Epi for Epidural Complications..HELP

RedCell · Oct 1, 2008

Sounds like the epidural was working well. Why do you want a big gun like epi? How about giving her a squirt of ephedrine to compensate until you catch up with the volume? Most OB units I have been on have standing orders for ephedrine if there is not an anesthesia provider readily available. Next time I would just get a verbal order from the guy so you are covered.

SmilingBluEyes · Oct 1, 2008

Are you sure you did not mean an order for ephedrine?

Calzonan RN · Oct 1, 2008

I'm pretty new at L&D so forgive me if I get this wrong, but I thought it was pretty standard to have an IV with any epidural. From what I understand a lot of the BP problems can be a result of not having enough volume in moms blood supply. We're required to give a bolus of about 1000 cc's of LR before an epidural and our CRNA's are in the hospital 24/7 in case anything happens after the epidural. Any problems I've had with a drop in B/P have been quickly solved by giving more fluids (so far). I did finish school at a hospital that had ephedrine at the bedside for every epidural, their CRNA's gave really strong epidurals and a lot of times they would have to use the ephedrine.

elanddeenrs · Oct 1, 2008

we also use ephedrine for these cases.

but, i do have to say-- sometimes you could bolus your little heart out and some BPs are just going to end up in the toilet.

CRNA2007 · Oct 1, 2008

Heres an idea just follow the orders given to you. You would end up killing that fetus and possibly the mother as well giving them epinephrine. Anethesia is not going to give you a standing order for epinephrine, but they can give you a standing order for some epherdrine in 5-10mg increments.

OK, my first day at a new hospital, not only do I have to argue with the anesthesiologist that I will NOT start the continuous infusion but, 25 minutes later mom's BP tanks to 75/40 and FHT to 45 bpm and all I can do is start O2 and squeeze the LR bag because they don't have standing orders for epi.!!!! Oh and yeah, Anesthesia is in his car and 15 minutes away already but, OB is there ready to cut her. Can anyone share with me your policies on RNs giving epinephrine? I'd like to get this going on our unit. Any ideas?? What do we need? Just a standing order from Anesthesia? Do we need policies, too? What's the process? Thanks.

jwk · Oct 2, 2008

OK, my first day at a new hospital, not only do I have to argue with the anesthesiologist that I will NOT start the continuous infusion but, 25 minutes later mom's BP tanks to 75/40 and FHT to 45 bpm and all I can do is start O2 and squeeze the LR bag because they don't have standing orders for epi.!!!! Oh and yeah, Anesthesia is in his car and 15 minutes away already but, OB is there ready to cut her. Can anyone share with me your policies on RNs giving epinephrine? I'd like to get this going on our unit. Any ideas?? What do we need? Just a standing order from Anesthesia? Do we need policies, too? What's the process? Thanks.

You argue with the anesthesiologist and want to give epi? Please, learn some pharmacology first before you really make yourself look foolish. Epi isn't indicated - ephedrine or neosynephrine probably are. And your anesthesia staff isn't in house, yet you have no standing orders or policies on how to deal with labor epidurals?

The BP could have dropped for any number of reasons - abruption for example. You have an OB there and he can't figure this out and treat it appropriately? BP's generally do not suddenly drop 25 minutes after a labor epidural is placed - it's likely due to another cause.

No offense, but this sounds like a scary place to be doing OB.

Elvish, BSN, DNP, RN, NP · Oct 2, 2008

Might be a good idea to let the OP get back to the thread and say whether she meant ephedrine and not epinephrine? That might clear up one issue.

And, we don't know if the OP meant continuous IV infusion, or continuous epidural infusion. The former, yes. The latter, there is no way in Hades I as an RN would start a continuous epidural infusion. Anesthesiologist or CRNA, but not me. That may be what she was referring to.

As far as 'just follow the orders you've got', if we all did that all the time, guess how many dead or injured patients we'd have. I'm sorry, but I'm NOT going to give PCN IV to someone who's got a documented anaphylactic reaction to Amoxil. Nope, nope, nope. And yes, that did happen.

There ARE times when questioning or outright refusing to follow an order is appropriate. This may or may not be one of those times but it's not outside the realm of possibility.

ScubaLvr · Oct 3, 2008

Wow...You guys have me feeling very defensive now so forgive my tone.

OK Note to self .... NEVER post at the end of a bad day!! Yes, I did mean EPHEDRINE.

And I suppose I thought the IV was too obvious to mention... oh wait I did. She had 1400cc in in the 40 minutes we were waiting for anesthesia to show up in the first place. This place has in house anesthesia from 7am-3pm only after that we are on our own with no orders for anything.

And YES...I ARGUE with the anesthesiologist... these Docs expect that after they have mixed up God-only-knows-what(because I'm NOT an anesthesia provider) combo of meds to prime, hook-up to the catheter, and start the EPIDURAL infusion. This I will continue to absolutely refuse to do. The very next day I had another doc prime, hook-up, and even load the pump but did not start it. Go figure.

I've been in L&D for 17 years... I don't think Mom's BP tanking 20-60 minutes after an epidural is all that unusual. Thankfully the kidlettes usually do OK but, when they don't, I sure would like to be able to do more than O2 and squeeze the IV bag. This particular mom had NOTHING else wrong with her...but that was the longest 10min. of my life.

I know I won't make any friends here refusing to start epidural infusions... the regular staff here doesn't seem to mind(I'm a traveller) I WON'T.

OH-- another funny thing they do... they insist on continuous cardiac monitoring during epidural infusion... I'M THE ONLY RN THAT HAS ACLS!! What good is the strip if no one can read it???

I would however like to get them standing orders for ephedrine.

Does anyone know whether that just requires sitting down with anesthesia and getting them to agree to standing orders or changing entire hospital policies??

crysobrn · Oct 3, 2008

We have standing orders for ephedrine at the bedside... The docs generally only stay 15 minutes to MAYBE a half an hour. We only have anesthesia in house during surgical hours so as soon as they are done they're off... Especially if it's nights.

I am pretty sure that they sat down at an OB comity mtg to do our standing orders. That way the OB's have a say in what anesthesia is ordering.