Epidural Man's uselss (but maybe not SO useless) problem based learning. 5 cases

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epidural man

epidural man

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So,

Case #1 -

32 y/o female presents for C/S. She has no contraindication for a spinal anesthetic. After all the appropriate measures are taken, a routine spinal anesthetic is flawlessly placed. Shortly after recumbancy, she complains of nausea, and SBP is in the low 80's. What might have been done to prevent this? (The low SBP, and besides the obvious of doing a general:p)

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-pre spinal fluid bolus (colloid or crystalloid)
-not entirely recumbant (left tilt) to avoid caval compression until the operation starts
-Put 10 mg of ephedrine in R/L after spinal (Our hospital doesn't have obstetric cases, but i met many - old - anesthesiolgists, who routinely do this in every C/S spinal to avoid hypotension and never failed)
 
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Some of our attendings are putting a Phenylephrine gtt up on pump, and beginning low dose infusion at the time of spinal needle insertion...this has seemed to completely remove hypotension (and thus nausea) from our ORs.
 
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LUD (always document)
Head down during initial spinal set up
Pre-spinal fluids + concomitant fluid administration during spinal anesthetic
If trending down, pre-emptive pressors
Lower LA dose + use narcotic vs. local only
Later on, don't push oxytocin. Slow it up once the uterus contracts.
 
sevoflurane said:
LUD (always document)
Head down during initial spinal set up
Pre-spinal fluids + concomitant fluid administration during spinal anesthetic
If trending down, pre-emptive pressors
Lower LA dose + use narcotic vs. local only
Later on, don't push oxytocin. Slow it up once the uterus contracts.
Click to expand...

This is what I do. Listen for increasing HR after spinal placement while you are placing leads, etc. If it's starting to go up, give neo. By the time you get a pressure, it's back up.
When I do a potentially longer case I add some clonidine now. Very smooth, no nausea.
 
I don't do this now, but one of my staff in residency would make up a pressor mix we called snake oil. In a 250 ml saline bag add 2 mg of phenylephrine and 100 mg of ephedrine. Put it on a dial a flow microdripper and let it rip.

I think he liked because the amount of phenylephrine was so small it would be hard for a resident to overshoot.

Every now and then some resident would chart it as snake oil. :confused:
 
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MTGas2B said:
I don't do this now, but one of my staff in residency would make up a pressor mix we called snake oil. In a 250 ml saline bag add 2 mg of phenylephrine and 10 mg of ephedrine. Put it on a dial a flow microdripper and let it rip.

I think he liked because the amount of phenylephrine was so small it would be hard for a resident to overshoot.

Every now and then some resident would chart it as snake oil. :confused:
Click to expand...
Neo drip I get. It's an old school, pre pump technique. You can count drips and document a dose if you want. 10 mg of ephedrine in 250 cc? Piss in the wind. Are you sure it wasn't 100?
 
MTGas2B said:
Every now and then some resident would chart it as snake oil. :confused:
Click to expand...

ha ha, now thats funny :) i hope none of those patients ever wanted to see their chart or god forbid a lawyer or the media get a hold of one of those charts.... snake oil would be a little hard to explain
 
MTGas2B said:
I don't do this now, but one of my staff in residency would make up a pressor mix we called snake oil. In a 250 ml saline bag add 2 mg of phenylephrine and 10 mg of ephedrine. Put it on a dial a flow microdripper and let it rip.

I think he liked because the amount of phenylephrine was so small it would be hard for a resident to overshoot.

Every now and then some resident would chart it as snake oil. :confused:
Click to expand...

:laugh:

Although I would say to the overshooting statement - the human body tolerates hypertension much better than hypotension.
 
Good answers,

But nobody suggested the answer I was looking for.

The 'guess what I am thinking answer' is pretreat with a 5-HT3 antagonist.

WHAT!!!??? you say?

View attachment Picture1.jpg

36 patients in each arm - so not a 'tiny' study.
 

Attachments

  • zofran and spinal.pdf
    184 KB · Views: 127
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Case #2

A healthy 24 y/o physically fit professional soccor player presents for a knee scope. Spinal anesthetic is planned. His resting heart rate is 43 bpm. A perfect spinal anesthetic is performed and surgery procedes. 20 minutes after the anesthetic was placed, his heart rate dips to 32, than quickly to 17, than all the lines on the monitor go flat.

What (or why) has this happened? What do you do?
 
An attending of mine said that ondasetron prevents also spinal induced bradycardia and syncope. He cited an article from france. he always pretreat syncope-prone patients (young, with a history of vague mediated LOC etc) with 4 mg of ondasetron before doing the spinal.

For case 2#
probably a little of midazolam or an atropine pretreatment would have prevent this .
I have seen this scenario once, the patient had two subsequent monitors flat line, and all started when the anestheiologist informed him that the operation had just started. From his past history he admitted several episodes of fear induced LOC.
 
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25-50 mg Ephedrine IM for case #1
 
Just a med student but here goes :laugh::

2nd patient already has high vagal tone from being an athlete (as evidenced by the low resting heart rate); sympathectomy from the spinal left this vagal tone uninhibited and pt went asystolic. Treat with atropine?
 
Atropine is no longer recommended for asystole.

Epi is your friend.
 
epidural man said:
:laugh:

Although I would say to the overshooting statement - the human body tolerates hypertension much better than hypotension.
Click to expand...

True, but I think the thing he worried about would be some resident leaving a neo drip wide open inadvertantly. Especially since they had been using this mix since the days when it wasn't cool yet to use neo in OB.
 
PreciousDex said:
Just a med student but here goes :laugh::

2nd patient already has high vagal tone from being an athlete (as evidenced by the low resting heart rate); sympathectomy from the spinal left this vagal tone uninhibited and pt went asystolic. Treat with atropine?
Click to expand...

I like your thought process. :thumbup:
 
epidural man said:
Good answers,

But nobody suggested the answer I was looking for.

The 'guess what I am thinking answer' is pretreat with a 5-HT3 antagonist.

WHAT!!!??? you say?

View attachment 17640

36 patients in each arm - so not a 'tiny' study.
Click to expand...

Thanks for this dude. :horns:

Honestly, I've never heard of zofran attenuating drops in BP with spinals. Interesting. It would be nice to have a bigger N, but nontheless, little harm to give it pre-spinal if your OB's can do skin to skin in less than an hour. If you are at a university setting, you may loose some of your anti nausea effects.
 
Case #2 -

So cardiac arrest after a spinal is not unheard of - and there are many reports in the literature, and probably a ton more not reported (one at our hospital).

Risk factor seems to be a bradycardic rythm prior to spinal, and probably some others.

This is imporantant because the question may be on your boards in some form, AND, you should think about it when doing spinals.

The answer for treatment, as sevo points out, is NOT atropine. Atropine has not been shown to work in this scenario. So grab the epi. I had this question on an ACE exam, so it's likely to show on the test.

It has been described to the Bezold-Jerasch reflex, but others disagree with this idea. Who cares what you call it. Nonetheless, it is thought to be due to an low preload state - an undefilled ventricle and the ventricle walls slap together, there are receptors there that when activated set up an arc that produces a HUGE parasympathetic discharge - enough to cause cardiac arrest, and it isn't reversed with atropine. It needs epi.

This reflex arc can be demonstrated nicely in animals. The cool thing is, the arc is completely reversed or abolished with 5-HT3 inhibitors. But what about in humans?

Well as someone mentioned, there was an 'article..' Actually, it wasn't an article, but a case report, and it wasn't from France, but it was written in French (Canadians...:rolleyes:)

They tried atropine (but remember, atropine doesn't work), then gave zofran. The cardiac arrest reversed.

View attachment Picture2.jpg

by the way, if you do have a guy with a low heart rate and you are going to do a spinal, I would pretreat to get his heart rate up a little bit.
 

Attachments

  • zofran prevents spinal cardiac arrest.pdf
    78.6 KB · Views: 120
Case #3

32 y/o had an uneventful spinal placed for a C/S. Because you didn't read the data regarding the fact that any dose greater than 100mcg morphine in the intrathecal space does not increase efficacy, but increases pruritis, you went ahead and put 250 mcg.

Anyway, in the PACU, she is horribly pruritic.

What could have been done to help prevent this annoying side effect of intrathecal opioids? Oh, besides the obvious of NOT using opioids, or less of a dose.
 
Case 4# -

33 y/o presents for cesarean delivery. She has no contraindications for a spinal anesthetic. AFter all the appropriate measures are taken, a routine spinal is flawlessly delivered. Shortely after delivery, she starts to shiver. What can be done to treat this?

I know you know the answer now,

So....


View attachment Picture4.jpg
 

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  • zofran after spinal prevents shivering.pdf
    196.6 KB · Views: 74
Case #5: 83 y/o patient with ischemic cardiomyopathy sp CABG x4 stent x3 EF 25% sp PM for 3rd degre AV block, DM type 2 with CKD dialysis for 10y, peripheral arteriopathy sp bilateral LE amputation and chronic MRSA infection, COPD Gold 4 still active smoker presents with sepsis due to pneumonia huge ulcerated neck tumor.

BP 75/34 HR 115 Temp 101, GCS 8

What could be done to save this patient?

You know the answer:
attach 1834
 
epidural man said:
Although I would say to the overshooting statement - the human body tolerates hypertension much better than hypotension.
Click to expand...

I almost code browned myself a few months ago when, after giving 100 mcg of phenylephrine after a low post-spinal BP the patient abruptly complained of a crushing severe headache and the next BP came back SBP >200. 50 mcg of NTG fixed the BP and the headache.

(No chance that I OD'd her with 1000 mcg; I don't do the double-dilution in one syringe thing to mix my neo. Always 10 mg into a 100 mL bag and drawn from there.)
 
dhb said:
Case #5: 83 y/o patient with ischemic cardiomyopathy sp CABG x4 stent x3 EF 25% sp PM for 3rd degre AV block, DM type 2 with CKD dialysis for 10y, peripheral arteriopathy sp bilateral LE amputation and chronic MRSA infection, COPD Gold 4 still active smoker presents with sepsis due to pneumonia huge ulcerated neck tumor.

BP 75/34 HR 115 Temp 101, GCS 8

What could be done to save this patient? "

Nothing
Click to expand...
 
dhb said:
Case #5: 83 y/o patient with ischemic cardiomyopathy sp CABG x4 stent x3 EF 25% sp PM for 3rd degre AV block, DM type 2 with CKD dialysis for 10y, peripheral arteriopathy sp bilateral LE amputation and chronic MRSA infection, COPD Gold 4 still active smoker presents with sepsis due to pneumonia huge ulcerated neck tumor.

BP 75/34 HR 115 Temp 101, GCS 8

What could be done to save this patient?

You know the answer:
attach 1834
Click to expand...

Don't worry. It's an ESRD patient. Nearly impossible to kill, even without Zofran.
Responded to a code the other day on the floor. Asystole upon discovery, down time unknown- don't think he was on tele. Tubed him, team got a pulse back. From asystole. With unknown down time. He was an ESRD patient.

Granted, the family withdrew care the next day, but still...
 
MTGas2B said:
I don't do this now, but one of my staff in residency would make up a pressor mix we called snake oil. In a 250 ml saline bag add 2 mg of phenylephrine and 100 mg of ephedrine. Put it on a dial a flow microdripper and let it rip.

I think he liked because the amount of phenylephrine was so small it would be hard for a resident to overshoot.

Every now and then some resident would chart it as snake oil. :confused:
Click to expand...

:laugh::laugh::laugh::laugh:

Thats some funny sh i t!!!:laugh:
 
dhb said:
Case #5: 83 y/o patient with ischemic cardiomyopathy sp CABG x4 stent x3 EF 25% sp PM for 3rd degre AV block, DM type 2 with CKD dialysis for 10y, peripheral arteriopathy sp bilateral LE amputation and chronic MRSA infection, COPD Gold 4 still active smoker presents with sepsis due to pneumonia huge ulcerated neck tumor.

BP 75/34 HR 115 Temp 101, GCS 8

What could be done to save this patient?

You know the answer:
attach 1834
Click to expand...

Putting down his smokes about six decades prior.
 
Lightwand said:
Nearly impossible to kill, even without Zofran.
Click to expand...

love it.

Anyway to summarize what we have learned

zofran does 5 things peri-spinal.

1. Anti-yack
2. Anti shiver
3. Anti pruritus
4. Anti drop in systolic post placement
5. May prevent or treat the so called bezold-jarasch


Also, we have learned that Medicare made a huge mistake years ago by including dialysis in part of it's coverage.
 
epidural man said:
love it.

Anyway to summarize what we have learned

zofran does 5 things peri-spinal.

1. Anti-yack
2. Anti shiver
3. Anti pruritus
4. Anti drop in systolic post placement
5. May prevent or treat the so called bezold-jarasch


Also, we have learned that Medicare made a huge mistake years ago by including dialysis in part of it's coverage.
Click to expand...

Sorry man I'm not buying it. Would love to try it tho....

Don't do OB anymore so can't do an anecdotal trial.

What I can add that I know works

FO SURE

is giving

ephedrine 10-20mg IV immediately after spinal placement.

Pretty much

eliminates nausea/vomiting.

Be aggressive with keeping the blood pressure up.

Don't wait for a

ninety systolic to treat and

your parturients won't

BARF.
 
jetproppilot said:
Sorry man I'm not buying it. Would love to try it tho....
Click to expand...

yeah maybe.

And I agree that preventing hypotension in whatever method is the best NV prevention.

I do find it fascinating that zofran in the setting of spinals has been shown, in some form of research, to do all that stuff I mentioned.

I'll give it to my spinal patients and I try to get all my residents to do it also. I know zofran isn't completely benign, but realistcally has such a low downside.
 
epidural man said:
I'll give it to my spinal patients and I try to get all my residents to do it also. I know zofran isn't completely benign, but realistcally has such a low downside.
Click to expand...

I read somewhere (i think is in "avoiding common anesthesia errors" but i'm not sure), "that every patient in the OR must recieve TWO drugs. ONE is oxygen the OTHER is ondasetron. But even them have contraindications"
 
bigdan said:
Some of our attendings are putting a Phenylephrine gtt up on pump, and beginning low dose infusion at the time of spinal needle insertion...this has seemed to completely remove hypotension (and thus nausea) from our ORs.
Click to expand...

this.

soap on board with this strategy as well. has virtually eliminated intraop nausea in all my cases. 50 mcg/min and generally never needs titration.
 
trinityalumnus said:
Putting down his smokes about six decades prior.
Click to expand...


I used this same avatar several years ago and it was the normal size. When I re-uploaded it last night (same .jpg from same thumb drive) it came out huge. I don't have a clue as to why or how ??????

When I was doing my dockside lifeboat refresher training on the Comfort (in freezing Baltimore harbor) we were hearing conflicting rumors about replacing/not replacing the two hospital ships. Some politicos in DC think the PR value of MEDRETES and humanitarian missions outweights the cost.

Sorry about the thread hijack.
 
trinityalumnus said:
I used this same avatar several years ago and it was the normal size. When I re-uploaded it last night (same .jpg from same thumb drive) it came out huge. I don't have a clue as to why or how ??????

When I was doing my dockside lifeboat refresher training on the Comfort (in freezing Baltimore harbor) we were hearing conflicting rumors about replacing/not replacing the two hospital ships. Some politicos in DC think the PR value of MEDRETES and humanitarian missions outweights the cost.

Sorry about the thread hijack.
Click to expand...

Did you have Navy verified status a few years ago? I think you get bigger avatars with a military account.
 
epidural man said:
yeah maybe.

And I agree that preventing hypotension in whatever method is the best NV prevention.

I do find it fascinating that zofran in the setting of spinals has been shown, in some form of research, to do all that stuff I mentioned.

I'll give it to my spinal patients and I try to get all my residents to do it also. I know zofran isn't completely benign, but realistcally has such a low downside.
Click to expand...


... except that it has been shown to produce the same complications as FDA-blackboxed droperidol ( love the latter) ;)
 
PreciousDex said:
Just a med student but here goes :laugh::

2nd patient already has high vagal tone from being an athlete (as evidenced by the low resting heart rate); sympathectomy from the spinal left this vagal tone uninhibited and pt went asystolic. Treat with atropine?
Click to expand...

Good reasoning for being "just a med student". The only thing I would change would be to treat with epi which gives you a HR and pressure boost. Epinephrine is now first line for total sympathetic blockade with high spinal.
 
bigdan said:
Some of our attendings are putting a Phenylephrine gtt up on pump, and beginning low dose infusion at the time of spinal needle insertion...this has seemed to completely remove hypotension (and thus nausea) from our ORs.
Click to expand...

I love this! And I know who the attending who taught me this trick, bigD ;)

I have started using this on most my c/s cases unless they are known hypertensive or pre eclamptic. I have yet to see a case of hypotension or n/v w/ this. Although some attending will freak the F out if they see a phenylephrine gtt, so choice wisely.
 
Robert Loblaw said:
this.

soap on board with this strategy as well. has virtually eliminated intraop nausea in all my cases. 50 mcg/min and generally never needs titration.
Click to expand...

having used this technique myself, it frequently needs titration to keep the BP within 20% of baseline and avoiding bradycardia.

I think a phenylephrine gtt is good for OB spinals, but it's certainly not cookie cutter and needs some titration to be effective.
 
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