Discussions for Module 6:  Patient-Controlled Epidural Analgesia for Labour

Questions are answered by module authors: Stephen Halpern MD MSc FRCPC and/or Martin van der Vyver MB ChB M.Med FFASA

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Question:

I'm thrilled to write that our administration is now pro-PCEA. We are setting up the hard limits on our equipment. Can you suggest your institution's settings for maximum hourly limit, maximum continuous infusion, and Bolus dose limits? Thank you.

3/28/2009 11:29:13 PM, P.S.

Dr. Halpern replies:

It is great that you have been able to institute PCEA at your institution. The range of acceptable doses is enormous, provided low concentrations of drugs are used. We use Bupivacaine 0.08% with 2ug of fentanyl. We are exploring the use of ropivacaine 0.1% as an alternative. We set the bolus between 5 and 8 ml. The lockout is standardized at 10 minutes to allow the dose to start to work. We run a background between 5 and 12 (sometimes 15 ml) per hour. We don’t set a maximum hourly dose, but 20-30 ml/hr would be reasonable. Leave yourself lots of room.

You may also link to a review article that Brendan Carvalho and I wrote for A&A. You can use it for reference. You will also see why it is unreasonable to specify narrow dosing regiments.

 

Question:

I have been trying to get the administration to support PCEA for years. We use dated continuous infusion pumps where the anesthetists have to MIX EACH infusion syringe and the OB nurses administer top-up boluses by DISCONNECTING the infusion and administering 5 mL bupuvacaine 0.25%. I am trying to reduce potential errors in mixing solutions and disconnecting the lines and get closer to PCEA by writing nursing orders to bolus 8 mL q 30 mins of 0.083% bupivacaine with 1.67 mcg/mL on a background rate of 10.5 mL/hr. The nursing administration has ordered the nurses not to because they feel that there needs to be an explicit policy for the (narcotic) 14 mcg of fentanyl that would be given by bolus. Ironically the same people are comfortable administering morphine 10 mg IM and morphine IV, and caring for postoperative patients who have received epidural and spinal epimorph post hysterectomy; c-section etc. Do you have any advice and are you aware of any safety information that could reassure those who are fearful? Thank you.

May 5, 2008 1:48:13 AM, P.S.

Dr. Halpern replies:

Regarding the safety. PCEA is an established, safe, mode of maintenance of labour analgesia, as is clinician topups. The doses you recommend are similar to doses that patients give themselves in many centres. Whether or not the nurse can give epidural opioids depends on their scope of practice as determined by their Provincial College (not the local administration). I would seek their advice. You may find that a nurse cannot administer a mixture that was mixed by someone else (ie a physician). At our hospital, we got the pharmacy to mix all of our syringes with the appropriate quality control and sterility etc. because of this issue.

 

Question:

Comment Under the heading of bolus volume the concentration of the bupivacaine should be 0.08% instead of 0.8%.

Nov. 23, 2005 at 13:20, U.T.


Dr. Halpern replies:

Correct. I apologize for the typo. The Webmaster has made the change.

 

Question:

Our center recently received new CSE kits so we no longer have to open up a separate needle and add it to our epidural kits. However I notice that these new kits ONLY have plastic loss of resistance syringes and do not contain the more commonly used glass syringe. I prefer using the glass syringe so I am hesitant to use these new kits. Anyone in other centers have this problem?

Nov. 10, 2005 at 12:25, H.F.

Dr. Halpern replies:

Many people prefer the plastic syringes (eg "Pulsator" by Simms). Try it, you might like it. The quality of the loss of resistance is similar, it is cheaper than glass and probably more environmentally friendly.

 

Question:

The Baxter® PCEA pumps at my institution quite often stop during infusion with an "OCCLUSION" alarm when successful manual delivery by syringe of a bolus dose of infusion solution indicates that blockage has not occurred. Do different brands of PCEA pumps differ in their sensitivity and reliability?

Nov. 10, 2005 at 12:24, J.L.

Dr. Halpern replies:

As far as I know, the standard pumps are quite reliable. You can change the pressure limits on most pumps. You need to ask your biomed people to look at it. Also, you can slow down the infusion rate. For example, if the bolus dose is 5 ml, you can deliver it over 2 minutes instead of 1 or "stat". This will reduce the pressure.

 


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