Advice: Spinal after epidural for c/s

[BIS40]

wanted advice from OB heavy hitters or usual veterans on here:

Seeking advice on pt with running epidural, wanting to change to spinal for c section because of doubt of epidural/patchy during day. Ive done this for certainty of spinal, but have gotten high spinal twice probably because of local combining with local from infusion, even though both times infusion off for at least 45 minutes before spinal.
Do others cut dose or wait longer? any advice appreciated.

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[lushmd]

I'm neither a veteran nor an "OB heavy hitter" but here are my thoughts:

(1) Why not just place a new epidural catheter (assuming you've already tried things like bolusing and pulling it back a bit)? This way, even if a C-section isn't done the pt has better labor analgesia and it can of course be used to provide anesthesia for a C-section.

(2) Re spinal following epidural, as I understand it, the concern is one of high spinal, possibly due to decreased intrathecal volume and/or local anesthetic pooling through the dural puncture. If one is to do this, it would seem prudent to turn off the epidural infusion and avoid bolusing through the epidural catheter prior to doing the spinal and also decreasing the dose/volume of the spinal injection. Having never done this (spinal following epidural), I'm at a loss re providing specific recommendations for turning off the infusion and decreasing the volume (some of my attendings have indicated that they would turn off the infusion for at least 1 hr and decrease the dose/volume by 20-25%). Of course, be vigilant for possible high spinal and discuss this possibility with the pt.

 

[Bertelman]

wanted advice from OB heavy hitters or usual veterans on here:

Seeking advice on pt with running epidural, wanting to change to spinal for c section because of doubt of epidural/patchy during day. Ive done this for certainty of spinal, but have gotten high spinal twice probably because of local combining with local from infusion, even though both times infusion off for at least 45 minutes before spinal.
Do others cut dose or wait longer? any advice appreciated.

There have been some extensive discussions of this in the recent past. Try a search

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=591362&highlight=spinal


Read the above thread. Feel free to re-open that thread for discussion purposes.

Blade

 

[dhb]

What needel size did you use when you had the high spinals? Some experimental data shows that with a 27G you don't have transfer from the epidural space to the subdural.

 

[seinfeld]

ALmost always do spinal for c-section with epidural in place for labor. I getting a patchy epidural for section.

I use my normal doses 1.6ml of 0.75% bupivicaine. Never had a problem.

 

[gaspasser2004]

Here's my decision tree for labor epidurals and C-sections:

1. When C/S called, ask patient if epidural is working okay. If yes, dose epidural. If no, then pull epidural and do spinal in OR.

2. If epidural working okay and bolused with lidocaine 2% 15 cc and feeling test pinch, wait five minutes if feasible. If level starts to appear, consider dosing more. If no level starts to appear, then go to sleep.

I think it is reasonable to do a spinal on a labor epidural that has been running for analgesia. I don't think it is worth the risk to do a spinal on top of a epidural you have dosed for a C/S.

 

[hoyden]

ALmost always do spinal for c-section with epidural in place for labor. I getting a patchy epidural for section.

I use my normal doses 1.6ml of 0.75% bupivicaine. Never had a problem.

Do you bolus your epidural prior to doing a spinal for CS ?

 

[Mman]

Do you bolus your epidural prior to doing a spinal for CS ?

Bolusing an epidural and then doing a spinal is the perfect recipe for getting a high spinal.

I will routinely pull an epidural and put in a spinal with a slightly smaller dose (maybe 1.2-1.4 mls of 0.75%), but I won't give a 10+ ml bolus through the epidural and then shortly thereafter place a spinal. That probably isn't wise.

 

[seinfeld]

Do you bolus your epidural prior to doing a spinal for CS ?

no

 

[jwk]

wanted advice from OB heavy hitters or usual veterans on here:

Seeking advice on pt with running epidural, wanting to change to spinal for c section because of doubt of epidural/patchy during day. Ive done this for certainty of spinal, but have gotten high spinal twice probably because of local combining with local from infusion, even though both times infusion off for at least 45 minutes before spinal.
Do others cut dose or wait longer? any advice appreciated.

If you have doubts about the epidural already, just replace it.

You've already demonstrated to yourself why you should not do a spinal on top of an epidural.

 

[huktonfonix]

CSE with 1-1.2 mg of 0.75 bupiv. dose up level as needed through new cath. Usually the spinal level is fine with the lower doses and Ive never had a high spinal with this although its not a high sample (10-20 ish)

 

[hoyden]

Bolusing an epidural and then doing a spinal is the perfect recipe for getting a high spinal.

I will routinely pull an epidural and put in a spinal with a slightly smaller dose (maybe 1.2-1.4 mls of 0.75%), but I won't give a 10+ ml bolus through the epidural and then shortly thereafter place a spinal. That probably isn't wise.

I know, that's why I've asked the question. Thanks.

Originally Posted by seinfeld View Post
ALmost always do spinal for c-section with epidural in place for labor. I getting a patchy epidural for section.

I use my normal doses 1.6ml of 0.75% bupivicaine. Never had a problem.

 

[seinfeld]

just in case it was not clear i remove the epidural prior to doing the spinal.

 

[Noyac]

I typically pull every epidural that rolls into the c/s room and place a spinal with a total volume of 2cc. My usual spinal dose is 100mcg PFMS with 1.8cc bupiv but if they had an epidural running I cut the bupiv down to 1.2cc and add fentanyl. It's still 2 cc's total, maybe 1.8cc total if they are smaller.

 

[Idiopathic]

probably done 100 c/s with running epidurals and probably only replaced a couple. we usually try and be proactive with patchy epidurals on the floor and replace them early since we have surgeons with a quick-trigger to go to CS

 

[nitroglycerine]

wanted advice from OB heavy hitters or usual veterans on here:

Seeking advice on pt with running epidural, wanting to change to spinal for c section because of doubt of epidural/patchy during day. Ive done this for certainty of spinal, but have gotten high spinal twice probably because of local combining with local from infusion, even though both times infusion off for at least 45 minutes before spinal.
Do others cut dose or wait longer? any advice appreciated.

How high was your high spinals? I regularly get T4 and sometimes T2 with the regular spinals.

 

[Jeff05]

I typically pull every epidural that rolls into the c/s room and place a spinal with a total volume of 2cc. My usual spinal dose is 100mcg PFMS with 1.8cc bupiv but if they had an epidural running I cut the bupiv down to 1.2cc and add fentanyl. It's still 2 cc's total, maybe 1.8cc total if they are smaller.

why not just dose the epidural?

 

[seinfeld]

Every time i use an epidural for c-section and its not 100% I kick myself for just not doing the spinal. If its more of an emergency thing and the epidural is working well, will start with 3CP boluses but in general i can get a spinal in place in less time than it takes to get a level with an epidural.

 

[nitroglycerine]

Every time i use an epidural for c-section and its not 100% I kick myself for just not doing the spinal. If its more of an emergency thing and the epidural is working well, will start with 3CP boluses but in general i can get a spinal in place in less time than it takes to get a level with an epidural.

Is 3CP 3% Chloroprocaine or 2%?
Thanks.

 

[seinfeld]

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