who pulls your labor epidurals?

[Intubate]

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We have been pulling our own (for 30yrs apparently), but have just started having the nurses pull them for us. I'm torn. In general, it will save time and hassle, but there are a couple potentially bad scenarios that I can think of(pulling the epidural on a thrombocytopenic (pre-ex) or coagulopathic (DIC) patient). What do you do?

 

[Consigliere]

Our CRNAs do. They put them in as well. Not worth the time or $$$ for us to do it.

 

[dhb]

The OB nurses after delivery. If the patient is coagulopathic she shouldn't be getting an epidural.

 

[Intubate]

The OB nurses after delivery. If the patient is coagulopathic she shouldn't be getting an epidural.

That's very insightful. Ever heard of any processes during labor/delivery that can lead to DIC?

 

[Dinkyconductor]

Our OB nurses are kind enough to pull them for us. There have been a few times when I've needed to leave them in (for HELLP, DIC, etc.), I just make it clear to the nurses that I don't want it pulled, then put tape all over it writing "DO NOT PULL" on the tape. Then I remind them a few more times not to pull it.

So far, that's been enough, but I'm sure the day will come when they pull it anyway.

We actually had a catheter shear off and the tip was left inside the patient a few weeks ago. I don't know whether this could have been prevented had a physician pulled it, the predominant thinking in our dept was that the catheter was faulty.

 

[Planktonmd]

That's very insightful. Ever heard of any processes during labor/delivery that can lead to DIC?

So, If they are in DIC and you pull the epidural instead of the nurse, how is this going to be better for the patient?
Do you do coagulation studies on every patient before you pull the epidural?
How frequently do you see DIC in your OB patients?

 

[Fooper]

Our OB nurses do it - never had a problem over many years. It is very nice for both us and the patients since we aren't in house. Otherwise, after-hours deliveries would have to wait until the next morning to have us pull the catheters.

 

[Intubate]

So, If they are in DIC and you pull the epidural instead of the nurse, how is this going to be better for the patient?
Do you do coagulation studies on every patient before you pull the epidural?
How frequently do you see DIC in your OB patients?

I'm not sure if you're just being difficult for its own sake or if you really don't get it.

Of course you don't pull the catheter in a DIC patient, that was my point. Like the pre-eclamptic with down-drifting platelets, you leave it in place and pull it later. I don't want a nurse "helping" by removing the catheter before they go to the ICU or something.

Of course I don't get coags on normal patients, but I do if they have DIC. That's part of the management. I also recheck platelets if the patient was low or decreasing to start with. You should too.

I've seen it twice in OB patients. Its well described. I wasn't saying its common, I was just pointing out that having nurses perform a procedure they don't understand might get you in trouble.

 

[militarymd]

who pulls them?

WHO CARES?

I don't

 

[2win]

who pulls them?

WHO CARES?

I don't

The enviromental guys in my place - they are better than my OB nurses...

 

[Arch Guillotti]

The nurses pull ours. Part of our paperwork is a protocol sheet we must sign detailing any preferences we might have about pulling the catheter - pull it out without further ado, get platelets first, call us, etc. They will not pull a catheter without this sheet being signed.

 

[dhb]

That's very insightful. Ever heard of any processes during labor/delivery that can lead to DIC?

At that point pulling the epidural shouldn't be your main concern 😕

 

[dhb]

I also recheck platelets if the patient was low or decreasing to start with. You should too.

Ok let's say you have a patient with 115.000/mm3 platelets pre-epidural (fairly common) normal coag, are you going to check platelets before pulling the epidural? 😕

 

[jwk]

Our OB nurses do it. Never a problem. Much ado about nothing.

 

[cchoukal]

The nurses pull ours. Part of our paperwork is a protocol sheet we must sign detailing any preferences we might have about pulling the catheter - pull it out without further ado, get platelets first, call us, etc. They will not pull a catheter without this sheet being signed.

This seems like a sensible approach. That way, none of your verbal instructions, writing on tape, etc, get lost in shift change or get forgotten (or at the very least, there's a paper trail and a physician order).

FWIW, at the U of Chicago, the L and D nurse pulls them, unless the pt is intending to have a PPTL, although sometimes they get pulled even in that group (which is why I think the order sheet might be helpful).

 

[Planktonmd]

Of course you don't pull the catheter in a DIC patient, that was my point. Like the pre-eclamptic with down-drifting platelets, you leave it in place and pull it later. I don't want a nurse "helping" by removing the catheter before they go to the ICU or something.

What I was trying to say: If the patient is in DIC or coagulopathic for any other reason then someone should know about it (preferably you) and tell the nurses not to pull the epidural!
Otherwise it doesn't matter who pulls the catheter.

 

[dhb]

Intubate?