Dry Catheter in OB

[Noyac]

Anyone out there placing these? I idea being that when you have many ladies in labor, some of which are ready for an epidural and some which are not, you place a catheter in and test it. You don't start it until they are ready. Lots of benefits and lots of downsides.

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[VolatileAgent]

Anyone out there placing these? I idea being that when you have many ladies in labor, some of which are ready for an epidural and some which are not, you place a catheter in and test it. You don't start it until they are ready. Lots of benefits and lots of downsides.

we do this occassionally. the upside is you do not have a lady in the middle of contractions trying to get positioned for an epidural. if it's already in and you know it's in, you can just start the infusion when the pain level becomes intolerable.

the downside is that there is a chance, just like always, that it will migrate. therefore, good practice would dictate that you are there to monitor the patient when the infusion is started. so, in essence, you'd have to make two trips to the bedside. a lot of people will give a phone order to start it, but this becomes a liability and patient care issue.

 

[2ndyear]

If it's an induction and they know they want it, then it makes sense to me.

 

[InGasWeTrust]

Im at Jackson/Miami

We place them in severe preeclamptics with bad airways.

Run 0.9% NaCl at 3cc/hr.


Problem down here is both the OB's and nurses dont have a clue, so we have to kindly inform them quite regularly that just because you order a dry cath, does not mean it will be done,. We(i.e Anesthesiologist) will make that determination.

 

[Noyac]

Im at Jackson/Miami

We place them in severe preeclamptics with bad airways.

Run 0.9% NaCl at 3cc/hr.


Problem down here is both the OB's and nurses dont have a clue, so we have to kindly inform them quite regularly that just because you order a dry cath, does not mean it will be done,. We(i.e Anesthesiologist) will make that determination.

Tell them that they are not ordering a epidural but instead requesting a consult.

 

[dr. mccoy]

Anyone out there placing these? I idea being that when you have many ladies in labor, some of which are ready for an epidural and some which are not, you place a catheter in and test it. You don't start it until they are ready. Lots of benefits and lots of downsides.

Don't reccomend you doing that unless you are confident you will be activating that catheter soon (e.g. CSE). The only way you can check the location of the catheter is to achieve a sensory level which you can only do by bolusing the catheter with local anesthetic.

 

[Noyac]

Don't reccomend you doing that unless you are confident you will be activating that catheter soon (e.g. CSE). The only way you can check the location of the catheter is to achieve a sensory level which you can only do by bolusing the catheter with local anesthetic.

I am very familiar with all the ups and downs of the dry cath. I was curious as to how many people are doing them.

So how do you check your CSE cath placement? Just the TD of lido with epi? Thats how I do mine. If you place a dry cath you can still test it. It should also be tested again b/4 starting the infusion.

I'm curious, how many people have seen a catheter migrate after being in for some time?

 

[dr. mccoy]

I believe the studies show that a majority of epidural catheters usually migrate out of the epidural space after about 8 hours. That is why if one is to do a postpartun BPS/BTL, it is probably better to just pull the catheter the next AM and do a spinal.

In the case of CSE, testing the catheter with lido and epi is fine. One should detect a sensory level by the time the spinal wears off in about 1.5-2 hours if the catheter is hooked up to an infusion pump without bolusing.

 

[Noyac]

I believe the studies show that a majority of epidural catheters usually migrate out of the epidural space after about 8 hours. That is why if one is to do a postpartun BPS/BTL, it is probably better to just pull the catheter the next AM and do a spinal.

In the case of CSE, testing the catheter with lido and epi is fine. One should detect a sensory level by the time the spinal wears off in about 1.5-2 hours if the catheter is hooked up to an infusion pump without bolusing.

Thanks for your input. Can you show me these studies? I agree that you should pull the cath if you are doing the BTL the next day. I don't even use a working cath if the pt needs to go for c/s. I just pull it and put in a spinal.

I don't follow your comment on the CSE. You will get a sensory level immediately with the TD. So are you saying that if you do the CSE and then just start the infusion, you will achieve a sensory level in 1.5 - 2 hours from the start of the infusion? This is what I do, do you do something different? I tell the pt to inform me or the rn if the level continues to rise, they can't move their legs, they can't feel anything. Even if the cath migrates intrathecal you will not get a total spinal if the pt is informed and the RN is experienced. I have a feeling we are saying the same thing. If so great, I will quit.

 

[VolatileAgent]

I believe the studies show that a majority of epidural catheters usually migrate out of the epidural space after about 8 hours.

i agree with noy. i'm going to have to see the evidence base for this statement. we run epidurals for days on post-op patients undergoing other procedures without this "majority in 8 hours" stuff.

noy, i've personally never seen a well-secured catheter migrate to somewhere it shouldn't be, with the emphasis being on 'well-secured'.

 

[johankriek]

if the epidural is in place and working.. use it... why would you go out of your way to give the patient another procedure...? one that invades csf.. if your cathether is working... I dont understand that thinking

 

[meddog1]

Why keep it dry? It's my understanding that current literature says that starting it early in labor doesn't impair labor progression. I suppose you could hook it to a pump on a low setting. Where I train, we get them in early if possible and dose them up right about the time they crank up the pitocin.

 

[meddog1]

I am very familiar with all the ups and downs of the dry cath. I was curious as to how many people are doing them.

So how do you check your CSE cath placement? Just the TD of lido with epi? Thats how I do mine. If you place a dry cath you can still test it. It should also be tested again b/4 starting the infusion.

I'm curious, how many people have seen a catheter migrate after being in for some time?

Before you begin infusing later, aspirate with a 3cc syringe and make sure you don't get heme or even CSF. Sometimes the cath will errode into a now-engorged epidural vessel This happened to me just today on OB. I got a call that the patient was having major breakthrough pain that came on fast. I disconnected the cath from the pump, aspirated and sure enough, drew back some serosanguinous fluid. I stopped the pump, DC'd the cath and the woman wound up getting Nalbuphine IV (worked like a champ) until we sectioned her a few hours later under a spinal.

 

[dr. mccoy]

i agree with noy. i'm going to have to see the evidence base for this statement. we run epidurals for days on post-op patients undergoing other procedures without this "majority in 8 hours" stuff.

noy, i've personally never seen a well-secured catheter migrate to somewhere it shouldn't be, with the emphasis being on 'well-secured'.

I did somewhat misspeak. What I was referring to was the 1999 consensus statement by Anesthesia and Analgesia. There are really only two studies that were done: one showed that there is a high success rate of epidural reactivation up to 24 hours, the other did not. Their final reccomendation is:

Epidural Reactivation
Several factors contribute to satisfactory epidural anesthesia for tubal ligation. The interval from delivery to tubal ligation is one factor affecting success of epidural reactivation. Viscomi and Rathmell (22) evaluated epidural reactivation after delivery and reported that 93% of catheters were functional for postpartum tubal ligation within 1–4 h of delivery. Only 68% of catheters, however, were functional during the next 4 h after delivery. These authors noted that additional time was also required in unsuccessful reactivations. Vincent and Reid (23) also evaluated success rates of epidural reactivation after delivery for tubal sterilization. Although the distance that the catheter was inserted into epidural space was not mentioned, a 100% success rate was reported within 8 h of delivery and a 55% success rate after 8 h. More recently, Goodman and Dumas (24) retrospectively examined the success rate of epidural reactivation based on the following delivery and tubal sterilization intervals: 1) <8 h; 2) 8 to <16 h; 3) 16 to <24 h; and 4) 24 h or more. Overall, 92% (129/140) of reactivations were successful with 80% successful reactivations occurring more than 24 h after delivery. Because studies of epidural reactivation have produced conflicting results, it is difficult to predict an interval that will guarantee successful reactivation. The Practice Guidelines for Obstetric Anesthesia suggest that epidural catheters placed for labor may be more likely to fail with longer postdelivery intervals (2). When postpartum tubal ligation is anticipated within several hours after delivery and the epidural catheter provided adequate labor analgesia, it is reasonable to attempt epidural reactivation. If the procedure is delayed beyond that time, epidural reactivation may fail. Although epidural replacement is one alternative when delivery to tubal ligation interval is prolonged, subarachnoid anesthesia may be a better alternative for such a time-limited procedure.

Also, what I am referring to is a dry epidural catheter which if reactivated with local may make a subsequent spinal anesthetic more difficult to perform and even possibly to dose. Thanks for an interesting discussion.

 

[Noyac]

if the epidural is in place and working.. use it... why would you go out of your way to give the patient another procedure...? one that invades csf.. if your cathether is working... I dont understand that thinking

I don't understand your post. What additional procedure are you talking about that invades the CSF?
If the cath is in then you are not going to be giving them a spinal later.

 

[Noyac]

Before you begin infusing later, aspirate with a 3cc syringe and make sure you don't get heme or even CSF. Sometimes the cath will errode into a now-engorged epidural vessel This happened to me just today on OB. I got a call that the patient was having major breakthrough pain that came on fast. I disconnected the cath from the pump, aspirated and sure enough, drew back some serosanguinous fluid. I stopped the pump, DC'd the cath and the woman wound up getting Nalbuphine IV (worked like a champ) until we sectioned her a few hours later under a spinal.

serosanguinous is not necessarily intravascular, actually rarely intravascular. It may be heme remaining after placement or a vessel that has been breached. But why not replace it after you pulled it?

 

[meddog1]

serosanguinous is not necessarily intravascular, actually rarely intravascular. It may be heme remaining after placement or a vessel that has been breached. But why not replace it after you pulled it?

The cath was multi-fenestrated so the thought was that with her presentation of rapid ceasatin of analgesia the cath was not in the epidural space yet "somewhere." There was no fluid comming out of her back (dressings dry) so the thought was that there may have been migration (at least partly) into a vessel and the heterogeneous fluid I drew back was a mix of blood and already infused anesthetic - of course we don't know for sure though. The pt however did not have any vascular type of clinical presentation one might expect from bupivicaine. We ddin't replace it because I was the only anesthesia resident on the floor and I was getting hammered at the time so she got the Naubaine as a tie-over but then became too much of a slug to comply with positioning. This with her body habitus made a lateral decubitus approach unappealing as well. So waited for her to wake up a little and then got the SAB in the OR. Worked out well in this case.

 

[Noyac]

The cath was multi-fenestrated so the thought was that with her presentation of rapid ceasatin of analgesia the cath was not in the epidural space yet "somewhere." There was no fluid comming out of her back (dressings dry) so the thought was that there may have been migration (at least partly) into a vessel and the heterogeneous fluid I drew back was a mix of blood and already infused anesthetic - of course we don't know for sure though. The pt however did not have any vascular type of clinical presentation one might expect from bupivicaine. We ddin't replace it because I was the only anesthesia resident on the floor and I was getting hammered at the time so she got the Naubaine as a tie-over but then became too much of a slug to comply with positioning. This with her body habitus made a lateral decubitus approach unappealing as well. So waited for her to wake up a little and then got the SAB in the OR. Worked out well in this case.

What a f'in mess.