Discussions for Module 5 : CSE and Mobile Analgesia for Labour

Questions are answered by module author: Eric Goldszmidt MD FRCPC

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Question:

Is Ropivacaine 1.5 mg plus 20 mcg of fentanyl appropriate for CSE. I have been using Ropivacaine instead of Bupivacaine for years

Sept 23, 2013 at 08:54, A.M.

Dr. Goldszmidt replies:

Thank you for your question.

Ropivacaine is certainly an acceptable alternative to bupivacaine for CSE for labour. In determining your dose, however, you must take into account that ropivacaine is less potent than bupivacaine by a factor as high as 0.6. The 1.5 mg dose you quote may be equipotent to approximately 1 mg of bupivacaine and is low in my experience. If I were to use ropivacaine for a CSE, my dose would be 2.5-3 mg. 

 

Question:

Can we use small doses of IV midazolam/fantanl for an uncooperative patient while placing an epidural? 

April 26, 2013 at 08:54, M.S.

Dr. Goldszmidt replies:

Thank you for your question.

In my experience, it is extremely rare that a patient requesting an epidural will be so uncooperative as to require IV sedation and nearly all women can manage to be still between contractions with some coaching and good support from partner and/or nurse, however, it does occur occasionally and there are a number of options.

First, I recommend being sure that the reason for lack of cooperation is not that delivery is imminent and that in fact there is no time for an epidural.

Second, sedation options include using N20 (if available) or IV fentanyl. Usually, if I am going to do this, I give 100 mcg of fentanyl. It is important that you explain to the patient what you are proposing and that she agrees. I strongly recommend against midazolam in labour because of the antegrade amnesia which patients find very distressing as their recall of events is poor and they are usually quite upset afterwards if they have inadequate recollection of the birthing process. We never administer midazolam without explicitly explaining the amnesia issue and getting a clear consent. We have even removed it from the carts in our csection ORs. I have never used it in labor for this or any other indication.

A final option is to do a CSE using a two needle technique i.e first do a single shot spinal then do the epidural. Just remember that the plain bupivicaine we use is slightly hypobaric and will rise if the patient sits for a prolonged time to do the sequential technique. I do not use this method, myself but am aware that others have.

I hope that answers your question.

 

Question:

In my hospital we do not use tocolysis, so for women who are very distressed and are unable to sit still, I do perform a two level CSE with bupivacain 0.25 and no Fentanyl in the spinal, then the epidural with a relaxed gravida one level higher. Do you think I should give Fentanyl as well and what are your views on the two level approach? Thank you for your reply.

Jan. 3, 2010 at 15:53, D.M.

Dr. Goldszmidt replies:

Thank you for your questions. In my experience, there are very few patients who cannot actually sit still enough for an epidural. Perhaps once per year, I do have one who is so out of control that I actually use 100 mcg of IV fentanyl prior to doing the procedure. I have never used a single shot spinal in this situation and wonder if you can do the spinal, why not the full procedure?

Regarding the two-level technique, if one lacks the equipment to do a needle-through needle technique, it is an acceptable alternative. The only theoretical downsides are twofold. First you lose the potentially protective effect of using the spinal needle as a check on the position of the epidural needle in difficult cases and secondly, the patient, who receives plain bupivacaine (which is actually hypobaric) spends longer out of the supine position than with a single level technique which allows more time for the spinal block to set in an assymetric manner.

I would consider adding the fentanyl to the spinal cocktail and lowering the dose of local anesthetic. The fentanyl, either intrathecal or epidural, is a local anesthetic sparing agent with a rapid onset and is of value regardless of the neuraxial technique being used. Currently, I use 1.75 mg of plain bupivacaine with 15 mcg of fentanyl. We have found that higher doses, do not provide better analgesia but do result in an unacceptably high rate of fetal bradycardias. (Whitty R, Goldszmidt E, Parkes R.K., Carvalho J.C.A. Determination of the ED95 for intrathecal plain bupivacaine combined with fentanyl in active labor. Int J Obstet Anesth 2007; 16: 341-5).

 

Question:

I have experience with some patients complaining of severe perineal pain with prolonged second stage of labor despite complete sensory and motor block. How would you deal with this problem?

Nov. 23, 2005 at 12:59, U.T.

Dr. Goldszmidt replies:

I believe that this type of breakthrough pain is indicative of dysfunctional labor and is a potential risk factor for the need for instrumental or operative delivery. In dealing with this pain, I usually resort to higher concentration local anesthetics. Usually 0.25% bupivacaine is effective. If not, I may try 2% lidocaine. Sometimes, I also add fentanyl (100 mcg). The sacral nerves are thicker and may require higher concentrations than those that were necessary for the thoraco-lumbar nerves.

 

Question:

Sometimes you get to the epidural space and you have (-) csf and when you do the spinal(27G whitacre) through the epidural needle and you inject your spinal dose,when you remove the spinal needle you notice slow dripping from the epidura hub!? What are the poss exp?

Nov. 23, 2005 at 12:57, Y.M.

Dr. Goldszmidt replies:

There are several possibilities, one is that you have nicked the dura with the epidural needle. If you use loss of resistance to saline, it may be this. You may also be getting CSF leaking back into the epidural space. Finally, I commonly notice some drops of fluid when I do epidurals, particularly in patients who are edematous or in the later stages of labor. This fluid is often blood tinged. I believe this is interstitial fluid within the epidural space.

 

Question:

Although I am using 25G or even 27G spinal needles, still some patients develope postspinal headache. What is your comment?

Nov. 23, 2005 at 12:54, I.O.

Dr. Goldszmidt replies:

According to the literature, the risk of PDPH after 25G spinal in obstetric patients is around 1% whereas with a 27G it is around 0.5-1%. In my experience, PDPH from spinal needles are usually milder and of shorter duration than headaches caused by punctures with epidural needles. Another thing to remember is that in smaller patients, it is possible to get a dural puncture with the guide needle or with the needle used for freezing if these are inserted fully. These headache would be as severe as a puncture with an epidural needle.

 

Question:

What guage of spinal needle do you recommed when administering CSE for labour? At our institution we have a choice between 25g. and a 27g Whitacre needles.

Nov. 10, 2005 at 12:48, K.H.

Dr. Goldszmidt replies:

The importance of needle size relates to the likelihood of getting a postdural puncture headache. As such, smaller is better. Given the choice you present me with, I would opt for the 27G needle. Remember, the needle you use must have sufficient length beyond the end of the epidural needle to be effective. It should be at least 12-13 mm longer.

 

Question:

Our centre has "needle through needle" CSE kits which have 26G Whitacre needles. Due to the length and gauge, I frequently find that CSF flows extremely slowly, if at all!

Nov. 10, 2005 at 12:47, H.F.

Dr. Goldszmidt replies:

I work with the same kit and I rarely have a problem. The incidence of failure to obtain CSF at CSE in laboring patients is approximately 5%. The most likely reason is that the spinal needle is not within the thecal sac. The most common reason for this would be that your epidural needle is not in the epidural space. (Incidentally, having a spinal needle to pass as a test is very useful in difficult epidurals for avoiding accidental dural puncture). Other reasons include dural tenting, angulation of the epidural needle such that the spinal needle passes lateral to the thecal sac, insufficient needle length or having passed totally through the thecal sac. The size of the needle should not be an impediment, especially with patients in the sitting position. CSE's in the lateral position work just as well but may involve a slower CSF flow. Remember, we do single shot spinals with 27 G needles without difficulty.

If you do fail to get CSF and you are sure that your epidural needle is well positioned, you have two choices: you can abandon the spinal portion and pass your epidural catheter as usual or, alternatively, you can give the spinal dose, observe the clinical effect and manage your epidural as appropriate. The logic here is that you have nothing to lose as the amount of medication involved is quite small if injected into any other space. You should however have a high index of suspicion for a failed spinal in this setting.

 


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