troubleshooting epidurals

Dr Keri Ashpole

Nov 2012

Epidurals for Labour: Troubleshooting

Troubleshooting Epidurals

1. Standard Labour Epidural

2. Complications related to where the catheter can be

3. Inadequate Analgesia

4. Dural tap

5. Golden Rules for epidurals

Standard Labour Epidural

Get patient into Position

Epidural Insertion

Epidural Insertion

Secure WellOnly 4-6 cm of catheter left in the epidural space

What block do we need for a labour

epidural?

• First Stage of Labour:

- block to T10 for uterine

contractions

• Second Stage of Labour:

- sacral block for delivery

• Autonomic

• Sensory

• Motor

What Drugs and doses to use?• Low Dose Mix (LDM) for Labour Epidurals:

• Mobile mix

• 0.1% bupivacaine + 2mcg/ml Fentanyl

• First top up:

• 10mls + 10mls LDM test dose (anaesthetist)

• Start LDM Infusion / PCEA

• 30 min to achieve block

• Further bolus doses may be given

• Maximum strength in the room 0.25% bupivacaine?

What Drugs and doses to use?• What drug factors affect the quality of our block?

• Concentration

• Volume

• Rate and pressure of injection

• What epidural factors affect the quality of our block?

• Where the catheter is!!!

Epidural troubleshooting after

Injection : Complications - Where

is the catheter?

Why are all Epidural top up’s a test Dose?

1. Intravenous (Bloody tap)

Tips:

1.Don’t pass catheter

during a contraction

2. Inject saline as you

withdraw catheter last

few cm

Where could your epidural catheter be? 1. Intravenous - in Batson’s plexus (LA toxicity)

• S&S - depend on blood concentration

• Mx - ABC, intralipid

2. Subarachnoid - high block (total spinal)• Incidence 1 in 5000 – 50,000, more common after ‘pepper potting’

• S&S- hypotension, difficulty speaking, agitation , resp/cardiac arrest

• Mx – ABC , wedge, vasopressors, delivery

3. Subdural - high patchy block• Possibly 1 in 100?

• Slow onset block with thoracic /cervical blocks but poor lumbar block

• S&S – pain, rarely significant hypotension , Horner’s syndrome

• Mx – re-site epidural

Why are all Epidural top up’s a test Dose?

2. Subarachnoid

Note:

SA catheter migration

(Dural tap with touhey

discussed later)

Skin

Termination of

spinal cord

Dural sac

Epidural space

Ligamentum

flavum

Spinous process

Supraspinous

ligament

Intraspinous ligament

Ep

Where could your epidural catheter be?

Where could your epidural catheter be? 1. Intravenous - in Batson’s plexus (LA toxicity)

• S&S - depend on blood concentration

• Mx - ABC, intralipid

2. Subarachnoid - high block (total spinal)• Incidence 1 in 5000 – 50,000, more common after ‘pepper potting’

• S&S- hypotension, difficulty speaking, agitation , resp/cardiac arrest

• Mx – ABC , wedge, vasopressors, delivery

3. Subdural - high patchy block• Possibly 1 in 100?

• Slow onset block with thoracic /cervical blocks but poor lumbar block

• S&S – pain, rarely significant hypotension , Horner’s syndrome

• Mx – re-site epidural

Why are all Epidural top up’s a test Dose?

3. Subdural

Tips:

1. Feels hard to inject

Subdural Block

Subdural Block

Where could your epidural catheter be? 1. Intravenous - in Batson’s plexus (LA toxicity)

• S&S - depend on blood concentration

• Mx - ABC, intralipid

2. Subarachnoid - high block (total spinal)• Incidence 1 in 5000 – 50,000, more common after ‘pepper potting’

• S&S- hypotension, difficulty speaking, agitation , resp/cardiac arrest

• Mx – ABC , wedge, vasopressors, delivery

3. Subdural - high patchy block• Possibly 1 in 100?

• Slow onset block with thoracic /cervical blocks but poor lumbar block

• S&S – pain, rarely significant hypotension, Horner’s syndrome

• Mx – re-site epidural

Epidural troubleshooting after

Injection : Inadequate Analgesia

Inadequate analgesia (I:10)

• 10% labour epidurals (2% completely)

• 1% SSS

Causes:

1. Adequate spread but breakthrough pain

2. Inadequate spread

Inadequate analgesia (I:10)

• Check list : patient & epidural

• History - Gravida / Stage of labour / position of baby

• Epidural Chart - What drugs and how much?

• Pump

• Catheter

• Epidural Site

We need to check the ‘Right Dose of the Right

Drug in the Right Place’ has been given

Adequate spread but breakthrough Pain

• Patient Factors:

• Malrotation - OP baby

• Second stage - LDM may not be sufficient **

• Scar rupture

• Abruption

** Risk v Benefit: no pain v motor block (instrumental)

Inadequate spread • Epidural or Patient Factors:

• Unilateral block

• Missed Segment

• Patchy block * think subdural* - re-site epidural

• Groin or perineal - hand delivered top up LDM or 0.25%

bupivacaine

Failed Blocks – Inadequate Spread

Foraminal Escape

Failed Blocks – Inadequate Analgesia

Foraminal Escape

• Pull catheter back 1cm

• Bolus with patient on their

side

• Large volume LDM

• Re-assess

• Further bolus of 0.25%

bupivacaine?

• Re-site

Failed Blocks – Inadequate Spread

Median Epidural Septum

Failed Blocks – Inadequate Analgesia

Median Epidural Septum

• Low volume injected

unilateral block

• Greater volume some

movement to the right

• Attempt re-site

• Likely will be the 2%

epidurals that don’t work

• SSS for LSCS

Complications

Complications

• Bloody Tap / LA Toxicity

• High Block

• Patchy Subdural Block

• Inadequate Analgesia

• Dural tap

Dural Tap • incidence < 1%

• Recognise - Re-insert stylet!

• To confirm CSF - warm fluid / pH / protein / glucose

• ADMIT and inform

• spinal catheter / re-site / abandon

• local protocol

AFTER A DURAL TAP ALL TOP UP’S BY ANAESTHETIST

Golden Rules for Labour Epidurals

Golden Rules• All epidural top ups are a test dose

• Always aspirate before injection

• Have a system for managing substandard epidurals

• 2% do not improve despite ‘Rescue measures’

• If it is not working take it out !

• Documentation/ Explanation

• Re-site - Ask for help?

Any Questions?