One sided labor epidural fix

[VolatileNavyDoc]

Just curious what most of you guys do with a one sided epidural. In residency, we spent a lot of time pulling catheters back, bolusing the catheter, assessing the patient, blah blah blah.

Now, I just replace the catheter immediately if there is a hint that it's one sided. The last thing I want to do is deal with an inadequate epidural when we go back for c-section at 3AM.

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[WholeLottaGame7]

Just curious what most of you guys do with a one sided epidural. In residency, we spent a lot of time pulling catheters back, bolusing the catheter, assessing the patient, blah blah blah.

Now, I just replace the catheter immediately if there is a hint that it's one sided. The last thing I want to do is deal with an inadequate epidural when we go back for c-section at 3AM.

If the working side is the patient's down side, I'll have them roll-over and bolus, especially if it's early after placement and I suspect the issue might be that the total volume of solution in the epidural space is low. Otherwise, I'll try pulling it back once, but I definitely don't futz around with it as much as I did earlier in residency. As I got faster/more comfortable with epidurals over time, my threshhold for pulling/replacing got much lower.

 

[pjl]

Pull back/bolus x1
If no improvement in 30 min replace, assuming patient is ok with that.

 

[risnwb]

I take the shotgun approach: Bolus large volume of dilute anesthetic, turn them to the side with less of a block, and pull the catheter a cm or two ( I tape around the edges of the tegaderm so I can see catheter insertion point, and I just pull it back through the tegaderm. Takes two seconds ). If no better in 20 mins I replace.


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[Planktonmd]

Take it out and try again.

 

[BLADEMDA]

Take it out and try again.

Agree. Private practice success rates with Epidurals in OB exceed 95%. Plankton has this one right: replace it.

Feel free to turn the mommy on the other side and bolus the catheter but IMHO that option doesn't work most of the time so don't dick around for more than 20-25 min before replacing the catheter.

 

[Noyac]

If the working side is the patient's down side, I'll have them roll-over and bolus, especially if it's early after placement and I suspect the issue might be that the total volume of solution in the epidural space is low.

I have never believed this to be true. Just saying.

I don't mess with an inadequate epidural ( one sided etc). I pull and replace.

 

[bcat85]

I also have a pretty low threshold for replacing epidurals. I typically reposition and bolus, pull back 1-2 cm and bolus, and then just replace it. I've seen some folks kick the can down the road for hours (repeated boluses, multiple repositions, etc.) only to get called for an emergent/urgent c/s that becomes a GA because of a still inadequate epidural. Not fun.

 

[Mman]

When I have an epidural where they have less of a level on 1 side than the other and are still hurting I'll usually pull the catheter back and manually bolus it with 5-6 mls of 0.25% bupivicaine. Fixes the problem about 90% of the time. The 10% of the time it doesn't I replace the catheter at a different interspace.

The question for me is WTF should I do when the 2nd catheter is 1 sided on the same side. Curse the connective tissue in their epidural space that is denying my local the chance to spread there? Try a 3rd epidural? Fortunately I've only run into this once or twice in my career.

 

[sevoflurane]

springwound catheter.

 

[pgg]

Depends, if it's a really lopsided block I'll just pull and replace. If it's kind of a bit uneven I'll try a top-off with the hurting side down. Part of it is managing the patient's expectations. Some just don't realize that our intent is not to make them completely numb and immobile, or they think that a bit of tightness or awareness of a contraction is a problem.


I don't bother with adjusting catheter depth. When I was a junior resident and had the usual # of junior resident crappy epidurals I played that game and it never seemed to work. I wasted countless minutes of my life measuring a level with broken tongue depressors and gloves full of ice. Futzing around with catheters either just delayed replacement and wasted more of my time in the aggregate, or the patient delivered with a crappy epidural before I got around to replacing it. 9 times out of 10 a crappy epidural is crappy because the catheter's in the wrong place.

If a patient was exceptionally anxious about the procedure and would be upset about redoing it, I guess I'd probably let her limp along a while longer with position changes and top-offs (100mcg of epidural fentanyl hides many sins ... for a little while) before recommending replacement.

 

[Mman]

9 times out of 10 a crappy epidural is crappy because the catheter's in the wrong place.

My question would be what possible place could an epidural catheter be that is providing a good level on 1 side (say at least T8 to S2) but not a good level on the other side?

 

[pgg]

My question would be what possible place could an epidural catheter be that is providing a good level on 1 side (say at least T8 to S2) but not a good level on the other side?

Subdural catheters produce weird blocks. I had an epidural in residency that I believe was subdural - it gave the patient an epidural block all the way up to and including a Horner's on that side, and almost nothing on the other side. This is the zebra case though.

For the more common crappy epidurals that are patchy or one sided - I've always guessed that most of these 1-sided catheters are either way off midline in nerve root territory, or not epidural at all, but that some volume (10-15 mL of local fills a lot of space) has made its way into the epidural space starting on one side. Patchy blocks correlate highly with the experience level of the person placing them, so I don't believe it's septae or other patient anatomy causing the issue, usually. But who knows?

Regardless, I think it's mostly an exercise in wishful thinking and self-delusion to play with these catheters. Replace and be done with it.

 

[Planktonmd]

Two things never get better on their own: A crappy IV and a crappy epidural.

 

[Mman]

Subdural catheters produce weird blocks. I had an epidural in residency that I believe was subdural - it gave the patient an epidural block all the way up to and including a Horner's on that side, and almost nothing on the other side. This is the zebra case though.

For the more common crappy epidurals that are patchy or one sided - I've always guessed that most of these 1-sided catheters are either way off midline in nerve root territory, or not epidural at all, but that some volume (10-15 mL of local fills a lot of space) has made its way into the epidural space starting on one side. Patchy blocks correlate highly with the experience level of the person placing them, so I don't believe it's septae or other patient anatomy causing the issue, usually. But who knows?

Regardless, I think it's mostly an exercise in wishful thinking and self-delusion to play with these catheters. Replace and be done with it.

I dunno. It's not that uncommon for me to see 1 sided blocks even by guys that have been doing it since the 70s. It happens. And it almost always fixes it perfectly by pulling the catheter back. At least in my experience. If I have 10 epidurals that are iffy on 1 side I only need to replace about 1 to get them all perfect.

 

[deleted9493]

I used Braun epidural catheters exclusively in residency and found probably 10% ended up being one sided or at least one side being dominant in terms of analgesia.

In private practice I have switched to Arrow, springwound catheters and rarely have paraesthesias on insertion and haven't had to replace a catheter yet (and no reports of 'bad' epidurals). At first I was hesitant to believe that it would make THAT much of a difference, but I am here to tell you that it does seem to.

Also, the Arrow catheters seem to have a much more snug fit allowing me to leave it at 3-4cm depth and not worry that having left it shallow that it's going to displace.

 

[BLADEMDA]

http://forums.studentdoctor.net/threads/labor-epidurals.648151/
Bolus through the needle and the incidence of one sided blocks becomes negligible.

 

[pgg]

http://forums.studentdoctor.net/threads/labor-epidurals.648151/
Bolus through the needle and the incidence of one sided blocks becomes negligible.

I do CSEs for everyone. Never bolus through the Tuohy ... though I do push a few cc of the saline in the LOR syringe in before threading the catheter.

 

[Noyac]

springwound catheter.

I knew you would say that.

 

[polar403]

When I have an epidural where they have less of a level on 1 side than the other and are still hurting I'll usually pull the catheter back and manually bolus it with 5-6 mls of 0.25% bupivicaine. Fixes the problem about 90% of the time. The 10% of the time it doesn't I replace the catheter at a different interspace.

The question for me is WTF should I do when the 2nd catheter is 1 sided on the same side. Curse the connective tissue in their epidural space that is denying my local the chance to spread there? Try a 3rd epidural? Fortunately I've only run into this once or twice in my career.

Talk with the patient about a spinal prior to delivery. Turn the epidural off and remove it. Wait an hour or so (depending on the estimated volume in the epidural space) and then immediately prior to delivery, roll the patient into lateral decub and place the spinal. Then pray they actually deliver before the spinal wears off.

I've done this a couple times when an epidural wasn't working well and there wasn't time to replace it and bolus it up. Everyone was happy.

 

[IlDestriero]

Take it out and try again.

Exactly. Replace and be back in bed in 15 minutes.

 

[Consigliere]

I tell the CRNA to replace it. I don't dirty my hands doing labor epidurals.

 

[Noyac]

I tell the CRNA to replace it. I don't dirty my hands doing labor epidurals.

Do you also let them do your central lines?

 

[Consigliere]

Do you also let them do your central lines?

Nope. Just the simple crap any well-trained monkey can do.

 

[pgg]

Nope. Just the simple crap any well-trained monkey can do.

It takes a more dextrous monkey to put in an epidural in a patient with an extra 100 pounds of baby weight, than to stick in a big IV with ultrasound.

If you don't want to do OB because you're lazy or the pay is poor or you don't like dealing with histrionic women at 2 in the morning, OK, but let's not draw monkey skill lines in the sand. In the end, all the needle driving we do is monkey work.

 

[Consigliere]

Please allow Sweet Brown to explain things for me:

 

[Mman]

I put in the epidural because I get paid a lot of money to do it so I want the best person to do it. Could I have a CRNA do it for me? Sure. But I'd rather not clean up their mess if they get a high spinal from it or we have to crash back for a c-section. I'm ultimately responsible for it so I'm the one doing it. I mean even on a medicaid epidural I still collect more than enough money to make it worth my while for 5-10 minutes of actual procedure time.

If you want to get out of being responsible for the CRNAs screw up (if something happens) with a labor epidural, simply have the OB be the supervising physician. I cover the OR in more than 1 small hospital where this is the case.

 

[DRSTOYSTORE]

Somehow I came accros this thread and at the end of the day it made me laugh with the sweet brown video.