II. Epidural placed but: No Anesthesia:
Cause:
1. Catheter not in epidural space, IV, out through a foramen.
Management:
1. Labor: Repeat epidural; consider switch to continuous spinal or combined spinal-epidural (CSE) (Chapter 70).
2. Cesarean Section:
a. repeat epidural.
b. switch to spinal, CSE or general anesthesia.
III. Epidural placed but: One-sided analgesia:
Cause:
1. Patient position (Chapter 30).
2. Anatomic or functional division of epidural space (Chapter 32).
Management:
1. Labor:
a. turn patient to opposite side and supplement dose (1/3 to 1/2 initial dose).
b. pull epidural catheter back 0.5 to 1 cm and redose.
c. add narcotic to local anesthetic (Chapter 60).
d. repeat epidural.
2. Cesarean Section:
a. repeat epidural.
b. switch to spinal, CSE or general anesthesia.
IV. Epidural placed but: 'patchy' anesthesia or missed segment:
Cause:
1. Air used for loss of resistance technique.
2. Scarring or deformation of epidural space (eg. kyphoscoliosis).
3. Anatomical variations of epidural space.
Management:
1. Labor:
a. turn patient to opposite side and supplement dose.
b. pull epidural catheter back 0.5 to 1 cm and redose.
c. add narcotic to local anesthetic.
d. repeat epidural.
2. Cesarean section:
a.repeat epidural.
b. switch to spinal, CSE or general anesthesia.
c. ask surgeon to supplement with local infiltration if area small (Chapter 100).
d. supplement with IV or inhalational analgesia if discomfort mild.
V. Epidural placed, segmental level adequate, but block not intense enough:
Cause:
1. Insufficient time allowed for block to 'mature'.
2. Inadequate concentration of local anesthetic.
3. Loss of local anesthetic (volume) through intervertebral foramina.
4. Patient perception of adequacy of sensory block.
Management:
1. Labor:
a. allow more time for development of block.
b. add narcotic,
c. increase concentration of local anesthetic,
d. redose.
e. wait 3-5 minutes.
2. Cesarean section:
a. allow more time for development of block.
b. redose,
c. increase concentration of local anesthetic,
d. add narcotic,
e. wait 2-3 minutes.
f. supplement with IV/inhalation analgesics.
g. proceed to general anesthesia if necessary.
VI. Epidural placed, satisfactory intensity of block but inadequate segmental level:
(Chapter 8)
Cause:
1. Inadequate volume of local anesthetic.
2. Loss of local anesthetic volume out through intervertebral foramina (Chapter 1).
3. Insufficient time allowed for block to reach desired level.
Management:
1. Labor:
a. allow more time for development of height of block.
b. redose; consider using larger volume to achieve higher segmental spread.
2. Cesarean section:
a. allow more time for development of height of block.
b. add volume.
c. repeat epidural.
d. switch to spinal, CSE or general anesthesia.
VII. Previously working epidural, now appears not to be working:
Cause:
Epidural catheter has probably become displaced.
Management:
1. Labor:
a. examine catheter insertion site.
b. if catheter position appears satisfactory and intravascular migration has been excluded, give a significant dose, ie. repeat of initial dose,
c. if no improvement in appropriate period of time, REPLACE!
2. Cesarean section:
a. examine catheter insertion site.
b. give significant dose,
c. if no response, consider replacement, spinal, CSE, or general anesthesia depending on circumstances and time.
VIII. Other suggestions:
1. Patients with a long labor, 5 or more hours, may become mentally fatigued, even with a well functioning epidural. Butorphanol 0.5mg IV may produce an improved mental state.
2. Do not allow a block to recede; top up by the clock if not using a continuous infusion.
3. Always allow adequate time for the selected local anesthetic to become effective.
4. If quality of analgesia for cesarean section is found to be inadequate after surgery has commenced, the choices for action become limited, ie. a change to spinal, CSE or repeat epidural is no longer an option.