Epidural-induced Hypotension

RaeT,RN · Oct 11, 2005

Our policy is to hydrate with 500-1000cc bolus prior to placement. We also have a standing order (or now I think the correct term is, "it is in our order set") for 5mg Ephedrine IVP for SBP

I ended up giving my pt on Thurs 45mg total of Ephedrine over the course of the morning, and I wanted to understand exactly what was going on with my pt - what it was that made her BP bottom out. What was odd was that she didn't start to drop until about an hour after she had gotten her epidural. Knowing what I know about supine hypotension, I try my best NOT to put my pts on their backs. The reason I asked this question is because we had an anesthesiologist new to our facility, with my pt being the first epidural he did. I just wondered if he gave her too much, and that was what did it . . .

I understand that there is a sympathetic block that happens, which will make the pt unable to compensate for hypotension, but what I wanted to know was what caused the initial drop in the first place. Thank you all for the links; I will investigate further.

RaeT,RN · Oct 11, 2005

Ok, now I understand. I had to dig out the cobwebs of A&P and remember about the sympathetic nervous system and vasal tone. THANK YOU for your responses!!!:)

NurseNora, BSN, RN · Oct 11, 2005

More of a mommy question than a nurse question but if someone (me) has had a severe hypotensive episode after an epidural, including loss of fetal heart tones, would it be likely to happen again if I ever decide to have another pregnancy/epidural?

Having had severe hypotension after one epidural doesn't predispose you to having it happen again. Discuss this with your OB and anesthesiologist anyway. Forewarned is forearmed.

Preloading with fluid, avoiding supine position, and immediate recognition and treatment of developing hypotension can avoid the severe hypotension you experienced previously.

NurseNora, BSN, RN · Oct 11, 2005

This is it, in a nutshell. It's so common, you should plan for it, and if possible, have your MD/anesthetist draw up a premixed syringe of ephedrine, labeled and marked for you, to give in the case you need it emergently, to bring that blood pressure back up. Ours do this, and it's saved my bacon on more than one occasion.
We usually use anywhere from 5-10 mg Ephedrine, drawn up in a TB syringe, prepared by the MD, if needed.
deb

In my hospital, we have standing orders to mix 1 amp of Ephedrine (50mg/ml) with 9ml of normal saline. This results in a concentration of 50mg/10ml or 5mg/1ml. I find this much easier to administer than using a TB syringe.

csours · Oct 11, 2005

The loss of sympathetic tone is related to the concentration and volume of local anesthetic used by the Anesthetist (ropivicaine or bupivicaine). The preloading of fluid helps reduce the loss of tone.

blueheaven · Oct 11, 2005

So that is why my BP bottomed out when I had my last baby! that was 23 years ago today...LOL I just loved it when the anesthetist was taking my BP q2seconds (it seemed like) and my IV was running wide open, and I ask him what is going on.....and he says "Nothing" :banghead:

chadash · Oct 11, 2005

So that is why my BP bottomed out when I had my last baby! that was 23 years ago today...LOL I just loved it when the anesthetist was taking my BP q2seconds (it seemed like) and my IV was running wide open, and I ask him what is going on.....and he says "Nothing"

When I was having my second baby 24 years ago, had an epidural...could feel each little cutcutcut, started shivering like wild...real nice nurse (actually a guy) stayed right there reassuring me the whole time, made a big difference. Don't know about my bp, but they did add something to my IV that helped the shivers and nausea....:typing

moonbeamsmom · Oct 12, 2005

So that is why my BP bottomed out when I had my last baby! that was 23 years ago today...LOL I just loved it when the anesthetist was taking my BP q2seconds (it seemed like) and my IV was running wide open, and I ask him what is going on.....and he says "Nothing"

That's one thing I didn't like - not being told what was going on! I was so out of it, I thought everyone was coming in to watch me push! :chuckle :rotfl:

Equus419 · Nov 17, 2005

Actually, when I attended Michelle Murphy's advanced fetal monitoring class this April, she went in to GREAT depth as to the physiology of why boluses over 500 ml were a CAUSE of maternal hypotension in relationship to epidurals... :-)

Lisa

I am a labor and delivery nurse and have been for several years and one of the best resolutions for decreasing hypotensive episodes is to hydrate your pt with at least a 1000ml to 1500ml of LR or NS as a bolus prior to epiddural placement and do not keep your pt flat on her back for long periods of time, this is where the vagal response happens. Instead put a small roll under one of her hips so the pt is slightly tilted. Follow these 2 steps and you should be ok.:)

Dayray, RN · Nov 17, 2005

Actually, when I attended Michelle Murphy's advanced fetal monitoring class this April, she went in to GREAT depth as to the physiology of why boluses over 500 ml were a CAUSE of maternal hypotension in relationship to epidurals... :-)
Lisa

What did she say?

epiphany · Nov 17, 2005

PS: be careful in pre-epidural hydration, particularly if a patient is on Pitocin (which acts like anti-diuretic hormone). Some studies are suggesting pre-load of NS or LR of 500ml-to 1000ml MAX is all you need to offset the possiblity of hypotension in patients. Too much fluid volume overload is at least as bad as too little. Keep careful I/O on all patients on IV fluids in labor. Watch your balances. Pulmonary edema, while rare, is something I have seen in women over-hydrated in labor and immediately after. Even in healthy women, you have to be careful.
Know where the ephedrine is, and how to use it, if you don't already, or make sure you have an Anesthetist immediately available, to handle this, as needed.
deb

Thanks for that info, deb. Very useful for new nurse like me.

athomas91 · Nov 17, 2005

epidurals have a MUCH lower rate of hypotension than a spinal - however it can occur

you are correct that a bolus of 1000cc of fluid is your best defense against the hypotension as it is caused by a sympathectomy (where the local spreads up to a T4 or nipple line level) - the sympathectomy in turn will lower the patients vasomotor turn thus lowering the BP.

so to maintain the BP you up the fluid volume to offset the change and moderate the patients response.

ephedrine 5 mg IV will help as you all have found - but once you use approx 50mg w/o significant results - they are likely to have tachyphylaxis which is a mechanism that most view as tolerance.

you can now use phenylephrine (neosynephrine) which used to be contraindicated but has since been proven not to decrease blood flow to placenta/fetus

ephedrine is an alpha and beta agonist - so you will see HR and BP go up

neo is a pure alpha - you will see BP go up - you will actually see a compensatory decrease in HR

hope this helped