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- Jun 6, 2019
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Does anyone else find that about 5% of epidurals are inexplicably weird?
Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.
First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.
Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.
She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).
Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.
Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.
She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.
To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.
Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.
Also - when considering local anesthetic limits, is there a statute of limitations where the ropi I gave 8 hours ago shouldn’t be counted towards my totals? I would think plasma concentrations would be pretty low by that point. Especially if some of this medication was not in the epidural space.
Any guidance or thoughts are appreciated. Thanks I’m advance for weighing in. What would you do?
Normal BMI primigravid, 40w, at 4cm. Requests epidural. Nice normal patient.
First epidural is uneventful. Loaded with 10cc 0.2% ropi. Hour later I get called for one sidedness. I always leave 4cm in, so tried a single bolus of 10cc 0.2% ropi. 4 hours of comfort, but then one sided again. Another bolus. Still one sided. -I offer replacement.
Site looks fine. Straightforward replacement.
10cc 0.2% ropi load - called in 30min for subjective breathlessness, motor block in legs, and a single desat to 87% while sleeping.
She is conversant, strong in upper extremities and speech. I pause the bag (0.125% bupi/2mcg per cc fentanyl that was running at 10) till some motor block resolves. Fire it back up at that point (60 min later).
Now intense pain with contraction, bolus 0.2% ropi x 10cc. No relief. Another bolus 30 minutes later as I truly believe the catheter must be good. Nothing.
Offer 3rd epidural - straightforward placement - bolus 0.2% ropi x 10cc.
She’s comfortable until delivery. Arrest of descent after 4h pushing, try 12cc of 1.5% lido epidurally for a forceps delivery but she can’t take it. They try a pudendal block which Seems to help, but forceps unsuccessful.
To OR for section - she seems more comfortable through contractions and legs are heavy, but at this point, I don’t want to give more local nor subject her to anything that even might be painful (stretching/uterus on abdomen) after all she’s been through over the last 16hours. So we put a tube in and all is well.
Perplexing that the catheter that gave her a high-ish epidural couldn’t make her comfortable for labor thereafter. Site looked pristine too.
Also - when considering local anesthetic limits, is there a statute of limitations where the ropi I gave 8 hours ago shouldn’t be counted towards my totals? I would think plasma concentrations would be pretty low by that point. Especially if some of this medication was not in the epidural space.
Any guidance or thoughts are appreciated. Thanks I’m advance for weighing in. What would you do?