Labo(u)r Epidural Survey

[Oggg]

---

Members do not see this ad.

1) Sitting
2) Betadine (I'd prefer chloroprep if hosp had it)
3) Hat + Mask + Glove
4) L2-3, L3-4, L4-5
5) Midline
6) Bevel up
7) LOR
8) LOR with saline
9) 5-6cm
10) 8-10cc 0.125% bupiv (+3cc test dose)
11) 0.2%ropiv w/fent 2mcg/ml
12) 6-10cc/h continuous (6cc if ~5' tall, 8cc average, 10cc if 6')
13) PCEA 4cc q15-20min

When the OB nurse calls me, I usually say, please sit the pt up for me. I think it has happened 1-2 times in 4 years that the pt is sitting up for me when I come in. At least the nurses are good about fluid bolus and reglan/pepcid/bicitra. I do an abbreviated consent and explain the PCEA during placement. After the epidural is placed, I connect the tubing and load the pump. Then I fill out the anesthesia record. I can be out of there in maybe 16-20 minutes.

When I was in residency, I rotated at a women's hospital, and they were highly streamlined. All patients watched a video, filled out a health questionaire, and signed a consent on admission. When I entered the room, the patient was sitting with back exposed. My attending taught me to rotate the kit and open it the same way every time, so that the meds were far, and the needles and syringes were close. Instead of hunting for that needle, your muscle memory will reach for it on that side of the tray. In that hospital we could definitely be out of there in 10 minutes...

 

[DrN2O]

So how many people skip the test dose? How about bolus through the tuohy? I can see how bolus the tuohy can save a few minutes, but I just do a CSE which is even faster. Still do the test dose though.

 

[USAnesthesiaDoc]

1) Sitting
2) Betadine, sometimes chloraprep
3) Hat + Mask + Glove
4) L2-3
5) Midline
6) Bevel up
7) LOR
8) LOR to air
9) 4 cm
10) Mix 1.5% lido with epi 5 ml (what's in the kit) plus 10 ml bupiv 0.25%, several ml for skin and then give 8-10 ml epidurally, 1/2 through needle, 1/2 through catheter
11) 0.0625% bupiv w/fent 2mcg/ml
12) 12-15 ml/hr continuous (depending on patient height)
13) PCEA 5 ml q 15 min

 

[Yangkower]

Just started a new job. Went to do an epidural and asked the nurse if patient already received bicitra. She said they don't give bicitra for labor epidurals. Is bicitra standard of care or academic dogma?

 

[countingdays]

1) Sitting
2) Betadine
3) Hat Mask
4) L3-4, 4-5
5) Midline
6) Bevel up
7) LOR with continuous pressure
8) LOR saline
9) 5cm
10) Bolus 10mL of 0.25% Bupivicaine plus 4mL 1.5%lidocaine with epi through the Tuohy
11) Infuse 0.2% Ropivicaine
12) Dose 10mL/hr
13) PCEA 4 q20min

 

[BLADEMDA]

Blade's Technique for Success:

1. Position- Sitting 80% vs Lateral 20% (if you don't succeed with the epidural after 2 sticks switch positions!)

2. Chloraprep- This is superior for penetrating the epidermis. The alcohol/Chlorhexidine mix is better

3. Yes- Mask, Hat, Sterile Gloves- No Gown unless you are clumsy or a pig.

4. L3-L4 is the proven spot in the literature. For the "larger size woman" I prefer L2-L3. For extreme obesity (think over 400 pounds) go as high as needed which could mean L1-L2.

5. Midline stick- Paramedian works well but it will increase the chance of hitting a vein significantly.
Don't go Paramedian unless all other options fail (you have tried the lateral and sitting
positions)

6. Bevel aimed up. But, no real evidence for up vs down so it's your call.

7. LORT

8. Saline is slightly better than air but if you are slick with minimal air (less than 3 mls) then it's a wash.

9. I dilate the space so threading the catheter in 5-7 cm ( I prefer the 7) isn't an issue. If you don't
dilate the space stick with 4-6.

10. Yes, I bolus through the needle. Be careful and never bolus if you have the slightest doubt about
the location of the needle tip. Intrathecal bolus is life threatening to the patient.


11 I use whatever is cheapest for my infusion. I'm not a big fan of .0625 Bup or .25% Bup but anything in between is fine.

12. Infusion rate is usually 8-10 mls per hour

13. PCEA- Studies show it improves patient satisfaction. If you have it use it.

 

[bigdan]

Blade - Congrats on post #10,000.

Yangkower - I hope dogma; never in residency did I request (or hear of from others) Bicitra being given before an epidural for planned vaginal delivery.