Help me remember how to do OB!

[BDanes]

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So this is a plea to the board for any advice, tips, or tricks w doing OB anesthesia.

I haven't done it for years, and have been offered some shifts starting this week. Luckily I will have CRNA help and they all have experience. So besides learning my way around the OB floor, I need some help with simple things those of you do routinely in private practice.

I am looking for what you use for initial drugs and dosing for epidural a, maintenance dose and rates. How far are you leaving catheters in? Any tips for placement when running into trouble?
If you get a dural puncture do you just do a spinal catheter or redo at higher level?

I know a lot of this will be similar to riding a bike, but I don't want to look silly to the nurses when I start. I have no problem asking them questions and for help, but I also don't want to be in a position deferring to them either.

Also, any tips that you can offer or things you'd wished you'd have known to make the job smoother would be great. I'm sure there are things I'm forgetting, so feel free to tell me. Things you have learned from experience or that you can't read in a book are gold!

Thanks!

 

[Dejavu]

Bolus epidurals with 7-10 ccs of 0.125% Bupiv, run them at 8cc/h with a PCEA of 4cc with a lock out of 15 minutes with 0.125 or more dilute with some Fentanyl.

Catheters in about 4-5cm beyond the end of the touhy, threaded north, but I have seen them work headed south (if you cannot get it north), you just have to give slightly higher doses. But it is uncommon as hell, in my experience.
Around 12 to 14 ccs of 2% Lido with 50-100 mcgs of Fentanyl for c-section. Redose as necessary.
Spinal for c/s- Heavy 0.75% Bupiv 1.6ccs with 80mcgs of Dilaudid for postop pain. Gets you around T4.

Get your pressor ready, the BP will go down. Tilt pt toward the left to off load the vena cava. Used to be phenyl was a no-no in OB, probably not any more. Some people argue it is better.

Wet tap, move up a level.

Lots of ways to do this stuff, this is how I remember doing it. I also haven't done it in a while but now will, rarely, have to do OB anesthesia again.

(Legal disclaimer )Usual disclaimer that this might be all innaccurate, so you are the one to decide for yourself.
Gotta go, hope this helps a little.

 

[pgg]

My basic OB recipes:

Labor: CSE for everyone. Intrathecal dose 1 mL 0.25% bupivacaine + 15 mcg fentanyl. Infusion of 0.125% bupiv + 2 mcg/mL fentanyl at 8 mL/hr with 6 mL PCEA q15min lockout.

Scheduled section: Zofran 4 mg. Skip the Bicitra and Reglan. Spinal with 1.6 mL 0.75% hyperbaric bupiv + 15 mcg fentanyl + 0.2 mg morphine. 1.4 mL if the surgeon is speedy. 500 mcg phenylephrine squirted in new 1 L IV bag, run wide open from the time I scrub her back and glove up. Toradol.

Section with epidural: Zofran 4 mg. Usually give Bicitra and Reglan. Usually ~15 mL 2% lido. 100 mcg fent + 3 mg morphine through the catheter up front, if we're not doing the section for NRFHT, otherwise I give it after delivery. Toradol.

I rarely need to deviate from any of that.


Next wet tap, hopefully never , thread intrathecal catheter, use it, pull next day. (I know there's been some recent doubt cast on the utility of leaving the intrathecal catheter in 24h to reduce odds of PDPH.)

 

[sevoflurane]

Hefty T-burg utilization while spinal sets up.

 

[Bertelman]

A couple weeks ago, had a primip @ 3 cm in obvious discomfort during contractions, mostly calm in between. She spoke some Eastern European language, and father was barely able to translate.

Epidural placement was smooth as hell. LOR @ 5, easy thread. Bolused 5 cc in the Tuohy, another 5 cc in the cath prior to hooking up infusion. First few contractions seemed to be less intense, shorter. As I was finishing my paperwork and walking out, she had a rough one. I'm thinking hell no, not this one.

Sure enough, 10 minutes later got a page saying it's not working. Now, I only do this gig maybe once a month, and I wasn't familiar with this nurse. And obviously language was a barrier, so i chose to just drop another catheter. Sit her back up, the second one goes in just like the first, one level up. Bolus through the needle, again through the cath, tape it up. Sit her down, this time I stick around for a couple more contractions. Still no relief. I'm not buying this, so I reluctantly ask them to check her.

Boom, 10 cm. Primip dilated from 3-10 with posture waiting for me to do my thing. This is obviously way more common with multips, but it can still happen. I wish I had put more faith in my technique and asked for a check after the first. Alternatively, given clear communication you can ask the Pt if the contractions feel differently, more pressure, feel like you need to poop, etc.

I'm sure many of you will tell me I should have done a CSE the second time. I've thought about it, but frankly I did only a couple in residency, and like I said I do maybe 5 epidurals a month. I'm not convinced I have the numbers to become comfortable with that technique.

 

[BDanes]

Thanks for the replies!
I like the idea of phenylephrine in the bag, but what about when you have to add the Pit? Is that no problem w mixing?

So our bags are premixed w the 0.125 and 0.25 marcaine w fent. It seems like I remember just taking 10 mL off the premix bag as my initial bolts and then running the epidural.

What do you guys do when you get a one sided block? Do you back catheter out a cm and small bolus or just pull and redo?

 

[bullard]

Thanks for the replies!
I like the idea of phenylephrine in the bag, but what about when you have to add the Pit? Is that no problem w mixing?

So our bags are premixed w the 0.125 and 0.25 marcaine w fent. It seems like I remember just taking 10 mL off the premix bag as my initial bolts and then running the epidural.

What do you guys do when you get a one sided block? Do you back catheter out a cm and small bolus or just pull and redo?

Don't screw around. Just pull and redo. In the long run, that saves a lot of time.

 

[bullard]

A couple weeks ago, had a primip @ 3 cm in obvious
Boom, 10 cm. Primip dilated from 3-10 with posture waiting for me to do my thing. This is obviously way more common with multips, but it can still happen. I wish I had put more faith in my technique and asked for a check after the first. Alternatively, given clear communication you can ask the Pt if the contractions feel differently, more pressure, feel like you need to poop, etc.

I'm sure many of you will tell me I should have done a CSE the second time. I've thought about it, but frankly I did only a couple in residency, and like I said I do maybe 5 epidurals a month. I'm not convinced I have the numbers to become comfortable with that technique.

I did all CSE in residency and I think it was great because we were so busy that it allowed us to get out of the room (and onto the next epidural or section) that much faster. No bolusing the catheter with your 6-8 mLs of bupiv 0.125 or 0.25%. Now that I'm in a much lower volume practice, I can take the time to bolus the catheter and not leave until mom reports the contractions are getting better. So now I never bother to do CSE. CSE is not hard but in your situation I agree it's not worth it.

Yes, definitely have to ask for a recheck if RN says the epidural's not working. Sometimes they've made rapid change and just need a redose, but often it's because they're 10 cm, it's time to push, and you're off the hook. 🙂

 

[bullard]

Toradol post c-section: how much are you guys giving? 30 mg at the end of the case? 15 mg q6h x 4 after the case? More?

Intrathecal catheter: If the BMI is really high and/or if I've been struggling for a while, I'll thread the catheter intrathecally. Like your 5'4", 300 pound medicaid patient who screams when you inject the local in the skin and can't sit still for even a minute. Otherwise, easier to just pull the Tuohy and try again a level above.

 

[countingdays]

This is what I give. May be old school, but works well with no problems. I'd change it if it were broken.

Epidural: Bolus 10mL 0.25% Bupiv + left over lidocaine from the kit then run 0.2% ropivicaine at 10mL/hr + 4q30.

Epidural for section: 20mL 2% lidocaine (no chloroprocaine available for almost a year. Used to do 10+10)

Spinal: 1.8mL 0.75% Bupivicaine + 0.25mg Duramorph.

 

[Dejavu]

Thanks for the replies!
I like the idea of phenylephrine in the bag, but what about when you have to add the Pit? Is that no problem w mixing?

So our bags are premixed w the 0.125 and 0.25 marcaine w fent. It seems like I remember just taking 10 mL off the premix bag as my initial bolts and then running the epidural.

What do you guys do when you get a one sided block? Do you back catheter out a cm and small bolus or just pull and redo?

I guess I would pull it back and test with 1% Lido 10cc.

That takes about as long as getting set up to do another one and may save a second procedure for the pt.

IMHO

 

[caligas]

Intrathecal catheter: If the BMI is really high and/or if I've been struggling for a while, I'll thread the catheter intrathecally. Like your 5'4", 300 pound medicaid patient who screams when you inject the local in the skin and can't sit still for even a minute. Otherwise, easier to just pull the Tuohy and try again a level above.[/QUOTE]

Tayloring your decision to the specific situation instead of hard and fast rules about what the right thing to do is? Thats madness.

 

[Gern Blansten]

For spinal catheters, I would do what the group is used to. If you place a spinal cath and it is never done at your hospital, you may have colleagues that mistakenly dose it as an epidural. Must be clearly labeled and your colleagues in anesthesiology and OB must be aware. Some hospitals still have OB's that give topoff doses for delivery, so that could be a disaster if they are unaware or have no idea how to manage it.

 

[BDanes]

Gypsy- what does +4 q30 mean?

Great points everyone. Doing shift now. It is like riding a bike. Epidurals and spinals all smooth. The guys here apparently don't really check levels for spinals. I'm not sure how I feel about that. Also, one guy runs his epidural at 14/hr to start. What say you?

 

[Gern Blansten]

Gypsy- what does +4 q30 mean?

Great points everyone. Doing shift now. It is like riding a bike. Epidurals and spinals all smooth. The guys here apparently don't really check levels for spinals. I'm not sure how I feel about that. Also, one guy runs his epidural at 14/hr to start. What say you?

I rarely check either. They are either adequate or they aren't. I don't waste a bunch of time doing multiple checks.
14ml/hr is not too high in my opinion. The patients probably don't complain. The OB may complain if the motor block is too much or if it leads to hypotension (probably not too common). I have seen many run 14/hr and do well with it. I usually do 11 or 12. Sometimes 10.

 

[urge]

The guys here apparently don't really check levels for spinals.

I don't check either. They are either screaming or not. That is check enough.

 

[IlDestriero]

Toradol post c-section: how much are you guys giving? 30 mg at the end of the case? 15 mg q6h x 4 after the case? More?

Intrathecal catheter: If the BMI is really high and/or if I've been struggling for a while, I'll thread the catheter intrathecally. Like your 5'4", 300 pound medicaid patient who screams when you inject the local in the skin and can't sit still for even a minute. Otherwise, easier to just pull the Tuohy and try again a level above.

Toradol 30mg q6h X 4 doses. First dose in the OR while closing.

PS 300 lbs isn't very big... 😱