Re-dose SAB ?

[Monty Python]

A coworker last night was called for labor analgesia in a woman who wanted to go all-natural, but who changed her mind as delivery grew imminent (as gauged by the very experienced and reliable L&D RN). I don't know her Gs and Ps. My coworker opted for a quick and successful SAB with 2.5 mg bupi (1 ml of 0.25%) with 15 mics of fentanyl. The patient became comfortable very quickly. VS and FHR remained WNL. Within five minutes the OB did an exam, announcing the need for a stat c-section due to breech presentation. I have no idea why this was a sudden discovery by the OB.

My coworker opted for GETA after the patient flunked the Allis test (no surprise, as the SAB was only dosed for labor, not a c-section) and everything went smoothly. Pt had a Mal 1 airway with all other indicators WNL (per chart). Just for academic discussion what would others have done in this scenario? GETA? Another spinal (what dose), assuming there was adequate time? A CSE in lieu of spinal when called for labor analgesia for anticipated imminent delivery? I personally would have performed CSE, with epidural inserted "just in case" but not dosed. When this case took place my coworker had no backup in house.

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[Libertas]

Could also do an epidural ....

While I would not redose a spinal in the case where a full dose had been recently administered (and block was not adequate) a known 2.5mv dose I think it may be reasonable to dose again. I'd probably give ~10mg hyperbaric in that case (never done that or seen anybody do it...hypothetical)

 

[pgg]

I do labor CSEs for everyone. After getting burned a couple times by nurses & OBs who assured me that delivery was imminent, only to see mom in a not-yet-delivered state a couple hours later after the labor spinal had worn off ... I don't do single shot labor spinals any more.


To answer your question though, I think an ordinary spinal would be fine. I don't think you even need to adjust the dose. What's the worst that'll happen? She got 2.5 mg of bupivacaine for the labor spinal, which is more or less equivalent to 1/3 of a mL of the 0.75% bupiv in the spinal kits. A reasonable spinal dose for a c-section is anywhere from 1.2 - 2.0 mL of that 0.75% stuff, +/- some narcotic. You're not going to get a high spinal if you put another 1.4 mL of 0.75% bupiv in there, but you will get a nice dense block for a c-section.

Of course, depending on how "stat" the stat c-section really is, GA may be the better option anyway because of time considerations.

 

[Random Anesthesiologist]

Could you use an ester instead of amide?

 

[pgg]

Could you use an ester instead of amide?

You could, but why? What problem are you trying to avoid by switching classes of local?

 

[PainDrain]

I have once "re-dosed" a spinal. Scenario went like this: 30 something G1p0 morbidly obese and airway wasn't great. She was 5'4" so I did my usual 1.6ml bupi, 20mcg fentanyl and 0.2mg morphine. Placed spinal and got barely any block, like to the thighs. I then did another spinal and put another 1.4mls in and initially I didn't have a block beyond the umbilicus. I sat her on her head for about five minutes before the level rose to the appropriate level. I couldn't explain the situation. It was weird. And I know the first spinal was in because she had no pain post op after the local wore off.

 

[Infexious]

.

 

[fakin' the funk]

I have once "re-dosed" a spinal. Scenario went like this: 30 something G1p0 morbidly obese and airway wasn't great. She was 5'4" so I did my usual 1.6ml bupi, 20mcg fentanyl and 0.2mg morphine. Placed spinal and got barely any block, like to the thighs. I then did another spinal and put another 1.4mls in and initially I didn't have a block beyond the umbilicus. I sat her on her head for about five minutes before the level rose to the appropriate level. I couldn't explain the situation. It was weird. And I know the first spinal was in because she had no pain post op after the local wore off.

For the second time in as many months on this board, I spread the tale of "true failed spinal."

Look it up. Dural ectasia. Nontrivial incidence. I've had two, and I'm < 2 years out of residency

 

[fakin' the funk]

Within five minutes the OB did an exam, announcing the need for a stat c-section due to breech presentation. I have no idea why this was a sudden discovery by the OB.

My coworker opted for GETA after the patient flunked the Allis test (no surprise, as the SAB was only dosed for labor, not a c-section) and everything went smoothly.

Stat C-section for breech?

100% I would have dosed another spinal with 1.2-1.4ml 0.75% bupi, another 10mcg fentanyl, 150mcg morphine. Your isobaric 2.5mg dose ought to be "locked in" right in low thoracic levels where it first got to.

 

[Mman]

Not sure why a c-section is stat for breech, I'm assuming there was fetal bradycardia and breech presentation. If the OB thought I had time to redo a spinal, I'd redo a spinal with a smaller dose than my usual (maybe 1 ml of 0.75%) and it would be just fine. If no time, nighty night.

No real risk of an additional dura puncture aside from increased risk of PDPH later on.

I presume your coworker had no option but GA since it was stat and the patient was already prepped and draped and OB with knife in hand. I'd have tried to assess levels prior to prepping and draping so that if I had time to do another spinal I could do it before all that time was wasted.

 

[Twiggidy]

It all depends on how stat that c-section really was. For the ladies in ultra pain i alway give 25 mcg spinal fentanyl and place my epidural and start the EPCA. If there's not in agony but have still requested an epidural, I skip the fentanyl.

I probably would've done the GETA. I realize the original spinal dose was small, but at my institution we have not so good nurses and very splitting OBs so the last thing I need is a potential high spinal.