Practices doing both CSE and Epidurals for labor

[leaverus]

so why am i going to go above and beyond ( and more importantly arguably add a level of risk ) for a possible 2-5 minute difference (which is like 1-2 contractions)?

wait til you get pregnant, youll feel differently. as for me, the answer to your question is simple: because I don't like to see people in pain. all those other guys who do the checking in, giving fluids, drawing labs blah blah blah are not in the vocation of pain relief. I am.

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[Noyac]

In some ways this is like the surgeon who complains about a 10 minute delay and then goes on to take 4.5hrs to do a hernia...

Labor and contractions have been happening for hours (sometimes days).

There are so many other factors that are at play to determine the time that the contraction pain stops and mom gets comfy.... at what point do they go to the hospital, how long does check in take, now we start the iv and give a bolus, hold on the nurses are changing shift, hold on i have to go to the bathroom, etc...

so why am i going to go above and beyond ( and more importantly arguably add a level of risk ) for a possible 2-5 minute difference (which is like 1-2 contractions)? im not even going to dose through the needle... i do it the way i always do it and dont let the hysterics of the others throw me off and lead me to a complication...needle gets placed, catheter goes in, test dose, bolus 2% lido with epi.

The only time that I have done DPE was as a resident, and while i agree that it doesnt make sense to puncture the dura and then not give anything, i was taught that the purpose of the puncture is to confirm proper epidural positioning if a possible false loss of resistance should occur during a difficult placement. meaning that if you can puncture the dura through the tuohy then you are in the right place with your tuohy , which again is an assumption

It's not completely for the pt. It's so that I can get out of there sooner.

 

[deleted162650]

Imagine you are in the worst pain of your life. Someone walks in and says "I can take all your pain away right now, or 15 mins from now. Which would would you like?"

 

[deleted50478]

Imagine you are in the worst pain of your life. Someone walks in and says "I can take all your pain away right now, or 15 mins from now. Which would would you like?"

It's more like, "I can take your pain away in 10-12 minutes. I can spend slightly longer setting up my kit and taking out narcotics but wait slightly less time for the meds to kick in once given (cse), or I can spend less time getting ready and more time waiting for the meds to work (cle). Either way you'll be comfortable in about 10-12 minutes."

 

[deleted162650]

It's more like, "I can take your pain away in 10-12 minutes. I can spend slightly longer setting up my kit and taking out narcotics but wait slightly less time for the meds to kick in once given (cse), or I can spend less time getting ready and more time waiting for the meds to work (cle). Either way you'll be comfortable in about 10-12 minutes."

My CSE set-up time is identical to CLE set-up time, and doesn't involve checking out or drawing up any additional meds. I've posted the technique a few times in the past, so I don't wanna do it again. I wish I could say I invented it, but I stole it from the guys at one of the busiest OB hospitals in the state. They came up with it specifically because it's fast both to set up and to kick in. It's the RonCo of labor analgesia techniques.

 

[deleted697535]

Don't laugh. I use 1/8th bupi + fent 2/mL for my LOR fluid.

How do you maintain sterility? I dont personally like using other than filtered needles for anything going into the CSF. And also only from glass vials so the drawing up needle doesnt pass through any membranes. How do you get around that?

 

[nimbus]

How do you maintain sterility? I dont personally like using other than filtered needles for anything going into the CSF. And also only from glass vials so the drawing up needle doesnt pass through any membranes. How do you get around that?

That's a little excessive. It's unnecessary. How do you draw up PF morphine or Bupiv 0.5%. Ours requires drawing through rubber stoppers.

 

[deleted162650]

How do you maintain sterility? I dont personally like using other than filtered needles for anything going into the CSF. And also only from glass vials so the drawing up needle doesnt pass through any membranes. How do you get around that?

What @nimbus said. Although I do wear an ortho space helmet.

 

[deleted697535]

That's a little excessive. It's unnecessary. How do you draw up PF morphine or Bupiv 0.5%. Ours requires drawing through rubber stoppers.

I can't really answer that as I've never worked in a place that didn't have some easy means of getting around those stoppers.

Personally I don't really care but I do remember some staff being picky about that

 

[deleted697535]

I remember scrubbing for a spinal one day for a 90 year old broken hip in residency. When I emerged from the scrub room minutes later my staff had everything for the spinal drawn up and laid out with his bare hands laughing at me.

I'm new to North America so maybe not yet

 

[leaverus]

With that being said, I know the HA risk in the literature is no different than standard epi but I've personally seen quite a few HA's from my partners CSE's in the last few weeks (I don't really do CSE's). We use a 25g pencil point needle for the spinal.

those HA aint from the spinal part of the cse; your partners are doing something wrong (or misdiagnosing pdph). I do 25G spinals routinely - and I would guess most people here too - and have probly seen one pdph (and even that I'm still not convinced was from the spinal) in years of practice. and you've seen "quite a few in a few weeks"???

 

[facted]

those HA aint from the spinal part of the cse; your partners are doing something wrong (or misdiagnosing pdph). I do 25G spinals routinely - and I would guess most people here too - and have probly seen one pdph (and even that I'm still not convinced was from the spinal) in years of practice. and you've seen "quite a few in a few weeks"???

We're all pretty experienced and trust me, it's from the spinal needle. I exclusively do epidurals (no CSE), and tried a dural puncture epi to see what the fuss was all about (with a 25 g spinal), and my patient got a PDPH the next day.

I'm not saying it's common, and it's CERTAINLY not severe and we just treat conservatively, but if you think putting a 25g needle in someone's dura is risk free, you're wrong. With a 25g pencil-point needle, your risk could be as high as 5% (see article below). We've certainly had some patients with spinal for C-Section get HA's as well. It's not a zero risk.

Do pencil-point spinal needles decrease the incidence of postdural puncture headache in reality? A comparative study between pencil-point 25G Whitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients

 

[Arch Guillotti]

those HA aint from the spinal part of the cse; your partners are doing something wrong (or misdiagnosing pdph). I do 25G spinals routinely - and I would guess most people here too - and have probly seen one pdph (and even that I'm still not convinced was from the spinal) in years of practice. and you've seen "quite a few in a few weeks"???

agree completely.

 

[Noyac]

We're all pretty experienced and trust me, it's from the spinal needle. I exclusively do epidurals (no CSE), and tried a dural puncture epi to see what the fuss was all about (with a 25 g spinal), and my patient got a PDPH the next day.

I'm not saying it's common, and it's CERTAINLY not severe and we just treat conservatively, but if you think putting a 25g needle in someone's dura is risk free, you're wrong. With a 25g pencil-point needle, your risk could be as high as 5% (see article below). We've certainly had some patients with spinal for C-Section get HA's as well. It's not a zero risk.

Do pencil-point spinal needles decrease the incidence of postdural puncture headache in reality? A comparative study between pencil-point 25G Whitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients

This is very interesting to me. At least half of my group does CSE and I can not remember the a single PDPH from one. Our needle is a 27g but local practice is for c/s is to remove any epidural catheter and place a spinal in most cases. This is with a 25g and I still can not recall a single PDPH. Obviously, I am not there everyday and therefore some may have occurred but if the incidence was truly as some here claim then you would think I would have seen one. So I wonder if something else is going on?

 

[BLADEMDA]

This is very interesting to me. At least half of my group does CSE and I can not remember the a single PDPH from one. Our needle is a 27g but local practice is for c/s is to remove any epidural catheter and place a spinal in most cases. This is with a 25g and I still can not recall a single PDPH. Obviously, I am not there everyday and therefore some may have occurred but if the incidence was truly as some here claim then you would think I would have seen one. So I wonder if something else is going on?

IMHO, the majority of headaches after a 25G non cutting needle for a SAB are very mild not requiring a blood patch. I do think the PDPH runs around 5% after a 25G Sprotte or Whitacre puncture but the vast majority of these do not require any follow-up or patches and resolve in 48-72 hours on their own. That's why most of us doing a lot of OB using 25G non cutting needles rarely (less than 1 percent) need to do a blood patch on these patients.

CSE is a good technique but the dura is still being punctured resulting in a small chance of a very mild headache for a few days. This technique is well tolerated by patients and the need for a blood patch secondary to the dural puncture is very rare.

 

[facted]

IMHO, the majority of headaches after a 25G non cutting needle for a SAB are very mild not requiring a blood patch. I do think the PDPH runs around 5% after a 25G Sprotte or Whitacre puncture but the vast majority of these do not require any follow-up or patches and resolve in 48-72 hours on their own. That's why most of us doing a lot of OB using 25G non cutting needles rarely (less than 1 percent) need to do a blood patch on these patients.

CSE is a good technique but the dura is still being punctured resulting in a small chance of a very mild headache for a few days. This technique is well tolerated by patients and the need for a blood patch secondary to the dural puncture is very rare.

Agree with all of this, and I think that the headache might be so mild that it might depend on patient population on whether your finding out about it. Our patients are very "vocal" and tell is about it, but it really is mild and we don't patch them.

 

[deleted162650]

Our patients are very "vocal" and tell is about it

Ironic that the CSE was developed in NYC to deal with the "high maintenance" patients.

 

[pgg]

IMHO, the majority of headaches after a 25G non cutting needle for a SAB are very mild not requiring a blood patch. I do think the PDPH runs around 5% after a 25G Sprotte or Whitacre puncture but the vast majority of these do not require any follow-up or patches and resolve in 48-72 hours on their own. That's why most of us doing a lot of OB using 25G non cutting needles rarely (less than 1 percent) need to do a blood patch on these patients.

CSE is a good technique but the dura is still being punctured resulting in a small chance of a very mild headache for a few days. This technique is well tolerated by patients and the need for a blood patch secondary to the dural puncture is very rare.

Someone should do a study to see what percentage of new mothers have a mild headache in the first few days after delivering a baby.

 

[deleted697535]

Ironic that the CSE was developed in NYC to deal with the "high maintenance" patients.

Was the Cse was developed in new York?

 

[facted]

Was the Cse was developed in new York?

A quick pubmed seems to show a lot of the early work was done by RE Collis et al in the UK. We all know the stoic British aren't complaining of PDPH. Lol

 

[dhb]

Someone should do a study to see what percentage of new mothers have a mild headache in the first few days after delivering a baby.

They certainly didn't have one 9 months prior.

 

[deleted697535]

A quick pubmed seems to show a lot of the early work was done by RE Collis et al in the UK. We all know the stoic British aren't complaining of PDPH. Lol

Fairly sure that 100% wasnt true, same as most things in North America lol

 

[zzsleepytinizz]

If you have some attendings doing epidurals and some doing CSE's for laboring patients, do you have 2 seperate Epidural trays (i.e. CSE and Epidural trays)? Or do you just have one tray and add on/subtract additional equipment? The Tuohy angle seems too acute in the epidural tray in my practice to add in a spinal needle without risk of the needle bending so am wondering what others do.

I am currently completing an obstetrical anesthesiology fellowship (spare me any negative comments) and I am at a hospital that does both CSEs and epidurals for laboring patients. I completed my residency in a hospital that all the attendings did straight epidurals for all patients. I am now two months int my fellowship, and I have seen unresponsive uterine tetany with resultant fetal bradycardia and stat c-section. The anesthesia carts have freshly made nitro syringes, just to treat uterine tetany. I was at a high volume OB hospital during residency and did 5 months of OB and never witnessed uterine tetany s/p plain epidural. That case, the patient was given bupi with 20 mcg of fentanyl. I also had a patient who became extremely hypotensive and unresponsive with extreme fetal bradycardia to the 50s. Also with 20mcg of fentanyl in the spinal.

Honestly, you would have a higher chance convincing me to jump off a bridge than convincing me to do CSEs with fentanyl in the spinal for laboring patients. If someone is a multip and advanced I do like to do a CSE with 1mL 0.25% bupi. But I actually don't notice a difference in satisfaction regarding patients who received epidurals vs CSE. By the time I am done taping and setting up the pump both groups are in way less pain and are happy. I think people are less satisfied when you do a procedure which leads them to getting emergency surgery, or a procedure that leads to multiple to rush into the room screaming about their baby's heart rate and slapping an oxygen mask on their face. Also I, too, inject straight into the tuohy needle. 10mL 0.125% bupi.

Ooops, and to answer your question I drop a 27g pencan needle into a regular epidural kit

 

[facted]

I am currently completing an obstetrical anesthesiology fellowship (spare me any negative comments) and I am at a hospital that does both CSEs and epidurals for laboring patients. I completed my residency in a hospital that all the attendings did straight epidurals for all patients. I am now two months int my fellowship, and I have seen unresponsive uterine tetany with resultant fetal bradycardia and stat c-section. The anesthesia carts have freshly made nitro syringes, just to treat uterine tetany. I was at a high volume OB hospital during residency and did 5 months of OB and never witnessed uterine tetany s/p plain epidural. That case, the patient was given bupi with 20 mcg of fentanyl. I also had a patient who became extremely hypotensive and unresponsive with extreme fetal bradycardia to the 50s. Also with 20mcg of fentanyl in the spinal.

Honestly, you would have a higher chance convincing me to jump off a bridge than convincing me to do CSEs with fentanyl in the spinal for laboring patients. If someone is a multip and advanced I do like to do a CSE with 1mL 0.25% bupi. But I actually don't notice a difference in satisfaction regarding patients who received epidurals vs CSE. By the time I am done taping and setting up the pump both groups are in way less pain and are happy. I think people are less satisfied when you do a procedure which leads them to getting emergency surgery, or a procedure that leads to multiple to rush into the room screaming about their baby's heart rate and slapping an oxygen mask on their face. Also I, too, inject straight into the tuohy needle. 10mL 0.125% bupi.

Ooops, and to answer your question I drop a 27g pencan needle into a regular epidural kit

This. I also think it greatly depends on your OB's and if they understand that the CSE caused the issue and can be fixed with other things. But as you say, the overall stress of those few minutes during a uterine tetany for all involved is just so not worth it in my opinion. My patients are pretty comfortable maybe 2 minutes after laying down...so the CSE might have saved them one contraction?

 

[BLADEMDA]

I am currently completing an obstetrical anesthesiology fellowship (spare me any negative comments) and I am at a hospital that does both CSEs and epidurals for laboring patients. I completed my residency in a hospital that all the attendings did straight epidurals for all patients. I am now two months int my fellowship, and I have seen unresponsive uterine tetany with resultant fetal bradycardia and stat c-section. The anesthesia carts have freshly made nitro syringes, just to treat uterine tetany. I was at a high volume OB hospital during residency and did 5 months of OB and never witnessed uterine tetany s/p plain epidural. That case, the patient was given bupi with 20 mcg of fentanyl. I also had a patient who became extremely hypotensive and unresponsive with extreme fetal bradycardia to the 50s. Also with 20mcg of fentanyl in the spinal.

Honestly, you would have a higher chance convincing me to jump off a bridge than convincing me to do CSEs with fentanyl in the spinal for laboring patients. If someone is a multip and advanced I do like to do a CSE with 1mL 0.25% bupi. But I actually don't notice a difference in satisfaction regarding patients who received epidurals vs CSE. By the time I am done taping and setting up the pump both groups are in way less pain and are happy. I think people are less satisfied when you do a procedure which leads them to getting emergency surgery, or a procedure that leads to multiple to rush into the room screaming about their baby's heart rate and slapping an oxygen mask on their face. Also I, too, inject straight into the tuohy needle. 10mL 0.125% bupi.

Ooops, and to answer your question I drop a 27g pencan needle into a regular epidural kit

I'm old and do straight epidurals. I bolus through the epidural needle (8 ml of 0.25% Bup with fentanyl 100 ug) on a fairly routine basis. Patients are comfortable in about 3-5 minutes after this technique. No issues.

That said, I encourage others who are hesitant to bolus through the needle to use a 25G or 26 G non cutting needle just to puncture the dura (no drugs). Then dilate the space with dilute Bupivacaine 0.125% about 15 mls or if uncertain about the location of the epidural needle (it takes about 500 epidurals to really get comfortable with bolusing through the needle) dilate the space with 10 mls of NS. I find the dural puncture technique very effective for patients in extreme pain or those who have very low pain tolerance. I do not recommend a CSE technique as it is not needed for laboring patients.

So, that's my 2 cents on the matter after decades in this business. All these techniques are effective in the right set of hands but I like to keep it simple.

 

[Noyac]

I'm old and do straight epidurals. I bolus through the epidural needle (8 ml of 0.25% Bup with fentanyl 100 ug) on a fairly routine basis. Patients are comfortable in about 3-5 minutes after this technique. No issues.

That said, I encourage others who are hesitant to bolus through the needle to use a 25G or 26 G non cutting needle just to puncture the dura (no drugs). Then dilate the space with dilute Bupivacaine 0.125% about 15 mls or if uncertain about the location of the epidural needle (it takes about 500 epidurals to really get comfortable with bolusing through the needle) dilate the space with 10 mls of NS. I find the dural puncture technique very effective for patients in extreme pain or those who have very low pain tolerance. I do not recommend a CSE technique as it is not needed for laboring patients.

So, that's my 2 cents on the matter after decades in this business. All these techniques are effective in the right set of hands but I like to keep it simple.

I agree with everything here except that CSE's are not for laboring pts. I bolus through the touhy when I don't do a CSE. And I bolus saline through the needle in all of my thoracic epidurals as well.

But I find the CSE to be very useful in my practice because I am not in house for OB and when I get called in the middle of the night I want to be back in bed within an hour. If I do a CSE I can "run" out of the room and to the parking lot immediately after placement because, what's the worst thing that can happen with 1cc of IT bupivicaine? Uterine tetany aside, which I have never seen in 15 yrs of PP and another 4 yrs of residency.

 

[BLADEMDA]

I agree with everything here except that CSE's are not for laboring pts. I bolus through the touhy when I don't do a CSE. And I bolus saline through the needle in all of my thoracic epidurals as well.

But I find the CSE to be very useful in my practice because I am not in house for OB and when I get called in the middle of the night I want to be back in bed within an hour. If I do a CSE I can "run" out of the room and to the parking lot immediately after placement because, what's the worst thing that can happen with 1cc of IT bupivicaine? Uterine tetany aside, which I have never seen in 15 yrs of PP and another 4 yrs of residency.

I understand your post. But, if instead of giving the spinal bupivacaine 2.5 mg, you just simply puncture the dura and bolus dilute local the onset time of your LUMBAR epidural block will be under 3 min. The evidence favors the DPE over CSE and it adds only 2-3 minutes before mommy gets comfortable. Give it a try.

"We conclude that the DPE appears to offer a favorable risk-benefit ratio for initiating and maintaining analgesia in laboring parturients."

Dural Puncture Epidural Technique Improves Labor Analgesia... : Anesthesia & Analgesia

 

[mmag]

We have Braun Espocan CSE sets. Folks who want to do CSE's just grab one and open it onto our regular epidural kits.

 

[Noyac]

I understand your post. But, if instead of giving the spinal bupivacaine 2.5 mg, you just simply puncture the dura and bolus dilute local the onset time of your LUMBAR epidural block will be under 3 min. The evidence favors the DPE over CSE and it adds only 2-3 minutes before mommy gets comfortable. Give it a try.

"We conclude that the DPE appears to offer a favorable risk-benefit ratio for initiating and maintaining analgesia in laboring parturients."

Dural Puncture Epidural Technique Improves Labor Analgesia... : Anesthesia & Analgesia

And I understand your point but instead of placing 10cc of 0.125% bupivicaine in the epidural space, as benign as that is, placing 1 cc of 0.25% bupivicaine intrathecally is even more benign. Therefore, in the middle of the night when I want to get the hell outta there and away from the drama, nothing gets me out of town faster. Plus I know nothing bad can happen when I do the CSE and I am driving home. If anything ere to happen it would be apparent before I left.

Think of me as the Road Runner. Beep beep Shep bang

 

[facted]

And I understand your point but instead of placing 10cc of 0.125% bupivicaine in the epidural space, as benign as that is, placing 1 cc of 0.25% bupivicaine intrathecally is even more benign. Therefore, in the middle of the night when I want to get the hell outta there and away from the drama, nothing gets me out of town faster. Plus I know nothing bad can happen when I do the CSE and I am driving home. If anything ere to happen it would be apparent before I left.

Think of me as the Road Runner. Beep beep Shep bang

Not sure what not wanting to come back has to do with it? I'm in house, but trust me, I don't want to go back to see the pt either. And with CLE with 14ml of approx .1%, my patients are all comfortable within 2-3 mins after laying down and I don't get called back. The other issue with CSE that people sometimes see, is the false expectations of a spinal during the rest of labor for the patient. But to each their own. Whatever works...

 

[Noyac]

Not sure what not wanting to come back has to do with it? I'm in house, but trust me, I don't want to go back to see the pt either. And with CLE with 14ml of approx .1%, my patients are all comfortable within 2-3 mins after laying down and I don't get called back. The other issue with CSE that people sometimes see, is the false expectations of a spinal during the rest of labor for the patient. But to each their own. Whatever works...

You are not understanding my post. I don't really care how fast they get comfortable I care how fast I can comfortably get out of there. 1cc vs 14cc is the difference. There is much less risk with putting 1cc IT than 14cc epidurally. I will admit that it is a minuscule difference but I like it.

 

[facted]

You are not understanding my post. I don't really care how fast they get comfortable I care how fast I can comfortably get out of there. 1cc vs 14cc is the difference. There is much less risk with putting 1cc IT than 14cc epidurally. I will admit that it is a minuscule difference but I like it.

And what is the risk of 14ml of 1/8th bupi epidurally? Hypotension? Very rare, actually. Our nurses can give ephedrine if need be. Have never seen uterine tetany or high level from this. I HAVE seen uterine tetany and stat section from 1ml of IT local.

More importantly, I think you have a much higher risk of getting called back for a top-up after a CSE an hour or two later than you do from a well-loaded epidural.

 

[Noyac]

And what is the risk of 14ml of 1/8th bupi epidurally? Hypotension? Very rare, actually. Our nurses can give ephedrine if need be. Have never seen uterine tetany or high level from this. I HAVE seen uterine tetany and stat section from 1ml of IT local.

More importantly, I think you have a much higher risk of getting called back for a top-up after a CSE an hour or two later than you do from a well-loaded epidural.

It’s how I choose to practice and I didn’t come to this after only a few years of training and private practice. I am not asking you to change how you do things either. And if you actually knew my outcomes and the number of times I get called back then I would continue this discussion, but you don’t so I will end it here.

 

[deleted162650]

More importantly, I think you have a much higher risk of getting called back for a top-up after a CSE an hour or two later than you do from a well-loaded epidural.

Sorry, but this is fake news. I get far fewer bolus requests for CSE pts than those with straight CLE's. The quality of analgesia is superior after CSE even long after the spinal portion has worn off. I do tell pts they will be extra comfy for the first 60-90mins and that it will back off a little after that as it should.

It seems to me there is a clear pattern emerging here. Those that have had "poor" experiences with CSE's are the ones that have given larger IT doses. Those that give a "mild" IT dose tend to love the technique. Food for thought.

Either way, we are splitting chinchilla pubes here. Both techniques are effective, and as usual - it's the Indian more than the arrow. Discussions like this though are what separate us from the midlevels. We agonize and debate over minutia because we want the very best for our patients and we want to be the very best ourselves. I bet you won't see clinical debate like this over at allnurses.

 

[Twiggidy]

Sorry, but this is fake news. I get far fewer bolus requests for CSE pts than those with straight CLE's. The quality of analgesia is superior after CSE even long after the spinal portion has worn off. I do tell pts they will be extra comfy for the first 60-90mins and that it will back off a little after that as it should.

It seems to me there is a clear pattern emerging here. Those that have had "poor" experiences with CSE's are the ones that have given larger IT doses. Those that give a "mild" IT dose tend to love the technique. Food for thought.

Either way, we are splitting chinchilla pubes here. Both techniques are effective, and as usual - it's the Indian more than the arrow. Discussions like this though are what separate us from the midlevels. We agonize and debate over minutia because we want the very best for our patients and we want to be the very best ourselves. I bet you won't see clinical debate like this over at allnurses.

I stand by this response including the opening sentence (lol).