Inadequate CLE level

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narcusprince said:
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.
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With good reason. Epidural vein engorgement during pregnancy makes paramedian approaches a bloody mess.
 
Lads are ye reading any of the latest literature or what?
Pib is programmed intermittent bolus (less motor block equal analgesia and possibly less sections), dpe is a safe technique, and possibly better and faster than a regular epidural...



Please read about these things before you rubbish them. You sound like dinosaurs... Should we bring back halothane too?

I do apologise if you have read the lit and then disparage them!
 
Now we are talking about movies and dead characters. I have a q: Is Han Solo dead dead????
 
🙂
pgg said:
It was good until the ending. The ending was insulting.

None of those dead people are going to stay dead and every one of us knows it.
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The ending is straight from the original comic book that was written 30 years ago.


screen-shot-2018-03-16-at-82734-pm-1094040.jpeg


I liked it. Bad guy won this round. 🙂
 
I also liked how the movie huminized Thanos.... nice touch really.
 
sevoflurane said:
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. 😵
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Haha waitaminute, I don't want to mislead anyone. Those are doses for straight epidurals, I don't do CLEs anymore.

No laboring pt will wait an hour to reach that full 50-72ml/hr dose if her epidural was working well before with basal alone. But if it's the issue of recruiting all the ports in the multiport catheter, then problem can be often solved with the first couple big volume boluses.
 
Foodie said:
Haha waitaminute, I don't want to mislead anyone. Those are doses for straight epidurals, I don't do CLEs anymore.

No laboring pt will wait an hour to reach that full 50-72ml/hr dose if her epidural was working well before with basal alone. But if it's the issue of recruiting all the ports in the multiport catheter, then problem can be often solved with the first couple big volume boluses.
Click to expand...

Haha... I think I'm the one confused. What is a straight epidural? If you have a basal rate going, that in my mind is a continuous labor epidural by definition. I honestly don't follow up much on the OB literature as I find there really isn't much more I can change to reliably get my patients comfy by the time I leave the room. I bolus with high injection pressures with all of my test dose, left over lidocaine +/- some rop out of the bag--> and most (90%) are super comfy by the time I leave the room which is usually < 10 minutes. The rest I don't hear from so that to me means that we achieved the desired effect shortly after.

In my mind, If I've bloused 50-72ml of LA through the epidural in a one hour period, that epidural is not working optimally and needs to be replaced.

I'm definitely NOT criticizing. Your post was just of interest to me as the total narcotic and LA dosage is much much larger than I have ever given over a one hour period. I would argue that the 100-144 mcg/hr of fentanyl definitely is playing a part in that analgesic regimen and may skew the effectiveness of the actual LA delivered into the epidural space. Again, just discussing with you.

:highfive:

We have had some minor discussions about switching to intermittent boluses for our laboring patients. So I think for me that is a legit discussion on this thread although we have not adopted that delivery method as of yet.

I also think that doing a dural puncture without giving any meds is not something I will adopt given the success of our CLE with PCEA.
The risk of paresthesias and possible HA or just the fact that it's the "new kid" on the block does not convince me one bit of it's superiority over a simple CLE with PCEA.

My 2 cents.

Good discussion.
 
sevoflurane said:
I honestly don't follow up much on the OB literature as I find there really isn't much more I can change to reliably get my patients comfy by the time I leave the room.

I also think that doing a dural puncture without giving any meds is not something I will adopt given the success of our CLE with PCEA.
The risk of paresthesias and possible HA
Click to expand...

There are some interesting things going on in OB now that i am aware of in the lit...

Oxytocin bolus dose is down to 0.35 units now or something in an oxytocin naieve patient. 3 units if oxytocin tolerant. after that think abut second line agent

PIBs seem to be the way forward. Modest benefits but thats still progress.

Avoiding lidocaine test dose also!!

DPE seems to be progress and safe too. We might need to get special touhy needles so the spinal needle comes straight out and not angled upwards but still overall reasonably safe

There is definitely ways to improve practice! which means less sections, more sleep for us, less expense on the system!?!
 
sevoflurane said:
Haha... I think I'm the one confused. What is a straight epidural? .
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I apologize, I mistyped -- I meant I don't do CSEs anymore. :smack: But that's bc I'm lazy. I do CLEs all the time, probably more often than I would like.

For anyone who is curious, this is how I do 'em. Midline. Go as low as possible. Inject 10-15ml sterile NS into epidural space once I get LOR with NS to open up the epidural space. Thread cath 3-5cm into epidural space. Tell pt to sit up straight (important if pt is obese), watch epidural cath get pulled into pt's back. Inject test dose, monitor. Tape. Set up pump with 0.125% bupi + 2mcg/ml fent bag at 10-12ml/hr basal with 10-15ml bolus q15min. By this point pt is comfortable enough to be able to listen to me. This is when I tell pt to call if pain doesn't improve after 2 boluses, bc it may mean that the epidural may not be working anymore. I also tell pts that 95% of the pts do not need to use the pain button at all. I stay around for a little while to make sure everyone is happy and safe.

My colleagues run pump rate similarly and we haven't had complaints or adverse events.

Laboring pts don't wait >30 min to alert the RN if CLE stops working, so no one gets that much fentanyl or LA. What's most important to me is that if an epidural stops working, I replace it before pt is unable to sit still for another one or before I need to use it for C/S.

Many ways to skin a cat. Do what works for you.
 
Newtwo said:
There are some interesting things going on in OB now that i am aware of in the lit...

Oxytocin bolus dose is down to 0.35 units now or something in an oxytocin naieve patient. 3 units if oxytocin tolerant. after that think abut second line agent

PIBs seem to be the way forward. Modest benefits but thats still progress.

Avoiding lidocaine test dose also!!

DPE seems to be progress and safe too. We might need to get special touhy needles so the spinal needle comes straight out and not angled upwards but still overall reasonably safe

There is definitely ways to improve practice! which means less sections, more sleep for us, less expense on the system!?!
Click to expand...

I'm reading a bit on PIBs right now. There's something there I must admit. I say that anything that gets me called less and in the OR less in the middle of the night is ok with me.
 
My pumps are fairly new and do not have the capability to do PIBs as far as I’m aware. The studies show modest statistically significant benefit in certain metrics, but I’m not convinced of their clinically significant benefits. Shorter labor by 12 minutes? Certainly not enough to convince anyone of incurring the expense of buying all new pumps capable of PIB (the studies I read used the acronym of PIEB).

I’m also not convinced that there is much more we can do in anesthesia to favorably change the c-section rate. It is my experience that things like failed inductions and failure to progress c-sections are entirely OB and patient dependent. Some patients just don’t want to push and some OBs just don’t want to wait.

PIB has some interesting points, but I would hardly say that continuous infusions are analogous to still using halothane. Sevo and des both clearly are better agents. PIB is not clearly a better method of providing labor analgesia.

Poking the dura just seems like a completely unnecessary extra step to me. Maybe the patient is comfortable 2 minutes faster, but is that clinically significant? It is rare that a patient is not already comfortable and snoozing by the time I finish programming the pump and touching up my charting.
 
Last edited:
Newtwo said:
There are some interesting things going on in OB now that i am aware of in the lit...

Oxytocin bolus dose is down to 0.35 units now or something in an oxytocin naieve patient. 3 units if oxytocin tolerant. after that think abut second line agent

PIBs seem to be the way forward. Modest benefits but thats still progress.

Avoiding lidocaine test dose also!!

DPE seems to be progress and safe too. We might need to get special touhy needles so the spinal needle comes straight out and not angled upwards but still overall reasonably safe

There is definitely ways to improve practice! which means less sections, more sleep for us, less expense on the system!?!
Click to expand...
Avoiding lido test dose? Where is that? I just read the Anesthesiology OB update article and that wasn't mentioned.. Any data on that?
 
Twiggidy said:
I'm reading a bit on PIBs right now. There's something there I must admit. I say that anything that gets me called less and in the OR less in the middle of the night is ok with me.
Click to expand...
What is PIB? I'm fortunately in a part of the USA where I can get Mr. Pibb and I put it in my head every chance I get.
 
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