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... Wrong thread.
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All of this reminds me of a case not that long ago where the parturient was full-term and was febrile with RSV. She couldn't lay flat without uncontrollable coughing. Had been delayed with SROM, and needed to go for a c-section not emergently but ASAP.
Any guesses what happened and what I did? (The consultants seeing her before me where talking intubation, prolonged ICU stay, etc.)
Let me guess. You put in a spinal and they delivered a baby.
Yep.
Multiple people masturbated over that case for >36 hours. I had her breathe some 4% lidocaine and gave her 0.2 of hydromorphone IV (as an antitussive). Put the spinal in. Laid her down. She didn't cough once. Baby came out screaming.
You should have seen the pulmonology consult. The guy basically told her she was going to die. Terrified the OB/GYN. I told her and the patient not to worry. In the end who looked like a rockstar? Not the pulmonologist.
(Of course, we were loaded for bear in that room. Didn't need any of it, but were ready. Which is the point I tried to make earlier... in a nutshell... be ready, but trust your skills and training.)
I don't think anyone is overly concerned of a high spinal happening in reality but the discussion went there more as a board question due to previous spinal instrumentation/fusion. Theoretically, I could happen so we discussed it.excuse my ignorance ... why is this patient at increased risk of a high spinal?
I know she's short and fat and pregnant ... am I missing something here? it seems like most of our obstetric population fits that description.
One thing that has not been mentioned that I would question as I have little experience in NA techniques w/ lumbar fusions- would anyone hesitate because of potential scar tissue/adhesions within the dura/IT space making a NA block unreliable? I think I would. I've seen Neuro guys struggle with anatomy on lumbar redos enough to stay away from it.
The difficult airway is my concern here, and I would attack this head on and not try and dance around it and have to confront it under non-ideal circumstances.
For labor epidural, sure go ahead and see if you can make the patient comfy with an epidural. For an urgent/emergent case in which a surgical block is needed, no thank you.
The scar tissue is within the epidural space, not intra-thecal. The patient still has free flowing CSF. They presumably still have bowel and bladder function and the ability to walk. The postop abnormal anatomy is all external to the dura. They aren't going subdural on their lumbar fusion, although occasionally they can accidentally tear the dura which would be the same as you causing a hole in the dura with a touhy needle. We do spinals on patients that have had a lumbar fusion all the time without difficulty.
Good stuff. Thanks Mman. Great information that will change my approach to these patients.
Hypothetical- If a patient with a history of lumber fusion comes in for vaginal delivery after uncomplicated pregnancy, would you do an epidural, CSE, or continuous spinal? I like the idea of a continuous spinal, but I am pretty sure no hospitals I go to have anything other than the 18G Tuohys.
Out of curiosity guys, do you need a special spinal catheter to place an ingrate cal catheter or can you use the epidural catheter? Do you use the epidural kit...can you elaborate?
In my personal experience, obese pts rarely get PDPH.
interesting observation ... is there any supporting evidence beyond your observation?
*not trying to be a smart ass
Thanks RxBoy. So you just wet tap with the 18g Touhy and thread the epidural catheter? What's yr infusion of choice and at what rate?