When do you refuse a labor epidural

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facted said:
Not telling them is malpractice in my opinion. They need to know what to look for, and you should clearly document so the next provider knows how good the headache story is.
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well i explain to all my patients the risk of headache, and severity symptoms etc
 
twoliter said:
How about a patient that has had had back surgery that left her epidural space absent or very scarred but with no neurologic defects now. I think a spinal catheter would be reasonable. (Think no-to-little epidural space from L1-L5.)
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In response to people defending an IT catheter in OB:

Believe me, I am not trying to be harsh or a d*ck, but if you're trying to convince yourself that an IT catheter on an OB patient is ok, I am sorry but I truly believe you're kidding yourself. It is one thing to go ahead and leave a spinal catheter in after an inadvertent wet tap, it is another thing to go for an IT catheter as your initial and primary plan.

In response to twoliter, that would be a terrible idea. Consult for CLE, lady potentially has no epidural space, and you want to place an IT cath? So what happens when she comes in with a debilitating spinal HA? We are consultants and it is ok to say, "You are not a candidate for an epidural." I cannot stand it when a surgeon brings an ASA 5 patient to the OR and says, "Well, I was consulted and I have to do something." I had a patient a few years back for an AKA revision. She came down hypotensive, her lips were pursed in the "O" sign as we call it, and she was clearly ready to move on. She was septic from her AKA wound all the way to her psoas muscle. I told the surgeon that she was likely not going to make it through the surgery and probably not for another 12 hours. He persisted, claimed the above, and we did the case under femoral PNB. She made it through but passed away in the middle of the night.

Anyways, we occasionally get the consult for the lady with prior scoliosis correction who is pregnant. If I do not feel we can go above or below the scars, then I tell her the risk outweighs the benefit. I prefer to see films and it is certainly possible that an epidural can be done depending on what type of lumbar surgery was performed. There was a great thread on this a few months back.

It is hammered into our minds as residents that OB patients pose excessive airway risks. Do they? Sure, but GETA for a C-section is a much, much better plan 99.99% of the time than a spinal catheter. That's just my opinion and I fully understand there are many ways to skin a cat, this to me is almost always the wrong choice to make.
 
I'll concede that example may not have been the best. But you haven't really explained why you think IT catheters are such a terrible option.
 
I'm surprised at the negative reaction to IT catheters.

Obviously it shouldn't ever be the plan for an uncomplicated labor. Or even as plan B for a patient who's simply a difficult/impossible epidural.

But for a patient known or anticipated to be a difficult epidural, with a compelling reason (not just pain relief) to have neuraxial anesthesia, where you want absolute confidence in the catheter ... totally reasonable. Admittedly uncommon.

It's a magnificent anesthetic for both labor and c-section. It needs caution. Clear labeling of catheter, and good turnover if you're relieved. Obviously very high PDPH risk. But everything we do is r:b and there are patients where the benefits outweigh the risk.
 
pgg said:
I'm surprised at the negative reaction to IT catheters.

Obviously it shouldn't ever be the plan for an uncomplicated labor. Or even as plan B for a patient who's simply a difficult/impossible epidural.

But for a patient known or anticipated to be a difficult epidural, with a compelling reason (not just pain relief) to have neuraxial anesthesia, where you want absolute confidence in the catheter ... totally reasonable. Admittedly uncommon.

It's a magnificent anesthetic for both labor and c-section. It needs caution. Clear labeling of catheter, and good turnover if you're relieved. Obviously very high PDPH risk. But everything we do is r:b and there are patients where the benefits outweigh the risk.
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i think they saying, there are very very few reasons to go for intentional IT catheter for OB, when you can just do GA
 
psychbender said:
At my old residency program, we left them in for 24 hours. I can't say if it helped our PDPH or blood patch rate, as residents didn't get a good look at the big picture data.

Sent from my SM-G930V using SDN mobile
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It is a lower risk patient population but we also have a surprisingly low PDPHA after lumbar drains are removed typically 2-3 days postop. And it's a 14g Tuohy hole. We do maybe 20/year and I know of only 1 patient who needed a blood patch in over 5years.
 
nimbus said:
It is a lower risk patient population but we also have a surprisingly low PDPHA after lumbar drains are removed typically 2-3 days postop. And it's a 14g Tuohy hole. We do maybe 20/year and I know of only 1 patient who needed a blood patch in over 5years.
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Odd cause our spinal headache rates after wet tabs on ob is like 40%.
 
anbuitachi said:
Odd cause our spinal headache rates after wet tabs on ob is like 40%.
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Rate of PDPH following wet tap has a lot to do with how diligent your followup is and how you phrase your questions.

If you don't take a temperature you can't find a fever, right?

Some non-zero number of patients just suck it up and get better in a week or so without us ever knowing.
 
nimbus said:
It is a lower risk patient population but we also have a surprisingly low PDPHA after lumbar drains are removed typically 2-3 days postop. And it's a 14g Tuohy hole. We do maybe 20/year and I know of only 1 patient who needed a blood patch in over 5years.
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The kind of patients who get lumbar drains tend to be the kind of patients who stay supine for a while ...
 
pgg said:
The kind of patients who get lumbar drains tend to be the kind of patients who stay supine for a while ...
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We do them exclusively for TEVARs. In uncomplicated cases they are OOB to chair POD1 and the drains are removed POD2.
 
narcusprince said:
1. How did you get burned? 2. Why not do a quick spinal? Get her comfortable then place the epidural. 3. No hard fast numbers if they can stay still they get an epidural.
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So, a quick spinal with bupivacaine (as opposed to just 15-25 mcg Fentanyl) would impact the test dose. They are going to get a bit of a saddle block even with marcaine. Sure, it won't occur as rapidly as with the 1.5% Lido in the test dose, but it does impact your ability to determine IT placement of the catheter.

Thoughts?
 
Magnus67 said:
1cc 0.25% Bupivicaine 25mcg fentanyl for my single shots. I tell them 2hrs if not delivered I'll consider one repeat. Very rarely need too.


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Do you use Bupivicaine from a spinal tray? Or just the bupivicaine which you would use to dose an epidural (because ours says "Not for Spinal use" on the label).

Indeed I do not know the baricity of the epidural labeled marcaine....... I'm 99% sure it does not have dextrose added, so is it isobaric then? I feel I should know this. I will look closer next time.... ugggghhhh
 
GA8314 said:
So, a quick spinal with bupivacaine (as opposed to just 15-25 mcg Fentanyl) would impact the test dose. They are going to get a bit of a saddle block even with marcaine. Sure, it won't occur as rapidly as with the 1.5% Lido in the test dose, but it does impact your ability to determine IT placement of the catheter.

Thoughts?
Click to expand...

GA8314 said:
Do you use Bupivicaine from a spinal tray? Or just the bupivicaine which you would use to dose an epidural (because ours says "Not for Spinal use" on the label).

Indeed I do not know the baricity of the epidural labeled marcaine....... I'm 99% sure it does not have dextrose added, so is it isobaric then? I feel I should know this. I will look closer next time.... ugggghhhh
Click to expand...

"Epidural" bupi is isobaric and is used for SAB's thousands of times every day despite what the label says.

Oh, and test doses are for academics. I CSE everybody and haven't test dosed in a solid 4 years. Arrow caths will not go IT unless your tuohy is through the dura.
 
I do not test dose CSEs. I start the infusion and leave the room.

If by some fluke the Arrow catheter was intravascular, we'll know in an hour when the patient is hurting. No harm done from a slow infusion of low-concentration epidural mix.

If by some fluke the Arrow catheter was intrathecal, we'll know in an hour when the block is denser than desired. No harm done from a slow infusion of low-concentration epidural mix.
 
ok. thanks for the great responses. i really appreciate this.

i'll still do a test dose for intravascular and for documentation i think.
 
Anyone tried spinal with bupiv plus duramorph for these "not candidate for epidural" patients? I would like to, but I'm not sure how well duramorph would work for contraction pain after the bupivacaine wears off.
 
I used to give them all CSEs with Bupi, duramorph, fent and Epi. back in the day. We had to be in the hospital with a running epidural. 🙁 Then I would peace out for a few hours. Bolus epidural when the pain and I returned later. Sometimes I got lucky and she would deliver. 3-4 hours was the norm. Shortest was ~2 with rapidly progressing labor, max was >8 on one chick. I thought she must have delivered and they were calling me about someone else.


--
Il Destriero
 
facted said:
Not telling them is malpractice in my opinion. They need to know what to look for, and you should clearly document so the next provider knows how good the headache story is.
Click to expand...
That's a bold statement!
 
facted said:
On a side note, is anyone leaving in IT catheters for 24hrs? Supposedly far lower headache risk, down to about 10%.
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I have only placed one in my career and that was intentional and I must say unnecessary. It was for a bilateral TKA.
 
Consigliere said:
Why is that sad? Do you know what percentage of anesthesiologists this applies to? I'd say the majority.
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I would hope not.

When I did residency (FM) there were bunches of CRNAs but they never placed the epidurals on our laboring patients. When my wife had our girls at a different hospital, there were lots of CRNAs but the anesthesiologist did the epidural there as well.

Now maybe its a regional thing as both hospitals were in the same state, though different cities.
 
Gaseous Clay said:
In response to people defending an IT catheter in OB:

Believe me, I am not trying to be harsh or a d*ck, but if you're trying to convince yourself that an IT catheter on an OB patient is ok, I am sorry but I truly believe you're kidding yourself. It is one thing to go ahead and leave a spinal catheter in after an inadvertent wet tap, it is another thing to go for an IT catheter as your initial and primary plan.

In response to twoliter, that would be a terrible idea. Consult for CLE, lady potentially has no epidural space, and you want to place an IT cath? So what happens when she comes in with a debilitating spinal HA? We are consultants and it is ok to say, "You are not a candidate for an epidural." I cannot stand it when a surgeon brings an ASA 5 patient to the OR and says, "Well, I was consulted and I have to do something." I had a patient a few years back for an AKA revision. She came down hypotensive, her lips were pursed in the "O" sign as we call it, and she was clearly ready to move on. She was septic from her AKA wound all the way to her psoas muscle. I told the surgeon that she was likely not going to make it through the surgery and probably not for another 12 hours. He persisted, claimed the above, and we did the case under femoral PNB. She made it through but passed away in the middle of the night.

Anyways, we occasionally get the consult for the lady with prior scoliosis correction who is pregnant. If I do not feel we can go above or below the scars, then I tell her the risk outweighs the benefit. I prefer to see films and it is certainly possible that an epidural can be done depending on what type of lumbar surgery was performed. There was a great thread on this a few months back.

It is hammered into our minds as residents that OB patients pose excessive airway risks. Do they? Sure, but GETA for a C-section is a much, much better plan 99.99% of the time than a spinal catheter. That's just my opinion and I fully understand there are many ways to skin a cat, this to me is almost always the wrong choice to make.
Click to expand...

Do the risks outweigh the benefits, no blanket statement either way. But if they are huge and the airway just looks moderate place the IT catheter. And this definitely depends on your OB setup. If you're at a place with close back-up, people available for help it would be OK. OB places I've been to the C-sections were on a separate floor, one anesthesiologist there, staff who didn't know how to help, one tech 7-3.
Placing the IT cath depends on your experience. I haven't seen a true debilitating spinal HA in years, I don't know how a cath vs a wet tap changes that.
I worked at a place that had a high volume spine program, and those ladies came back for their pregnancies. IT catheters worked great. Most pregnant women don't want to be put asleep, although this shouldn't be a factor it is, anyone who has had a kid knows this; if someone told your wife she wouldn't be there when the kid was born but another she would be what do you think she would pick, what do you think when this goes out into the community. GETA is not better than an IT catheter I guarantee you that, OB airways can go south fast, especially if you have no catheter and now she's back for an urgent C-section. Don't really understand the argument, the only downside you've mentioned is 'debilitating spinal headache.' If you can do enough coaching, set expectations it shouldn't be a problem, compare that to their sore throat/eventual ENT evaluation if they're a tough airway. Oh and they can't coo to their baby the way their magazine told them too? Call your lawyer.
 
Consigliere said:
Why is that sad? Do you know what percentage of anesthesiologists this applies to? I'd say the majority.
Click to expand...

Quoted from Apocalypse Now:
Every minute I stay in this room, I get weaker, and every minute Charlie squats in the bush, he gets stronger.

I think we need to be mindful of this analogy. We in ACT practices need to be aware that when labor epidurals are delegated out to CRNA's (sadly, and I do not agree with this structure in my group, but we have 70/30 CRNA/Doc coverage on OB overnight, but we come in for C/S's if a CRNA is in house) and other things...

Ignore the analogy to our practice at your own risk.
 
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