walking epidurals

[willie sutton]

Question for the old pro's:

How high a concentration of bupi can you give and still maintain a 'walking epidural?'

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[Planktonmd]

The best way to do that is doing CSE:
You put fentanyl only in the spinal and place the epidural catheter and allow her to ambulate.
This should give several hours of analgesia until she gets uncomfortable, then you bolus the epidural and she stops walking.
My advice: Don't mess around with epidural bupivacaine and walking, and better yet don't do walking epidurals.

 

[Noyac]

I think they are a bad idea in most situations.

 

[VolatileAgent]

I think they are a bad idea in most situations.

agreed.

epidural in -> bedrest. or, wait until someone slips and fails and sues you, like one of the PP guys who guest-attends at our institution has had happen to him.

 

[powermd]

The best way to do that is doing CSE:
You put fentanyl only in the spinal and place the epidural catheter and allow her to ambulate.
This should give several hours of analgesia until she gets uncomfortable, then you bolus the epidural and she stops walking.
My advice: Don't mess around with epidural bupivacaine and walking, and better yet don't do walking epidurals.

Have you noticed any problems with decels and fentanyl-only spinals in pregnant women? Last night my attending was discussing how nobody can figure out why solo fentanyl intrathecal causes decels in patients, yet it's less common (but still occurs) when fentanyl is given with bupivicaine. Epidural clonidine supposedly has a risk of 30% of patients developing fetal decels. That makes some sense if clonidine passes to the fetus. I haven't looked any of this up myself, but this particular attending is like a walking encyclopedia of medicine, so I suspect his assertions are well founded. This came up after I suggested doing a CSE on an uncomfortable woman ~5 cm dilated (multiparous) having scattered late decels. My attending wanted me to do a straight epidural so future decels wouldn't be blamed on our spinal injection (I would have done 2.5 mg bupi with 20 mcg fent). The literature suggests this has something to do with fetal head engagement vs disengagement- if it's not engaged, decels are more common. The mechanism of this phenomenon is something of a mystery.

In response to the walking epidural issue- all our patients are on bedrest once the epidural goes in. It makes sense that you would be wide open to a lawsuit if a patient fell with a so-called walking epidural.

 

[Planktonmd]

Have you noticed any problems with decels and fentanyl-only spinals in pregnant women? Last night my attending was discussing how nobody can figure out why solo fentanyl intrathecal causes decels in patients, yet it's less common (but still occurs) when fentanyl is given with bupivicaine. Epidural clonidine supposedly has a risk of 30% of patients developing fetal decels. That makes some sense if clonidine passes to the fetus. I haven't looked any of this up myself, but this particular attending is like a walking encyclopedia of medicine, so I suspect his assertions are well founded. This came up after I suggested doing a CSE on an uncomfortable woman ~5 cm dilated (multiparous) having scattered late decels. My attending wanted me to do a straight epidural so future decels wouldn't be blamed on our spinal injection (I would have done 2.5 mg bupi with 20 mcg fent). The literature suggests this has something to do with fetal head engagement vs disengagement- if it's not engaged, decels are more common. The mechanism of this phenomenon is something of a mystery.

In response to the walking epidural issue- all our patients are on bedrest once the epidural goes in. It makes sense that you would be wide open to a lawsuit if a patient fell with a so-called walking epidural.

If I remember correctly there was some data about prolonged decelerations after intrathecal (Fentanyl + Bupivacaine) in the context of CSE for labor, and there was also data about fetal decelerations after IV Fentanyl in Parturients, both these things make physiological sense ( Uterine hypo perfusion for the first and fetal fentanyl effect for the second).
There was also some data about uterine tetany after intrathecal Fentanyl given late in labor.
I don't recall any solid data about Fentanyl given alone intrathecally causing decelerations, but any effective analgesia, especially if fast acting like a spinal, could cause rapid engagement of the head, because of pelvic relaxation, and consequently cause variable decelerations.
Anyway I am in no way a "walking encyclopedia" like your attending, and this is why he is a big shot academic guy and I am a simple private practice anesthesiologist
Returning to the main subject, I don't like walking epidurals, and I haven't done one in years, but if for any mysterious reason you find yourself compelled to do one, I still think the safest way would be a CSE with a narcotic only spinal during the ambulatory period followed by bupivacaine epidural and bed rest.

 

[Noyac]

One of my fellow residents in New Mexico started a study while we were residents. It compared CSE's. Group one was Fent 20mcg with 2.5mg Bupiv, group 2 was fent 20mcg only an group 3 was saline. He stopped the study early b/c the fent only group had a much higher incidence of fetal decel's and nausea. This study was never completed but it did make an impression on me. I still use fent only from time to time but I mostly notice that these pts really itch more than the combined fent and bupiv CSE's. If I ever decided to do a walking epidural, it would be fentanyl only in the spinal and bedrest the minute the epidural bupiv started.

 

[VentdependenT]

You ever bust out a merperidine neuraxial? From my little books its supposed to give a good sensory and even motor block at 1mg/kg intrathecally. We use Fent/Bup/Morphine for CSE for c-section and 2.5mg (1ml of 0.25%bupie) with 25ucg fenty for the spinal portion of a CSE for labor. We do "dilute" the latter with CSF to give a bigger volume and hit smore dermatomes. Seems to work.