Positive allis after spinal

[TaoistDoc]

Had a case recently where crna did spinal. Pt draped. Positive allis test.

I got called to room. Pt had about t10 level.

Ob and patient prefers to do case under spinal.

I redid spinal, only injected 1.2ml bupivacaine.

Had to put pt in trendelenburg for about 4 minutes to get adequate level after.

Case went fine.

What are your thoughts on repeating spinal after inadequate level?

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[Libertas]

I think safest options at the point where you have an apparently failed subarachnoid block, but with signs of some level, are limited. Either general anesthesia or wait until the block resolves to repeat the spinal. I would also be somewhat concerned about placing an epidural because of epidural volume expansion heightening your existing block.

 

[Mman]

What are your thoughts on repeating spinal after inadequate level?

I'll usually sit them up and put in an additional 0.5 ml of the hyperbaric .75%. You don't need much to push it up a few levels.

 

[Arch Guillotti]

I would also be somewhat concerned about placing an epidural because of epidural volume expansion heightening your existing block.

I would either do a low dose spinal like Mman said or do an epidural. I wouldn't be too worried about the epidural volume expansion issue. The biggest pain is failing an Allis after the patient is prepped and draped.

 

[GhostTree]

what was the dose of the initial spinal?

 

[TaoistDoc]

what was the dose of the initial spinal?

1.8ml .75% hyperbaric bupiv according to my crna. Lay down quickly after injection too. Pt was only 5'6''ish

 

[TaoistDoc]

I think safest options at the point where you have an apparently failed subarachnoid block, but with signs of some level, are limited. Either general anesthesia or wait until the block resolves to repeat the spinal. I would also be somewhat concerned about placing an epidural because of epidural volume expansion heightening your existing block.

I agree that is is what they teach you in residency and probably the right answer for boards. But I feel like it may be different in practice. When the OB, patient, and family are looking to you to make the neuraxial work so that they can do the section with the patient awake, its harder to convince yourself to put the patient to sleep.

 

[Libertas]

I think an epidural would be my strong preference if I was going to repeat neuraxial. You just have no way to predict how two subarachnoid doses will stack together. It may be different if the patient had no block at all with the first dose.

I agree that is is what they teach you in residency and probably the right answer for boards. But I feel like it may be different in practice. When the OB, patient, and family are looking to you to make the neuraxial work so that they can do the section with the patient awake, its harder to convince yourself to put the patient to sleep.

 

[Arch Guillotti]

1.8ml .75% hyperbaric bupiv according to my crna. Lay down quickly after injection too. Pt was only 5'6''ish

Did you watch the CRNA perform the spinal?

 

[deleted59964]

if completely elective -- I would delay (call next patient) and repeat
if non elective but not emergent I'd repeat the spinal with my normal dose, but keep a good head up position -- and I'd warn the patient that I may need to put them off to sleep
if emergent -- GA

 

[PainDrain]

1.8ml .75% hyperbaric bupiv according to my crna. Lay down quickly after injection too. Pt was only 5'6''ish

That is a pretty hefty dose for anyone and 5'6" isn't that tall. I would venture to guess the spinal was not in or maybe she got a little csf and the needle moved during injection. I did have a case recently where I put in 1.8 and had to refuse. Even then I had to stand her on her head to get a level. She was tall though and there was a question of a "herniated disc".

 

[Metalblade]

I had a case like this a few years ago. Perfect spinal: birefringence, was able to re-aspirate CSF at the end of injection, but pt didn't have nearly an adequate level with 1.6 of hyperbaric. Not wanting to redo the spinal for fear of a high spinal, I placed an epidural, bolused 10-15cc Lido 2% intermittently. By the end of the case, pt had weakness in both her arms and had decreased sensation almost up to her neck. My guess here is that the local in the epidural space slowly seeped into the subarachnoid space through the dural puncture; hence by the end of the case, she had essentially developed a high spinal. Now, I would probably convert to GA if easy airway, or else redo spinal with lower dose rather than attempt an epidural.

 

[chocomorsel]

Never heard of an allis test. Had to google it. What does it have to do with a spinal?

 

[Urzuz]

Never heard of an allis test. Had to google it. What does it have to do with a spinal?

An allis clamp is the name of the clamp obstetricians typically use to pinch the patient's belly and test for adequate anesthesia before making incision for a C-section.

 

[fakin' the funk]

Dude, that initial description sounds like a true failed spinal.

True failed spinal = you actually inject real local in the dose you intend into actual intrathecal space, and you either get weak block or no block.

As opposed to "fake" failed spinal where either the local was bad or drawn up wrong or saline was injected or it wasn't really CSF, etc. Which is probably more common.

Check it out, the incidence is non-negligible. Most common cause is dural ectasia. I.e., patient has enormous CSF volume and your local just doesn't travel (referring to heavy local). There's a decent review in the anesthesia literature on this. I know, because I had one . A senior OB where I work (thousands of C/S's) said he has seen several cases of this before.

My vote would be GA >>> intrathecal catheter. Repeating a single shot spinal would be unpredictable, at best.

 

[chocomorsel]

An allis clamp is the name of the clamp obstetricians typically use to pinch the patient's belly and test for adequate anesthesia before making incision for a C-section.

Thanks. Had no idea. I know what an allis clamp is. Just thought it was spelled "Alice" and totally didn't make the connection. Lol.

 

[Colba55o]

I have never repeated a spinal either in residency or pp..if it failed it failed and I say go to GA unless there is some truly compelling reason which I don't think exists here.
Mom and OB may make a stink about it at the time, but once baby is out do you really think she is going to care that much that she was asleep as long as baby is healthy? The risk of a high spinal and an emergent securing of the airway would be a much more negative experience that she would recall and has potential for more problems.

 

[Noyac]

Repeating the spinal is very risky. Would not be my first, second or third choice.
I would just put the pt to sleep 99% of the time.
Epidural placement maybe but it would be a very slow dosing plan and I'd tell the OB to go get some coffee and wait til I call them.
I might consider having the OB inject local at the incision site and hope that the spinal works from the on but that would be a suckass c/s. Plan would be GA if it didn't work.

Moral of the thread: do you own spinals. Don't let crnas do them. You don't know what really went on and now you are trying to remedy as bad situation.