complex regional pain syndrome i reflex.31

8/6/2019 Complex Regional Pain Syndrome I Reflex.31

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OBSTETRIC ANESTHESIA RESIDENT HANDBOOK

RESIDENT SCHEDULE

OPERATING ROOM SET UP

PREANESTHETIC EVALUATION

HIGH RISK CONSULT SERVICE

ASEPTIC TECHNIQUE

EPIDURAL PLACEMENT AND MAINTENANCE

COMBINED SPINAL EPIDURAL (CSE) PLACEMENT

CESAREAN DELIVERY WITH IN SITUEPIDURAL

TOPPING OFF LABOR EPIDURALS

CATHETER PULLS

SUBARACHNOID BLOCKS

COMPLICATIONS OF NEURAXIAL TECHNIQUES

OBSTETRIC ANESTHESIA CURRICULUM


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RESIDENT SCHEDULE

The resident schedule is as follows: on months when 2 residents are rotating on theservice, one will be designated the a.m. resident and the other will be the p.m.

resident. The a.m. resident should arrive no later than 6:45 and will stay until 3 p.m.;the other resident will arrive at 11 a.m. and stay until 7 p.m. There is often a flurry

of epidural placements between 6:30 and 7:00 a.m., so the early resident mightconsider coming earlier when possible.

Each week the a.m. and p.m. resident will alternate. You are responsible for agreeing

who will be the a.m. and p.m. resident the first week and for alternating thereafter.The first day on the service both residents can arrive at 6:45 so that the more senior

resident can orient the other. When only one resident is on the rotation, he/sheshould arrive no later than 6:45 a.m. and stay until 5 p.m. In the near future, we

hope to have overnight call facilities for residents, and at that time we will tweak the

schedule once again to ensure optimal exposure to procedures on the L&D ward.

Please note that you are responsible for contacting both Patty Burke and the staffmember on L&D if you have an unanticipated emergency or illness and are unable to

get to work. The same applies if you request an additional vacation day that was not

originally scheduled.

When the a.m. resident arrives, he/she should check the anesthesia machine and

ensure that emergency drugs and equipment for the administration of a generalanesthetic are immediately available. The cases for the day are usually posted on the

white bulletin board; scheduled labor inductions are listed in a binder at the nursingstation or, if the patient is already inhouse, on the bulletin board. The CRNA on L&D

can also provide updates for the days schedule.

Daily resident duties include: attend the safety rounds at 7:30 a.m. each morning

in the 2nd floor neonatal conference room, when possible; fill out the preanesthesia

evaluation papers on each patient requesting an epidural or scheduled for Cesareandelivery, cerclage, tubal ligation, etc. (the packet of papers is usually in the patients

chart or on the clipboard in the anesthesia work room); place epidurals onceproperly trained and prepared, and fill out all the relevant paperwork; troubleshoot

and topoff epidurals, as needed; provide neuraxial or general anesthesia for

operative procedures, remaining with the patient and charting appropriatelythroughout; attend all lectures offered by staff, colleagues, and fellows; perform

postoperative visits on all patients from the preceding day (a list of patients will be

provided); and provide continuity of care for all antepartum patients (these are thepatients being observed on the floor whose status should be reassessed on a daily

basis). If two residents are available during the hours between 11 a.m. and 3 p.m.(when shifts overlap), one will be expected to run the floor, placing and

troubleshooting epidurals, while the other is in charge of surgical cases. Antepartum

and postpartum visits can be divided between residents, or residents can alternatethese duties week by week.


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In addition to the above duties, each resident is responsible for making a

PowerPoint on a subject of interest for presentation during the final week on therotation. We will also assign a series of Jackpot questions at the beginning of the

rotation; we expect you to research the answers and be prepared to answer thesequestions at a designated Jackpot answer session each week (below is a list of

resources to aid in your research). Further, when time permits, you will be expectedto take over surgical procedures already underway, relieving the CRNA andassuming responsibility for those obstetric patients in the operating suites. Finally,

occasionally you will be asked to perform preoperative assessments on both high

risk parturients and nonobstetric patients scheduled for outpatient surgery atTulane Lakeside in the anesthesia preoperative evaluation clinic on the 1stfloor.

These preoperative evaluations require your familiarity with preoperativeguidelines, anesthetic implications of a variety of disease processes, and with

further workup algorithms that might be necessary to optimize a patient for

surgery. The preoperative evaluation clinic provides a good learning opportunity,particularly in preparation for the Oral Boards.

The L&D ward is marked by peaks and lulls; residents should take advantage ofdowntime by studying, reading, preparing the final PowerPoint presentation, and

answering the Jackpot questions. The third floor office has several texts andquestion books, as well as three computers with PowerPoint capacity. Please take

advantage of these facilities for study, research, etc.

Finally, a very informative and recently updated reference book to help guide you

during this rotation is Obstetric Anesthesia Handbookby Sanjay Datta, BhavaniShankar Kodali, and Scott Segal. It is available at Amazon and other online

companies. You should also be intimately familiar with the 2007 ASA Practice

Guidelines for Obstetric Anesthesia (seeAnesthesiology2007;106:84363 or simplyGoogle ASA Obstetric Anesthesia Guidelines; these guidelines are also printed in

the back of Chestnuts Obstetric Anesthesia text). Other resources you may find

helpful include: Chestnuts Obstetric Anesthesia: Principles and Practice, 4th Ed;Clinical Anesthesiologyby Morgan, Mikhail and Murray (with particular emphasis on

the Local Anesthetics and Obstetric Anesthesia chapters); andAnesthesia Review: AStudy Guide to Anesthesia and Basics of Anesthesia by Lorraine Sdrales and Ronald

Miller (again, with emphasis on the Local Anesthetics and Obstetric Anesthesia

chapters). These and other texts, including LongneckersAnesthesiology, MillersAnesthesia: 2 Volume Set , and Barashs Clinical Anesthesia are in the 3rd floor office,

although I encourage you to purchase the Obstetric Anesthesia Handbook.

OPERATING ROOM SET UP

Each morning and after each case, the anesthesia machine and all equipment must

be checked and left ready for any emergency that might arise.

The following items must be immediately available and ready to use:


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Anesthesia machine with breathing circuit (that has been tested for leaks) and

mask

BP cuff, EKG, and SpO2 cable

Laryngoscopes and blades (be sure to check each handle and blade)

Styletted ETT of all sizes (6.0, 6.5, 7.0) Immediately available ephedrine, phenylephrine, and succinylcholine. Atropine,

glycopyrrolate, and epinephrine should be readily accessible

A secure, readily available induction agent and syringe

Working suction with tip attached

Ambu bag

Oral airways

Stethoscope

A fully stocked obstetric hemorrhage cart and difficult airway cart are immediately

available in the OR common area

PREANESTHETIC EVALUATION

Patients on the L&D floor are to be seen and evaluated upon nurse or obstetricianrequest. In addition, we often elect to evaluate all patients considered high risk as

soon as possible, including patients scheduled for trial of labor after Cesarean

(TOLAC), obese patients, patients with known or suspected difficult airways,multiplegestation parturients, severe preeclamptics, etc.

A focused H&P should include age, gravid and para state, weeks gestation, any

complications of current pregnancy, reason for C/S (if applicable), reason for prior

C/S (if applicable), previous anesthetics, height, weight, allergies, comorbidities,

airway, heart and lung examination, any relevant labs (platelets for a patient withknown gestational thrombocytopenia, platelet disorder, HELLP, or clinical history ofbleeding; urine protein for patients with preeclampsia; blood glucose for patient

with DM, etc.), NPO status, and anesthetic assessment and plan. A baseline maternal

blood pressure and fetal heart tones (FHTs) should also be documented.

For review of systems, it is important to evaluate whether patients with

preeclampsia have visual changes, edema, abdominal pain, headache, or any signs ofeasy bleeding/bruising. Ask all parturients about GERD, as well as n/v, SOB, CP, and

palpitations, when appropriate.

HIGH RISK CONSULT SERVICEIn concert with the Obstetrics Department, we recently launched a highrisk consultservice. Obstetricians have been asked to identify parturients considered high risk

and send them for an anesthesia consult in advance of the estimated date of

confinement (EDC). Highrisk patients include, among others, super morbidly obesewomen with other comorbidities, patients with severe scoliosis, patients at risk for

hemorrhage (previa, accreta, percreta, for example), patients with bleedingdisorders or congenital heart disease, etc. This consult service also gives us an


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opportunity to meet patients with anesthesia concerns, including those with a

history of difficult epidural placement, in advance. Our goal is to assess thesepatients, order any relevant consults or further workup, and craft an anesthetic

assessment and plan, which, in turn, will be circulated among all relevant parties.Residents will, on occasion, be asked to conduct a full H&P on highrisk patients in

the preoperative evaluation clinic on the 1st

floor at Tulane Lakeside, present theirfindings to the staff or fellow, and dictate a report. We will provide a template fordictation and ensure access to the dictation services.

Importantly, remember to ask the patient to inform the anesthesiologist that shewas seen in the highrisk clinic when she comes in for her delivery. Also, record the

name of the obstetrician on the H&P, the patients telephone number (in the eventthat we have to contact her for followup), and the EDC on the H&P. We have

separate binders for highrisk patients, both those to be delivered and those

already delivered, in the anesthesia stock room on the L&D floor. Printed copies ofour dictation or of our H&P are to be placed in alphabetic order in the to be

delivered binder until the patient presents for delivery, at which time we can pullthe copies and attach them to the patients clipboard.

ASEPTIC TECHNIQUEInfectious complications of neuraxial techniques are rare, but on the rise. The

causative organism in the case of meningitis is most often traced to the

nasopharnygeal bacteria (specifically, alphahemolytic streptococci) of theanesthesia provider. As a result, it is considered standard of care to wear a mask, as

well as sterile gloves and a scrub hat, while performing neuraxial procedures. It isalso reasonable to consider routinely placing a cap on the patient. Chloroprep has

been proven to be superior to Betadine in terms of its bactericidal properties. It is

not yet available in (or FDA approved for) spinal and epidural kits, but can bedropped onto your open sterile field if you prefer to use it for prepping the patients

back. Finally, handwashing has been shown to be the most effective way to prevent

the spread of nosocomial infection; changing gloves is not a substitute for washinghands with each new patient contact. For more information, please refer to Terese

Horlocker and Denise Wedels Infectious complications of regional anesthesia inBest Practice & Research Clinical AnaesthesiologyVol. 22, No. 3, pp. 451475, 2008.

EPIDURAL PLACEMENT AND MAINTENANCEAfter your H&P is complete and you have withdrawn the appropriate epidural

medications (more below) and pressors (ephedrine and phenylephrine), roll one of

the two epidural carts into the patients room (one cart is located in the anesthesiastock room; the other is in the common area between the ORs). Make sure that the

cart is properly stocked before using it. The epidural solution of 0.1% bupivacainewith 2 mcg/mL of fentanyl and the ephedrine are located in the Pyxis in the OR

common area. Premade syringes of a loading dose are located in the anesthesiastock room, along with a premade solution of phenylephrine at a concentration of

100 mcg/mL.


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Confirm that the patient has a working IV and consider either a crystalloid preload

(this is controversialplease refer to the ASA Obstetric Anesthesia Guidelines and

to your attending staffs clinical judgment) or coload.

Although we do not routinely administer aspiration prophylaxis for epidural

placement, it is reasonable to consider giving Bicitra 30 mL PO before starting,

particularly if there is any concern that the patient may go for an urgent/emergent

Cesarean delivery (for example, if there is fetal distress or imminent breechdelivery).

Nursing guidelines (AWHONN) state that a nurse should be present during all

epidural placements in order to monitor both the mother and the fetus and in the

event of unanticipated complications. The ASA Obstetric Anesthesia guidelines state:the fetal heart rate should be monitored by a qualified individual before and after

administration of neuraxial analgesia for labor.

Wash hands; wear gloves, hat and mask.

The patient can be placed in either lateral or seated position during placement. The

former may provide greater comfort, decrease patient movement, and decrease theincidence of intravascular cannulation, while the latter position may facilitate

visualization of the patients anatomical landmarks.

Our epidural kits are equipped with Tuohy needles (we currently stock both 17 G

and 18 G needles); either loss of resistance to air or saline (per your comfort level

and your staffs preference) is suitable for advancing into the epidural space.

Warn the patient of the possibility of a paresthesia before threading the catheter.

The literature states that threading the catheter 35 cm into the epidural spacereduces the incidence of unilateral block, intravascular cannulation, paresthesias,

and catheter knotting. Defer to your staff s judgment when threading the catheter.

Note that it is important to document both the distance to the epidural space andwhere the catheter is taped to the skin.

Place the patient in a slight lateral tilt during epidural dosing; the nurses are very

helpful with positioning, and most rooms are equipped with hip rolls/pillows

specifically for this purpose.

The catheter should be tested with 3 mL increments of local anesthetic with

frequent negative aspirations (i.e., draw back the syringe before each injection to

ensure that there is no blood backflow) and frequent blood pressure readings. Thetraditional test dose with 1.5% lidocaine with epinephrine can be substituted by

administering your choice of local anesthetic solution (see next bullet)

incrementally with frequent negative aspirations.


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Once subarachnoid and intravascular catheter placement have been ruled out, the

full loading dose should be administered in slow, divided doses with frequent

negative aspirations. We currently have 2 loading dose options: a premade syringewith 0.0625% bupivacaine with 100 mcg of fentanyl can be administered, followed

by patientcontrolled epidural anesthesia (PCEA) pump settings of 12 mL/hour,with 4 mL bolus every 10 minutes (12/4/10). Alternatively, withdraw 20 mL of theepidural solution (0.1% bupivacaine solution with 2 mcg/mL) from the bag and

administer in divided doses, followed by PCEA settings of 8 mL/hour, with bolus of8 mL every 15 minutes (8/8/15).

Evaluate the quality and level of the block, observing the patient for roughly 15

minutes and recording 3 blood pressure readings.

Our new Hospira PCEA pumps are excellent for delivering labor analgesia and are

fairly simple to use. They require special tubing, so be sure to grab the dedicated

tubing from the stock room before you enter the patients room; alternatively, extratubing is stocked in the epidural placement carts. Each pump is encased in a hard

plastic case/lockbox and has a key (attached via a rubberband) for securing ourepidural solutions. When programming the pump, first plug it in (the nurses

routinely unplug the pumps after deliveries). Next, press the ON/OFF button. Thepump performs a self test and asks that you press ENTER. Next you get 3 program

options: press #3 (CLEAR PROGRAM, SHIFT, and HISTORY). If it says KEYPAD

LOCKED, press OPTIONS and then press # 3 (FULL LOCK). It then asks you to enterthe lock sequence number; to unlock the pump so that you can reprogram it, enter

13000. Then resume programming, electing CLEAR PROGRAM, SHIFT, and

HISTORY. It will say CLEARING PROGRAM. Next it asks whether you want

continuous, bolus only, or continuous + bolus. Choose #3 (CONT + BOLUS). The nextpage asks you to set the rate and press ENTER WHEN DONE. Next it asks youwhether you want to program a loading dose. Say NO. The next page asks for the

BOLUS dose; set it and press ENTER. The following page asks for BOLUS LOCKOUT;

enter 10 or 15 minutes, depending on your regimen, and press ENTER. Next it asksfor your hourly limit; select #4 (NO LIMIT SELECTED). Next it asks you to enter

CONTAINER SIZE; enter 250 mL if you havent removed any solution from the bag;

enter 230 mL if you have withdrawn a 20 mL loading dose from the bag. The nextpage is for AIR SENSITIVITY. Press 2 mL (option #2). Then theres a program review

option, and you must press the down arrow to review the program parameters youhave selected. When the review is complete, press ENTER. The program will be

saved and you must press START to begin the infusion.

Program the PCEA pump at either 12/4/10 or 8/8/15, depending on which loading

dose you administered, and explain to the patient that she should press the patientcontrolled analgesia button as often as she likes to get a little extra medicine.

Explain that the pump is programmed and will not deliver too much medicine or

permit an overdose (that is, it will deliver the bolus only every 10 or 15 minutes,


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depending on your settings, regardless of how often she presses the button).

Emphasize the importance of pressing the button as soon as she feels the slightestdiscomfort in order to optimize her pain management. Several studies have

demonstrated broader, improved spread of the epidural solutions when the patientuses the PCEA button; faster boluses are thought to be superior to a continuous slow

infusion without the intermittent boluses.

After an epidural has been placed, please write the time of placement on the board

next to patients room number (write, for example, Epi at 6:45 am).

COMBINED SPINAL EPIDURAL (CSE) PLACEMENT

CSEs are ideal for multiparous parturients who present at an advanced stage of

dilation, as well as for laboring patients who present in pain early in labor. They are

also routinely performed for C/S (with higher doses of local anesthetic and opioids)when the length of the surgery might outlast the duration of a spinal (e.g., for repeat

C/S with tubal ligation, an extremely obese patient whose surgery might take a long

time, etc.). That said, the decision to use a particular analgesic or anesthetictechnique should be individualized, based on obstetric or fetal risk factors, the

preferences of the patient, and the judgment of the anesthesiologist. Discusswhether a CSE is appropriate for your patient with staff.

For a laboring CSE, we are having pharmacy provide premade syringes with 1 mL

of 0.25% bupivacaine and 15 mcg of fentanyl. Check out the premade syringe from

the anesthesia stock room refrigerator. Note that these syringes are not currentlyavailable and that several solutions with varying amounts of local anesthetic and

opioid are suitable for a CSE; your attending staff will guide you on this front.

Identify the epidural space with a Touhy needle via the loss of resistance (LOR)technique. LOR to either air or saline is appropriate; some prefer air to ensure thatdroplets upon dural puncture are CSF and not saline seeping out of the epidural

space.

Pass the 25G Whitacre spinal needle through the Touhy needle until you

appreciate a give or dural pop. Then withdraw the stylette from the 25GWhitacre and, once CSF is visualized, attach a sterile 3 mL syringe in which you have

drawn up your solution of 0.25% bupivacaine and fentanyl, and inject without prioraspiration. Using a non Luerlok (i.e., sliptip) 3 mL syringe may facilitate injection of

the CSE solution, as you can avoid having to twist the syringe to the 25G Whitacre

and thereby reduce your risk of dislodging the needle. 3 mL non Luerlok syringesare stocked in the epidural carts.

Other approaches to a CSE technique include the ESPOCAN combined spinal

epidural anesthesia set, equipped with an 18G Touhy and a 27 G spinal needle, and

the individually wrapped 27G Whitacre, which passes with ease through the 18G


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Touhy in the Braun kit. Also, a 25G Whitacre can pass through an 18G Touhy, but

you may detect some resistance.

After the spinal solution is administered, the patients feet should start to feel

warm and contractions should begin to feel less painful within a few minutes.

Patients might become hypotensive from the rapid and profound pain reliefassociated with CSE placement, so be ready to treat with ephedrine. Also, fetalbradycardia associated with the opioid in the CSE solution is not uncommon, and

may also be treated with ephedrine, fluids, oxygen by face mask, and by placing thepatient in different positions (the nurse is very helpful with these maneuvers).

Once the CSE solution has been administered, withdraw the 25 G (or 27 G) needle,

while keeping the Touhy needle in place, and quickly thread the epidural catheter.

Do not dose the epidural catheter. Rather, start the epidural infusion at the routinesettings. Sufficient epidural solution should accumulate in the epidural space by the

time the CSE solution wears off. From time to time, it is helpful to ask the patient to

press the PCEA button within 30 minutes after the procedure and, again, 30 minuteslater to ensure that enough epidural solution has accumulated before the CSE wears

off.

Warn the patient that she might expect pruritus, which is usually selflimited.

CESAREAN DELIVERY WITH IN SITUEPIDURAL

When a C/S is called on a patient with an epidural in place, first confirm that the

epidural is working. Assess the quality and level of the block with the white plastic

swords that are stocked in the top drawer of our epidural cart. Feel the patients legsto assess whether they are both warm (from localanesthetic induced vasodilation).

Ask the patient whether she has been comfortable, and ask her to roll slightly to theside while you assess whether the catheter is still in place and still at the site whereit was originally taped (refer to the labor anesthetic record for this information).

Withdraw the following medications from the Pyxis: 2 vials of 2% lidocaine with

epinephrine (also available in the epidural carts), fentanyl 100 mcg (50 mcg per mL

concentration), duramorph 5 mg (0.5 mg per mL concentration), midazalam 2 mg,three 10 unit vials of oxytocin, ondansetron, and ephedrine 50 mg and

phenyephrine 10 mg (if you no longer have the pressors that were drawn duringepidural placement for that patient). If theres any reason to suspect uterine atony

(for a patient who has had a prolonged induction, a patient with suspected fetal

macrosomia, or a multiplegestation parturient, for example), pull methergine +/hemabate from the icebox in the stock room. The nurses can pull Cytotec

(Misoprostol) from their Pyxis (we do not have access to it). Please be familiar with

dosing regimens, indications and contraindications of each of these drugs.

In patients room, ensure that Reglan 10 mg IV, Bicitra 30 mL PO, and Ancef have

been administered and that the patient has a working IV for fluid administration.


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Note that some obstetricians hold off on administration of Ancef until after the baby

is delivered; the nurse is aware of individual obstetrician preferences.

Disconnect the pump infusion and discard the remaining solution. Then, for non

emergent cases, slowly dose the catheter with 2% lidocaine with epi and

bicarbonate (8.4% solution) in a ratio of 9 mL of lidocaine to 1 mL of thebicarbonate. The bicarbonate serves to raise the pH of the local anesthetic closer toits pKa and hasten onset. Depending on the patients block prior to dosing, you may

need up to 20 mL of the lidocaine with epi/bicarbonate solution to achieve a T4block (block at the nipple line). Give this solution in 35 mL increments with

negative aspiration between each dose and with frequent blood pressure readings.

Note that patients who have had the higher PCEA infusion rate of 12 mL/hr, patients

who have had a documented wet tap with an 18 G or 17 G needle, and those who have

received a CSE may require significantly less 2% lidocaine with epi and bicarb.

For emergent cases, test the catheter in the usual fashion, ruling out intravascular

and intrathecal migration, and dose with 20 mL of 3% 2chloroprocaine withbicarbonate (2 mL bicarbonate per 20 mL of chloroprocaine).

If the epidural block is equivocal, it is prudent not to dose more than 10 mLs of 2%

lidocaine with epi and bicarb (as always, in divided doses) prior to consideringother anesthetic alternatives such as a spinal for the C/S. 10 mL of 2% lidocaine is

more than sufficient to confirm that an epidural is or is not working, as the patient

should get a clear level and dense motor block with that amount. If more than 10 mLof the 2% lidocaine is administered in an epidural that is equivocal, you risk a high

spinal if the decision is made to abandon that epidural and convert to a spinal.

Have the patients husband or significant other wait in the labor suite (OR clothesare stocked in each room) or outside the OR, where OR pants, shirt, hat, and maskare available, until the patient is prepped and draped and checked for an adequate

anesthetic level.

In the OR, place the patient in left uterine displacement (LUD) and administer

oxygen by nasal canula or face mask.

Administer fentanyl 100 mcg per epidural once it has been confirmed that the

epidural quality and level are adequate. We routinely administer Duramorph

(preservativefree morphine) at a dose of 33.5 mg per epidural for postoperativepain relief.

From time to time, the epidural blocks unexpectedly provides inadequate

anesthesia/analgesia during a C/S, and the patient requires IV analgesic adjuvants

such as ketamine, fentanyl or, occasionally, propofol, per your staffs preference. Ifyou withdraw ketamine from the Pyxis, please ensure that it is the 10 mg/mL

concentration, as another, higher concentration is also available. Also, ensure that


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the patients pain is not due to failure to redose the epidural at the appropriate

interval.

Once the baby is delivered, start your oxytocin infusion. Premade bags of 20 units

pitocin in D5LR are available. Alternatively and more often, we place 30 units in 500

mL of LR. Keep the oxytocin infusion open initially; then reassess uterine tonewithin a minute or two and turn down infusion if tone is good. When you start theinfusion, inform the patient that she might feel flushed or lightheaded and that she

might develop a headache. Please be familiar with side effects and adverse effects ofoxytocin.

Document all doses of local anesthetic administered, in both the labor room and in

the OR, as well as vital signs during dosing. Document time of fentanyl and

duramorph administration, in addition to your routine careful documentation of allintraoperative events. We currently record intraoperative events on the labor

epidural document when we transfer to the OR rather than change to a separate OR

record. Indicate on the record the transfer to OR, time, and indication for C/S.

Postoperative orders are to be filled out for each patient who receives duramorph.

After an operative delivery, you are responsible for setting up the OR for the next

possible emergency. Ensure that clean equipment, including breathing circuit, nasal

canula, ETTs, masks, EKG leads, pulse oximeter, blood pressure cuff and cable, and

suction are readily available. Dispose of all used syringes, and waste all unusednarcotics.

Accompany the patient back to the room and document a final set of vital signs and

the end time.

TOPPING OFF LABOR EPIDURALS

If you get called for inadequate analgesia in a patient with a labor epidural, ask the

patient where exactly she hurts and whether her block was adequate earlier in the

course of her labor; check the sensory dermatome level with the white plasticsword; evaluate whether the patient has a motor block; feel whether both legs are

equally warm; check the labor anesthetic record for previous dose, time and result

of last top off and for whether the epidural was a difficult placement; and turn thepatient slightly to her side to assess whether the catheter is still in place and still at

the original insertion site (see anesthetic record to see where catheter was taped atthe skin).

Check the infusion pump, tubing, and bag of bupivacaine solution to rule out

malfunctions, leaks, or empty bags.

Determine the position of the fetus, the station, and the latest cervical exam from

the nurse. This may influence the drug you choose to administer.


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Several top off regimens are appropriate, depending on nature of the patients

pain. For example, if the patient has a dense motor block but a low dermatomal

sensory level, you might consider administering a relatively large volume of a lowconcentration local anesthetic such as 1/8 % bupivacaine or 1% lidocaine or a bolus

from the 0.1% bupivacaine epidural pump solution. Alternatively, if the patient hasa weak or equivocal block and is in great discomfort, a few mLs of 2% lidocaine or % bupivacaine is appropriate. Fentanyl 100 mcg per epidural and/or a few mLs of a

high concentration local anesthetic such as % bupivacaine or 2% lidocaine isoften helpful when delivery is imminent and the patient is complaining of perineal

pain. Similarly, a high concentration local anesthetic and fentanyl per epidural are

useful prior to vacuum or forceps delivery and for manual extraction of the placentaand laceration repairs.

Record the sensory level both before and after your intervention, as well as vital

signs (including fetal heart tones).

Be sure that you have ephedrine readily available as well as a working IV prior to

any top offs. Also, stay in constant communication with the patient during top offs inorder to evaluate CNS changes that may result from an unanticipated bolus of local

anesthetic in the intravascular or intrathecal space. Be aware that catheters canmigrate into subarachnoid and intravascular locations; it is essential also to

administer top offs in divided doses with frequent negative aspirations.

CATHETER PULLS

If you have the opportunity, it is good practice to pull the epidural catheter

yourself, documenting that the tip is in tact. If resistance is met, it is often helpful to

ask the patient to flex her back or assume the position that she was in duringepidural placement.

After the catheter is pulled, you can close out the chart, documenting the delivery

time, Apgars, etc.

Empty the infusion bag and document waste in mLs on the anesthetic record.

If a patient has any complications such as atony, concern for retained products, or

excessive bleeding during delivery, it is prudent to leave the catheter in situ until

concerns have been resolved and the nurse is ready to transfer the patient to thepostpartum unit.

SUBARACHNOID BLOCKSWhen a spinal anesthetic is indicated for a Cesarean delivery, ensure that the

patient has a working IV and has received Reglan 10 mg, Bicitra 30 mL PO, andAncef (unless the obstetrician prefers to hold antibiotics until after delivery).

Consider an IV crystalloid preload or coload. According to the ASA Obstetric


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Anesthesia guidelines: Intravenous fluid preloading may be used to reduce the

frequency of maternal hypotension after spinal anesthesia for Cesarean delivery;although fluid preloading reduces the frequency of maternal hypotension, initiation

of spinal anesthesia should not be delayed to administer a fixed volume ofintravenous fluid. The timing of your fluid administration is controversial; defer to

your staff.Ensure that the OR is properly equipped with suction, a breathing circuit, a face

mask, nasal cannula, working laryngoscope and blade, ETTs of varying sizes, emesis

basin, emergency medications, succinylcholine, an induction agent, etc.

Withdraw fentanyl, duramorph, versed, pitocin, ephedrine and phenylephrine

(unless a bag with phenylephrine 100 mcg/mL has been prepared already) from thePyxis, as in the case of an epidural for C/S.

Open and prepare the spinal tray (located in the neuraxial block cart in each OR)

equipped with a 25 G pencilpoint needle. Note that we have more than one spinaltray, so review the box contents before opening.

In a sterile fashion, draw up 1.42.0 mLs (depending on patients height, weight,

and number of prior Cesarean deliveries, as well as on your staffs preference; weoften use 1.6 mLs) of the 0.75% bupivacaine into the sterile syringe. Use the filterstraw that is provided in the kits to draw up your local anesthetic, as glass particles

from the glass bupivacaine vial can otherwise contaminate your anesthetic solution.

Have an assistant draw up fentanyl (1020 mcg, depending on your staffs

preference) and duramorph (100200 mcg, depending on staffs clinical judgment)

in a TB syringe and insert it into your bupivacaine solution. Alternatively, drop a TBsyringe onto your sterile field and withdraw the appropriate amount of each opioid

while an assistant holds the vials for you. Push air bubbles out your spinal mix prior

to starting the procedure.

Occasionally we also add epinephrine to our local anesthetic/opioid mix for

subarachnoid blocks in order to prolong the effect and, possibly, for enhancedanalgesia. The epinephrine is available in the kits, and you can do an epi wash

before drawing up your 0.75% bupivacaine by showering the inside of your syringe

with epi. Alternatively, consider adding 100200 mcg of epinephrine to your localanesthetic/opioid solution. Note that some practitioners prefer to avoid epinephrine

in the setting of preeclampsia or hypertension. Also, please be careful to distinguishbetween the epinephrine and bupivacaine glass vials, both of which are supplied in

the kits. When drawing up your medications, look at the vial, read the expiration

date and concentration of the bupivacaine, and keep the smaller epinephrine glassvial a safe distance away in order to minimize medication errors.

The patient may be seated or in the lateral position during placement of asubarachnoid block. All monitors should be in place and your pressors should be

immediately available (some may prefer to pretreat with IV or IM ephedrine).

After the 25 G pencil point needle is advanced through the introducer until a dural

pop is detected, withdraw the stylette and watch for CSF backflow. Attach the

syringe with the spinal solution carefully to the 25 G and hold steadily in place; it ishelpful to visualize a small whirl of CSF in the syringe prior to injecting the solution


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by gently withdrawing the syringe. Warn the patient that her legs will start feeling

heavy and warm as the solution is administered into the intrathecal space.

After administering the solution, have the patient immediately lie down (if she had

been seated) or roll over on her back (if she had been in the lateral position) andplace the patient in left uterine displacement. Administer oxygen by nasal cannula

or face mask, take frequent blood pressure readings, and maintain constantcommunication with the patient for several minutes as the spinal sets up. Ask thatthe patient alert you if she begins to feel nauseated, lightheaded, confused or dizzy,

as these are early signs of hypotension or a high block. Be prepared to treat withephedrine or phenylephrine and IV hydration. Be familiar with the OR set up,

particularly with where emergency equipment and drugs are located.

If patients get anxious and feel that they cannot breathe, for example, reassurance

and continuous communication is often helpful, as is having the significant other

join you in the OR. Versed in 12 mg IV also helps alleviate the anxiety, althoughsome practitioners prefer to hold off until after delivery.

Assess the level of your block with the white plastic swords. Ask the patient to

squeeze your hands is an effective way to rule out a high block, as is listening for astrong, unchanged voice.

Alternative spinal kits and needles are available for difficult cases, such as super

morbidly obese parturients. Please defer to your staff.

For repeat Cesarean deliveries (a third or fourth C/S), patients who are super

morbidly obese, patients who have had multiple abdominal procedures and have

suspected adhesions, patients who desire tubal ligation after Cesarean delivery,patients with previas, accretas, or other uterine pathology, etc. a combined spinal

epidural may prove an appropriate anesthetic technique. The CSE for a surgical

procedure is performed in the same manner as a CSE for laboring patients, but the0.75% bupivaine/opioid solution described in this section (+/ epinephrine) is

administered in lieu of the lighter local anesthetic solution used during labor. Whenperforming a CSE for surgical procedures, thread the catheter quickly after

administration of the anesthetic solution and place patient supine with LUD as

swiftly as possible.

COMPLICATIONS OF NEURAXIAL BLOCKS

Hypotension:

Hypotension is a common side effect of administration of local anesthetic in the

epidural or subarachnoid space.

Confirm LUD, evaluate the patient for symptoms (n/v, dizziness, lightheadedness,etc.), and assess the fetal heart tracings.

Open the IV fluids and administer ephedrine if the patient is symptomatic, the fetus

is in distress, or if there is a greater than 20% drop in SBP. Consider oxygen by mask

or positional maneuvers. Get help, if necessary.

Check the patients anesthetic level and rule out inadvertent spinal, accidental

excess local anesthetic dose, etc.


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Wet Tap:

Remain calm and reassure patient. Immediately take a course of action: either

thread the catheter intrathecally or remove the Tuohy needle and attempt epidural

placement at another level.

If you opt to thread the epidural catheter into the intrathecal space, 25 cm

(maximum) should suffice. Confirm backflow of CSF, and dose the intrathecalcatheter for a laboring patient per your staffs preference. You might start with 1 mL

of 0.25% bupivacaine with fentanyl 15 mcg (as we do with CSEs for laboring

patients), followed by a continuous infusion of 1 mL of 0.1% bupivacaine with 2mcg/mL of fentanyl per hour. Adjust you dose as necessary, but be sure to opt for

continuous infusion on the pump settings and to disable the patientcontrolleddosing option. Tell the patient that her catheter is in the CSF space and that she

might be at risk of a headache, explaining that wet tap with headache is a not

unusual complication of epidural placement. Label the catheter as intrathecal,advise the nurse and all staff, and write intrathecal catheter on the board next to

the patients name.

If you opt to remove the Touhy and attempt epidural placement at another level,advise the patient that she might develop a headache. Also, be aware that dosing the

epidural in the setting of a prior frank wet tap might require dosing adjustments.Dose the epidural prudently and with frequent assessements and blood pressure

measurements; reassess the patient frequently during the course of her labor.Document that the patient had a wet tap on both the labor record and in our

logbook in the stock room. Also, pass on the word to staff and team members who

take over after you. Follow up on these patients for 35 days postpartum, assessingfor any signs of postdural puncture headache (PDPH).

On occasion it takes multiple attempts to locate the epidural space, placing the

patient at risk for a dural tear even in the absence of a frank wet tap. Please inform

the patient and team members who assume care once your shift is over that thepatient may be at risk for a headache. Communication is essential in this scenario, as

otherwise the patient may go untreated for a PDPH.

PDPH:

Whether the patient is in the hospital or at home, obtain and review the chart.

Evaluate needle size, difficulty of placement, number of attempts, and whether there

was a frank wet tap. The nursing supervisor is available 24 hours/day in the

hospital and can obtain the anesthetic record from Medical Records at any hour.

Evaluate the nature of the headache. When did it start? Is it positional? Where does

it hurt? Is it totally relieved when lying down? Does patient have tinnitus, visualchanges or nuchal rigidity? Does she recall whether the epidural placement was

difficult or was she warned that she might develop a headache? Does she have a

history of headaches, and is this headache similar to her usual headache? Has sheresumed her normal caffeine intake and has she been eating? Does she have a

history of high blood pressure, was her pregnancy complicated by high bloodpressure or preeclampsia, and what is her blood pressure currently? Is she febrile?


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Examine the spinal/epidural injection site and assess patients motor strength.

Assess also the patients hydration status.

Conservative management for a PDPH is a good option for 24 hours. Consider bed

rest, with the head of the bed flat; hydration; scheduled motrin or fioricet;antiemetics, if necessary; have the patient resume her caffeine intake and avoid

alcohol; explain the probable etiology of the headache and the epidural blood patchtreatment option.

A blood patch can be considered if the patient declines conservative treatment, is

to be discharged that day, has documented evidence of a frank wet tap, or fails

conservative treatment. Explain all the risks and benefits of an epidural blood patch

and have patient sign a consent form prior to the procedure. An anesthetic recordshould be filled out for a blood patch. A fellow or staff member will either perform

the blood patch or assist you.

After a blood patch, instruct the patient to avoid straining, rapid bending, bearing

down, or lifting heavy objects for several days. Also ask her to refrain from alcohol

intake. She can continue taking motrin or fioricet (taper the latter in the usual

fashion).Request that the patient return to the ER or for an anesthesia consult if the

headache recurs, a fever or stiff neck develops, she develops numbness or weakness

in her lower extremities or bowel/bladder dysfunction, if increased redness or

tenderness develops at the injection site, or if she has any questions or concernsabout her anesthetic care.

Advise the patient that in a small percentage of the cases, a second epidural blood

patch may be required. Give her statistics regarding the success rate of a first blood

patch, the success rate of a second, the timeframe for resolution of the headache if itrecurs, etc.

Record that a blood patch was performed on that patient in the log in the stock

room.

Asymmetic Sensory Block:

A unilateral block is a common complication of epidural procedures. It is often

associated with a catheter being threaded (or migrating) too deep into the epiduralspace (literature suggests that threading the epidural catheter 35 cm is optimal) or

with having the patient lie on one side for too long.

To troubleshoot, roll the patient on her side and ensure that the catheter is at the

proper depth at the skin; if it has migrated inward, pull it back to the site where it

was originally taped at skin and, after repositioning the patient on the side without

the block, either give a manual bolus of a local anesthetic solution or ask that thepatient press her PCEA button. If the catheter is still where it was originally taped,

roll the patient on the side that has diminished analgesia, withdraw the catheter 12cm and bolus as above. Remember to aspirate prior to administering any bolus.

Patchy Block:

Assess where the patient is feeling discomfort. Does she have a window of pain?

Is she experiencing perineal pain immediately prior to delivery?


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Rule out a subdural block; to do this, you must be familiar with the manifestations

of a subdural block. If you feel certain that the patient is experiencing a subdural

block, consider immediately replacing the catheter.

If the patient is experiencing perineal pain, consider fentanyl 100 mcg per epidural

or a few mLs of a dense local anesthetic solution, as described in the troubleshooting

section.If the epidural is working properly and the patient has a window of pain, consider

a bolus of a dense local anesthetic solution with the patient lying with the unblockedsegment down. Have a low threshold for replacing these catheters, as it is often

difficult to remedy a window.

Fetal Bradycardia:

Ensure that the nurse is present and has placed the patient on her side to avoid

compression of the blood vessels.

Consider oxygen by mask.

Evaluate the patient for symptoms of hypotension; take a blood pressure reading.

If the patient is symptomatic or hypotensive, open the IV fluids and administer

ephedrine. Administering ephedrine is often helpful also in the absence of overt

hypotension.

Notify your team if the bradycardia continues and if there is concern for imminent

C/S.

Have 20 mL of 3% 2chloroprocaine with 2 mL of bicarbonate drawn up for

immediate dosing of the epidural if proceeding to the OR emergently is imminent.

Intravascular Injection:

When testing a catheter, remember that every dose is considered a test dose. Use

3 mL increments of local anesthetic with frequent negative aspirations and frequentblood pressure readings.

To assess for intravascular injections, ask if the patient has ringing in the ears,

dizziness, circumoral numbness or a metallic taste on the tongue, restlessness, or

suddenonset anxiety. Watch for tachycardia (if an epinephrinecontaining localanesthetic was used) and for seizure (if a large amount of high concentration local

anesthetic was dosed at once). Also, take a small syringe and draw back for blood

when evaluating a suspicious scenario. Hold the syringe below the level of thepatient as you gently and protractedly draw back.

Of note, remember that we routinely administer 100 mg of lidocaine intravenously

in the OR without noting any of these signs and symptoms described above; several

mLs of the local anesthetic solution may be necessary for the patient to detect anysensory changes. Also, be reassured that we use low concentrations of local

anesthetic in small, incremental doses with frequent aspirations in order to

minimize complications of intravascular injections. Lastly, the soft, wirereinforcedcatheters in common use today have a lower incidence of intravascular cannulation.

In the event of a known intravascular injection of doses greater than a test dose or

if the patient is symptomatic, stop injecting, get help STAT, prepare for

administering oxygen and protecting/supporting the airway, and prepare


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emergency drugs, including lipid. Have a low threshold for transfer to the OR, if the

problem persists.

OBSTETRIC ANESTHESIA CURRICULUM: LEVEL 1

Note: For specifics on fulfilling the 6 core competency requirements, please refer to theObstetric Anesthesia guidelines posted on the Tulane departmental Website. The

following provides an abbreviated version of expectations for your manual skills

development and your core knowledge acquisition over the course of your rotations in

Obstetric Anesthesia. The curricula below are modified from the Society for Obstetric

Anesthesia and Perinatology (SOAP), and are not intended to be exhaustive.

Manual Skills Development:

Residents are expected to learn and develop proficiency in the following skills

during routine cases: 1) epidural catheter placement with a success rate of 70% bythe end of the month; minimal number of wet taps 2) subarachnoid block placement

with a success rate of 7080%

Core Knowledge Acquisition:

A) Maternal physiology prior to labor and deliverya. Cardiovascular system: cardiac output, stroke volume, heart rate,

systemic vascular resistance, blood pressure, and blood volume

b. Describe the effects of supine position on blood pressure and uterineblood flow

c. Pulmonary, respiratory and airway: functional residual capacity, tidalvolume, respiratory rate, minute ventilation, alveolar ventilation,

work of breathing, airway resistance, chest wall compliance, arterial

blood gases, ventilation/perfusion matching, and Mallampati (bothover the course of pregnancy and during labor)

d. Gastrointestinal: gastric motility, gastric emptying, lower esophagealsphincter tone, gastric pH, risk of aspiration pneumonitis

e. Hematologic: hematocrit, blood volume, platelets, white blood cells,coagulation factors, fibrinogen

f. Renal: BUN, Cr, glomerular filtration rate, renal blood flowg. Endocrine and metabolism: progesterone, estrogen, prolactin,

aldosterone, angiotensin, rennin, cortisol, prostacyclin, thromboxane,insulin and glucose, etc.

h. Musculoskeletal: back pain, sciatica, carpel tunnel syndrome, lordosisi. Central nervous system: pain tolerance, anesthetic requirements for

both general and regional anesthesia

B) Fetal and placental physiologya. Embryogenesisb. Placental development and structurec. Placental gas exchange, nutrient transport, drug transferd. Fetal circulation


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e. Fetal evaluation: Intrauterine growth restriction (IUGR), nonstresstest (NST), biophysical profile (BPP), fetal heart rate (FHR), fetal bloodgas values, etc.

C) Neonatal physiologya. APGARb. Physiologic adaptations to extrauterine life, including circulatory andrespiratory changesc. Resuscitation of the newborn: what is the role of the anesthesiologist?

D) Local anestheticsa. General principles of LA pharmacologyb. Criteria for selecting specific LAsc. Describe effects on maternal circulation, uterine tone, uterine blood

flow, and FHR

d. Effect of vasoconstrictorse. Effect of sodium bicarbonate on onset and durationf. Signs and symptoms of systemic toxicityg. Neurotoxic effectsE) Agents affecting uterine tonea. Agents that affect uterine tone: volatile agents, ketamine,

nitroglycerineb. Tocolytics: Ethanol, Mg, calcium channel blockers, etc.c. Uterotonics: Pitocin, Cytotec, Methergine, Hemabate.

F) Opioids:a. Opioid agonists for neuraxial blockadeb. Treatment of opioid side effectsc. Mixed agonistantagonistsd. Effects on the fetus

G) Drug interactionsa. What are the effects of vasoactive agents on the onset, intensity, and

duration of sensory and motor effects of LAs?

b. What are the effects of opioids on the onset, intensity, and duration ofsensory and motor effects of LAs?

c. What is the effect of sodium bicarbonate on the onset, intensity, andduration of LAs?

d. How does magnesium affect neuromuscular blocking drugs?H) Management of labor

a. Describe the first (active and latent phases), second and third stagesof labor

b. Describe the effects of uterine contractions on placental exchange andfetal oxygenation

c. Describe the anatomy of the epidural spaced. What are the clinical manifestations of uterine hypertonus and

hyperstimulation

e. Does epidural analgesia affect labor?f. How does labor affect maternal hydration, ventilation, and

hemodynamics?


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I) Regional anesthetic techniques for the obstetric patienta. Describe techniques available for routine labor and vaginal delivery,

vacuum or forceps delivery, manual extraction of the placenta, uterine

inversion, nonurgent and emergent Cesarean delivery, dilation andcurettage (D&C), tubal ligation, and cervical cerclage

b. Describe neurologic pathways that convey pain during the first andsecond stages of laborc. List all regional anesthetic techniques that can produce effective

analgesia in the first and second stages of labor

d. List absolute and relative contraindications of regional anesthesiae. Describe the hemodynamic effects of epidurals and subarachnoid

blocksf. List complications of regional anesthesia, including PDPH, backache,

nerve palsy, meningitis, abscess, and hematoma

J) General anesthetics for obstetricsa. What are some of the concerns about administering general

anesthesia to a parturient, both early in pregnancy and at term?b. List indications for general endotracheal anesthesiac. What are the ventilatory requirements for parturients?d. Describe how drugs used in the induction and maintenance of general

anesthesia affect uterine tone, fetal perfusion, and the neonate

e. Describe the steps of the difficult airway algorithmK) Resuscitation

a. Describe clinical factors (both maternal and fetal) that are predictiveof a need for neonatal resuscitation

b. Describe ideal management of maternal resuscitationL) Complications of anesthesia during pregnancy

a. Aspiration pneumonitisb. Failed intubationc. Complications during emergenced. PDPHe. Common neurologic complications

M)Anesthetic management of nonobstetric surgery during pregnancya. Describe advantages and disadvantages of performing elective

operations during the first, second and third trimesters of pregnancy

b. When is fetal heart monitoring (FHM) indicated?c. Do our anesthetic agents affect the fetus? Which ones? How?d. Discuss the effects of maternal hypotension, hyperventilation,

hypoventilation, and blood transfusion on fetal well beingN) Ethical Issues

a. Discuss the potential for maternalfetal conflicts of interestb. Discuss the current gestational ageweight limits for fetal viabilityc. Discuss informed consent issuesd. Demonstrate an understanding of divergent religious points of view

O) Crisis aversion


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a. Diabetes, with emphasis on the criteria for diagnosis, indications fortherapy, effect of pregnancy on the disease process, fetal effects of thedisease, and the effects of treatment on both mother and fetus

b. Thyroid disease, with emphasis on diagnosis and treatment of bothhypothyroidism and hyperthyroidism

H) Substance abusea. Identify risks and complicationsb. Recommend postoperative pain control strategiesc. Develop a plan for complications of withdrawal

I) Immunologic diseaseJ) Neurologic disorders

a. Multiple sclerosisb. Spinal cord injuryc. Myasthenia gravisd. Seizure disorders

K) Respiratory diseasea. Asthma, including the pathophysiology, the effects of pregnancy onasthma, and asthmas effects on pregnancyb. ARDS

L) Cardiovascular diseasea. Congenital heart diseaseb. Ischemic heart diseasec. Valvular heart diseased. Peripartum cardiomyopathy

M)Hematologic and thromboembolic diseasea. Anemiasb. Thalassemiasc. Sickle cell diseased. Thrombocytopeniase. Platelet and bleeding disordersf. Anticoagulation medications

N) Morbid ObesityO) Malignant HyperthermiaP) Renal diseaseQ) Liver diseaseR) Musculoskeletal disorders

a. Scoliosisb. Rheumatoid arthritisc. Spina bifidad. Prior back surgery

OBSTETRIC ANESTHESIA CURRICULM: LEVEL 3

A) Act independently as a consultant, formulating an anesthetic plan for highrisk parturients


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B) Develop critical evaluation skillsC) Develop management and leadership skills

a. Demonstrate independenceb. Develop communications skillsc. Demonstrate leadershipd. Supervise junior residentse. Teach junior residents and participate in management tasksf. Introduction to clinical researchg. Bedside teaching

complex regional pain syndrome i reflex.31

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