labor epidural cocktail

[Jimmy LaRoux]

at my institution we use .125% bupi + fentanyl 2mcg/ml in all labor epidurals. what do you use in your cocktail? do some of you make higher percentage bupi cocktails (something between .125 - .25%) for multiparous patients and use lower .125% for the g1's?

i've experimented using a higher percentage bupi on a patient that's already had 4 svd and it didn't slow her labor and more importanly she felt absolutely *nothing*. but it's difficult to know what percentage and in which multiparous patient a more aggressive mixed labor epi will be appropriate.

Some old timers please give some of your experience.

---

Members don't see this ad.

 

[Mman]

Usually 0.1% Bupiv + 2 mcg/ml Fentanyl. Sometimes I mix it up and go with 0.1% Ropiv + 0.5 mcg/ml Sufentanil.

 

[dhb]

1.4mg/ml ropi + 0.5mcg/ml sufenta at 8ml/h

 

[2ndyear]

I start out with more narcotics, usually 50 mcg fentanyl right after the test dose, load with 1% Lido 6-12 mL. Sometimes then do another 50 mcg fentanyl or increase the concentration of fent in the infusion.

 

[BADMD]

My wife informs me that she would have enjoyed a cocktail with her labor epidural.

BAD, MD
EM Guy

 

[dhb]

My wife informs me that she would have enjoyed a cocktail with her labor epidural.

BAD, MD
EM Guy

your wife maybe, your child maybe not...

 

[Intubate]

I use the premixed 0.2% ropivicaine 100 ml bottle with 75mcg of sufentanil (the other 25 mcg goes straight in with 10 ml of the ropiv as a bolus). The good-- you never get called for a top up (rarely anyway). The bad-- lots of motor block (not really bad-- they're extremely happy). In residency we used 0.04% (not a misprint-- 0.04%!) bupivicaine with a tiny amount of fentanyl. This is water. When it worked it was great, but everyone needed a topup. OK if you have a resident to top everyone up, not ok for private practice.

 

[USAnesthesiaDoc]

We use PCEA infusion solutions consisting of bupivacaine 0.0625% and sufentanil 2 mcg/ml. I usually bolus 3-4 ml of 1.5% lido + epi through the epidural needle to dilate space/test, and then 10 ml of bupivacaine 0.25% + epi through the catheter (in 5 mL increments), then immediately start the above infusion at 10 to 12 mL an hour. Never get called for top-ups.

 

[Mman]

We use PCEA infusion solutions consisting of bupivacaine 0.0625% and sufentanil 2 mcg/ml. I usually bolus 3-4 ml of 1.5% lido + epi through the epidural needle to dilate space/test, and then 10 ml of bupivacaine 0.25% + epi through the catheter (in 5 mL increments), then immediately start the above infusion at 10 to 12 mL an hour. Never get called for top-ups.

Probably never get called for topups because they are getting 20+ mcg of sufent an hour. That's a pretty healthy dose.

 

[dhb]

Probably never get called for topups because they are getting 20+ mcg of sufent an hour. That's a pretty healthy dose.

That's more than i give for surgery...

 

[USAnesthesiaDoc]

Probably never get called for topups because they are getting 20+ mcg of sufent an hour. That's a pretty healthy dose.

Sorry that was a typo. The sufent is at a concentration of 1 mcg/mL, the rest is correct.

 

[Laurel123]

I run 0.125% bupiv with 2mcg/ml of fentanyl at 12 ml/hr.

Bolus with .2% bupiv and 100 mcg of fentanyl, 10 ml. Rare top-up. Usually it is a lady that is complaining of pressure or vaginal and rectal pain.

 

[epidural man]

We use PCEA infusion solutions consisting of bupivacaine 0.0625% and sufentanil 2 mcg/ml. I usually bolus 3-4 ml of 1.5% lido + epi through the epidural needle to dilate space/test, and then 10 ml of bupivacaine 0.25% + epi through the catheter (in 5 mL increments), then immediately start the above infusion at 10 to 12 mL an hour. Never get called for top-ups.

we used the 1/16th percent of bupiv but recently changed to 1/8th% because I think people were running the rate to low. If done right, this dilute solution seems to work great.

 

[Planktonmd]

we used the 1/16th percent of bupiv but recently changed to 1/8th% because I think people were running the rate to low. If done right, this dilute solution seems to work great.

Why don't you use the same language like the rest of us?
Is it too difficult to say we used 0.0625% and now we use 0.125 %?
If 0.125% with fentanyl 2mcg/cc doesn't work then there is something wrong with the epidural.

 

[USAnesthesiaDoc]

Why don't you use the same language like the rest of us?
Is it too difficult to say we used 0.0625% and now we use 0.125 %?
If 0.125% with fentanyl 2mcg/cc doesn't work then there is something wrong with the epidural.

I agree. Occasionally, patients need additional boluses as they go through transition or if the block becomes patchy or one-sided, but in general, 0.0625% bupivacaine with fentanyl or sufentanil is more than adequate for labor. This can be inadequate if the original bolus when the catheter is placed does not make the patient comfortable or if the infusion is not started soon enough. I've only had to use 0.125% bupivacaine in cases of thoracic epidurals in post-thoracotomy patients, but even then, an increase to 0.1% bupivacaine is often enough.

 

[dhb]

Why don't you use the same language like the rest of us?
Is it too difficult to say we used 0.0625% and now we use 0.125 %?
If 0.125% with fentanyl 2mcg/cc doesn't work then there is something wrong with the epidural.

Technically your 0.125% isn't that anymore once it's been diluted by your fentanyl that's why i like to use mg/ml...

 

[Planktonmd]

Technically your 0.125% isn't that anymore once it's been diluted by your fentanyl that's why i like to use mg/ml...

So lets see:
You take 95 cc of 0.125% Bupivacaine ( That would be 1.25 mg /cc for you) and you add 5 cc of Fentanyl, this will give you 100 cc of a solution that contains Bupivacaine 1.1875 mg / cc or 0.11875% and 2.5 mcg/cc fentanyl.
So lets say you want to write the order for the pharmacist:
according to you, you write: 100 cc of Bupivacaine 1.1875 mg/cc and Fentanyl 2.5 mcg/cc.
How likely is it for the pharmacist to hate you for this order??

 

[dhb]

How likely is it for the pharmacist to hate you for this order??

I do it myself
I draw 35ml of 0.2% ropivacaine add 5ml of sufentanil 5mcg/ml and 10ml 0.9% saline in a 50ml syringe and voila

 

[tussionex]

So lets see:
You take 95 cc of 0.125% Bupivacaine ( That would be 1.25 mg /cc for you) and you add 5 cc of Fentanyl, this will give you 100 cc of a solution that contains Bupivacaine 1.1875 mg / cc or 0.11875% and 2.5 mcg/cc fentanyl.
So lets say you want to write the order for the pharmacist:
according to you, you write: 100 cc of Bupivacaine 1.1875 mg/cc and Fentanyl 2.5 mcg/cc.
How likely is it for the pharmacist to hate you for this order??

plankton, come to my hospital...i won't hate you for it!
it's my job to do the math and prepare an elegant product.

 

[Planktonmd]

plankton, come to my hospital...i won't hate you for it!
it's my job to do the math and prepare an elegant product.