Jetpearl Number 16: Labor epidurals

[jetproppilot]

If you've performed or (more frequently) inherited a "patchy" labor epidural,

monkey with it

ONCE. For about twenty minutes.

Whatever trick you wanna do...reinject with a stronger local anesthetic concentration, turning her first on the hurting side; pull it back a cuppla centimeters; etc.

Heres the Jetpearl MONEY SHOT:

Using tricks of the trade to make a patchy epidural completely functional rarely takes more than twenty minutes. If your tricks don't work within that time span,

Place another epidural.

You'll save the parturient alotta pain.

And yourself alotta headaches/phone calls.

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[cchoukal]

Agree completely. I'll give a patchy epidural one "pull back and redose" routine, but I can't stand it when people talk themselves into accepting what is clearly a suboptimal catheter.

 

[sweetalkr]

Agreed, EXCEPT:

what do you do when you inherit this patchy epidural (since my epidurals always work ) when the pt is late in labor or progressing? 8cm and multip, etc. when you aren't sure you have time for a CSE.. do you go for a spinal shot of something and hope it lasts?

 

[jetproppilot]

Agreed, EXCEPT:

what do you do when you inherit this patchy epidural (since my epidurals always work ) when the pt is late in labor or progressing? 8cm and multip, etc. when you aren't sure you have time for a CSE.. do you go for a spinal shot of something and hope it lasts?

Delivery is either imminent or it isn't.

If it is, well, mommas been birthin' babies for hundreds of years now. Give her some "its gonna be ok" anesthesia.

If it isnt, it takes just a cuppla minutes to place a functional catheter.

I'm a fan of CSE so I'd sit her up, drive the Tuohy, drive the 27" spinal needle, place 2.5mg bupiv and a little opioid, remove spinal needle, place cath.

If you're not a CSE fan, sit her up, drive Tuohy, place cath, shoot in 8-10mL 3% chloroprocaine.

Problem solved.

 

[bullard]

I don't try pulling it back. I don't have her change sides. If she doesn't get comfy with some 1% lido + bupiv 0.25%, I place a new epidural and curse the douchebag who placed the original epidural and signed out to me without replacing it.

 

[Fastrach]

I don't try pulling it back. I don't have her change sides. If she doesn't get comfy with some 1% lido + bupiv 0.25%, I place a new epidural and curse the douchebag who placed the original epidural and signed out to me without replacing it.

I've actually been surprised how often the pull-back works, I'd say at least 25% of the time in my experience.

 

[jetproppilot]

I've actually been surprised how often the pull-back works, I'd say at least 25% of the time in my experience.

Soooo...lemme put 25% success in perspective for you..

I'm on the button at a Harrah's 5-10 No Limit table....my holed low pair looks good pre flop so I raise to thirty. I get raised by the big blind to ninety and I call. Flop is Ace King Ten. Big blind dude bets the pot.

I'd say theres about a one in four chance my 6 6 has him beat.

So I'm gonna fold.

Yeah, the "pull back" works sometimes...just like me reraising this dude (who I'm convinced has an ace or a king, or tens and up) may work sometimes.

I'll agree with you....MAYBE 25% of the time my reraise will work in this situation...maybe 25% of the time pulling back an epidural works.

That may be pushing it, tho.

Its really good. To know when to fold your bet. And start over. Twenty five percent success AINT THAT GREAT.

 

[lfesiam]

nice pearl JP.

reading them daily and also the old Venty's procedure post.

gonna need it soon... ~CA1 year here I come.

btw, Jet, will you be offering a one year fellowship of "Jetpearls"? sign me up.

 

[jetproppilot]

I don't try pulling it back. I don't have her change sides. If she doesn't get comfy with some 1% lido + bupiv 0.25%, I place a new epidural and curse the douchebag who placed the original epidural and signed out to me without replacing it.

You'll have a better chance of making a patchy epidural work with 2% lido or .5% bupiv. With all due respect you are wasting your time mixing concoctions of lower strength local anesthetics.

Hit a patchy epidural with a big gun. If the big gun fails, at least you've left nothing to chance.

 

[Fastrach]

Soooo...lemme put 25% success in perspective for you..

I agree with you JPP-- as you said in the original post, I'll monkey with it for no more than 20 min, where usually my first move is the pull-back, along with a stiff bolus. If that fails, out with the old catheter, in with the new.

 

[drccw]

You'll have a better chance of making a patchy epidural work with 2% lido or .5% bupiv. With all due respect you are wasting your time mixing concoctions of lower strength local anesthetics.

Hit a patchy epidural with a big gun. If the big gun fails, at least you've left nothing to chance.

sure you can get almost anything to work with 2%lido, or 0.5% bupiv... but is it worth it? You gotta get it to work with your infusiuon, which is what between 1/10% to 1/16% bupiv... if you're needing the nuclear bomb of local anesthetic, then it's time for a new epidural.. cause once the bomb goes off, the mama is gonna want it again, and again, and again... it's like crack... I fiddle with the damn thing once, then I sit them up, and put a new one in.... I only give 2% if they are cutting the belly..

 

[doctor712]

Give her some "its gonna be ok" anesthesia.

JPP,

You're going to hand in a great first draft man...

'Nuff said.

D712

 

[jwk]

sure you can get almost anything to work with 2%lido, or 0.5% bupiv... but is it worth it? You gotta get it to work with your infusiuon, which is what between 1/10% to 1/16% bupiv... if you're needing the nuclear bomb of local anesthetic, then it's time for a new epidural.. cause once the bomb goes off, the mama is gonna want it again, and again, and again... it's like crack... I fiddle with the damn thing once, then I sit them up, and put a new one in.... I only give 2% if they are cutting the belly..

You're just hurting yourself if you don't want to give a 2% bolus for labor. "Patchy" and "inadequate" are two different things to me. Most of the time when I get called for a redose, it's just for inadequate pain relief. That 2% Lido bolus helps them get back on top of their pain, and most of the time, they're not going to need another one. If you have a "patchy" or one-sided block, or they're just not getting comfortable with a big bolus, then sure, by all means replace it.

 

[SleepIsGood]

Agreed, EXCEPT:

what do you do when you inherit this patchy epidural (since my epidurals always work ) when the pt is late in labor or progressing? 8cm and multip, etc. when you aren't sure you have time for a CSE.. do you go for a spinal shot of something and hope it lasts?

100 mcg of fentanyl throgh the epidural. Walk away. If she's a multi that'll be good enough.