labor epidural to c-section transition

[VentdependenT]

Well I just did a case that blew.

I placed a CSE for a young healthy g1p0 this afternoon. Got immediate relief. Put epidural in L3-4, 4cm in space. Several hours later, failure to progress despite strong pushing in stage II labor----->c-section. Mom ok, baby ok. I dose her up with 10cc lido 2% (my stupid tired resident ass friggen forgot the bicarb). She says her legs feel numb but the right inner thigh is having pain. I pull epidural back 1 cm and dose the next 10cc. Back to room.

We have to move her to the table, legs weak, numb. Temperature level bilateral T-4, negative pinch test by the OBGYN. By now the Lido has had a good 15 minutes to do its magic. GO TIME. Skin incision....no pain. First tug on the uterus and she is screaming in pain.

Attending and I slug in 150ucg fenty and another 10cc 2%lido through the epidural stat. Screaming with every tug on the uterus, she says its pain, not pressure. Kid pops out pretty quick. Anypoops we had to give another 175ucg fent, 50mg ket, 3mg versed, AND 60% nitrous (still able to answer questions while breathing the stuff) to finally get her moderately comfortable. Even at the end of the surgery when we put the abd pads on she belted out a yelp.

WTF!

Although I am far from experienced, I haven't had this happen to me before. I felt like a friggen dip-$hit.

Attending wasn't upset (one of our best teachers). He said that since the kid came out so quick that there was no need to put her to sleep and have the dad and ob attending see her with the tube hangen out. He said he wouldn't have falted me if I decided to put her to sleep though.

That blew man. She was comfortable back in the LDR and actually said thanks. Kid did great.

I hadn't realized that bicarb had such an impact on the setup of the block.

Should I have used 2-chloro-pro? Haven't used that stuff yet. Guess I should start "experimenting" with it. Whats your rec's peeps?

---

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[huktonfonix]

the bicarb does make a difference, but I haven't noticed a huge difference (maybe a few minutes which could be important in an absolute crash) in setup time with 2 lido +epi + bicarb vs 3 chloro. However, this case just sounds like one of those sh@t happens things with the epidural since your lido should have had plenty of time to set in. Sounds like the block had some random patchiness (if thats a word) and you did what you had to do to keep her comfortable (ket, N20). Based on your exam anyone would have assumed that she had enough of a level to cover uterine discomfort.

 

[Planktonmd]

Well I just did a case that blew.

I placed a CSE for a young healthy g1p0 this afternoon. Got immediate relief. Put epidural in L3-4, 4cm in space. Several hours later, failure to progress despite strong pushing in stage II labor----->c-section. Mom ok, baby ok. I dose her up with 10cc lido 2% (my stupid tired resident ass friggen forgot the bicarb). She says her legs feel numb but the right inner thigh is having pain. I pull epidural back 1 cm and dose the next 10cc. Back to room.

We have to move her to the table, legs weak, numb. Temperature level bilateral T-4, negative pinch test by the OBGYN. By now the Lido has had a good 15 minutes to do its magic. GO TIME. Skin incision....no pain. First tug on the uterus and she is screaming in pain.

Attending and I slug in 150ucg fenty and another 10cc 2%lido through the epidural stat. Screaming with every tug on the uterus, she says its pain, not pressure. Kid pops out pretty quick. Anypoops we had to give another 175ucg fent, 50mg ket, 3mg versed, AND 60% nitrous (still able to answer questions while breathing the stuff) to finally get her moderately comfortable. Even at the end of the surgery when we put the abd pads on she belted out a yelp.

WTF!

Although I am far from experienced, I haven't had this happen to me before. I felt like a friggen dip-$hit.

Attending wasn't upset (one of our best teachers). He said that since the kid came out so quick that there was no need to put her to sleep and have the dad and ob attending see her with the tube hangen out. He said he wouldn't have falted me if I decided to put her to sleep though.

That blew man. She was comfortable back in the LDR and actually said thanks. Kid did great.

I hadn't realized that bicarb had such an impact on the setup of the block.

Should I have used 2-chloro-pro? Haven't used that stuff yet. Guess I should start "experimenting" with it. Whats your rec's peeps?

Sometimes your Epidural catheter travels down rather than up, so you end up with the tip at the sacral level and no matter how much local you put in you will not get the T10 level you need for the uterus because the local will escape through the foraminas before reaching that level.
It's not about Sodium bicarb.

 

[Noyac]

And here lies the reason I pull epidurals for c/s and place a spinal. I used an epidural for a c/s last week. It was the first one I have done under epidural in over 2 years to my best recollection. It was a stat stat c/s. FHR 60's for 5-10min. I pushed 20cc 2% lido with 2 cc bicarb and .2 cc epi on the way to the OR. I used it for a few reasons. I could dose it on the way. I had placed it only 1 hr earlier. And I was the one that placed it so I was confident it was in the right place not that I don't trust my partners but I was intimately familiar with it.

 

[Laurel123]

Well, while it is your first patchy epidural, it wont be your last! That is just the nature of epidurals and the nature of OB anesthesia. Bicarb does help speed the onset of lido for a few minutes, but I doubt it would have mattered in your case. I just always have ketamine and versed ready to give. I think is the academic center, if the mom is thin and still screaming, I may have converted. In the private world, I have a guy that can skin to skin in ten minutes. So by the time I even get my propofol drawn up, hes already popped the uterus back in. Anyways, sounds like typical OB, just remember that when the patient gets to snowed, its safer to just do a general.

 

[Noyac]

Well, while it is your first patchy epidural, it wont be your last! That is just the nature of epidurals and the nature of OB anesthesia. Bicarb does help speed the onset of lido for a few minutes, but I doubt it would have mattered in your case. I just always have ketamine and versed ready to give. I think is the academic center, if the mom is thin and still screaming, I may have converted. In the private world, I have a guy that can skin to skin in ten minutes. So by the time I even get my propofol drawn up, hes already popped the uterus back in. Anyways, sounds like typical OB, just remember that when the patient gets to snowed, its safer to just do a general.

Yes indeed.

I wish my OB's could do a c/s in 10 min when needed. I have 2 that can do it in 30 mins which is nice.

I really agree with your last statement, GETA is safer than deep sedation in most circumstances.

 

[VentdependenT]

Talked to her in the am. No recall after she heard the words "cut the umbilical cord." She said thanks.

I left the epidural in and ran a Fentanyl/Bupivicaine infusion for post op pain. The thing worked. Post op pain controlled. Go figure.

 

[milrisome]

Have to agree. Sometimes you're the fly, sometimes you're the windshield. I almost always take them out and go for a spinal for C/S though. It's a much more dense anesthesia, especially for visceral pain. Like Noy I might use my own epidural if fresh. But if there's any question, like needing to bolus, a "patchy" block, inadequate pain relief, etc., that epidural's going in the trash.

Same thing for PPTL...Forget the day-old epidural. It almost always fails. Just take it out and save yourself and everyone else a headache.

 

[milrisome]

BTW, are you routinely doing CSE for labor?

 

[VentdependenT]

No I dont routinely use CSE for labor. Only if the patient is writhing in pain do I use it. I use 0.5cc of 0.25% bupivicaine, 25ucg Fentanyl, and pull back a cc of csf then inject.

 

[dA pilot]

And here lies the reason I pull epidurals for c/s and place a spinal. QUOTE]

Any worry of high spinal after epidural anesthesia?

 

[dhb]

Something similar happened to me indirectly: put in a couple of epidurals in the morning which were working fine at 5pm we roll one in for c-section dose her up with 15cc of 2% lido did fine.
The second one goes for c-s later with the on call attending, she can't get good pain relief with the epidural which had been working fine and she ended up going the ketafol way too.
Patient had uncontrolled bleeding went to angio to get the uterine art embolized but the radiologist couldn't get it done because of arterial vasospasm so they ended up doing a hysterectomy at ( in the morning.
I came in the next day and say the patient in the PACU with no uterus 😱

 

[jetproppilot]

BTW, are you routinely doing CSE for labor?

Yes.

For seven years now.

 

[Planktonmd]

Something similar happened to me indirectly: put in a couple of epidurals in the morning which were working fine at 5pm we roll one in for c-section dose her up with 15cc of 2% lido did fine.
The second one goes for c-s later with the on call attending, she can't get good pain relief with the epidural which had been working fine and she ended up going the ketafol way too.
Patient had uncontrolled bleeding went to angio to get the uterine art embolized but the radiologist couldn't get it done because of arterial vasospasm so they ended up doing a hysterectomy at ( in the morning.
I came in the next day and say the patient in the PACU with no uterus 😱

Anybody knows why people do GA with unprotected airway on a pregnant woman when an epidural doesn't work instead of just doing a proper GETA?

 

[Laurel123]

Yes. I dont even know why we bother to leave those epidurals in for PPTL. They never work. I usually do a general with ET for the PPTL so the mom doesnt have to sit in the recovery with numb legs for three hours.

I usually give the epidural a try,though. Especially if the nurse tells me that the mom has been snoozing for the last few hours and hasnt felt a contraction. I would guess about 75 percent work well. If the moms been complaining of pain, and then she pretty much hops over to the next bed, then I just pull it out and do spinal.

 

[dhb]

well sedation isn't exactly GA... (in this case i don't know for sure if it was propofol or midaz)

 

[Intubate]

Yeah, this happens. Sometimes it may be related to block height or you just need more time, but sometimes its just patchy. For me, 2 mg of midazolam followed by 10mg increments of ketamine is the key here. I keep them awake and breathing, but amnestic. I don't ever use propofol or fentanyl unless they're going to sleep. I keep talking with them, saying everythings ok and afterwards, they're happy.

I do always check a sensory level before starting (make sure they have a reasonable bilateral block), but nothings perfect. Sometimes you have to limp through.

 

[zippy2u]

Dude, ya didn't dose the epidural correctly... Bicarb wasn't your problem. It's 2mls of fentanyl through the epidural cath, then 20mls of 2% lido with or without epi. If ya want epi use 5 mikes/cc and don't use the pre made solution. Always add 2mls of bicarb to the 20 ccs of the lido to ward off evil spirits.Look back in some old ASA refresher books and there was a dude whose last name started with a "G" out of Pennsylvania who always had a section called "How to make an Epidural Work". Regards, -----Zippy

 

[usnavdoc]

Dude, ya didn't dose the epidural correctly... Bicarb wasn't your problem. It's 2mls of fentanyl through the epidural cath, then 20mls of 2% lido with or without epi. If ya want epi use 5 mikes/cc and don't use the pre made solution. Always add 2mls of bicarb to the 20 ccs of the lido to ward off evil spirits.Look back in some old ASA refresher books and there was a dude whose last name started with a "G" out of Pennsylvania who always had a section called "How to make an Epidural Work". Regards, -----Zippy

This is what I was thinking. Im on my CA2 OB rotation now, and this has been my srtategy. T8-10 level on pump and called for urgent untimed C/S. Dose 20ml 2% Lido with epi. 50-100 MCG fent once in the room and ready to go. Usually get a t2 level with good surgical anesthesia. Why not use the premade solution? Havent been using Bicarb, How much faster does the block set in?

 

[johankriek]

Well I just did a case that blew.

I placed a CSE for a young healthy g1p0 this afternoon. Got immediate relief. Put epidural in L3-4, 4cm in space. Several hours later, failure to progress despite strong pushing in stage II labor----->c-section. Mom ok, baby ok. I dose her up with 10cc lido 2% (my stupid tired resident ass friggen forgot the bicarb). She says her legs feel numb but the right inner thigh is having pain. I pull epidural back 1 cm and dose the next 10cc. Back to room.

We have to move her to the table, legs weak, numb. Temperature level bilateral T-4, negative pinch test by the OBGYN. By now the Lido has had a good 15 minutes to do its magic. GO TIME. Skin incision....no pain. First tug on the uterus and she is screaming in pain.

Attending and I slug in 150ucg fenty and another 10cc 2%lido through the epidural stat. Screaming with every tug on the uterus, she says its pain, not pressure. Kid pops out pretty quick. Anypoops we had to give another 175ucg fent, 50mg ket, 3mg versed, AND 60% nitrous (still able to answer questions while breathing the stuff) to finally get her moderately comfortable. Even at the end of the surgery when we put the abd pads on she belted out a yelp.

WTF!

Although I am far from experienced, I haven't had this happen to me before. I felt like a friggen dip-$hit.

Attending wasn't upset (one of our best teachers). He said that since the kid came out so quick that there was no need to put her to sleep and have the dad and ob attending see her with the tube hangen out. He said he wouldn't have falted me if I decided to put her to sleep though.

That blew man. She was comfortable back in the LDR and actually said thanks. Kid did great.

I hadn't realized that bicarb had such an impact on the setup of the block.

Should I have used 2-chloro-pro? Haven't used that stuff yet. Guess I should start "experimenting" with it. Whats your rec's peeps?

stop doing combined spinal epidurals.. the catheter was not tested properly..
Maybe thats the cause of maybe it was just one of those things...

once in a while you have to struggle through a c section with a patchy epidural.. and do what you did..

anyway, in my experience in OB.. DONT GET FANCY....

 

[zippy2u]

Because the commercially prepared lido with epi is rather acidic to ensure stability of the epi. Prolly the more acidic the soln, the less effective it is. Guru's name by the way was Brett Gutsche out of Penn. Regards, ---Zip

 

[Planktonmd]

well sedation isn't exactly GA... (in this case i don't know for sure if it was propofol or midaz)

If the patient who has a non-functioning epidural allows you to pull her uterus out and play with it she is under GA not "sedation" !

 

[Noyac]

And here lies the reason I pull epidurals for c/s and place a spinal. QUOTE]

Any worry of high spinal after epidural anesthesia?

Nope.

 

[Noyac]

BTW, are you routinely doing CSE for labor?

Yes

 

[milrisome]

I don't routinely...I feel like by the time I get the catheter in, bolus, turn around and do my paperwork, they're usually comfortable. And then I know I have a functional catheter and I probably won't have to go back to fix things later on. If they need more than usual, I just start them on a higher infusion rate. I don't know, but I think it prevents going back.

And that's key at 2 am.

 

[sdn1977]

Dude, ya didn't dose the epidural correctly... Bicarb wasn't your problem. It's 2mls of fentanyl through the epidural cath, then 20mls of 2% lido with or without epi. If ya want epi use 5 mikes/cc and don't use the pre made solution. Always add 2mls of bicarb to the 20 ccs of the lido to ward off evil spirits.Look back in some old ASA refresher books and there was a dude whose last name started with a "G" out of Pennsylvania who always had a section called "How to make an Epidural Work". Regards, -----Zippy

You are one of the most dryly funny people on ths site! I love the "warding off evil spirits" - kinda speaks both languages- professional & patient. You have got to be one of those anethesiologistis who keeps people smiling even as they fall asleep...you'd be a pleasure to work with!

totally off topic - sorry!.

 

[VentdependenT]

Thanks for the advice yall.

Helps greatly actually. Zip, I'll give it a shot next time I have a FRESH epidural. I will also have a LOW THRESHOLD for yanking and coverting to spinal now.

As always, my SDN people show me the light.

As for converting to GA we didnt go there. She was still answering questions even while breathing Nitrous. It was a fast procedure, about 20 min to close once the kid popped out. Like I said, we could have gone either way and we were close. But what we did worked. Was it the easiest thing? I don't think so.

Don't think that I wasn't making sure she was responsive. It was a deep MAC, but a mac none the less.

 

[Mman]

I generally will give 100 of Fentanyl down the epidural immediately and then chase it with 5 ml of 2% lido with epi and bicarb. Then I titrate another 5 ml of the lido mixture every 4-5 minutes checking levels before giving the next dose.

For some patients with a dense block from the PCEA that's been running, they might only need 200 mg of lidocaine to get a t4 level. Others need a full 400 mg to get a good level.


From my N of about 50 for patients with an epidural going back to c-section, I'm guessing the epidural has worked fine 85-90% of the time. A few needed some nitrous or ketamine or midaz, particularly when the uterus was exteriorized.

 

[jwk]

And here lies the reason I pull epidurals for c/s and place a spinal. I used an epidural for a c/s last week. It was the first one I have done under epidural in over 2 years to my best recollection. It was a stat stat c/s. FHR 60's for 5-10min. I pushed 20cc 2% lido with 2 cc bicarb and .2 cc epi on the way to the OR. I used it for a few reasons. I could dose it on the way. I had placed it only 1 hr earlier. And I was the one that placed it so I was confident it was in the right place not that I don't trust my partners but I was intimately familiar with it.

OB mecca here - 98% of C/S are done under epidural, 2% GA, maybe a few (literally <10) a year get a spinal - no CSE's ever. Labor epidurals get ropivicaine and fentanyl on a pump after initial dosing during placement. For our C/S we use almost exclusively 2% lido with epi (premix out of the bottle) with one cc of bicarb (Neut) per 10cc of lido. Our conversion rate to GA for a failed epidural is well under 0.5%. The big difference on all our epidurals is that initial dosing at placement is done through the needle, not the catheter. We think we get a better and more consistent spread of local doing it that way.

 

[pd4emergence]

I usually use the epidural if it is there and has been working. I always ask the OB nurse how comfortable the patient has been and try to get an idea of what kind of level the patient has. If it has not been working, I pull it and go for a spinal. I usually use 3% chloroprocaine if stat, it works fast (to me faster than 2% lido with bicarb and epi) and lasts long enough for nearly all of our OB's to finish. There have been a few who had to get some fentanyl and versed while the uterus was out but very rarely do I have to convert. I try not to do the room air general thing. I think if you are slamming them with stuff to keep them comfortable you might as well protect the airway provided you feel you can get a tube in. I also put in Duramorph for post op pain control (usually 3 mg in epidurals). We have good protocols in place for our duramorph patients ie pulse ox 24 hours, no other pain meds without calling us and so on. The duramorph works well for pain but they itch so we make sure and order the some benadry/narcan infusion.

 

[Laurel123]

OB mecca here - 98% of C/S are done under epidural, 2% GA, maybe a few (literally <10) a year get a spinal - no CSE's ever. Labor epidurals get ropivicaine and fentanyl on a pump after initial dosing during placement. For our C/S we use almost exclusively 2% lido with epi (premix out of the bottle) with one cc of bicarb (Neut) per 10cc of lido. Our conversion rate to GA for a failed epidural is well under 0.5%. The big difference on all our epidurals is that initial dosing at placement is done through the needle, not the catheter. We think we get a better and more consistent spread of local doing it that way.

Interesting practice. So when you do a c/s that does not have an epidural in, do you get loss of resistance and then put all 20cc of the 2% lido through the needle? And then place the catheter? Do you test dose through the needle or catheter? What about a semi-crash C/S where you have time to do a local, but not much time? And why do you do epidurals instead of spinals for C/S? Just curious... thanks

 

[jwk]

Interesting practice. So when you do a c/s that does not have an epidural in, do you get loss of resistance and then put all 20cc of the 2% lido through the needle? And then place the catheter? Do you test dose through the needle or catheter? What about a semi-crash C/S where you have time to do a local, but not much time? And why do you do epidurals instead of spinals for C/S? Just curious... thanks

I think it's exclusively epidurals simply because we do so many of them. Routine C/S (scheduled) will get all 15-20cc through the needle after a test dose through the needle, then the catheter is placed. Once the catheter is threaded, a test dose is given through that as well. Semi-crash (or urgent - see other debate on another thread) we usually have time to dose on the way to the OR, literally while rolling down the hall if we have to. By the time the patient is on the table, prepped, and draped, we're usually good to go. Our OB's are confident in our abilities because of our high volume, so if it takes a couple minutes to pop in or dose an epidural, they're willing to give us the time to do that. The true emergent C/S that does not have an epidural will get a crash GA, although I've seen a few spinals if they OB is not already standing in the room ready to go.

 

[BLADEMDA]

OB mecca here - 98% of C/S are done under epidural, 2% GA, maybe a few (literally <10) a year get a spinal - no CSE's ever. Labor epidurals get ropivicaine and fentanyl on a pump after initial dosing during placement. For our C/S we use almost exclusively 2% lido with epi (premix out of the bottle) with one cc of bicarb (Neut) per 10cc of lido. Our conversion rate to GA for a failed epidural is well under 0.5%. The big difference on all our epidurals is that initial dosing at placement is done through the needle, not the catheter. We think we get a better and more consistent spread of local doing it that way.

Agree with JWK. Since 1979 to the present Epidurals dosed with 2% lido with epi right out of the bottle. Very low failure rate. In the late 1990's we switched to Spinal over Epidural for C-Sections (when no Epidural in place).
Spinal is faster, denser block and needs less sedation for break-through pain (this statement confirmed in peer reviewed study).

Venty, you just had one of those OB cases with a patchy epidural. You will see it again in your career if you do OB. If I can get away with it I like sedation as well but like Noyac says you need to know when to convert to GA.

This was a good case for you. You will be a better attending for it.

Blade

 

[Noyac]

I think it's exclusively epidurals simply because we do so many of them. Routine C/S (scheduled) will get all 15-20cc through the needle after a test dose through the needle, then the catheter is placed. Once the catheter is threaded, a test dose is given through that as well. Semi-crash (or urgent - see other debate on another thread) we usually have time to dose on the way to the OR, literally while rolling down the hall if we have to. By the time the patient is on the table, prepped, and draped, we're usually good to go. Our OB's are confident in our abilities because of our high volume, so if it takes a couple minutes to pop in or dose an epidural, they're willing to give us the time to do that. The true emergent C/S that does not have an epidural will get a crash GA, although I've seen a few spinals if they OB is not already standing in the room ready to go.

So you guys choose an epidural over a spinal in a emergent c/s that is npt under GA? This seems like a lot of wasted time to me. You have to place the needle, test dose it, thread the cath, test it, and tape it in place. I would have my spinal in and we would be prepping by the time you would be threading your cath.

I agree with dosing thru the needle. i did it that way as well b/4 I switched to CSE's in the laboring pt. But I always went with spinals for c/s b/c it is denser and the duramorph is more effective when administered intrathecally.

Now if you guys are running the epidurals post-op for pain management then I can see doing it your way. But then they don't get up and walk the halls as soon and the c/s incision isn't as painful as the vertical abd incision therefore I don't see post-op epidurals as necessary.

 

[jwk]

So you guys choose an epidural over a spinal in a emergent c/s that is npt under GA? This seems like a lot of wasted time to me. You have to place the needle, test dose it, thread the cath, test it, and tape it in place. I would have my spinal in and we would be prepping by the time you would be threading your cath.

I agree with dosing thru the needle. i did it that way as well b/4 I switched to CSE's in the laboring pt. But I always went with spinals for c/s b/c it is denser and the duramorph is more effective when administered intrathecally.

Now if you guys are running the epidurals post-op for pain management then I can see doing it your way. But then they don't get up and walk the halls as soon and the c/s incision isn't as painful as the vertical abd incision therefore I don't see post-op epidurals as necessary.

Actually, all our C/S patients keep their epidural about 24 hours postop. They get bupivicaine 0.0625% with fentanyl. They're up and walking in the afternoons after an AM C-section.

 

[milrisome]

Isn't that a lot of work to manage all those post c/s epidurals for 24 hours? We just use duramorph with the spinal.

 

[jwk]

Isn't that a lot of work to manage all those post c/s epidurals for 24 hours? We just use duramorph with the spinal.

We have a group of acute-pain service nurses that keep up with these patients (both epidural and IV PCA) , as well as them being seen by an anesthesiologist daily. On any given day, we're probably managing 80-100 actue pain patients.

 

[Noyac]

We have a group of acute-pain service nurses that keep up with these patients (both epidural and IV PCA) , as well as them being seen by an anesthesiologist daily. On any given day, we're probably managing 80-100 actue pain patients.

WOW, that sounds painful.

 

[jwk]

WOW, that sounds painful.

Just guessing, because I have no real idea of finances of the group - but just in round numbers, at $20/unit average, and I think I read that the RVG lists management of post-op pain pumps at 3 units per day, then multiply by 80-100 patients per day, that ends up at $4800-6000 per day. That does not include professional fees for blocks that are placed strictly for post-op pain control and not for the operative procedure itself.

 

[epidural man]

BTW, are you routinely doing CSE for labor?

In the busy OB hospital in my town, about 90% of the docs do combined, and they put bupivicaine in the spinal. I think there is good data to show that CSE makes your epidural success rate go up.

Venty, any thought that you had a subdural catheter? There is a guy at the hospital I just mentioned that for a while when he would get a patchy block, he would grab a flouro machine and do epiduragraphy, and all 7 times, it was subdural.

I have always thought that weird results and patchy epidurals were probably subdural.

 

[Noyac]

I think there is good data to show that CSE makes your epidural success rate go up.

Do you have this data?

I suspect it is residents that the data is based on and that would make sense. I doubt that the success rate would go up very much for someone that has been placing epidurals for years.

 

[epidural man]

Do you have this data?

I suspect it is residents that the data is based on and that would make sense. I doubt that the success rate would go up very much for someone that has been placing epidurals for years.

Noyac,

I don't have the data. That is why I specified I THINK. I remember Julia Pollock at Virginia Mason talking about it on an Audio Digest lecture and remember looking at the handout that comes with those at the references but never got around to reading the study.

The point about these studies being done in the hands of residents is most certainly the case -

 

[Mman]

I much prefer a spinal to an epidural for a planned c-section (i.e. patient isn't in labor). I mean if they have a working epidural on the floor, dosing it up works quite well most of the time. Plus it's a much quicker procedure in general.

However, in my limited expierence (maybe 120 c-sections or so), the patients that get a spinal are more comfortable during the procedure. There's a lot less hand holding and a lot less strained faces by mom with the denser block. Epidurals can work good for skin incision, but sometimes (20% maybe) the patient will be feeling quite a bit of tugging when the uterus is getting jacked all over the place.


I'm curious about dosing 20 mls through the needle, threading the catheter, and then giving a "test dose" down the catheter. In the traditional sense, a test dose of local + epi will test for both an intrathecal or intravascular catheter. Having already put 20 ml of local in the epidural space I can't imagine you'd have any way of detecting an intrathecal catheter with the test dose. It'd be more of a look at the HR. And depending on how long it took to inject through the needle, thread the catheter, withdraw the needle, snap on the connector, etc., how well can you even detect an intravascular catheter? I mean the patient's HR and BP could both be impacted by the large epidural dose they received a few minutes before.

It's an interesting way of doing things and I'm sure it works quite well, but I'm having trouble wrapping my brain around some of the specifics.

 

[jwk]

I'm curious about dosing 20 mls through the needle, threading the catheter, and then giving a "test dose" down the catheter. In the traditional sense, a test dose of local + epi will test for both an intrathecal or intravascular catheter. Having already put 20 ml of local in the epidural space I can't imagine you'd have any way of detecting an intrathecal catheter with the test dose. It'd be more of a look at the HR. And depending on how long it took to inject through the needle, thread the catheter, withdraw the needle, snap on the connector, etc., how well can you even detect an intravascular catheter? I mean the patient's HR and BP could both be impacted by the large epidural dose they received a few minutes before.

It's an interesting way of doing things and I'm sure it works quite well, but I'm having trouble wrapping my brain around some of the specifics.

That's why we aspirate as well, looking for blood or CSF once the catheter is threaded. HR changes from an intravascular injection of lidocaine with epi, whether through the needle or catheter, are almost immediate and not very subtle.

We've got a large retrospective study that has been sent for publication, something like 50,000 cases. I'm sure it will raise some eyebrows, but it will be hard to argue with the numbers.