Case: prolonged neuraxial blockade following cesarean section

[MirrorTodd]

21 year old female approx 5 and half feet, 90kgs undergoes SAB using 12mg Bup, 0.1mg duramorph, 10mcg fent and 100mcg epi for cesarean with triplets. Case is uneventful, however 12 hours later pt remains insensate in bilateral lower extremities with no motor function, no return of bladder function, although pt does complain of pain at the suture site. Overnight, the pt's sensation/motor function slowly returns to close to normal approx 18 hours after surgery with the ability to stand and ambulate approx 24 hours following surgery. Causes of prolonged neuraxial blockade? Would you call for a neuro consult given her improving exam? Or rather schedule for outpt neuro follow up? Personally, I want to just chalk this up to bad luck on her part and all's well that ends well, cause I can't really think of why this lady had prolonged blockade.
Of note: this is the second time this has happened this month and both blocks were performed by the same resident.

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[marr65]

What will neurology do if you have a normal neuro exam? I have a feeling that your resident added more than 100mcg of epi.

 

[deleted162650]

Of note: this is the second time this has happened this month and both blocks were performed by the same resident.

Are you “Asking for a friend”?

 

[MirrorTodd]

Are you “Asking for a friend”?

Lol I almost put in a disclaimer that I'm not "asking for a friend"
Ultimately I dont think there is anything to do. Consulting neuro is overly conservative IMO. She's better already and we don't even have a specific question to ask them.
Supposedly there are reports of prolonged blockade in individuals with low csf volume.

 

[coffeebythelake]

If she is completely neuro intact I wouldn't worry about it. But agree that duration is much much longer than expected.

 

[Southpaw]

Lol I almost put in a disclaimer that I'm not "asking for a friend"
Ultimately I dont think there is anything to do. Consulting neuro is overly conservative IMO. She's better already and we don't even have a specific question to ask them.
Supposedly there are reports of prolonged blockade in individuals with low csf volume.

What are you asking neuro? You should know and understand what is going on in this acute period better than them. If you consult neuro your basic question is 'we can't figure out why this patient isn't doing what others typically do. can you figure it out for us?'. If you're worried about epidural hematoma, cauda equina, or something else, then do the work up.

Sounds to me, since lightning struck twice and the common denominator is a resident, that this is med error til proven otherwise.

 

[Planktonmd]

100 mcg of Epi is too much IMHO, and I am not sure why you need Epi at all added to Bupivacaine for a c section?
How long does a C Section take where you are?

 

[deleted162650]

12mg Bup

Or 12mL Bup?

 

[Volatile]

I agree with the above, twice in one month by the same resident makes me lean towards drug error. BTW 100mcg of epi is not an absurd dose, peeps frequently give 200mcg at large academic centers.
I have seen similar presentations twice in my career, both times I did not obtain urgent MRI/consult because both patients had resolving blocks albeit very slowly. Both ended up having full neuro fxn by the next morning w/ no long term sequelae (I admit I was nervous as hell for them overnight). I suspect we occasionally run across patients who either have very slow turnover of csf, or potentially there is a pocket of csf there with cephalad/caudal constriction (and you inject into the pocket) so those nerves see a high concentration of local for a prolonged period of time and take a hit.

 

[abolt18]

100 mcg of Epi is too much IMHO, and I am not sure why you need Epi at all added to Bupivacaine for a c section?
How long does a C Section take where you are?

100mcg is a lot to me too.

 

[MirrorTodd]

100 mcg of Epi is too much IMHO, and I am not sure why you need Epi at all added to Bupivacaine for a c section?
How long does a C Section take where you are?

Variable just generally no more than 2-3 hours since we're a training institution. I agree about the epi and I am not putting epi in my spinals anymore since I'm a CA3 and have more leeway about mixing up the drugs based on our protocols.

 

[MirrorTodd]

Or 12mL Bup?

While that's "possible" I suppose, it's extraordinarily unlikely, since we have an attending who is in the room guiding the spinal and our kits come with 0.75% bup in 2ml vials.

 

[woopedazz]

Why do you put epi in a SAB anyway? It's not exactly filled with arterioles.

 

[PainDrain]

Why do you put epi in a SAB anyway? It's not exactly filled with arterioles.

Is this really a legit question?

 

[deleted875186]

I don’t think it’s a drug error, maybe the resident added a full 2mL of bupi, but the block is still much longer than expected.

I would not add the epi, but that’s preference.

I agree that I would skip the neuro consult.

 

[dabears505]

Did you notice any hemodynamic abnormalities or high block at all during the procedure?

 

[cchoukal]

I had a plain bupiv spinal get to hour 6, and I imagéd him. It’s all well and good to think and hope that it’ll wear off, but in the unlikely case that a hematoma were the culprit, you’d miss the opportunity to treat it. Given that the patient can provide no exam other than flaccid paralysis, I’m not sure what we’d have to go on, other than hunch, which is not defensible, and epidemiology, to say it wasn’t a hematoma.

 

[woopedazz]

Is this really a legit question?

It is. (For a LSCS). I've honestly never used it in a LSCS SAB. Just seems like an increased risk of side effects with low gain potential. Do people routinely use intrathecal epi here?

 

[triggermaster]

100mcg is a lot to me too.

Dose-ranging effects of intrathecal epinephrine on anesthesia/analgesia: a meta-analysis and metaregression of randomized controlled trials - PubMed

Intrathecal epinephrine has dose-dependent clinical and adverse effects. Doses of 100 µg or less prolonged sensory and motor block duration but were associated with greater incidence of hypotension or PONV. Intrathecal epinephrine doses greater than 100 µg prolonged sensory and motor block and...

pubmed.ncbi.nlm.nih.gov

 

[abolt18]

Dose-ranging effects of intrathecal epinephrine on anesthesia/analgesia: a meta-analysis and metaregression of randomized controlled trials - PubMed

Intrathecal epinephrine has dose-dependent clinical and adverse effects. Doses of 100 µg or less prolonged sensory and motor block duration but were associated with greater incidence of hypotension or PONV. Intrathecal epinephrine doses greater than 100 µg prolonged sensory and motor block and...

pubmed.ncbi.nlm.nih.gov

This literally makes zero sense whatsoever.

 

[dannyboy1]

12 hours of flaccid paralysis and completely insensate? You are lucky it wore off, definitely would have gotten neuro involved at 4-6 hours. Hematoma would be extraordinarily unlikely with a 25g spinal needle. I would think maybe the resident was much higher than he thought and injected the cord....
Either way all’s well that ends well.

 

[deleted162650]

While that's "possible" I suppose, it's extraordinarily unlikely, since we have an attending who is in the room guiding the spinal and our kits come with 0.75% bup in 2ml vials.

I was half joking, but you would be amazed how stupid “smart” people can be. About a month ago at a surgery center I told the PACU RN to give 6.25 of phenergan. The dude drew up 6.25mLs!!!!! Thank God another nurse saw it and caught it before it was given to the patient. You’d think a lightbulb woulda gone off by the time he cracked vial #7. SMH.

 

[deleted697535]

never once seen or given it epi. it sounds like a terrible idea all round. do people do it routinely and it is worth it? just use iso, or cse or epidural or ga. anything! get a new surgeon!!

theres no way any c section should outlast 1.6mls of bupi? these surgeons must noy be fast... any decent ob should have babies out by 40 mins tops

 

[DocVapor]

never once seen or given it epi. it sounds like a terrible idea all round. do people do it routinely and it is worth it? just use iso, or cse or epidural or ga. anything! get a new surgeon!!

theres no way any c section should outlast 1.6mls of bupi? these surgeons must noy be fast... any decent ob should have babies out by 40 mins tops

I know of at least one academic center where uncomplicated C/S are at a minimum 1.5 hours and actually routinely last long enough that Anesthesia is having to do the whole midazalam/ketamine bandaid.

Slow OB-GYN, with a senior resident, a junior resident, maybe an off-service resident, and a med-student... And everyone gets their hands involved.

 

[MirrorTodd]

I know of at least one academic center where uncomplicated C/S are at a minimum 1.5 hours and actually routinely last long enough that Anesthesia is having to do the whole midazalam/ketamine bandaid.

Slow OB-GYN, with a senior resident, a junior resident, maybe an off-service resident, and a med-student... And everyone gets their hands involved.

Exactly, babies come out fast, but closing is the thing that takes the most time.

 

[DrZzZz]

It was slow where I trained, and while we were more willing to do a CSE for the larger ladies or those on their 4th or 5th section, we otherwise were happy to just peek over the drapes and tell the attending/resident that they had about 5-10 minutes left on the spinal when they were dicking around. That usually got them to speed up.

 

[AdmiralChz]

I know of at least one academic center where uncomplicated C/S are at a minimum 1.5 hours and actually routinely last long enough that Anesthesia is having to do the whole midazalam/ketamine bandaid.

This was our norm (more like 2 hours) in residency. Our OBs were heinously bad. It’s not much better at my academic shop now.

I admit to never adding straight epi to my spinals, I will sometimes add an epi “wash” and anecdotally it seems to last 30-60 minutes more and helpful for 4+ redos (at 5 or 6, it’s CSE time but we don’t have adequate equipment for easy CSEs so I don’t do it much). In training we added like 10-15 mcg of Clonidine which helped but also made mom sleepy.

Back to the original case, I guess there’s no chance it could have been tetracaine...? Or even stranger, a CYP3A4 mutation/deficiency? I admit I’m just spit-ballin’ there.

 

[DrOwnage]

This makes 0 sense to me at that long of a duration. Even isobaric spinals which stay at the same level of that dosage last a maximum of 5-6 hours. It wouldn't make sense that even with some CSF flow issue (which would basically render it basically isobaric) it would last 12 hours. Even with every possible thing that could go wrong anatomically the presentation has to be one of medication error. Never heard of intrathecal morphine overdoses causing flaccid paralysis or same with fentanyl. The timing (12-18 hours) would make sense with IT morphine... However duramorph comes in 5-10cc vials which you wouldn't even be able to pull up with the 5cc slip tip syringe in most kits. However epinephrine seems like the easier drug to mess up. I'm assuming even if he gave the whole vial (1cc, 1000mcg) that there would be some other red flag with the patients vitals. Since its a section, albeit triplets, neuropathy, bilateral at that, makes no sense.

Someone needs to watch this resident pull up his drugs because hes found the holy grail of spinals.

 

[IlDestriero]

Variable just generally no more than 2-3 hours since we're a training institution.

OMG. If a cs lasts more than an hour they’re doing it wrong.

 

[abolt18]

OMG. If a cs lasts more than an hour they’re doing it wrong.

My last OB call shift we did 2 c/s. Each one was > 3 hours. 1.5-2h is very common here sadly. Looking forward to the private life one day.

 

[dchz]

I trained at a place that really tried the push the old school "you don't know what you're doing if you use ultrasound" machisimo. I admittedly bought into myself. It's 2020. More shame will come to you with wrist and neck hematomas vs taking the extra minute to throw some lube on the probe (that's what he/she said) and get the line in faster and safer. Plus, if you're really wanting to nickel and dime your earnings, bill for the picture.

Personally, I feel like ultrasound guided techniques make you look more skilled and advanced than the person down the hall thumping their chest doing blind sticks.

Lately I've realized I'm pretty hard on myself... I would be doing a case and everything is going as smooth as possible, but I would feel like a failure and constantly apologized.... LOL

I think it's because I have some of the slickest people I've seen in my career here and I just feel inadequate for being the new guy.... Or my parents did a number on me telling me I was never good enough...