Puzzling Case

Kinda like Mil's bleeding lady who stayed bradycardic.

27y/o female, G3, with current fetal demise at 23 weeks, induced for delivery of same. Pitocin killing her, needs epidural.
Previous history of HTN, on a B blocker, compliance unknown. No other med history.

Visibly upset, crying, shaking, etc.

BP/HR pre epidural 150s/90s, HR 100-105. All labs wnl.

CSE placed, ropivicaine 4mg/sufentanil 1 ug intrathecally, catheter placed, taped. No epi in solution.

Laid her down, HR goes into 140s, BP to 105/70 or so. HR goes to near 160 over the next cuppla minutes...phenylephrine 100ug, thinking her autoregulation needs a higher MAP. BP comes up to 130s. HR keeps climbing.

Asymptomatic. No CP, no SOB. Another pop of phenylephrine. BP now 140s systolic.
Watched her for about 15 minutes thinking HR would eventually decrease. It didnt.
Maximum HR went into 180s...

So the first theory of low SVR (with subsequent increased HR compensation) from the intrathecal dose didnt work since I brought her SVR up with the neo, BP came up, but HR didnt fall. As a matter of fact HR kept climbing.

labetolol 5mg......POOF! Two minutes later HR goes from 180s to 90 within about 30 seconds. BP stabilizes in the 120s.

So I fixed her, but I dont know why it worked.

A HR that high speaks of PAT....but the evolution of PAT is typically abrupt, not a gradual over 15-20 minutes rise from sinus-tach ranges to PAT ranges.
And a small dose of B blocker shouldnt abruptly stop PAT. And why would she go into PAT in the first place? No previous h/o PAT. And if it were sinus tach, one typically sees a gradual decrease with B blocker intervention, not an abrupt one.

A 20 something year old in that kind of emotional distress is certainly capable of sinus rates that high.

By the time the ekg person got there it was all over.

Any thoughts?

militarymd said:

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HAHAHAH

ok Mil, enough with the extravagant smilies. Indulge me with your brilliance.

Noyac said:

Sorry but I have nothing informative to say either. I'm just glad that Mil didn't come up with a great explanation making me feel dumb and ignorant. But then again it would be nice to have an explanation. Could we blame it on a possible drug error like Mil's case?

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wish I could. no chance unless the stuff was labeled wrong.

Idiopathic said:

So, i find it odd that this woman was a gravid female who may have been on beta blocker therapy during pregnancy? Im not sure I have seen a pregnant woman on beta blockade. If she was removed from therapy, recently perhaps, could we just be seeing an exaggerated sympathetic response? (even if she wasnt previously on beta blockade-we could still see this)? It was explained to me that sinus tach is always a response to some other physiological condition. Did she have impaired venous return? (i.e. ivc compression?) that got relieved around the time you gave the labetalol?


Or maybe she did some methamphetamine right before she was induced.

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Nice thought process. Possibly an exaggerated sympathetic response with appropriate HR increase, with the BP held lower than expected by the low SVR induced by the intrathecal LA.

Geez, now we sound like a cuppla fleas hypothesizing why the urine sodium is lower than expected.

No impaired venous return.

Didnt look like the meth type.

zippy2u said:

Prolly that CSE technique you do quite frequently. Wouldn't have happened if ya just did Zip's run o' the mill epidural. Somethin' to be said of the KISS technique in anesthesia. Regards, ---Zip

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THE ZIPSTER IS BACK AND HAS SPOKEN

yeah ok zip

davvid2700 said:

I agree.. why would anybody go out of their way to put a hole in a laides dura when you dont have to.. Especially when the known trouble in OB is Spinal headaches.. I dont care how small your needle is..

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My headache incidence doing CSE is no greater than yours doing straight epidural.

jetproppilot said:

My headache incidence doing CSE is no greater than yours doing straight epidural.

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And thats not meant as a nasty comeback. Its the truth. Your implication that a CSE technique somehow causes more potential morbidity than a straight epidural is not true.

BTW, I have nothing to gain by selling this technique, and I myself was initially skeptical when my partner from previous gig brought it to our practice.

Have you ever tried it in obstetrics for say, a cuppla weeks straight? Or a month straight? How can you be critical of something that you've probably never gotten good at, or tried for a length of time?
Look, I could care less how you run your epidurals. But many people who try CSE for labor analgesia like it. Its fast, no dosing the catheter, the woman gets comfortable quicker, and your risk of a high spinal is negligible, since you're using a small intrathecal dose with no catheter dosing.

jetproppilot said:

And thats not meant as a nasty comeback. Its the truth. Your implication that a CSE technique somehow causes more potential morbidity than a straight epidural is not true.

BTW, I have nothing to gain by selling this technique, and I myself was initially skeptical when my partner from previous gig brought it to our practice.

Have you ever tried it in obstetrics for say, a cuppla weeks straight? Or a month straight? How can you be critical of something that you've probably never gotten good at, or tried for a length of time?
Look, I could care less how you run your epidurals. But many people who try CSE for labor analgesia like it. Its fast, no dosing the catheter, the woman gets comfortable quicker, and your risk of a high spinal is negligible, since you're using a small intrathecal dose with no catheter dosing.

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seattledoc said:

Here's my thoughts on the PDPH risk post CSE.
First, there is a certain risk of headache with every epidural, i.e., you're going to poke the Touhy through the dura once in a while. Sometimes you'll get a gusher, other times it'll be occult. (let's say 2%, to throw out a number)

Second, every time the 25g or 27g spinal needle goes through the dura there is a risk of headache (let's say 2%)

So, with a CSE technique, how can the risk still be 2%? These risks should be additive. I don't think the correct answer is 4%, I think it is much closer to 2%, but it's gotta be higher the 2%. And to see the difference between 2% and 2.1%, you gotta be doing a serious amount of CSE's.

And in closing, who really cares about the difference between 2 and 2.1%, it's fairly irrelevant a one person's practice. What will that be, a couple of headaches per decade?

CSE's are a nice technique.

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I do about 40 CSEs a month for labor analgesia (up 'til Katrina...our volume is down now but pre Katrina our unit was doing around 160-180/month, so about 40+ per doctor). Since May 04 when I started this gig, I've had 3 PDPHs, out of about 680 epidurals. Thats a .4% incidence.

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