Inadequate CLE level

[lizzers729]

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Searched previous threads but didn't find anything specific to this topic.

Relatively fresh out of residency, and I'm having issues with CLE levels not being adequate. I usually do DPE (which I found a lot of posts about so I know the forum's feeling on those) to confirm midline. I bolus the last 2 mL of the test dose and then set the pump up and have the patient push the PCEA button for the first time. They are usually comfortable by the time I leave the room.

I was on call yesterday and got called about each of my (two) epidurals. The patients were comfortable when I left with good bilateral levels but a few hours later started experiencing worsening pain and each had a level around L1-2 bilaterally (despite supposedly pushing their PCEA button appropriately - I couldn't check one of the pumps because it had been reset). I hand bolused the bag solution (5 mL 0.2% ropi) twice for each of them, and they were comfortable and smiling again. And then educated them (again) on pushing their PCEA button.

I've seen varying strategies on setting up pumps (high basal, low bolus and vice versa), and I've played with each but do not have enough experience to know which is best. I started both of them on 5/8/20 min and ended up switching to 8/5/15 min.

I know people say if the epidural requires more than 1-2 top offs it should just be replaced, but since they each had a bilateral level and +CSF on DPE, I wasn't jumping up and down to replace them. Thoughts on inadequate levels, pump settings, etc? Am I just under-dosing the ropi (used to 0.125% bupi+fent)? I considered using epidural fentanyl too (we just use plain ropi on the pumps) - didn't seem to run into this issue as much in residency where we used bupi + fent). Or are they just not pushing the button enough?

Bonus question: tips on making the glass LOR syringe not sticky? How I learned in residency is not holding up well and I find myself constantly removing the syringe and trying to make it glide easy.

 

[Arch Guillotti]

Searched previous threads but didn't find anything specific to this topic.

Relatively fresh out of residency, and I'm having issues with CLE levels not being adequate. I usually do DPE (which I found a lot of posts about so I know the forum's feeling on those) to confirm midline. I bolus the last 2 mL of the test dose and then set the pump up and have the patient push the PCEA button for the first time. They are usually comfortable by the time I leave the room.

I was on call yesterday and got called about each of my (two) epidurals. The patients were comfortable when I left with good bilateral levels but a few hours later started experiencing worsening pain and each had a level around L1-2 bilaterally (despite supposedly pushing their PCEA button appropriately - I couldn't check one of the pumps because it had been reset). I hand bolused the bag solution (5 mL 0.2% ropi) twice for each of them, and they were comfortable and smiling again. And then educated them (again) on pushing their PCEA button.

I've seen varying strategies on setting up pumps (high basal, low bolus and vice versa), and I've played with each but do not have enough experience to know which is best. I started both of them on 5/8/20 min and ended up switching to 8/5/15 min.

I know people say if the epidural requires more than 1-2 top offs it should just be replaced, but since they each had a bilateral level and +CSF on DPE, I wasn't jumping up and down to replace them. Thoughts on inadequate levels, pump settings, etc? Am I just under-dosing the ropi (used to 0.125% bupi+fent)? I considered using epidural fentanyl too (we just use plain ropi on the pumps) - didn't seem to run into this issue as much in residency where we used bupi + fent). Or are they just not pushing the button enough?

Bonus question: tips on making the glass LOR syringe not sticky? How I learned in residency is not holding up well and I find myself constantly removing the syringe and trying to make it glide easy.

What is DPE?

Slick the inside of the glass syringe with some saline.

 

[lizzers729]

What is DPE?

Slick the inside of the glass syringe with some saline.

Sorry, dural puncture epidural. So a CSE without injecting meds. And I do slick the syringe with saline and twist it all around, but it still keeps sticking! 😕

 

[vector2]

What is DPE?

Slick the inside of the glass syringe with some saline.

I have found the exact opposite with regard to slicking. The glass is already super slick straight out of the box. Saline patchily adsorbs to the inner surface and creates more friction for me.

High bolus / low basal is a superior method, and I would not replace an epidural that had a bilateral level and positive CSF DP. Did the level come up when you bolused from the bag? Onset and duration of sensory block is slower and shorter with ropi so just check to see if they've actually been pressing the demand then go up on the bolus dose and frequency.

 

[deleted697127]

Searched previous threads but didn't find anything specific to this topic.

Relatively fresh out of residency, and I'm having issues with CLE levels not being adequate. I usually do DPE (which I found a lot of posts about so I know the forum's feeling on those) to confirm midline. I bolus the last 2 mL of the test dose and then set the pump up and have the patient push the PCEA button for the first time. They are usually comfortable by the time I leave the room.

I was on call yesterday and got called about each of my (two) epidurals. The patients were comfortable when I left with good bilateral levels but a few hours later started experiencing worsening pain and each had a level around L1-2 bilaterally (despite supposedly pushing their PCEA button appropriately - I couldn't check one of the pumps because it had been reset). I hand bolused the bag solution (5 mL 0.2% ropi) twice for each of them, and they were comfortable and smiling again. And then educated them (again) on pushing their PCEA button.

I've seen varying strategies on setting up pumps (high basal, low bolus and vice versa), and I've played with each but do not have enough experience to know which is best. I started both of them on 5/8/20 min and ended up switching to 8/5/15 min.

I know people say if the epidural requires more than 1-2 top offs it should just be replaced, but since they each had a bilateral level and +CSF on DPE, I wasn't jumping up and down to replace them. Thoughts on inadequate levels, pump settings, etc? Am I just under-dosing the ropi (used to 0.125% bupi+fent)? I considered using epidural fentanyl too (we just use plain ropi on the pumps) - didn't seem to run into this issue as much in residency where we used bupi + fent). Or are they just not pushing the button enough?

Bonus question: tips on making the glass LOR syringe not sticky? How I learned in residency is not holding up well and I find myself constantly removing the syringe and trying to make it glide easy.

Your hospitals standard epidural solution is straight local? I would ask someone from your group for guidance on what typical practice is in your hospital. There are obviously a lot of different ways to program an epidural but anything out of the norm may be misinterpreted by nursing staff that don’t know you.

 

[lizzers729]

Your hospitals standard epidural solution is straight local? I would ask someone from your group for guidance on what typical practice is in your hospital. There are obviously a lot of different ways to program an epidural but anything out of the norm may be misinterpreted by nursing staff that don’t know you.

Yup, plain ropi. I've asked a few other people (and honestly just set the pumps how they were previously programmed by other people...just got here about a month ago) and haven't gotten solid answers. I just wanted to make sure it wasn't something with my technique or programming I guess.

 

[lizzers729]

I have found the exact opposite with regard to slicking. The glass is already super slick straight out of the box. Saline patchily adsorbs to the inner surface and creates more friction for me.

High bolus / low basal is a superior method, and I would not replace an epidural that had a bilateral level and positive CSF DP. Did the level come up when you bolused from the bag? Onset and duration of sensory block is slower and shorter with ropi so just check to see if they've actually been pressing the demand then go up on the bolus dose and frequency.

Yeah, I was able to get them both comfortable again. We take home call, so I was trying to make sure there wasn't something I was missing or could be doing differently to avoid being called multiple times. Per the nurse and the patients, they were pushing the button, but after a lot of reading today, I'm thinking maybe they weren't pushing it as often as reported to me.

and so do you just use air instead of saline in the syringe?

 

[AdmiralChz]

Try without intentional dural puncture.

Sounds like you need more bolus, too.

I’m gonna ask the dumb question, what’s “CLE?”

 

[pgg]

5 mL/hr seems a little low to me.

We don't usually have 0.2% ropiv around any more, but I don't remember using different settings for it compared to the 0.125% bupi + fent that is our standard now. Most of us start at 8 or 10 mL/hr with a 6-8 mL bolus q 15 min.


As for doing DPEs, I think the advantages that study showed were mostly due to the inexperienced people doing the procedures in the study (residents at a teaching hospital). Lower PDPH incidence is probably because of fewer 17g wet taps when using a depth finding gauge. Better analgesia is probably because beginners got better catheters placed by using a depth finding gauge. I'm not convinced that DPEs add much in experienced hands. If you're going to poke the dura, I think you should put something in there.

 

[pgg]

Try without intentional dural puncture.

Sounds like you need more bolus, too.

I’m gonna ask the dumb question, what’s “CLE?”

CLE = continuous lumbar epidural

 

[Foodie]

Sounds like you're not having trouble reaching the epidural space if you are getting bilat relief.

These Portex LOR plastic syringes require no special tricks:
Portex® Plastic 'Loss Of Resistance' Syringes, Pain Management | Smiths Medical

I think you need to increase both your basal rate and bolus dose with lower concentration of local anesthetic. Epidurals are more volume dependent than concentration dependent. I typically run 0.125% bupi+ 2mcg/ml fent bag at 10-15ml bolus q15min with 10-12ml/hr basal rate.

 

[lizzers729]

Try without intentional dural puncture.

Sounds like you need more bolus, too.

I’m gonna ask the dumb question, what’s “CLE?”

What difference will not doing an intentional dural puncture make in the epidural a few hours later? Just out of curiosity.

And just a higher bolus dose on the pump?

 

[lizzers729]

5 mL/hr seems a little low to me.

We don't usually have 0.2% ropiv around any more, but I don't remember using different settings for it compared to the 0.125% bupi + fent that is our standard now. Most of us start at 8 or 10 mL/hr with a 6-8 mL bolus q 15 min.


As for doing DPEs, I think the advantages that study showed were mostly due to the inexperienced people doing the procedures in the study (residents at a teaching hospital). Lower PDPH incidence is probably because of fewer 17g wet taps when using a depth finding gauge. Better analgesia is probably because beginners got better catheters placed by using a depth finding gauge. I'm not convinced that DPEs add much in experienced hands. If you're going to poke the dura, I think you should put something in there.

Thanks, maybe I'll try bumping the dosing up a little. 8/5/15 is what I'm used to seeing.

Admittedly, I probably use DPE as a crutch for lack of confidence as I have not consistently done epidurals, so I've never really been able to develop a great reliable technique or method for troubleshooting. I definitely can tell when it feels right, it's really just when it's iffy that I like having that confirmation. But we have the CSE kits (which I choose to use cuz ya never know when it's going to be randomly difficult), so I feel bad opening it and not using the spinal needle. I've also gotten loss a few times and not gotten CSF or that "dural pop." One (yes, one haha) time I threaded the catheter anyway, and ended up with a one-sided block. The other times, I've re-sited the epidural needle with good results. I'm hesitant to give intrathecal meds because I prefer the feedback that the epidural is working, and I do think the dural puncture helps the epidural set up faster (again my "n" isn't anywhere near most of the posters on here, so this could change as I get more consistent experience).

 

[Planktonmd]

You don't need to puncture the dura to achieve good initial analgesia! Is this something you were taught to do in residency?
If you don't like to get called back frequently you need to be more aggressive with your initial bolus and maybe add Fentanyl to the infusion.
Bolusing with Ropivacaine 0.2% is not potent enough.
If you have to use Ropivacaine I would suggest bolusing with Ropivacaine 0.5% 8-10 ml divided in 2 doses then run Ropivacaine 0.2% with Fentanyl 2.5mcg/ml at 10 ml hour basal rate, and a PCEA of 3 ml with a 15 mins lock out.
You might need some ephedrine or phenylephrine initially but I guarantee you that you will sleep better and your patients and nurses will start to actually like you.

 

[GravelRider]

I run ropi 0.2% at 10. It prevents a lot of calls. Occasionally I’ll get a call that she’s “too numb” to push, but I’ll take that. Use whatever initial bolus you like. Poking the dura seems like an unnecessary extra step and potentially keeps me in a parturient’s room 15 seconds longer than I want to be in there.

 

[narcusprince]

Searched previous threads but didn't find anything specific to this topic.

Relatively fresh out of residency, and I'm having issues with CLE levels not being adequate. I usually do DPE (which I found a lot of posts about so I know the forum's feeling on those) to confirm midline. I bolus the last 2 mL of the test dose and then set the pump up and have the patient push the PCEA button for the first time. They are usually comfortable by the time I leave the room.

I was on call yesterday and got called about each of my (two) epidurals. The patients were comfortable when I left with good bilateral levels but a few hours later started experiencing worsening pain and each had a level around L1-2 bilaterally (despite supposedly pushing their PCEA button appropriately - I couldn't check one of the pumps because it had been reset). I hand bolused the bag solution (5 mL 0.2% ropi) twice for each of them, and they were comfortable and smiling again. And then educated them (again) on pushing their PCEA button.

I've seen varying strategies on setting up pumps (high basal, low bolus and vice versa), and I've played with each but do not have enough experience to know which is best. I started both of them on 5/8/20 min and ended up switching to 8/5/15 min.

I know people say if the epidural requires more than 1-2 top offs it should just be replaced, but since they each had a bilateral level and +CSF on DPE, I wasn't jumping up and down to replace them. Thoughts on inadequate levels, pump settings, etc? Am I just under-dosing the ropi (used to 0.125% bupi+fent)? I considered using epidural fentanyl too (we just use plain ropi on the pumps) - didn't seem to run into this issue as much in residency where we used bupi + fent). Or are they just not pushing the button enough?

Bonus question: tips on making the glass LOR syringe not sticky? How I learned in residency is not holding up well and I find myself constantly removing the syringe and trying to make it glide easy.

Your rate is not high enough. I like 7/4/15/4 ropivicaone 0.2% catheter treated 6-8cm. Bolus all the saline through epidural needle or if your ballsy bolus 3-4cc of 0.2% ropi through the thouy needle. Rarely do I get called back after my CLE.

 

[deleted162650]

As others have already pointed out, your problem is simple:

Not enough drug dude.

In the immortal words of Adam Sandler's The Goat:

"Crank it up F*cker!"

 

[AdmiralChz]

What difference will not doing an intentional dural puncture make in the epidural a few hours later? Just out of curiosity.

And just a higher bolus dose on the pump?

You might find you have a more predictable dose-response relationship. Just a thought - can’t really hurt, and what you are doing now isn’t working.

 

[NightNight]

Or just take it out of the patients hands.

Low-med basal and Intermittent mandatory bolus (if your pumps can be set for this).

 

[Consigliere]

I think a DPE (never heard that term in 20 years) is quite possibly the most r_etarded thing I have ever heard. You intentionally puncture the dura, increasing the risk for a PDPH, just to see if you're in the right spot!? Mind blown.

 

[deleted697535]

What difference will not doing an intentional dural puncture make in the epidural a few hours later? Just out of curiosity.

And just a higher bolus dose on the pump?

Pain is subjective. If you take their pain away more quickly with the dpe depending on the size hole you've made, when that initial bolus epidural/dpe wears off they feel equal pain to another straight up epidural but much more pain than after the initial amazing analgesia they got. So they complain. I surmise.

Also no opioid epidural labour infusions as standard? Is that a thing??

And home call as a resident?? Wtf??? Are you joking me? For your whole residency?

 

[deleted697535]

I think a DPE (never heard that term in 20 years) is quite possibly the most r_etarded thing I have ever heard. You intentionally puncture the dura, increasing the risk for a PDPH, just to see if you're in the right spot!? Mind blown.

Dpe? It's not new and doesn't incr pdph as far as the lit goes. It's a 27g thru the touhy. Better pain control by a few mins than a epidural without the bad side affects of cse

 

[Biohazard685]

Dpe? It's not new and doesn't incr pdph as far as the lit goes. It's a 27g thru the touhy. Better pain control by a few mins than a epidural without the bad side affects of cse

What's the diff between cse and dpe? With dpe there are no meds given IT?

 

[deleted162650]

What's the diff between cse and dpe? With dpe there are no meds given IT?

Yup. It’s one of the more ret*rded techniques.

 

[dhb]

It's a 27g thru the touhy

25g

 

[Hoya11]

Thanks, maybe I'll try bumping the dosing up a little. 8/5/15 is what I'm used to seeing.

Admittedly, I probably use DPE as a crutch for lack of confidence as I have not consistently done epidurals, so I've never really been able to develop a great reliable technique or method for troubleshooting. I definitely can tell when it feels right, it's really just when it's iffy that I like having that confirmation. But we have the CSE kits (which I choose to use cuz ya never know when it's going to be randomly difficult), so I feel bad opening it and not using the spinal needle. I've also gotten loss a few times and not gotten CSF or that "dural pop." One (yes, one haha) time I threaded the catheter anyway, and ended up with a one-sided block. The other times, I've re-sited the epidural needle with good results. I'm hesitant to give intrathecal meds because I prefer the feedback that the epidural is working, and I do think the dural puncture helps the epidural set up faster (again my "n" isn't anywhere near most of the posters on here, so this could change as I get more consistent experience).

Epidural is all about feel IMO. So the more you do the better, and in the beginning everybody struggles.

I would consider that maybe you are NOT in the epidural space with your "iffy" attempts.

And then with your needle outside (shallow to) the epidural space, but midline (ish), you get CSF back after passing the spinal needle.

So then you are fooled into thinking you must be in the epidural space because I got CSF back, but you are too shallow, and thread the catheter anyways into some other space..

Hence a patchy block/no block.

Instead of DPE for the "iffy" feels, i would just withdraw the tuohy to skin and start over again.

You want to feel everything the whole way through, its a process: the engaging of the ligament from muscle feeling tight, the crisp LOR, the feeling in your fingers that you are in the space before you push the syringe, and the feeling of the syringe without resistance pushing in NS. You want to have lots of those confirmatory signs. I think the DPE technique is hindering you from relying more on other instincts/feels.

 

[deleted162650]

Epidural is all about feel IMO. So the more you do the better, and in the beginning everybody struggles.

I would consider that maybe you are NOT in the epidural space with your "iffy" attempts.

And then with your needle outside (shallow to) the epidural space, but midline (ish), you get CSF back after passing the spinal needle.

So then you are fooled into thinking you must be in the epidural space because I got CSF back, but you are too shallow, and thread the catheter anyways into some other space..

Hence a patchy block/no block.

Instead of DPE for the "iffy" feels, i would just withdraw the tuohy to skin and start over again.

You want to feel everything the whole way through, its a process: the engaging of the ligament from muscle feeling tight, the crisp LOR, the feeling in your fingers that you are in the space before you push the syringe, and the feeling of the syringe without resistance pushing in NS. You want to have lots of those confirmatory signs. I think the DPE technique is hindering you from relying more on other instincts/feels.

Maybe you missed the part where they get comfy with a bolus with nice symmetrical block. Dose is just way too low especially using ropi and no narcotic.

Agree about just needing more experience/comfort level though.

 

[narcotics999]

In residency, we do CSE. Give IT 15 mcg fentanyl or 3cc from the bag.

Now, I only do straight epidural. after 3cc test dose, I give 5ml 0.25%, 5cc 0.125% bupi (less if short or bp low) before pump. Usually in 5 minutes, the pain comes down. I know that the epidural is working.

PCEA 0.2% ropi +2mcg/ml fentanyl 10/5/15. Tell the pt to push the button when she starts to feel uncomfortable (from 1/2/10 to 3/10), not too painful.

you give too little. For plain ropi, I run 12-16cc/ml. I don't like it though

 

[Hoya11]

Maybe you missed the part where they get comfy with a bolus with nice symmetrical block. Dose is just way too low especially using ropi and no narcotic.

Agree about just needing more experience/comfort level though.

It certainly may be a volume / narcotic issue and the epidural is in the space

But keep in mind we have an inexperienced provider without confidence in his feel, using a strange alternate technique, and we have a high percentage of the patients not doing well.. i think its right to consider its not in the epidural space

I dont think the report of the some relief initially, followed by misery , on multiple occasions is convincing enough to me that the epidural was initially successful, i mean how are we assessing that initial block to be so confident that it occurred? its just report from mom who has a lot going on and just wants the epidural to be over

 

[lizzers729]

It certainly may be a volume / narcotic issue and the epidural is in the space

But keep in mind we have an inexperienced provider without confidence in his feel, using a strange alternate technique, and we have a high percentage of the patients not doing well.. i think its right to consider its not in the epidural space

I dont think the report of the some relief initially, followed by misery , on multiple occasions is convincing enough to me that the epidural was initially successful, i mean how are we assessing that initial block to be so confident that it occurred? its just report from mom who has a lot going on and just wants the epidural to be over

Of the TWO epidurals I refered to in my first post, I got them both comfy again with hand boluses. They used one of them without issue for a c-section, so I’m confident it was in the space.

Also, I was taught to do DPE by an OB anesthesiologist during residency. And actually, one of the other MDs here does it as well, so it’s not just some “strange alternate” technique I made up. Uptodate mentions it as improving 1st time success and ensuring a bilateral block.

Thanks everyone for the info. I will try to rely less on DPE and start with higher infusion rates. The ropi is our standard, but I wonder if just giving some epidural fentanyl at the beginning would help? I don’t feel compelled to increase my initial bolus as they are legitimately comfy when I leave the room.

These were 2 of the 4 epidurals (2 of which have been used without issue for c-sections so if anything confirms they are functioning it’s that IMO) I’ve done at my new job. Since the inadequate level wasn’t something that happened to me a lot previously, and it happened twice on the same day, I just thought I’d look to the forum for experience and input .... But thanks.

 

[lizzers729]

Pain is subjective. If you take their pain away more quickly with the dpe depending on the size hole you've made, when that initial bolus epidural/dpe wears off they feel equal pain to another straight up epidural but much more pain than after the initial amazing analgesia they got. So they complain. I surmise.

Also no opioid epidural labour infusions as standard? Is that a thing??

And home call as a resident?? Wtf??? Are you joking me? For your whole residency?

Yes, our standard is ropi. I don’t work in an area with endless resources/supply, but likely it’s a pharmacy thing. I’ll try to investigate more.

And no, I’m not a resident.

 

[d9sccr]

Of the TWO epidurals I refered to in my first post, I got them both comfy again with hand boluses. They used one of them without issue for a c-section, so I’m confident it was in the space.

Also, I was taught to do DPE by an OB anesthesiologist during residency. And actually, one of the other MDs here does it as well, so it’s not just some “strange alternate” technique I made up. Uptodate mentions it as improving 1st time success and ensuring a bilateral block.

Thanks everyone for the info. I will try to rely less on DPE and start with higher infusion rates. The ropi is our standard, but I wonder if just giving some epidural fentanyl at the beginning would help? I don’t feel compelled to increase my initial bolus as they are legitimately comfy when I leave the room.

These were 2 of the 4 epidurals (2 of which have been used without issue for c-sections so if anything confirms they are functioning it’s that IMO) I’ve done at my new job. Since the inadequate level wasn’t something that happened to me a lot previously, and it happened twice on the same day, I just thought I’d look to the forum for experience and input .... But thanks.

The epidural fentanyl bolus is quickly absorbed into the blood and potentially isn't going to tell you whether you have a functional catheter or not as mom is clearly going to get some pain relief. Just stick with above bupi top-off after your test dose to know. You SHOULD add some fentanyl to the bag of ropi hanging though and increase your infusion rate on the ropi. Anything from 2-4mcg/ml should work well.

 

[sevoflurane]

Turbo diesel epidural cocktail:

.2% rop with 2mc/ml of fentanyl through spring wound catheter

Basal of 12 ml/hr (room to go up here)
PCEA 4-5 ml q 30 min.

One thing I learned once I graduated residency is how much higher I could run these epidurals compared to my academic institution.

For me this cocktail was essential at my last practice as we did not have 24hr in house OB anesthesia.

In 7 years I can’t remember if I ever was called back to manage an OB patient that didn’t have a good working epidural.

 

[deleted697535]

Do people still do basal infusion rates of epidural as opposed to pib?

 

[anbuitachi]

at my academic institution, we do basal of 10m/hr bupi + fent. and PCEA q10-15 mins.

DPE is very popular here and is supported. I've done plenty of DPE and never had a single headache afterwards. i mostly do it if the patient has a lot of pain and i want to give her quicker relief without the ridiculous itch from CSE

 

[Twiggidy]

I think a DPE (never heard that term in 20 years) is quite possibly the most r_etarded thing I have ever heard. You intentionally puncture the dura, increasing the risk for a PDPH, just to see if you're in the right spot!? Mind blown.

1000% Agree. Who is out there teaching this? Your main problems are
1) Too low a medication dose
2) Bad technique

Try your best to palpate midline, engage the ligament, and find LOR. Place the catheter and test. If you’re having trouble go paramedian (which can be a lifesaver especially for thoracic)

As others have said, if you’re going to risk a PDPH at least do the patient a favor initially and put 15-25 mcg of fentanyl in the CSF so her pain goes away.

 

[Twiggidy]

Yes, our standard is ropi. I don’t work in an area with endless resources/supply, but likely it’s a pharmacy thing. I’ll try to investigate more.

And no, I’m not a resident.

Also to address the glass syringe issue. I hate it too. We have the plastic ones that I like a lot more, but, if I’m forced to use the glass (say I’m so tired and forget to open the plastic one) I fill the glass syring with the saline in the kit and do LOR with saline. Im sure someone in your residency had to show you that move. Some argue it’s more
“physiologic” than air anyway.

 

[Orin]

Relatively fresh out of residency, and I'm having issues with CLE levels not being adequate. I usually do DPE (which I found a lot of posts about so I know the forum's feeling on those) to confirm midline.
...
I hand bolused the bag solution (5 mL 0.2% ropi) twice for each of them, and they were comfortable and smiling again. And then educated them (again) on pushing their PCEA button.
...
Am I just under-dosing the ropi (used to 0.125% bupi+fent)? I considered using epidural fentanyl too (we just use plain ropi on the pumps) - didn't seem to run into this issue as much in residency where we used bupi + fent). Or are they just not pushing the button enough?

My bet is that your lack of success is due to the change solution combined with your preferred technique. You're basically guaranteeing a CSF leak which will dilute out your epidural solution. Your ropi is probably diluting down, and without an opioid diffusing around to help you out, you're betting on dilute local to win.

It probably gets better and more reliable the further away you get from your dural puncture, and if you manually bolus a boat load, it probably spreads better and has a higher local concentration before the dilution effect happens.

 

[Orin]

Bonus question: tips on making the glass LOR syringe not sticky? How I learned in residency is not holding up well and I find myself constantly removing the syringe and trying to make it glide easy.

The old put a few drops of saline in and push the plunger with the tip occluded to get the shaft lubricated generally works for me, but sometimes there are some poorly made glass syringes that stick a bit more than others and require taking out the plunger/reseating/twisting to smooth off something that get it stuck.

Who makes the syringes/kits you are using now?

 

[deleted162650]

at my academic institution, we do basal of 10m/hr bupi + fent. and PCEA q10-15 mins.

DPE is very popular here and is supported. I've done plenty of DPE and never had a single headache afterwards. i mostly do it if the patient has a lot of pain and i want to give her quicker relief without the ridiculous itch from CSE

I CSE everybody and I’ve never had a patient itch. WTF are you putting in there??

 

[sevoflurane]

Sounds like you're not having trouble reaching the epidural space if you are getting bilat relief.

These Portex LOR plastic syringes require no special tricks:
Portex® Plastic 'Loss Of Resistance' Syringes, Pain Management | Smiths Medical

I think you need to increase both your basal rate and bolus dose with lower concentration of local anesthetic. Epidurals are more volume dependent than concentration dependent. I typically run 0.125% bupi+ 2mcg/ml fent bag at 10-15ml bolus q15min with 10-12ml/hr basal rate.

Just checking my math here...

So your patients may get up to 72 ml/hr of .125% bupi and 144 mcg/hr of fentanyl?

Seems high, but just curious more than anything.

 

[GravelRider]

Do people still do basal infusion rates of epidural as opposed to pib?

Pib?

 

[Twiggidy]

I CSE everybody and I’ve never had a patient itch. WTF are you putting in there??

I’ll back him up a bit. Straight fentanyl makes some of them itch, 3 cc of the labor bag won’t. My theory is that the bupiv in the labor bag numbs where they would itch with just fentanyl. That’s just observation though.

 

[narcusprince]

Just checking my math here...

So your patients may get up to 72 ml/hr?

Thats a super high level of analgesia. I have not used fentany in an epidural except for c sections in 6 years. Before we get on the bad technique train. Those epidurals were able to be used for c sections. A few more questions do you tread the epidural cather to 20cm at skin and withdraw to appropriate depth? How much catheter is treaded into the epidural space? We use multi oriface catheters which riquire at least 6 in the epidural space. In my experience doing L and D I have never had to go paramedian.

 

[anbuitachi]

I CSE everybody and I’ve never had a patient itch. WTF are you putting in there??

I’ll back him up a bit. Straight fentanyl makes some of them itch, 3 cc of the labor bag won’t. My theory is that the bupiv in the labor bag numbs where they would itch with just fentanyl. That’s just observation though.

They are literally scratching their entire body afterwards. we put straight up fentanyl. we don't inject the bag. too hard to maintain sterility

 

[Twiggidy]

They are literally scratching their entire body afterwards. we put straight up fentanyl. we don't inject the bag. too hard to maintain sterility

Unplug the labor bag where you connect the tubing prior to starting and place on flat sturdy surface
Open a 3 cc syringe on to the open kit
Place elbow on the bag for support and stick the 3 cc syringe with a needle from the kit into the place you unplugged
Draw up desired amount

I do the same when drawing the 20 cc bolus from the labor bag if I don’t do CSE

If your nurse is helpful they can hold the bag, just don’t stick them with the needle.

 

[IMGASMD]

If your nurse is helpful they can hold the bag, just don’t stick them with the needle.

Temptation is all too real.

 

[Twiggidy]

Temptation is all too real.

It why I had to learn to not need them. I’ll shank somebody.....Need to stop watching Oz

 

[deleted162650]

They are literally scratching their entire body afterwards. we put straight up fentanyl. we don't inject the bag. too hard to maintain sterility

Ya, straight fentanyl CSE’s are almost as dumb as DPE’s. 2.5cc of bag solution is where it’s at. It’s not hard to maintain sterility. I’ve personally done hundreds this way over the last 5 years, and it’s the predominant technique at the busiest L&D unit in the state with no infections there either.

Put bag on top of the cart with the port facing you right at the edge of the cart. Open the epidural tray over the bag so that the sterile paper wrap covers all but the port. Now you can hold/stabilize the bag with your sterile hand over the drape while you draw up the solution with your other sterile hand.

 

[sevoflurane]

Thats a super high level of analgesia.

I agree. I thought I had the turbo diesel recipe for CLE. Not anymore...

@Foodie has somehow defeated Thanos, taken the gauntlet and harvested the power of the infinity stones into his CLE technique.

That dose makes my turbo diesel look like diluted water. 😵