Labor Epidural- Clinical

[sevoflurane]

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So over the weekend I get a call from OB for a labor epidural.

Obese, gestational diabetes with some mild pre-eclampsia. BP 148/95. Platelets stable @ 117 (gestational thrombocytopenia)

L2-3 interspace. Epidural easily placed. Negative for heme or csf.

“Let me know if you feel any ringing in the ears, metallic taste in your mouth, etc, etc”

Epidural test dose goes in...

2 minutes later the HR goes from 84-125 BPM.

What do you do and is this a positive test dose?

 

[pie944]

So over the weekend I get a call from OB for a labor epidural.

Obese, gestational diabetes with some mild pre-eclampsia. BP 148/95. Platelets stable @ 117 (gestational thrombocytopenia)

L2-3 interspace. Epidural easily placed. Negative for heme or csf.

"Let me know if you feel any ringing in the ears, metallic taste in your mouth, etc, etc"

Epidural test dose goes in...

2 minutes later the HR goes from 84-125 BPM.

What do you do and is this a positive test dose?

Was she having a contraction at the time of the test dose? Any other associated symptoms? Had her heart rate been fairly consistent up until that point or bouncing around? It seems like a significant amount of time passed between the test dose and the increase in heart rate.

I once had a CSE, BMI 50+, no issues, no adjustments, negative for heme and csf. Went as quick as on one of those super skinny individuals and I was doing a jig behind her. I do the same line as above, test dose in, within ten seconds 'I feel weird' and heart rate shoots up from 70s -> 130s. I think I denied it for a second. I had threaded in the catheter 6-7 cm in the space, so pulled it back a couple cm, aspirated, nothing, repeated test dose while warning her that feeling might come back. Test dose in, within ten seconds 'I feel weird' and HR again shot up. Pulled it, replaced.

Only positive intravascular test dose I've ever had.

 

[pgg]

What do you do and is this a positive test dose?

Bolus the epidural with 4 cc of esmolol and see if it goes down to 70.

 

[sevoflurane]

'


Was she having a contraction at the time of the test dose? Any other associated symptoms? Had her heart rate been fairly consistent up until that point or bouncing around?

I once had a CSE, BMI 50+, no issues, no adjustments, negative for heme and csf. Went as quick as on one of those super skinny individuals and I was doing a jig behind her. I do the same line as above, test dose in, 'I feel weird' and heart rate shoots up from 70s -> 130s. I think I denied it for a second, I had threaded in the catheter 6-7 cm in the space, so pulled it back a couple cm, aspirated, nothing, repeated test dose while warning her that feeling might come back. Test dose in, 'I feel weird' and HR again shot up. Pulled it, replaced.

Only positive intravascular test dose I've ever had.

No contraction at the time of the test dose. Looking back at the strip, the HR had not been bouncing around. Mid 80's. She was not positive for any symptoms of intravascular injection.... but her HR went from 84-125 in 2 minutes.

 

[rsgillmd]

So over the weekend I get a call from OB for a labor epidural.

Obese, gestational diabetes with some mild pre-eclampsia. BP 148/95. Platelets stable @ 117 (gestational thrombocytopenia)

L2-3 interspace. Epidural easily placed. Negative for heme or csf.

“Let me know if you feel any ringing in the ears, metallic taste in your mouth, etc, etc”

Epidural test dose goes in...

2 minutes later the HR goes from 84-125 BPM.

What do you do and is this a positive test dose?

Confirmed real increase in heart rate as opposed to artifact? PVCs/PACs on the rhythm strip when this happened? I'm assuming here, because you didn't mention it, that the patient was not having a contraction. Any neuro symptoms such as ringing in the ears or funny taste in the mouth -- I assume not because you didn't mention it, but just want to double check. I'm also assuming negative aspiration of your catheter. Any indication of a block starting to set in from the test dose you gave?

Basically if I had any doubts, I would probably repeat the test dose. Nothing wrong with establishing a block with 1.5% Lido w/Epi before starting your infusion. But without any more info indicating it, 2 minutes later doesn't smell like an intravascular injection to me. That's just one of those cases where I wouldn't leave the room until it was clear that I had a block and the epidural did not need to be redone.

 

[periopdoc]

What is her blood pressure now (with the increased heart rate)?

- pod

 

[sevoflurane]

What is her blood pressure now (with the increased heart rate)?

- pod

B.P. after test dose is 155/97

HR 125

 

[sevoflurane]

Confirmed real increase in heart rate as opposed to artifact? PVCs/PACs on the rhythm strip when this happened? I'm assuming here, because you didn't mention it, that the patient was not having a contraction. Any neuro symptoms such as ringing in the ears or funny taste in the mouth -- I assume not because you didn't mention it, but just want to double check. I'm also assuming negative aspiration of your catheter. Any indication of a block starting to set in from the test dose you gave?

Basically if I had any doubts, I would probably repeat the test dose. Nothing wrong with establishing a block with 1.5% Lido w/Epi before starting your infusion. But without any more info indicating it, 2 minutes later doesn't smell like an intravascular injection to me. That's just one of those cases where I wouldn't leave the room until it was clear that I had a block and the epidural did not need to be redone.

Great response... especially that last line.

 

[Consigliere]

When in doubt, pull it out. Repeat epidural. End of discussion.

 

[pie944]

No contraction at the time of the test dose. Looking back at the strip, the HR had not been bouncing around. Mid 80's. She was not positive for any symptoms of intravascular injection.... but her HR went from 84-125 in 2 minutes.

In my only experience the positive intravascular test dose showed itself within seconds. That being said, I'd pull it back 1-2 cm(if space allows), aspirate, repeat the test dose. I'd watch her vitals prior to the repeat test dose, make sure they're consistent, and if the same bump happens I'd pull it.

 

[sevoflurane]

You guys are all over this one. Nice job.

Yeah... 2 minutes is INSANELY long for a test dose to manifest itself in a partrurient with a high CO... I've seen pressors take forever to manifest themselves due to poor circulation time...usually in the elderly sick patient with poor EF. Not in an o/w healthy OB patient.

Epidrural catheter is only 4 cm in the space. Options are:

1) Keep it

2) Test dose again

3) Pull it

What do you want to do?

 

[pie944]

As Hans Gruber said, hit it again.

Repeat the dose.

 

[sevoflurane]

As Hans Gruber said, hit it again.

Repeat the dose.

Good job.

I didn’t believe it given the ease of placement, negative aspiration and lack of symptomatology.

That’s exactly what I did. Repeat dose. I explained to her the situation and asked her to let me know if she felt any of the aforementioned symptoms.

3 cc’s of 1.5% with epi 1:200k.

Guess what...

HR goes up to 138 bpm. (FHR good)

 

[sevoflurane]

NO SYMPTOMS....

What now?

 

[sevoflurane]

oh yea... it takes a good couple minutes to get to 138 BPM.

 

[pie944]

NO SYMPTOMS....

What now?

Pull it.

The duration between dose and increase in heart rate seems long, but the fact it happened twice is hard to argue against. If you keep it in, even assuming this is just a horrible coincidence, it is going to keep you wondering about where that tip is and end up costing you more time and worry than if you just replaced it.

 

[sevoflurane]

You betcha.

There was no way I was walking out of there.

So... It gets pulled.

L1-2 Interspace. Easily placed. Negative for heme and CSF.

HR comes down to 130 BPM in the interim.

What now? Bolus with 1.5% lido with epi?

What's the effect of epineprhine on uterine blood flow? Is it a concern here?

 

[pie944]

Excellent distraction from Powerpoint work.

In terms of the fetus, the epinephrine is transient and similar to a uterine contraction, so not a concern in this situation.

Since the mother's heart rate is still high, you can use another medication for the test dose local anesthetic vs opioid. You'll get two for one, rule out an intravascular test dose and start getting the patient comfortable.

 

[Idiopathic]

to digress, my first epidural as an attending was smooth, but a little heme in the catheter, test dose was negative for HR, but patient had been on labetalol until that morning, so I wasnt convinced. my thought at the time was, "well, lets see if we can get a block", so I gave 5cc of 2% lidocaine through the catheter.

ill preface the conclusion by saying that the catheter was intravascular.

i will then tell you that I have never experienced before or since then the reaction that this patient had to intravenous lidocaine. we frequently push 100mg on induction of general anesthesia, so I thought "no big deal". well let me tell you, its a good thing we put those patients to sleep immediately after, because in my n of 1, they have the potential to go completely [email protected]**** crazy.

she started by getting light headed, thinking she was going to pass out, and complaining of classic lidocaine sy/sx - ringing in ears, tingling and numbness in lips, dizziness (no hemodynamic instability). she then actually said, "i think im going to have a seizure", and she went to sleep, arousable but snoring.

long story short, this went on for about 30 minutes. i stood by her bed with the crash cart and the intralipid in my hand, even though it didnt really fit for dose toxicity - you never know for sure. oh also her airway looked terrible.

after about an hour, i replaced the catheter and everything was fine.

SO, my brilliant idea probably wasnt a terrible one, but now if i suspect IV catheter at all, it just gets replaced on the spot.

 

[pgg]

To be a little more serious, I'm curious what kind of catheters you're using. I haven't had an intravascular catheter since switching from stiff plastic to the soft coil-wound Arrows ... 5 years ago when I was a CA1. And I did/do a lot of OB.

I've seen pressors take forever to manifest themselves due to poor circulation time...usually in the elderly sick patient with poor EF. Not in an o/w healthy OB patient.

I don't know if I would read too much into the two minute delay, at least as evidence arguing against the catheter being intravascular. Yeah, it's kind of a long time, but it wouldn't surprise me if something injected into one of those tiny little epidural veins (now with the catheter occluding a big part of it) had super slow flow back to the central circulation. Though granted 3cc is lot to just sit in tiny epidural vein.

I'd pull and replace.

So... It gets pulled.

L1-2 Interspace. Easily placed. Negative for heme and CSF.

HR comes down to 130 BPM in the interim.

What now? Bolus with 1.5% lido with epi?

So in the time it took you to pull the catheter and place a new one, her HR is still 130? I know you're good and fast, but the time from noticing her HR up --> hmm, think about it for a bit --> wait --> remove --> go up a level --> re-local skin --> needle in --> LOR --> catheter threaded --> ready for test dose ... probably took a few minutes. I'm inclined to think her HR isn't still up from the epi you gave her before.

So I'd hold off on re-testing the new catheter until her vitals were back to baseline, or some other problem manifested itself, or I figured out what was really happening.

 

[sevoflurane]

To be a little more serious, I'm curious what kind of catheters you're using. I haven't had an intravascular catheter since switching from stiff plastic to the soft coil-wound Arrows ... 5 years ago when I was a CA1. And I did/do a lot of OB.



I don't know if I would read too much into the two minute delay, at least as evidence arguing against the catheter being intravascular. Yeah, it's kind of a long time, but it wouldn't surprise me if something injected into one of those tiny little epidural veins (now with the catheter occluding a big part of it) had super slow flow back to the central circulation. Though granted 3cc is lot to just sit in tiny epidural vein.

I'd pull and replace.




So in the time it took you to pull the catheter and place a new one, her HR is still 130? I know you're good and fast, but the time from noticing her HR up --> hmm, think about it for a bit --> wait --> remove --> go up a level --> re-local skin --> needle in --> LOR --> catheter threaded --> ready for test dose ... probably took a few minutes. I'm inclined to think her HR isn't still up from the epi you gave her before.

So I'd hold off on re-testing the new catheter until her vitals were back to baseline, or some other problem manifested itself, or I figured out what was really happening.

Naaaice dude. A lot of good critical thinking there.

You bet I use the spring would catheter. SOOOOOOOO HARD to place those in a vein. One of the many reasons I like them. Stiff catheters can be put anywhere.

I'm supah fast...

But not that fast.

 

[pie944]

Any new signs or symptoms? Heart rate is sinus tachycardia? Oxygen saturation? Level of discomfort?

FHR and Tocodynamometer tracings unchanged?

 

[sevoflurane]

I don't know if I would read too much into the two minute delay, at least as evidence arguing against the catheter being intravascular. Yeah, it's kind of a long time, but it wouldn't surprise me if something injected into one of those tiny little epidural veins (now with the catheter occluding a big part of it) had super slow flow back to the central circulation. Though granted 3cc is lot to just sit in tiny epidural vein.

I don't know... those venous plexy (sp?) are pretty large... like the size of a hand vein. In the laboring patient they are bigger.

But that is neither here or there... every positive test dose I've ever had, I've seen a response pretty darn quickly. This is an outlier for sure.

 

[sevoflurane]

Any new signs or symptoms? Heart rate is sinus tachycardia? Oxygen saturation? Level of discomfort?

FHR and Tocodynamometer tracings unchanged?

No new symptoms besides the increase BP and HR. We don't have EKG readily available for our OB population.

FHR and TOCO are solid.

 

[sevoflurane]

So I'd hold off on re-testing the new catheter until her vitals were back to baseline, or some other problem manifested itself, or I figured out what was really happening.

Let me refer you to your earlier post:

Bolus the epidural with 4 cc of esmolol and see if it goes down to 70.

... except it wasn't epidural.

 

[Stank811]

With 3cc of 1.5% lidocaine with epi is testing two separate potential clinical complications. Lidocaine is to test for intrathecal administration while epi it to test for intravascular. If you are not convinced with your HR changes with your initial test dose and there is no evidence of intrathecal catheter than you could always proceed with 1mg/kg of 2% lidocaine which is also nice in pts with PIH if you are concerned about BP. Just did this the other day and worked great. Initial test dose gave a quick bump in HR from 90-115-120 range....repeated with 3cc of 2% lidocaine and pt reported that her lips were tingling and felt really dry all of a sudden. This was also with soft tipped catheter but I placed it R paramedian in lateral position (practicing different techniques) so who knows if that had anything to do with it. Pulled back the catheter and repeated test dose with 2% lidocaine and no symptoms so used the epidural without complications.

 

[Consigliere]

This thread is dumb. Pull the catheter, replace. If you want all this mental masturbation, you should have went into internal medicine.

 

[sevoflurane]

This thread is dumb. Pull the catheter, replace. If you want all this mental masturbation, you should have went into internal medicine.

Dont' get your panties in a bunch there Consigliere... the epidural has already been pulled and replaced at this point in the thread.

 

[periopdoc]

Well Consig, I guess we could turn it into yet another gun thread since the clinical masturbation is so useless.

- pod

 

[fakin' the funk]

Let me refer you to your earlier post:

... except it wasn't epidural.

Ah. I think what you're saying is that it's subdural, that you're getting a bizarre autonomic block/effect without a parallel sensory and motor block.

In any case, if it went in super easy the first time, pull and repeat at a different level.

If it happens again, well I guess no epidural for this person with abnormal neuraxial anatomy.

 

[sevoflurane]

Ah. I think what you're saying is that it's subdural, that you're getting a bizarre autonomic block/effect without a parallel sensory and motor block.

In any case, if it went in super easy the first time, pull and repeat at a different level.

If it happens again, well I guess no epidural for this person with abnormal neuraxial anatomy.

Nope. No subdural (thankfully).

Here is how it went down:


So at this point, we have dosed the first epidural with 5cc's... and then another 3cc's. I replaced it and the HR didn't come down. Weird... so I gave a 20 mg of esmolol to iatrogenicaly bring it down.

Thankfully it stayed there (100's).

But I did something different before bolusing the catheter this time around.

This time I told the patient to let me know if she had any ringing in the ears, metallic taste, palpatations, etc... and sat there for another 2 minutes without bolusing the catheter.

Sure enough... the HR started to creep up to 130 again (esmolol long gone at this point).

I dropped everything I was doing and went around to the patient and asked how she was feeling... She said she was "a little" nervous. At this point I realized everything I was seeing could have just been a supratentorial effect (not exogenous epi, but endogenous epi) which manifested itself shortly after I asked her to look out for symptoms. Must have freaked her out.

So I taped the epidural (without testing it) and got her back supine. Thereafter, her HR started to dip down under 120, 110, 90's... At that point I ninja ninja pushed another 5 cc's of lido with epi to test out the integrity of the epidural w/o telling her what I was doing. HR stayed exactly the same.

This patient was quiet, but was internally "Wound Up". Everytime I told her I was bolusing the catheter she pumped some natural epi out of her adrenals.

Kinda hard to pick up at first and def. caught me off guard.
Needless to say after 3 boluses, she was comfy.

Made me want to get some urinary metaneprhines.

 

[periopdoc]

Solid ninja work and a great case.

-pod

 

[Idiopathic]

Nope. No subdural (thankfully).

Here is how it went down:


So at this point, we have dosed the first epidural with 5cc’s... and then another 3cc’s. I replaced it and the HR didn’t come down. Weird... so I gave a 20 mg of esmolol to iatrogenicaly bring it down.

Thankfully it stayed there (100’s).

But I did something different before bolusing the catheter this time around.

This time I told the patient to let me know if she had any ringing in the ears, metallic taste, palpatations, etc... and sat there for another 2 minutes without bolusing the catheter.

Sure enough... the HR started to creep up to 130 again (esmolol long gone at this point).

I dropped everything I was doing and went around to the patient and asked how she was feeling... She said she was “a little” nervous. At this point I realized everything I was seeing could have just been a supratentorial effect (not exogenous epi, but endogenous epi) which manifested itself shortly after I asked her to look out for symptoms. Must have freaked her out.

So I taped the epidural (without testing it) and got her back supine. Thereafter, her HR started to dip down under 120, 110, 90's... At that point I ninja ninja pushed another 5 cc’s of lido with epi to test out the integrity of the epidural w/o telling her what I was doing. HR stayed exactly the same.

This patient was quiet, but was internally “Wound Up”. Everytime I told her I was bolusing the catheter she pumped some natural epi out of her adrenals.

Kinda hard to pick up at first and def. caught me off guard.
Needless to say after 3 boluses, she was comfy.

Made me want to get some urinary metaneprhines.

this is a good point and why i never ask patients to let me know if they feel anything weird, etc. ive found out that they will tell me if they feel weird, whether i ask them or not, and the power of suggestion is very real. i push the test dose, watch the heart rate and wait 90 seconds, after which i ask them about their legs to make sure they arent numb and to make sure they didnt feel intravascular lidocaine symptoms.

 

[BLADEMDA]

this is a good point and why i never ask patients to let me know if they feel anything weird, etc. ive found out that they will tell me if they feel weird, whether i ask them or not, and the power of suggestion is very real. i push the test dose, watch the heart rate and wait 90 seconds, after which i ask them about their legs to make sure they arent numb and to make sure they didnt feel intravascular lidocaine symptoms.

Thousands placed. I do the same as you.

 

[DrN2O]

How slow did you inject through the epidural that she didn't feel it going down the back? Most of them can tell me they feel the cold bolus when the catheters are taped to their backs.

 

[sevoflurane]

Some do, some don't. This one didn't. Bolused it pretty fast... prolly 2-3 seconds.

 

[jwk]

this is a good point and why i never ask patients to let me know if they feel anything weird, etc. ive found out that they will tell me if they feel weird, whether i ask them or not, and the power of suggestion is very real. i push the test dose, watch the heart rate and wait 90 seconds, after which i ask them about their legs to make sure they arent numb and to make sure they didnt feel intravascular lidocaine symptoms.

True dat! I've quit asking as well. I while back I had a patient tell me she got a funny taste in her mouth - as we were rolling into recovery 90 minutes after the epidural was placed. Hmmmmm.

 

[ranvier]

One month into OB and it seems that NPO, anxious, tired parturients all endorse a funny taste in their mouth...

 

[Sufenta]

The lidocaine in the test dose is meant to detect intrathecal catheters, the dose is only 45 -60 mg. Its unlikely to cause neuro symptoms if intravascular, so I dont bother to ask. The large epidural bolus, however, would cause neuro symptoms. These are ur friend because they may stop you from progressing to cardiac toxcity, which is much worse to manage, so I definitely ask.

Ive reduced my routine dose of pre propofol lido to 50 from 100 after having someone with the neuro symptoms & impending doom reaction. I induced the pt right away, but it was obviously very unpleasant.

I placed intravascular thoracic epidural yesterday...seem to have a knack for it. I probably thread too far. I aspirated negative, gave 2-3 ml, aspirated a bit of blood in the catheter. HR ok so far, gave the rest, hr from 60 to 110, aspirate blood freely. In my experience, the initial aspiration is always negative, then draws blood after the HR response, annoying.

 

[Arch Guillotti]

I have had a few positive test doses over time. One developed clear neuro symptoms after 40 mg of lidocaine that went IV. 100 mg lidocaine is guaranteed to give you a deer in the headlights reaction.

The lidocaine in the test dose is meant to detect intrathecal catheters, the dose is only 45 -60 mg. Its unlikely to cause neuro symptoms if intravascular, so I dont bother to ask. The large epidural bolus, however, would cause neuro symptoms. These are ur friend because they may stop you from progressing to cardiac toxcity, which is much worse to manage, so I definitely ask.

Ive reduced my routine dose of pre propofol lido to 50 from 100 after having someone with the neuro symptoms & impending doom reaction. I induced the pt right away, but it was obviously very unpleasant.

I placed intravascular thoracic epidural yesterday...seem to have a knack for it. I probably thread too far. I aspirated negative, gave 2-3 ml, aspirated a bit of blood in the catheter. HR ok so far, gave the rest, hr from 60 to 110, aspirate blood freely. In my experience, the initial aspiration is always negative, then draws blood after the HR response, annoying.

 

[Idiopathic]

The lidocaine in the test dose is meant to detect intrathecal catheters, the dose is only 45 -60 mg. Its unlikely to cause neuro symptoms if intravascular, so I dont bother to ask. The large epidural bolus, however, would cause neuro symptoms. These are ur friend because they may stop you from progressing to cardiac toxcity, which is much worse to manage, so I definitely ask.

Ive reduced my routine dose of pre propofol lido to 50 from 100 after having someone with the neuro symptoms & impending doom reaction. I induced the pt right away, but it was obviously very unpleasant.

I placed intravascular thoracic epidural yesterday...seem to have a knack for it. I probably thread too far. I aspirated negative, gave 2-3 ml, aspirated a bit of blood in the catheter. HR ok so far, gave the rest, hr from 60 to 110, aspirate blood freely. In my experience, the initial aspiration is always negative, then draws blood after the HR response, annoying.

my point is that the act of asking provokes symptoms. your argument is that asking if they feel tingling, etc. may clue them in that they are having those symptoms, in a population where the risk of an intravascular catheter in the setting of negative heme aspiration is less than 1:1000. so very low PPV, yet you would replace a catheter based on those symptoms? i think asking with an epidural bolus (i.e. 400mg of lidocaine) as you go back for c-section is reasonable, but at that point there is usually a functioning epidural catheter so its less likely to be intravascular. as far as bupiv for labor epidurals, its very unlikely to give a toxic dose - i hardly ever give more than 25mg at a time. asking makes us feel better, but its an extremely nonspecific test

 

[Direct Laryngoscopy]

I possibly had a positive test dose yesterday (I'm not fully convinced). First labor epidural place with positive heme so I pull the cath. Placed another epidural, one level up NO HEME, gave a test with 3cc and as I'm giving test dose pt says she feels light headed and HR goes from 80 --> 125. HR goes back down to 80 in about 90 secs and symptoms go away. The attending I was working with seem to be convinced it was positive, so we pull cath. He places epidural and proceeds to wet tap pt, but gets epidural and neg test dose.

I wasn't convinced of positive test dose because the timing of symptoms (while I'm injecting),and the fact I had no blood in cath. How soon could one see increased HR during test dose? In my instance, it just seemed too fast.