Epidurals overnight for IOL

[Status Sciaticus]

Actually it could be my call to make. There are limited resources available off hours. I’m paid to be on call to cover urgent OR, trauma and OB emergencies. If people are asking me to provide non-urgent services during an overnight shift it is my call to ensure I’m available for emergencies.

No it really isnt. A surgeon says a patient is urgent/emergent, are you going to argue otherwise? I expect that you have a backup available? Also taking the above-mentioned 15 minutes to do an epidural is not a significant amount of time. Most trauma call backs are 20 minutes. And most ORs take longer to set up even for emergent cases. And if there is an absolute emergency that you need to attend to, you can always drop the epidural and come back once things settle out.

If it was really your call to make, then go ahead and refuse to do these 'non-urgent' epidurals. See how that shakes out and report back to us.

How long does an epidural take?

Under 5 minutes usually?

What if the hospital isn't paying you a stipend to do in house call and you are only getting paid for the service?

Then you F3cked up
Also if you are just being paid for the service, then youre getting paid to do the procedure. More reason to do the epidural.

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[Bertelman]

How long does an epidural take? Back when I did them routinely:
I walk in the room, brief convo.
Get her sitting up while I open the tray.
Invariably has a contraction once they sit up.
I tell her I will start after the next contraction, which is about the time it takes me to set up the tray.
Once the next contraction starts, I've got lido in my hands, do the skin wheel.
Epidural catheter threaded before next contraction hits.
- this is for actively laboring women

 

[medicine2wallstreet]

Man I would love if bertelman was my attending. This guy gets it.

 

[triggermaster]

Evening induction for our OBs means starting a cervical ripening agent around 7-9pm then pit whenever cervix is favorable. Often that’s not til next morning, sometimes that’s at 1am, but with the plan being to ideally deliver next day during business hours. Our group has a dedicated doc covering L&D in house 24/7. Overnight doc comes in at 5pm and is getting paid well for it. All seems reasonable in that context. But you’re welcome to disagree.

Our inductions could be at 8, 10, 11pm or 1am and the plan is to start pit 4 hours later. It’s just wrong for OBs to be able to screw you like this. At least when you do OR cases at night that could have waited the surgeon also has to wake up. OB scheduling inductions with 3am epidural sleep through the whole thing- selfish a holes.

 

[nimbus]

I think it depends on the setup and your perspective. If you’re covering other rooms in addition to the labor deck, night time epidurals can be annoying. But if you’re taking dedicated OB call, it can be disappointing to get 0-2 epidurals during a night shift. Some of our partners at our busy women’s hospital are disappointed if they get less than 10. On a very busy night they can do 15-20. That’s considered an attribute and it’s why they work there. Also, the nurses at this hospital will have the patient consented, sitting, with a tray, gloves, and infusion at the bedside before the anesthesiologist enters the room.

 

[triggermaster]

I think it depends on the setup and your perspective. If you’re covering other rooms in addition to the labor deck, night time epidurals can be annoying. But if you’re taking dedicated OB call, it can be disappointing to get 0-2 epidurals during a night shift. Some of our partners at our busy women’s hospital are disappointed if they get less than 10. On a very busy night they can get 15-20. That’s considered an attribute and that’s why they work there.

Agree. It totally depends on your setup. If you are a salaried employee on call for emergencies who gets nothing but a ruined night’s sleep it sucks to do induction epidurals. If you are busy and making bank or would be awake anyway, then it’s not so bad.

 

[Volatile]

I agree we are a service line and have limited control. However if you don’t ever ask questions or attempt to push back you have absolutely no control. I would suggest radiologists have done a better job of this than us as a profession. For example do you see them doing epidural blood patches under flouro after hours or on weekends? I have seen anesthesiologists do these all the time and I’m not taking about on patients where we caused the Pdph.

Sounds like the IOL schedule I’m taking about is standard practice everywhere. However I’d push back on the idea that this is best practice for the patient as the patient is up most of the night getting induced and the complications we want to avoid overnight can still come up the next night as some of these G1s end up as failure to progress 18-24 hours later.

At my last hospital we never performed blood patches on weekends or after hours. At my current hospital we don’t do them after hours. We may do them on a weekend day shift only if we’re not busy.

 

[LaryngoSpazz]

Agree. It totally depends on your setup. If you are a salaried employee on call for emergencies who gets nothing but a ruined night’s sleep it sucks to do induction epidurals. If you are busy and making bank or would be awake anyway, then it’s not so bad.

Now some people can finally see my perspective.

I guess if most of you prefer to do stuff that’s not urgent at night just to make extra money because you’re paid on production I get it but at the same time it’s stupid. If you pushed back and moved those things to daytime hours they would still get done and you could still bill for it, you just wouldn’t need to have your call person up all night. Who wants to do 20 epidurals overnight - no thanks.

Now I understand why it may be “$tandard of care.”

 

[Dr. Rude]

At my last hospital we never performed blood patches on weekends or after hours. At my current hospital we don’t do them after hours. We may do them on a weekend day shift only if we’re not busy.

A few years ago I had the following scenario. Patient calls late afternoon after being directed to from radiology post myelogram HA. Classic PDPH. You reassure them and give them an appointment for late morning the following day to come in for EBP eval. They show up at 2am in the ER. Your call is in house nothing and nothing else going on when the ER calls you.
Do you patch her? Tell her to keep her appointment the following day? Something else?

I patched her. Not happily or gladly.

 

[repititionition]

A few years ago I had the following scenario. Patient calls late afternoon after being directed to from radiology post myelogram HA. Classic PDPH. You reassure them and give them an appointment for late morning the following day to come in for EBP eval. They show up at 2am in the ER. Your call is in house nothing and nothing else going on when the ER calls you.
Do you patch her? Tell her to keep her appointment the following day? Something else?

I patched her. Not happily or gladly.

Where do you direct a patient to actually come in TO for EBP eval? This is a challenge from my perspective. We don’t have a clinic, and telling patients to present to the ED at a pre-arranged time also feels bizarre.

 

[psycho-matic]

It's safer to have them induce at midnight to be ready to deliver during the day when there is a full staff of obestetricians for emergencies. You need to suck it up and do the epidural during overnight hours. The overnight induction and during the day delivery is common practice. You part in this process as an epiduralist takes 15 minutes. They have to watch the laboring patient all day. They want an awake and alert obstetrician.

One would think OBs would learn to place their own labor epidurals...

 

[nimbus]

One would think OBs would learn to place their own labor epidurals...

Some old time OBs did.

 

[psycho-matic]

Some old time OBs did.

Not rocket science lol

 

[Bertelman]

Where do you direct a patient to actually come in TO for EBP eval? This is a challenge from my perspective. We don’t have a clinic, and telling patients to present to the ED at a pre-arranged time also feels bizarre.

We used to have them present to IR. I think they just come to L&D now. You just need to find a place with a room big enough for the procedure, a unit accustomed to admits/discharges, and a nursing staff comfortable with the procedure.

 

[GassYous]

One would think OBs would learn to place their own labor epidurals...

I don't even trust some of them to do ob stuff

 

[Angus Avagadro]

Some old time OBs did.

As a resident, I can remember OB residents having to spend some time on our service. I think it was a board requirement for them back then.

 

[IlDestriero]

To clarify, I’m asking only about non urgent inductions of labor. For example, patient is an induction for dates, she is scheduled to arrive on OB floor at say 6pm, pitocin started at 10pm, request for epidural at 1am.

That’s routine practice.

 

[Volatile]

A few years ago I had the following scenario. Patient calls late afternoon after being directed to from radiology post myelogram HA. Classic PDPH. You reassure them and give them an appointment for late morning the following day to come in for EBP eval. They show up at 2am in the ER. Your call is in house nothing and nothing else going on when the ER calls you.
Do you patch her? Tell her to keep her appointment the following day? Something else?

I patched her. Not happily or gladly.

Definitely stinks but we wouldn’t patch her at night. But our hospital was small and our sub specialists and ER knew we only performed them during duty hours so they never asked. Everyone needs to be on the same page. Patients that would show up in the ER would get a cocktail, if they didn’t improve they would place a consult to be seen in our PAC clinic. Never heard of any patient complaints.

 

[PpfSuxTube]

A few years ago I had the following scenario. Patient calls late afternoon after being directed to from radiology post myelogram HA. Classic PDPH. You reassure them and give them an appointment for late morning the following day to come in for EBP eval. They show up at 2am in the ER. Your call is in house nothing and nothing else going on when the ER calls you.
Do you patch her? Tell her to keep her appointment the following day? Something else?

I patched her. Not happily or gladly.

Never patch someone inside 48 hours. Team that performed the procedure should also assess 1st.
Get emerg to stuff some lido up the nose.

Never patch anyone at 2am in emerg.

Only in pacu with someone available to help, and only at some reasonable hour... pain is never an emergency. Literally no one has ever died of pain definitely not pdph. Why do ppl think pain is an emergency...

 

[Gaseous Clay]

Never patch someone inside 48 hours. Team that performed the procedure should also assess 1st.
Get emerg to stuff some lido up the nose.

Never patch anyone at 2am in emerg.

Only in pacu with someone available to help, and only at some reasonable hour... pain is never an emergency. Literally no one has ever died of pain definitely not pdph. Why do ppl think pain is an emergency...

So if your mom, wife, daughter, or you yourself were absolutely so miserable they went to the ER, would you appreciate if someone took care of it? An epidural blood patch takes a few minutes and you can also abandon it if you are needed elsewhere.

My prior vacation coverage once told someone on a Saturday morning to follow up with us on Monday. That did not sit well with me. 2 AM I understand but otherwise just do the d*mn procedure.

 

[PpfSuxTube]

So if your mom, wife, daughter, or you yourself were absolutely so miserable they went to the ER, would you appreciate if someone took care of it? An epidural blood patch takes a few minutes and you can also abandon it if you are needed elsewhere.

My prior vacation coverage once told someone on a Saturday morning to follow up with us on Monday. That did not sit well with me. 2 AM I understand but otherwise just do the d*mn procedure.

Inside 48 hours, no don't touch. No evidence.
Don't care who it is.

Also stuff lido up the nose.
Relax buddy

 

[Arch Guillotti]

So if your mom, wife, daughter, or you yourself were absolutely so miserable they went to the ER, would you appreciate if someone took care of it? An epidural blood patch takes a few minutes and you can also abandon it if you are needed elsewhere.

My prior vacation coverage once told someone on a Saturday morning to follow up with us on Monday. That did not sit well with me. 2 AM I understand but otherwise just do the d*mn procedure.

Seriously just go down there and do quit being a lazy bum and leaving it for the next guy, even though thats what they would do to you

 

[ScarfTheVerb]

I used to work at a small suburban hospital with low volume OB. I was Q2-3 home call and the OBs did not start pit until 6 or 7am out of courtesy to us. No weekend inductions either. Whenever I’d get a middle of the night call for an epidural the OB nurse would start with “sorry, but could you please come in…” Usually they’d try to bridge the gap with some fentanyl if it was close to morning.

I don’t miss being on call all the time but I do miss the collegiality of the small hospital and those OB nurses who tried their best to protect my sleep.

 

[GassYous]

So if your mom, wife, daughter, or you yourself were absolutely so miserable they went to the ER, would you appreciate if someone took care of it? An epidural blood patch takes a few minutes and you can also abandon it if you are needed elsewhere.

My prior vacation coverage once told someone on a Saturday morning to follow up with us on Monday. That did not sit well with me. 2 AM I understand but otherwise just do the d*mn procedure.

Well I'd like to be fresh for the morning cases without having to drive to the hospital in the middle of the night + setup time + procedure time and charting

 

[Dr. Rude]

Inside 48 hours, no don't touch. No evidence.
Don't care who it is.

Also stuff lido up the nose.
Relax buddy

Disagree for wet taps on Labor epidurals. I don’t think they should leave the hospital without EBP if still with HA. They can’t take care of the baby.

 

[Angus Avagadro]

Disagree for wet taps on Labor epidurals. I don’t think they should leave the hospital without EBP if still with HA. They can’t take care of the baby.

Someone please update my thinking, but it was my understanding there was data suggesting that EBP was more effective if delayed and performed 48 hrs after the puncture. In the past, I have done a couple in the ER if I was available. I believe it's more of an act of compassion than out of necessity as it could be managed for a few hours with meds. Coming to the ER on Fri night on Labor Day weekend and being told to wait until Tues to be seen would be unacceptable, imo.

 

[Simba1711]

Must be nice. This was the opposite of my experience. When I was in residency the l and d nurse paged me to come preop a patient. Told her I was with a patient in a C-section. She didn’t understand and wanted me to leave the patient in the or just so I can preop the patient. Her response was what If there is an emergency. Other times they would call and tell me it’s a stat epidural only for them to be playing on their phone at the desk with nothing set up in the room when I show up.

I haven’t done ob since residency.

I used to work at a small suburban hospital with low volume OB. I was Q2-3 home call and the OBs did not start pit until 6 or 7am out of courtesy to us. No weekend inductions either. Whenever I’d get a middle of the night call for an epidural the OB nurse would start with “sorry, but could you please come in…” Usually they’d try to bridge the gap with some fentanyl if it was close to morning.

I don’t miss being on call all the time but I do miss the collegiality of the small hospital and those OB nurses who tried their best to protect my sleep.

 

[GassYous]

Must be nice. This was the opposite of my experience. When I was in residency the l and d nurse paged me to come preop a patient. Told her I was with a patient in a C-section. She didn’t understand and wanted me to leave the patient in the or just so I can preop the patient. Her response was what If there is an emergency. Other times they would call and tell me it’s a stat epidural only for them to be playing on their phone at the desk with nothing set up in the room when I show up.

I haven’t done ob since residency.

Hate this line. Some dinky outside hospital transferred a patient at 2 am and the nurse calls me at 3 am to preop. I ask why "because there might be an emergency". Wtf??

 

[rick roller pump]

Hate this line. Some dinky outside hospital transferred a patient at 2 am and the nurse calls me at 3 am to preop. I ask why "because there might be an emergency". Wtf??

Private practice OB is so much better because they can't abuse residents with pointless tasks. In residency we were expected to pre-op every OB admit and consent them for an epidural in advance. So f'ing dumb. I am still mad about being paged at 3am to pre-op a patient when there was no urgency what so ever. This policy was made by the fellowship trained OB anesthesiologists of course.

 

[Simba1711]

How are the l and d nurses on ob in private practice ? Are they more reasonable and respectful ?

 

[ScarfTheVerb]

More respectful, but certainly not more reasonable.

 

[dabears505]

Must be nice. This was the opposite of my experience. When I was in residency the l and d nurse paged me to come preop a patient. Told her I was with a patient in a C-section. She didn’t understand and wanted me to leave the patient in the or just so I can preop the patient. Her response was what If there is an emergency. Other times they would call and tell me it’s a stat epidural only for them to be playing on their phone at the desk with nothing set up in the room when I show up.

I haven’t done ob since residency.

You're a lucky man never having to deal with that nonsense again

 

[Drangue]

Also, the nurses at this hospital will have the patient consented, sitting, with a tray, gloves, and infusion at the bedside before the anesthesiologist enters the room.

What? Where is this place?

 

[PpfSuxTube]

Disagree for wet taps on Labor epidurals. I don’t think they should leave the hospital without EBP if still with HA. They can’t take care of the baby.

The literature around blood patch is so sketch no one know optimal timing, dose etc.

 

[nimbus]

What? Where is this place?

Busy women’s hospital with about 9000 deliveries per year, west coast.

 

[rick roller pump]

How are the l and d nurses on ob in private practice ? Are they more reasonable and respectful ?

I have only had one job so hard to generalize but for me it is way better. Get Epic message to do epidural, message back when I am heading up. All equipment in the room when I get there. Talk with patient. Set up tray as nurse positions. Place epidural. Bolus. If busy I will leave (if I don't hear back again I just assume it's working fine). If I have time I will chart and then check back on the patient. Nurses set up and connect infusion with PCEA so never get called to bolus (if I do then often times it just needs to be replaced). Nurses will give prn phenyl and ephedrine. So most epidurals I am in and out in 15 minutes and never get called again.
As opposed to residency where they would call you and patient wouldn't even have an IV and the nurse would refuse to place one and you need to grab all your supplies.

 

[Bertelman]

What? Where is this place?

My place is like that. Chart opened to consent, my gloves, the nice ones even have tape cut on the table.

 

[Dr. Rude]

The literature around blood patch is so sketch no one know optimal timing, dose etc.

Agree, but, MAYBE waiting 72-96 hours MIGHT be optimal for first EBP success. But sending a woman home with a newborn and a PDPH without patching her is not in the best interest of patient care and missing the forest for the trees.

 

[PpfSuxTube]

Agree, but, MAYBE waiting 72-96 hours MIGHT be optimal for first EBP success. But sending a woman home with a newborn and a PDPH without patching her is not in the best interest of patient care and missing the forest for the trees.

With respect, I didn't ever say anything about sending anyone home. Was that you? Or someone else? Sorry, I can't recall...

All I said was the literature around timing of ebp is so sketchy that there's no way anyone should be arm wrestled into doing one at 2am especially for a non OB situation which is what was originally quoted. And there is reasonable evidence for sphenopalatine also.

Then the woke brigade arrived and insinuated this was heinous behavior akin to manslaughter and so were here...

Joke joke!

 

[Dr. Rude]

With respect, I didn't ever say anything about sending anyone home. Was that you? Or someone else? Sorry, I can't recall...

All I said was the literature around timing of ebp is so sketchy that there's no way anyone should be arm wrestled into doing one at 2am especially for a non OB situation which is what was originally quoted. And there is reasonable evidence for sphenopalatine also.

Then the woke brigade arrived and insinuated this was heinous behavior akin to manslaughter and so were here...

Joke joke!

Fair enough. Simple question. Almost all vaginal delivery patients go home 24-48 hours post delivery. Is there anybody who wouldn't patch a patient with a wet tap and PDPH and send her home?

 

[PpfSuxTube]

Fair enough. Simple question. Almost all vaginal delivery patients go home 24-48 hours post delivery. Is there anybody who wouldn't patch a patient with a wet tap and PDPH and send her home?

Honestly inside 48 hours no. That was the number I learned in residency and unless someone shows me otherwise...

I'm not getting involved in the hyperbole of OB.

 

[gcc322]

Consensus Practice Guidelines on Postdural Puncture Headache

This consensus statement describes the process of creating evidence-based guidelines for postdural puncture headache that considered risk factors, preventive measures, and therapies and their adverse effects.

jamanetwork.com

If ebp performed within 48hr pt should be counseled that they may require another ebp before resolution of symptoms. (B)

 

[PpfSuxTube]

Consensus Practice Guidelines on Postdural Puncture Headache

This consensus statement describes the process of creating evidence-based guidelines for postdural puncture headache that considered risk factors, preventive measures, and therapies and their adverse effects.

jamanetwork.com

If ebp performed within 48hr pt should be counseled that they may require another ebp before resolution of symptoms. (B)

Thank you. Level of evidence for most of that isn't high. No ebp at 2am

 

[Maz777]

No blood patches in the middle of the night. That's just basic common sense.

But, yes, blood patch before they get discharged even if it is the weekend. It's your epidural complication, and you shouldn't kick the can down the road to someone else. It's not ideal to have a patient re-present to the ED within 48hrs of discharge due to a PDPH. Offer a blood patch or SPG block (if they don't want another needle in their back) before discharge.

Any time you do a blood patch, you should obviously consent them that their HA might recur and might need another blood patch. The blood doesn't magically heal the hole in the dura/CSF leak. Body has to heal itself, which takes time.

 

[DocVapor]

If it's a PDPH after labor epidural that myself or one of my partners did I'll do the EBP whenever but preferably during daylight hours.

If it's the call from the ER that I got 2 months ago at 11 pm on Saturday for a 35 y/o woman with 8 month history of severe headaches being worked up by Neurosurg and got a lumbar puncture on Friday at the competing hospital system (different EMR so no records)... yeah no, she can go back to them. Not touching that with a 10 foot pole any time of day or night.

 

[LivetoTell]

Would you not feel guilty turning away a potential PDPH patient at night from the ER after they sat waiting for hours? It’s obvious we make the L&D RNs life so much easier after the pt has their epidural. However, I never see that reflected back at anesthesia. They know we work 24 hour shifts, but it seems that is rarely taken into account ( just asking to be reasonable). We’ve had providers written up because they deferred the requesting epidural to the next provider (near shift change 20 -30 min). The horror!

 

[pgg]

What? Where is this place?

Most non-academic places I've worked are like this.