Practical epidural help for a PGY1

[Loot]

Hey guys,

I am a PGY1 in Anesthesia, I do a few months on-service during my first year and but I feel underprepared for some of my nights on-call, primarily in regards to troubleshooting/managing epidurals. My institution is very much a learn on your own sort of place, so I was wondering if some of the more experienced members here could help me with what are some of the common/basic problems overnight.

As a note, most epidurals are labour epidurals and we run Bupi 0.06%, fent 2/ml, 10ml/hour with demand doses of 5ml every 10 minutes. I typically load my patients with 15cc of 0.125% Bupi.

1. If a patient appears to have a proper sensory level of block, but is still having some pain over the area, what would be the best way to proceed? I don’t want to raise the sensory level, so is it appropriate to use a higher concentration but low volume ie. 2-3cc of 0.25 Bupi. Will this effectively mix with the volume of anesthestic already present in the epidural space and increase the density of the block?

2. Is it ok to mix different local anesthetics? Say a patient is on a bupi infusion, would it be appropriate to give a Lidocaine bolus if I wanted a more rapid action say when the patient is almost fully dilated and is still in pain?

3. How frequently can I top up patients? Bupi has an effect for roughly 2 hours – is it ok to top-up epidurals frequently as long as the sensory level is not higher than say T6? I am thinking of a patient I had seen that had a good sensory level of block, but still had pain that would return quickly after getting bolused and was getting topped up every hour with 10cc + demand doses. When I came on, I was a bit hesitant of topping her up despite her pain given the quantity she received.

4. What would be a good way to hit sacral/rectal pain near the end of labour?

5. Any other advice you think would be useful for a PGY1 doing overnights?

These questions are probably simple, but I haven’t really figured out the right/wrong answers on my own. It would be a great help if you guys could guide me a bit.

Thanks,

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[BobBarker]

Hey guys,

I am a PGY1 in Anesthesia, I do a few months on-service during my first year and but I feel underprepared for some of my nights on-call, primarily in regards to troubleshooting/managing epidurals. My institution is very much a learn on your own sort of place, so I was wondering if some of the more experienced members here could help me with what are some of the common/basic problems overnight.

As a note, most epidurals are labour epidurals and we run Bupi 0.06%, fent 2/ml, 10ml/hour with demand doses of 5ml every 10 minutes. I typically load my patients with 15cc of 0.125% Bupi.

Seems a little too dilute but you aren't going to be able to change the defacto block mixture.



1. If a patient appears to have a proper sensory level of block, but is still having some pain over the area, what would be the best way to proceed? I don’t want to raise the sensory level, so is it appropriate to use a higher concentration but low volume ie. 2-3cc of 0.25 Bupi. Will this effectively mix with the volume of anesthestic already present in the epidural space and increase the density of the block?

Give 100mcg epidural fentanyl. They will go to sleep and quit bothering you.

2. Is it ok to mix different local anesthetics? Say a patient is on a bupi infusion, would it be appropriate to give a Lidocaine bolus if I wanted a more rapid action say when the patient is almost fully dilated and is still in pain?
Yes, it's ok to give lidocaine in this manner. I would use 5-10ccs of 1% in that situation.




3. How frequently can I top up patients? Bupi has an effect for roughly 2 hours – is it ok to top-up epidurals frequently as long as the sensory level is not higher than say T6? I am thinking of a patient I had seen that had a good sensory level of block, but still had pain that would return quickly after getting bolused and was getting topped up every hour with 10cc + demand doses. When I came on, I was a bit hesitant of topping her up despite her pain given the quantity she received.

You can top them off frequently. But it is better to figure out what is actually wrong. Is the pump working correctly? Has the catheter migrated partially out? Are they addicted to lidocaine? If it isn't working right it is usually easier to replace it.



4. What would be a good way to hit sacral/rectal pain near the end of labour?

100mcg epidural fentanyl. If they are still a ways from pushing .25% bupi can be used.

5. Any other advice you think would be useful for a PGY1 doing overnights?

If you have time, don't leave the labor suite until the pt is comfortable or obviously feeling better. Replace poor epidurals early, you don't want to use one for a c/s. If a pt is hurting you should probably do a cse but I usually just give them the rest of the lidocaine in the tray after the test dose then go about setting my pump up, etc. Some pt's are just crazy, sensitive, have unrealistic expectations. You can tell usually how big of a pain they are going to be by how much they jump during local infiltration.


These questions are probably simple, but I haven’t really figured out the right/wrong answers on my own. It would be a great help if you guys could guide me a bit.




Thanks,

 

[Orin]

Everyone has their own troubleshooting methods and treatment algorithm.

1. If a patient appears to have a proper sensory level of block, but is still having some pain over the area, what would be the best way to proceed?

I'd try a higher concentration first to see if this hot spot can be covered. I want to know if the catheter is salvagable for surgical anesthesia or if I need to replace it. I do fentanyl second if they have some benefit as it'll keep them quiet regardless.

2. Is it ok to mix different local anesthetics? Say a patient is on a bupi infusion, would it be appropriate to give a Lidocaine bolus if I wanted a more rapid action say when the patient is almost fully dilated and is still in pain?

Mixing is fine, but the effects can be hard to predict.

3. How frequently can I top up patients?

My rule is once every 2 hours. If they are having trouble more frequently then that, we need to talk about expectations, replacement of the cathter, and other possible problems that might present with breakthrough pain.

4. What would be a good way to hit sacral/rectal pain near the end of labour?

I like 8 of 0.125% with 100 mcg of Fentanyl.

 

[dhb]

As a note, most epidurals are labour epidurals and we run Bupi 0.06%, fent 2/ml, 10ml/hour with demand doses of 5ml every 10 minutes. I typically load my patients with 15cc of 0.125% Bupi.

This is more than enough, if they still have a painful spot (usually sacral or inguinal depending on the baby's position) i go strait to clonidine 150mcg
Also in my experience you get more complains if you go from a higher concentrated solution to a lower: load them with the same solution you are running the infusion with.

 

[pgg]

IMO .06% isn't enough, I don't know why anyone likes to use it, it produces too many phone calls with no advantage over .125% ... if you have any power to pick your starting drug, I'd go with .125% bupiv + 2 mcg/mL.

As posted earlier, 100 mcg epidural fentanyl helps, especially with pain at time of delivery when the OB or midwife / doula pair doesn't want her "too numb" to push (funny that my phone just tried to autocorrect "doola" to "fools").

You might get less sacral sparing with L4-5 epidurals than L2-3 so I usually put the epidural in as low as I can feel a good space. That might just be superstition though.

I don't favor bolusing labor epidurals with lidocaine. When it wears off (soon) they just complain about the less-dense block they have from the infusion.

 

[sleepallday]

Honestly, I'm a little surprised a PGY1 is managing epidurals.

Having said that, I agree with the above, 0.6% seems to dilute.

There is no limit to how many times you can top off an epidural as long you are not exceeding the toxic limit. But frequent need for a top offs should tell you that the epidural is probably not working.

Epidural does not reliably cover sacral pain. Any fentanyl give via epidural is going to work systemically just as if given IV.

If you cannot increase the bupivacaine concentration, I would consider increasing the rate.

 

[IanMcGalt]

10cc of 0.25% Bupivicaine for her and change the infusion to 0.125+2mcg, a quiet room and a pillow for you.

 

[Loot]

Thanks for the advice guys, it was very helpful. And you are right, a PGY1 shouldn't be managing epidurals alone - but at my institution we also do solo overnight call in the ICU (cardiac/transplant/medical ICU), CCU, NICU; so it's par for the course - good experience, but also dangerous.

 

[deleted171991]

Swimming with sharks in deep waters is a great experience... if you survive.

 

[deleted682700]

Practically speaking, do the epidurals at a higher level, say , L3L4
Insert the catheter at least 8 cm into the space. Books says 5 cm. the catheters are being placed at 1cm dilatation and the lady has a good 12 hrs to suffer and when the patients invariably move. The catheter comes out and now it doesn't work when u need it the most particularly in morbidLy obese.
Insert the catheter to 8 cm inside the space.Now give your infusions and viola, they won't call u and also the Ob will turn off your epidurals because they say it's very dense. I also warn the patients to not expect 100 percent pain relief at the end. As they have to push the baby out.
The only down side is that increased possibility of blood in the epidural tubing, I hate the peri fix stuff ones, instead use the arrow soft ones that come with combined spinal epidural.
BTW I do cse on all patients, so that I know it's in the right spot and have had no problems. Our nurses are spoilers they call me at 8-10 cm dilation and want me to perform miracles. That's my textbook of Ob anesthesia

 

[GaseousClay]

What kind of program puts an intern who's not doing a full year of anesthesia on OB call overnight?

 

[Wiscoblue]

Going by the spelling of "labour" I'd say the OP is in Canada or UK or some other commonwealth country. Not uncommon for a first year to be in charge of an epidural while the consultant is playing golf or getting drunk, or both.

 

[deleted162650]

What kind of program puts an intern who's not doing a full year of anesthesia on OB call overnight?

Perhaps the same kind of program that can't bother to teach the very basics of epidural management. I'm all for not being spoon-fed, but if the program can't/won't even teach the basics, how can they even call themselves a training program.

 

[Consigliere]

Hey guys,



As a note, most epidurals are labour epidurals and we run Bupi 0.06%, fent 2/ml, 10ml/hour with demand doses of 5ml every 10 minutes. I typically load my patients with 15cc of 0.125% Bupi.



Thanks,

Yikes!

 

[amyl]

I agree with that solution being suboptimal - 0.125% bupi w fentanyl 2mcg/ml is what I use. 10cc basal with 6cc bolus q 15 minutes. Very rare for me to be called for boluses but if I'm called I use 7-10cc 1% lido pf. I guess I use specifically that bc nurses pull it anyway for local in case of significant episiotomy repair so it's pulled from the accudose and readily available. I do like lidocaine boluses over bupi as I'm usually running upstairs to cover ob while I have a 100 other things going on downstairs so I want a quick answer is it working or no.... Because if I've gotta redo it it has to be quick... A surgeon is usually waiting on me elsewhere

 

[Mman]

Practically speaking, do the epidurals at a higher level, say , L3L4
Insert the catheter at least 8 cm into the space. Books says 5 cm. the catheters are being placed at 1cm dilatation and the lady has a good 12 hrs to suffer and when the patients invariably move. The catheter comes out and now it doesn't work when u need it the most particularly in morbidLy obese.
Insert the catheter to 8 cm inside the space.

WTF???

8 cm in the space? That increases your risk of a bloody catheter or getting CSF from the catheter as well as increases your chances of a one sided block. I generally leave about 4-5 cm in the space and still occasionally have to pull the catheter back to 3 cm because of a 1 sided block.

(knock on wood) I've never had a catheter come out (out of thousands) and I can't imagine any advantage from putting that much catheter in the space. Seems to me you would exponentially increase (the albeit small) risk of the catheter getting twisted on itself.

 

[deleted682700]

WTF???

8 cm in the space? That increases your risk of a bloody catheter or getting CSF from the catheter as well as increases your chances of a one sided block. I generally leave about 4-5 cm in the space and still occasionally have to pull the catheter back to 3 cm because of a 1 sided block.

(knock on wood) I've never had a catheter come out (out of thousands) and I can't imagine any advantage from putting that much catheter in the space. Seems to me you would exponentially increase (the albeit small) risk of the catheter getting twisted on itself.

All theoretical academicians will tell u 5. I have done for 15 yrs and failed epidural, one sided block ,less than 1-2 per year. Pdph nada. If you take the time to read , I said in my textbook and practice this is what helps. May be in academics, they can get tenured track by showing differences between 5 and 8 cm.
what catheters do u use?
what are the problems that u face in your Ob population

 

[kazuma]

I also agree with the bloody catheters and one sided epidurals if threaded deep. I usually thread 3-4cm and I rarely get one sided epidurals.

One thing I also do that helps is to place my left thumb directly over the center of the spinous process and then insert the needle directly midline of my thumb. This helps your trajectory stay midline from the start. When I've been called for blood patches or to help place a "difficult" epidural or spinal I sometimes see multiple needle marks that are up to 1-2 cm off from midline. I once had a patient tell me she was poked 13 times for her epidural and now had a spinal HA. I placed the blood patch easily on the first attempt. Funny thing was that most of the needle marks were lined up in the middle of a butterfly tramp stamp which was actually off centered. The resident was tricked by using the crooked tramp stamp as a surface landmark.

 

[scudrunner]

Finding the the midline is key for quick, easy placement.

Interesting observation the other day- I placed an epidural in a thin woman whose contractions were pretty intense. Epidural went in lickity-split, then as I was pulling it back she started huffing and puffing with a little flexion/extension of her back. The catheter was moving in/out a solid 1/2 cm or more with each breath. It became quite clear how catheters migrate out of the epidural space.

Also, I've been doing less hydrodissection upon getting loss of resistance and I've noticed my 5cc of 1.5% lido test dose (test with 3, then add the other 2) has been providing decent pain relief. Nice to take the edge off until they get positioned in bed and the pump gets hooked up.

 

[pjl]

Finding the the midline is key for quick, easy placement.

Interesting observation the other day- I placed an epidural in a thin woman whose contractions were pretty intense. Epidural went in lickity-split, then as I was pulling it back she started huffing and puffing with a little flexion/extension of her back. The catheter was moving in/out a solid 1/2 cm or more with each breath. It became quite clear how catheters migrate out of the epidural space.

The catheters "lock" in place at the ligament. Especially in super morbidly obese the catheter will move at skin level. Have them sit straight up before taping and you will see them suck in about a cm. I tape in that position on the big ones. Haven't seen it matter much for smaller people. 1/2 cm shouldn't dislodge an epidural, but the amount of movement 5 inches of back fat can do may. I thread those in a generous 6 - 7 cm.

Regarding 8 cm of threading, with the stiff plastic epidurals that definitely increases one sided blocks. 1-2 failed/one sided blocks a year seems like a pretty low rate for someone doing a lot of epidurals...obviously your technique works for you, so more power to you.

There are hundreds of ways to bolus or start an epidural, find your own best, but 15 mL seems a bit heavy handed.
I use the 1/8% bup w/ 2 fent/mL, 10 mL. Agree with slightly more concentrated infusion probably helping with OP issues.

 

[Mman]

All theoretical academicians will tell u 5. I have done for 15 yrs and failed epidural, one sided block ,less than 1-2 per year. Pdph nada. If you take the time to read , I said in my textbook and practice this is what helps. May be in academics, they can get tenured track by showing differences between 5 and 8 cm.
what catheters do u use?
what are the problems that u face in your Ob population

I find it hard to believe you do a ton of epidurals and only get 1-2 a year that are failed or 1 sided enough to require intervention and never get PDPH by threading them in that far. And I'm certainly not in academics. I'll probably do about 6-10 epidurals today (we do about 2500 a year) and I'm busy so getting it right the first time is of utmost importance. But complications happen. There is no way to prevent things like getting heme catheters or CSF or 1 sided blocks. You can try to minimize the risks, but you can't eliminate it.

And as for catheters coming out...just doesn't happen if you tape it well at the skin. If I get a lady 400+ lbs, I might thread 5-6 cm on them for the sake of a little extra care with all that fat. But for any of our normal patients (200-350) lbs I don't treat them any differently with epidurals.

But whatever works for you is obviously good for you (though I certainly wouldn't tell an intern to thread it in 8 cm).

 

[drrosenrosen]

I recently attended the Ca Society of Anesth meeting, where there was a lecture reviewing recent literature on OB analgesia. Key findings they discussed:

CSEs with 15-25mcg fentanyl work very well, but even just puncturing the dura (with a spinal needle) without administering IT meds improves block satisfaction and decreases one sided blocks, with no increased incidience of PDPH.

PCEAs work better than just basal infusions, but basal infusions with programmed intermittent boluses work even better than PCEAs

 

[dhb]

But for any of our normal patients (200-350) lbs I don't treat them any differently with epidurals.

so happy our normal is still 150 lbs. I agree i've never had a catheter "fall out" and my taping technique is the most basic out there. I leave 4-5cm in.
One key point is that the patient is your ally to good placement, i more and more ask them to alert me if they feel something on one side or another and redirect accordingly.
For example yyesterday i had a LOR at 7cm but when i threaded the catheter the patient had a left paresthesia so i backed up shot more to the right and this time LOR came at 6cm! no paresthesia with the catheter; so i was probably initially over a nerve root on the left the first time which would have resulted in a crappy epidural.

 

[ph8]

The catheters "lock" in place at the ligament. Especially in super morbidly obese the catheter will move at skin level. Have them sit straight up before taping and you will see them suck in about a cm. I tape in that position on the big ones. Haven't seen it matter much for smaller people. 1/2 cm shouldn't dislodge an epidural, but the amount of movement 5 inches of back fat can do may. I thread those in a generous 6 - 7 cm.

Regarding 8 cm of threading, with the stiff plastic epidurals that definitely increases one sided blocks. 1-2 failed/one sided blocks a year seems like a pretty low rate for someone doing a lot of epidurals...obviously your technique works for you, so more power to you.

There are hundreds of ways to bolus or start an epidural, find your own best, but 15 mL seems a bit heavy handed.
I use the 1/8% bup w/ 2 fent/mL, 10 mL. Agree with slightly more concentrated infusion probably helping with OP issues.

The bolded text is solid advance. Once you've placed your epidural catheter, and before you tape it down, have your pt sit up straight and watch the catheter "adjust" its depth (especially the BMI 50+ ladies). The most I've seen the catheter "self-adjust" is about 3 cm. I leave 6cm of catheter beyond the depth of my tuohy/hausted needle, we use the arrow epidural kits with the flextip catheter.

I've replaced many an epidural in a super morbidly obese pt because too little catheter was left behind and the catheter migrated out. It's pretty easy to pull back a cm or two of catheter and re-tape it, and much more difficult to find that epidural space at 9 cm a second time.

OP, you've gotten solid advice from all. Here are my 2 cents to answer your questions:

1. pain over what area? try to place the painful area in a dependent position. In my anecdotal experience, LA tends to move with gravity. You could use a higher concentration, but it's tough to make LA go to a specific nerve distribution. if there's a point where the fetus is "stuck" in their path of descent, and lighting up a nerve plxues/root, 0.2% ropi is my go to, and works every time.

2. yes. be careful with lido boluses. i've seen pt's get tachyphylaxis to 2% lido, and if you have to go to c/s, you want that 2% lido to work. see answer #4 for sacral labor pain

3. If you're bolusing med's 2 hrs or less, then it's time to reassess the epidural AND reassess the pt's expectations. epidural does not equal pain free. epidural equals tolerable labor pain. women who are pregnant have a 7-10 pound bowling ball (fetus) that must exit their body, and this small detail re: path of exit is...how shall I say....overlooked. there are two possible ways for this exit to happen, and neither is particularly comfortable.

4. see answer #1....LA goes with gravity. sit the pt bolt upright in bed and try to get the LA to bathe the sacral nerve roots. In my anecdotal experience, this seems to work.

5. see advice from prior posts.

how I miss 0.2% ropi....Pop in the epidural, load 'em with 6-8 mL , set infusion for 8-10mL/hr, and never got a single call for a redose.

 

[Mman]

how I miss 0.2% ropi....Pop in the epidural, load 'em with 6-8 mL , set infusion for 8-10mL/hr, and never got a single call for a redose.

Is there some reason you can't get it anymore? That's what we use for our infusion. I like it because patients never complain of the itching I'd say with narcotic solutions, though once in a great while I'll switch to a solution with fentanyl for the added analgesia from the narcotic (though it's very rare for me to ever need that).

 

[ph8]

Is there some reason you can't get it anymore? That's what we use for our infusion. I like it because patients never complain of the itching I'd say with narcotic solutions, though once in a great while I'll switch to a solution with fentanyl for the added analgesia from the narcotic (though it's very rare for me to ever need that).

It's probably a combination of poor reimbursement/negotiated rate for the epidural and the comparative expense of ropi vs significantly cheaper bupi.

 

[epidural man]

I recently attended the Ca Society of Anesth meeting, where there was a lecture reviewing recent literature on OB analgesia. Key findings they discussed:

CSEs with 15-25mcg fentanyl work very well, but even just puncturing the dura (with a spinal needle) without administering IT meds improves block satisfaction and decreases one sided blocks, with no increased incidience of PDPH.

PCEAs work better than just basal infusions, but basal infusions with programmed intermittent boluses work even better than PCEAs

I bet programmed boluses with patient boluses would work the best. Quick...someone do that study.

 

[BlackTalon]

A randomised comparison of variable-frequency automated mandatory boluses with a basal infusion for patient-controlled epidural analgesia during labour and delivery

This trial was conducted to compare the analgesic efficacy of administering variable-frequency automated boluses at a rate proportional to the patient's needs with fixed continuous basal infusion in patient-controlled epidural analgesia (PCEA) during labour and delivery. We recruited a total of 102 parturients in labour who were randomly assigned to receive either a novel PCEA with automated mandatory boluses of 5 ml administered once, twice, three or four times per hour depending on the history of the parturient's analgesic demands over the past hour (Automated bolus group), or a conventional PCEA with a basal infusion of 5 ml.h−1 (Infusion group). The incidence of breakthrough pain requiring supplementation by an anaesthetist was significantly lower in the Automated bolus group, three out of 51 (5.9%) compared with the Infusion group, 12 out of 51 (23.5%, p = 0.023). The time-weighted mean (SD) hourly consumption of ropivacaine was similar in both groups, 10.0 (3.0) mg in the Automated bolus group vs 11.1 (3.2) mg in the Infusion group (p = 0.06). Parturients from the Automated bolus group reported higher satisfaction scores compared with those in the Infusion group, 96.5 (5.0) vs 89.2 (9.4), respectively (p < 0.001). There was no difference in the incidence of maternal side-effects and obstetric and neonatal outcomes.

 

[pastafan]

Here is a trick that has worked for me over the years. When you have a severely morbidly obese patient it is not always possible to feel anything in the midline. Interestingly, no matter their size, patients know where the center of their back is located. As you push down on what you believe to be midline ask the patient if you are in the middle of their back.

 

[pgg]

Low thoracic epidurals work for labor, too. Sometimes the morbidly obese have less fat depth at that level. And the spinous processes at the T10-12 level are nearly horizontal so they're generally technically as easy as lumbars.

 

[deleted162650]

As you push down on what you believe to be midline ask the patient if you are in the middle of their back.

This same principle works when you've got the Touhy in and run into what seems like a wall of bone. Take your hands off the pts back and just push/tap the Tuohy on the bone. Ask them if it feels left, right, or midline and adjust your trajectory accordingly.

 

[drrosenrosen]

This same principle works when you've got the Touhy in and run into what seems like a wall of bone. Take your hands off the pts back and just push/tap the Tuohy on the bone. Ask them if it feels left, right, or midline and adjust your trajectory accordingly.

I find this technique helpful in general. Even if you're not on bone, the patient should be able to tell you if she's feeling it to one side or midline.

 

[deleted162650]

I find this technique helpful in general. Even if you're not on bone, the patient should be able to tell you if she's feeling it to one side or midline.

This is probably a similar technique to what was used when these patients get pregnant in the first place.