C-Section

[militarymd]

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You does an epidural for C-section....not numb enough says the lady....so now what?

 

[jwk]

Depends on how much you've given her, how long you've waited, and how soon you NEED to the the C/S. The best answer is probably give more local through the epidural catheter and wait a little longer. It is not unusual for us to give up to 30cc of Lido 2% w/epi.

If you have an epidural in for labor, and have been getting good pain control (all ours are on pumps) there's no reason you shouldn't get good levels for a C/S. If you haven't been getting good pain control, the epidural should have already been replaced. The longer the epidural has been in, the more wary we become. We'll pop in 10cc and wait a couple of minutes. If they get no change in level, they may get their epidural replaced. Better to replace it then than think about it after giving 20+cc of local. If they get too much of a one-sided block, we'll pull the catheter back 1cm and then finish dosing.

SAB after inadequate epidural anesthesia is NEVER indicated and will do nothing but burn you big time.

Our failed epidural-convert to GA for C/S is extremely low, on the order of 1/4%. We rarely do a general except for true crash C/S. With plain lidocaine or lido w/epi and bicarb, we often have a workable block in less than five minutes. That's long enough to dose as we're rolling down the hall to the OR, getting mom on the OR table, and prepping/draping.

 

[jetproppilot]

Depends on how much you've given her, how long you've waited, and how soon you NEED to the the C/S. The best answer is probably give more local through the epidural catheter and wait a little longer. It is not unusual for us to give up to 30cc of Lido 2% w/epi.

If you have an epidural in for labor, and have been getting good pain control (all ours are on pumps) there's no reason you shouldn't get good levels for a C/S. If you haven't been getting good pain control, the epidural should have already been replaced. The longer the epidural has been in, the more wary we become. We'll pop in 10cc and wait a couple of minutes. If they get no change in level, they may get their epidural replaced. Better to replace it then than think about it after giving 20+cc of local. If they get too much of a one-sided block, we'll pull the catheter back 1cm and then finish dosing.

SAB after inadequate epidural anesthesia is NEVER indicated and will do nothing but burn you big time.

Our failed epidural-convert to GA for C/S is extremely low, on the order of 1/4%. We rarely do a general except for true crash C/S. With plain lidocaine or lido w/epi and bicarb, we often have a workable block in less than five minutes. That's long enough to dose as we're rolling down the hall to the OR, getting mom on the OR table, and prepping/draping.

Nice post, JWK.

Good to see you.

Our epidural failure rate is also very low.

I differ a little in handling eoidural failures.

Our failure rate is very, very low. But it does occasionally happen like you said.

If a lady is persistently uncomfortable I dont mess around with trying to manipulate the catheter (i.e. pulling it back). I just throw in another one.

In the rare occasion surgical analgesia is inadequate for the C section and we're already prepped an draped, she buys an endotracheal tube.

One could argue that after a failed catheter, local anesthetic volume has been maximized, so throwing in more local may potentially exceed maximum allowable local anesthetic doses.

But thats not why I'll put parturient to sleep after a failed catheter. Especially if we're already prepped and draped.

Its because I feel comfortable with a GA for a C section and IMHO said-published risk is way overblown.

 

[militarymd]

What's up with my L&D ward????

I had 2 epidurals (perfect ones at the beginning) fail after 5 hours....?????

Maybe it is something to do with how our nurses move our patients around???

 

[jetproppilot]

What's up with my L&D ward????

I had 2 epidurals (perfect ones at the beginning) fail after 5 hours....?????

Maybe it is something to do with how our nurses move our patients around???

Maybe, bro, but I wouldnt think too much of it unless you see a longer trend.

Probably just sequestered bad luck.

My previous gig.....didnt move pt alot

Current gig.....nurses turn pt to left side, then right side every so often since most of the OBs here request that. Pure witchcraft. The turning b u l l s hit hasnt increased my failure rate over my previous gig.

So again, probably bad luck.

You probably wont see another one for a year.

 

[jwk]

But thats not why I'll put parturient to sleep after a failed catheter. Especially if we're already prepped and draped.

Its because I feel comfortable with a GA for a C section and IMHO said-published risk is way overblown.

I would agree - as you know, I don't make those decisions. 😉

At my previous gig, we probably did at least 50% GA for sections, maybe more. Only one pucker-producing airway incident in 12 years there, no aspirations, and more than a few times were solo prior to the anesthesiologist getting there because the baby and/or mom were in trouble. If we came in on call and there was no epidural in place, chances are they bought a tube.

Gee, I still like this open forum... 😉

 

[jwk]

Maybe, bro, but I wouldnt think too much of it unless you see a longer trend.

Probably just sequestered bad luck.

My previous gig.....didnt move pt alot

Current gig.....nurses turn pt to left side, then right side every so often since most of the OBs here request that. Pure witchcraft. The turning b u l l s hit hasnt increased my failure rate over my previous gig.

So again, probably bad luck.

You probably wont see another one for a year.

I agree - bad luck - unless of course it keeps happening in which case we can blame it on Jet just for the hell of it.

>24 hours the failure rate spikes pretty good - probably 1/2 of our patients that keep their epidural catheter after delivery end up going to sleep the next day for their tubal ligation - 20cc and no joy = ETT

 

[jetproppilot]

I would agree - as you know, I don't make those decisions. 😉

At my previous gig, we probably did at least 50% GA for sections, maybe more. Only one pucker-producing airway incident in 12 years there, no aspirations, and more than a few times were solo prior to the anesthesiologist getting there because the baby and/or mom were in trouble. If we came in on call and there was no epidural in place, chances are they bought a tube.

Gee, I still like this open forum... 😉

One of our CRNAs, JWK, during her displacement from New Orleans from the storm, worked with a group that still did GAs for EVERY C section. 😱

Yeah, a little excessive in my opinion.

But yet another testimony against all the alleged taboos we are taught as anesthesia residents.

Since I'm on a roll, and the cuppla Cakebread Cabernet glasses I've consumed are adding to my need to disseminate the truth, ( ),

heres some Jet prophecies:

1)You CAN put a parturient to sleep. Safely.

2)You don't have to ventilate before you give a relaxant if you are using an appropriate amount of sux....(when's the last time you saw an attending cancel a case after administration of an induction agent with subsequent inability to ventilate.....what do they do....they give the relaxant...)

3)You don't have to torture parturients with bicitra.

4) All the pepcid/reglan we give preoperatively to "GERD" patients is a waste of money and nursing time.

5) Ordering a pre-op "breathing treatment" on an asymptomatic asthmatic/COPDer is a waste of time/$

6) Most of the preoperative work-ups we order are needless, unless they are directed specifically at a premedical problem.....

you dont need a CXR unless the pt is exhibiting dyspnea

I have never ordered PFTs in ten years of experience

you don't need a post dialysis K+ before you go to the back.

an ASA 1 for a knee-scope/tonsillectomy/ACL/BTL/D&C/gallbladder/carpal tunnel/ ...etc etc....needs NO LABS.

any elective MAC needs no labs.

7)Holding up an urgent-but-not-emergent case because the dude ate breakfast 3 hours ago is a joke.

8) Bleeding times are totally useless in our arena

9) You CAN push protamine fast in appropriate situations.

10) After separation from cardiac bypass, if the heart looks like a million bucks , no need to say "give a hundred...." ...."give a hundred".... ....."give a hundred" .....

have the pump tech roll in the volume, and give NTG as needed.....

11) a cardiologist who has been consulted preoperatively to evaluate a sick dude who needs a lap-chole who tells you a SWAN is needed for the case....

has no idea what he is talking about.....

12) SWANS are rarely useful during the intraoperative phase of a CABG..(I like them for pre-op pulmonary hypertensive patients.....nothing else)

13)You can pre-op 99.99999% of patients on the day of surgery without affecting cancellation rate

14) You CAN safely give a cuppla cee-cees of sux on the floor intubation

15) You don't need an a-line for fem-pops

16) The Selleck maneuver is a waste of time. Give your medicines, wait 30 seconds, and intubate.

17) Putting in an already-inflated-LMA is easier, using The Jiggle technique.

18) Rapid sequence inductions are not needed for GERD/DM/renal patients

19) Rapid sequence inductions are only needed when pt has acute abdominal situation (bowel obstn) or ate a Whopper less-than-three-hours-ago

20) There is no right blade. Individuals become deft with different blades. Its all about your own prowess when it comes to getting the tube in.


.................



whew..........


thats enough for now.

 

[rn29306]

I'm no Nastradamos, but I think that faint roar quickly building steam and shaking your New Orleans crib are the masses of anesthesia up-and-comers shouting....

MORE, MORE

Drink some more of that high-priced shizzle, come back and bring the heat.

 

[jetproppilot]

I'm no Nastradamos, but I think that faint roar quickly building steam and shaking your New Orleans crib are the masses of anesthesia up-and-comers shouting....

MORE, MORE

Drink some more of that high-priced shizzle, come back and bring the heat.

OK, RN237884755400482825772342402383-94-21349-1249-......( )

heres some HEAT.

1) Wanna be a franchise player in this biz? Put all-your-surgeons-cell phone numbers on your cell phone........follow this, because this is how you become a millionairre.....remembering that all surgeons care about (patient safety assured) is arriving and doing their case without delay........

and the following is real-life s h it....

.......jet dials surgeons number.....time, 0712...

"Hey Ed, its Bill, the anesthesia dude at Touro. Good Morning."

"Good morning, Bill. Whats up?"

"Where are you?"

"I'm pullin' into the parking lot."

"Great. We're going to sleep in room eight. We're ready for ya when you get here."

"GREAT. I'll see you in ten minutes."

and the banter between successful anesthesiologist and surgeon continues....

 

[Noyac]

OK, RN237884755400482825772342402383-94-21349-1249-......( )

heres some HEAT.

1) Wanna be a franchise player in this biz? Put all-your-surgeons-cell phone numbers on your cell phone........follow this, because this is how you become a millionairre.....remembering that all surgeons care about (patient safety assured) is arriving and doing their case without delay........

and the following is real-life s h it....

.......jet dials surgeons number.....time, 0712...

"Hey Ed, its Bill, the anesthesia dude at Touro. Good Morning."

"Good morning, Bill. Whats up?"

"Where are you?"

"I'm pullin' into the parking lot."

"Great. We're going to sleep in room eight. We're ready for ya when you get here."

"GREAT. I'll see you in ten minutes."

and the banter between successful anesthesiologist and surgeon continues....

I thought I was the only one that had all of my surgeons #'s on my phone. 👍

PS: I didn't vote b/c it depends on how much time I have. And i usually pull the epidural in teh OR for a c/s and put a spinal in unless I placed the epidural myself. Just a habit i have formed. Not saying that it is the right way to do it.

I see that the forum has bee busy for the last week. Lots of good stuff here. Nice to see. 👍

Jet, I was born at Touro. Were you my Mom's anesthesiologist?

 

[jetproppilot]

I agree - bad luck - unless of course it keeps happening in which case we can blame it on Jet just for the hell of it.

HAHAHHAHAHAHAHAHAHAHAHAHAHHAHA

with all due respect, JWK,

BLOW ME.

 

[jetproppilot]

I thought I was the only one that had all of my surgeons #'s on my phone. 👍

PS: I didn't vote b/c it depends on how much time I have. And i usually pull the epidural in teh OR for a c/s and put a spinal in unless I placed the epidural myself. Just a habit i have formed. Not saying that it is the right way to do it.

I see that the forum has bee busy for the last week. Lots of good stuff here. Nice to see. 👍

Jet, I was born at Touro. Were you my Mom's anesthesiologist?

Funny trivia here, Mike.

My wife was born at Touro too.

And she's your age.

And she's from this area, unlike me.

Have you dated my wife???? 😡



Its OK, friend.

The past is the past.

And, uhhhhhh, by the way,

I'm not worried.

Your wife is a hottie.....(sorry bro, just speaking the truth...those mountain-biking pics drove me to take a cold shower......)

I love my wife, Mike.

But....uhhhhh.....with all due respect.....

your wife is still a hottie.

 

[Noyac]

Funny trivia here, Mike.

My wife was born at Touro too.

And she's your age.

And she's from this area, unlike me.

Have you dated my wife???? 😡



Its OK, friend.

The past is the past.

And, uhhhhhh, by the way,

I'm not worried.

Your wife is a hottie.....(sorry bro, just speaking the truth...those mountain-biking pics drove me to take a cold shower......)

I love my wife, Mike.

But....uhhhhh.....with all due respect.....

your wife is still a hottie.

Thanks for checkin out my wife, I have to agree with you.

And don't tell me your wife's name just encase I do know her. 😀

I'm sure she's a hottie as well and so, yeah I may know her. 😍

On a side note. I just got back from surfing in Mexico and my wife got a case of Montezuma's Revenge. She was not such a hottie at that point. But i still love her.

 

[jetproppilot]

I just got back from surfing in Mexico and my wife got a case of Montezuma's Revenge. She was not such a hottie at that point. But i still love her.

I concur.

So your XY companion gets sick from the Mexican Curse.

Essentially a hot chick hurling, and calling you to-the-table concerning the significance of your third-world-thrill-trips-and-the-potential-sequelae-of-being-involved-in-same.

And after all-the-above,

she still loves you.

Man,

whatta wife, Mikey.

 

[jetproppilot]

I concur.

So your XY companion gets sick from the Mexican Curse.

Essentially a hot chick hurling, and calling you to-the-table concerning the significance of your third-world-thrill-trips-and-the-potential-sequelae-of-being-involved-in-same.

And after all-the-above,

she still loves you.

Man,

whatta wife, Mikey.

XX.

 

[VentdependenT]

One of our CRNAs, JWK, during her displacement from New Orleans from the storm, worked with a group that still did GAs for EVERY C section. 😱

Yeah, a little excessive in my opinion.

But yet another testimony against all the alleged taboos we are taught as anesthesia residents.

Since I'm on a roll, and the cuppla Cakebread Cabernet glasses I've consumed are adding to my need to disseminate the truth, ( ),

heres some Jet prophecies:

1)You CAN put a parturient to sleep. Safely.

2)You don't have to ventilate before you give a relaxant if you are using an appropriate amount of sux....(when's the last time you saw an attending cancel a case after administration of an induction agent with subsequent inability to ventilate.....what do they do....they give the relaxant...)

3)You don't have to torture parturients with bicitra.

4) All the pepcid/reglan we give preoperatively to "GERD" patients is a waste of money and nursing time.

5) Ordering a pre-op "breathing treatment" on an asymptomatic asthmatic/COPDer is a waste of time/$

6) Most of the preoperative work-ups we order are needless, unless they are directed specifically at a premedical problem.....

you dont need a CXR unless the pt is exhibiting dyspnea

I have never ordered PFTs in ten years of experience

you don't need a post dialysis K+ before you go to the back.

an ASA 1 for a knee-scope/tonsillectomy/ACL/BTL/D&C/gallbladder/carpal tunnel/ ...etc etc....needs NO LABS.

any elective MAC needs no labs.

7)Holding up an urgent-but-not-emergent case because the dude ate breakfast 3 hours ago is a joke.

8) Bleeding times are totally useless in our arena

9) You CAN push protamine fast in appropriate situations.

10) After separation from cardiac bypass, if the heart looks like a million bucks , no need to say "give a hundred...." ...."give a hundred".... ....."give a hundred" .....

have the pump tech roll in the volume, and give NTG as needed.....

11) a cardiologist who has been consulted preoperatively to evaluate a sick dude who needs a lap-chole who tells you a SWAN is needed for the case....

has no idea what he is talking about.....

12) SWANS are rarely useful during the intraoperative phase of a CABG..(I like them for pre-op pulmonary hypertensive patients.....nothing else)

13)You can pre-op 99.99999% of patients on the day of surgery without affecting cancellation rate

14) You CAN safely give a cuppla cee-cees of sux on the floor intubation

15) You don't need an a-line for fem-pops

16) The Selleck maneuver is a waste of time. Give your medicines, wait 30 seconds, and intubate.

17) Putting in an already-inflated-LMA is easier, using The Jiggle technique.

18) Rapid sequence inductions are not needed for GERD/DM/renal patients

19) Rapid sequence inductions are only needed when pt has acute abdominal situation (bowel obstn) or ate a Whopper less-than-three-hours-ago

20) There is no right blade. Individuals become deft with different blades. Its all about your own prowess when it comes to getting the tube in.


.................



whew..........


thats enough for now.

I should print this thing up and hang it in the monitoring room. I have a lot to learn man.

 

[militarymd]

300 + views and only 15 total votes????

Come on....vote!!!

 

[Bobblehead]

300 + views and only 15 total votes????

Come on....vote!!!

Some of us don't do any of those? 😉

 

[stephend7799]

It is not unusual for us to give up to 30cc of Lido 2% w/epi.

.

I think 30cc is too much to bolus. to get a level.. If you have to give 30 cc to get an adequate level and the catheter is in good position.. you will get a high level and you will have some explaining to do to the patient after you intubate her and put her to sleep..

 

[stephend7799]

One of our CRNAs, JWK, during her displacement from New Orleans from the storm, worked with a group that still did GAs for EVERY C section. 😱

Yeah, a little excessive in my opinion.

But yet another testimony against all the alleged taboos we are taught as anesthesia residents.

Since I'm on a roll, and the cuppla Cakebread Cabernet glasses I've consumed are adding to my need to disseminate the truth, ( ),

heres some Jet prophecies:

1)You CAN put a parturient to sleep. Safely.

2)You don't have to ventilate before you give a relaxant if you are using an appropriate amount of sux....(when's the last time you saw an attending cancel a case after administration of an induction agent with subsequent inability to ventilate.....what do they do....they give the relaxant...)

3)You don't have to torture parturients with bicitra.

4) All the pepcid/reglan we give preoperatively to "GERD" patients is a waste of money and nursing time.

5) Ordering a pre-op "breathing treatment" on an asymptomatic asthmatic/COPDer is a waste of time/$

6) Most of the preoperative work-ups we order are needless, unless they are directed specifically at a premedical problem.....

you dont need a CXR unless the pt is exhibiting dyspnea

I have never ordered PFTs in ten years of experience

you don't need a post dialysis K+ before you go to the back.

an ASA 1 for a knee-scope/tonsillectomy/ACL/BTL/D&C/gallbladder/carpal tunnel/ ...etc etc....needs NO LABS.

any elective MAC needs no labs.

7)Holding up an urgent-but-not-emergent case because the dude ate breakfast 3 hours ago is a joke.

8) Bleeding times are totally useless in our arena

9) You CAN push protamine fast in appropriate situations.

10) After separation from cardiac bypass, if the heart looks like a million bucks , no need to say "give a hundred...." ...."give a hundred".... ....."give a hundred" .....

have the pump tech roll in the volume, and give NTG as needed.....

11) a cardiologist who has been consulted preoperatively to evaluate a sick dude who needs a lap-chole who tells you a SWAN is needed for the case....

has no idea what he is talking about.....

12) SWANS are rarely useful during the intraoperative phase of a CABG..(I like them for pre-op pulmonary hypertensive patients.....nothing else)

13)You can pre-op 99.99999% of patients on the day of surgery without affecting cancellation rate

14) You CAN safely give a cuppla cee-cees of sux on the floor intubation

15) You don't need an a-line for fem-pops

16) The Selleck maneuver is a waste of time. Give your medicines, wait 30 seconds, and intubate.

17) Putting in an already-inflated-LMA is easier, using The Jiggle technique.

18) Rapid sequence inductions are not needed for GERD/DM/renal patients

19) Rapid sequence inductions are only needed when pt has acute abdominal situation (bowel obstn) or ate a Whopper less-than-three-hours-ago

20) There is no right blade. Individuals become deft with different blades. Its all about your own prowess when it comes to getting the tube in.


.................



whew..........


thats enough for now.

Jet:

the more parturients you put the sleep, the more chance you have for a failed airway.. regional is the way to go.. There is a reason we put in spinals.. If everyone in the country started putting all pregnant patients to sleep there would be some failed airways.. (see physiologic changes in pregnance please.. and read in scneider and levinsons where anesthesia related complications due to airway mishaps fall in maternal mortality now and 50 years ago when everyone was going to sleep )..

You should attempt to ventilate prior to administering non depolarizer because your ability to ventilate will affect your choice of relaxants. if you plan on giving sux no need to ventilate, i agree ..

Risk is never overblown..

 

[jetproppilot]

Jet:

the more parturients you put the sleep, the more chance you have for a failed airway.. regional is the way to go.. There is a reason we put in spinals.. If everyone in the country started putting all pregnant patients to sleep there would be some failed airways.. (see physiologic changes in pregnance please.. and read in scneider and levinsons where anesthesia related complications due to airway mishaps fall in maternal mortality now and 50 years ago when everyone was going to sleep )..

You should attempt to ventilate prior to administering non depolarizer because your ability to ventilate will affect your choice of relaxants. if you plan on giving sux no need to ventilate, i agree ..

Risk is never overblown..

Nice post.

And I dont wanna minimize risk.

But I humbly disagree with you.

Risk in certain clinical scenerios is overblown in anesthesia training.

MOST of the time, one can safely put a parturient to sleep if neuraxial anesthesia fails.

And I think not relaying this in anesthesia training is a mistake, since the results, at least for the first cuppla years outta residency, are clinicians scared a h itless when they are forced into that situation.

Fifty years ago there was no pulse oximetry. No ETCO2. Airway management tools were sparce compared to current day.

Anesthesia residents were not as well trained as today.

Yes, I agree that neuraxial anesthesia is choice one for parturients.

But if you've gotta go to sleep, no need to pee your pants, especially when you reach the level of really being a deft laryngoscopist.

 

[militarymd]

Jet:

the more parturients you put the sleep, the more chance you have for a failed airway.. regional is the way to go.. There is a reason we put in spinals.. If everyone in the country started putting all pregnant patients to sleep there would be some failed airways.. (see physiologic changes in pregnance please.. and read in scneider and levinsons where anesthesia related complications due to airway mishaps fall in maternal mortality now and 50 years ago when everyone was going to sleep )..

You should attempt to ventilate prior to administering non depolarizer because your ability to ventilate will affect your choice of relaxants. if you plan on giving sux no need to ventilate, i agree ..

Risk is never overblown..

It's ok to have an opinion, but in this case, you're wrong.

Just survey how anesthesia is done in other civilized countries. For example, Germany, where some would argue that medicine is more advanced than ours.

They put over 70% of their elective C-sections to sleep without any more complications than we have.

The old texts are just that....OLD.

But their logic, we should not be putting these old , FAT, COPDer's to sleep, because we're going to lose their a//ws.

 

[jwk]

I think 30cc is too much to bolus. to get a level.. If you have to give 30 cc to get an adequate level and the catheter is in good position.. you will get a high level and you will have some explaining to do to the patient after you intubate her and put her to sleep..

I don't start out with 30cc. I start with 10cc on most patients. If their level is increasing, I'll continue dosing as needed to get a level getting close to T3. Most patients get about 20cc +/- .

The epidural space is highly variable between patients. I've seen 5' women need 25cc and 6' women need 10-15cc to get a T3-4 level. No cookbook anesthesia here - each patient's dosage is individualized based on how their epidural level is progressing.

 

[jwk]

Jet:

the more parturients you put the sleep, the more chance you have for a failed airway.. regional is the way to go.. There is a reason we put in spinals.. If everyone in the country started putting all pregnant patients to sleep there would be some failed airways.. (see physiologic changes in pregnance please.. and read in scneider and levinsons where anesthesia related complications due to airway mishaps fall in maternal mortality now and 50 years ago when everyone was going to sleep )..

You should attempt to ventilate prior to administering non depolarizer because your ability to ventilate will affect your choice of relaxants. if you plan on giving sux no need to ventilate, i agree ..

Risk is never overblown..

1) The more PATIENTS (parturient or not) you put to sleep, the more chance you have for a failed airway.

We probably do about 5 spinals a year for 6000+ C/S. Better than 98% are done with epidural here, less than 2% GA, with a small fraction of those for failed blocks as stated previously.

 

[The_Sensei]

Jet:

the more parturients you put the sleep, the more chance you have for a failed airway.. regional is the way to go.. There is a reason we put in spinals.. If everyone in the country started putting all pregnant patients to sleep there would be some failed airways.. (see physiologic changes in pregnance please.. and read in scneider and levinsons where anesthesia related complications due to airway mishaps fall in maternal mortality now and 50 years ago when everyone was going to sleep )..

You should attempt to ventilate prior to administering non depolarizer because your ability to ventilate will affect your choice of relaxants. if you plan on giving sux no need to ventilate, i agree ..

Risk is never overblown..

Stop being a *****, Frank!

 

[militarymd]

The reason I put this poll up is because of the issue with high spinals after dosing an epidural.

It is well known that there is a tendency for spinals to go "high" and cause the need to do GA if you do a spinal after dosing an epidural.

Based on this known risk, most of the experienced clinicians I know avoid spinals after a failed epidural unless there is some overwhelming indication for regional.....and I can't think of one of those indications right now...

I'm surprised at the number of people who are willing to risk a high spinal...based on the results of the poll.

 

[cloud9]

It's ok to have an opinion, but in this case, you're wrong.

Don't hold back now, just tell it like it is.

 

[MDEntropy]

No lit supported right intrathecal LA dose to avoid a high spinal after a failed epidural.

Go to sleep after a failed epidural - unless the c-section isn't reallly that emergent - in which case wait a couple hours +/- (what did you have in the epidural?), place a spinal.

I think one of the most important reasons (perhaps the most) to use a neuraxial block, if you can, is so mom can experience/remember the birth.

When you first place a labor epidural - how far in do you thread the catheter past the point of LOR (initially)? Would you rather have more to pull back or avoid occasional early dysfunction which is often alleviated by pulling the catheter back (e.g. one sided block)?

 

[jetproppilot]

No lit supported right intrathecal LA dose to avoid a high spinal after a failed epidural.

Go to sleep after a failed epidural - unless the c-section isn't reallly that emergent - in which case wait a couple hours +/- (what did you have in the epidural?), place a spinal.

I think one of the most important reasons (perhaps the most) to use a neuraxial block, if you can, is so mom can experience/remember the birth.

When you first place a labor epidural - how far in do you thread the catheter past the point of LOR (initially)? Would you rather have more to pull back or avoid occasional early dysfunction which is often alleviated by pulling the catheter back (e.g. one sided block)?

I thread mine 5cm every time.

And unless the lady is 350 lbs or some other reason making first one difficult, I've found in my experience thats its just easier for me to pull it out and put in another one.

The majority of the times I used to play with the catheter trying to get it to work I just ended up wasting 30 minutes, when I can place a new one in five.

 

[militarymd]

No lit supported right intrathecal LA dose to avoid a high spinal after a failed epidural.

Go to sleep after a failed epidural - unless the c-section isn't reallly that emergent - in which case wait a couple hours +/- (what did you have in the epidural?), place a spinal.

I think one of the most important reasons (perhaps the most) to use a neuraxial block, if you can, is so mom can experience/remember the birth.

When you first place a labor epidural - how far in do you thread the catheter past the point of LOR (initially)? Would you rather have more to pull back or avoid occasional early dysfunction which is often alleviated by pulling the catheter back (e.g. one sided block)?

I wonder why the German's don't think this is important....or for that matter many rural practices that don't have high ivory tower snobs doing anesthesia.

 

[militarymd]

I thread mine 5cm every time.

And unless the lady is 350 lbs or some other reason making first one difficult, I've found in my experience thats its just easier for me to pull it out and put in another one.

The majority of the times I used to play with the catheter trying to get it to work I just ended up wasting 30 minutes, when I can place a new one in five.

I do 3 cm, and I also just put in a new one rather than dicking around wasting time.

 

[militarymd]

Don't hold back now, just tell it like it is.

I try not to hold back....repression just causes hypertension and generalized tight-a s s ed behaviors.....

 

[MDEntropy]

And unless the lady is 350 lbs or some other reason making first one difficult, I've found in my experience thats its just easier for me to pull it out and put in another one.

The majority of the times I used to play with the catheter trying to get it to work I just ended up wasting 30 minutes, when I can place a new one in five.

Totally agree with this. As such though, I'm surprised you don't thread in less from the start.

 

[MDEntropy]

I wonder why the German's don't think this is important....or for that matter many rural practices that don't have high ivory tower snobs doing anesthesia.

About 10% of c-sections in the U.S. take place under GA but things were very different 25 years ago.

Maybe it's the guys who insist on GA who are the snobs.

 

[militarymd]

About 10% of c-sections in the U.S. take place under GA but things were very different 25 years ago.

Maybe it's the guys who insist on GA who are the snobs.

There aren't any guys that I know of who insists on GA....only guys who think that GA is OK......and it is....based on International data and experience.

On the other hand, I know of many snobs who practice only in the US who think the "academic spinal" is the ONLY way to go.....

I don't know....seems pretty clear to me who the snobs are.

 

[CanGas]

When you first place a labor epidural - how far in do you thread the catheter past the point of LOR (initially)? Would you rather have more to pull back or avoid occasional early dysfunction which is often alleviated by pulling the catheter back (e.g. one sided block)?

Ask and ye shall receive

http://www.anesthesia-analgesia.org/cgi/reprint/82/4/894
The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space.

Complications can occur during epidural placement for women in labor. As many as 23% of epidural anesthetics may not provide satisfactory analgesia. The cause of this may be technical. This study was undertaken to determine the optimal distance that a multiorifice catheter should be threaded into the epidural space to maximize analgesia and minimize complications. One hundred women in labor were enrolled in this prospective, randomized, and double-blind study. Patients were randomly assigned to have the epidural catheter threaded 3, 5, or 7 cm into the epidural space. After placement of the catheter and administration of a test dose with 3 mL of 0.25% bupivacaine, an additional 10 mL of 0.25% bupivacaine was administered in two divided doses. Fifteen minutes later, the adequacy of the analgesia was assessed by a blinded observer. We found that catheter insertion to a depth of 7 cm was associated with the highest rate of insertion complications while insertion to a depth of 5 cm was associated with the highest incidence of satisfactory analgesia. For women in labor who require continuous lumbar epidural anesthesia, we recommend threading a multiorifice epidural catheter 5 cm into the epidural space.

 

[jetproppilot]

As such though, I'm surprised you don't thread in less from the start.

Dont be surprised.

Incidence of one-sided/patchy block with my catheter placements is nearly non-existent.

5cm works good for me.

 

[Noyac]

Dont be surprised.

Incidence of one-sided/patchy block with my catheter placements is nearly non-existent.

5cm works good for me.

Me too.

 

[Noyac]

So Mil, if a pt comes to the OR after having a failed delivery and an epidural running for some amount of time. Would you say it risks a high spinal if I pull the epidural and put a spinal in b/c I find spinals less troublesome than even working epidurals? Or are you saying high spinal risk is only after s larger bolus and no block?

 

[militarymd]

So Mil, if a pt comes to the OR after having a failed delivery and an epidural running for some amount of time. Would you say it risks a high spinal if I pull the epidural and put a spinal in b/c I find spinals less troublesome than even working epidurals? Or are you saying high spinal risk is only after s larger bolus and no block?

The second. It's been pretty well documented that doing a spinal after bolusing an epidural is associated with high spinals.

I'm pretty sure that all the folks who trained under Synder at UCSF would consider it not within standard of care.

I'm pretty surprsied at the poll results.