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Bizarre Reaction to Spinal (OB)

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

  1. Planktonmd

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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

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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

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

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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

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  7. Noyac

    Noyac ASA 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

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

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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
     
    #58 urge, Sep 6, 2017
    Last edited: Sep 6, 2017
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  10. acidbase1

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    ^^^^ yes

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

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

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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.
     
    #61 urge, Sep 6, 2017
    Last edited: Sep 6, 2017
  13. urge

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    Psychogenic Nonepileptic Seizures: Background, Pathophysiology, Etiology

     
  14. Planktonmd

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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

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  17. urge

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    I would assume.

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

     
  18. urge

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

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  20. urge

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

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  22. Psai

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  23. acidbase1

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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
     
  24. Orin

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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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  25. acidbase1

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

    narcusprince Rough Rider

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    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.
     
  27. narcusprince

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    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.
     
  28. ranvier

    ranvier I can't anesthetize a rumor.

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

    pgg Laugh at me, will they?
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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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  30. Twiggidy

    Twiggidy ASA 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
     
  31. Twiggidy

    Twiggidy ASA 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
     
  32. leaverus

    leaverus New Member

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    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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  33. anbuitachi

    anbuitachi ASA Member

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

    IlDestriero Ether Man
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    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.


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  35. IlDestriero

    IlDestriero Ether Man
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    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.


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  36. Hoya11

    Hoya11 Senior 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.
     
  37. IlDestriero

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    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.


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  38. IlDestriero

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


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  39. urge

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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.
     
  40. 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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  41. leaverus

    leaverus New Member

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

    Noyac ASA 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.
     
  43. Arch Guillotti

    Arch Guillotti Senior 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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  44. Noyac

    Noyac ASA Member
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    So then why didn't it work?
     
  45. Arch Guillotti

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

    Noyac ASA Member
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    Doubt that
     
  47. IlDestriero

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  48. acidbase1

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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
     
  49. urge

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    That's all these guys know, drug errors.

     
  50. acidbase1

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  51. fakin' the funk

    fakin' the funk ASA 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.
     
  52. fakin' the funk

    fakin' the funk ASA 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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