Statistically the incidence of PDPH with CSE is similar to just epidural, or somewhere around 1%. But count me in the category that says if I never poke a hole in your dura you can't get a headache whereas if I do even with a small needle you might.
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Statistically the incidence of PDPH with CSE is similar to just epidural, or somewhere around 1%. But count me in the category that says if I never poke a hole in your dura you can't get a headache whereas if I do even with a small needle you might.
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I think that's the opposite of the case. What about fetal bradycardia after cse? I've seen a few stat c-sections after cse placements.
"I did it this way in the past when I had a crna in house to manage the epidural. Now I place them and go home, so I just do CSE's since I think they are safer for me to leave right after placement. How much trouble can one get into with 1cc of marcaince and 20mcg of fentanyl?"
"I did it this way in the past when I had a crna in house to manage the epidural. Now I place them and go home, so I just do CSE's since I think they are safer for me to leave right after placement. How much trouble can one get into with 1cc of marcaince and 20mcg of fentanyl?"
D
deleted162650
Just curious, at what depth you got your wet tap compared to the depth at which you presumably found the epidural space on your first 2 attempts? Also, were you using a stiff cath or a soft spring wound cath? In my experience the rate of intravascular caths with the soft spring wound variety approaches 0%.
Also, from what you describe with your frequent checking of LOR, I assume you mean you are advancing the needle then checking LOR, then advancing, then checking, etc. (intermittent technique). IMO this is a poor technique. The continuous pressure LOR technique is superior as you are continuously assessing for LOR and can more easily detect slight differences in resistance and can stop as soon as you lose resistance.
Tip: If you are clearly in the epidural space, but the the catheter doesn't want to thread, push upward (cephalad) on the shaft of the Tuohy as you are threading the cath. This tips the tip of the Tuohy down ever so slightly and creates a little pocket for the cath to slide into. I just recently learned this one, and it works so well I can't believe I was never taught this before. In fact, I now just do this empirically on every epidural and the cath slides in like buttah every time (and that's after CSE w/o dilating the space up with fluid first).
D
deleted162650
Fetal brady is something I see occasionally but it's pretty much always self limited and resolves fairly rapidly. It's generally in the women that are super super uncomfortable and get great relief right away with the CSE. Often times it's due to a tetanic uterine contraction which is easily treatable with a shot of sublingual NTG (feel mom's belly and it if feels like a rock then you know what to do). If they proceed to section I guarantee it's because baby was already tenuous and they were headed that way regardless (CSE may just expedite things and eliminate the hours of hemming and hawing resulting in a 2am C/S). Trust me, if I was repeatedly having to take pts back for urgent/emergent C/S after CSE there's no way I would continue to do them.
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Disagree. Even with performing straight epidural placement, you may get an occult dural rent that requires blood patch.
You disagree with me stating that the 2 procedures have statistically similar rates of PDPH? PDPH can happen with just an epidural. But if I never poke any hole in the dura it can't leak out. I understand that sometimes you have an unrecognized wet tap, but that odds of that are likely identical to CSE since you both stop moving the Tuohy needle at the same point.
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There was a time when I remember this happening on rare occasions. I think there was/is a trend towards less or no bolus before placement in current academic centers. Maybe someone in one of these facilities can address this. But as long as a decent bolus is in just prior to the CSE I haven't seen fetal Bradycardia very often and if it does occur ephedrine seems to work real well.
In my training we did a study that never got published. It looked at 3 different CSE doses:
1) 2.5mg bupiv with 20mcg fent
2) 2.5 mg bupiv
3) 20mcg fent
The results showed that the mixture had the least SE's. The straight fent pts puked and had more pruritis. The straight local pts had fetal bradycardia more. And the combo had less of both. I have no good explanation but we can all speculate. I also do not know if the study would have met statistical significance. Just food for thought.
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In my 10+yrs of doing Cse's, I've never had a PDPH from one. And I don't recall any of my partners that do them having one either.
Disagree that intermittent is poor technique. My N > 3000 (but im sure not as many as some others) due to pain fellowship/brief stint doing pain under fluoro. I prefer continuous when the patient is prone (just seems natural), but intermittent when pt sitting due to my hands just being more comfortable, and I have certainly tried both. I can feel when I enter/pop into the space before i push the syringe of saline into it. I can feel when I enter the ligament before I feel the rock hard syringe most of the time. To each there own. I feel that intermittent allows you to advance under more control and less likely of false loss of "wow the syringe just emptied but it felt wierd am I in? " With intermittent you feel every step of the way. And if you do it right your bites are very small especially as you approach the target, which I feel reduces changes of wet tap.
And I was just throwing something out there on my previous post, could have been anything...
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Regarding fetal bradycardia after a CSE -
In my practice it's a really rare occurrence. I use 1/2 mL of .25% bupiv plus 1/2 mL of fentanyl, for a total of 1 mL that's 1.25 mg of bupiv and 25 mcg of fentanyl.
For a while I tried 1-2 mL of our .125% bupiv + 2 mcg/mL fent infusion mix but it wasn't as effective. The money's in the narc.
The mechanism of the decel certainly isn't maternal hypotension. Rather, it's likely the abruptness of pain relief that reduces circulating catecholamines, particularly epi, and the abrupt decrease in beta agonist activity causes increased uterine tone. A hit of NTG is all they really need. I can't remember the last time I needed to give it though.
In my practice it's a really rare occurrence. I use 1/2 mL of .25% bupiv plus 1/2 mL of fentanyl, for a total of 1 mL that's 1.25 mg of bupiv and 25 mcg of fentanyl.
For a while I tried 1-2 mL of our .125% bupiv + 2 mcg/mL fent infusion mix but it wasn't as effective. The money's in the narc.
The mechanism of the decel certainly isn't maternal hypotension. Rather, it's likely the abruptness of pain relief that reduces circulating catecholamines, particularly epi, and the abrupt decrease in beta agonist activity causes increased uterine tone. A hit of NTG is all they really need. I can't remember the last time I needed to give it though.
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Yes exactly. What he said.
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Blade what does a dural rent feel like? Im a continuous pressure guy and its eaither loss or no loss of resistance.
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Even with continuous pressure It is possible to slightly nick the dura or a partial nick. The tuohy needle itself may not have penetrated the dura but upon threading the catheter it goes intrathecal.
One of the clues to a Dural rent or partial nick is the presence of more fluid back through the needle than usual (if you use saline in your syringe). Unlike an actual Dural puncture you may only notice a few mls of fluid that appears to drip drip from the needle. Sometimes the fluid even stops dripping after a few seconds. Of course, some on SDN will claim that the drip drip is just the saline coming back out due to the increased pressure in the space; from my experience this may not be the case but instead a partial nick or Dural rent so I proceed more cautiously.
For those that just use air the presence of any fluid is clearly a sign that the dura has been hit at least partially. I've seen at least a half dozen epidurals where the needle was negative for CSF (no fluid) but the catheter was intrathecal. If you are going to bolus through the needle a heightened awareness of the risk of such a bolus includes injecting partially into the CSF and potentially an intravenous injection.
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I understand this but have yet to actually see any "solid" supporting data to describe this situation. It never ceases to amaze me what some people can do with a needle and a catheter.
D
deleted162650
A stiff Braun style cath can go through "scored" dura. A soft spring wound cath will not go through "scored" dura. There is a paper out there on this.
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My experience correlates 100% with what Blade describes.
And sheer statistics dictate that cannot be true unless you just don't do many. With a single poke from a 27 g needle (with somebody with 10-30 years experience doing it) we see them back with a PDPH about 0.5% of the time. Not all need blood patches, but occasionally. It happens. A hole in the dura occasionally causes a PDPH and there is no way to prevent that.
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The CRNAs where I work place labor epidurals. I don't dirty my hands with such a menial task.
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Started my CSE sample set yesterday...8 cm dilation, multip, had just arrived, intact membranes. 2.5 mg bupiv intrathecal. Pt said "you're a life-saver" before I had her taped. I did a lot of CSEs in residency, but got away from it from the "dural puncture" standpoint, but the data doesn't convince me that I'm increasing my PDPH risk, so I'll try again. As far as OP questions...no pretreatment (too much nausea from the bicitra), no preference to timing of epidural, epidural infusion 0.1 Bupiv/2 mcg/mL fent at 14/5/20. Plts 80k or more unless trending precipitously.
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Started my cse set. G1p0 38 weeks 6cm in 10/10 pain squirming jumping around bed. Place cse with 1 ml 0.5% bupi. Actualky placed spinal from spinal kit vs cse thouy. Place cle I will be john brown in 20 minutes surgeon calls to take patient back for csection pt normotensive increased late decels in baby. interesting enough get go the or and try to bolus epidural too high pressures in syringe. Replace epidural and bolused 10ml lido and she did fine.
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5 mg of bupiv is a lot for a labor intrathecal dose. I use 1.25 mg (1/2 a mL of .25%) plus some fentanyl. And I think the money is in the fentanyl.
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Have you ever seen someone localize with the whitacre introducer needle? I saw that a few days ago pt nearly jumped off the table, saved a few minutes but I would much rather be localized with the 25 gauge localization needle. It looked slick but too rough for me. Pgg would you have redone the spinal for the c/s and what dose or would you replace the cle and bolus up?
D
deleted162650
Yeah, that seems a little rough. I'll just take the extra 3 secs and improve the pt's experience a little. One of the old timers that just retired from our local high volume women's center would just go paramedian with the 25g Whitacre - no introducer and no local. When he got it first pass (85% of the time) it didn't appear any more painful than a local wheal. I felt a little bad for the pts that required a 2nd or 3rd pass though.
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hey a few questions (I think this has been discussed last in 2011 but wanted to see if any new data/reviews are out there)
regarding intrathecal fent for cesarean...
1. if using 13.5 mg .75% bupy + duramorph .2mg for spinal, does fent improve analgesia? (specifically visceral component), some people on prior forums have said they omit the fent if using >12.5 mg bupy
2. if you give fent, what is optimal dose with minimal SE's? (chestnut -"other investigators have observed that spinal fentanyl in doses as low as 6.25ug improves quality and duration of cesarean delivery anesthesia" , the reference is from 1990's)
3. how does addition of fentanyl effect onset of adequate analgesia and duration of analgesia for cesarean? I've read different things, including one test question that claimed it speeds onset, but does not change duration
regarding intrathecal morphine for cesarean...
1. is .1 mg better than .2mg? we are using .2mg ...chestnut - "A spinal morphine dose of .1mg was found to be optimal, producing post cesarean delivery analgesia comparable to that provided by doses as high as .5mg, but with less severe pruritis"...why is my place using .2mg?
regarding intrathecal fent for cesarean...
1. if using 13.5 mg .75% bupy + duramorph .2mg for spinal, does fent improve analgesia? (specifically visceral component), some people on prior forums have said they omit the fent if using >12.5 mg bupy
2. if you give fent, what is optimal dose with minimal SE's? (chestnut -"other investigators have observed that spinal fentanyl in doses as low as 6.25ug improves quality and duration of cesarean delivery anesthesia" , the reference is from 1990's)
3. how does addition of fentanyl effect onset of adequate analgesia and duration of analgesia for cesarean? I've read different things, including one test question that claimed it speeds onset, but does not change duration
regarding intrathecal morphine for cesarean...
1. is .1 mg better than .2mg? we are using .2mg ...chestnut - "A spinal morphine dose of .1mg was found to be optimal, producing post cesarean delivery analgesia comparable to that provided by doses as high as .5mg, but with less severe pruritis"...why is my place using .2mg?
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I did my PI project for MOCA a few years ago comparing 0.1 to 0.2 mg, and found 0.2 to offer better pain relief without more side effects. Caveats:
- N was small, only 20 in each group
- the 0.2 group also got fentanyl
- the 0.2 group was a retrospective chart review; the 0.1 group was prospective
http://forums.studentdoctor.net/thr...erformance-assessment-and-improvement.901829/
These days my practice is to let the residents do whatever they want, but I make the case for 15 mcg fentanyl + 0.2 mg morphine in spinals with 1.6 mL or less of the 0.75% heavy bupivacaine, skip the fentanyl for higher doses. We do a lot of 2 mL spinals because, well, academics. Where the fentanyl shines is in letting you cheat with lower doses of bupivacaine when you have fast surgeons and want to minimize PACU time.
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The rate is 2-4% with modern, 24-27g, noncutting needles. How can you claim this?
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This is an interesting subject, too.
Most studies that attempt to measure the incidence of PDPH with 25-27 g needles report rates in the 3% range. I believe their data, but I have to admit I don't take it seriously for two reasons.
1) Studies are done at academic institutions, where most of the procedures are done by inexperienced people - residents and SRNAs. Beginners have more needle passes, and probably more unrecognized punctures. In short, any needle is substantially more traumatic in the hands of a CA-1 than an attending.
2) Not all PDPHs are created equal. We deliver something around 4,000 babies a year at this academic hospital and we get our share of wet taps. I would say that the majority of wet taps with 17 g Tuohy needles come back for treatment of PDPHs. Women who get spinals for labor or c-section just aren't coming back with headaches. Are they having them? Probably, at a rate of 2% or so, but apparently they're not as bad as the 17 g holes. We also get called for PDPHS for LPs done in the ER with 22 g cutting needles a few times per month, and those patients are often nearly as miserable as the postpartum women. This tells me that
- a PDPH from a 17 g Tuohy is a predictable event and the patients let us know about it
- a PDPH from a 22 g cutting needle happens sometimes and the patients let us know about it
- but PDPHs from 25 g pencil point needles only seem to be noticed when researchers doing studies go looking for them
I guess what I'm saying is, I'll start caring about PDPHs from my 25 g pencil-point spinals when the patients do.
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I use 200mcg duramorph and 20mcg fentanyl with the hyperbaric bupi spinal kit for my c/s spinals. Rarely get itching, but great postop control. Most don't use pca that's routinely provided by the OBs until 16-24h later.
Most of my attending do it this way or are ok with me doing it this way.
Most of my attending do it this way or are ok with me doing it this way.
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Are there complaints after ortho cases? We use the same spinal kits, so that's why I ask. I've seen PDPH of course with a 17g tuohy but never from the 24-25g needle. Even with cses.
D
deleted162650
The typical ortho pt is much lower risk for PDPH than the typical OB pt based on age alone. It's fairly uncommon for a 22g cutter to cause a PDPH in the 60+ crowd. With the ortho pts I'm surprised I don't get a puff of dust back instead of CSF half the time.
If a woman has a vaginal delivery, she probably goes home on post delivery day 1. So if she gets a PDPH from the spinal portion of a CSE it probably doesn't really present until she is at home. And the overwhelming majority of people aren't going to tell their doctor if they have a headache at home and they certainly aren't going to seek treatment unless it persists for a long time and is completely debilitating them.
The headache from a 17 or 18 g needle puncture presents sooner and so is more likely to get treated in the hospital.
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Diagnostic LPs go home a couple hours after they get their 22 g dural punctures in the ED. They come back with their headaches. Why wouldn't SVD'ers who got 25 g spinals come back with theirs, if they were getting them?
SVD'ers who got 17 g wet taps with their labor epidurals sometimes go home a day later. They come back with their headaches.
The 17 and 22 g dural taps seem to produce those debilitating headaches that prompt people to get treated. The 25 g ones don't. Of all the blood patches I've ever done, I'm hard pressed to remember even ONE that was from a 25 g needle. It's always LPs from the ED or Tuohy slips from OB. Always. This is why I don't worry about PDPHs from my labor CSEs.
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I guess we do a fair amount of knees for obesity wear/tear in the 40s/50s age range. Plus the increasing BMI the mamas seem to have at the tertiary center. Still don't see it. Was just curious.
D
deleted162650
I'll also add that I've never seen a PDPH from 24-27g for a C/S. These pts are all in house for 3-4 days and I'm sure we'd be hearing about it if it was happening with any degree of regularity. You can argue all you want based on theoretical grounds but the reality of the situation is that the increased risk of PDPH from a CSE is so ridiculously small it's just not worth worrying about.
In what world are your c-section patients in house for 3-4 days? They should all be out the door the morning of POD #2. And I'll say if you've never seen one, you haven't seen enough. They happen.
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Those of you that claim to 2-4% HA rate need to look at the technique emplyed by those with this high of a rate.
I have thousands of CSE's and don't recall one PDPH. And if my partners cases are added to that since we frequently get to take care of others mishaps, I have many thousands of cases to pull from.
I have thousands of CSE's and don't recall one PDPH. And if my partners cases are added to that since we frequently get to take care of others mishaps, I have many thousands of cases to pull from.
D
deleted162650
In my neck of the woods C/S's stay until POD#3 (and sometimes #4 if there was anything out of the ordinary with mom or baby) - this is true at more than 1 hospital out here so maybe it's a regional thing? Anyways, we are not fielding calls for HA's on these pts so while I'll agree that the incidence is not zero, it's pretty damn close (and way to close for me to not perform CSE's).
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Just wanted to say that as a CA-1, these sorts of posts keep me coming back (despite all the doom-and-gloom) - it's a great learning experience to hear how different attendings do things. Thank you guys (and gals) for taking the time to post and share knowledge with those of us youngsters.
I'm starting OB in January, so I look forward to being one of those "traumatic" CA-1s with a needle (I've certainly struggled with my mid-thoracics so far).
I'm starting OB in January, so I look forward to being one of those "traumatic" CA-1s with a needle (I've certainly struggled with my mid-thoracics so far).
D
deleted162650
Lumbar epidurals are an order of maganitude easier than thoracics. I think a thoracic epidural is probably the most technically difficult procedure we do.
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Mid-thoracic ones can be a challenge for sure.
Low thoracic ones (T10-12) are often easier than lumbars in obese people, and are useful for labor analgesia.
overnight OB hot take: do morbidly obese patients hurt a lot less when you place their labor epidural? After doing yet another labor epidural on a patient with a BMI of 65 it occurred to me that she didn't make one peep the entire time and that almost always seems to be the case in my experience. Do they just have much lower density of nerve fibers than tiny little skinny patients (is it a fixed number of nerve fibers spread over a larger volume/surface area)?
As much as I am no fan of needing the 6 inch needle, those patients almost never flinch the entire time I'm back there. Entirely subjective of course, but piqued my curiousity.
As much as I am no fan of needing the 6 inch needle, those patients almost never flinch the entire time I'm back there. Entirely subjective of course, but piqued my curiousity.
D
deleted162650
I have noticed that and totally agree with your observation. I've also thought the same thing about nerve fiber density. Sounds good. Let's go with that.
Our c section moms also stay 3 nights. My wife was given the option to stay a fourth night with our second, and she had no complications, the nurse told me they offer it to all c section moms. I wonder why there's not a more concrete standard for this, interesting.
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Ah, the mythical plica mediana dorsals.
I rarely have issues with my labor epidurals not working well for a c-section anymore. I don't thread the catheter in further than 4 cm unless there is a concern for a lot of back fat shearing forces. Anecdotally, I have found from having to replace labor epidurals or converting to general anesthesia in a c-section that if the catheter is threaded in >5 cm it tends to not produce a satisfactory block. I imagine it's because the wire-reinforced catheter veers off to one side or the other.
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I've had enough BMI 35-50 patients who are essentially hyperalgesic to disagree with your observation. Many also seem to have no concept of how difficult an epidural on them can be. "OWWWWW Oh my god, is it over yet? IS IT GONNA WORK? HONEY IS IT GONNA WORK???!!!!"
35-50? I call those normal patients, as in those are the ones I'm comparing to. I'm talking fat ones. BMI 60, 70, 80, etc. If your BMI is 35 and you are getting a labor epidural you are amongst the skinnier patients I will take care of that day.
