CSE and spinal headache

[deleted875186]

I do almost entirely traditional epidurals for labor (DPE occasionally for questionable LoR to avoid a 17G dural puncture). The onset is very fast with an appropriate loading dose. One-sided and misplaced epidurals are still pretty rare in my hands.

For specifics, I leave 5cm of catheter in the epidural space starting the catheter bend facing straight down (not sure if that makes a difference).

Our mix is 0.2% ropivicaine with 2mcg/mL fentanyl which I bolus initially through the catheter with a syringe with the aim of better spread. We don't currently have lidocaine test doses in our kits due to shortage, so I use 3mL of the loading dose as the test dose to make sure it's not intrathecal. I end up giving 11-22 mL total from a syringe including the test dose in divided doses while setting up the pump and they get comfortable real quickly. It's custom practice for patients to be preloaded with 1L of LR to make sure nobody is hypovolemic, but I'll start cautiously before it's finished usually. Always with phenylephrine on me.

That seems like a big bolus to me, you probably get excellent spread. How often are you seeing hypotension?

For comparison I will typically bolus 6 ml of bupi 0.1% with fentanyl, sometimes 8-10 ml, typically patients comfortable when I check in 10-15 mins. Maybe I should give a bigger bolus.

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[abolt18]

That seems like a big bolus to me, you probably get excellent spread. How often are you seeing hypotension?

For comparison I will typically bolus 6 ml of bupi 0.1% with fentanyl, sometimes 8-10 ml, typically patients comfortable when I check in 10-15 mins. Maybe I should give a bigger bolus.

0.1% bupi with 2mcg/ml fentanyl is what we had in our pumps and I always just bolused from the bag, typically give them 10cc up front then have them push the button immediately after to get an additional 5cc (and learn how to push the dang button). So 15 in total. I may decrease to about 5+5 if their BP is marginal or they're really small.

 

[IMGASMD]

I am surprised we are talking about one sided epidural, no one brought up the difference that different types of catheter can introduce. My favorite hands down is multipore soft catheter. Absolutely hated the one with stiff catheter with single end pore. We were out of soft catheter for a few months. Doing OB were pure misery during those months.

My place now have soft catheter with one end pore, aren’t my favorite, but probably good enough.

 

[Southpaw]

I do almost entirely traditional epidurals for labor (DPE occasionally for questionable LoR to avoid a 17G dural puncture). The onset is very fast with an appropriate loading dose. One-sided and misplaced epidurals are still pretty rare in my hands.

For specifics, I leave 5cm of catheter in the epidural space starting the catheter bend facing straight down (not sure if that makes a difference).

Our mix is 0.2% ropivicaine with 2mcg/mL fentanyl which I bolus initially through the catheter with a syringe with the aim of better spread. We don't currently have lidocaine test doses in our kits due to shortage, so I use 3mL of the loading dose as the test dose to make sure it's not intrathecal. I end up giving 11-22 mL total from a syringe including the test dose in divided doses while setting up the pump and they get comfortable real quickly. It's custom practice for patients to be preloaded with 1L of LR to make sure nobody is hypovolemic, but I'll start cautiously before it's finished usually. Always with phenylephrine on me.

Direction of catheter prior to threading has been looked at and I believe facing down was the most prone to error. If I can find the study I’ll post it.

 

[Southpaw]

Let’s be honest, if any of us were a patient in this situation, you would ask for a straight epidural, no dural puncture, lowest risk of complications.

I’d want a CSE.

 

[DocVapor]

Plain epidural for me. Push 4 cc saline through toughy with loss. 3 cc 1.5% lido with epi that comes in the kit as test dose through soft wire-wound end hole catheter. Then draw up rest of 1% local into test dose syringe with some extra leftover saline, all from kit, up to 10 cc total volume. Give ~8 cc of that solution as loading dose. Put dressing and tape up well then lay down. Spend time programming and hooking up pump setting appropriate expectations. Within that timeframe they're comfortable. If not, have them push button. 1/8% Bupi with 2mcg/ml Fentanyl in pump solution.

Say "You won't see me again, so congratulations in advance!" Walk away. Chart. Done.

 

[pgg]

I felt the catheters were more likely to thread smoothly after a big bolus through the tuohy, but it could have been my imagination.

If you do LOR with saline, pushing 4 or 5 cc of that through the Tuohy when you get your loss accomplishes the same thing.


I used to do CSEs for everyone. One cc of 0.25% bupiv and a bit of fentanyl, or two cc of the 0.125%+fent infusion mix. Patients loved it.

I just sort of stopped though when CSE kits were on "national shortage" supply chain limbo, and never started up again. I give the rest of what's in the test dose vial, start the infusion, then hit the PCEA button for a 5 mL hit of the infusion mix. I go do my charting and stick my head in the room again on my way off the OB floor - they're always comfortable at that point, or well on their way to it.

I think we underdetect PDPHs by a large margin - none of us picked this specialty for the long term patient contact and followup. We hear about the ones that have a RAGING headache a couple days later, but many PDPHs symptoms aren't debilitating or get masked/clouded by all the other reasons a sleep deprived stressed new mother might have a headache. It's self evident that patients with a hole in the dura are at higher risk than patients without a hole in the dura - so these days, absent a compelling reason to put a hole in it, I don't.

 

[zizzer]

That seems like a big bolus to me, you probably get excellent spread. How often are you seeing hypotension?

For comparison I will typically bolus 6 ml of bupi 0.1% with fentanyl, sometimes 8-10 ml, typically patients comfortable when I check in 10-15 mins. Maybe I should give a bigger bolus.

It is a big dose, but I noticed I was getting a bunch of calls about "nonworking" epidurals when our hospital ran out of the 5mL test dose vials, when in reality, they were just underloaded. I usually only give the upper ends of that dose to patients with a lot of pain during late labor to try to get sacral spread. As I said, they almost all have gotten about 1L of LR so it's pretty rare to find somebody hypovolemic. A few get hypotensive, but that's pretty easy to treat with IV agents so I'm not too worried about it.

 

[patriot6]

This has turned into a great thread; loving hearing everyone's practice.

DPE, thread catheter, 5ccs of test lido 1.5%, bolus with 5-8ccs of 0.25% bupi.

I'm considering dropping the dural puncture after comments made here.

 

[Maz777]

This has turned into a great thread; loving hearing everyone's practice.

DPE, thread catheter, 5ccs of test lido 1.5%, bolus with 5-8ccs of 0.25% bupi.

I'm considering dropping the dural puncture after comments made here.

I do exactly as you do (5cc test dose, 5cc 0.25%). Once I get a PDPH from a DPE, I will likely reflexively stop doing it. But until that time.

 

[gcc322]

Slightly off topic - I work at a small community hospital that does about 750 deliveries/year and we take home call. They run continuous epidural infusions (no patient bolus) for maintenance. I would like to switch to PCEA with background or PIEB, however I have gotten some pushback in regards to the patient controlled boluses and no anesthesiologist in house.

I am hesitant to push too much for a change because historically it has resulted in more work for my department despite the evidence supporting better patient care. It always seems like patients are at both ends of the spectrum with continuous infusions (too high a level or requiring physician administered boluses)

 

[The Duck Knows]

Slightly off topic - I work at a small community hospital that does about 750 deliveries/year and we take home call. They run continuous epidural infusions (no patient bolus) for maintenance. I would like to switch to PCEA with background or PIEB, however I have gotten some pushback in regards to the patient controlled boluses and no anesthesiologist in house.

I am hesitant to push too much for a change because historically it has resulted in more work for my department despite the evidence supporting better patient care. It always seems like patients are at both ends of the spectrum with continuous infusions (too high a level or requiring physician administered boluses)

What do you run infusions at? It seems like a way to get your foot in the door would be to make it so the max dose with PCEA is equal to your max dose now. Even if it doesn’t make sense (something like 5cc once an hour with 10cc/hr background), it will help them get more comfortable

 

[Urzuz]

Why is everyone doing CSE’s? What is the benefit? I have found that the onset of pain relief is pretty rapid if you just give the entire 5 cc test dose epidural.

There’s evidence to suggest that CSEs result in better analgesia in stage 1 of labor and less top ups.

A Randomized Controlled Comparison of Epidural Analgesia... : Anesthesia & Analgesia

g the first and second stages of labor and at delivery in women receiving CSE or traditional epidural analgesia at a busy private maternity hospital. METHODS: Healthy, term parturients received epidural or CSE analgesia for labor pain upon request. Epidural analgesia was initiated with 0.125%...

journals.lww.com

FWIW, this study was conducted a very busy women’s hospital which is covered by experienced private practice MDs

 

[Southpaw]

There’s evidence to suggest that CSEs result in better analgesia in stage 1 of labor and less top ups.

A Randomized Controlled Comparison of Epidural Analgesia... : Anesthesia & Analgesia

g the first and second stages of labor and at delivery in women receiving CSE or traditional epidural analgesia at a busy private maternity hospital. METHODS: Healthy, term parturients received epidural or CSE analgesia for labor pain upon request. Epidural analgesia was initiated with 0.125%...

journals.lww.com

FWIW, this study was conducted a very busy women’s hospital which is covered by experienced private practice MDs

Also fewer boluses and fewer replacements

 

[repititionition]

Also fewer boluses and fewer replacements

My OB training had two sites, a low/intermediate volume academic place (mostly straight epidurals) and a baby factory quasidemic place (99% CSE). While there are a ton of uncontrolled variables, the more or less straight epidural experience was nonstop evaluations for boluses, etc., while the CSE practice was almost always set it and forget it with a seriously low callback rate.

I also had my first (?) PDPH following 27g pencil point CSE, which shook me off my 100% CSE practice, but I think in short time I’ll be back to it.

 

[Drwine]

If I am unsure about LOR, I put downward pressure on the needle and inject again. If it is a true LOR there will be no difference on the resistance. If it is in ligaments or soft tissue it will be harder to inject.

 

[Southpaw]

I also had my first (?) PDPH following 27g pencil point CSE, which shook me off my 100% CSE practice, but I think in short time I’ll be back to it.

I've heard rumors of this, but never personally seen it. I've never had a PDPH off a 25/27 pencil point. Even if I did I'd still do CSEs and believe them superior.

 

[xtina0]

The incidence of a pdph with a 27g pencil point needle is 1%- 25g increases it up to 2%- make sure the needle is pencil point otherwise the increase rate of PDPH you describe is very unusual- I've done thousands of DPE's/CSE's and honestly I can't say I've ever seen a pdph from this. Now if your sitting there poking the dura over and over because you can't aspirate back then maybe you are increasing the risk- if this a labor epidural no reason to aspirate - you don't need your spinal to work for analgesia that's why you have your catheter there.

 

[nimbus]

We used to do intrathecal morphine for CABGs and other pump cases. Always used 27g pencil point and I had one PDPH using that needle.

 

[Urzuz]

The incidence of a pdph with a 27g pencil point needle is 1%- 25g increases it up to 2%- make sure the needle is pencil point otherwise the increase rate of PDPH you describe is very unusual- I've done thousands of DPE's/CSE's and honestly I can't say I've ever seen a pdph from this. Now if your sitting there poking the dura over and over because you can't aspirate back then maybe you are increasing the risk- if this a labor epidural no reason to aspirate - you don't need your spinal to work for analgesia that's why you have your catheter there.

In your first sentence you say the incidence of PDPH is 1% and 2% with 27g and 25g pencil needles respectively. In your second sentence you say that you’ve never seen PDPH after having done thousands of them.

Clearly one of these statements is false…

 

[deleted875186]

As someone said earlier, I think the incidence of “mild PDPH” symptoms is higher than reported in the literature or anecdotally seen by us since we rarely follow up with patients beyond perhaps day 1 after delivery. Even then, a mild headache is attributed to labor.

It makes sense that a CSE would increase chance of a headache. I would not want one.

 

[zizzer]

I rarely follow up on my own patients for routine labor analgesia anyway. Whoever's on the next day usually does. Are you guys following up every routine CSE yourself 24h later?

 

[Katheudontas parateroumen]

If I am unsure about LOR, I put downward pressure on the needle and inject again. If it is a true LOR there will be no difference on the resistance. If it is in ligaments or soft tissue it will be harder to inject.

Interesting. never heard this one before

 

[Arch Guillotti]

100% CSE. 1 cc .25% bupi. In and out of the room in 12 minutes.

 

[xtina0]

In your first sentence you say the incidence of PDPH is 1% and 2% with 27g and 25g pencil needles respectively. In your second sentence you say that you’ve never seen PDPH after having done thousands of them.

Clearly one of these statements is false…

this is the incidence they quote at the soap meetings vs . my experience

 

[deleted875186]

this is the incidence they quote at the soap meetings vs . my experience

Because you don’t have good follow up on patients, we miss headaches.

 

[Southpaw]

this is the incidence they quote at the soap meetings vs . my experience

I’ve never seen these numbers. We do quote roughly 1% risk of PDPH with labor epidurals though my department’s number is far far below that. I’ve personally never had a patient with a 25g or 27g pencil point spinal require a blood patch. There’s nothing special about my needles or my technique poking the dura and I’ve had partners who have had patients that require a blood patch after multiple passes with a 25g pencil point.

I think the risk of headache requiring blood patch after 25/27g pencil point durotomy is probably 0.05-0.1%. So low that not doing a CSE for fear of needing to do a blood patch is silly.

 

[pgg]

The incidence of a pdph with a 27g pencil point needle is 1%- 25g increases it up to 2%

I've done thousands of DPE's/CSE's and honestly I can't say I've ever seen a pdph from this.

You haven't seen any because you haven't looked.

You just wrote that the incidence is 1-2% ... odds are you've caused dozens of them.

 

[deleted875186]

I do think CSE works better, the catheter seems to work better, just like I believe a DPE catheter works better.

But the risk is not worth it. Why risk a headache, why instrument the back more, why add time and cost by dropping a spinal needle and meds, why risk fetal bradycardia with a dose of spinal bupi. I have had fetal bradycardia after a CSE and regretted doing the spinal, luckily I only do it when I think delivery is imminent and the patients deliver expeditiously, otherwise I would hate to be the reason a patient got a CS.

 

[Lecithin5]

Love reading about ppl’s practices. I respect the variety that is out there. I perform about 1 cse (specifically talking about labor analgesia) out of about the 800 labor epidurals that I perform per year. Straight epidural works great. Can start getting a patient comfy within 5-10 min. Don’t have to worry about whether an epidural is truly going to work down the line in case of c section.

My philosophy is this: if me or my wife were to ever need an epidural, I would not want anyone touching the dura if it’s not really necessary. Even with a 27g. Just don’t feel that the potential benefit is worth the risk (either of getting a pdph, or of having a false sense of security that the epidural will work well enough once the spinal dose wears off). And regarding dural puncture epidurals, more studies coming out saying that their benefits are probably overstated (will try to find them…)

 

[Sleeplessbordernights]

100% CSE. 1 cc .25% bupi. In and out of the room in 12 minutes.

1 cc it’s all you give in the spinal part of this? Im starting in a very busy OB hospital next year and Tbh Im not experienced in CSE at all, just the epidural part, any tips?

 

[deleted875186]

1 cc it’s all you give in the spinal part of this? Im starting in a very busy OB hospital next year and Tbh Im not experienced in CSE at all, just the epidural part, any tips?

From what I recall, 2.5 mg bupi and 10-15 mcg fentanyl for CSE spinal dose. The opioid is what gives more rapid pain relief and also thought to be the culprit for uterine hypertonicity and the increased incidence of fetal bradycardia seen with CSE techniques …. May be why arch does not do any opioid.

 

[deleted875186]

A lot if people will approximate this dose with 2-3 cc of the epidural bag mix injected intrathecal. Something about injecting stuff from a pharmacy compounded bag intrathecal creeps me out though.

 

[repititionition]

one more person in the 1cc 1/4% gang. no opioid.