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I see no upside to coming into a new place and doing things differently than everyone else while everyone is telling you to stop. Trying to logically or rationally explain something to an OB nurse doesn’t work, it’s akin to how you can’t be logical or rational with a toddler.
 
I give lidocaine 2% 5cc's and sufentanil 12,5 mcg. Works like a charm.
I don't tell the L&D nurses what I'm putting in the epidural. That epidural is my business. I will troubleshoot it.

If they ask me what I put in, "the usual stuff"

Our L&D nurses are exceptionally dim bulbed...
 
dhb said:
You would probably get more positive answers if you asked if people give a bolus of low concentration local anesthetic.
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Not sure I understand your reply.
San Marzano said:
I see no upside to coming into a new place and doing things differently than everyone else while everyone is telling you to stop. Trying to logically or rationally explain something to an OB nurse doesn’t work in the same way that you can’t be logical or rational with a toddler.
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Ahhh, the problems with communicating via the internet. I have not done what you suggest, but more the opposite - I fully understand the problem with coming in and changing everything. But this one area is almost an ethical concern since I feel that I'd be treating the nurses and compromising the patient. Hence my question about other's experience with the initial epidural bolus. I'm asking a scientific question and perhaps there's no good scientific answer, in which case anecdotal replies would be welcome.
 
CodeBlu said:
I give lidocaine 2% 5cc's and sufentanil 12,5 mcg. Works like a charm.
I don't tell the L&D nurses what I'm putting in the epidural. That epidural is my business. I will troubleshoot it.

If they ask me what I put in, "the usual stuff"

Our L&D nurses are exceptionally dim bulbed...
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Thanks. That is helpful. I know others who love sufenta too.
This is all I'm asking for the folks who want to respond.
 
LineAndBerry said:
Folks, how many of you use a fentanyl bolus alone prior to starting your dilute infusion (of bupiva or ropi + fent)?

I ask because I stopped giving a 5 or 10 cc bolus of concentrated local (0.25% bupiva seems most common?) after 15 years of practice. I was seeing rare but occasional maternal hypotension and occ. fetal HR effects, plus maternal numbness and weakness, as expected.

I started just using fentanyl and for the past 10 years or so that seems to work beautifully, with almost zero side effects. I just start the infusion within an hour of the fent bolus and everything seems to be great for the duration of the epidural.
However, I just started a new position and the nurses are very bent out of shape that I am not giving the local bolus. They expect their patients to be numb, it's "how they did it forever", and anything less means to them that "the epidural is not working". Not sure if I should just go along with their usual practice to keep the peace.
I'm getting a ridiculous amount of resistance, considering my epidurals work great with no side effects. It's just so hard to make any change in institutional practice and we all know that L & D nurses can be particularly non-adaptive (which I realize can be both good and bad).​
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TBH I would have a problem with your practice as well, and I think its well outside of the ordinary...

I usually give 8cc of 1/8% bupi after the Lido test dose. Then run the narcotic/bupi infusion...

If you were going to put an epidural in my wife, and then just give fentanyl for an hour, I would absolutely have a problem with that. Why are you not giving the local sooner? Do you not believe that local plus narcotic is more effective than narcotic alone? Why are you waiting an hour to start the local? You want them to put the foley in after just 100 bolus of fentanyl? If you are worried about hypotension a) it happens regardless of what you do, learn to deal with it and b) try giving more dilute local, with more volume to spread where it needs, but less HD effects due to reduced potency.

I wonder what time of hospital you were working at for the past ten years where this practice was acceptable? probably somewhere stuck in another era. Did these fentanyl epidurals "work great with no side effects?" or did the nurses just not care as much that the patients had inadequate analgesia but no hypotension
 
Agree with the above 100%. And I don’t think I’ve ever given 10ccs of .25% bupi from the get go as it requires an extra step and seems like a big initial dose. I used to use fentanyl/rop @ 2 mcg/ml of fentanyl and it works great. I am now using .2% rop after left over skin local and test dose. They are comfy in just minutes.

Relief from fentanyl by itself is a combo of both epidural narcotic and systemic absorption. Not a great way to test your epidural IMO.
 
I use different dosing regimens based on what the Pt is doing. Early in labor and not having much pain? Give some dilute local there's no need to rush to get her comfortable. Really bad pain and contracting every minute? Either a CSE or what I've found to work nearly just as quick and save the step of the spinal is to give the 3 cc test dose then give the remaining 2.5 cc test dose as the first half bolus combined with 4-6 cc of 0.25% bupiv and they're comfortable before i leave the room. Somewhere between those two I'll give 4 and 4cc of 0.25%.

There was a time I wasn't giving fentanyl and felt like pts were comfortable with local only, then started adding fentanyl in and women seemed maybe a little happier with it possibly clouding the effectiveness of the epidural early but ultimately if it was my wife I'd want her to get the fentanyl.

Whether or not your institution does "walking epidurals" will also affect how you dose up your epidurals.
 
Sevo is correct, giving fentanyl alone is kinda senseless because it becomes systemic in a mater of minutes. You might as well give it IV just before placing the epidural so the pt starts to get relief sooner. It’s the same thing.
 
Another thing to consider is that one big reason to place an epidural is to avoid those larger doses of fentanyl that the nurses are giving these pts. There is plenty of literature out there that shows negative effects on the fetus when comparing epidural vs IV narcotics. Plus the epidural is less sedating and the moms are more cooperative. The list goes on and on. At least in my mind it does.
 
Noyac said:
Another thing to consider is that one big reason to place an epidural is to avoid those larger doses of fentanyl that the nurses are giving these pts. There is plenty of literature out there that shows negative effects on the fetus when comparing epidural vs IV narcotics. Plus the epidural is less sedating and the moms are more cooperative. The list goes on and on. At least in my mind it does.
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Welcome back Noy. Hope it was a rewarding trip for you. 👍
 
Noyac said:
It was. That was the hardest I have ever worked. It was both physically and emotionally exhausting and rewarding at the same time.
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Where you go?

OP, when you are doing something that literally no one else does, it’s time to re-evaluate your practice.
 
I was taught to bolus with the epidural bag (or something similar). So I give 10-20cc (depending on height of pt) 0.125% bupiv. Minimal side effects, especially if RN gives IV bolus beforehand. Pt's expectations are set from the beginning. And I don't have to worry about another controlled substance to take care of.
 
SaltyDog said:
Where you go?

OP, when you are doing something that literally no one else does, it’s time to re-evaluate your practice.
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I went on a quick Spine SurgicL mission to Belize. I may write up a narrative on this. It is probably a worthy read for everyone. We did pedi scoliosis cases all week. 🙁
 
LineAndBerry said:
Psai said:
DPE
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??
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DPE = "dural puncture epidural"

Opinions differ on the risk/benefit profile espoused by the Cappiello study that introduced them (procedures performed by trainees), vs the risk/benefit out in the not-academic world. I don't do them. I think if you're going to stick something through the dura, you ought to put some drugs through the needle while you're there.
 
I can't remember the last time I gave an epidural fentanyl bolus to a laboring patient for the reasons stated above- it is mostly systemically absorbed.
 
Where's the 3rd option? No fent, no high conc...

I give 15ml 0.08% bupi and call it a day, start our solution (.1% with 2mcg/ml fent) at 12ml/hr. I almost never get called back.
 
It doesn't take much local to provide profound analgesia with a well-placed epidural catheter. 5mL of test dose lidocaine will do it for most. Glad others have rightly pointed out that bolusing epidural fentanyl is equivalent to giving intravenously. Limiting systemic/fetal exposure to depressants such as fentanyl while giving mother good analgesia is the main benefit of the labor epidural to begin with.
 
Noyac said:
I went on a quick Spine SurgicL mission to Belize. I may write up a narrative on this. It is probably a worthy read for everyone. We did pedi scoliosis cases all week. 🙁
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Awesome. Mission trips are definitely on my list, but gonna have to wait till the kids are a bit older. Would love to hear about it.

Pedi scoli with limited resources sounds pretty interesting.
 
Everyone at my hospital does a bolus of bag mix with 2 mcg/ml fentanyl at the start and starts PIEB with patient controlled epidural bolus as needed, works excellent. Only time I’ll bolus epidural fentanyl is for second stage labor if epidural is not covering and I don’t want to cause weakness with more local. Otherwise I will troubleshoot epidural, pull back catheter, bolus with local, or just replace before too much hassle.

I do agree that labor ad delivery nurses sometimes set the wrong expectation that the patient will be “numb”.
 
dipriMAN said:
Everyone at my hospital does a bolus of bag mix with 2 mcg/ml fentanyl at the start and starts PIEB with patient controlled epidural bolus as needed, works excellent. Only time I’ll bolus epidural fentanyl is for second stage labor if epidural is not covering and I don’t want to cause weakness with more local. Otherwise I will troubleshoot epidural, pull back catheter, bolus with local, or just replace before too much hassle.

I do agree that labor ad delivery nurses sometimes set the wrong expectation that the patient will be “numb”.
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Are you feeling anything? Yes!
Not numb!
 
There's a lot to be said for just doing what the locals do. Most of these small decisions just don't matter that much.

Prove that you're flexible and good enough to get things done a multitude of ways. Don't underestimate the value of the nurses liking you, especially when you're the FNG. Even when you're not new, when complications happen (and they will) the absolute last thing you need is a cadre of nurses talking about how Dr You does it differently than everyone else. It's stupid, but there are more important hills to die on.

Labor epidurals, more than anything else we do, are a matter of managing expectations and making people happy. So make people happy and get out.
 
For labor epidurals:
-5mL test dose, (3ml for thoracic).
-chase with remaining lido 1% in the kit after doing the skin localization. Usually about 5mL remains.
-10mL bolus off the pump (bupi 0.55%+2mcg/mL fentanyl), start at 10mL/h

-nix the 1% if they are early and comfortable

-if I feel like doing CSE I do 1ml bupi 0.25% and do the same bolus off the pump. Shouldn't give you any worse hypotension since it's priming the epidural space on the same nerves the spinal dose is affecting. The only nerves that the spinal may reach MORE would be the sacral roots which don't have sympathetic fibers anyway. The CSE is not really all THAT much faster than my routine LE method and it requires more steps, not so sure CSE is totally worth it.

Also I dunno if I've ever had an issue with hypotension with these strategies. At least no one is calling me about it. RNs usually get ~500mL through their 1L bolus by the time I get the epidural in. Usually pt is cruising after about 5 more contractions from time of test dose.
 
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