Impromptu

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25 year old female patient with a labor epidural. Obstetrician decides that she has been stuck at 7 cm long enough and a C-section should be performed for failure to progress. Do you dose up your labor epidural to a C-section level? Or do you instead remove the epidural and perform a new spinal?

I will leave the question as this, as I do not want to color the responses with my baggage.
 

JWebar

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I will always try to do a surgical epidural block, but only if I am certain the catheter is working and/or I have time to test it properly. Works wonders and with very good hemodynamic stability.

Also, I always give the bolus before the pt transfers from one bed to the other. Epidural catheters tends to move during transfer.
 

Twiggidy

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Dose the epidural. You'll know if it's working or not because the nurses would've been calling you with "She's still in pain" calls all night prior to the c-section.
 

MirrorTodd

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That's why we prep bang-sticks. 19cc 2% lido, 1 meq bicarb, and 100mcg epi in a 20cc syringe. 5cc on way to OR, 5cc in OR, and 5cc after monitors, test level, another 5 if it's not there yet. So far, I've only had one not get a surgical level, so we pulled the catheter and did a spinal.
 
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hununuh

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If you do spinal after having an epidural run all night, how do you dose the spinal? Isn't the patient at risk of getting high spinal, theoretically?
 

IMGASMD

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If you do spinal after having an epidural run all night, how do you dose the spinal? Isn't the patient at risk of getting high spinal, theoretically?
Is the epidural working or not? A few times that I had to do spinal after either one-sided or epidural just not working. 0.8ml of heavy bupivican+250mcg duramorph. Or just put the patient to sleep...
 
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I give at least 15-20 mL of 2% lidocaine in the labor room before coming back to the OR. They are usually able to move themselves in the OR, and will have a block while they start to prep so you can check.

If it’s non emergent, and I’m not confident about the catheter, than maybe place the spinal. Otherwise it’s just more time spent, and more risk for the patient.
 
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pgg

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If the epidural has been good, use it.

Otherwise do a spinal with your usual c-section dose.

I've never in my life seen a "high spinal" from an ordinary 1-2 mL 0.75% hyperbaric bupiv spinal after an epidural was dosed, nor have I ever heard a credible story of it happening.

I have heard plenty of people call ordinary post-spinal hypotension they failed to pre-empt with appropriate phenylephrine dosing a "high spinal" though. It's not. If they don't get bradycardic and go apneic, it's not a high spinal.
 
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Mman

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I only use the epidural if it is working perfectly. If there is any wishy-washy about patchy blocks or hot spots or one side feels more numb than the other, pull the catheter and do a spinal at a slightly reduced dose compared to normal.
 

okayplayer

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I only use the epidural if it is working perfectly. If there is any wishy-washy about patchy blocks or hot spots or one side feels more numb than the other, pull the catheter and do a spinal at a slightly reduced dose compared to normal.
My exact approach.
 

facted

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Working well, use it. You might be surprised, but after years of giving 15-20ml 2% lido w/epi in residency, moved down to 10ml and typically that's more than enough.

If there is any question as to epidural efficacy in labor, pull it and place spinal. The key is get this info BEFORE you top-up and realize it's been crappy epidural. That's where the risk of high spinal is.
 

facted

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If the epidural has been good, use it.

Otherwise do a spinal with your usual c-section dose.

I've never in my life seen a "high spinal" from an ordinary 1-2 mL 0.75% hyperbaric bupiv spinal after an epidural was dosed, nor have I ever heard a credible story of it happening.

I have heard plenty of people call ordinary post-spinal hypotension they failed to pre-empt with appropriate phenylephrine dosing a "high spinal" though. It's not. If they don't get bradycardic and go apneic, it's not a high spinal.
There are quite a few case reports of it happening, though typically after epidural Is first dosed for section, didn't work properly and then spinal placed. Risk is not zero.
 

DrZzZz

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Working well, use it. You might be surprised, but after years of giving 15-20ml 2% lido w/epi in residency, moved down to 10ml and typically that's more than enough.

If there is any question as to epidural efficacy in labor, pull it and place spinal. The key is get this info BEFORE you top-up and realize it's been crappy epidural. That's where the risk of high spinal is.
Agreed. In training, virtually everyone got 20cc. As an attending, I'm usually giving 10-15cc and that works just fine.

Also only dosing them if it's been a solid epidural. If there has been any patchiness, I ask how they responded to any previous boluses (ie. did a bolus given during labor cover the patchy area or not). If the bolus covered it, I'll probably still use the epidural. Otherwise, spinal. No reduced dosage assuming there's been no recent epidural bolus given.
 
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Arch Guillotti

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I've never in my life seen a "high spinal" from an ordinary 1-2 mL 0.75% hyperbaric bupiv spinal after an epidural was dosed, nor have I ever heard a credible story of it happening.
I have. It's not a myth.
 
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Mman

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I base my spinal dose on how relatively well the epidural is working. Total crap epidural equals 1.5 ml. Mostly working but kinda patchy equals 1.0 ml. Working great except for maybe 1 hot spot equals 0.5 mls.

Have not yet had to intubate anybody for a high spinal with an N probably approaching 1000.
 

Twiggidy

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I think a take away is also to really evaluate the patients that are asking for boluses. I know not everyone experience pain the same way, but even look at the epidural insertion site. You'd be surprised how many migrate out from sweaty ladies in pain or from a partner who was half asleep/didnt care (myself included) and placed a half arsed epidural. A properly placed epidural really should not need multiple boluses, that is unless they're 10cm and about to deliver.
 

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No high spinals after giving usual spinal dose for a less than perfect an epidural PCEA infusion running for many hours. Two high spinals after dosing a less than perfect epidural PCEA with the usual C-section dose...then giving a spinal dosage (slightly reduced).
 

Mman

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I think it is most dangerous doing a spinal in an epidural that just recently got a bolus. That large volume of local sitting in the epidural space is both compressing the dura and waiting to seep into the CSF when you poke a hole through it.
 

Arch Guillotti

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I think it is most dangerous doing a spinal in an epidural that just recently got a bolus. That large volume of local sitting in the epidural space is both compressing the dura and waiting to seep into the CSF when you poke a hole through it.
Agree. The local may or not be dilute. The spinal needle is in all likelihood a small gauge but you can get translocation into the CSF as well as enhanced cephalic spread from increased volume of the epidural space.
 

pgg

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I have. It's not a myth.
The source of my skepticism is that every time I've really asked detailed questions to someone who had a "high spinal" in a situation like this, what they end up describing isn't really a high spinal. Just hypotension.

To be clear, you've witnessed hypotension, bradycardia, and apnea after a normal c-section spinal dose was given after a bolused epidural?

I've seen a genuine high spinal after an intrathecal catheter got bolused like an epidural, but I admit I've always mostly dismissed the idea of a post-epidural-high-spinal as one more bit of OB anesthesia dogma.
 

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The source of my skepticism is that every time I've really asked detailed questions to someone who had a "high spinal" in a situation like this, what they end up describing isn't really a high spinal. Just hypotension.

To be clear, you've witnessed hypotension, bradycardia, and apnea after a normal c-section spinal dose was given after a bolused epidural?

I've seen a genuine high spinal after an intrathecal catheter got bolused like an epidural, but I admit I've always mostly dismissed the idea of a post-epidural-high-spinal as one more bit of OB anesthesia dogma.
Several years back based on things I read on this forum I did SAB a couple times after bolusing the epidural when I didn’t get the coverage I needed. Patient very quickly complained of difficulty breathing, voice became a whisper, with detrimental vital signs at the same time. Did they go apneic? No. But it bothered me enough to adopt the following mantra:
  • I only bolus perfect epidurals if they go to section
  • If the epidural isn’t perfect I take it out and place spinal
  • If the epidural gets bolused I won’t follow it with a spinal. Patient goes to sleep
 
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DM27

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Several years back based on things I read on this forum I did SAB a couple times after blousing the epidural didn’t get the coverage I needed. Patient very quickly complained of difficulty breathing, voice became a whisper, with detrimental vital signs at the same time. Did they go apneic? No. But it bothered me enough to adopt the following mantra:
  • I only bolus perfect epidurals if they go to section
  • If the epidural isn’t perfect I take it out and place spinal
  • If the epidural gets bolused I won’t follow it with a spinal. Patient goes to sleep
This also what I was taught to follow and I agree with it completely.

My definition of perfect is simply: If the patient is a reasonable person and says they have been overall comfortable, I consider this perfect. If the patient is not a reasonable person, but has a clearly present bilateral level, or a nurse I trust who is confident that they have not been complaining of actual pain, I consider this perfect.

Someone I worked with would titrate 2% Lido to lower extremity motor loss for confirmation if his opinion was it was working but the patient was unreliable, I can get the purpose of this practice but I did not adopt it.
 

okayplayer

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Several years back based on things I read on this forum I did SAB a couple times after blousing the epidural didn’t get the coverage I needed. Patient very quickly complained of difficulty breathing, voice became a whisper, with detrimental vital signs at the same time. Did they go apneic? No. But it bothered me enough to adopt the following mantra:
  • I only bolus perfect epidurals if they go to section
  • If the epidural isn’t perfect I take it out and place spinal
  • If the epidural gets bolused I won’t follow it with a spinal. Patient goes to sleep
Exactly my approach. Very low threshold to pull epidural and do a spinal.
 

OneFellSwoop

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I’ve had two experiences of a spinal becoming higher after dosjng an epidural that was then inadequate. One was a post partum tubal ligation, and one was a c section. Both patients had very numb and weak hands, however it didn’t reach brainstem levels, thankfully!
 

Twiggidy

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I’ve had two experiences of a spinal becoming higher after dosjng an epidural that was then inadequate. One was a post partum tubal ligation, and one was a c section. Both patients had very numb and weak hands, however it didn’t reach brainstem levels, thankfully!
Make sure you really evaluate “numb hands”. I hear that one a lot also. It’s usually the BP cuff. If it’s bilateral hand numbness then maybe but at this point you’re really talking about knocking out the brachial plexus at the brainstem

For me a high spinal really means they should apneic with a HR rate darn near in the 30s

I’ve had a handful get hypotension and have HR in the 40s
 

lostlost2

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This is just what I do.
  • If good reliable epidural, bolus it
  • Questionable epidural?
    • If no time, GA
    • If have time and no recent bolus, do spinal usual dose
    • If have time and recent bolus, ok airway --> do GA + bad airway --> low dose CSE
 

Mman

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I tend to start ramping the bed into reverse trendelenberg if the levels are going high quickly. I've seen people get soft voices and desat requiring cpap, but never intubation.
 
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Impromptu

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OP here.

Thanks for the many responses. I am hearing mixed reviews on spinals, which is what I am experiencing with my new group. I went through a recent period wherein I dosed the seemingly well functioning labor epidural with a good amount of 2% lidocaine (15-20 mL), but was not getting the surgical anesthesia that I wanted for a C-section, especially in the post delivery portion. The OBs in my new job are quite a bit slower than at my previous one. With an epidural in place, I can give my medications throughout.

Have you heard of batches of lidocaine deteriorating or just not being as high quality as other batches?

What are your thoughts on the vagus nerve's impact on C-section comfort?

3% chloroprocaine is an excellent adjunct, as it works fast and chances of LAST are very low. Other adjuncts that I use after the baby is out, instead of converting to general are midazolam (time travel medicine), morphine, fentanyl, ketamine (wonder if it treats/prevents post partum depression), and nitrous. These are all patient specific. I tend to avoid small doses of propofol, but others like it. Any others that you like?
 

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Lecithin5

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Make sure you really evaluate “numb hands”. I hear that one a lot also. It’s usually the BP cuff. If it’s bilateral hand numbness then maybe but at this point you’re really talking about knocking out the brachial plexus at the brainstem

For me a high spinal really means they should apneic with a HR rate darn near in the 30s

I’ve had a handful get hypotension and have HR in the 40s
Agreed, and not just numb hands, but which part of hand and forearm (thumb vs medial forearm etc)
 

OneFellSwoop

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Make sure you really evaluate “numb hands”. I hear that one a lot also. It’s usually the BP cuff. If it’s bilateral hand numbness then maybe but at this point you’re really talking about knocking out the brachial plexus at the brainstem

For me a high spinal really means they should apneic with a HR rate darn near in the 30s

I’ve had a handful get hypotension and have HR in the 40s
That’s a point well taken. I should have been more specific, in both cases there was hand/arm numbness bilaterally and weakness up through elbow flexion as well as loss of shoulder muscle coordination. I had to defer skin to skin in the case of the c section due to the weakness.