Monitoring for epidurals

[ssmallz]

In residencey it was standard for nurses to put on NIBP and cycle them Q5 as well as pulse oxs while we do epidurals. In PP, I've noticed a lot of nurses don't do this and a lot of the time pulse ox's aren't even in the room. When asked why this is, the response was "A lot of the guys don't use them and they just use the BP and pt symptoms for test dose".

So my question is to the PP guys out there. What kind of monitoring is standard at your practice? If you don't use a pulse ox, what to do you for test dose? Do you ever call for a pulse ox if you are unsure about the test dose? According to the ASA guidelines, we should be utilizing live pulse ox as well as Q5 min BP. It takes 5 seconds to do and doesn't hurt so I can't figure out why it's not done on everyone. Seems like just laziness to me but I'm hoping some of the others on this board can enlighten me

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[Mman]

I require a pulse ox with audible tone and NIBP cycling. Many other members of my group do not use the pulse ox. But that's irrelevant to me. The nurses know that without the pulse ox, I'm not doing the epidural. In my eyes, it's safer for detecting IV injection of the test dose.

 

[rsgillmd]

At my current institution we use a 3-lead EKG to get the heart rate. This was in place before I got here and wasn't worth changing.

Where I trained for residency we used a pulse ox for heart rate.

Even when a pulse ox is attached to a patient, you can't see the waveform on the L&D monitor, so you can't tell if a number is real or not when it seems strange.

Don't forget to wait the full 30 seconds. I've seen some delayed increases in heart rate/onset of symptoms around the early to mid-20 second mark.

 

[rsgillmd]

In residencey it was standard for nurses to put on NIBP and cycle them Q5 as well as pulse oxs while we do epidurals. In PP, I've noticed a lot of nurses don't do this and a lot of the time pulse ox's aren't even in the room. When asked why this is, the response was "A lot of the guys don't use them and they just use the BP and pt symptoms for test dose".

So my question is to the PP guys out there. What kind of monitoring is standard at your practice? If you don't use a pulse ox, what to do you for test dose? Do you ever call for a pulse ox if you are unsure about the test dose? According to the ASA guidelines, we should be utilizing live pulse ox as well as Q5 min BP. It takes 5 seconds to do and doesn't hurt so I can't figure out why it's not done on everyone. Seems like just laziness to me but I'm hoping some of the others on this board can enlighten me

Which ASA guidelines are you looking at? No mention in the OB Anesthesia guidelines. Basic anesthesia monitoring guidelines specifically say they are not meant for the obstetrical patient in labor.

 

[PedsAnesMD]

I always use q2 minute NIBP monitoring (for first 10 minutes, then q5-15 minutes)and pulse oximetry(for test dose monitoring) during my labor epidural placements. I order the labor nurses to do this if they aren't doing it. Better safe than sorry.

 

[ssmallz]

Which ASA guidelines are you looking at? No mention in the OB Anesthesia guidelines. Basic anesthesia monitoring guidelines specifically say they are not meant for the obstetrical patient in labor.

I couldn't find any specifically for obstetric pt so I was referring to the basic monitoring ones. I can only assume that those would be the minimum requirements and anything specifically written for OB would have to be more strict than those or delve into details about fetal heart monitoring

 

[rsgillmd]

I couldn't find any specifically for obstetric pt so I was referring to the basic monitoring ones. I can only assume that those would be the minimum requirements and anything specifically written for OB would have to be more strict than those or delve into details about fetal heart monitoring

I figured as much. Just wanted to make sure I hadn't missed any recent changes.

FHR is discussed on page 845 in the "Practice Guidelines for Obstetric Anesthesia" PDF file downloaded from ASA. I cut and pasted it below:

Recommendations. The fetal heart rate should be monitored by a qualified individual before and after administration of neuraxial analgesia for labor. The Task Force recognizes that continuous electronic recording of the fetal heart rate may not be necessary in every clinical setting and may not be possible during initiation of neuraxial anesthesia.

Regarding test doses, I think any anesthesiologist you talk to would agree that there needs to be monitoring of the heart rate. I don't think you will find a consensus on pulse ox vs EKG. I personally don't think it matters, as long as you use something objective (I wouldn't trust a finger on the pulse to be able to reliably detect a change).

The catheters we use in my current institution tend to go intravascular 1-2% of the time. So I changed my practice from residency (rarely did a test dose -- just did a CSE and started the infusion) to always doing a test dose. I just make sure to do it in between contractions, or on the descent of a contraction if the heart rate is stable. In my experience, while patients do generally complains of dizziness or tinnitus or feeling of increased heart rate, this is not always the case. So long story short, to not use an objective heart rate monitor, in my opinion, is just laziness. I would not settle for it.

If they mention your colleagues, explain to them that at this point you are taking care of the patient and not your colleagues.

"But Dr. So and So does/doesn't do this" is a pretty common nursing excuse when you breach their routine. But I don't want to derail the thread, so I won't discuss that further.

 

[ssmallz]

I figured as much. Just wanted to make sure I hadn't missed any recent changes.

FHR is discussed on page 845 in the "Practice Guidelines for Obstetric Anesthesia" PDF file downloaded from ASA. I cut and pasted it below:

Recommendations. The fetal heart rate should be monitored by a qualified individual before and after administration of neuraxial analgesia for labor. The Task Force recognizes that continuous electronic recording of the fetal heart rate may not be necessary in every clinical setting and may not be possible during initiation of neuraxial anesthesia.

Regarding test doses, I think any anesthesiologist you talk to would agree that there needs to be monitoring of the heart rate. I don't think you will find a consensus on pulse ox vs EKG. I personally don't think it matters, as long as you use something objective (I wouldn't trust a finger on the pulse to be able to reliably detect a change).

The catheters we use in my current institution tend to go intravascular 1-2% of the time. So I changed my practice from residency (rarely did a test dose -- just did a CSE and started the infusion) to always doing a test dose. I just make sure to do it in between contractions, or on the descent of a contraction if the heart rate is stable. In my experience, while patients do generally complains of dizziness or tinnitus or feeling of increased heart rate, this is not always the case. So long story short, to not use an objective heart rate monitor, in my opinion, is just laziness. I would not settle for it.

If they mention your colleagues, explain to them that at this point you are taking care of the patient and not your colleagues.

"But Dr. So and So does/doesn't do this" is a pretty common nursing excuse when you breach their routine. But I don't want to derail the thread, so I won't discuss that further.

You didn't derail the thread at all, that was exactly what I wanted to know. Being new to private practice when you're fresh outta residency is tough. I wanna go with the flow but I gotta put pt safety first. The first hospital I went to, the nurse would routinely not have any monitors on the pt. I would get ready to ask for the heart rate and they would give me one that was 10 minutes old. 😱 I'd have to look over the pts shoulder only to find no pulse ox on. I would then ask for one and watch the nurse frantically look one and then tell me "I can't find it, lets just go ahead with out it, I'll just feel the pulse w/my fingers" 👎 Eventually, she would call another nurse who would bring the a pulse ox and a test dose would be given. When talking to these nurses and explaining how it was done in residencey I'd get responses like "Boy they really spoiled you guys in residencey"😕

I didn't think anything of it until I went to a 2nd hospital where the same thing happened. No pulse ox, no EKG no nothing. It's so frustrating so thats why I posted the thread. I wanted to see what the other PP attendings out there were doing. I agree that EKG can be substituted for pulse ox b/c all you're really looking for is change in HR but I feel like it's just laziness on the part of the nursing staff not use either one. The worst part is that when you bring this up to the nurses they look at you like you're making them do an unreasonable amount of work and you should just go with the flow. Hosptial politics are fun😡