Intraop bolusing of labor epidural

[TheLoneWolf]

Work at a place with an OB residency so c section times vary widely but is expected with learners.

One attending is so slow that c sections routinely run 3-4 hours including primary elective c sections. Blood loss>1.2-1.5 L. Our department has given feedback but OB won't change. Their department is aware and won't touch on the subject.

Some do CSEs for this. My limited experience is that the hyperbaric bupi spinal pools around the sacral nerves as they are sitting upright while the epidural catheter is threaded and taped so block height does vary.

For those who have had similar situations, when do you bolus the epidural after the spinal and how much do you routinely give? I test with cold sensation and dose with 5-10 mls of 2% lido if the block is receding.

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[GassYous]

Work at a place with an OB residency so c section times vary widely but is expected with learners.

One attending is so slow that c sections routinely run 3-4 hours including primary elective c sections. Blood loss>1.2-1.5 L. Our department has given feedback but OB won't change. Their department is aware and won't touch on the subject.

Some do CSEs for this. My limited experience is that the hyperbaric bupi spinal pools around the sacral nerves as they are sitting upright while the epidural catheter is threaded and taped so block height does vary.

For those who have had similar situations, when do you bolus the epidural after the spinal and how much do you routinely give? I test with cold sensation and dose with 5-10 mls of 2% lido if the block is receding.

Show them the youtube video of the indian guys doing it in 3-4 minutes

 

[repititionition]

Show them the youtube video of the indian guys doing it in 3-4 minutes

If OBs could be appealed to by shaming their terrible surgical skills, we’d all be spared a lot of BS.

 

[jwk]

Work at a place with an OB residency so c section times vary widely but is expected with learners.

One attending is so slow that c sections routinely run 3-4 hours including primary elective c sections. Blood loss>1.2-1.5 L. Our department has given feedback but OB won't change. Their department is aware and won't touch on the subject.

Some do CSEs for this. My limited experience is that the hyperbaric bupi spinal pools around the sacral nerves as they are sitting upright while the epidural catheter is threaded and taped so block height does vary.

For those who have had similar situations, when do you bolus the epidural after the spinal and how much do you routinely give? I test with cold sensation and dose with 5-10 mls of 2% lido if the block is receding.

That's absurdly outside the bounds of even close to being normal. You need to do more than give feedback. Routinely losing 3 units of blood on a C/S? Really? We go nuts when they take longer than an hour, especially when we have folks that can knock them out in less than 15 minutes.

That being said - straight epidural for unknown length C-section makes more sense. Why mess with a CSE for fast onset when speed clearly isn't a concern.

 

[Southpaw]

Work at a place with an OB residency so c section times vary widely but is expected with learners.

One attending is so slow that c sections routinely run 3-4 hours including primary elective c sections. Blood loss>1.2-1.5 L. Our department has given feedback but OB won't change. Their department is aware and won't touch on the subject.

Some do CSEs for this. My limited experience is that the hyperbaric bupi spinal pools around the sacral nerves as they are sitting upright while the epidural catheter is threaded and taped so block height does vary.

For those who have had similar situations, when do you bolus the epidural after the spinal and how much do you routinely give? I test with cold sensation and dose with 5-10 mls of 2% lido if the block is receding.

Not speaking to the slowness of the OB as everyone has touched on it, but like @jwk said if I know I’m going to need it I’d rather just place an epidural and run with that. Specifically, I like DPEs in this situation.

I don’t really like CSEs for anything aside from labor analgesia. For a CS, the patient stays sitting while you thread the epidural catheter and all the heavy bupi goes sacral. Also, the S part of the CSE will be denser than your E part, and when you start using the E the patient may complain. In actuality your E is fine but the patient is used to the block density of the S mentally. The lack of such a dense block will mean you’re giving more sedation than you’d prefer while using the epidural. Anecdotally speaking, if you just place and use the epidural for the case I think you’ll have better results over a large n.

 

[periopdoc]

I like the CSE for the nice, dense block it provides while the epidural is setting up. Why dose with hyperbaric? I do all my spinals with either 0.5% or 0.25% anymore. If I was in your shoes, I would give 15mg of bupi up front and start a 2% lidocaine epidural infusion at 8cc per hour, starting about an hour into the case. Supplement with 5cc boluses of 2% as necessary.

 

[Southpaw]

I like the CSE for the nice, dense block it provides while the epidural is setting up. Why dose with hyperbaric? I do all my spinals with either 0.5% or 0.25% anymore. If I was in your shoes, I would give 15mg of bupi up front and start a 2% lidocaine epidural infusion at 8cc per hour, starting about an hour into the case. Supplement with 5cc boluses of 2% as necessary.

This sounds solid. For knees and hips I’ve seen 15mg isobaric bupi last easily 3 hours, sometimes over 4. How long will it last for a CS in a preggo?

 

[periopdoc]

Unfortunately, it's variable, but I would say 2.5 to 3 is the most common

 

[PAC2DO]

I’m also at an academic place where OBs take 2.5 hrs easily for a primary elective c/s. They blame that it takes more time because they externalize the uterus or patients are sicker. We mostly do CSEs but puts combination of heavy bupi/fent/duramorph (if BMI allowed) in the spinal med. Once we give the spinsal, we thread the catheter and put the pt in T burg till we get T4 level. We typically dose epidural if the patient starts complaining or some attendings will hook up the epidural catheter to a pump in about 1-1.5 hr and run 2% lido at 8ml/hr. Some prefer hand bolusing the epidural catheter with 5 cc of 2% lido after dosing the test dose.

 

[patriot6]

i would do a CSE in your scenario for the reason periopdoc mentioned -- i like the dense spinal while the epidural sets up. the downside with this technique is that you have to be very quick threading your catheter to avoid sacral spread like you mentioned. if you encounter any difficulty threading the catheter, or if you get an IV catheter, or if there's any delay in getting the catheter positioned at all, your spinal is pretty much hosed.

did quite a few CSEs for long sections in training. just got to have everything ready to go immediately after dosing sab.

 

[IMGASMD]

I would just do a epidural. Dose with lido 2%. If it takes long to set up, it takes long to set up……. Like others have said, seems like time doesn’t matter where you are.

I heard of places that they would just tube everyone for knees/hips, because of the slowness….(4-6 hours)
Can’t even fathom the concept of taking more than 2 hours to do a primary c-section. The longest case I was present during training was a C-Hys. That one was about 3 hours. A lot of that time was trying many things to stop bleeding…. And OB getting consent and explaining what’s happening to the patient.

 

[deleted875186]

Interesting replies above.

I personally would try a spinal with isobaric 15 mg, or with hyperbaric 15 mg and epinephrine and see if I could get it to last. I’ve had spinals with 10-12.5 mg isobaric last well over 3-5 hours in the orthopedic population.

I would place a CSE, I would only start to dose the epidural after 2 hours, never seen a spinal wear off before that, would go with 5 cc chloroprocaine to start by hand, check level, and then continue if inadequate level.

 

[Anestheezee]

I think it's been studied that prolonged CS time increases the risk of surgical site infection. Might be worth exploring this concept with the department.

 

[Lecithin5]

Cse: 1.4-1.8 cc of 0.75 bupi; after about hour and a half- 2 hours (can also do a quick toothpick test at that time on patient), start intermittent epidural bolusing 2 percent lido, 5-10 cc at a time. This should last you at least another hour….ad infinitum

 

[surgndoc]

The same mg dose of isobaric will last longer than hyperbaric - don’t ask me why but it’s true. 15mg iso spinal should cover the whole thing, if you’re really feeling it you could probably get away with 17.5mg(bilateral TKR dose) for the whole c/s if they really are 4hr range. Or just cse with 15mg iso bupi spinal and give 5ml lido as needed as it’s wearing off. Easy. Don’t see why straight epidural only from the start would give any benefit.

 

[anbuitachi]

its one thing to take 2-3 hours. its another to consistently lose 1.5 to 2 L of blood. that OB is dangerous. needs to be escalated to beyond OB department if they refuse to do anything

 

[Southpaw]

If it’s true you’re running 3-4 hours and the OB department is tolerating that, then I would be honest with the patient pre-operatively.

‘Ma’am this surgery will take 3-4 hours. As opposed to leaving you awake that entire time, after your baby is out we will put you to sleep. That will be just as safe for you as spinal anesthesia, and there will be no concern of our spinal medications wearing off nor will we need to sedate you heavily as you will not be comfortable lying awake for 3 hours while open surgery is performed after your baby is out.’

But seriously if EBL is that high routinely that surgeon should also require far more blood transfusions on their patients than other OBs. My guess is length of stay in the hospital is also longer. I think such a long record of poor performance on a routine surgery should find its way to peer review.

I really can’t imagine a routine CS taking much more than an hour of anesthesia time.

 

[jwk]

its one thing to take 2-3 hours. its another to consistently lose 1.5 to 2 L of blood. that OB is dangerous. needs to be escalated to beyond OB department if they refuse to do anything

yep - that's a patient safety/risk management issue.

 

[zizzer]

its one thing to take 2-3 hours. its another to consistently lose 1.5 to 2 L of blood. that OB is dangerous. needs to be escalated to beyond OB department if they refuse to do anything

He said 1.2-1.5L.

I currently do CSE with hyperbaric 0.75% bupivacaine with the catheter and tegaderms opened and ready to go but may switch to isobaric options after reading here. As somebody who hasn't used isobaric bupivacaine in years for spinals, anything tips for things to be aware of? Would you all recommend 3mL of 0.5% bupivicaine?

 

[anbuitachi]

He said 1.2-1.5L.

I currently do CSE with hyperbaric 0.75% bupivacaine with the catheter and tegaderms opened and ready to go but may switch to isobaric options after reading here. As somebody who hasn't used isobaric bupivacaine in years for spinals, anything tips for things to be aware of? Would you all recommend 3mL of 0.5% bupivicaine?

acutally he said "Blood loss>1.2-1.5 L. "

so greater than that. which is awful

 

[deleted875186]

He said 1.2-1.5L.

I currently do CSE with hyperbaric 0.75% bupivacaine with the catheter and tegaderms opened and ready to go but may switch to isobaric options after reading here. As somebody who hasn't used isobaric bupivacaine in years for spinals, anything tips for things to be aware of? Would you all recommend 3mL of 0.5% bupivicaine?

I’ve actually never used it for CS, only main OR cases.

 

[TheLoneWolf]

I think it's been studied that prolonged CS time increases the risk of surgical site infection. Might be worth exploring this concept with the department.

The surgeon had boasted that they have "the lowest infection rate" of all members of a large OB department. Not to me but to other staff who passed it on to me.

 

[TheLoneWolf]

If it’s true you’re running 3-4 hours and the OB department is tolerating that, then I would be honest with the patient pre-operatively.

‘Ma’am this surgery will take 3-4 hours. As opposed to leaving you awake that entire time, after your baby is out we will put you to sleep. That will be just as safe for you as spinal anesthesia, and there will be no concern of our spinal medications wearing off nor will we need to sedate you heavily as you will not be comfortable lying awake for 3 hours while open surgery is performed after your baby is out.’

But seriously if EBL is that high routinely that surgeon should also require far more blood transfusions on their patients than other OBs. My guess is length of stay in the hospital is also longer. I think such a long record of poor performance on a routine surgery should find its way to peer review.

I really can’t imagine a routine CS taking much more than an hour of anesthesia time.

This surgeon is smart enough to work with residents so they will routinely blame long surgical times or high blood loss on the residents.

No insight into how dangerous she is. Refers to herself as "well I'm the attending" when she wants to discuss plans with me.

 

[patriot6]

Refers to herself as "well I'm the attending" when she wants to discuss plans with me.

"as am I" is the correct response

 

[TheLoneWolf]

acutally he said "Blood loss>1.2-1.5 L. "

so greater than that. which is awful

The absolute worst part is when we hit the 3 hour mark, the patients start becoming uncomfortable and disinhibited from laying still for so long in addition to actively going into hypovolemic shock. Cold clammy extremities, confused, lethargic and the OB will write it off as us needing to give better sedation.

To some degree, I feel that ACOG needs to step up and give a formal statement of how dangerous OB anesthesia is and implement national protocols, in concert with anesthesiology input. Hold them to account as I feel like I'm not the only one here who occasionally feels like a patsy for their misadventures.

 

[TheLoneWolf]

If it’s true you’re running 3-4 hours and the OB department is tolerating that, then I would be honest with the patient pre-operatively.

‘Ma’am this surgery will take 3-4 hours. As opposed to leaving you awake that entire time, after your baby is out we will put you to sleep. That will be just as safe for you as spinal anesthesia, and there will be no concern of our spinal medications wearing off nor will we need to sedate you heavily as you will not be comfortable lying awake for 3 hours while open surgery is performed after your baby is out.’

But seriously if EBL is that high routinely that surgeon should also require far more blood transfusions on their patients than other OBs. My guess is length of stay in the hospital is also longer. I think such a long record of poor performance on a routine surgery should find its way to peer review.

I really can’t imagine a routine CS taking much more than an hour of anesthesia time.

The surgery tech came to me and said please do the double epidural thing because any case with that OB is very long. Senior resident rushes in to OR to tell me the same thing .....before an elective primip section.

I got weird responses from the OB when I popped in a CSE.

OB; "Why are you putting in a CSE? Do you know that I prefer it?"

Ob: "Do you put in a CSE for all your C sections? "

Me: yes

 

[TheLoneWolf]

Not speaking to the slowness of the OB as everyone has touched on it, but like @jwk said if I know I’m going to need it I’d rather just place an epidural and run with that. Specifically, I like DPEs in this situation.

I don’t really like CSEs for anything aside from labor analgesia. For a CS, the patient stays sitting while you thread the epidural catheter and all the heavy bupi goes sacral. Also, the S part of the CSE will be denser than your E part, and when you start using the E the patient may complain. In actuality your E is fine but the patient is used to the block density of the S mentally. The lack of such a dense block will mean you’re giving more sedation than you’d prefer while using the epidural. Anecdotally speaking, if you just place and use the epidural for the case I think you’ll have better results over a large n.

I had read about a technique to get around this issue of the hyperbaric sacralizing while threading and taping the epidural.

Place epidural at L3-4 and test dose. Tape in place.

Next, place spinal at level below with regular dose for a c section.

Lay flat and get started. Upside is knowing epidural catheter is in the correct position and local won't sacralize. Downside is 2 punctures and longer setup and placement.

 

[Southpaw]

The absolute worst part is when we hit the 3 hour mark, the patients start becoming uncomfortable and disinhibited from laying still for so long in addition to actively going into hypovolemic shock. Cold clammy extremities, confused, lethargic and the OB will write it off as us needing to give better sedation.

To some degree, I feel that ACOG needs to step up and give a formal statement of how dangerous OB anesthesia is and implement national protocols, in concert with anesthesiology input. Hold them to account as I feel like I'm not the only one here who occasionally feels like a patsy for their misadventures.

You need to start putting these ladies to sleep after the baby is out. I guess it helps if departmentally all of you are on the same page. Like if you're the lone anesthesiologist who puts these people to sleep, it probably doesn't help your cause, but still I think you need to do what you think is right by the patient. Lying awake for 3 hours while surgery is performed on you just seems miserable. Again, it helps if departmentally you all recognize what's going on and take a similarly conservative and honest approach (i.e. we don't have confidence in this surgeon, times are routinely 3 hours or more, so as a department we think its best to offer patients GETA once baby is out so we can focus on the resuscitation needs of the patient, etc.)

Also, it's been said here before, but I always find it weird how the worst surgeons are also often the most difficult to get along with. I'd tend to respond to things like 'Why are you putting in a CSE?' with 'I'm not confident a spinal will last long enough for this surgery'. Or to 'do you put CSEs in for all c sections?' I'd likely say something like 'I don't have many options outside of GETA for cases with an anesthesia time around 3 hours or more'. I'd probably be a little more sensitive and understanding, but maybe not, with her if the conversation wasn't around an awake patient.

 

[patriot6]

I had read about a technique to get around this issue of the hyperbaric sacralizing while threading and taping the epidural.

Place epidural at L3-4 and test dose. Tape in place.

Next, place spinal at level below with regular dose for a c section.

Lay flat and get started. Upside is knowing epidural catheter is in the correct position and local won't sacralize. Downside is 2 punctures and longer setup and placement.

nope; no telling where that catheter is.

The surgery tech came to me and said please do the double epidural thing because any case with that OB is very long. Senior resident rushes in to OR to tell me the same thing .....before an elective primip section.

I got weird responses from the OB when I popped in a CSE.

OB; "Why are you putting in a CSE? Do you know that I prefer it?"

Ob: "Do you put in a CSE for all your C sections? "

Me: yes

why lie? that was a perfect opportunity to say that other sections are an hour max skin to skin and a single shot SAB is very appropriate for that case duration, but not your typical case duration.

 

[TheLoneWolf]

nope; no telling where that catheter is.



why lie? that was a perfect opportunity to say that other sections are an hour max skin to skin and a single shot SAB is very appropriate for that case duration, but not your typical case duration.

She had this conversation with me intraop while I'm placing the CSE with all other attendant staff. Probably not the best time to critique her questionable surgical skills and a terrified patient who is just hearing that all other staff in the room have low confidence in her.

 

[patriot6]

She had this conversation with me intraop while I'm placing the CSE with all other attendant staff. Probably not the best time to critique her questionable surgical skills and a terrified patient who is just hearing that all other staff in the room have low confidence in her.

Fair. But if she's asking me the question, I'm going to tactfully give her an honest answer.

 

[deleted875186]

I had read about a technique to get around this issue of the hyperbaric sacralizing while threading and taping the epidural.

Place epidural at L3-4 and test dose. Tape in place.

Next, place spinal at level below with regular dose for a c section.

Lay flat and get started. Upside is knowing epidural catheter is in the correct position and local won't sacralize. Downside is 2 punctures and longer setup and placement.

Interesting idea, it might work the other way around, place spinal needle at L4-5 and get flow, stylet back in, then do the epidural above. Honestly though I try and minimize the number of passes of a spinal or epidural needle as I feel that’s the main risk of the procedure, so probably would never do this technique.

 

[deleted875186]

She had this conversation with me intraop while I'm placing the CSE with all other attendant staff. Probably not the best time to critique her questionable surgical skills and a terrified patient who is just hearing that all other staff in the room have low confidence in her.

Tough situation, you have to be mindful of what your saying in front of the patient as well as the tone.

I would probably have said something like “I wasn’t sure if a spinal block would be sufficient for the case duration so I decided to place a CSE” and leave it at that, but I agree you have to just give a honest answer.

 

[Arch Guillotti]

One attending is so slow that c sections routinely run 3-4 hours including primary elective c sections. Blood loss>1.2-1.5 L. Our department has given feedback but OB won't change. Their department is aware and won't touch on the subject.

This needs to be taken as far as you can, diplomatically of course. This is far beyond anything I saw when I was in academics.

 

[pgg]

This needs to be taken as far as you can, diplomatically of course. This is far beyond anything I saw when I was in academics.

Agreed. Risk management and peer review need to be involved.

 

[IMGASMD]

When I was in training, we had a few of those “surgeons”. Some of my attendings used to give the same dose as other OB/patients. Would ruthlessly announce in the middle of the c-section that is has been more than 2+ hours, and that’s why patient is uncomfortable.

However, in the back of everyone’s mind knows nothing will ever change. Are they willing to retrain this “surgeon”? Probably not.

 

[nimbus]

When I was in training, we had a few of those “surgeons”. Some of my attendings used to give the same dose as other OB/patients. Would ruthlessly announce in the middle of the c-section that is has been more than 2+ hours, and that’s why patient is uncomfortable.

However, in the back of everyone’s mind knows nothing will ever change. Are they willing to retrain this “surgeon”? Probably not.

Scariest part is that those surgeons are….ahem….“teaching” the residents.

 

[TheLoneWolf]

You need to start putting these ladies to sleep after the baby is out. I guess it helps if departmentally all of you are on the same page. Like if you're the lone anesthesiologist who puts these people to sleep, it probably doesn't help your cause, but still I think you need to do what you think is right by the patient. Lying awake for 3 hours while surgery is performed on you just seems miserable. Again, it helps if departmentally you all recognize what's going on and take a similarly conservative and honest approach (i.e. we don't have confidence in this surgeon, times are routinely 3 hours or more, so as a department we think its best to offer patients GETA once baby is out so we can focus on the resuscitation needs of the patient, etc.)

Also, it's been said here before, but I always find it weird how the worst surgeons are also often the most difficult to get along with. I'd tend to respond to things like 'Why are you putting in a CSE?' with 'I'm not confident a spinal will last long enough for this surgery'. Or to 'do you put CSEs in for all c sections?' I'd likely say something like 'I don't have many options outside of GETA for cases with an anesthesia time around 3 hours or more'. I'd probably be a little more sensitive and understanding, but maybe not, with her if the conversation wasn't around an awake patient.

My primary concern with putting them to sleep is being blamed for any excessive bleeding from GA. Data is murky on subject, some say no difference in GA vs neuraxial for c sections whereas others do.

 

[TheLoneWolf]

The same mg dose of isobaric will last longer than hyperbaric - don’t ask me why but it’s true. 15mg iso spinal should cover the whole thing, if you’re really feeling it you could probably get away with 17.5mg(bilateral TKR dose) for the whole c/s if they really are 4hr range. Or just cse with 15mg iso bupi spinal and give 5ml lido as needed as it’s wearing off. Easy. Don’t see why straight epidural only from the start would give any benefit.

I had thought of isobaric bupi spinal for this as I routinely use it for ortho cases. Isobaric tends to have less cephelad spread compared to hyperbaric so I am not sure if it reliably can reach T4 for a section. Also takes a little longer for onset compared to hyperbaric from my experience.

 

[psychbender]

My primary concern with putting them to sleep is being blamed for any excessive bleeding from GA. Data is murky on subject, some say no difference in GA vs neuraxial for c sections whereas others do.

If this "surgeon" ever brought that up, give historical blood loss from prior sections under CSE to shut him/her up. The unconcious patient also gives you the opportunity to be more firm in the source of bleeding when they claim their >1.5L EBL at the end of the case, before you wake the patient up.

 

[Maz777]

I forgot that GA causes bleeding during sections. I'll need to read up on those multiple RCTs that have been performed. Oh, wait, no data exists...

 

[Arch Guillotti]

I forgot that GA causes bleeding during sections. I'll need to read up on those multiple RCTs that have been performed. Oh, wait, no data exists...

Never seen it be a problem although 3-4 hours under ga might be a bit different.

 

[gunnershow]

A 3 hour C/S gives you plenty of time to hang a propofol infusion if you're so worried about volatile causing bleeding

 

[TheLoneWolf]

I forgot that GA causes bleeding during sections. I'll need to read up on those multiple RCTs that have been performed. Oh, wait, no data exists...

Cochrane is good enough for me

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004350.pub3/full

 

[psychbender]

Cochrane is good enough for me

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004350.pub3/full

Umm... that Cochrane review pretty well shows that there is no difference in blood loss between SAB/CLE and GA. A 1.7% vs 3.1% difference in change in hct is not an actual difference, despite the reviewers claiming that this is one. They also picked a standard mean difference in EBL, when the mean EBL would have sufficed, and turned a relevant and easily expressed number into a confusing and useless one.

 

[Maz777]

Cochrane is good enough for me

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004350.pub3/full

"Systematic" reviews and "meta"-analyses are publications of the (incredibly) weak. Combining a bunch of heterogenous studies together with different study designs, primary outcomes, methods, and biases is a complete waste of time.