"Top off"/ rescue epidural doses

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Mike1228

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About 3 weeks into my OB rotation
What's everyone's go-to top off/rescue dose for labor epidurals when block level has fallen and the mother is pain? I feel like a common/easy one is 5-10 Cc of 1% lido. I started to experiment with 1% lido/ 0.25% bupivacaine or 1% lido/ 0.1% Ropivicaine (we use 0.2% Ropi infusions at this site). Lido gives a little faster onset while the bup or ropi carries through longer. Plus each drug diluted allows for more volume to be given

Opinions??
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Give higher percent ropi or bupi for pain due to not a dense enough block. I give 0.25% bupi for this type of pain, plus or minus fentanyl, typically occurs around late stage 1 with discomfort from baby descending or just not enough density to cover contraction pain.

if block is not high enough just give more volume, higher volume from the bag or dilute local, typical 1/16 or 1/8 percent bupi:
 
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I'm on OB too and highly suspect that the overnight people just get loaded up with 2% lido cause every morning around 8 or 9am we start getting called for more and more boluses. Course it doesn't help that the current place doesn't use multi orifice catheters, nor do they give the women a pcea function, NOR are they very enthusiastic about replacing catheters! As it stands I've burned myself more than enough times with Lido and the women end up thinking that it's the only thing that works.
 
MirrorTodd said:
I'm on OB too and highly suspect that the overnight people just get loaded up with 2% lido cause every morning around 8 or 9am we start getting called for more and more boluses. Course it doesn't help that the current place doesn't use multi orifice catheters, nor do they give the women a pcea function, NOR are they very enthusiastic about replacing catheters! As it stands I've burned myself more than enough times with Lido and the women end up thinking that it's the only thing that works.
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The fabled "lidocaine junkie".
 
Just to reiterate what everyone else said, if you’re using lido to top off epidurals...don’t. Also, mixing different local anesthetics for this purpose is overly complicated and unnecessary. If the levels are inadequate, just top it off with more epidural solution - 0.2% ropi in your case. Almost every pump has a clinician bolus function hidden behind a menu. You don’t even need to draw up ropi. You can just bolus straight from the pump.

All of this is of course assuming the pain is from inadequate levels. Pain due to hotspots or patchiness is a different discussion.
 
SaltyDog said:
These aren’t any better than single orifice, and in some cases, may be worse.

Arrow spring wound caths FTW
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I'm putting that theory to the test next week. Only using multi orifice catheters in my epidurals since the hospital has them, just not in the kits. The other resident is gonna us the standard ones. Both are spring wound.
 
MirrorTodd said:
I'm putting that theory to the test next week. Only using multi orifice catheters in my epidurals since the hospital has them, just not in the kits. The other resident is gonna us the standard ones. Both are spring wound.
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100% gaurentee it won’t matter. As long as catheter is in the epidural space and running appropriate mix there shouldn’t be a difference.
 
MirrorTodd said:
I'm on OB too and highly suspect that the overnight people just get loaded up with 2% lido cause every morning around 8 or 9am we start getting called for more and more boluses. Course it doesn't help that the current place doesn't use multi orifice catheters, nor do they give the women a pcea function, NOR are they very enthusiastic about replacing catheters! As it stands I've burned myself more than enough times with Lido and the women end up thinking that it's the only thing that works.
Click to expand...
This sounds the worst possible scenario to cover labor epidurals overnight
 
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I've heard of people using 10 cc of straight saline. Personally if I'm accessing the catheter, and not doing a clinician bolus off the pump, I'm putting something dilute in there, generally 1/8th bupi. Rarely will use .25% bupi. During residency I got forced into the whole rigamarole of call backs every 2 hours because a dense block from .5% bupi wore off, and I vowed to not let that happen as an attending.
 
The only time I give lido is as the last ditch effort to see if the catheter works at all before I decide to replace it.

If the patient has some sort of level after getting lido, the catheter is in the right place. If patient still gets nothing, then it confirms that the catheter is not in the epidural space, and I replace it.

You can say the same thing for 0.25% bupi, but 2% lido works so much faster. On busy nights, I do not have the time to wait around for 0.25% bupi to kick in.
 
Mike1228 said:
About 3 weeks into my OB rotation
What's everyone's go-to top off/rescue dose for labor epidurals when block level has fallen and the mother is pain? I feel like a common/easy one is 5-10 Cc of 1% lido. I started to experiment with 1% lido/ 0.25% bupivacaine or 1% lido/ 0.1% Ropivicaine (we use 0.2% Ropi infusions at this site). Lido gives a little faster onset while the bup or ropi carries through longer. Plus each drug diluted allows for more volume to be given

Opinions??
Click to expand...
10cc syringe of 5cc 2% lido, 5cc bupi .25 mixed together. I usually give 8-10cc of that concoction.

I was taught the rule of 10s (no one else has heard of this apparently)

10cc of 2% lido should give you a T10 level in 10 minutes. I have found this to be true clinically if the catheter is working. If no level after 10cc of 2% lido, catheter does not work.
 
I also introduce to patients when I'm placing the epidural that, as labor progresses as baby's head comes down, we aren't gonna be able to take away that pressure pain. But you're close, hang in there! I think setting expectations can help at the end....with most reasonable patients.
 
linkin06 said:
I also introduce to patients when I'm placing the epidural that, as labor progresses as baby's head comes down, we aren't gonna be able to take away that pressure pain. But you're close, hang in there! I think setting expectations can help at the end....with most reasonable patients.
Click to expand...

Yes! I hate it when the ob nurse calls me for pain and I ask them when they were last checked and they give me attitude. Then the patient delivers ten minutes later. Like isn't this basically your only job? How are you so bad at it? God I don't miss ob at all.
 
DocVapor said:
I've heard of people using 10 cc of straight saline. Personally if I'm accessing the catheter, and not doing a clinician bolus off the pump, I'm putting something dilute in there, generally 1/8th bupi. Rarely will use .25% bupi. During residency I got forced into the whole rigamarole of call backs every 2 hours because a dense block from .5% bupi wore off, and I vowed to not let that happen as an attending.
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I have heard of people giving 0.5% bupi, it’s a ridiculous thing to do.

I’ll occasionally give 0.25% for a denser block but only as they get to 7-10 cm, any earlier and your killing yourself, need to set expectations as noted above. 0.125% should be sufficient for stage 1 in 95% of people.

I also always try to check a level once after I place the epidural to confirm that I have good bilateral coverage.
 
7 cc .25 bup with 50 fentanyl. Sometimes when they are like 8 cm that 50 fentanyl sub q absorption gets em through even if the catheter is free floating somewhere
 
Giving 10cc of 2% Lidocaine for laboring patients is like giving 10mg Metoclopramide for acutely nauseated patients in PACU. Both are terrible and antiquated practices which should be retired, like the woefully outdated anesthesiologists doing them.
 
Zekchar said:
Giving 10cc of 2% Lidocaine for laboring patients is like giving 10mg Metoclopramide for acutely nauseated patients in PACU. Both are terrible and antiquated practices which should be retired, like the woefully outdated anesthesiologists doing them.
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How much ob do you do?
 
Very busy OB service here (~7K/yr) and you are alone overnight. If I didn’t personally place the epidural then I will commonly top up with 10cc 2% lido. I don’t have the time to mess around and need to know if catheter is working in case the patient becomes a crash section.

If I personally placed the catheter then I will typically give 0.5% bupi +/- lido, fent, bicarb depending on the patient’s status.

It’s all voodoo anyway.
 
Zekchar said:
Giving 10cc of 2% Lidocaine for laboring patients is like giving 10mg Metoclopramide for acutely nauseated patients in PACU. Both are terrible and antiquated practices which should be retired, like the woefully outdated anesthesiologists doing them.
Click to expand...
lol wut
 
Guys I said 1% lido as an option, not 2%. Hell, you would use 2% lido to convert a labor epidural to a surgical epidural, thats way too dense of a block haha, kind of over kill. 1% lido will still give the quick onset but won't as dense.
I think I might just dilute my Ropi down to 0.1% for all top off doses. Yet, use 1% Lido only for mothers close to giving birth experiencing that sacral nerve pain, some quick relief
 
Mike1228 said:
Guys I said 1% lido as an option, not 2%. Hell, you would use 2% lido to convert a labor epidural to a surgical epidural, thats way too dense of a block haha, kind of over kill. 1% lido will still give the quick onset but won't as dense.
I think I might just dilute my Ropi down to 0.1% for all top off doses. Yet, use 1% Lido only for mothers close to giving birth experiencing that sacral nerve pain, some quick relief
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I stand by what I said, lidocaine should not be used. Use a longer acting local anesthetic.
 
Fentanyl is a waste of time and can cause fetal bradycardia with large doses. I'll never understand why some labor nurses give multiple fentanyl doses to patients before calling for the epidural. Local is king. Yeah and don't give lidocaine to mask your ****ty epidural or appease difficult patients. That's like turning up the oxygen to 100% rather than knowing why the patient is desatting.
 
I think almost all local anesthetics have their place with an epidural. I have used 2% lidocaine plenty of times on someone that is near delivery, never use it early on in labor. Usually give boluses with 1% lidocaine or 1/4% Bupivacaine. Sometimes use 0.5% bupivacaine. Sometimes add fentanyl to the bolus.
 
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I like to make a 10cc mixture of 1/4% bupi with 100mcg of fentanyl in there. Give 5-10cc depending on how much height you need. Empirically covers sacral sparing pain with the fentanyl, density issues with the 1/4%, and block height with the 10cc volume. Never had to be woken back up after that.
Still a resident but not for much longer fwiw.
 
Mman said:
I think almost all local anesthetics have their place with an epidural. I have used 2% lidocaine plenty of times on someone that is near delivery, never use it early on in labor. Usually give boluses with 1% lidocaine or 1/4% Bupivacaine. Sometimes use 0.5% bupivacaine. Sometimes add fentanyl to the bolus.
Click to expand...
Have you observed any motor deficit from lidocaine that makes it difficult for patients to push?

I’ve been always told that lidocaine causes greater motor block than bupivicaine or ropivicaine, so I was taught to avoid it when patients are near delivery.

Anybody know if this is true, and if so, why is that?
 
I usually give 100mcg fent + 5cc 0.25% bupi for a top off. If I didn't put in the catheter, I test for a level with ice before giving the dose.
 
This thread is hilarious. There is a lot of nerdy silliness here and I can assure you almost none of it makes a difference. Close your eyes, open the drawer and give 5 ccs of whatever local you grab first and go back to bed. Your epidural is either working or it’s not.
 
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SaltyDog said:
These aren’t any better than single orifice, and in some cases, may be worse.

Arrow spring wound caths FTW
Click to expand...
Love these and can't remember if I have even had one intravascular catheter since the switch many years ago.

I had a colleague who placed one last month and got blood back. Replaced at a different level and got blood back again! I recommended watching closely with frequent checks for epidural hematoma but nothing ever came from it. I am assuming it was more of a venous sinus than vessel. Other thoughts on what you would have recommended?
 
Zekchar said:
Giving 10cc of 2% Lidocaine for laboring patients is like giving 10mg Metoclopramide for acutely nauseated patients in PACU. Both are terrible and antiquated practices which should be retired, like the woefully outdated anesthesiologists doing them.
Click to expand...
So I know what you don't like, but what do you give? I endorse pulling the catheter back matters more than anything. Follow this up with a bolus of almost any of the above solutions. If the patient doesn't develop and maintain a good level with that, then the catheter needs pulled and replaced. You and her will be much happier much sooner.
 
j bones said:
I like to make a 10cc mixture of 1/4% bupi with 100mcg of fentanyl in there. Give 5-10cc depending on how much height you need. Empirically covers sacral sparing pain with the fentanyl, density issues with the 1/4%, and block height with the 10cc volume. Never had to be woken back up after that.
Still a resident but not for much longer fwiw.
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You have either discovered the holy grail of top-offs or the nurse didn't call you for other reasons. Speaking of, I would also caution against giving someone Fentanyl 100 mcg and walking off (it is essentially the same as giving IV and likely your MOA). I can imagine that with labor pain they will be fine, but I could see it adversely affecting mom/baby in your future but I hope not.

(triple post hat-trick FTW)
 
Mike1228 said:
About 3 weeks into my OB rotation
What's everyone's go-to top off/rescue dose for labor epidurals when block level has fallen and the mother is pain? I feel like a common/easy one is 5-10 Cc of 1% lido. I started to experiment with 1% lido/ 0.25% bupivacaine or 1% lido/ 0.1% Ropivicaine (we use 0.2% Ropi infusions at this site). Lido gives a little faster onset while the bup or ropi carries through longer. Plus each drug diluted allows for more volume to be given

Opinions??
Click to expand...
We've litigated quality of epidurals in another thread so I won't go into that.

If you're giving 1% lidocaine for epidural top offs then your attendings haven't taught you anything on OB rotation and you're wasting your time. Epidural top offs are quite simply some version of bupivacaine (0.25% or 0.5% depending on what is stocked). You can give like 6 cc of 0.25% bupivacaine and you'll catch up to any pain. If you need repeated top offs, check what the infusion rate (and the concentration of the solution), as I've come across many who I personally think run them too low. Maybe the only place I think 2% lido has during a labor epidural is a check to if the epidural is working. If you give 2% lido (like 4 cc) they should get some sort of motor block, maybe not full, but something (and you'll also probably drop their pressure some). At that point the block likely works and as said above a conversation is need on what is "normal to feel". Some patients perceive strong pressure as pain and will as for "top offs" all night. Sometimes I'll even throw in, "if I give too many of these you won't feel any contractions, which means you wont push, which increases the chances of a c-section". That tends to bring them around, but the caveat is you also want them comfortable, because comfortable patients have increase chances of successfully delivery, in my non-researched opinion.
 
BobLoblaw78 said:
So I know what you don't like, but what do you give? I endorse pulling the catheter back matters more than anything. Follow this up with a bolus of almost any of the above solutions. If the patient doesn't develop and maintain a good level with that, then the catheter needs pulled and replaced. You and her will be much happier much sooner.
Click to expand...

Facts:
1) Lidocaine has a greater (concentration equivalent) motor block than Bupi/Ropi
2) Goals of care on labor and delivery is to maximize sensory block while minimizing motor block
3) Lidocaine onset is faster than Bupi/Ropi
3a) a 5 minute speed of onset difference over the course of a multi hour labor process is irrelevant
4) I can achieve everything I need in a laboring patient with use of Bupi/Ropi

Exception:
If your partner has placed a crappy epidural and has bolused it in a sub-par fashion with subpar concentrations of Bupi or subpar volume of Bupi, 10cc of Lidocaine should delineate whether the epidural is appropriately positioned by profound lower extremity motor block.

Conclusion:
Lidocaine bolusing should not be in routine use on labor and delivery for top offs. There is a role for it in confirming catheter placement and of course when transitioning from labor epidural to C-Section, but it should not be a standard top off dose.
 
Twiggidy said:
We've litigated quality of epidurals in another thread so I won't go into that.

If you're giving 1% lidocaine for epidural top offs then your attendings haven't taught you anything on OB rotation and you're wasting your time. Epidural top offs are quite simply some version of bupivacaine (0.25% or 0.5% depending on what is stocked). You can give like 6 cc of 0.25% bupivacaine and you'll catch up to any pain. If you need repeated top offs, check what the infusion rate (and the concentration of the solution), as I've come across many who I personally think run them too low. Maybe the only place I think 2% lido has during a labor epidural is a check to if the epidural is working. If you give 2% lido (like 4 cc) they should get some sort of motor block, maybe not full, but something (and you'll also probably drop their pressure some). At that point the block likely works and as said above a conversation is need on what is "normal to feel". Some patients perceive strong pressure as pain and will as for "top offs" all night. Sometimes I'll even throw in, "if I give too many of these you won't feel any contractions, which means you wont push, which increases the chances of a c-section". That tends to bring them around, but the caveat is you also want them comfortable, because comfortable patients have increase chances of successfully delivery, in my non-researched opinion.
Click to expand...
Lol. Same explanation, posted 1 min apart.
 
Twiggidy said:
We've litigated quality of epidurals in another thread so I won't go into that.

If you're giving 1% lidocaine for epidural top offs then your attendings haven't taught you anything on OB rotation and you're wasting your time. Epidural top offs are quite simply some version of bupivacaine (0.25% or 0.5% depending on what is stocked). You can give like 6 cc of 0.25% bupivacaine and you'll catch up to any pain. If you need repeated top offs, check what the infusion rate (and the concentration of the solution), as I've come across many who I personally think run them too low. Maybe the only place I think 2% lido has during a labor epidural is a check to if the epidural is working. If you give 2% lido (like 4 cc) they should get some sort of motor block, maybe not full, but something (and you'll also probably drop their pressure some). At that point the block likely works and as said above a conversation is need on what is "normal to feel". Some patients perceive strong pressure as pain and will as for "top offs" all night. Sometimes I'll even throw in, "if I give too many of these you won't feel any contractions, which means you wont push, which increases the chances of a c-section". That tends to bring them around, but the caveat is you also want them comfortable, because comfortable patients have increase chances of successfully delivery, in my non-researched opinion.
Click to expand...
I have always felt that repeated top-offs are done to reach changeover so the problem is passed on. Additionally, I can't trust that epidural if it goes to c-section. The answer to both of those is to pull and replace. I make exceptions for those that appear 2 hours away from delivering.

In regards to rate- try programmed intermittent boluses. They work better
 
Zekchar said:
Lol. Same explanation, posted 1 min apart.
Click to expand...
C6A01C32-E094-4940-93DE-5E1F3AD136D4.gif
 
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