Labor Analgesia in a Parturient w/ a VP Shunt

[sthesia]

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22yo spanish-speaking G1PO female presents in active labor at 2am to L&D.

PMH
Placement of VP shunt as an infant for 'congenital hydrocephalus' in El Salvador
Shunt revised at age 9 following car accident in El Salvador
No neurological/neurosurgical f/u of shunt since age 9

A/W
MP 4, small mouth opening, TM distance <5cm

Ht: 5' 1" Wt: 215 lbs
VS: WNL
Pain: 9/10
FHR: 130s, Tracing: occasional variable decelerations

CBC + Coags
Within Normal Limits

Pt & obstetrician request epidural analgesia for labor.

What is the plan for labor analgesia?
Any specific considerations in this pt with regards to epidural anesthesia/analgesia?
Any specific considerations in the pt with regards to spinal anesthesia/analgesia?

 

[pgg]

Signs of increased ICP? No regional.
No signs of increased ICP? Regional.

I agree with this, but I'm not so sure I'm confident enough in my ability to get a solid enough history out of this Spanish-speaker who got her surgeries in El Salvador. You never know WTF those crazy foreign 3rd world surgeons might have done.

It's hard enough to get a list of allergies through a translator, let alone more subtle things like symptoms related to elevated ICP.

I'm inclined to say no to regional and give her a remi PCA.

 

[sthesia]

I'm inclined to say no to regional and give her a remi PCA.

That was my plan... up until I was thwarted by the fact that the public hospital where I train does not stock/dispense remifentanil.

 

[Bertelman]

That was my plan... up until I was thwarted by the fact that the public hospital where I train does not stock/dispense remifentanil.

I'm hoping you do OB at a separate facility from your primary training institution. Otherwise, you're telling us you've never used remi, and you thought this would be a nice virgin run.

 

[cchoukal]

Just to play devil's advocate, are you really worried about ICP? She has a shunt, right? Is it possible that it's not working? Sure, but shouldn't she have symptoms? Nausea, vomiting, headache, and diplopia shouldn't be that hard to tease out.

That said, I like the remi idea. Has anyone used that for labor?

 

[rsgillmd]

Just to play devil's advocate, are you really worried about ICP? She has a shunt, right? Is it possible that it's not working? Sure, but shouldn't she have symptoms? Nausea, vomiting, headache, and diplopia shouldn't be that hard to tease out.

That said, I like the remi idea. Has anyone used that for labor?

I've had a decent response with it. The patient's family loved me for it in the end. However, it is labor intensive trying to get it timed right with the patient's contractions. I started of bolus only, but ended up adding a small basal rate. Gave O2 via face mask and monitored end-tidal CO2. If you are very interested, I can email you a file of sample regimens with references.

However, I doubt remi would work well with someone who you can't communicate with easily. The patient has to understand when to press the button, or as in my success story, have family members who are L&D nurses in another hospital and can be trusted to press the button for the patient.

 

[sthesia]

I'm hoping you do OB at a separate facility from your primary training institution.

Yeah, the way my program is set up is that we do ~50% of our training at the public hospital where the resident gets to run the show and call pretty much all the shots with regards to pt management with Attending backup to discuss the overall plan & to help in emergency situations.

The other 1/2 of residency is spent at the private hospital, where it is all private cases with much more Attending oversight. It's here that we get more experience with things like remi drips (mostly for craniotomies), precedex infusions (for all sorts of sedation cases), and clevidipine drips (for cardiac and major vascular cases)... to name a few interesting things that we get to do.

Otherwise, you're telling us you've never used remi, and you thought this would be a nice virgin run.

It very well could have been a virgin run, and it wouldn't have been a big deal because the culture of our program at our public hospital is really to "learn by doing." Obviously, there is a caveat of 'Do No Harm.' We are really encouraged to discover all the different ways there are to "skin the cat."

 

[pgg]

Cool! You've done this for labor? I never wrote a remi PCA ever. How do you dose?

I have a tiny bit of experience with them. A hospital where I did a CA-3 OB elective offered them to needle-phobes or patients who had a contraindication to epidurals. Their informal protocol was 0.2 mcg/kg boluses and a 1 minute lockout, with a 0.02 mcg/kg/min basal rate, with adjustments made as needed. It was a very very busy place but I still only saw the technique used twice while I was there.

From what I saw, and what I was told, they are labor intensive because the above starting point was rarely adequate, and because of the extra paranoia about the risk of oversedation or apnea. I sat in the room with the attending about an hour each time watching the patient and the pulse ox, while repeatedly reprogramming the pump.

The nurses hated them because they weren't epidurals and they weren't everyday occurrences.

There's a bit of a learning curve for the patients since they need to hit the button as soon as they get a hint of an impending contraction, or the peak effect from the bolus is too late.

There was also the practical problem that a relatively high IV carrier fluid rate was needed in order to get the dose through the tubing and into the patient in a timely manner. Over a long labor that could be a lot of fluid. They solved this problem by using the very short Y tubing (roughly 2" for each branch of the Y) right at the IV catheter so there was almost no IV dead space between the PCA line and the patient.

No one at my home institution was willing to let me write for one, the whole thing being off-label voodoo, and I was only at the other place for a month. I haven't yet written for one since I finished.

 

[Bertelman]

It very well could have been a virgin run, and it wouldn't have been a big deal because the culture of our program at our public hospital is really to "learn by doing." Obviously, there is a caveat of 'Do No Harm.' We are really encouraged to discover all the different ways there are to "skin the cat."

I'm cool with skinning a cat different ways, I was just implying this would have been a poor choice of a first patient for someone learning to titrate remi. Clearly it sounds as though you have used it before.

 

[militarymd]

So, the consensus is that we are going to give a POTENT, difficult to tirate narcotic to a lady with a potentially increased ICP and a marginal a/w...where hypoventilation, bearing downing, straining, hispanic histronics is likely to occur?

But not a simple epidural which could allow a passive 2nd stage if necessary...where EVEN if you wet tap (I've never seen one, so I'm just assuming it does happen) her, the likelihood of badness is low?

 

[coprolalia]

22yo spanish-speaking G1PO female presents in active labor at 2am to L&D.

PMH
Placement of VP shunt as an infant for 'congenital hydrocephalus' in El Salvador
Shunt revised at age 9 following car accident in El Salvador
No neurological/neurosurgical f/u of shunt since age 9

A/W
MP 4, small mouth opening, TM distance <5cm

Ht: 5' 1" Wt: 215 lbs
VS: WNL
Pain: 9/10
FHR: 130s, Tracing: occasional variable decelerations

CBC + Coags
Within Normal Limits

Pt & obstetrician request epidural analgesia for labor.

What is the plan for labor analgesia?
Any specific considerations in this pt with regards to epidural anesthesia/analgesia?
Any specific considerations in the pt with regards to spinal anesthesia/analgesia?

Just want to know one thing...

How the hell did this chick get pregnant and by whom?

Seriously!

-copro

 

[DOme2009]

lol @ copro - haven't you heard of immaculate conception?

 

[periopdoc]

Epidural. Next.


- pod

 

[coprolalia]

lol @ copro - haven't you heard of immaculate conception?

Give's a whole new meaning to the concept "second coming" doesn't it?

-copro

 

[jennyboo]

VP shunt is not a contraindication to neuraxial anesthesia for labor and delivery. After taking a very simple history which can be easily obtained with the help of an interpreter (headaches, weakness/neurologic deficits, vision changes) I would place the epidural.

On our labor floor we don't do PCA for parturients. If no neuraxial anesthesia they get single doses of nalbuphine.

 

[coprolalia]

Whenever I see your screename, Jenny, I can't help but have that song "Jackie Blue" by the Ozark Mountain Daredevils go through my mind... I need help. Clearly.

-copro

 

[Idiopathic]

yeah epidural and dont tap her