OB epidural and WBC

[Planktonmd]

Let's see what everyone thinks on this one:
Assuming no other symptoms,
Would elevated white count make you hesitate to do an epidural in OB?
What if the white count was 20,000?
What if it was 30,000?
Is there a magic number?
What if there was, let's say, 85% Neutrophils and 10 % bands?
How about increased white count and ruptured membranes for 6 hours?

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[jetproppilot]

Let's see what everyone thinks on this one:
Assuming no other symptoms,
Would elevated white count make you hesitate to do an epidural in OB?
What if the white count was 20,000?
What if it was 30,000?
Is there a magic number?
What if there was, let's say, 85% Neutrophils and 10 % bands?
How about increased white count and ruptured membranes for 6 hours?

The incidence of septicemia in the patient population you are inferring to (chorioamniitis) is exceedingly low.

I'd probably put it in, but the 85% neutrophil thing has me thinking.....

 

[VentdependenT]

Let's see what everyone thinks on this one:
Assuming no other symptoms,
Would elevated white count make you hesitate to do an epidural in OB?
What if the white count was 20,000?
What if it was 30,000?
Is there a magic number?
What if there was, let's say, 85% Neutrophils and 10 % bands?
How about increased white count and ruptured membranes for 6 hours?

I would definitely hesitate but assuming no signs of impending SIRS/Septicemia/DIC and coags/cbc lookin ok I would most likely go for it....if it wasn't trending upwards and upwards.

Bandemia suggests something's going on. But what. Where?

I'm sure I stepped into some sort of tibia shattering hole here.

 

[Noyac]

Most likely i wouldn't really be concerned. But the OB provider would be one thing I would pay attention to. If it were a midwife, no way. Family pracitce, well it depends on the skills of said FP. Obstetritian the same.

The bands would make me search for a reason, however.

On a side note, I did cancel an epidural in a labor pt with a tooth abscess and not treated with antibx. She had fevers and chills with an elevated WBC count. Not a big deal except that she was the pt of a new midwife.

 

[coprolalia]

What's the concern here? Does she have some raging abscess below the insertion point?

And, didn't we cover this topic already?

http://forums.studentdoctor.net/showthread.php?t=297015

-copro

 

[Planktonmd]

What's the concern here? Does she have some raging abscess below the insertion point?

And, didn't we cover this topic already?

http://forums.studentdoctor.net/showthread.php?t=297015

-copro

So you obviously have a clear plan when it comes to these situations and I assume the plan is: just put the epidural in regardless of the white count or the differential even if the patient is not on antibiotics.
And any white count is acceptable isn't it?
Maybe she doesn't have a raging abscess but what if she has a raging [SIZE=-1]Chorioamnionitis?[/SIZE]does it matter if there is 85% neutrophils and 10 % bands?
I don't know the answers but obviously you do.

 

[coprolalia]

So you obviously have a clear plan when it comes to these situations and I assume the plan is: just put the epidural in regardless of the white count or the differential even if the patient is not on antibiotics.

No, I'd assess the patient for obvious signs of infection in the area. If no infection, then proceed. I don't think there's any strong evidence that an epidural provides a nidus for seeding provided you carefully prep and drape the insertion area.

And any white count is acceptable isn't it?

Well, is she in blast crises? I don't see how a white count, in and of itself, precludes one from inserting an epidural. Am I missing something? Please educate me.

Maybe she doesn't have a raging abscess but what if she has a raging [SIZE=-1]Chorioamnionitis?[/SIZE]does it matter if there is 85% neutrophils and 10 % bands?
I don't know the answers but obviously you do.

Chorioamniotis will be treated with antibiotics by the primary service. This does not preclude you from putting in an epidural, and nowhere in the literature will you find otherwise.

-copro

 

[Planktonmd]

No, I'd assess the patient for obvious signs of infection in the area. If no infection, then proceed. I don't think there's any strong evidence that an epidural provides a nidus for seeding provided you carefully prep and drape the insertion area.



Well, is she in blast crises? I don't see how a white count, in and of itself, precludes one from inserting an epidural. Am I missing something? Please educate me.



Chorioamniotis will be treated with antibiotics by the primary service. This does not preclude you from putting in an epidural, and nowhere in the literature will you find otherwise.

-copro

I am glad that you already have answers for all the questions so early in your career because I am still not there yet, although I have been in practice for a few years.

I am trying to get opinions from clinicians on how they approach this issue and not a recital of what the literature does or does not contain.
An increase in white count with bandemia could well mean systemic infection even in the abscence of other symptoms so the question is:
Should we ignore such a finding and place an indwelling foreign body in the epidural space regardless of how high the numbers are?
Is every Chorioamnionitis discovered and reated by OB's before we are consulted to do an epidural?

 

[coprolalia]

I am glad that you already have answers for all the questions so early in your career because I am still not there yet, although I have been in practice for a few years.

I am trying to get opinions from clinicians on how they approach this issue and not a recital of what the literature does or does not contain.
An increase in white count with bandemia could well mean systemic infection even in the abscence of other symptoms so the question is:
Should we ignore such a finding and place an indwelling foreign body in the epidural space regardless of how high the numbers are?
Is every Chorioamnionitis discovered and reated by OB's before we are consulted to do an epidural?

All I'm asking is show me the evidence that it does harm. If you can't, it's like worrying about a meteor falling from the sky and hitting you on the head.

-copro

 

[jetproppilot]

All I'm asking is show me the evidence that it does harm. If you can't, it's like worrying about a meteor falling from the sky and hitting you on the head.

-copro

I've been in this gig eleven years, Cop, and I still enjoy reading clinical posts, even if we've talked about it before.

Rarely is there a black and white answer, as evident by the posts by anesthesia-studs Noy and Venty.

I practice my trade not-conservatively by any stretch of the imagination.

And Plank's thread, as I said, has me thinking.

Thats partly why I pull up a chair in here.

To read, interact, think, and learn.

Aint gonna happen if dudes dont post threads like this.

 

[Planktonmd]

All I'm asking is show me the evidence that it does harm. If you can't, it's like worrying about a meteor falling from the sky and hitting you on the head.

-copro

Again,
I am not implying that you should or should not do the epidural, I am trying to get input from practicing clinicians on how they approach the situation of a parturient with increased WBC with bandemia and if there is a point where anyone feels uncomfortable doing the procedure.
So, I know that you feel very strongly about doing epidurals regardless of the WBC, but maybe not everyone agrees with you, and those other opinions might have some value as well.

 

[Intrathecal]

What's everyone's opinion on placing a labor epidural in someone who is HIV+? I've had people tell me that it is a contraindication to place an epidural in anyone who has HIV or a MRSA infection.

I guess in the case of the HIV patient, theoretically you could get blood with the virus into the epidural space and in turn cause seeding the virus in the CNS. But I read an article that says it has been done with no ill effects.

 

[Tenesma]

if in doubt do a general anesthetic.... or if the baby is going to be vaginal give them a remi-fentanyl PCA

 

[Noyac]

What's everyone's opinion on placing a labor epidural in someone who is HIV+? I've had people tell me that it is a contraindication to place an epidural in anyone who has HIV or a MRSA infection.

I guess in the case of the HIV patient, theoretically you could get blood with the virus into the epidural space and in turn cause seeding the virus in the CNS. But I read an article that says it has been done with no ill effects.

HIV virus is present in the CNS from the start of the infection. Therefore, no risk, proceed with epidural.

 

[Dinkyconductor]

HIV virus is present in the CNS from the start of the infection. Therefore, no risk, proceed with epidural.

Exactly. HIV is never a contraindication to an epidural. New onset herpes, though, is a contraindication.

 

[VentdependenT]

Exactly. HIV is never a contraindication to an epidural. New onset herpes, though, is a contraindication.

Genital herpes?

Lame I know. I don't know why I couldn't resist.