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Bizarre Reaction to Spinal (OB)

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

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  1. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    That's not how it works and it's not the bubbles in your spinal dose that I am referring to.
    You placed a large Tuohy in the epidural space opening it to air, and you probably injected air for LOR, then you created a passage into the intrathecal space with the spinal needle or maybe the tip of your Tuhoy was already intrathecal, now you got a big intrathecal bubble that travels all the way to the brain causing seizures and other badness.I have seen this scenario with CSE before.
     
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  3. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    The Duramorph is good for 24 hr pain relief. The fentanyl is highly lipid soluble so the intrathecal effect isn't long lasting. I'd argue, the anesthesia they get from the mixture is 99% bupivacaine at that point and the benefit of the fentanyl is nil. To try it out, do your next c-section with bupivacaine alone and see if there is any difference (spoiler alert: there isn't).

    now, if you're putting in a catheter and running a post operative EPCA a day or two that's another story.
     
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  4. acidbase1

    acidbase1 5+ Year Member

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    I'd prefer not to "wing it"
     
  5. acidbase1

    acidbase1 5+ Year Member

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    I see what you're saying. I am/was extremely confident on the procedure, though I guess it's still possible. However, the CTH was negative if it were a sizable amount (not sure how much air it takes) it would have shown up
     
  6. nimbus

    nimbus Member 10+ Year Member

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  7. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    You can give the duramorph via spinal and not have to place the epidural at all.
     
  8. facted

    facted ASA Member 7+ Year Member

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    Would explain failed spinal, but how does it explain the HTN?
     
  9. urge

    urge 10+ Year Member

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    Wouldn't the air show up on the CT scan?

    Back in the good old days before Ct scans the radiologists used to purposefully inject air via spinals to do plain head x rays. They all had a massive headache but I don't think they seized.

    Pneumoencephalography - Wikipedia
     
    Last edited: Sep 6, 2017
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  10. acidbase1

    acidbase1 5+ Year Member

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    ^^^^ yes

    One of the things the neurosurgeon and I discussed
     
  11. urge

    urge 10+ Year Member

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    The 1 patient I heard got a whole vial of neo didn't make it.
     
  12. urge

    urge 10+ Year Member

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    I have several issues with the above:

    1 Why are you dosing the epidural already when you have just given a medium dose of spinal local which should be good for a good while?

    2 How can you say she convulsed from lack of blood flow if you didn't measure the blood flow at any point?

    3 Do people tend to seize from asystole?

    I'm rather simplistic. I would say your patient had a big conversion reaction after the CSE. You were correct in doing a neuro workup because nobody will believe you if you ever said that.
     
    Last edited: Sep 6, 2017
  13. urge

    urge 10+ Year Member

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    Psychogenic Nonepileptic Seizures: Background, Pathophysiology, Etiology

     
  14. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    I missed the part where he mentioned CT scan, Yes it would show on CT.
    As for seizures in the presence of pneumocephalus, there are many case reports of seizures after dural puncture with radiological evidence of air in the ventricles. I actually have seen it twice.
    As for radiologists injecting gas to enhance the brain in the old days, you are right they did, and severe headache was a well-documented result, but maybe seizures were not observed because they only injected 30-40 ml?
     
  15. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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  16. urge

    urge 10+ Year Member

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    I would assume.

    http://acta.tums.ac.ir/index.php/acta/article/view/1769

     
  17. urge

    urge 10+ Year Member

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    Was she a nervous Nelly kind of patient?
     
  18. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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  19. urge

    urge 10+ Year Member

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    You know how they deal with psychogenic issues over there, right?
     
  20. urge

    urge 10+ Year Member

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  21. Psai

    Psai Account on Hold 2+ Year Member

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  22. acidbase1

    acidbase1 5+ Year Member

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    No she was actually normal and cooperative. I'm telling you guys, there was no penetration of the dura. Easy as pie. No pneumocephalus
     
  23. Orin

    Orin 7+ Year Member

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    I thought you did a CSE ;)

    Regardless, **** happens. If you rule the usual stuff, then it's a question of how weird it is. I'd still want that MRI to see what's going on where you injected.

    What was the uterine tone like? Any pathology on the fetal or cord side?
     
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  24. acidbase1

    acidbase1 5+ Year Member

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    Uterine tone was good, not sure about the cord
     
  25. narcusprince

    narcusprince Rough Rider 10+ Year Member

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    The gamma quadrant
    I did. Had an ob nurse give 5mg of neo. For a hypotensive patient. Iv nitroglycerin helped the situation. We got mom and baby back safetly. Nurses could no longer giver pressors on l and d anymore.
     
  26. narcusprince

    narcusprince Rough Rider 10+ Year Member

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    The gamma quadrant
    What about a possible epi/bupivicaine swap. What if you gave the full miligram of epi intrathecally could cause hypertension as well as massive cerebral vasoconstriction resulting in increased icp causing reflex bradycardia eventually to asystole.
     
  27. ranvier

    ranvier I can't anesthetize a rumor. 10+ Year Member

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    Good read. I don't miss OB.
     
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  28. pgg

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

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    The greatest benefit (IMO) to adding fentanyl to a spinal for c-section is that it allows you to cheat a bit and get away with less local. This is useful in that it shortens PACU time.

    I found it to be necessary when the OBs are fast and have 5 booked before noon, and a thinly staffed PACU can become a bottleneck if everyone has dense spinals that last longer than the surgery.

    If you're putting in 1.6 - 2.0 mL of 0.75% bupivacaine in every spinal then the fentanyl probably isn't super useful.
     
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  29. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    yeah. that's true. we don't have a crazy OB OR service like that, which is good for my sanity but bad for my checking acct, but I"m ok with that. but again, good tidbit to know for those new guys working super busy services
     
  30. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    and it's those mistakes the ruin our on call lives because now we're getting called every hour for low bPs
     
  31. leaverus

    leaverus New Member 10+ Year Member

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    Nowhere in particular
    too many people looking for zebras. sure the rare stuff are possible but most likely gave undiluted phenylephrine instead of glyco; the vials are same size and labels aren't that different. maybe pharmacy accidentally put a glyco vial in the neo slot.

    also probably not gonna convince acidbase otherwise but cse for routine C-section too much work. our pp OBs are dog slow too and single-shot spinal sufficient 99% of the time. but not criticizing, you do what you think is the right thing for your pts.
     
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  32. anbuitachi

    anbuitachi ASA Member 7+ Year Member

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    But i'm guessing at his institution he had pre made phenylephrine syringes
     
  33. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    I would guess one of the drugs wasn't what you thought it was. That's the most likely explanation.
    I'm ultra vigilant about drugs when I draw them up as peds usually has narrower safety margins, long liability, easy to make a 10x error, and I often hear about drug swaps here and at work with what I consider alarming frequency.
    I also often don't use drugs others have drawn up when I'm getting them out for a break.
    Recently there was a patient of a colleague that had a patient go suspiciously still after a reversal dose of neostigmine. It resolved after ~30 min. :(
    Something bumped the pressure up, way way up. It wasn't 15 Mcg of epi, or anxiety, or lido.


    --
    Il Destriero
     
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  34. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    My routine spinal is 1.4-1.6cc, 50mcg epi, 20 fent, .15 morphine.
    We have some complicated patients who had fetal surgery, etc. it's good for 2 hours. But, at 90 min I start tapping my watch.
    Less talkey talkey more sewey sewey.
    I haven't done a CSE in a decade, or more. [emoji33]


    --
    Il Destriero
     
  35. Hoya11

    Hoya11 Senior Member 10+ Year Member

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    The first thing I thought was an epi/bupi drug error also. That or a conversion reaction as mentioned. Another possibility is a small foreign body, a small piece of glass, rubber if you drew out of a bottle, piece of gauze for whatever reason, into CSF and into brain to cause seizure. If it were an epi/bupi drug error though you would think you would find the bottle of epi empty somewhere, that should have no reason to be empty.
     
  36. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    I don't see how some tiny foreign body would cause a seizure or hypertension. They put grids in people's brains, suture, glue, stimulators, gel foam, etc.


    --
    Il Destriero
     
  37. IlDestriero

    IlDestriero Ether Man 7+ Year Member

    I would also consider some bizarre cause for autonomic dysreflexia. Maybe some smart neurologist could create a zebra differential.
    MS, coke?, ???.


    --
    Il Destriero
     
  38. urge

    urge 10+ Year Member

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    Glyco and neo don't look the same where I'm at. Not sure about OP's institution.

    Why do you say he gave glyco before the event? I didn't see that anywhere.
     
  39. Crabbygas

    Crabbygas

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    I tend to favor a big neo dose as the answer. I know the OP says it didn't happen but guess what? If the patient had an IV and your hospital has neo then could have happened. I don't care what else was going on. That is way more likely than some stupid zebra unicorn hybrid.
     
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  40. leaverus

    leaverus New Member 10+ Year Member

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    Nowhere in particular
    Post #18: "I didn't give anything IV except glycopyrolate (regarding phenylephrine)"
     
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  41. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    This is it. You beat me to it.
    I read a case somewhere a few years ago where an anesthesiologist let the crna place the spinal and the epi was swapped for the marcaine. We worked through possible outcomes as the cSe had just happened and he was wondering if a spinal catheter with NS running for a day would be beneficial. Not sure if this was on this site or another site.
     
  42. Arch Guillotti

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

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    Doubtful. 1.6 ml was given whereas there is only a ml in the epi vial.
     
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  43. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    So then why didn't it work?
     
  44. Arch Guillotti

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

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    Didn't give it time to work probably.
     
  45. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Doubt that
     
  46. IlDestriero

    IlDestriero Ether Man 7+ Year Member

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  47. acidbase1

    acidbase1 5+ Year Member

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    I'm telling you, she never got hypotensive so there was no reason to give neo. And why the convulsions? Glyco and neo vials look nothing alike.

    Also, it wasn't a seizure bc the patient wasn't postictal
     
  48. urge

    urge 10+ Year Member

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    That's all these guys know, drug errors.

     
  49. acidbase1

    acidbase1 5+ Year Member

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  50. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    Have seen real BP 350/150 for ~60 seconds from likely drug swap. Pt lived. Likely developed a self-limited myocardial stunning. Would imagine 10mg of phenylephrine would do the same.
     
  51. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    Great thought. If I really wanted to do one more test to diagnose this weirdness, it'd be T/L spine MRI.
     

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