Labor Epidurals: Boluses and Tape Jobs

[siednarb]

First call as an attending this past Sunday - only MDA in house for 24 hours - was busy in the OR - but also put in 7 epidurals in the afternoon and got to see the results of my epidurals over the course of the evening - 2 went to section later that night with no problems - 2 delivered with good epidurals - the remaining 3 had problems getting adequate analgesia and were not happy with me. All 7 epidurals went easily with LOR with saline - no wet taps and even the ones that were complaining had some leg numbness. Suprisingly the 25 year old woman s/p gastric bypass and loss of 160# (now weighs 250) did great (despite having the tuohy burried at 9 cm) - but the skinny 31 y/o had issues - go figure

Just wondering what others do in terms of how much they give as a bolus (I did what I did during training - I used 10 ml out of the bag which has 0.125% Bupivicaine + 2 mcg/ml of fent) in addition to giving the full 5 ml 1.5% lidocaine test dose and then run them at 10 ml/hr. I've heard that some of my new partners use 0.25% bupivicaine for their boluses.

Lastly - tape job - I'm not sure if this was discussed on another forum - but we had some "expert" in residency come lecture to us to tape laterally to the side of the patient rather than up the shoulder. I also use the pac-man thingy and tegaderm with a loop of the catheter and a steri-strip over the loop - this usually anchors it pretty well. Just wondering what others do.

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[jwk]

First call as an attending this past Sunday - only MDA in house for 24 hours - was busy in the OR - but also put in 7 epidurals in the afternoon and got to see the results of my epidurals over the course of the evening - 2 went to section later that night with no problems - 2 delivered with good epidurals - the remaining 3 had problems getting adequate analgesia and were not happy with me. All 7 epidurals went easily with LOR with saline - no wet taps and even the ones that were complaining had some leg numbness. Suprisingly the 25 year old woman s/p gastric bypass and loss of 160# (now weighs 250) did great (despite having the tuohy burried at 9 cm) - but the skinny 31 y/o had issues - go figure

Just wondering what others do in terms of how much they give as a bolus (I did what I did during training - I used 10 ml out of the bag which has 0.125% Bupivicaine + 2 mcg/ml of fent) in addition to giving the full 5 ml 1.5% lidocaine test dose and then run them at 10 ml/hr. I've heard that some of my new partners use 0.25% bupivicaine for their boluses.

Lastly - tape job - I'm not sure if this was discussed on another forum - but we had some "expert" in residency come lecture to us to tape laterally to the side of the patient rather than up the shoulder. I also use the pac-man thingy and tegaderm with a loop of the catheter and a steri-strip over the loop - this usually anchors it pretty well. Just wondering what others do.

First - I would NEVER pull anything out of a bag and put it in the epidural. Call me paranoid, but by strict definition, once you pierce that bag and add meds to it, it's considered contaminated. The longer it's been hanging, the higher the risk. Start with fresh meds EVERY time and it's never a question.

Most of my boluses are 10cc of 2% plain lidocaine. You can argue whether epi should be used, but I personally don't use it. I like it plain because it's not going to last too long, but long enough to get them some relief and let the ropiv/fent in the pump do it's thing. If they got some decent relief but it didn't last long enough, I'd probably switch to .25% bupivicaine +/- epi. If they didn't get relief, then the epidural gets replaced. Some of the guys will jack it up to .33% bupivicaine if they know they have a good while before delivery.

Taping - BFD - if it stays in and works, you're doing it right, just like an endotracheal tube. We use tegaderm over the site - some use two long strips and run it up the back, others just over the site and 2" pink tape up the back. None of us tape it off to the side.

 

[2ndyear]

My new group is big on the 0.25% bupiv from the start, so I started doing it as well. 8-10 cc's in divided doses does seem to give a nice start. I usually give 50-100 mcg of fentanyl up front right after the test dose. Two functions, it gives some decent pain relief, and it's a second test dose. The bags at my new place can't be used to get anything out of, and I'm too antsy to wait for the pump to bolus it. I usually start at 12/hr unless early labor, 14 if screaming from the get go.

 

[jetproppilot]

First call as an attending this past Sunday - only MDA in house for 24 hours - was busy in the OR - but also put in 7 epidurals in the afternoon and got to see the results of my epidurals over the course of the evening - 2 went to section later that night with no problems - 2 delivered with good epidurals - the remaining 3 had problems getting adequate analgesia and were not happy with me. All 7 epidurals went easily with LOR with saline - no wet taps and even the ones that were complaining had some leg numbness. Suprisingly the 25 year old woman s/p gastric bypass and loss of 160# (now weighs 250) did great (despite having the tuohy burried at 9 cm) - but the skinny 31 y/o had issues - go figure

Just wondering what others do in terms of how much they give as a bolus (I did what I did during training - I used 10 ml out of the bag which has 0.125% Bupivicaine + 2 mcg/ml of fent) in addition to giving the full 5 ml 1.5% lidocaine test dose and then run them at 10 ml/hr. I've heard that some of my new partners use 0.25% bupivicaine for their boluses.

Lastly - tape job - I'm not sure if this was discussed on another forum - but we had some "expert" in residency come lecture to us to tape laterally to the side of the patient rather than up the shoulder. I also use the pac-man thingy and tegaderm with a loop of the catheter and a steri-strip over the loop - this usually anchors it pretty well. Just wondering what others do.

Dude, to be honest, I don't try and sell one technique over the other in anesthesia most times since theres a thousand ways to skin a cat in this biz...

BUT LEMME TELL YA, DUDE, CSE FOR LABOR ANALGESIA HAS THE POTENTIAL TO CHANGE YOUR ON-CALL LIFE.

I swear by it.

Tuohy to ES, slide in the spinal needle, give ropiv 2mg/sufenta 2.5ug or bupiv 2.5mg/fentanyl 25ug, remove spinal needle, insert catheter, run infusion.

Saves time for you and parturient. She's comfortable one minute later; you don't haffta wait to dose the catheter.

Virtually no need for ephedrine. I don't pull it anymore since I so rarely need it.

No risk of high spinal.

You don't haffta dose the catheter.

I really don't know why its not universally done for labor analgesia.

 

[leaverus]

10cc of 2% lido? Is that necessary? That's enough for surgical anesthesia. We use 10cc 0.125% bupi then start the infusion at 10cc/hr and seems to work fine. Regarding what jet said, i like cse also, but then you have an unproven catheter if she goes for a long section...it's risky - especially with OB residents; maybe if you're in a private practice job where the attendings are fast.

 

[jetproppilot]

10cc of 2% lido? Is that necessary? That's enough for surgical anesthesia. We use 10cc 0.125% bupi then start the infusion at 10cc/hr and seems to work fine. Regarding what jet said, i like cse also, but then you have an unproven catheter if she goes for a long section...it's risky - especially with OB residents; maybe if you're in a private practice job where the attendings are fast.

I respect your concern about the "unproven catheter."

I can tell you in experienced hands its not an issue.

 

[IceDoc]

I like Jet's technique too. (though I use narcs less often just because I get lots of complaints of itching)

If you're not going to do a CSE though, I would suggest that your bolus and infusions aren't high enough.
Bolus with Bupi 0.25% 8cc instead of 0.125%.....Result: Less Calls
Start infusion (we had Bupi 0.125%+Fent 2mcg/cc) at 12-14cc/hr....Result: Less Calls

 

[jwk]

10cc of 2% lido? Is that necessary? That's enough for surgical anesthesia. We use 10cc 0.125% bupi then start the infusion at 10cc/hr and seems to work fine. Regarding what jet said, i like cse also, but then you have an unproven catheter if she goes for a long section...it's risky - especially with OB residents; maybe if you're in a private practice job where the attendings are fast.

It's enough for surgical anesthesia for an episiotomy, but certainly not a C-Section. I want to knock their pain back down to an acceptable level quickly, which this does.

 

[LongSnow]

Some guys in my group do the CSE - it works well for them. I'll use it occasionally - but usually onlt for Csections I suspect may take forever. However, in private prctice, I have NEVER had a C-section outlast a marcaine spinal.

I don't - just don't lke the idea of puncturing the thecal sc if I don't have to.

I test dose cath 5 ml 1.5% lido, then bolus somewhere between 6-12 ml 0.2% Ropiv + 25 mcg Sufenta - works fast enough.

For a patient with weak legs but complaining of pain , I suspect the cath could have found its way into the anterior epidural space - for this I'll retract the cath a coupla' centimeters, redose, and wait and see. usually works - also usually works for one sided epidurals.

Do you have PCEA on your epidural pump? this saves alot of calls. Standard settings for pump are 0.2% ropiv (with 75 mcg mcg sufenta/100ml bottle) 12 ml/hr, + 5 ml patient controoled bolus q30 min for 22/hr max.

 

[snowman8]

One recent method I used to "skin the cat", for the initial bolus dose for a labor epidural is 8-10 ml of a solution of 5 ml of 2% and 5 ml of 25% (after 3ml test dose of 1.5% lido with epi). This gives a 10ml soln of 1% lido and 0.125% Bupi. IMHO I do not see excessive hypotension, but questionable if more lower extremity/pelvic weakness ? Rational, works faster than Bupi alone, and get a little longer duration and less weakness (than lido alone). Obviously my goal is to have a proven working epidural with minimal hypotension and weakness.

Theoretically not sure what giving 10 ml of 2 different LA in the same volume means from a applied pharmalogical/physiologist standpoint. From my understanding when dosing an epidural giving more volume means a higher level and giving a more concentrated LA means a denser block. But, what if you give 2 different LA's within the same volume. I assume same height, differential onset, but a more dense block. If I had to guess in terms of density of block, in terms of degree of sympathtectomy , analgesia, sensory block and motor block: 10 ml soln of 0.125% Bupi < 1% lido< ( 1% lido + 0.125% Bupi) < 0.25% Bupi< 2% Lido. Although in terms a labor analgesia, I assume all will do the job.

I use to use 8-10 ml 0.25% Bupi or 0.125 Bupi. Found that both work, just that 0.25% works faster. Although later (if I bolused with 0.25% Bupi), pts complain that epidural does not work as well after an infusion of Bupi 0.1% with Fent 2mcg/ml been running for several hrs. If I educate the pts about the more potent bolus, then I can sometimes avoid this painful page.

Now if i don't do a CSE (pt's high risk for c-section; like to have a proven working epidural; more important than 2-5 min of earlier analgesia) and am lazy and don't want to make up my concoction above I give 10-12 ml of 1% lido (after my test dose). Seems to work faster than 0.25% Bupi and last long enough for my infusion (which I usually start at 12ml, 10 ml if <5ft, 14 ml if > 5'8'') to reach an appropriate level.

 

[Laurel123]

I really like the CSE with the same formula as jet described above. It works so well for that patient that is screaming and squrirming like a mad woman because it works almost instantly and then I can leisurely thread the catheter and get her taped up. Also, when I get the woman at 9 - 10 cm or a woman that is 'changing quickly', I have found that no epidural dosing works fast enough. And granted, they will probably be popping out the baby in about 15-20 minutes anyways, they always remember their encounter as the 'epidural that didn't work' The CSE will work great and fast and consistantly and 15 minutes later the baby slides out comfortably.

All that being said, at my practice now, no one does CSE's, the group voted not to order the little CSE kits that make them so easy to do, the nurses have no idea what a CSE is - so I only do them rarely (the woman that is complete but is refusing to push becasue of the pain) I use the 5 ml of test dose, then follow with 8 to 10 ml of .25% bupiv with 100 mcg fent. They are almost always comfy by the time I finish my paperwork. Run infusion at 12 ml/hr.

 

[Arch Guillotti]

I don't beleieve in the unproven catheter dogma either. I find that if a CSE cath doesn't work (which is rare), the epidural gets repalced soon after the spinal dose wears off rather than gimping along with a crummey standard catheter and redosiing it/pulling it back, etc.

 

[snowman8]

I'm not worried about a CSE catheter that is not working all togther, but one that has a patchy or unilateral block. Most of the time if you get the spinal dose in with a CSE and the cath threads easily I know I wil have a functioing epidural, but can't be 100% positive that i will have an epidural that will provide an adequte bilateral block. In the pt that is high risk for c-section (which at my residency is >50% of the population) it is not fun to start a stat section with a patchy epidural. Like mentioned previously, all it takes is pulling back the cath a cm or so to fix this problem most of the time. I don't understand why you want 5 min earlier onset of analgesia instead of making sure you had an ideal epidural in this population.

 

[urge]

Dude, to be honest, I don't try and sell one technique over the other in anesthesia most times since theres a thousand ways to skin a cat in this biz...

BUT LEMME TELL YA, DUDE, CSE FOR LABOR ANALGESIA HAS THE POTENTIAL TO CHANGE YOUR ON-CALL LIFE.

I swear by it.

Tuohy to ES, slide in the spinal needle, give ropiv 2mg/sufenta 2.5ug or bupiv 2.5mg/fentanyl 25ug, remove spinal needle, insert catheter, run infusion.

Saves time for you and parturient. She's comfortable one minute later; you don't haffta wait to dose the catheter.

Virtually no need for ephedrine. I don't pull it anymore since I so rarely need it.

No risk of high spinal.

You don't haffta dose the catheter.

I really don't know why its not universally done for labor analgesia.

I do the exact same thing. Works very well.

 

[Laryngospasm]

I bolus 5cc .25 bup through the needle, slide in the catheter, test dose then 3-5 more bupiv. Pts are usually comfortable by the time they lay down.

 

[militarymd]

I respect your concern about the "unproven catheter."

I can tell you in experienced hands its not an issue.

This has been studied....Catheters are MORE likely to work...

As for PDPHA....this has been studied also....The headache rate is NO different.

CSE is better in EVERY single way....

Although I admit that I don't do it because I'm lazy.

 

[dfk]

This has been studied....Catheters are MORE likely to work...

As for PDPHA....this has been studied also....The headache rate is NO different.

CSE is better in EVERY single way....

Although I admit that I don't do it because I'm lazy.

well, i have to disagree here.
one way it is NOT better is when
the spinal wears off and the OB nurses
are calling you every 2 hours for a top-off
because the mum-to-be isn't as comfortable as
the initial injection.
for which, i choose not to do CSEs.

 

[Noyac]

I also do the exact same thing that Jet described.

 

[Noyac]

well, i have to disagree here.
one way it is NOT better is when
the spinal wears off and the OB nurses
are calling you every 2 hours for a top-off
because the mum-to-be isn't as comfortable as
the initial injection.
for which, i choose not to do CSEs.

I don't get those pages.

I tell the pt the first hour will be the strongest and then the epidural will settle into a consistent block. Also, if a nurse calls me for a top-up, I ask her what the block level is. If it's good then I don't bother coming. They now check levels b/4 calling me and only call if the level is falling or not present which means I haven't had a call in a few years as best I can remember.

 

[OldManDave]

First call as an attending this past Sunday - only MDA in house for 24 hours - was busy in the OR - but also put in 7 epidurals in the afternoon and got to see the results of my epidurals over the course of the evening - 2 went to section later that night with no problems - 2 delivered with good epidurals - the remaining 3 had problems getting adequate analgesia and were not happy with me. All 7 epidurals went easily with LOR with saline - no wet taps and even the ones that were complaining had some leg numbness. Suprisingly the 25 year old woman s/p gastric bypass and loss of 160# (now weighs 250) did great (despite having the tuohy burried at 9 cm) - but the skinny 31 y/o had issues - go figure

Just wondering what others do in terms of how much they give as a bolus (I did what I did during training - I used 10 ml out of the bag which has 0.125% Bupivicaine + 2 mcg/ml of fent) in addition to giving the full 5 ml 1.5% lidocaine test dose and then run them at 10 ml/hr. I've heard that some of my new partners use 0.25% bupivicaine for their boluses.

Lastly - tape job - I'm not sure if this was discussed on another forum - but we had some "expert" in residency come lecture to us to tape laterally to the side of the patient rather than up the shoulder. I also use the pac-man thingy and tegaderm with a loop of the catheter and a steri-strip over the loop - this usually anchors it pretty well. Just wondering what others do.

One of the most beautiful things about gas is that there are so many ways to skin the cat. In training, I learned the beauty of the CSE!! Dude, drop in 25mcg intrathecal fentanyl & she will literally fall in love with you! Seriously, it provides them with 60~90 minutes of damned-near total comfort and NO deleterious effects on hemodynamics, which is a SE of loading with the locals. The bag soln is purposefully a low-concentration to minimize motor & sympathetic blockade, but it also makes it as slow as Christmas coming on. If you CSE with fentanyl-only - more than enough time to ease on the epidural soln with minimal sympathectomy & minimal motor block. It is the $hit!

The downside, esp if your pt has been pre-prepped to expect a pain-free delivery is that the period of ecstacy is not permanent. (ever notice that is always a young, healthy lady with a very low pain threshold who knows a friend, who has a friends whose boyfriend's hairstylist's cousin had a painfree delivery - soup to nuts - and she wants whatever it was that she had?) So, I 'educate' all of them to realize that they will have 60 and MAYBE 90 minutes of total comfort, which is a superb time to nap & prepare for the real work later, and that once that resolves, she will again experience discomfort, but it will be much much better than it was pre-CSE.

I am not being dishonest or misleading, but clearly defining what they should expect. And, to get maximum effect, you have use both the CSE & the education. When I initially switched to using CSE, I had an increased number of calls like, "I was painfree and now I am hurting again..." They never hurt as bad as pre-analgesia, but they loved their honeymoon/painfree period & wanted it back. So, I modified my education to fully disclose what to expect & those calls largely disappeared.

I am telling you dude, it is the way to go!

 

[OldManDave]

10cc of 2% lido? Is that necessary? That's enough for surgical anesthesia. We use 10cc 0.125% bupi then start the infusion at 10cc/hr and seems to work fine. Regarding what jet said, i like cse also, but then you have an unproven catheter if she goes for a long section...it's risky - especially with OB residents; maybe if you're in a private practice job where the attendings are fast.

Several of the Dartmouth staff were anti-CSE for this reason. If you only use 25mcg of Fentanyl & NO LOCAL agents intrathecally, then you retain your testability. You can still use motor & sensory (alcohol swab or ice) because an opiate will not degrade those sensations. If your going to section & testing the epidural & they claim "no pain, but that feels cold", your epidural ain't working or is not adequately loaded.

Opiate-only intrathecal CSEs preserve your classic testing strategies for epidural/SAB for C/S.

 

[rsgillmd]

I don't beleieve in the unproven catheter dogma either. I find that if a CSE cath doesn't work (which is rare), the epidural gets repalced soon after the spinal dose wears off rather than gimping along with a crummey standard catheter and redosiing it/pulling it back, etc.

Arch, thank you. You voiced my thoughts exactly. I've had to replace a catheter only 2 times during my 3 years of residency.

 

[Arch Guillotti]

I don't get those pages.

I tell the pt the first hour will be the strongest and then the epidural will settle into a consistent block. Also, if a nurse calls me for a top-up, I ask her what the block level is. If it's good then I don't bother coming. They now check levels b/4 calling me and only call if the level is falling or not present which means I haven't had a call in a few years as best I can remember.

I can tell you what would happen if I asked the nurse what the level was:

"The what?"
or
"What's a level?"
"Can you just come and check her please?"

I mean I would get calls from them because the epidural pump was beeping and I would ask "What does the alarm say?" This would be met with the reply - "I don't know I haven't been in there I just heard it beeping out at the nurses station!"

 

[epidural man]

BUT LEMME TELL YA, DUDE, CSE FOR LABOR ANALGESIA HAS THE POTENTIAL TO CHANGE YOUR ON-CALL LIFE.

I swear by it.

Hear YE! Hear YE! AMEN. Can I get an AMEN?

First - I would NEVER pull anything out of a bag and put it in the epidural. Call me paranoid, but by strict definition, once you pierce that bag and add meds to it, it's considered contaminated. The longer it's been hanging, the higher the risk. Start with fresh meds EVERY time and it's never a question.

I disagree. I don't think it is a problem, but i could be wrong. I know of a lot of people who do it, but they stick to strick sterile technique (swab the bag part, use sterile gloves, etc.) First of all, the bolus of an epidural is coming from a new bag that hasn't had anything stuck in it except the pharmacist who added the bupivicaine and fentanyl - and I don't think it is contaminated otherwise we would hear of many more peri-partum epidural infections.

This has been studied....Catheters are MORE likely to work...

As for PDPHA....this has been studied also....The headache rate is NO different.

CSE is better in EVERY single way....

Although I admit that I don't do it because I'm lazy.

Again, HEAR YE, HEAR YE. However, be aware that intrathecal opioids will often cause a deceleration on the fetal heart tones that always resolves but a jumpy and scared OB doc can be freaked out by it - they just need some education.

I can tell you what would happen if I asked the nurse what the level was:

"The what?"
or
"What's a level?"
"Can you just come and check her please?"

I mean I would get calls from them because the epidural pump was beeping and I would ask "What does the alarm say?" This would be met with the reply - "I don't know I haven't been in there I just heard it beeping out at the nurses station!"

. You point out well the difference between academic nurses and private practice nurses. PP nurses don't have medical students and residents to do a bunch of crap that they should do, so they get much more comfortable with stuff they should know how to do, like change a freaking epidural bag. How ******ed is that - that nurses won't change an epidural bag?

 

[Noyac]

Several of the Dartmouth staff were anti-CSE for this reason. If you only use 25mcg of Fentanyl & NO LOCAL agents intrathecally, then you retain your testability. You can still use motor & sensory (alcohol swab or ice) because an opiate will not degrade those sensations. If your going to section & testing the epidural & they claim "no pain, but that feels cold", your epidural ain't working or is not adequately loaded.

Opiate-only intrathecal CSEs preserve your classic testing strategies for epidural/SAB for C/S.

Except that when you just give fentanyl the pt will itch like crazy. Add a small amount of local and the itching is lessened or removed. You can still test the catheter easily. You don't get anything like the block you would get with 3cc 1.5% lido in the CSF. You all have seen what 3cc of 1.5% lido does in the CSF right?

 

[Noyac]

I can tell you what would happen if I asked the nurse what the level was:

"The what?"
or
"What's a level?"
"Can you just come and check her please?"

I got those same replies. I told them I wasn't coming in till they gave me a level and that the level they give me had better match what I find if I do come in. If they didn't know how to check then they needed to find someone that did. I can do this in PP b/c I don't have all the BS to deal with that some of you have in academics. I also informed the OB providers that I required this and they totally agreed with me. Plus I am not in house when on call and if they want epidurals for their pts then the nurses need to know how to evaluate them. Life is better in PP for many reasons.

 

[Noyac]

Again, HEAR YE, HEAR YE. However, be aware that intrathecal opioids will often cause a deceleration on the fetal heart tones that always resolves but a jumpy and scared OB doc can be freaked out by it - they just need some education.

I was going to add that to my previous post but I read yours b/4 adding. You are absolutely right. The straight narc's cause more fetal brady than the combined narc/local, IMHbuteducatedO.

A classmate of mine in residency did the study but it wasn't published for some reason (therefore, it means nothing here) but we looked at the data and the straight narc CSE's had significantly more fetal brady. All resolved without incident however.

 

[OldManDave]

Except that when you just give fentanyl the pt will itch like crazy. Add a small amount of local and the itching is lessened or removed. You can still test the catheter easily. You don't get anything like the block you would get with 3cc 1.5% lido in the CSF. You all have seen what 3cc of 1.5% lido does in the CSF right?

Thanks for the advice Noyac, I will have to give your suggestion a try. Usually, I just leave them a PRN benedryl order for the itch.

 

[Monty Python]

they get much more comfortable with stuff they should know how to do, like change a freaking epidural bag. How ******ed is that - that nurses won't change an epidural bag?

In some states it's an unintended consequence and/or misinterpretation of the specific wording in the nurse practice act. In my state, it's against the law for non-CRNA RNs to have anything to do with a local anesthetic except for a few specific instances. Some Directors of Nursing have interpreted this as prohibiting an RN from changing a bag attached to a pain control catheter if the bag contains a local anesthetic.

Section 930, para D http://www.lsbn.state.la.us/documents/npa/npafull.pdf





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