CSE technique

[deleted875186]

Did a CSE recently in a multip who came in fast progressing. Easy epidural, good LOR, then good CSF flow, used 2 ml of bag mix (0.125 bupi and 2 mcg/ml fentanyl). Meanwhile threaded epidural, taped, set up pump, and patient still having significant pain. No relief at all she said. Bolused the epidural, came back 20 mins later and completely comfortable.

Should I use something else for the spinal dose? I do think the spinal worked well because she had a good equal level and excellent pain relief initially, that later was more one sided a few hours later presumably from the epidural. Anyway to make this spinal set in faster?

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[anbuitachi]

Did a CSE recently in a multip who came in fast progressing. Easy epidural, good LOR, then good CSF flow, used 2 ml of bag mix (0.125 bupi and 2 mcg/ml fentanyl). Meanwhile threaded epidural, taped, set up pump, and patient still having significant pain. No relief at all she said. Bolused the epidural, came back 20 mins later and completely comfortable.

Should I use something else for the spinal dose? I do think the spinal worked well because she had a good equal level and excellent pain relief initially, that later was more one sided a few hours later presumably from the epidural. Anyway to make this spinal set in faster?

more meds?

 

[deleted697127]

Seems within the range of normal. We use 12.5 of fentanyl which I’m sure helps our onset at the expense of itching. Maybe an issue with expectations?

 

[Laryngophed]

Did you hit a board favorite Tarlov cyst?

 

[deleted162650]

Could go slightly higher on dose - I use 2.5 of bag solution but 3 is also fine. Every once in while I’ll get one that just takes longer to set up. I think it’s just patient dependent.

 

[Crabbygas]

I'm going to be the sceptic and say just don't do a CSE. I think they are almost always a bad idea. The spinal frequently gives better pain control than the epidural and you don't get to find out if your epidural is working until the spinal wears off. Seriously, if you want the pain control to start 5 minutes sooner just do the epidural 5 minutes sooner.

 

[MTGas2B]

1 ml of 0.25% bupi.



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[polar403]

Just give 25 mcg of fentanyl and bolus the other 75 mcg through the epidural catheter. You will get good pain relief without analgesia that may wear off before they deliver.

 

[Psai]

The best cse is a dpe

 

[deleted162650]

I'm going to be the sceptic and say just don't do a CSE. I think they are almost always a bad idea. The spinal frequently gives better pain control than the epidural and you don't get to find out if your epidural is working until the spinal wears off. Seriously, if you want the pain control to start 5 minutes sooner just do the epidural 5 minutes sooner.

These are “theoretical” concerns that just don’t play out in real life. I’ve had a CSE all-comers approach for the last 5 years. Guess how many failed catheters I’ve had in that time after a successful CSE - zero. If you get CSF, you know you are midline and that your Tuohy is in the epidural space. I’ve also found that the quality of analgesia from the epidural is better long after the spinal dose has worn off with fewer top off requests than straight CLE’s (the DPE literature - even though that is the most ridiculous technique ever - supports this). Believe me, if I was getting called left and right for bolus requests I woulda stopped doing CSE’s long ago. Set it and forget it - it’s the Ronco of labor analgesia techniques.

 

[UscGhost]

My wife had a failed epidural catheter when she had a CSE done....so go figure haha. Spinal worked great.

I also fail to see the utility of it...it typically takes a few mins longer to do anyways. The patient has been having contractions for hours and now decides to get an epidural...do i need to perform an extra procedure to expedite pain relief by a few mins?

Maybe in those patients at 9cm that want an epidural and need relief asap.

 

[d9sccr]

We did them exclusively in training but I haven't done one since. I've done a few DPE after questionable LOR and don't notice a huge difference in time to pain relief even though studies suggest otherwise.

I'm gun-shy of doing them in PP, mostly bc of the real risk of increased C/S. I have no desire to be the reason why someone gets a section. I saw it happen several times in residency, most notably 3x on one rotation. It always seemed to happen when patients where in severe pain and fairly far along....which is pretty much when we get called to do epidurals in my practice

 

[Arch Guillotti]

I'm gun-shy of doing them in PP, mostly bc of the real risk of increased C/S.

Do you have a reference for this?

 

[Psai]

We did them exclusively in training but I haven't done one since. I've done a few DPE after questionable LOR and don't notice a huge difference in time to pain relief even though studies suggest otherwise.

I'm gun-shy of doing them in PP, mostly bc of the real risk of increased C/S. I have no desire to be the reason why someone gets a section. I saw it happen several times in residency, most notably 3x on one rotation. It always seemed to happen when patients where in severe pain and fairly far along....which is pretty much when we get called to do epidurals in my practice

You carry nitro?

 

[Hork Bajir]

For the PP dudes/dudettes out there who cover OB simultaneously to covering the OR- how do your groups handle pre-ops and consents? The whole business of "I need to be back from putting in the epidural in 20 minutes or less, otherwise you can't hack it in PP"... Does that time include getting relevant medical hx (ensuring no contraindications to epidural), getting consent, etc?

 

[narcotics999]

For the PP dudes/dudettes out there who cover OB simultaneously to covering the OR- how do your groups handle pre-ops and consents? The whole business of "I need to be back from putting in the epidural in 20 minutes or less, otherwise you can't hack it in PP"... Does that time include getting relevant medical hx (ensuring no contraindications to epidural), getting consent, etc?

I will assume if you do both OR and OB on call, it will be a low acuity, low volume community hospital with healthy patients. The contraindication for epidurals are mainly coagulopathy, significant cardiovascular issues, and patient refusal. It takes a minute to figure out.

 

[d9sccr]

Do you have a reference for this?

Couldn't find much but case reports. We were always told you when you get your sympathectomy you get unopposed parasympathetic tone and uterine hypertonicity. Should be relieved with nitro but occasionally isn't. Where we trained, even when it was relieved, the deceleration was often so profound that even when corrected, we often went straight to the OR.

 

[deleted162650]

Couldn't find much but case reports. We were always told you when you get your sympathectomy you get unopposed parasympathetic tone and uterine hypertonicity. Should be relieved with nitro but occasionally isn't. Where we trained, even when it was relieved, the deceleration was often so profound that even when corrected, we often went straight to the OR.

You're giving toooooo big of an IT dose, and you need to educate your OBs.

Here's 2 papers published by the guys whose technique I stole:

A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during f... - PubMed - NCBI

Prophylactic intravenous ephedrine to minimize fetal bradycardia after combined spinal-epidural labour analgesia: a randomized controlled study. - PubMed - NCBI

 

[polar403]

For the PP dudes/dudettes out there who cover OB simultaneously to covering the OR- how do your groups handle pre-ops and consents? The whole business of "I need to be back from putting in the epidural in 20 minutes or less, otherwise you can't hack it in PP"... Does that time include getting relevant medical hx (ensuring no contraindications to epidural), getting consent, etc?

Yes, it doesn’t take long to review the chart for red flags, ask the pertinent questions and have them sign the consent. It takes 2 minutes to prep and have your kit ready and you should have LOR and be threading the catheter within 1-2 minutes of putting local in. Occasionally even the best provider runs into issues and it takes longer than typical, but it shouldn’t take more than 20-30 minutes from getting the call to having the epidural in and moving on to other things.

 

[Gaslamp]

I did a lot of CSE's during training, but I could never justify it in private practice. I get a pretty good onset time by injecting all 5cc's of the lido c epi and what's left of the lido (used for infiltration) epidural.

 

[deleted162650]

I did a lot of CSE's during training, but I could never justify it in private practice. I get a pretty good onset time by injecting all 5cc's of the lido c epi and what's left of the lido (used for infiltration) epidural.

If I’m not doing a CSE, that’s exactly what I do as well.

 

[pgg]

Couldn't find much but case reports. We were always told you when you get your sympathectomy you get unopposed parasympathetic tone and uterine hypertonicity. Should be relieved with nitro but occasionally isn't. Where we trained, even when it was relieved, the deceleration was often so profound that even when corrected, we often went straight to the OR.

The theory is that the sudden profound pain relief from the intrathecal dose causes an abrupt decrease in circulating catecholamines, and the withdrawal of this beta agonist effect causes increased uterine tone.

The answer is to use a light IT dose in the first place, or be present and willing to give a small dose of NTG if there is a decel right after the CSE.

 

[d9sccr]

You're giving toooooo big of an IT dose, and you need to educate your OBs.

Here's 2 papers published by the guys whose technique I stole:

A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during f... - PubMed - NCBI

Prophylactic intravenous ephedrine to minimize fetal bradycardia after combined spinal-epidural labour analgesia: a randomized controlled study. - PubMed - NCBI

That may be, but the first paper 3.125mg bupi and 5mg fentanyl. We used 1.25mg bupi and 15mcg fentanyl. Based on the proposed mechanism I mentioned, I'd imagine "my" dose is smaller. Never done the prophylactic ephedrine for a labor CSE.

 

[deleted162650]

Your narcotic dose is the problem - not the local. The ephedrine made no difference, that’s why nobody does it. I was rotating with those guys while they were doing that study.

 

[Psai]

That may be, but the first paper 3.125mg bupi and 5mg fentanyl. We used 1.25mg bupi and 15mcg fentanyl. Based on the proposed mechanism I mentioned, I'd imagine "my" dose is smaller. Never done the prophylactic ephedrine for a labor CSE.

Damn 5 mg of fent holy

 

[deleted162650]

Damn 5 mg of fent holy

Ya, it’s really a bitch pushing in all 100cc’s but DAAAMN are they comfy - little itchy - but comfy.

 

[2Fast2Des]

I've been doing cse and it works great, just 1ml 0.25% bupi and no need to load the epidural and instant relief while you're threading catheter, test dosing, taping etc. I definitely tell them what to expect so I don't get called back for top offs and saying they're in pain when it's more of no more spinal effect.