Do you check the level of your spinal?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
No. It's a waste of time in the vast majority of cases.

Also, I don't do OB, so if for whatever reason the spinal isn't working by the time the incision is being made, the patient is getting a GA (the spinal isn't so critical that I would sit them up to do it again)
 
on L&D I just ask if the prep on their abdomen feels cold or not
 
I think starting that nonsense of checking levels leads to more trouble than it's worth. Like what if they say I can feel somewhere at last rib but not abdomen? Am I going to repeat it? Convert to a general for some subjective thing? If their legs are heavy, I know I'm in and just leave it.
 
Sleeplessbordernights said:
Obviously I know this is more importante for some procedures than others (ankle surgery vs c section),bu most of my attendings never check the level.
Click to expand...

I usually dont check level unless something was unusual or suspicious with the spinal placement. I have patient try to lift their legs up and if they can't then we are good.
 
The ex national chairman of the anesthesia council for my home country told me one time when i was starting, that the most common reason for anesthesiologists to be sued in that country was inadequate spinal levels during CS... I didnt ever read more into that but he was a serious dude... So I tend to check my OB spinals...

Never for anything else really unless ive completely butchered the spinal for some reason or another

Guess ive bn lucky to ever only have 1 inadequate spinal... And she had had lumbar spinal fusion plus the ortho surgeon is super fast so time from SAB to incision was minutes.. And it was mepiv low dose to enable that hospitals same day discharge protocols
 
Last edited by a moderator:
Sleeplessbordernights said:
Obviously I know this is more importante for some procedures than others (ankle surgery vs c section),bu most of my attendings never check the level.
Click to expand...
I don’t do spinals for ankle surgery. Seems like a poor choice given sciatic/acb’s. As for c/s i do a poor mans test and ask them to raise their legs/look for sympathectomy/ If they become nauseous, I guess you can take it as a good sign… but I don’t waste time. It’s either going to work or it won’t. If it doesn’t they are usually going to sleep, which should be a very infrequent event.
 
I check the level for sections because I have had a couple spinals remain a little low and the patients have complained of severe pressure during delivery. Also I do know of one lawsuit regarding pain during C section and I am not playing that game. Also I document both the level and Allis test negative in the chart most of the time.
 
coffeebythelake said:
Do u check for CSF at beginning and end of injection?
Click to expand...
Beginning of Injection yes, end no.

i like making sure I have free flow of CSF and the needle didn’t migrate out of the intrathecal space after hooking the syringe up (has happened to me maybe twice that I can recall). But at the end of the injection the deed is already done, I’m not going to readjust the spinal needle or put any more medication in, even if there wasn’t free flow at that point.

As I said above, spinals aren’t critical for the cases I do them on. Maybe my practice would be different in the OB world…
 
One of my biggest pet peeves in OB is fumbling a spinal with gases/ketamine/propofol… it has it’s place, but if the patient is in pain, just convert to GA.
 
nimbus said:
So what level do you all click on Epic? 😉
Click to expand...
I write on my paper chart - appropriate motor\sensory block and leave it at that. Although I have had incomplete\insufficient spinals where I have had to go GA during the case because the patient kept moving or moaning to incision, but then in PACU they wake up with some numbness\weakness in their legs. Even though I had a good CSF return. Although checking a level wouldn't prevent those scenarios, it either works or it doesn't
 
PainDrain said:
I check the level for sections because I have had a couple spinals remain a little low and the patients have complained of severe pressure during delivery. Also I do know of one lawsuit regarding pain during C section and I am not playing that game. Also I document both the level and Allis test negative in the chart most of the time.
Click to expand...

pressure is referred, your OBs are likely everting the uterus for closure, yes?

spinal local will poorly cover this, either need neuraxial or IV opioid or reassurance
 
repititionition said:
pressure is referred, your OBs are likely everting the uterus for closure, yes?

spinal local will poorly cover this, either need neuraxial or IV opioid or reassurance
Click to expand...
You are correct. It’s rare that they do this but Intrathecal opioid takes care of it most of the time.
 
coffeebythelake said:
I usually dont check level unless something was unusual or suspicious with the spinal placement. I have patient try to lift their legs up and if they can't then we are good.
Click to expand...
Some of my attendings are very particular about this, if we are talking about and ankle or knee they want the level at T10 at most
 
Here is an algorithm that will help answer this question.

Do I want undue stress and worry in my life right now?
Yes = check for spinal level.
No - relax and realize that a level tells you nothing useful.

I’m not sitting them up to do it again if it doesn’t work.

In OB, the Allis test does the trick anyway. How many times has your level checking given weird results or equivocal results because of timing, and the Allis test later reveals a great working spinal?
 
I delegate the OB spinal level check to Drs. Foley and Allis. I'll also ask the patient to let me know if their fingers get tingly - if necessary some reverse-T typically fixes a level that's too high.

They never get nauseous because I start a phenylephrine infusion at around 50 mcg/min (that dose depends on my chosen bupivacaine dose which in turn depends on the speed of my surgeon) as soon as the spinal goes in and the patient goes supine again. If there isn't an infusion pump handy I'll just squirt a 10 mg vial of phenylephrine into a liter bag of LR and run that in full speed, and it's close enough and easy enough to titrate. Hypertension would probably tip me off to a spinal that was too low to produce the expected sympathectomy but honestly I can't remember the last time I had an unexpected failed spinal.
 
pgg said:
If there isn't an infusion pump handy I'll just squirt a 10 mg vial of phenylephrine into a liter bag of LR and run that in full speed, and it's close enough and easy enough to titrate.
Click to expand...

do you just trash the bag after their BP is stable and hang a new one? I mean clearly you don't want to run in 10 mg of phenylephrine over the course of a csection. I would just stick a syringe in line and occasionally bolus it for a few minutes
 
Mman said:
do you just trash the bag after their BP is stable and hang a new one? I mean clearly you don't want to run in 10 mg of phenylephrine over the course of a csection. I would just stick a syringe in line and occasionally bolus it for a few minutes
Click to expand...
Yes

More often what actually happens is they've had 500 or so of a bolus of LR by the time the spinal is in, and I just put 5 mg in the 500 still in the bag, and it all ends going up in by the time the sympathectomy starts to fade.
 
pgg said:
Yes

More often what actually happens is they've had 500 or so of a bolus of LR by the time the spinal is in, and I just put 5 mg in the 500 still in the bag, and it all ends going up in by the time the sympathectomy starts to fade.
Click to expand...

I think our median csection patient gets about 400-600 mcg of phenylephrine after the spinal. It is hard to comprehend giving 10x that amount.
 
You know, you guys are right, it's been so long since I haven't had a pump in the room and needed to put the stuff directly in the bag ... We had prefilled syringes there. 10 ml of 100 mcg per. I put the whole thing in the bag, so it was 1000 mcg, just 1 mg. Not 10.

Thanks for the reality check. 😳🙂
 
pgg said:
I delegate the OB spinal level check to Drs. Foley and Allis. I'll also ask the patient to let me know if their fingers get tingly - if necessary some reverse-T typically fixes a level that's too high.
Click to expand...

My attending always tells me to check with a blunt tip needle going down the side like 10000x times, but lately I just nod to the OB resident and she knows to clamp down with the Allis to check for me. So much easier.
 
pgg said:
You know, you guys are right, it's been so long since I haven't had a pump in the room and needed to put the stuff directly in the bag ... We had prefilled syringes there. 10 ml of 100 mcg per. I put the whole thing in the bag, so it was 1000 mcg, just 1 mg. Not 10.

Thanks for the reality check. 😳🙂
Click to expand...

I wasn't doubting that there are many ways to skin the cat, but I was having a hard time picturing that much phenylephrine going into a patient. Patients stop complaining about nausea but all of a sudden have this raging headache...
 
Mman said:
I wasn't doubting that there are many ways to skin the cat, but I was having a hard time picturing that much phenylephrine going into a patient. Patients stop complaining about nausea but all of a sudden have this raging headache...
Click to expand...

I imagine @pgg slows down the infusion as the BP creeps up
 
I always check a level.

In OB I think it is essential, will T burg for an inadequate level. If you T burg everyone you’ll get some high levels and breathing difficulty, so I think checking the level is essential. But maybe if I just waited longer the level would come up and be fine …..

for an ortho surgery, just make sure level is up to T12 or T10 or so, literally one swipe of alcohol over the abdomen or hip, it’s about 10 seconds to test, and I write in the chart sensory level up to T10, vitals stable, patient comfortable. If I was having surgery I would want someone to check.
 
nimbus said:
I imagine @pgg slows down the infusion as the BP creeps up
Click to expand...

well sure, he also admitted he is using 10x less phenylephrine in the bag than he initially thought. Far easier to titrate 1 mg in a 1000 ml bag than 10 mg in a 1000 ml bag.
 
Eh, I check the level with ice for my sections. More so to give my patient the feedback of "oh yeah, it's working" more so than just heavy legs, especially when they can't reliably distinguish pressure/pain or have unrealistic expectations of a neuraxial technique. Usually the vital sign changes with the sympathectomy and the negative Allis are sufficient for me.

But I'm also at a training program where I have the time and the OB residents really like to tug away at the uterus and push on the patient. Kind of have to tailor the anesthetic technique to what they're doing on the other side of the drape.
 
usma05 said:
But I'm also at a training program where I have the time and the OB residents really like to tug away at the uterus and push on the patient. Kind of have to tailor the anesthetic technique to what they're doing on the other side of the drape.
Click to expand...
Nothing like an OB who flops the uterus on the abdomen and pokes at it for 20 minutes. 🙁
 
pgg said:
Nothing like an OB who flops the uterus on the abdomen and pokes at it for 20 minutes. 🙁
Click to expand...
Thats a really terrible thing. Even a rock solid spinal might not cover that... Its basically banned subject in the literature afaik but they still persist
 
Newtwo said:
Thats a really terrible thing. Even a rock solid spinal might not cover that... Its basically banned subject in the literature afaik but they still persist
Click to expand...
It's routine here. I do fentanyl in the spinal and that seems to help them tolerate it a lot more.
 
You must log in or register to reply here.

Similar threads

cockblockandrun
  • Question Question
Do you own your own video laryngoscope?
Replies
47
Views
1K
Nexus5
N
T
Mepivicaine spinal for ortho
Replies
23
Views
2K
ans2021
A
A
when do you check the E?
2
Replies
51
Views
4K
USCTrojan11
USCTrojan11
C
Kidney Transplant under spinal
2
Replies
79
Views
5K
MalloryWeiss
MalloryWeiss
DrOwnage
Would you: Take a pay cut so you don’t work for AMC/pay cut to do your own cases solo?
2
Replies
60
Views
4K
sloh
S
Top