well and hemodynamics have been stable. As mentioned, I rarely do them unless absolutely necessary

 

[Twiggidy]

Much appreciated. That was my thought. Interestingly enough it’s worked well and hemodynamics have been stable. As mentioned, I rarely do them unless absolutely necessary

I think most replies are comparing it to starting a grill with a flame thrower when a match will do. Although I guess the flame thrower is more fun.

 

[acidbase1]

Anyone use ropivicaine 0.2% for their infusions? What about a 2cc intrathecal dose of this with 2mcg of fentanyl?

 

[Mman]

for the rare occasions I do a CSE, I use 1 ml of 0.25% bupivacaine for my intrathecal dose. It's enough to quickly take the edge off those contractions but almost never has any significant hemodynamic change. Over the next 2 minutes while I'm threading the catheter and cleaning things up I will then assess whether or not I need to give any additional bolus through the catheter.

 

[Iso4ane]

One new thing that I heard that is making rounds is the Dural Puncture Epidural (DPE). You do the dural puncture, but don't dose those spinal. Then just run the epidural normally. Supposedly more effective and helps with confirmation of epidural space in those weird LoRs.

 

[deleted162650]

One new thing that I heard that is making rounds is the Dural Puncture Epidural (DPE). You do the dural puncture, but don't dose those spinal. Then just run the epidural normally. Supposedly more effective and helps with confirmation of epidural space in those weird LoRs.

Sorry, but if she’s gettin’ a labor epidural then it’s too late for the pull out method.

This is like the technique I would use if I was trying to talk the girl into a CSE:
“Come on baby. Okay, what if I just put in the tip? I won’t even finish.”

 

[sigrhoillusion]

One new thing that I heard that is making rounds is the Dural Puncture Epidural (DPE). You do the dural puncture, but don't dose those spinal. Then just run the epidural normally. Supposedly more effective and helps with confirmation of epidural space in those weird LoRs.

I've heard about those. I think the thought is that the local coming out of the catheter can also seep into the intrathecal space. That being said, I figure if you make the hole you might as well use it.

 

[Arch Guillotti]

typically the only time I administer an intrathecal dose is if patient is near complete, progressing quickly, or extreme discomfort. I use hyperbaric bupivicaine @ 7.5 mg. My question is how do you dose your epidural thereafter?

Dose is way too much.

 

[Arch Guillotti]

7.5 mg is a really large intrathecal dose for labor analgesia. I mean, you're most of the way to a surgical block with that. I'm surprised your patients who are near complete can push with that dose.

With a fast surgeon I'll do 1.2 mL of 0.75% bupivacaine + 15 mcg fentanyl, which is only 9 mg. For a c-section.

For labor analgesia, I think most of the people I know are using things like
- 1 mL of 0.25% (2.5 mg) maybe with 15-25 mcg of fentanyl
- 0.5 mL of 0.5% (2.5 mg) maybe with 15-25 mcg of fentanyl
- 2 mL of the 0.125% bupiv + 2 mcg/mL fent infusion mix (2.5 mg)
or thereabouts.

Or for those of us who don't want to mess around with getting fentanyl out of the pyxis or whatever and having to document the waste, etc. just skip it and give the marcaine.

 

[Arch Guillotti]

My typical standard epidural dosing (no intrathecal) is 8cc 0.125% marcaine throughly the tuohy then another 8cc 0.125% through the epidural catheter plus 100mcg of fentanyl.

I would give a denser dose of local and just skip the fentanyl.

 

[acidbase1]

Our infusion bags are 0.2% ropivicaine with 2mcg/cc fentanyl, anyone ever given intrathecal ropi?

 

[narcusprince]

Way to high dose for cse. I usually give 2.5 mg of bupi either 0.5% or 0.25%. I set the epidural infusion to 7/4/15/4 and tell the nurse and the patient to not hit button until 2 hours. Heavy bupi in my opinion 7.5% is for the operating room. How often you giving pressors?

 

[acidbase1]

Rarely, if ever. But again. I don’t do CSE for labor epidurals often. Had attendings do the same and it worked well.

We’ve established it’s high dose. Any input on ropi?

 

[acidbase1]

I also forgot to add, on shorter patients I’ll give 1/2cc heavy marcaine. The patients over 5’10 get the full cc. This particular patient had T8 levels thereafter

 

[narcusprince]

I have not used ropi intrathecally. I read a few weeks back someone had a dosing regimen. Straight epidural 5cc 0.2% ropi through touhy or catheter, then 7/4/15/4 infusion.

 

[Mman]

Any input on ropi?

While it can be used for a spinal, it sucks.

 

[acidbase1]

While it can be used for a spinal, it sucks.

Inferior to marcaine, but good enough to achieve analgesia while initiating levels through the epidural space?

 

[Maverikk]

What do you guys/gals dose for surgical anesthesia?

 

[Twiggidy]

Rarely, if ever. But again. I don’t do CSE for labor epidurals often. Had attendings do the same and it worked well.

We’ve established it’s high dose. Any input on ropi?

To quiet down a laboring patient, probably 1-2 cc of the 0.2% solution is just enough. That would be like 2-4 mg of ropiv which is plenty to get the patient comfortable and start a normal infusion

 

[Twiggidy]

What do you guys/gals dose for surgical anesthesia?

12 mg intrathecal bupivacaine

 

[acidbase1]

10.50-11.25mg-12mg depending on height

 

[Maverikk]

What do you do for surgical anesthesia epidurally? What do you do for long cases?

 

[Vaporized]

I was trained that epidural bolus after spinal drives the spinal dose cephalad. So I've carried that with me last few years. Anyways for CSE I am just trying to calm the women down not get surgical anesthesia. I do 3mg 0.75% or 2.5mg of the 0.25%. 7.5mg seems upper end and would likely wreck their pressures from what I see. I don't bolus but give 1 or 2 cc of test dose - makes me feel good if no blood on aspiration and no increase in HR or BP (for whatever that's worth after spinal).
I just was wondering, anyone use the PF lido in the vial? Senior guy here has been doing it with the CSE. I started doing 10-15mg of the PF lido since we had 0.75 bup shortage. Seems to work the same, and there is no extra step of drawing up an additional med and just easier since it's there.

 

[facted]

What do you guys/gals dose for surgical anesthesia?

1.6ml 0.75% bupi, 12.5mcg fent, 0.15mg duramorph

For epidurals: 10-15 ml of 2% 1:200,000 lido/epi, 2mg duramorph. Very rare to need more than this, though I trained in a place we have 20ml every time. Have noticed you really don't need more than 10 ml usually.

 

[Psai]

1.6ml 0.75% bupi, 12.5mcg fent, 0.15mg duramorph

For epidurals: 10-15 ml of 2% 1:200,000 bupi/epi, 2mg duramorph. Very rare to need more than this, though I trained in a place we have 20ml every time. Have noticed you really don't need more than 10 ml usually.

Really 2% bupi?

 

[deleted162650]

Have noticed you really don't need more than 10 ml usually.

Ya. Was always 20mL in residency too, but in the real world typically 12-15mL.

 

[facted]

Really 2% bupi?

My mistake. Lido.

 

[Vaporized]

1.6ml 0.75% bupi, 12.5mcg fent, 0.15mg duramorph

For epidurals: 10-15 ml of 2% 1:200,000 lido/epi, 2mg duramorph. Very rare to need more than this, though I trained in a place we have 20ml every time. Have noticed you really don't need more than 10 ml usually.

I have found this as well. When i started bolus them up 20ML of 2% in divided doses. Noticed a lot if women with floppy arms. Now 12-15 ML depending on how they reacted to local so far and no problems.

 

[projectpat]

For CSE, fentanyl 25 mcg intrathecally. Usually give remaining 75 mcg epidurally (100 mcg vials). If pt fully dilated, will give just 1 cc of 0.25% bupi.


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[Psai]

For CSE, fentanyl 25 mcg intrathecally. Usually give remaining 75 mcg epidurally (100 mcg vials). If pt fully dilated, will give just 1 cc of 0.25% bupi.


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Epidural fent causes a ton of itching

 

[Arch Guillotti]

Epidural fent causes a ton of itching

Maybe at 25 mcg but lesser doses rarely cause bad itching.

 

[Twiggidy]

Epidural fent causes a ton of itching

Epidural? I would agree intrathecal during labor fentanyl makes their skin crawl but i've never seen it with epidural.

 

[deleted162650]

Epidural fent causes a ton of itching

This is false.

 

[Noyac]

Epidural? I would agree intrathecal during labor fentanyl makes their skin crawl but i've never seen it with epidural.

Wow we have entered the “never” zone. I thought that zone was reserved exclusively for me.
Have you not seen pts with TEA’s for surgical cases when they are on the floor post-op?

Fentanyl whether place intrathecal ly or epidurally will cause the pt to itch. Period!
The question is, is it an issue?

 

[Twiggidy]

Wow we have entered the “never” zone. I thought that zone was reserved exclusively for me.
Have you not seen pts with TEA’s for surgical cases when they are on the floor post-op?

Fentanyl whether place intrathecal ly or epidurally will cause the pt to itch. Period!
The question is, is it an issue?

Dang. I just got Sean Spicer'd.

 

[deleted875186]

What do you thinks helps prevent or treat itching with fentanyl after a c section spinal?? We usually use 15-20 mcg fentanyl. I’ve read Zofran before the spinal is supposed to prevent it, I give it but can’t tell if there’s a difference. We don’t have Nubian in the room. Otherwise the Benadryl usually doesn’t help. Anyone do anything else?

 

[deleted162650]

What do you thinks helps prevent or treat itching with fentanyl after a c section spinal?? We usually use 15-20 mcg fentanyl. I’ve read Zofran before the spinal is supposed to prevent it, I give it but can’t tell if there’s a difference. We don’t have Nubian in the room. Otherwise the Benadryl usually doesn’t help. Anyone do anything else?

Low dose narcan (even in gtt form) is often see as “last line” treatment.

 

[deleted162650]

Fentanyl isn’t a huge culprit when it comes to itching. At least not unless you’re using stupid doses. IT/epidural morphine on the other hand - now that **** will make you look like Tyrone Biggum.

 

[Twiggidy]

Fentanyl isn’t a huge culprit when it comes to itching. At least not unless you’re using stupid doses. IT/epidural morphine on the other hand - now that **** will make you look like Tyrone Biggum.

"My feet are strong"

 

[Psai]

I dunno guys I've used a few 15 mcg intrathecal for spinals with no issues but pushed the rest epidurally on some and had those women start the squirm scratch dance five minutes later

Also have had women get lido bicarb epi in the epidural for their csection, then start the postop bag with fent and see them scratching away a few hours later. Maybe like 5-10% or so, and only a handful needed intervention. Anecdotal of course with a low n compared to you guys but I think it's a thing

 

[Noyac]

Dang. I just got Sean Spicer'd.

The “period” wasn’t really directed at you but more of a statement that they all itch to some degree.

 

[Noyac]

What do you thinks helps prevent or treat itching with fentanyl after a c section spinal?? We usually use 15-20 mcg fentanyl. I’ve read Zofran before the spinal is supposed to prevent it, I give it but can’t tell if there’s a difference. We don’t have Nubian in the room. Otherwise the Benadryl usually doesn’t help. Anyone do anything else?

Noth8ng works great but I give zofran like you stated. If it gets bad I call for some Nubian. I like Benadryl for the ones that are amp’d up It just sedates them which helps maybe.

 

[Noyac]

I dunno guys I've used a few 15 mcg intrathecal for spinals with no issues but pushed the rest epidurally on some and had those women start the squirm scratch dance five minutes later

Also have had women get lido bicarb epi in the epidural for their csection, then start the postop bag with fent and see them scratching away a few hours later. Maybe like 5-10% or so, and only a handful needed intervention. Anecdotal of course with a low n compared to you guys but I think it's a thing

I stopped putting fentanyl in the spinals for the routine c/s because I felt like they start to itch around 20 minutes after placement. They usually want to reach up and scratch their nose. Once I see that I’m starting to give something. Usually we are done before it becomes an issue. I do put it in the spinals that have had an epidural running. I pull the epidural for these cases but I don’t give the full 13mg of marcaine to these pts so I add some fentanyl. This is just what I’ve developed over 15 yrs of OB.

For the labor CSE I use both marcaine and fentanyl because I don’t stick around to have to deal with the itching. The nurses get to deal with it. We did a study looking at fetal brady after CSE when I was a resident and the combo, marcaine and fentanyl had the least. So I stuck with it. Don’t think the resident doing the study ever published it.

 

[Twiggidy]

Noth8ng works great but I give zofran like you stated. If it gets bad I call for some Nubian. I like Benadryl for the ones that are amp’d up It just sedates them which helps maybe.

I agree here. When I was on an intrathecal fentanyl streak I would tell the nurses to give them benadryl and I quite honestly don't think it relieve the itching more so than helped them take a nap. Now I've just been using 3 cc from the labor bag and get no itching complaints (when I do an intrathecal).