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LOL, what? Bolusing a labor epidural once a CS is called seems dumb to you?
Dosing spinals for C/S after Epidural
- Thread starter NeedleJockey
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Look, after a CS is called you have a few options. If she doesn’t have an epidural bring her back and do a spinal. If she’s been in labor and has an epidural you can do a few things
1) cut the infusion, pull epidural, do spinal in OR
2) cut infusion and do CSE in OR
3) give half bolus and check levels. If you’ve got a good epidural and like your levels, go ahead and continuing bolusing as needed for CS levels (this is predominately what I do)
4) if you’ve started to bolus but don’t like how it’s looking (patchy, one sided, etc.) then stop bolusing and you can still proceed w small spinal dose or CSE (if you think you need the E and you’d likely be fine
5) replace epidural with another epidural
6) at any point you can elect to go to sleep if you don’t like how it looks and feel that option has become safest for mom and baby.
I’m just saying that once you start bolusing a labor epidural for CS you limit your ability to poke holes in the dura and think it’ll all be okay, especially with a labor epidural that’s been fully dosed for CS. I don’t like more holes in the dura there. I either go to sleep (most likely) or replace the epidural with another epidural and hope it works. But I still have a strong inclination that GETA is in the near future. Just my opinion as someone who does a lot of OB.
1) cut the infusion, pull epidural, do spinal in OR
2) cut infusion and do CSE in OR
3) give half bolus and check levels. If you’ve got a good epidural and like your levels, go ahead and continuing bolusing as needed for CS levels (this is predominately what I do)
4) if you’ve started to bolus but don’t like how it’s looking (patchy, one sided, etc.) then stop bolusing and you can still proceed w small spinal dose or CSE (if you think you need the E and you’d likely be fine
5) replace epidural with another epidural
6) at any point you can elect to go to sleep if you don’t like how it looks and feel that option has become safest for mom and baby.
I’m just saying that once you start bolusing a labor epidural for CS you limit your ability to poke holes in the dura and think it’ll all be okay, especially with a labor epidural that’s been fully dosed for CS. I don’t like more holes in the dura there. I either go to sleep (most likely) or replace the epidural with another epidural and hope it works. But I still have a strong inclination that GETA is in the near future. Just my opinion as someone who does a lot of OB.
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When the section is called you immediately make your decision: either uou are going to use the current labor epidural or not. If you doubt the epidural at all, the best way to avoid needing to incorporate GA is to not bolus the epidural), pull it, and do a spinal with a lower dose than you would use for scheduled C/S (or CSE if your surgeons are really, really slow). My main reason for replying to this thread initially was to counter the contention that you shouldn’t do a spinal after an epidural has been in, which is just plain wrong and may actually lead to worse outcomes (higher incidence of rescue GA if your replacement epidural is also patchy/inadequate).
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My practice:
C/S Is called, only a few real options:
1. If a true STAT -> try bolusing epidural in room and during transport and hope for best
2. If time and epidural perfect: Bolus epidural.
3. If time and epidural imperfect: Stop infusion, delay as long as you can until OB gets annoyed, then pull epidural - SAB / CSE
Backup for everything is GETA. Sometimes depending on patient disposition, GETA might actually get bumped up to Plan A.
My personal feeling is we need to stop being so scared of GETA in this patient population.
C/S Is called, only a few real options:
1. If a true STAT -> try bolusing epidural in room and during transport and hope for best
2. If time and epidural perfect: Bolus epidural.
3. If time and epidural imperfect: Stop infusion, delay as long as you can until OB gets annoyed, then pull epidural - SAB / CSE
Backup for everything is GETA. Sometimes depending on patient disposition, GETA might actually get bumped up to Plan A.
My personal feeling is we need to stop being so scared of GETA in this patient population.
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If they haven't been calling me about the epidural (patchy, one-sided, breakthrough pain) then I'm going all in on dosing up the epidural aggressively with 2% Lido w Epi. If it fails me, we're doing GA. That simple.
If I've received any calls about the epidural not working well in any way, then I'd consider pulling it and doing a spinal or just commit to GA.
If I've received any calls about the epidural not working well in any way, then I'd consider pulling it and doing a spinal or just commit to GA.
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Bolusing a patchy epidural you better have time. If after 10cc in 5cc divided doses and you have little surgical effect. If you have time sit up spinal, if no time and airway favorable geta, if the airway is not favorable I probably would attempt a few pokes at the spinal. Also its very important that with obese patients or challenging airways put that epidural in early. If they have a history of difficult epidural placement CSE to make sure the epidural is in the right place.
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well yes and no. Similar situation 2 weeks ago. Day guy handed over this lady with "patchy epidural" to me the new night guy, slow progress, almost definite section but not called yet. Previous night guy had put it in. Day guy was being lazy and never even checked it. Assumed just gonna do a spinal if section called. He did give 2-3 bolus during the day which annoyed me I have to say
Anyways I went it and had a look at it. It had been pulled almost totally out. Only max 1 cm could have been in epidural space...
So I replaced epidural, patient comfy 15 mins later. Section called 45 mins later. Easy peasy...
My point being is that it's important to at least check and assume nothing.
Most parturients have an absolutely fine epidural space. The epidural placement itself is much more likely to the problem...
But agreed spinal > epidural for cs. But if cs not called yet but likely, I'm checking that old thing myself find out the real truth
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One of the most annoying ob thing is this put the epidural in early. Now days they ask you at like 1 cm dilation to put in the epidural. Of course 24 hrs later after 3 or 4 bonuses you get into these situations where you have no idea if the epidural is actually working, or is it that the epidural was put in when they were hardly having painful contractions. Also these super early epidurals feel like they almost always go to c section.
Replacing for labor analgesia is a different ballgame than replacing for surgical anesthesia. I spinalize every questionable labor epidural. I will prolly get a high spinal at some point and I will GETA without thinking twice. Not the end of the world. Being afraid of GETA in OB is one of my (many) pet peeves.
You replaced it for labor analgesia. As we all do. I don’t bolus up a labor epidural if it isn’t working great. Pull and spinalize. Get into trouble when you bolus a crappy catheter.
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There are certain situations in OB where I want to avoid geta and I have a fully dosed epidural that isn’t at surgical levels. I’m simply saying that placing another epidural is fine. If you disagree with this, tell me why.
I also agree that the difficulty of the ob airway is way overblown.
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That's why you should go through and through when you replace it so you know you're going to be in the right space. Also, some local will leak into the dural space so she's good
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It's "fine" in the sense that it's not unsafe and probably works.
It should be an exceptionally rare event that you find yourself in the OR with a "fully dosed" epidural that isn't working. They generally don't come out of nowhere. Most of us will pull sketchy epidurals before doing them up.
Avoiding general anesthesia because of the "OB airway" is silly, but there are good reasons to avoid it if possible -not the least of which is so the woman can remember the birth of her child, or because volatile anesthetics cause uterine atony and nitrous is **** (I propofol TIVA all my GETA sections but lots of people just use gas +/- nitrous).
What I'm getting at is that if you find yourself in an OR with a dosed-up labor epidural that isn't working more than once every couple years - you're probably dosing up too many lousy epidurals when you should pull them and do a spinal.
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Maybe I’m just a bad anesthesiologist I dunno. I understand why a lot of anesthesiologists hate OB. I find it hard to be as algorithmic as some here. Like you said, most normal moms want to stay awake and remember the birth of their child. Doing this a decade now, with OB anesthesia being 50% of my practice in a non-academic high volume referral center, I’ve been in situations where it seems like y’all would just put da tube in or place the spinal hoping for the best with a dosed up epidural. I guess that’s fine. All I’m saying is that I have a lot of patients that ask me if there are alternatives to that. And there are, so I discuss the options with them.
Kindly point me to the evidence in which volatile anesthetics are associated with uterine atony or increased bleeding risk.
I will wait.
There's a poorly done study in a random Scandinavian journal in which they excised human LUS myometrium from TWENTY patients and then exposed them to des and sevo that everyone bases this myth upon. There is no actual in vivo data or outcomes data for this nonsense. Again, not a single study has ever associated volatile anesthetics with actual atony or increased bleeding risk (you know, things that are clinically relevant, not in vitro myometry of dead tissue). Super high-level evidence.
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That's news to me (I'm not being sarcastic).
Volatile anesthetics cause dose-related uterine relaxation. I don't think this is controversial and it definitely isn't subtle during a c-section done with a MAC of gas. Nitrous can reduce the amount of gas you need, but nitrous has its own issues and I prefer not to use it.
Now of course that relaxation doesn't persist and increase bleeding risk postop, but it sure has an effect during surgery. If you're lucky enough to have an OB who can get the uterus and skin closed in 10 minutes perhaps it doesn't matter.
I'll keep on going with the TIVAs though.
There is no evidence that the use of volatile anesthetics increases uterine atony or bleeding. None.
Unless you routinely anesthetize pregnant rats. Then, my apologies, I shouldn't make bold assumptions like that.
We have less-than-stellar OB/Gyns that book their surgical cases as "D&C/D&E: please no volatile anesthetics." Literally, in their surgical booking based on rat data. I roll my eyes and I turn the dial up.
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The comparison of caesarean section bleeding between... : European Journal of Anaesthesiology and Intensive Care
ntravenous anaesthesia (TIVA) using a nationwide inpatient database in Japan. DESIGN Observational study. SETTING Nationwide inpatient database in Japan from April 2012 to March 2020. PATIENTS Women who underwent caesarean section under general anaesthesia. MAIN OUTCOME MEASURES Volume of...
journals.lww.com
Not the best study obviously for many reasons but there probably won’t be a great one as it is generally difficult to conduct randomised controlled trials in the setting of an urgent c-section under general anesthesia.
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Have you ever tried to run a trial on pregnant women?
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This is the fallacy of our collective love affair with evidence based medicine. No randomized controlled trials of pregnant woman undergoing general anesthesia to compare surgical bleeding? Well, guess it’s all nonsense and let’s throw out any observational or non-human studies.
I bet you skydive without a parachute too ‘cause that hasn’t been proven to be effective by randomized controlled trials (see article: Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials
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You're being awfully sarcastic for a guy who thinks volatiles don't relax the uterus.
It's exactly the terrible OBs who take 3x as long as they should to do a section, and 6x as long in the obese non-primaries with 10 pound babies, where I don't want to use volatile anesthetics.
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Except people see it all the time?
You sound like one of my attendings. He refused to believe that ace/arb induced hypotension was a thing and showed me some metaanalysis cochrane review about it but that's not really helpful when the only thing helping the blood pressure is big pushes of vaso...
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Scenario: labor epidural in place, c-section called, dosed up in the OR (10-20cc 2% lido w/ epi), patchy and patient uncomfortable
My go to options:
A) consider giving additional local anesthetic into epidural and wait if I have time. Sometimes patchy epidurals resolve with more volume because the additional fluid facilitates spread within the epidural space
B) give OBGYN local anesthetic to apply directly onto planned surgical incision site IN ADDITION TO small doses of intravenous ketamine
C) GETA
What I never do:
D) sit patient up, pull epidural, perform a spinal (we have had many cases at my hospital where this exact practice has resulted in high spinal - you're literally just guessing how much anesthetic to dump into the intrathecal space)
My go to options:
A) consider giving additional local anesthetic into epidural and wait if I have time. Sometimes patchy epidurals resolve with more volume because the additional fluid facilitates spread within the epidural space
B) give OBGYN local anesthetic to apply directly onto planned surgical incision site IN ADDITION TO small doses of intravenous ketamine
C) GETA
What I never do:
D) sit patient up, pull epidural, perform a spinal (we have had many cases at my hospital where this exact practice has resulted in high spinal - you're literally just guessing how much anesthetic to dump into the intrathecal space)
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Never heard of giving more local after 15-20cc of 2% lido. A seems very close to a LAST scenario.
B. I do know a scenario of a partner of mine who did this and traumatized the patient. Potentially very bad patient satisfaction.
C. GETA I agree with that plan if you do not have time.
D. Sitting the patient up and doing a spinal with 1.2 cc if heavy bupi may lead to high/total spinal which brings you back to C. Risk total spinal.
Of all the dangerous scenarios listed. Last is the most challenging to manage.
Honestly glad we are all having this debate. I wouldn’t do what your doing but I am grateful for the discussion.
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Here is my approach, trained at a very very busy OB place and I’ve worked at some very busy OB places and some not very busy places. I don’t like OB but I do like paying my bills and going on vacation.
#1. Round on your epidurals. I don’t care what my partners say or did, I check them with ice in a glove, look at the site. Takes 2 min per patient, catheters move. Some patients don’t complain enough about that one patchy spot. Most people realistically don’t round on them, do it, when you get there and a few hours before you go to sleep. I haven’t replaced a lot doing this but I know it’s saved me more than a few times when that 3am section was called.
#2 don’t be afraid to replace. I think this is the biggest reason people run into high spinals. Patting my own back here but the only way you get good is by repetition and running into difficult cases. I’ve hubbed the 13cm tuohy to get an epidural that worked for a csection in a gargantuan once before. Remain calm, talk to the patient and get it done. Don’t accept a ‘good enough’ epidural ever.
Now you’re called for a csection. What matters here is the urgency.
If you’ve rounded but it’s been awhile, check again. If it’s busting through the door it’s bolus in room or GA, obviously. Have a glidescope.
It’s ‘urgent,’ (most common reason for high spinal): bolus 7cc lido w/epi in the room assuming 5-10 min to in the OR. Push hard. Check in the OR, do spinal with 0.8-1.1cc if not getting adequate levels, and you should get adequate levels checking with ice with that amount of lido. Be efficient. Lie them down, adjust table, have to be aware of timing with this, let them lie flat 1-2 minutes, talk to them about what they’re feeling, adjust table.
Non-urgent/Failure to progress: assuming 15-30 minutes to room. Check levels, stop epidural; levels not perfect don't bother bolusing. Spinal. I had OB fellowship trained friend who in this situation would inject 20cc of PF saline into the epidural after stopping it to ‘dilute it out’
One other gripe, having done a lot of OB, do a cse/dpe if they’re huge. Especially if it’s a 5am epidural for an induction. One partner's handoff was usually ‘I think this one’s good but it may be spotty’ I finally told her to stop putting in spotty epidurals, don't hand over garbage or at least let the person know. If you’re not confident or haven’t done a lot of OB, do CSEs/DPEs for everyone until you get confident enough. I’ve had enough of the uncommon ‘kind of’ get a loss, but I know it’s not the real thing, it's not an easy feeling to have and still advance the tuohy
#1. Round on your epidurals. I don’t care what my partners say or did, I check them with ice in a glove, look at the site. Takes 2 min per patient, catheters move. Some patients don’t complain enough about that one patchy spot. Most people realistically don’t round on them, do it, when you get there and a few hours before you go to sleep. I haven’t replaced a lot doing this but I know it’s saved me more than a few times when that 3am section was called.
#2 don’t be afraid to replace. I think this is the biggest reason people run into high spinals. Patting my own back here but the only way you get good is by repetition and running into difficult cases. I’ve hubbed the 13cm tuohy to get an epidural that worked for a csection in a gargantuan once before. Remain calm, talk to the patient and get it done. Don’t accept a ‘good enough’ epidural ever.
Now you’re called for a csection. What matters here is the urgency.
If you’ve rounded but it’s been awhile, check again. If it’s busting through the door it’s bolus in room or GA, obviously. Have a glidescope.
It’s ‘urgent,’ (most common reason for high spinal): bolus 7cc lido w/epi in the room assuming 5-10 min to in the OR. Push hard. Check in the OR, do spinal with 0.8-1.1cc if not getting adequate levels, and you should get adequate levels checking with ice with that amount of lido. Be efficient. Lie them down, adjust table, have to be aware of timing with this, let them lie flat 1-2 minutes, talk to them about what they’re feeling, adjust table.
Non-urgent/Failure to progress: assuming 15-30 minutes to room. Check levels, stop epidural; levels not perfect don't bother bolusing. Spinal. I had OB fellowship trained friend who in this situation would inject 20cc of PF saline into the epidural after stopping it to ‘dilute it out’
One other gripe, having done a lot of OB, do a cse/dpe if they’re huge. Especially if it’s a 5am epidural for an induction. One partner's handoff was usually ‘I think this one’s good but it may be spotty’ I finally told her to stop putting in spotty epidurals, don't hand over garbage or at least let the person know. If you’re not confident or haven’t done a lot of OB, do CSEs/DPEs for everyone until you get confident enough. I’ve had enough of the uncommon ‘kind of’ get a loss, but I know it’s not the real thing, it's not an easy feeling to have and still advance the tuohy
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D
deleted1183938
Did you at that point turn off the epidural when she complained of spotty? How long did you wait till the spinal? And 1.4 cc of 0.75 is enough for a virgin spinal in many patients.
D
deleted1183938
How do you dose your epidural?? And by any “issue” what do you mean??
