Hypotheticall speaking...

[clubdeac]

So I know the answer is to leave out the anesthetic but just curious what would happen. Coming from a PMR background I'm a little uncertain of the exact concentrations needed to cause issues. Hypothetically speaking, if you injected 2cc 0.25% Marcaine intrathecally at T4-5 or T5-6 would you shut down the patient's respiratory/cardiovascular system? I've got a end stage cancer patient that comes in for q3 month thoracic epidurals and his epidurogram always looks a little strange. Never had any issues though and reports excellent relief up until the next injection. I know, when in doubt leave out the anesthetic...

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[hyperalgesia]

So I know the answer is to leave out the anesthetic but just curious what would happen. Coming from a PMR background I'm a little uncertain of the exact concentrations needed to cause issues. Hypothetically speaking, if you injected 2cc 0.25% Marcaine intrathecally at T4-5 or T5-6 would you shut down the patient's respiratory/cardiovascular system? I've got a end stage cancer patient that comes in for q3 month thoracic epidurals and his epidurogram always looks a little strange. Never had any issues though and reports excellent relief up until the next injection. I know, when in doubt leave out the anesthetic...

Make sure pt consents to risks and be prepared to intubate in worst case. I don't like the public forum...

 

[101N]

I've seen this go south very quickly. IMO, never worth the risk in IPM.

 

[hyperalgesia]

This is also VA pt, which means we don't have to be hypervigilant regarding CYA. It's just what is best for the pt.

 

[lobelsteve]

This is also VA pt, which means we don't have to be hypervigilant regarding CYA. It's just what is best for the pt.

Yup, just let them go to IMS after you mess them up.

 

[pastafan]

Marcaine would be hypobaric and 2 cc is a significant volume IT. Expect the worst...

 

[hyperalgesia]

I don't like the public forum...

 

[SeniorWrangler]

The problem with marcaine is that it has onset in 5-8 minutes and duration up to 4 hours plus, that's a very long time if it's a high spinal. I guess you could place a catheter, give a test dose of lidocaine and wait a little while with the guy on the table, but if it's a high spinal you're still in trouble. It may be time for a frank discussion with your anesthesia colleagues who would need to help you out in case of a jam.

 

[BobBarker]

Labor Spinal dose of marcaine intrathecal is one cc of o.25% and 25mcg fentanyl, then thread an epidural catheter.

 

[clubdeac]

Ok so 2cc 0.25% at T4-5 would definitely give a high spinal. That's all I needed to know. Will leave out the marcaine next time and will see if it works just as well. Suspect it will.

 

[NJPAIN]

The problem with marcaine is that it has onset in 5-8 minutes and duration up to 4 hours plus, that's a very long time if it's a high spinal. I guess you could place a catheter, give a test dose of lidocaine and wait a little while with the guy on the table, but if it's a high spinal you're still in trouble. It may be time for a frank discussion with your anesthesia colleagues who would need to help you out in case of a jam.

The catheter followed by lidocaine test dose is the only way to go if you MUST do this. Sounds like this guy needs a pump or implanted epidural if he "must" have an epidural.


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[Aether2000]

Most non-glucose containing bupivicaine is borderline isobaric/slightly hypobaric. Here is a discussion of baricity of bupivicaine http://bja.oxfordjournals.org/content/93/4/568.full.pdf and here is a discussion of how high hyper/iso/hypobaric solutions travel after a 2.5ml intrathecal thoracic injection http://clinicaldepartments.musc.edu... club/august 2012/baricity and block_bell.pdf

 

[pastafan]

Most non-glucose containing bupivicaine is borderline isobaric/slightly hypobaric. Here is a discussion of baricity of bupivicaine http://bja.oxfordjournals.org/content/93/4/568.full.pdf and here is a discussion of how high hyper/iso/hypobaric solutions travel after a 2.5ml intrathecal thoracic injection http://clinicaldepartments.musc.edu/anesthesia/intranet/education/journal club/august 2012/baricity and block_bell.pdf

Interesting articles although #2 has the patient sitting and injection is at L3-4 not thoracic level.

SeniorWrangler is spot on regarding discussion with anesthesiologists before you need them emergently. Nothing worse than being called stat to an unexpected cluster.

clubdeac please post follow-up report. You could always put in a catheter allowing you the option to add meds as needed based on the response.

 

[Ducttape]

you obviously do not need to use just Marcaine. if you are hellbent on providing some anesthesia postprocedure, dilute out the local... for example, 0.5 cc of 0.25% Marcaine + 2 mL of steroid of choice + 1.5 mL NS would give effective concentration of 0.0625%, a typical epidural pump concentration... (someone check my math, doing this in my head...)

but prob still best to leave it out...

 

[Stim4me]

Ok so 2cc 0.25% at T4-5 would definitely give a high spinal. That's all I needed to know. Will leave out the marcaine next time and will see if it works just as well. Suspect it will.

Club that dose of marcaine accidentally injected IT via any route at that level would knock out your cardio-acellerator fibers and would cause a high spinal AND cardiopulmonary arrest. When we give hypobatic IT spinals for labor we inject 1ml with fentanyl at the L3-5 level and are ready to trendelenburg the patient and intubation them if the spinal goes to high... just use decadron at that level

 

[bedrock]

Would never use local for a cervical or thoracic epidural. Brief temporary gain is not worth the risk.