Epidural top-up

block education emergency management obstetrics anaesthesia spinal Oct 09, 2023

What does the anaesthetic nurse need to know about an epidural top-up for caesarean section? 🧐

4 things:
1️⃣ What drugs do you need? πŸ’Š
The most common formulation for top up is 2% Lignocaine with adrenaline (ensure it is safe for epidural administration). It is also common to add fentanyl up to 100mcg. Some centres may differ from this!

2️⃣ What is Plan B? πŸ” 
The risk of failed epidural top up is 10-20%, and your options will depend on how far through the procedure you are:
πŸ‘‰ Perform spinal or repeat epidural (if surgery has not started)
πŸ‘‰ Convert to GA (if surgery has started) *see our post on GA Caesar
πŸ‘‰ Supplement with IV drugs (if baby has been delivered)

4️⃣ Red flags for failed top up 🚩
πŸ‘‰ Poor functioning epidural prior to caesarean (you can ask the patient this!)
πŸ‘‰ Multiple boluses on labour ward (you can check the chart for this!)
πŸ‘‰ Urgent case

4️⃣Side effects of top up
πŸ‘‰ Local anaesthetic toxicity (rare)
πŸ‘‰ High block (see our post on high spinal)
πŸ‘‰ Tachycardia (due to adrenaline if catheter is intravenous)
πŸ‘‰ Shivering (common side effect of epidural)

The bottom line is that most epidural top ups work well, but your team should always be prepared for plan B! πŸ‘Œ

Build knowledge βœ…
Improve safety βœ…

Ref: https://resources.wfsahq.org/atotw/conversion-of-labour-epidural-analgesia-to-anaesthesia-for-caesarean-delivery/

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