Labor epidural in patient with acute zoster

[pgg]

Otherwise healthy multiparous woman, in labor, requesting epidural. Has an active shingles lesion over her lower back/hip. She's taking acyclovir.

Would you place an elective labor epidural (through or very close to the affected area)?

If she was scheduled for an elective c-section, would you do a single-shot spinal?

Would your answer to either question change if the visible lesion didn't extend to midline (needle insertion point)?

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[Planktonmd]

Not a good idea regardless of the location of the lesions relative to the insertion site.
There is some evidence that placing an epidural could cause Myelitis in patients with acute Zoster.

 

[pgg]

We declined and she delivered with the help of fentanyl and pudendal blocks from her OB.

I do see that epidurals (including steroids) are being offered to treat the symptoms of shingles itself in some people though, so I was just curious if anyone would do a labor epidural or spinal.

 

[sevoflurane]

I don't believe the benefit outweighs the risk. Just imagine her with HSE a couple days after epidural placement.

 

[deleted171991]

Better be safe than sued, err... sorry. 😀

 

[Planktonmd]

So...
We really don't know... in other countries people are treating post-herpetic neuralgia with epidural analgesia very successfully... actually they go as far as stating that epidural analgesia is the gold standard.
On the other hand there are a few case reports of badness happening after an epidural in the acute phase of herpes Zoster.
So... since we live in the good old US of A and since lawyers here are everywhere... we need to be conservative.
Conservative is not necessarily what's best for the patient but it is what people do to stay out of trouble.
Sad reality... but true

 

[AlgundiA]

So...
We really don't know... in other countries people are treating post-herpetic neuralgia with epidural analgesia very successfully... actually they go as far as stating that epidural analgesia is the gold standard.
On the other hand there are a few case reports of badness happening after an epidural in the acute phase of herpes Zoster.
So... since we live in the good old US of A and since lawyers here are everywhere... we need to be conservative.
Conservative is not necessarily what's best for the patient but it is what people do to stay out of trouble.
Sad reality... but true

So could one argue that the "acute" phase of zoster is when they are feeling the pain but and when the blisters have started to form but have not yet ruptured/crusted over...and therefore if the OP's pt already had to healing blisters and was taking acyclovir (though we don't know for how long), she could have received an epidural? (is that similar to what has been done in other countries as you mentioned?)

 

[HollATme]

Similar to what Planktonmd was saying, but I added a few things....

Isn't an epidural a great thing for acute herpes zoster? It may even prevent post-herpetic neuralgia.

Sure, a complication could occur. Complications could occur all the time with anything we could do. If one properly addresses the complications/side effects and alternatives, then proper consent has been provided and should one occur it should not lead to a lawsuit. Perhaps I'm wrong here??

We do a central line for a case that necessitates one - if we happen to cause an inadvertent SVC rupture, we deal with it.

As long as everything is addressed, and if a complication occurs, and patient is made aware of it and we deal with it effectively - sure, you could be taken to court, but you're not gonna lose. Am I incorrect in this assessment??

It's just easy to not do it, because the less we do, the less we can potentially cause an issue. Plus, it's elective. Laboring moms don't need an epidural. So, I can see where one would NOT want to place one due to the potential for major complications. This, for sure, is definitive.

 

[sethco]

How many times have you seen an SVC rupture from a central line? Also, how would you "deal with it"?

 

[Noyac]

Been a long time since I've visited this site. Hows the back and forth bantering going?
Oops, that's for another thread.

I have a different take on this topic than some of you. I also come from a pain clinic background where I routinely performed epidurals for these pts with moderately good results. The only problem was that the epidural would wear off after a few days of relief and they would return. But it did help the pt get through those very difficult acute breakout times. The last time I did this was 4 mons ago on a elderly gentleman that was suicidal from the pain and all the meds where making him confused. That is a no brainer for me.

Think about the herpes in its dormant phase. Where does it reside? Answer, in the dorsal root. Therefore, the virus is already central so the epidural won't cause central spreading. Can it cause a greater spreading tho? I don't know but I am unaware of any good reports claiming this. But the way I look at it is, who cares, it's already in the area.

So I would make sure the consent explains all this in laymans term and proceed barring any open ulcers or potentially infectious sites.

But the fentanyl pudendal block approach works well too.

 

[Planktonmd]

Been a long time since I've visited this site. Hows the back and forth bantering going?
Oops, that's for another thread.

I have a different take on this topic than some of you. I also come from a pain clinic background where I routinely performed epidurals for these pts with moderately good results. The only problem was that the epidural would wear off after a few days of relief and they would return. But it did help the pt get through those very difficult acute breakout times. The last time I did this was 4 mons ago on a elderly gentleman that was suicidal from the pain and all the meds where making him confused. That is a no brainer for me.

Think about the herpes in its dormant phase. Where does it reside? Answer, in the dorsal root. Therefore, the virus is already central so the epidural won't cause central spreading. Can it cause a greater spreading tho? I don't know but I am unaware of any good reports claiming this. But the way I look at it is, who cares, it's already in the area.

So I would make sure the consent explains all this in laymans term and proceed barring any open ulcers or potentially infectious sites.

But the fentanyl pudendal block approach works well too.

Glad to see you back 🙂

 

[Laryngophed]

Been a long time since I've visited this site. Hows the back and forth bantering going?
Oops, that's for another thread.

I have a different take on this topic than some of you. I also come from a pain clinic background where I routinely performed epidurals for these pts with moderately good results. The only problem was that the epidural would wear off after a few days of relief and they would return. But it did help the pt get through those very difficult acute breakout times. The last time I did this was 4 mons ago on a elderly gentleman that was suicidal from the pain and all the meds where making him confused. That is a no brainer for me.

Think about the herpes in its dormant phase. Where does it reside? Answer, in the dorsal root. Therefore, the virus is already central so the epidural won't cause central spreading. Can it cause a greater spreading tho? I don't know but I am unaware of any good reports claiming this. But the way I look at it is, who cares, it's already in the area.

So I would make sure the consent explains all this in laymans term and proceed barring any open ulcers or potentially infectious sites.

But the fentanyl pudendal block approach works well too.

I feel like I've seen a ghost. And I'm glad for that.


Good to see you back. Stick around, won't you?

 

[Noyac]

Heard you asked about me, Plank. Thanks for checking up.

As far as being back goes, well we'll see.

 

[sevoflurane]

As far as being back goes, well we'll see.

What... bad ass bike building >>>> SDN? 😉

While I agree, its still good to see you back on here. 👍

 

[Jay K]

We do a central line for a case that necessitates one - if we happen to cause an inadvertent SVC rupture, we deal with it.

Lip service