Spinals for C-sections

[Arch Guillotti]

All this is fantastic and sounds great but unfortunately we still don't really know what exactly happens when you add epinephrine to local anesthetics intrathecally, and we don't know how it spreads or where it acts.
We do know though that epinephrine causes nerve ischemia that is sometimes clinically significant when added to local anesthetics in nerve blocks and that's why many people avoid using it in nerve blocks.
So if we are concerned about iscehemia when we inject a 1/200,000 solution around a big nerve like the sciatic nerve shouldn't we be concerned about injecting it around the cord and the nerve roots?
And for those who say it has not been reported that there was cord ischemia with intrathecal epi you need to remember that people only report things that they diagnose and if something is undiagnosed or attributed to another cause it will not be reported.

I don't have any worry at all about it.

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[Arch Guillotti]

To answer the question regarding failed epidural and proceeding with spinal. First it would depend on the status of baby and m0m. If the section was urgent IE fetal bradycardia, fetal distress. I would proceed with general anesthesia after failed bolus of epiduiral. If the section was due to failure to progress I would wait 4-6 hrs and pull the epidural catheter and redose with a spinal. How about the other way what if you had a failed spinal(bad bupi) would you place an epidural and proceed? Or straight to general anesthesia?

As I'm studying for my oral boards, this seems like a very diplomatic, boards-y kind of answer. From a practical standpoint, as mom is lying on the OR table exhausted from a prolonged labor, the OB and scrub tech have scrubbed with instruments in hand staring at me, I can't imagine announcing to everyone, "Alright peeps, let's hold on the section for now and take five.....hours."

If I were a board examiner I would fail someone for delaying the c/s 4-6 hours as presented. The board examiners I knew from residency were all ivory-tower types to some degree but they were all also very practical and pragmatic. Delaying the c/s is neither practical or pragmatic. If you are that concerned about neuraxial mishaps then redo the epidural. Keep it simple.

 

[narcusprince]

Arch, Good points. Good thing I am done with orals. My concern also would be local anesthestic toxicity with redoing an epidural and giving another 15- 20ml of 2% lidocaine(400mg). I would not fail somoene for delaying a surgery in a stable patient and stable baby due to concerns about local anesthetic toxicity. The tree pivots with the airway examintation. If non-reassuring delay the case until the lidocaine has theoretically metabolized. If the airway is reassuring proceed with general anesthesia. One thing the board examiners look for is flexibility.

 

[Arch Guillotti]

Arch, Good points. Good thing I am done with orals. My concern also would be local anesthestic toxicity with redoing an epidural and giving another 15- 20ml of 2% lidocaine(400mg). I would not fail somoene for delaying a surgery in a stable patient and stable baby due to concerns about local anesthetic toxicity. The tree pivots with the airway examintation. If non-reassuring delay the case until the lidocaine has theoretically metabolized. If the airway is reassuring proceed with general anesthesia. One thing the board examiners look for is flexibility.

I have never had a problem with it. The redo dose usually isn't as much as the original. Anyways, use chloroprocaine if you really think LA toxicity will be a problem.

 

[pgg]

The choice isn't limited to GA vs an unsafe spinal vs waiting 4-6hrs. If you had a shaky epidural, bolused it up anyway, got an inadequate block, and are worried about getting a high spinal from a subsequent intrathecal dose ... you can always CSE the patient with a reduced intrathecal dose and have a fresh / presumably good catheter in place to augment or extend that reduced dose.

Waiting 4-6 hrs for a FTP called c-section is stirring up unnecessary trouble. You can still safely get it done with regional.

 

[BLADEMDA]

https://books.google.com/books?id=T...pinephrine dose for spinal anesthesia&f=false

Read page 88. Adding Epi to your spinals (Bupivacaine or tetracaine is perfectly safe) meets the standard of care.

 

[BLADEMDA]

The choice isn't limited to GA vs an unsafe spinal vs waiting 4-6hrs. If you had a shaky epidural, bolused it up anyway, got an inadequate block, and are worried about getting a high spinal from a subsequent intrathecal dose ... you can always CSE the patient with a reduced intrathecal dose and have a fresh / presumably good catheter in place to augment or extend that reduced dose.

Waiting 4-6 hrs for a FTP called c-section is stirring up unnecessary trouble. You can still safely get it done with regional.

I've got my Glidescope handy if needed so once the epidural fails the patient is likely to get a GA.

We have discussed this topic on SDN.

http://forums.studentdoctor.net/threads/failed-epidural-for-c-section-now-what.591362/

 

[Planktonmd]

https://books.google.com/books?id=TZbnM0nPbk8C&pg=PA88&lpg=PA88&dq=epinephrine dose for spinal anesthesia&source=bl&ots=42t9q-FscV&sig=7Nyd0Uht5kh24ZJVg-2eu-M9VI0&hl=en&sa=X&ei=9GfuVMa7JonAggT7k4GQDQ&ved=0CCQQ6AEwAzgU#v=onepage&q=epinephrine dose for spinal anesthesia&f=false

Read page 88. Adding Epi to your spinals (Bupivacaine or tetracaine is perfectly safe) meets the standard of care.

Ah... what can I say... google book of anesthesia and professor Blade.com have spoken the truth and defined the standard of care... all other arguments are now futile!

 

[BLADEMDA]

Ah... what can I say... google book of anesthesia and professor Blade.com have spoken the truth and defined the standard of care... all other arguments are now futile!

Shnider and Levinson's Anesthesia for Obstetrics
edited by Samuel C. Hughes, Gershon Levinson, Mark A. Rosen, Sol M. Shnider

This is a mainstream textbook.

 

[Mman]

I have no evidence or studies, but...

When you do a nerve block with 30 mls of 1:200K epi, you are putting 150 mcg of epinephrine in a confined space with a nerve. When you do a spinal with 100 mcg of epi (which I don't personally do I find the wash gives the extended duration I need just fine), you are putting 100 mcg of epi in a free flowing fluid space that quickly dilutes it. Is there much of a difference? I mean the epi in the spinal is more concentrated, but you are putting it into a relatively much larger volume of fluid which dilutes it. It's also a smaller dose of epi than the nerve block (because of the higher total volume).

I really can't imagine it makes a bit of difference in terms of risk. The risk from the spinal is the risk of epidural hematoma. The risk of ischemia in the cauda equina has to be as close to zero as you can get. I mean you aren't doing the injection into the spinal cord.

 

[narcusprince]

The choice isn't limited to GA vs an unsafe spinal vs waiting 4-6hrs. If you had a shaky epidural, bolused it up anyway, got an inadequate block, and are worried about getting a high spinal from a subsequent intrathecal dose ... you can always CSE the patient with a reduced intrathecal dose and have a fresh / presumably good catheter in place to augment or extend that reduced dose.

Waiting 4-6 hrs for a FTP called c-section is stirring up unnecessary trouble. You can still safely get it done with regional.

Their are other options. If the spinal if the epidural is inadequete the surgeon could supllement local vs IV ketamine + local. Their are wider options. However patchy bolused epidural, re-assuring airway, failure to progress= GETA + RSI.

 

[Noyac]

Their are other options. If the spinal if the epidural is inadequete the surgeon could supllement local vs IV ketamine + local. Their are wider options. However patchy bolused epidural, re-assuring airway, failure to progress= GETA + RSI.

The local or even the local with ketamine supplement is always an option thrown around here but I gotta say, it a bad option.

 

[pgg]

Their are other options. If the spinal if the epidural is inadequete the surgeon could supllement local vs IV ketamine + local. Their are wider options. However patchy bolused epidural, re-assuring airway, failure to progress= GETA + RSI.

I can count on zero fingers the occasions when I've witnessed an OB effectively administer local during a section. And that's not a knock on OBs, just a statement that it's not possible to turn a trainwreck of an augmented labor epidural into a good anesthetic with local. There's no way that local from the surgeon is going to cover the patient's pain when they drag the uterus out and lay it on the belly. The incision's around T11-12 but we aim for T4-ish blocks for a reason. If the OB is giving local, then the patient's in pain and having a lousy birth experience and it's your fault.

So the lesson residents ought to be getting from this line of discussion is simply to NOT put yourself in situations where you are likely to have to utter words like "local to the surgeon" or entertain ketamine, or propofol, or nitrous, because your patient is in pain during a c-section. I don't believe most labor epidurals need to be pulled and a SAB given when a section is called, but if it's given you any reason to doubt it, just pull it.

 

[Mman]

[QUOTE="pgg, post: 16230114, member: 84904" I don't believe most labor epidurals need to be pulled and a SAB given when a section is called, but if it's given you any reason to doubt it, just pull it.[/QUOTE]



Do a spinal, go ahead with GA, whatever. If you aren't convinced the epidural is going to be great before they make incision, don't use it. Just setting yourself up for failure and the mom up for a crappy experience. I've talked to plenty of moms that had an epidural for their last c-section and while they were technically awake during the procedure they have a terrible memory of it and want nothing to do with having it happen again. A great epidural can work well for a c-section. But if it's not great, don't bother.

 

[narcusprince]

I personally have never had to ask the surgeon to supplement local. As a staff I have never had to augment with Ketamine. I don't proceed unless the patient is adequetly blocked up to T8. Agreed that a terrible birthing experiance when their are better options is your fault. The local + Ketamine route is often discussed as a last resort in dinosaur textbooks. The obstetrician that I routinely work with has done a case with ketamine and local. And from her story I would never ever want to subject my patients to such trauma.