Bizarre Reaction to Spinal (OB)

Discussion in 'Anesthesiology' started by acidbase1, Sep 5, 2017.

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  1. acidbase1

    acidbase1 5+ Year Member

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    Hey gents, so I had a bizarre reaction during one of my cases the other day. Called a few people back at the program and nobody had ever heard of anything like this before.

    G1P0 presents for scheduled primary CS 2/2 CPD. No PMH, no issues with pregnancy. Perform CSE, small 81kg about 5'6 tall, procedure goes without any issues don't even have to redirect tuohy. Gertie marx needle goes through perfectly, CSF comes back, give 11.25mg 0.75% hyperbaric bupivicaine with 10mcg of fentanyl. Thread catheter, no heme/CSF ect ect.

    After taping catheter in place, I notice she has more motor than i am typically accustomed to. I check levels, nothing other than "her feet feeling tingly". I then give 5 cc 2% lidocaine through the epidural catheter. Shortly thereafter patient begins complaining of terrible HA, begins vomiting, and blood pressure is 250/120. I then notice her HR slowly begins to drop from 100's to 80's to 60's to 40's than goes asystolic from what I'm assuming was a vagal/baroreceptor reflex from the elevated BP. Patient begins convulsing from lack of cerebral blood flow. About 5-10 seconds later patient regains consciousness, is A&O x 3, but still complaining of severe HA. We check FHT's which are then depressed so we go to sleep for crash CS. Before going to sleep I checked repeatedly for adequate hand strength which was intact/strong, even though I knew high spinal was unlikely. I even rechecked catheter for CSF/heme throughout the case, nothing.

    Baby is delivered, APGAR 8 and 9. I wake mom up and she complains of absolutely NOTHING, no N/V, not even a mild HA. She has T4 levels and is perfectly comfortable in PACU. I get a stat non contrast CTH, everything is normal. Check patient again next day, absolutely nothing wrong.

    Anyone have a similar case?
     
    Last edited: Sep 5, 2017
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  3. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    I wonder if it could be related to rebound intracranial hypertension. Although you weren't doing a blood patch, you were giving epidural meds and then getting the symptom profile as a result. It's a stretch.
     
  4. skypilot

    skypilot 2K Member 10+ Year Member

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    Local Anesthestetic Systemic Toxicity? LAST Somehow occurred during the Epidural Bolus and you got a systemic Cardiovascular collapse? Cure for which is CPR and Intralipid?
     
  5. acidbase1

    acidbase1 5+ Year Member

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    With 5cc of lidocaine (100 mg) and 12 mg of marcaine? The same thing crossed my mind during the procedure but didn't seem plausible
     
  6. xd2005

    xd2005 10+ Year Member

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    Been a lurker for years, but attending at academic practice for a couple of years now, do a fair chunk of OB.
    Also as bizarre, but possible subdural marcaine + epidural injection raising ICP and exacerbating "level" of marcaine? Cushings made worse by the seizing/vomiting. Props in keeping your cool tho. :)
     
  7. CaliCatheter

    CaliCatheter 2+ Year Member

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    Plain lido or did it have epi?
     
  8. acidbase1

    acidbase1 5+ Year Member

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    Plain lidocaine. I also thought a lot about the possibility of a subdural injection, however, the fact that I had good bilateral T4 levels postoperatively makes this unlikely.
     
  9. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    I vaguely recall discussing this in another thread ...

    For c-sections, you routinely give 1.5 mL of the hyperbaric bupiv from the kit, and do a 3 mL epidural test dose (presumably with 1.5% lido + epi), and give 5 mL of 2% lido?

    That doesn't make a lot of sense to me (still). I can't connect the dots between that weird protocol and this weird case, but weird begets weird ... :)


    If it was the epi making her hypertensive she wouldn't get bradycardic.

    I'm not buying LAST from 145 mg of lidocaine, even if 100% of it went intravascular, and that wouldn't cause hypertension anyway.

    Consider a drug error/swap (i.e. a big phenylephrine bolus)?
     
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  10. Ezekiel2517

    Ezekiel2517 Anesthesiologist 10+ Year Member

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    Could have nothing at all to do with your spinal or epidural. It seems like everything that happened is a result of the pressure being super high. Figure out why the pressure was so high.
     
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  11. Arch Guillotti

    Arch Guillotti Senior Member Lifetime Donor SDN Administrator 10+ Year Member

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    1 mg phenylephrine was given instead of 100 mcgs.
     
  12. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    all plausible regarding drug errors, but never mention giving Neo
     
  13. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    After 1.5 mL of intrathecal hyperbaric bupiv chased with 8 mL of epidural lidocaine ... of course he gave some neo. ;)
     
  14. nimbus

    nimbus Member 10+ Year Member

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    Or neo 10mg instead of reglan 10mg
     
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  15. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    what low budget hospital doesn't have pre-mixed Neo?!:)
     
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  16. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Mine :yeahright:
     
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  17. nimbus

    nimbus Member 10+ Year Member

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    We got premixed neo about 10 years ago after a similar incident.
     
  18. acidbase1

    acidbase1 5+ Year Member

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    Hold up, I don't routinely give lido or lido with epi test dose. I typically give the spinal dose and that's it 99/100 times.

    The only thing I do different than you is reduce my spinal dose for the pregnant patient
     
  19. acidbase1

    acidbase1 5+ Year Member

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    I didn't give anything IV except glycopyrolate (regarding phenylephrine)
     
    Last edited: Sep 5, 2017
  20. Orin

    Orin 7+ Year Member

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    If you rules out common things, it sounds like a robust Cushing reflex secondary to intraspinal hypertension.

    I'd be interested in an MRI of the L-spine but purely for academic purposes.
     
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  21. FFP

    FFP Grunt, cog, body, pompous ass Gold Donor 7+ Year Member

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    That one is a killer. Literally. I am not sure one could recover the patient from that mistake.
     
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  22. nimbus

    nimbus Member 10+ Year Member

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    How long did it take for her BP to come down? Did you have to give anything? It still sounds like neo overdose. Did the nurses give any "reglan"?
     
  23. nimbus

    nimbus Member 10+ Year Member

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    It is surviveable.
     
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  24. Arch Guillotti

    Arch Guillotti Senior Member Lifetime Donor SDN Administrator 10+ Year Member

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    Yep
     
  25. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    A vial? Really? Not that I ever want to see it.
     
  26. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Gotcha, I misremembered from the other thread. :)

    I don't know then.

    I kind of like the Cushing theory above.
     
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  27. acidbase1

    acidbase1 5+ Year Member

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    No, I sat there and watched everything unfold without giving anything. I asked for hydralazine (didn't have any handy) but by the time it got there we were asleep. I titrated down her BP with my anesthetic and it was controlled from there on out

    The only thing I gave was 0.4 of glycopyrolate for the bradycardia.
     
    Last edited: Sep 5, 2017
  28. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Yeah

    One of our M&Ms years and years ago was for a phenylephrine drug swap. Not just a dilution error ... a whole 1 mL vial of the 10 mg/mL stuff.

    I guess there's only so hard your arterioles can squeeze before they can't squeeze any more. And if your other organs can handle it for a couple minutes ... healthy humans are hard to kill.
     
  29. acidbase1

    acidbase1 5+ Year Member

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    I definitely felt like it was a Cushing response from the get go. Why the interspinal HTN though? I discussed the case w a neurosurgeon and he commented on a possible preexisting intracranial pathology like a saccular aneurysm or mass. The aneurysm theory was debunked with the normal CTH. No mass either.
     
  30. nimbus

    nimbus Member 10+ Year Member

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    Yep I've attended 2 such M+M's at 2 different institutions. Both patients did fine.
     
  31. FFP

    FFP Grunt, cog, body, pompous ass Gold Donor 7+ Year Member

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    The one I was told about had died.

    I always wonder WTH is the FDA doing by not outlawing these concentrated vials, except for compounding pharmacy use. Same for the insulin vial, or the big epi vial outside of jet syringes for codes etc.

    But, hey, we need a black-box warning for droperidol. :bang:
     
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  32. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    They were too busy wringing their hands delaying approval for sugammadex and taking droperidol away from us.
     
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  33. nimbus

    nimbus Member 10+ Year Member

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    The FDA decision makers are not familiar with anesthesia workflows and I doubt they even consider preventing drug swaps to be part of their regulatory mission. We often get random changes in vial cap colors without any notice or warning depending on the latest deal our pharmacy makes. And our perfusionists do use the concentrated vials.

    As for insulin I always order a 1unit/ml drip from our pharmacy if I'm going to give any. I don't trust myself with U100....feels like a loaded gun.
     
  34. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    A big bubble of air most likely entered the intrathecal space while you were doing the epidural and caused a pneumocephalus, which explains all the symptoms you mentioned.
     
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  35. FFP

    FFP Grunt, cog, body, pompous ass Gold Donor 7+ Year Member

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    I wouldn't swear for that. I have seen a very similar picture after a peripheral nerve block (it may have been an interscalene) done by one of my very experienced colleagues in the PACU, except we never got to the profound bradycardia/asystole and seizure part, because I promptly treated the hypertension, and then the symptoms went away. It was very strange to see the BP go to 220 in a couple of minutes in a normotensive individual (she also got very nauseous), especially since it happened after a while, not during the block (which was with ropi and traces of epi). It was also in a childbearing age female, like here. We have no idea what happened.
     
    Last edited: Sep 6, 2017
  36. nimbus

    nimbus Member 10+ Year Member

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    That would show up on CT.
     
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  37. acidbase1

    acidbase1 5+ Year Member

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    Anothing thing I discussed with my attendings. No air was in the spinal dose
     
  38. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    Off topic #1: Why a CSE for a primary C/S on a normal sized chick??

    Off topic #2: with regards to the survivability of the vial of Neo bolus, in residency a CRNA gave 4mg of Levophed to an otherwise healthy patient in pre-op thinking he drew up Decadron. Needless to say, hilarity ensued - but the guy lived largely unscathed.
     
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  39. acidbase1

    acidbase1 5+ Year Member

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    Why CSE? Flexibility and duramorph.

    FPOBs are slow and this was a PPTL
     
  40. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    You can put duramorph in a spinal too.

    How slow is slow? Just curious. How often do you have to dose the catheter? Taking the time to thread the cath means your spinal level will set up lower which increases the odds of needing that cath where there otherwise wouldn't be a problem - self-fulfilling prophecy.

    Interesting case. I've got no idea.
     
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  41. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    But how slow? I'm assuming FPOB means "family practice OB" but still, are they 2 hrs slow? a 12 mg marcaine spinal can afford you plenty of time and you can also give duramorph in the spinal. you just need to get taught some of the private practices tricks to do so
     
  42. acidbase1

    acidbase1 5+ Year Member

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    I like fentanyl in my spinal dose. Wouldn't feel comfortable adding more narcotic if that's what you are eluding to...

    Some of the guys will take up to 2 hours, rarely dose the catheter but have had a failed/partial spinal a few times so it was nice to have in place.

    I lay the patient down to tape in the catheter so it doesn't make that much of a difference in terms of level, (30 seconds to a minute more). I always have T4 with 11.25 mg dose. I increase the dose to 12mg if they're above 5'7. Voodoo I know
     
  43. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    It is routine practice pretty much everywhere to put both fentanyl and Duramorph in the spinal.
     
  44. acidbase1

    acidbase1 5+ Year Member

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    I've done plenty of spinals for c sections it's just personal preference. I don't see the drawback of having the epidural catheter
     
  45. acidbase1

    acidbase1 5+ Year Member

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    Not where I trained but good to know thx
     
  46. Orin

    Orin 7+ Year Member

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    What level did you think you were at with your spinal? Regardless, this is purely academic unless you can get an MRI of the L-spine in the next day or so. You could do a very focused motor exam of her lower extremities. I assume she has no gross deficits, but I would be interested if she was slightly hyperreflexic, had a touch of spasticity, or even a few beats of clonus. Specifically I'd check patellar vs achilles on her.
     
  47. acidbase1

    acidbase1 5+ Year Member

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    L3/L4. I did Neuro exam after spinal wore off, everything intact. What abnormality of the L spine could cause something like this?
     
  48. Scotty_G

    Scotty_G Junior Member 10+ Year Member

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    Yes CSE in non academics for a c-section?! You shouldn't need to do that even if 2 hrs. IMHO spinal is superior for c-section and if it took so long that the spinal wore off you can always wing it for the last remaining part (Propofol/ketamine/benadryl etc etc)
     
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  49. Scotty_G

    Scotty_G Junior Member 10+ Year Member

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    What if patient had dural ectasia?
     
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  50. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    Was there a CT?
     
  51. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Chestnut recommends it. I posted a picture from his book in another thread a while back:

    Duramorph/Bupiv Spinals

    Other opinions in that thread.

    I still put 15 of fentanyl and 0.2 of morphine in all my spinals for section.
     

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