continous(infusion) spinal for labour analgesia after 'wet tap'

Started by savitaku, July 20, 2006, 10:47:39 PM

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savitaku

Following accidental dural puncture during epidural for labour analgesia, current recommendation appears to be to thread the catheter in the subarachnoid space and use it as such.
What drug(s) and doses appear to work the best for a 'continous subarachnoid infusion ' in this situation ?

jafo1964

we dont use infusions
we stay with 1 ml of 0.5% hyperbaric bupivacaine, repeated at the earliest evidence of discomfort
The original 24G catheters approved for continuous spinals are associated with a possibility of cauda equina syndrome.
Threading in a 16 or 18G epidural catheter must definitely increase that risk.
Also moving pt to Post-op with catheter in SA space may increase the risk of direct infection transmission to meninges
I am in favour of removing the catheter ASAP.
Use it for intra-op anaes but remove the catheter before shifting him from OT
For post op analgesia just prior to catheter removal you may want to inject a long acting intrathecal narcotic like Morphine or Buprenorphine

yogenbhatt1

There are times that there is a wet tap. As a reflex an an anaesthesiologist removes the needle. This does not prevent the leak. In my group the protocol is to first put the styllet back in the needle. Wait and think. Was it easy to give epidural in the first place? Will the patient allow again at another space?
If no, then we push the catheter inside and accept it as a continuous spinal. The dose for Epidural labour analgesia is 0.2 ml of 0.5 % Bupivacain Heavy, plus 25 mcg of Fentanyl. One has to keep in mind that when we are injecting such a small volume, catheter capacity also matters. But keep your concentration same and keep injecting as per need.
I read some where, not to remove the catheter on the same day. The protein in the CSF that keeps leaking around the catheter forms a coagulum around the catheter and prevents PDPH ( Post Dural puncture headache)  later on when the cath is removed 2 days later. Yes, we do lock up the catheter and make it non functional, so by error, no one injects something for pain. We keep it inside to prevent the PDPH and if required for some emergency later on.
Remember the PDPH  is really bad, specially after a labour analgesia, as there is  a leak of CSF, every time uterine contraction takes place.

kumar

how much to repeat ? when to repeat? In sub arachnoid labour analgesia 0.2 ml of 0.5% bupivacaine and 25 mcg fentanyl.

yogenbhatt1

Hi,
Sorry for a delayed responce. If an intrathecal cath is accpeted by us in labour analgesia, we inject on demand dose. It is needed almost every one hourly. Only problem we have encountered is an occasional severe tonic contraction leading to severe foetal brady which ended up in a section. On detailed inqueiry I was told by a few friends who have been in labour analgesia for some time in institution, I was told that it is due to circulating Catecholamines due to sever pains, as you give intrathecal and suddenly cut off pain, the catecholamines work on the uterus and give tonic contractions which give a continuous pressure on baby and give bradycardia. Treatment is to give Terbutaline or NTG to relieve the tonic contraction.

ashok-jadon

 Dear friend,
how circulating catecholamine will cause uterine contracture(severe contraction) we all know B1 stimulation is having tocolytic effect. The brady cardia is due to withdrawl of catecholamine after sudden relief of pain, which causes bradycardia. It is short lived and will not harm baby any way.