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[yogenbhatt1]

Gave an Epidural Labour Analgesia.
23 yr, tall, 106 kg primie.
Gave Epidural. The one who gives, knows that he is in the space, the way the feel is there, the way the NS goes, the way the catheter slides smoothly.
Catheter was fixed at 13 cm.
There was no action after first 15 ml of 0.1 % Bupivacain with 30 mic Fent.
Waited for 30 mins. Withdrew Catheter to 9.5 cm. Gave 10 ml again.
Epidural acted in 5 mins and the patient was actually smiling and went off to sleep after 10 mins.
Next dose again had poor action.
Anyway LSCS was now decided, and I had no intention to give GA if Epidural does not act, at 3 in the morning.
Removed the cath, gave spinal and finished it.
I invite comments.
May be many will learn through that.
Regards

[jafo1964]

Dr. Bhatt
I have the greatest regard for your knowledge and technical skill.
Above all I appreciate your quest for constantly trying to learn and iron out any thing that is not in tune with current evidence of good anaesthetic practice.
Hope we can continue to learn on this site and inspire youngsters to go beyond what we have achieved.

Now to the problem
Epidural catheters should be inserted only 3 to 6 cms into space.

Less than 3 cms – in 3 lateral eyed epidural catheters, we commonly use, the 3 eyes may not completely lie in the epidural space and hence we may have a patchy distribution of what is known as the “Multi-compartment block”. I believe this can be avoided by using a single terminal orifice epidural catheter.

More than 6 cms insertion  - 2 things can commonly happen. First the catheter exits the epidural space along with the emerging nerve roots via the intervertebral foramina and comes to lie in the paravertebral gutter. Hence block may be unilateral and/or  patchy.
Secondly more than 6 cm insertion has been found to increase the incidences of catheters double folding on themselves. Greater lengths of inserted catheters also increase the risk of inadvertent Intravascular and subarachnoid placement of catheters.

So in the first instance a 13 cm insertion probably took the catheter to the paravertebral gutter. Pulling it out did the trick. I wonder why the second dose had poor action.

Epidural catheters greater than 6 cm insertion has been used in paediatric patients via the caudal space. But positioning of catheter in these scenarios is done under C-Arm guidance.
regs

[yogenbhatt1]

HI,
Thanks, That is a great scientific explanation.
We had thought of the same. Only because the patient was fat I went to 13 cm ( Keeping 6 cm of tissues and next 7 cm inside) but I still withdrew the cath and it worked too.
2nd dose, I am not sure what happened. Nor did I wait sufficient to see if it works, as I honestly said that at 3 in the morning alone I had no intention of giving a GA to this obese patient.
Either case the theory of the cath entering outside the space and not acting is quite possible.
Regards. ( It is so surprising that one can build an opinion on each other simlpy by reading replies. Best wishes to you )

[neelam nalge]

   Hello;
 Inserted a epidural for inguinal hernia patient with COPD + IHD .single shot uneventful.gave 3 cc of 2% adr.xylocaine,followed by 10 cc of 0.75% ropivacaine.Action till thighs. ?? ??waited ;then injected 5cc more.action till ing ligament.After 10 Min's 5cc more.surgeon ready with scalpel on my head.(I had already wasted his so much precious time.).7cc more after 10minutes.pt draped.
I gave 1 MGM fulsed .spo2 94% with nasal o2.surgeon checked with toothforcep action till T10 app.(Everyone happy.)With skin incision patient started screaming
 ???All eyes on me asking for option.
 ???with total dose of ropivacaine
     1.can I change to epidural sensorcaine.was EP cath a problem.
     2.cant dare to give GA to this pt in this setup.
     3.can I remove the cath and give spinal.scared about hypotension.
     4.Ask the surgeon to supplement with ing block?.Then total so much ropivacaine+his 25ml of 2% adr xylo with 0.5% sensorcaine... ???Plus cant give much iv supplements with his kind of lungs.
     Your suggestions and experiences awaited.

4     4

[yogenbhatt1]

HI,
Not uncommon at all.
Best is to accept that it is not working.
Repeat the Epidural if possible, or give a single shot spinal and manage it.
Hypotension is not very difficult to manage, while the complications of GA in this pt will be difficult to manage.
Time and again, when we have realised that our epidural is not working in Labour Anagesia, we have resited the cath and sucessfully.
It is catheter placement related.
A good statement is " the epidural catheter does not have an eye at its tip", it is a blind procedure.
Regards