Rapid Epidural Lidocaine Onset

[soorg]

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I saw someone do this about a year ago: STAT CS, pt. with running epidural, goes to OR. After neg test dose, put patient in slight Trendelenburg, and push 15-20cc 2% Lido with epi as fast as you can. Got a T4 level in 2 minutes. Avoids having to use 3% chlorprocaine.

Anybody else seen this? I've done it a few times myself; works really well, although, as usual, must be certain that the catheter is in the epidural space before pushing all that LA.

 

[Planktonmd]

I saw someone do this about a year ago: STAT CS, pt. with running epidural, goes to OR. After neg test dose, put patient in slight Trendelenburg, and push 15-20cc 2% Lido with epi as fast as you can. Got a T4 level in 2 minutes. Avoids having to use 3% chlorprocaine.

Anybody else seen this? I've done it a few times myself; works really well, although, as usual, must be certain that the catheter is in the epidural space before pushing all that LA.

This is exactly what I do everyday!
Even for routine C sections for failed labor with an existing epidural.
I give the whole dose of (Lidocaine + Bicarb + Epi) that I think the patient is going to need one shot and it works almost as fast as a spinal.

 

[jwk]

Ditto here - do it every day. If we can get to the labor room before they head down the (long) hall/haul to the OR, we can usually get an acceptable level before the incision.

I didn't think anyone was still using chloroprocaine - I haven't used it in more than 15 years.

 

[aredoubleyou]

thanks for the posts! This would be heresy at my program...but ive always wondered why not do this.

also, plank - how much bicarb? How important do you think it is for epidural onset?

 

[Planktonmd]

thanks for the posts! This would be heresy at my program...but ive always wondered why not do this.

also, plank - how much bicarb? How important do you think it is for epidural onset?

1 cc bicarb for each 9 cc of Lido.
I think it makes Lidocaine work faster but It might be pure Voodoo

 

[proman]

1 cc bicarb for each 9 cc of Lido.
I think it makes Lidocaine work faster but It might be pure Voodoo

What does this make the pH? Bicarb has a pH of 8.5 and our 2% lidocaine with epi is 4.5.

I don't add bicarb to the 2% lidocaine without epi because that has a pH of 6.5 (but then I have to add the epi).

 

[jwk]

1 cc bicarb for each 9 cc of Lido.
I think it makes Lidocaine work faster but It might be pure Voodoo

When dosing for C/S with an epidural in place, I squirt 2cc of bicarb into the 20cc glass vial of Lido 2% /c epi - a little faster than having to measure it up as I draw up meds out of two different bottles. I do think it speeds things up when using Lido /c epi, but doesn't seem like it does anything for the plain Lido, I guess because of the difference in pH anyway. For an emergent C/S I'll just use 2% plain since I don't want to take the time to mess with mixing anything.

 

[BDanes]

I haven't done ob in a while, but I personally hate epidural vs spinal for c/s. I know you have to use it when you've got it, but I hate dealing with the patient during uterine evac/closure. I give small doses of ketamine. Opioids never seem to work as well.

What do you guys use for this aspect of the epidural section? Never done the 15-20cc bolus, but will try it next time.

 

[dhb]

18 ml 2% lido+epi + 2 ml NaHCO3 almost always gets it done.

The problem is generally not the level of the block but the intensity. I recently had a spinal for an ACL repair and i was amazed by the level of "feel" that is preserved, i thought the block would be more profound.

I can fully understand that the amount of pulling involved must be very uncomfortable under epidural anesthesia.

 

[Mman]

My usual cocktail for dosing up a labor epidural for c-section.

Lidocaine 2% + epi with 2 mls of Bicarb added to a 20 ml syringe. Ends up being about 21 mls (19 lidocaine, 2 bicarb) in the syringe.

Depends on how urgent the c-section is. If I've got a little time, I'll incrementally dose it. First I put 100 mcgs of Fentanyl down the epidural and then 5 mls of local. 4-5 minutes later I'll put another 5 mls of local down it. At this point we are hopefully back in the OR and on monitors. I'll being cycling the cuff and checking a level. If it's not already at T6, I'll give another 5 mls.

The majority of the time, 15 mls is plenty to get a good level for a c-section and to not cause too much hypotension. Sometimes the patients have a dense block to T4 with only 10 mls and I stop there, but that is fairly rare. If 15 mls was enough to get us going, I'll reserve the last 5 mls for a point in the procedure where the patient is uncomfortable.


If I'm in a real hurry and it's either the epidural works quick or they are getting a tube, I'll just push 15-20 mls as a bolus while wheeling down the hallway and hope it works before they cut skin.

 

[silvester78]

This is exactly what I do everyday!

it works almost as fast as a spinal.

Does this "massive" administration of epidural local anesthetic lower the arterial blood pressure as a spinal does? How often have to use some ephedrine (or sth like that)? Or is the pretreatment with fluids enough to keep an acceptable Blood pressure most of the times?

 

[jwk]

Does this "massive" administration of epidural local anesthetic lower the arterial blood pressure as a spinal does? How often have to use some ephedrine (or sth like that)? Or is the pretreatment with fluids enough to keep an acceptable Blood pressure most of the times?

Who says it's a massive dose?

If the pressure drops, we treat it and move on. No big deal.

 

[jwk]

Agree that spinals are preferred for C-section as opposed to Epidural, but with a labor epidural that has worked well, 18 ml 2% lido+epi + 2 ml NaHCO3 almost always gets it done. Maybe a coupla ml less if they are very short or a coupla more if very tall.

I would humbly disagree that spinals are preferred. We use epidurals on virtually all of our C/S patients -and we do more than 5000 of them a year. Those patients then get the benefit of post-op epidural narcotics with a pump for 24-36 hrs.

 

[silvester78]

Who says it's a massive dose?

I used the word "massive" for the rapid administration of the full epidural dose. This is something I 've never done (I don't do Obstetrics, so I have the time to give incremental dosing).

 

[paiute]

thanks for the posts! This would be heresy at my program...but ive always wondered why not do this.

also, plank - how much bicarb? How important do you think it is for epidural onset?

I dilute the 2% lidocaine down to 1% with a 50:50 mix of bicarb, then I add 50 mcg of fentanyl and push it in 5-10 ml increments, waiting about 1-3 minutes between each dose. Pushing the whole thing at once might increase your chances of a seizure (happened to a partner).
Also, let me add that pushing the dose through a needle (fast push) seems to open up the epidural space and produce a denser block. The catheter push, even using lots of pressure, is slow and doesn't open up the space as well (the block is patchy).

 

[pseudomarc]

Provided you have a good epidural that has been tested, lidocaine with adrenaline and bicarbonate works beatifully. Where I work we mix 20ml lidocaine 2%, 2ml preservative-free bicarb 8.4% and 0.1ml epi 1:1000.

15-25ml of that gets the job done. I usually add fentanyl 100mcg for good measure, plus diamorphine 2.5-3mg at the end for long-lasting pain relief. If you push the whole volume in one go, you'll have a good block in 4-5 minutes almost every single time. It causes hypotension, perhaps a bit less than a spinal, but you can treat that easily as you would for a spinal.

Of course you MUST test the block before allowing the surgeons to proceed. In the rare occasions the block in not quite good enough, you can consider putting in a spinal at that stage (if you have the time).

Then you are faced with the interesting dilemma of how much local to put down a spinal in those circumstances. But that's a different story...

PS: Hi everybody. I'm a 2nd year resident lurking from somewhere in Britain. After a year of doing so much obstetric anaesthesia that it's coming out of my ears, I couldn't resist adding my 2p's worth...