Intrathecal opioids for labor analgesia

[timtye78]

Went and saw a laboring patient today. She was dilated to a 6, and the nurse had the pitocin cranked-she was in agony! otherwise healthy, no fetal issues.

My impression was this might be a good time to try a CSE-hadn't done one since CA-1, and felt like I wanted to do it.

My plan CSE and 20-25 mcg fentanyl intrathecal, using 0.2% ropivicaine and 2 mcg/cc for the epidural catheter. I had no problem technically. Placed the intrathecal fentanyl and turned on the continuous epidural infusion at 10 ml/hr.

Within about 1 minute the patient started to itch. After about two minutes from intrathecal placement, she noted obvious pain relief, and about 30 minutes later appeared euphoric and was extremely happy with her anesthetic. Baby delivered fine.

I must say I am impressed with her level of satisfaction, especially since she became pruritic-which I never was asked to treat.

My question is this. Chestnut text says the optimum dose for intrathecal opioids for labor analgesia is unknown, but I was curious if anecdotally you guys out there get good/better results with less and what do you like to use?

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[Noyac]

They seem to itch more with 25 mcg than with 20mcg in my experience. But I find that they itch even less when I add 1cc of 0.2% ropiv or 2.5% bupiv. The only time that i leave the local out is when the idiot midwife thinks that the pts BP is too high and therefore doesn't give a fluid bolus.

 

[meddog1]

They seem to itch more with 25 mcg than with 20mcg in my experience. But I find that they itch even less when I add 1cc of 0.2% ropiv or 2.5% bupiv. The only time that i leave the local out is when the idiot midwife thinks that the pts BP is too high and therefore doesn't give a fluid bolus.

I have been wanting to do some CSEs on the vaginal deliveries, and I noted you are using 1cc of local. What sensory-level is your target with the SAB portion of your anesthetic?

 

[timtye78]

After a little more reading on CSEs, I noticed that Chestnut recommends adding a little bupivicaine, and their recommended dosages depend on whether or not the patient is early or late in labor-early>lower dosages, and late->higher dosages.

It also said that 5 mcg intrathecal fentanyl is associated with less pruritus, although it is a little more extra effort to measure out 0.1 cc (from a 50mcg/cc concentration). I think I will try 5mcg, and 10 mcg as well and see what happens.

I don't think the goal for intrathecal local anesthetic is a level per se (assuming your goal at this time is labor analgesia), since you have the epidural catheter, you should be able to dose it up as needed. My patient that I wrote about only had a measured level of T11 bilateral, although I never gave her the usual 10 ml bolus in her epidural cath.

Otherwise if you were giving a dose to obtain a certain level, ie for C/S, then 99% of the time you wont need the CSE(ie epidural cath) unless you anticipate a long, long procedure time (eg someone with many previous C/S who may have a lot of scarring). Before anyone says they would be worried about 'dosing up' an epidural catheter in one of these CSEs, Chestnut says that dosing up the epidural does NOTextend the SAB cephalad BUT extends the block CAUDAD, so a high/total spinal from one of these is unlikely.

fascinating stuff..

 

[InGasWeTrust]

Noy,

We have the same problem down here in S. Florida with the OB residents/nurses scared to give a little volume to hypertensive patients for CSLEA.

They also kill me, when they think it is going to be quicker to get anesthesia with a catheter insitu from floor versus a CSE in the OR. In my experience at worst they are equivalent, but usually the CSE is quicker.

They also section every primid insight....lol, but that is another topic altogether.

 

[Noyac]

I have been wanting to do some CSEs on the vaginal deliveries, and I noted you are using 1cc of local. What sensory-level is your target with the SAB portion of your anesthetic?

Not shooting for a level therefore, I don't even check to see what level I am at. I suspect it is low. You are treating stage one labor. Therefore, all you need to cover is cervical dilation which is the lower lumbar nerves if I remember right. Its been a while since I looked at the distribution.

 

[ZA_Gasman]

They also section every primid insight....lol, but that is another topic altogether.

/hijack
ROFL!
I thought it was only our OBs who did that. Seems to be a problem of international concern!!!
/hijack off

 

[InGasWeTrust]

ZA Gasman

I have seen it a few times, where the nurse will determine a non reassuring FHT, and the OB without even having examined a strip, or trying O2, or LUD will call for a section(some woman have delivered vaginally while awaiting for an OR to free up here).....lol

The other night a G4P3 with 3 NSVD in honduras got sectioned at and I **** you not at 9/C/+2 for?...... Arrest of active phase!.....lol Even the pt, was like WTF


But I digress....we use 20 mikes of fentanyl here seems to chill out all laboring women except those with supratentorial issues with minimal sideffects.

 

[Noyac]

unfortunately, no 2 OB pts are the same.

Just as no 2 OB providers are the same.

Have I mentioned, I hate OB?

 

[The_Sensei]

unfortunately, no 2 OB pts are the same.

Just as no 2 OB providers are the same.

Have I mentioned, I hate OB?

Me too. I was on call and we sectioned half of south Jersey. If I hear the term "failure to progress" or "non-reassuring fetal heart rate" one more time the OBs here are going to experience "my fist in their face" or "my foot in their groin".

 

[Frank Rizzo]

ZA Gasman

(some woman have delivered vaginally while awaiting for an OR to free up here).

Thats a daily occurence where I'm at!

As far as the CSE, 15mcg of fentanyl seem to work nicely for me.

 

[hokie]

I routinely use 10-15mcg fentanyl plus 0.6-0.7cc 0.25% bupivicaine. I see very little itching with this mix. Also I've noticed at higher doses some patients (particularly younger G1's) tend to get too comfortable... meaning that when the spinal dose wears off they are never as satisfied with the level of analgesia from the catheter. I have become more selective on CSE vs straight epidural for this reason.