Menu Icon Search
Close Search

About the ads

Failed Epidural for C section-Now What?

Discussion in 'Anesthesiology' started by BLADEMDA, 01.05.09.

  1. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member

    SDN Members don't see this ad. (About Ads)
    A basic bread and butter case, or is it?

    25 year old female with prolonged labor now going to the O.R. for C Section. Labor Epidural has worked pretty well.

    CRNA doses Epidural with 20 cc of 2% lidocaine, HCO3 and epi 1:200,000.
    7 minutes later block is still patchy.

    The patient weights 250 and is 5'1" but otherwise healthy. Normal labs for pregnant patient. normal vitals and baby is fine.

    Now what? Patient wants REGIONAL and asks to be awake. OB MD is fine with giving you 20-30 minutes to "do your thing" (Neuraxial Anesthesia).
    Last edited: 01.05.09
  2. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Any Resident want to list NORMAL physiologic changes in Pregnancy (late term)? How about a few of them?

    Anyone want to comment on OBESE vs. THIN female patient as described in this thread? That is, does obesity make a difference in this clinical scenario?

    Of Course, peer reviewed references will be provided by me shortly but take a stab at the case.
  3. ProRealDoc

    ProRealDoc Anti-AANA

    Joined:
    01.02.09
    Messages:
    1,218
    Status:
    Attending Physician
    SDN 5+ Year Member

    Do spinal using only 60% of normal dose.
    Last edited: 01.05.09
  4. dhb

    dhb Member Lifetime Donor

    Joined:
    07.12.06
    Messages:
    2,593
    Status:
    Attending Physician
    SDN 7+ Year Member
    cardiac: increased blood volume, cardiac output
    pulm: decreased FRC, compliance, respiratory alcalosis
    gi: slower gastric emptying, ge reflux
    general: edema especially oral/tongue , engorgement of epidural venous plexus.

    Provided adequate positioning obese patient are not more difficult to intubate, mask ventilation may be more challenging, regional too.

    If a good 15min has gone by you could go for a spinal with the risk of getting a high/total spinal.
    I've never done this but you can do a bilateral field block the name of which i can't remember but between the abdominal muscle you can catch the nerves supplying the abdomen.
  5. dhb

    dhb Member Lifetime Donor

    Joined:
    07.12.06
    Messages:
    2,593
    Status:
    Attending Physician
    SDN 7+ Year Member
    Reducing dosage is good for people who overdose routinely (eg 12.5-15mg) if you're giving 7 to 10 mg of bupivacaine there's not much to reduce.
  6. huktonfonix

    huktonfonix board certified!

    Joined:
    10.03.03
    Messages:
    733
    Status:
    Attending Physician
    SDN 7+ Year Member
    theres a few options in place. my choice would be a CSE so I could theoretically raise the level if needed with a 7.5 mg + fentanyl spinal dose. You could also just do a straight reduced spinal as previously mentioned. If you want a guarantee, then an intrathecal catheter is also a possibility with PDPH risk in mind. Either way it should be explained about the risk of a "high spinal". Appropriate emergency airway equipment should be ready and available considering her body habitus and an airway exam should be performed.

    Oh, and what part of the epidural is "patchy"? that might make a difference too since other options could include local infiltration, intercostal block, ilioinguinal ( i think) block, etc....
  7. ProRealDoc

    ProRealDoc Anti-AANA

    Joined:
    01.02.09
    Messages:
    1,218
    Status:
    Attending Physician
    SDN 5+ Year Member

    Heme: dilutional anemia, hypercoagulable state with elevations in all coagulation factors but more pronounced with fibrinogen and factor VII.
    Reproductive: uterine circulation lack of autoregulation and is susceptible to hemodynamic changes.
  8. SleepIsGood

    SleepIsGood Support the ASA !

    Joined:
    04.15.06
    Messages:
    1,968
    Status:
    Fellow [Any Field]
    SDN 5+ Year Member
    Despite the OB saying that he will give you 20-30 min,etc

    The CRNA already pushed that much med. Typically lido effects peak at 12-15 min. You should theoretically be ok to redose and try a spinal,etc on a normal pt...however, this is a pregnant pt and pg patients are more sensitive to local anesthetics d/t the effects of progesterone,etc.

    So why risk it? Does the patient have a good airway exam regardless of her obesity?

    IF so...I say explain to the pt the risk of high spinal,etc and the possibility of toxicity from the meds that were given. Relay to her that you understand that she would prefer to be awake and that you understand the importance of that experience. However, you are her advocate and her safety is your number one priority and you believe putting her to sleep is safer.

    If her a/w exam is acceptable. Do a RSI, put her to sleep, get baby out, wake her up.

    If a/w unacceptable.....then do awake fiberoptic.:thumbup:
  9. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    03.12.05
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    I disagree with your assessment that 12-15 mg of hyperbaric bupiv is "overdosing".

    I routinely give 15mg unless the parturient is very short, let her sit there for 30 seconds before laying her down, and give prophylactic IV ephedrine 10-15 mg immediately regardless of starting blood pressure.

    If you're only giving 7mg eventually you will eventually run into your block being inadequate for a surgical plane of anesthesia.

    As far as the case Blade has posted I'd put her to sleep.

    No question.

    Performing a spinal after a big epidural bolus carries a pretty significant risk of a high spinal.

    You may get lucky. You may not.

    Believe me, I've tried it.:laugh:

    I won't do it again.

    Automatic general if lady just gotta big epidural bolus that didnt work in my book.
  10. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Very good answers. I will tell you what I normally do as well. I have done well over two thousand Spinal for OB. You need 10 mg of Bupivicaine with Dextrose as a minimum otherwise a few will fail. I have found 12 mg or so to be very adequate and 15 mg unnecessary. Probably, there is more hypotension with 12mg compared to 10 mg but the block is routinely excellent at around T4-T6 level. Even with 12 mg only about half need much, if any pressor agents.

    As you all know Phenylephrine is as safe as Epherine for OB patients. So, I choose the pressor based on HR. But, I have seen some SEVERE bradycardia with 100 micrograms of phenyephrine even with baseline heart rates of 110-120 prior to administration. This population can be extremely sensitive to large doses of phenyephrine.

    As for the patient desribed JPP and Sleep are correct. I proceeded with a spinal 10 minutes after the CRNA dosed the epidural. I used 10 mg bupivicaine with dextrose and guess what happened?:eek:

    So, I did a thorough literature search on the subject. I found that there is NO CONSENSUS on whether one should reduce the amount of bupivicaine in this situation. In fact, it probably doesn't make a difference and the risk of a high spinal requiring intubation is at least 11-15%.
  11. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    A-1078
    2000
    Total Spinal Anesthesia Requiring Tracheal Intubation in Parturients: The Association with Failed Epidural AnesthesiaScott E. Helsley, MD,PhD; Elizabeth Bell, MD; Terrance W. Breen, MD; Donald Penning, MD
    Anesthesiology, Duke University Medical Center, Durham, NC, United StatesIntroduction: Lumbar epidural anesthesia is commonly used for Cesarean section (CS). If anesthesia is inadequate, one must replace the catheter or convert to spinal or general anesthesia. The risks of general anesthesia for CS are well documented, therefore many choose spinal anesthesia in this situation. Recent reports suggest that subarachnoid block following epidural anesthesia increases the likelihood of high spinal block, with blocks >C8 in 11% in patients after failed epidural versus less than 1% in patients who had a spinal anesthesia alone1. The present study was designed to determine the incidence of high spinal requiring endotracheal intubation and assisted ventilation.

    Methods: After IRB approval, analysis of an observational database from 2/98 to 3/00 revealed 904 spinals placed for Cesarean Section.

    Results: Of 904 patients undergoing CS under subarachnoid block, 69 of these patients had labor epidural analgesia prior to spinal anesthesia (45 continuous lumbar epidurals and 24 combined spinal epidurals). Three patients required tracheal intubation for high spinal block. Two of these three patients received continuous lumbar epidural analgesia prior to a single-shot spinal. Thus the incidence of total spinal anesthesia requiring tracheal intubation was approximately 3% (2 of 69) versus much less than 1% following spinal anesthesia alone (1 of 835). As shown in the table below, among the patients who received epidural labor analgesia, no differences were noted between those with and without high spinals with respect to bupivacaine dose, body mass index(BMI) and position during placement of the spinal block. All but 4 spinals were placed in the sitting position. All 4 of those who received spinal anesthesia in the lateral position were in the labor analgesia group, but none led to high spinal. The single case of high spinal following subarachnoid block alone received 13.5 mg of hyperbaric bupivacaine while in the sitting position.

    Conclusions: These data suggest that high spinal anesthesia requiring tracheal intubation occurs more commonly in patients who received prior labor epidural analgesia compared to single-shot spinal anesthesia. The data do not suggest a relationship between total spinal anesthesia and dose of bupivacaine, patient position during placement of the subarachnoid block or BMI. We are unable to recommend a dose of intrathecal bupivacaine after failed epidural. Vigilance for evidence of respiratory insufficiency remains important. 1 Furst, SH and Reisner, LS Journal of Clinical Anesthesia 7:71-74; 1995.high spinalspinal (not high)BMI (kg/m2)31.6(±6.9)33.3(±0.9)bupivacaine (mg)12.12(±0.9)12.36(±0.3)Figure 1
    [​IMG]Copyright © 2008, American Society of Anesthesiologists.
    All rights reserved.
  12. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    1: J Clin Anesth. 1995 Feb;7(1):71-4.[​IMG] Links

    Risk of high spinal anesthesia following failed epidural block for cesarean delivery.

    Furst SR, Reisner LS.
    Department of Anesthesiology, University of California, San Diego 92103, USA.
    Recent case reports suggest there may be an increased risk of abnormally high blockade ("high spinal") from subarachnoid anesthesia if it is performed immediately after epidural anesthesia. We describe two cases of high spinal anesthesia following failed epidural block in obstetric patients scheduled for cesarean delivery. Using a retrospective chart review, we estimate the incidence of high spinal anesthesia to be 11% in patients after prior failed epidural blockade versus fewer than 1% in patients undergoing spinal anesthesia alone.
    PMID: 7772363 [PubMed - indexed for MEDLINE]
  13. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment.

    Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A.
    Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital, Miami, FL 33136, USA.
    BACKGROUND: The incidence of obesity has been dramatically increasing across the globe. Anesthesiologists, are increasingly faced with the care for these patients. Obesity in the pregnant woman is associated with a broad spectrum of problems, including dramatically increased risk for cesarean delivery, diabetes, hypertension and pre-eclampsia. A thorough understanding of the physiology, associated conditions and morbidity, available options for anesthesia and possible complications is therefore important for today's anesthesiologist. METHODS: This is a personal review in which different aspects of obesity in the pregnant woman, that are relevant to the anesthesiologist, are discussed. An overview of maternal and fetal morbidity and physiologic changes associated with pregnancy and obesity is provided and different options for labor analgesia, the anesthetic management for cesarean delivery and potential post-partum complications are discussed in detail. RESULTS AND CONCLUSION: The anesthetic management of the morbidly obese parturient is associated with special hazards. The risk for difficult or failed intubation is exceedingly high. The early placement of an epidural or intrathecal catheter may overcome the need for general anesthesia, however, the high initial failure rate necessitates critical block assessment and catheter replacement when indicated.
  14. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Spinal Anesthesia for Cesarean Section Following Labor Epidural Analgesia: A Retrospective AnalysisMustafa Albayrak, M.D., Annemieke Dijkstra, M.D., W. Anton Visser, M.D., Eric Boersma, M.Sc., Ph.D., Mathieu J.M. Gielen, M.D., Ph.D.
    Anesthesiology, Amphia Hospital, Breda, NetherlandsIntroduction

    Failure of epidural anesthesia for cesarean section (CS) has been reported in up to 20% of cases. However, spinal anesthesia (SA) for CS after failed epidural anesthesia has been associated with a high incidence of deleterious effects. Therefore, in our practice, patients who have had labor epidural analgesia (LEA) and who present for secondary CS, receive SA without prior epidural top up dosing.

    To confirm the safety of this practice, we performed a retrospective analysis of 128 cases of SA for secondary CS after LEA, compared to 508 cases of only SA.

    Methods

    We examined the medical records of women who underwent secondary CS from January 1, 2001 to May 1, 2005. We compared outcome data of patients who received SA only, to those of patients who received SA after LEA (SA/LEA) (Table). Data were analyzed using appropriate statistical testing.

    Results

    Data are presented in the table as a percentage or median (interquartile range).

    Discussion

    In conclusion, when administering SA following LEA, we did not find an increased incidence of serious side effects (severe hypotension, high or total spinal block, decreased Apgar scores). More patients were given ephedrine in the SA/LEA group. We believe these preliminary results indicate that our technique of SA instead of epidural top-up dosing is safe. Given the high incidence of insufficient surgical epidural anesthesia for CS, we believe this method merits further investigation.[table1]

    Anesthesiology 2007; 107: A672SA (n=508)SA/LEA (n=128)pPatiens with RR systolic < 100 mm Hg (%)23.824.40.88Patients who were given ephedrine (%)33.245.20.012Dosage of used ephedrine (mg)10 (10-15)10 (10-15)0.65High spinal (%)0.20.80.36Total spinal requiring intubation001Insufficient block requiring conversion to general anesthesia (%)2.83.90.56Apgar scores after 1 minute9 (8-9)9 (8-9)0.545Apgar scores after 5 minutes10 (9-10)10 (9-10)0.995Copyright © 2008, American Society of Anesthesiologists.
    All rights reserved.
  15. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Spinal vs. Epidural Anesthesia after Failed Epidural Anesthesia for Cesarean DeliveryAlexander M. DeLeon, M.D., Cynthia A. Wong, M.D., Nicole Higgins, M.D., Robert A. McCarthy, Pharm.D.
    Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IllinoisIntroduction

    High spinal anesthesia is associated with spinal anesthesia after failed epidural anesthesia for cesarean deliveries (1). We hypothesized that spinal anesthesia after failed epidural anesthesia would result in a higher incidence of “high spinal anesthesia” compared to repeat epidural anesthesia for cesarean delivery and that in parturients who receive spinal anesthesia after failed epidural anesthesia, the intrathecal dose of bupivacaine is higher in patients with “high spinal" compared to those without.

    Methods

    After IRB approval, we reviewed obstetric anesthetic records from March 1, 2006, to December 31, 2006. Included were parturients with a singleton gestation undergoing non-emergent cesarean delivery, with failed conversion of epidural labor analgesia to anesthesia. Failed epidural conversion was defined as 1) inability to use a labor epidural catheter to initiate anesthesia (e.g. dislodged catheter), or 2) inadequate surgical anesthesia after initiation of epidural anesthesia. Non-emergent cesarean deliveries were defined as those in which a second neuraxial procedure was performed. Cases were excluded if either a second neuraxial procedure was not attempted or not successfully performed. Two treatment groups were defined based on the second anesthetic: 1) spinal group and 2) repeat epidural group. The outcome variable was the incidence of high spinal anesthesia (defined as use of positive pressure ventilation with a sensory level > T2). Secondary outcomes included the operating room in-time to incision interval, 1- and 5-min Apgar scores, umbilical cord arterial pH, and vasopressor use. Within the spinal group, the intrathecal bupivacaine dose of parturients with high spinal anesthesia was compared to doses in parturients who did not have high spinal anesthesia. The Fisher exact and the Mann-Whitney U tests were used to compare treatment groups, and within the spinal group, high spinal to no-high spinal subgroups. P < 0.05 was used to reject the null hypothesis.

    Results

    Of the 7603 labor records reviewed, 18 cases matched our criteria (see table). Among the patients in the spinal group, the mean bupivacaine dose associated with high spinal anesthesia was 10.0 mg (SD 1.9 mg) and 9.8 mg (SD 1.3 mg) in parturients without high spinal anesthesia (NS). Within the spinal group, there was no difference in incidence of high spinal between those who had and had not received prior epidural local anesthetic boluses. Apgar scores , time intervals, and vasopressor use were not different.

    Discussion

    Spinal anesthesia after failed epidural anesthesia is associated with an increased incidence of high spinal anesthesia and decreased umbilical artery pH compared to repeat epidural anesthesia. Based on these findings, when time permits repeat epidural anesthesia should be initiated after failed epidural conversion rather than spinal anesthesia. Further study is required to determine if a smaller intrathecal local anesthetic dose is associated with a decreased risk of high spinal anesthesia.

    References

    1. J Clin Anesth. 1995;7:71-4.[table1]

    Anesthesiology 2007; 107: A673TableSpinal (n=7)Repeat epidural (n=11)P-valueHigh spinal anesthesia [N(%)]3 (43%)0 (0%)0.0431-min Apgar*89NS5-min Apgar*99NSUmbilical artery pH* (range)7.085 (6.98-7.23)7.280 (7.17-7.35)0.024OR-Incision interval* [min(range)]23 (10-59)40 (13-80)NS*median valuesCopyright © 2008, American Society of Anesthesiologists.
    All rights reserved.
  16. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    03.12.05
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    Those kinda comments are just not reflective of the real world.

    I don't like residents reading that kinda s hit because it does more harm than good IMHO.

    Exceedingly high?

    Cmon Dude, gimme a break.

    Risk of difficult/failed intubation increased with obesity?

    Yes.

    Assuming you're deft with a blade, though, exceedingly high is vastly overstated.
  17. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Previous Abstract | Next Abstract Printable Version A-1021
    2002
    Spinal Anesthesia for Cesarean Section after Failed Labor Epidural Analgesia: Retrospective Analysis of Two Dosing RegimensRakesh B. Vadhera, M.D.; Falguni J. Siswawala, M.D.; Dmitry Portnoy, M.D.; Aristides P. Koutrouvelis, M.D.
    Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TexasIntroduction: The recommendations on the use of spinal anesthesia (SAB) for c-section after failed labor epidural anesthesia have varied, ranging from avoiding SAB completely 1,2 to reducing the dose of local anesthetic (LA) by 20-30% 3 to using a normal dose of LA 4,5. At our institution, we compared the latter two dosing regimens--using the standard amount of LA in SAB vs. using a reduced dose of LA in SAB in situations where the epidural block was inadequate. The outcome measures were the incidence of total SAB and failed or inadequate SAB.

    Methods: In a retrospective, non-randomized study analyzing the two different dosing schedules used at our institution, patients who received SAB for c-section after labor epidural analgesia were reviewed for indication for conversion to SAB, documentation of block and efficacy of epidural analgesia before SAB, duration for which the infusion was stopped prior to SAB, level of block, blood pressure changes, treatment of hypotension, and postoperative complications. Patients were separated into 2 groups based on LA dosage: Group A (1.5cc of 0.75% heavy bupivacaine with 20 mcg fentanyl) and Group B (reduced dose of LA with 15 mcg fentanyl for SA). The reduced amount of LA used in Group B was calculated (shown below) using the hypothesis that spinal segments already partially blocked require only half the amount of LA to produce total SAB when compared to segments with no block.

    Calculated Dose=

    # of segments with no block+ # of segments with some block (0.5) x Dose ÷ 18 (i.e., the total target segments required to achieve a T-4 block)

    Results: Forty-seven charts were reviewed where patients underwent c-section under SAB after failed epidural block (Group A=24 patients; Group B=23 patients). Group A accounted for 2 cases of total SAB while Group B had none. Neither group had any failed SAB.

    Discussion: The data suggest a possibility of total SAB anesthesia after failed epidural blocks when a standard dose of LA was utilized. The data also showed no failed SAB when a reduced dose of LA was used. The data also suggest that there is a way to calculate the dose of LA for SAB in such circumstances.

    References:

    1. Int J Obstet Anesth 1994;3:153.

    2. J Clin Anesth 1995;7:71.

    3. Anesth Analg 1994;78:1029-1035.

    4. Anesth Analg 1995;81:654-656.

    5. Br J Anaesth 1991;66:596-607.

    Anesthesiology 2002; 96: A1021Copyright © 2008, American Society of Anesthesiologists.
    All rights reserved.
  18. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    http://www.anesthesia-analgesia.org/cgi/reprint/78/5/1033-a

    This "letter" in 1994 had a small sample of 17 patients. They used 10 mg of bupivicaine for the spinal dose after a failed epidural. They repoted only 1 in 17 had a high spinal block. Go figure.

    That is where I got my 10 mg dosage. The question still remains would 7.5 mg of bupivicaine avoid the "high spinal" in this case scenario?
  19. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    It is a known fact that morbid obesity decreases the local anesthetic requirement for epidural anesthesia in pregnant patients.

    In addition, morbid obesity increases the likelihood of a failed epidural significantly; plus, it is much more likely that obese patient will end up needing a C-section.
    Last edited: 01.05.09
  20. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Relax. I did not say those comments. An Academic OB MD (A) did who clearly is afraid of just about any type of airway. OB airways are in general no more difficult that the one's we see in the O.R. every day.
  21. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    1: Br J Anaesth. 2006 Jan;96(1):106-10. Epub 2005 Nov 25.[​IMG] Links

    Obese parturients have lower epidural local anaesthetic requirements for analgesia in labour.

    Panni MK, Columb MO.
    Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Centre, Durham, NC 27710, USA. [email protected]
    BACKGROUND: There are no studies comparing local anaesthetic requirements for obese and normal parturients. Obesity has been associated with a higher incidence of Caesarean section and higher levels of epidural block have also been found in obese obstetric patients, suggesting they may require less local anaesthetic. The aim of our study was to estimate the minimum local analgesic concentration (MLAC) of bupivacaine for obese and non-obese parturients. METHODS: Otherwise healthy parturients (n=32) requesting epidural analgesia were enrolled in this up-down sequential allocation study. Women were in active labour (3-6 cm cervical dilatation) with visual analogue pain scores (VAPS) >40/100 mm. Subjects with BMI >30 kg m(-2) were allocated to the obese group and BMI < or = 30 kg m(-2) were allocated to the normal group. The initial epidural dose for both groups was 20 ml 0.1% w/v bupivacaine (20 mg), with a dosing increment of 0.01% w/v VAPS < or = 10/100 mm defined effective analgesia. The MLAC was estimated using up-down reversals and probit regression with P<0.05 as significant. RESULTS: Groups were similar except for BMI and weight (P<0.001). Local anaesthetic requirements were significantly (P<0.001) reduced by a factor of 1.68 (95% CI 1.32-2.29) in the obese group, with significantly higher initial level of block (P<0.001). CONCLUSION: We found obese parturients to have significantly decreased epidural bupivacaine analgesic requirements. A contributing factor to obese patients having more difficult labours may be that relatively larger doses of local anaesthetic are administered than actually required. It may be worth considering lowering the concentrations and doses with which we initiate analgesia in obese parturients.
  22. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Before JPP jumps all over me again I DO NOT routinely reduce my Bupivicaine dosages (either Epidural or Spinal) for morbid obesity. Several Thousand Epidurals in that population with no problems.

    But, in the case described, perhaps the 20cc 2% lidocaine plus 10mg spinal bupivicaine AND the morbid obesity contributed to the high spinal.

    Would 7.5 mg bupivicaine do the trick next time? OR, should we just do GA?
  23. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    03.12.05
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    Didnt aim the gimme a break at you, Dude.

    Was aimed at the study authors.
  24. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    03.12.05
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    I had a high spinal on a non-obese lady that gotta reduced spinal dose after the epidural failed.

    Theres really no way to discern scientifically how much subarachnoid local anesthetic to give after an epidural has been dosed.
  25. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    JPP I agree with you. That is why I decided to post this thread. Even after a few hours searching our journals there is no consensus. My place isn't DA U and we have 99% success rate with our spinals and 95% with our Epidurals. I don't see a lot of FAILED Anything.

    If I was going to attempt this again I would make sure the patient understood the risks (Short of Breath, probably going to sleep anyway, etc.) prior to attempting the spinal.

    Anybody willing to re-do the Epidural? If so, how much do you dose her with? Again, my place isn't DA U and I need to finish this 40 minute case already.
  26. SleepIsGood

    SleepIsGood Support the ASA !

    Joined:
    04.15.06
    Messages:
    1,968
    Status:
    Fellow [Any Field]
    SDN 5+ Year Member
    The other reason I said "just put her to sleep" is because even with a failed spinal for example I think it's a better route. I try to tell all pg pts that there is always the possibility of GETA.

    I once did a spinal like I always do. Got great return of CSF. Gave 1/2 the med, aspirated again, gave teh rest of the med, blah blah. Perfect textbook spinal...so I thought. OBs 'test' with their pick ups...pt is in PAIN. So we give it time....She's still in lots of PAIN. My attending comes in, we just go ahead and do GETA. It's just unpredictable how much Local Anesthetic she actually got and how sensitive she actually is.

    As an attending of mine says, "the tube is always good".:laugh:
  27. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    So, you are saying use 6-7 mg of bupivicaine with Dextrose? Any published data to support that statement? Any personal cases to support that dose?
  28. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    GA wuld be my choice.
    I would not do a spinal after giving an epidural bolus.
  29. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Yes. I got it. But, if the patient understands the risks and wants to give it a shot why not try it? Most spinals only take 5 minutes.

    I bet 6 mg would have done the trick in my case. But, I won't be as enthusiastic next time to test my hypothesis.
  30. jwk

    jwk AA-C ASA-PAC Contributor

    Joined:
    04.30.04
    Messages:
    3,006
    Location:
    Atlanta, GA
    SDN 10+ Year Member
    No one has mentioned adding more local to the existing epidural. Give another 5cc, check a level. If the block is improved fine. If it's improved and not high enough, give another After that, it's sleepy time. We don't do spinals or CSE's for C-sections anyway, but in no event would we ever place a spinal after a dosed epidural.
  31. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    03.12.05
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    Spoken by ONE OF THE MASTERS of this forum.:thumbup:
  32. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    This is an unacceptable risk for me and if the patient says that she understands and accepts the risk this means that she actually doesn't.
    You bolus the epidural and you try to make it work if it doesn't then it's GA time.
  33. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    JWK,

    The reason for your statement is because the EXACT dosage for this type of patient is unknown. We don't have the data to conclusively say how much to give or if a spinal should be done at all.

    I did give an extra 5 ml's of local through the epidural. Still, not good enough for the case. So, either GA or do a SAB. I have only done TWO of these in my career and the first one was successful. But, I don't consider 50% success worthy of much.

    Would I try it again? Yes, under the right circumstances and with the right patient. However, next time she gets 6 mg.

    The BEST Oral Board answer is GA after failed Neuraxial Anesthesia for a C section. Then, get ready for the Aspiration or difficult intubation scenario next as part of that oral exam
  34. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    JWK,

    I respect your opinion and I agree with it in principle. However, there is debate about this issue and in NO WAY would a SAB after failed Epidural be considered malpractice. In fact, some OB experts would perfom a Combined Spinal Epidural or Spinal technique


    2003: Portnoy Dmitry; Vadhera Rakesh B
    Mechanisms and management of an incomplete epidural block for cesarean section.
    Anesthesiology clinics of North America 2003;21(1):39-57.
    Epidural blockade is an important option for anesthesia in parturients undergoing abdominal delivery. Despite the multiple benefits of this method, there is at least one significant downside--a relatively high occurrence of unsatisfactory anesthesia that requires intervention. Depending on the presumed mechanism of epidural block failure and other clinically relevant factors (e.g., timing of diagnosis, urgency of the procedure, and so forth), certain effective measures are recommended to successfully manage this demanding situation. In general, it is important to make every effort to make the pre-existing epidural effective or replace it with another regional technique, because overall, regional anesthesia is associated with significantly lower maternal mortality. It is important to identify a dysfunctional epidural block preoperatively before a maximum volume of local anesthetic has been administered. If catheter manipulation does not produce substantial improvement, and there is no time constraint, it is safe and reasonable to replace the epidural catheter. However, risks associated with excessive volume of local anesthetic should be kept in mind. Additional epidural injections or a second catheter placement might be considered under special circumstances. Single-shot spinal anesthesia after a failed epidural may provide fast onset and reliable surgical anesthesia. Available data, although limited and contradictory, suggest the possibility of unpredictably high or total spinal anesthesia. Many authors, however, believe that appropriate precautions and modifications in technique make this a safe alternative. These modifications include limiting the amount of epidural local anesthetic administered when diagnosing a nonfunctioning epidural and decreasing the dose of intrathecal local anesthetic by 20% to 30%. If there is no documented block when the spinal is inserted, and more than 30 minutes have passed from the last epidural dose, it is probably safe to use a normal dose of local anesthetic. Continuous spinal anesthesia with a macro catheter might be a dependable alternative, particularly if large amounts of local anesthetic have already been used or the patient's airway is a cause for concern. Although there are no reports of combined spinal epidural anesthesia being used in this context, it would appear to be an attractive alternative. It allows the anesthesiologist to give smaller doses intrathecally, while still offering the flexibility of augmenting the block if needed. When inadequate epidural block becomes apparent during surgery there are limited alternatives. Depending on the origin and the pattern of inadequate anesthesia, options may include psychological support, supplementation with a variety of inhalational and intravenous agents, and local anesthetic infiltration. Induction of general anesthesia is typically left as a backup option, but must be strongly considered if the patient continues to have pain/discomfort.
  35. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    I think knowing when to proceed with GA and how to do it safely is the most important part of doing OB anesthesia successfully.
  36. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Available data, although limited and contradictory, suggest the possibility of unpredictably high or total spinal anesthesia. Many authors, however, believe that appropriate precautions and modifications in technique make this a safe alternative.
  37. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member

    Sure and 99% of the time I agree with you. But, with the right patient and the right situation doing a spinal for this scenario seems very reasonable.

    What if she had a KNOWN difficult airway and couldn't be intubated by the BEST person in your Group? What if she insisted on your at least trying the spinal and you refused? What is she was a Physician who knew all the risks and wanted you to try?
  38. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    Most academic OB anesthesiologists are affraid of GA and this fear is reflected in thier literature and in the BS they teach the residents.
    I have seen a couple of new grads who literally don't know how to do a c section under GA.
  39. Trisomy13

    Trisomy13 ultra crook

    Joined:
    04.13.04
    Messages:
    1,227
    Location:
    mountain home
    Status:
    Attending Physician
    SDN 10+ Year Member
    According to Chestnut, there is no change in gastric emptying during gestation, but a decrease in esophageal peristalsis and intestinal transit time. Decreased gastric emptying occurs during labor.

    Nit-picking, I know.

    The failed epidurals I have seen here tend to get the plastic cigar and a nap.
  40. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    I don't give regional anesthesia to anyone who doesn't consent to GA.
    If she had a known dificult airway she will get awake FOB intubation.
    If no one can intubat her in my group then she should not be having surgery at our hospital.
  41. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Options baby. You got to know ALL your options. Is SAB an option? The literature says YES.
  42. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    03.12.05
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    Resident colleagues,

    please read what Plank wrote above.

    Then reread it.

    Then read it again.

    Because it is VERY VERY TRUE.:thumbup::thumbup:
  43. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member

    You would do a FOB intubation from the get go? If she can't be intubated that doesn't mean she can't be ventilated. What if she shows up in ACTIVE labor in the E.R.? You can't dump her somewhere else?


    Of course she CONSENTS to GA. But, if she BEGS you to just try the spinal and is an OB MD you wouldn't give it a shot? Why not? You can always intubate her.

    I agree that 99% of the time GA is the way to go. But, is redoing the Neuraxial Anesthesia an option?
  44. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    Sure, it is an option.
    Not a great one, but it is an option :D
  45. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    So, if it IS an option what dose would you suggest the NEXT time I try this SAB after failed Epidural (I hope it won't be any time soon)?

    Bupivicaine 10mg was too much. Do you agree that 6-7 mg Bupivicaine MAY (I stress MAY) result in good anesthesia yet avoid the high spinal?
  46. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    Yes, a pregnant woman who is in labor with a history of difficult itubation gets awake FOB if regional fails.
    If she shows up in labor in the ER with a known difficult intubation she will get a regional that is most likely going to work: A CSE or an intrathecal catheter.
  47. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    11.02.06
    Messages:
    4,982
    Location:
    The South
    Status:
    Attending Physician
    SDN 7+ Year Member
    No, if I have to continue with a regional plan (still a bad choice) I would place an intrathecal catheter and bolus very slowly.
    That is the safest way to approach this situation.
  48. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    04.22.07
    Messages:
    11,623
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    In my part of the woods I keep things real simple. If she has a history of a very difficult intubation we do an epidural early on in labor. We make sure one of our top studs does the Epidural. We communicate with the OB and discuss the situation. The OB needs to understand that EMERGENCY C section must be avoided as the airway comes first.

    Any hint of trouble and we cut her. We have had this a few times over my career and so far I am batting 100%.

    On one occasion we brought the patient in for a scheduled C section under Spinal. That has a 99.5% or better success rate in experienced hands.
  49. huktonfonix

    huktonfonix board certified!

    Joined:
    10.03.03
    Messages:
    733
    Status:
    Attending Physician
    SDN 7+ Year Member
    there was a recent study in Anesthesiology using 6.5 mg (could have been 6) of heavy bupivicaine for C/S using a CSE technique. I believe they had a 5-10 percent rate of inadequate block. The block also took a longer time to reach an adequate level (somewhere around 10-15 minutes, I would have to look at the study again, but I dont have access at the moment). This could be an argument for using that particular amount of bupivicaine and hoping to get an adequate block. However, Im not aware of any literature supporting the safety of this amount following full C/S epidural dosing.
  50. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    03.12.05
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    You're trying to be scientific about something you can't be scientific about.

    You mind as well go to the casino and put a hundred bucks in a slot machine and hope for the best.

// Share //

Style: SDN Universal