Download - Troubleshooting Epidurals
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Dr Keri Ashpole
Nov 2012
Epidurals for Labour: Troubleshooting
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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
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Standard Labour Epidural
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Get patient into Position
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Epidural Insertion
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Epidural Insertion
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Secure WellOnly 4-6 cm of catheter left in the epidural space
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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
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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?
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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!!!
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Epidural troubleshooting after
Injection : Complications - Where
is the catheter?
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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
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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
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Why are all Epidural top up’s a test Dose?
2. Subarachnoid
Note:
SA catheter migration
(Dural tap with touhey
discussed later)
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Skin
Termination of
spinal cord
Dural sac
Epidural space
Ligamentum
flavum
Spinous process
Supraspinous
ligament
Intraspinous ligament
Ep
Where could your epidural catheter be?
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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
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Why are all Epidural top up’s a test Dose?
3. Subdural
Tips:
1. Feels hard to inject
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Subdural Block
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Subdural Block
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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
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Epidural troubleshooting after
Injection : Inadequate Analgesia
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Inadequate analgesia (I:10)
• 10% labour epidurals (2% completely)
• 1% SSS
Causes:
1. Adequate spread but breakthrough pain
2. Inadequate spread
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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
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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)
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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
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Failed Blocks – Inadequate Spread
Foraminal Escape
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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
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Failed Blocks – Inadequate Spread
Median Epidural Septum
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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
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Complications
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Complications
• Bloody Tap / LA Toxicity
• High Block
• Patchy Subdural Block
• Inadequate Analgesia
• Dural tap
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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
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Golden Rules for Labour Epidurals
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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?
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Any Questions?