Ob epidural assessments

[coffeebythelake]

It's been a while, guys... but I might be getting back to doing some L&D and OB..

Can I get a rundown of doing an OB epidural assessment? When I get called to "top off" the epidural? What kind of dose are we using? Anything u do different if the patient c/o mostly rectal pressure and 10 cm dilated?

First step is to assess if problem is Density vs. Spread...

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[GassYous]

It's been a while, guys... but I might be getting back to doing some L&D and OB..

I'm sorry to hear that.

 

[LivetoTell]

It's been a while, guys... but I might be getting back to doing some L&D and OB..

Can I get a rundown of doing an OB epidural assessment? When I get called to "top off" the epidural? What kind of dose are we using? Anything u do different if the patient c/o mostly rectal pressure and 10 cm dilated?

First step is to assess if problem is Density vs. Spread...

I try to emphasize the use of the PCA button. I tell the RN to push it three times, if that still doesn’t work, call me back. If I have to “top off” I prefer to use Rop 0.5% because it will last longer, and possibly spare you from getting up again in the middle of the night. So, Rop 0.5% 7cc’s + 5cc’s of sterile saline. Plus or minus 4ucg of Precedex. ACCRAC had a good podcast very recently on using dex for neuraxial.

If there dilated 9-10, and it’s sacral pain, I do the same, but semi sit them up while bolusing. All the while emphasizing, the epidural will not get rid of pressure.

 

[Toothpickwars]

This is an excellent resource:

https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/50a.%20OBAnes%20Pocket%20Guide%20v2023.5%2005-12-23.PDF.pdf

 

[kb1900]

Fent and .125% bupi for a top off. 12cc total volume.

I wish we had ropi and more aggressive top offs.

For lac repairs I like chloroprocaine 2-3%

For the record I’m a resident.

 

[coffeebythelake]

The pcea is 0.125% bupi with sole fentanyl.

How about Lido 2% for more density followed with 0.25% bupi?

 

[Lecithin5]

Generalities/averages: spread issue/hot spot/one sidedness I usually give 10cc off the pump. Density issue I’ll give 5cc of quarter percent bupi +- 100mcg fent. Can even consider 2 percent lido.

Obviously lots of variables and factors affect the above, such as blood pressures, pt’s weight/height, etc.

 

[coffeebythelake]

Generalities/averages: spread issue/hot spot/one sidedness I usually give 10cc off the pump. Density issue I’ll give 5cc of quarter percent bupi +- 100mcg fent. Can even consider 2 percent lido.

Obviously lots of variables and factors affect the above, such as blood pressures, pt’s weight/height, etc.

Any specific pearls for instances of bad rectal pressure close to pushing? 10/10 rectal pressure pain with contractions.

 

[repititionition]

bolusing with lido is a bad idea unless you are doing an instrumented delivery. you’ll never get them back to the same density and you’ll be called back over and over.

for rectal pressure in late labor, bolus straight fent. we don’t like to admit it but it’s essentially giving IV fent. DPE helps to avoid the problem in the first place.

 

[abolt18]

Any specific pearls for instances of bad rectal pressure close to pushing? 10/10 rectal pressure pain with contractions.

Fentanyl 50mcg in the epidural and "sorry the sacral nerves are outside of where the epidural covers, not much more we can do about this."

But I usually tell them immediately after I place the epidural that the latest stage of labor will come with perineal/between the legs pain that the epidural likely won't help with. Seems to save me a lot of calls?

I just test for a level with ice in a glove. If they have an inadequate level I bolus 10 extra cc from the pump and increase the infusion rate from 8 to 12/hr (0.125 bupi w 1.25mcg/mL fentanyl). If the level seems appropriate but still having vague pain, I'll do 8-10 of 0.25% bupivacaine and increase their base infusion rate.

 

[abolt18]

bolusing with lido is a bad idea unless you are doing an instrumented delivery. you’ll never get them back to the same density and you’ll be called back over and over.

for rectal pressure in late labor, bolus straight fent. we don’t like to admit it but it’s essentially giving IV fent. DPE helps to avoid the problem in the first place.

I only do DPE when I have a questionable LOR or really difficult placement on a really huge patient and I want to increase my confidence in the success. Otherwise, feels like overkill for the average patient.

 

[cytocide]

Depends on your nurses. Depends on your patients. Giving saline is underrated. DPE is stupid.

 

[coffeebythelake]

I only do DPE when I have a questionable LOR or really difficult placement on a really huge patient and I want to increase my confidence in the success. Otherwise, feels like overkill for the average patient.

Why do DPE when u can do CSE

 

[abolt18]

Why do DPE when u can do CSE

Cause that would require me to have the nurse run to the pyxis (or call another nurse to do it) then draw up drugs while I'm holding a needle in a location that was hard to access already. The only drug I have in the room when I place my epidural is the bag and the nurse has some ephedrine. Takes her two seconds to open a spinal needle onto my tray.

For me DPE is maybe a couple times/year to confirm I'm in the right place. FWIW I haven't done a DPE in a long time, but I maintain that it is a good maneuver available if you're just not totally confident in your LOR.

 

[repititionition]

FWIW I DPE 99% of people and my callback rate for evaluation/bolus/whatever is about 1%. I sleep a lot more after starting to DPE everyone.

OH, and I rarely CSE because the spinal dose sets expectations too high for ongoing block density.

DPE + activation with bag mix is a winning formula.

 

[abolt18]

FWIW I DPE 99% of people and my callback rate for evaluation/bolus/whatever is about 1%. I sleep a lot more after starting to DPE everyone.

OH, and I rarely CSE because the spinal dose sets expectations too high for ongoing block density.

DPE + activation with bag mix is a winning formula.

Completely agree with CSE setting inappropriate expectations. Also masks an epidural that doesn't work.

 

[cytocide]

I wonder how many patients would consent for an extra hole in the dura just because.

 

[Arch Guillotti]

Completely agree with CSE setting inappropriate expectations. Also masks an epidural that doesn't work.

so just tell them what to expect? your second statement doesn’t really have any factual basis.

 

[NeedleJockey]

Any specific pearls for instances of bad rectal pressure close to pushing? 10/10 rectal pressure pain with contractions.

Call this the ‘butt bolus’, 10cc .25 bupiv solves the problem.

 

[Lecithin5]

I wonder how many patients would consent for an extra hole in the dura just because.

Agree. If I were to ever need an epidural, no in hell would I allow anyone to knowingly violate my dura, no matter the needle gauge size (I’m talking about those who routinely do cse/dpe, not the rare occasions…). Just my 2 cents.

 

[Lecithin5]

Any specific pearls for instances of bad rectal pressure close to pushing? 10/10 rectal pressure pain with contractions.

Sometimes there isn’t much you can do besides: sit patient up; 100mcg fentanyl; 5 cc 0.25% bupi; cross your fingers

 

[coffeebythelake]

Call this the ‘butt bolus’, 10cc .25 bupiv solves the problem.

Do u change the pcea in any way, or just bolus to top off?

 

[NeedleJockey]

Do u change the pcea in any way, or just bolus to top off?

No change to infusion. Our mix is 0.1 ropiv with 2 mcg fentanyl, usually run it at 12-14cc an hour with a 5cc q20min pcea, they’ve usually hit the pcea 1-2 times with no improvement. The 10cc push gets there and don’t get called back 90% of the time, the other 10% is for another bolus 3 hours later.

 

[dabears505]

Painful change of circumstances

 

[Bryan O’Blivion]

10 cc 0.25% bupi. 100 mcg fentanyl if you feel like pulling it.

 

[abolt18]

so just tell them what to expect? your second statement doesn’t really have any factual basis.

If they are numb from a spinal, and the epidural isn't working, you won't know it as soon because they're comfortable and then they're not. How is this not factual? It will delay the time to identifying a failed epidural. I'd rather find out it failed before I fall back to sleep.

 

[coffeebythelake]

How does the density of epidural block w lidocaine compare to bupi?

1% lido ~= 0.25% bupi?
2% lido ~= 0.5 bupi?

 

[teacher2md]

If they are numb from a spinal, and the epidural isn't working, you won't know it as soon because they're comfortable and then they're not. How is this not factual? It will delay the time to identifying a failed epidural. I'd rather find out it failed before I fall back to sleep.

This is commonly cited as a reason to not do CSE’s, but it’s just not backed up by evidence.

CSE does not delay identification of failed epidural

 

[dabears505]

If you do a cse and get good pain relief, what are the chances you won't get a functioning epidural?

 

[cchoukal]

If you do a cse and get good pain relief, what are the chances you won't get a functioning epidural?

6.6%, according to the paper. The statement that a CSE does not delay identification of a failed catheter, though, is a little misleading. The overall time is the same, but 50% more failed catheters are identified in the first 30 min without CSE.

 

[teacher2md]

6.6%, according to the paper. The statement that a CSE does not delay identification of a failed catheter, though, is a little misleading. The overall time is the same, but 50% more failed catheters are identified in the first 30 min without CSE.

I think it’s actually the opposite? Failed CSE is more likely to be recognized in first 30 minutes compared to failed epidural. From the Discussion section:

“When only failures occurring during the first 120 min after placement were analyzed in 15-min intervals, more failed catheters from CSE than from EPID were recognized in the first 30 min from placement; however, no differences were seen beyond the first 30 min.”

 

[cchoukal]

I think it’s actually the opposite? Failed CSE is more likely to be recognized in first 30 minutes compared to failed epidural. From the Discussion section:

“When only failures occurring during the first 120 min after placement were analyzed in 15-min intervals, more failed catheters from CSE than from EPID were recognized in the first 30 min from placement; however, no differences were seen beyond the first 30 min.”

Wow, you’re right! Talk about an example of seeing what you want to see (says the guy who doesn’t do CSE).