Dosing spinals for C/S after Epidural

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NeedleJockey

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I pull labor epidurals going to C-Section and place a single shot spinal if there is a 'window' or any issue at all with the epidural prior to loading it to stay out of trouble. Recently did this and dosed 1.2cc standard heavy .75% bupiv., spinal went high enough for apnea necessitating GETA. Pt had been pushing for 4 hours on a failed 3 day induction for Pre-E, which I think may have been a factor-soft tissue edema/venous engorement displacing CSF?

My usual dose with standard heavy 0.75% bupiv for a planned c/s is 1.5cc, w 0.15ml duramorph.
Would love to hear the group's thoughts.
Thanks in advance.
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NeedleJockey said:
I pull labor epidurals going to C-Section and place a single shot spinal if there is a 'window' or any issue at all with the epidural prior to loading it to stay out of trouble. Recently did this and dosed 1.2cc standard heavy .75% bupiv., spinal went high enough for apnea necessitating GETA. Pt had been pushing for 4 hours on a failed 3 day induction for Pre-E, which I think may have been a factor-soft tissue edema displacing CSF?

My usual dose with standard heavy 0.75% bupiv for a planned c/s is 1.5cc, w 0.15ml duramorph.
Would love to hear the group's thoughts.
Thanks in advance.
Click to expand...
Do a search. Discussed ad nauseum in the past.
 
NeedleJockey said:
I pull labor epidurals going to C-Section and place a single shot spinal if there is a 'window' or any issue at all with the epidural prior to loading it to stay out of trouble. Recently did this and dosed 1.2cc standard heavy .75% bupiv., spinal went high enough for apnea necessitating GETA. Pt had been pushing for 4 hours on a failed 3 day induction for Pre-E, which I think may have been a factor-soft tissue edema/venous engorement displacing CSF?

My usual dose with standard heavy 0.75% bupiv for a planned c/s is 1.5cc, w 0.15ml duramorph.
Would love to hear the group's thoughts.
Thanks in advance.
Click to expand...
I would consider other causes for the symptoms that you have attributed to high spinal.

Maybe hypotension causing loss of consciousness.
 
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I do not adjust my spinal dose in such cases.

I do not believe 1.2 mL of heavy 0.75% bupi caused a high spinal.

Symptomatic hypotension, maybe. You didn't mention her vitals. I'm just guessing she needed more vasopressor than you gave.
 
Yes it’s been discussed many times, but still a good topic.

This is a true phenomenon and oddly most people don’t believe it until they see it.

I give 1cc of heavy with no narcotic. Other people will actually only do general because they’ve seen it too many times.

It’s most common after someone gives a c-section dose bolus to a poorly functioning epidural and then decides to do a spinal.
 
Gator7 said:
I give 1cc of heavy with no narcotic.
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Why skip the narcotic? If you're worried about a high block, why skimp on the one component that facilitates a reduction in the volume/dose of the local anesthetic?


It's wild that people think a difference of a couple TENTHS of a cc can affect the phsycial spread of local in the CSF to the point of inducing hemodynamic collapse. As with all hyperbaric spinals, just watch the level, tilt the table if you need to, don't be timid with the phenylephrine, and have a few mcg of epi somewhere in the cart for the rare patient who surprises you.
 
Make the decision early to convert to spinal. Don't give any bupivicaine top off epidural doses if you are thinking that a c section is on the near horizon. Do the spinal sitting and see where the level is going before lying down flat. Have pressors.
 
Drwine said:
Make the decision early to convert to spinal. Don't give any bupivicaine top off epidural doses if you are thinking that a c section is on the near horizon. Do the spinal sitting and see where the level is going before lying down flat. Have pressors.
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My last high spinal was like this. Stopped the patchy catheter 90 min before OR, and no bolus. Spinal was 1.2, maybe 1.3 mL, heavy. Hands tingly -> respiratory distress -> voice change -> unconscious ->ETT. Felt like I took all precautions and it still happened.
 
cchoukal said:
My last high spinal was like this. Stopped the patchy catheter 90 min before OR, and no bolus. Spinal was 1.2, maybe 1.3 mL, heavy. Hands tingly -> respiratory distress -> voice change -> unconscious ->ETT. Felt like I took all precautions and it still happened.
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I just can't wrap my brain around how 1.2 mL of heavy bupi gets a level above T1 because of an epidural. A crappy epidural that was shut off an hour and a half earlier, at that.

I've just got no glass spine / reduced CSF volume / physiology mental model that can make it make sense.

But I have been surprised by patients that get oddly high levels from straight spinals. It happens, rarely. I just can't help but suspect that these cases of high spinals after labor epidurals have nothing whatsoever to do with the presence or absence of an epidural.

Maybe I'm wrong. 🙂
 
cchoukal said:
My last high spinal was like this. Stopped the patchy catheter 90 min before OR, and no bolus. Spinal was 1.2, maybe 1.3 mL, heavy. Hands tingly -> respiratory distress -> voice change -> unconscious ->ETT. Felt like I took all precautions and it still happened.
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Too much. .7-.8 ml, inject slowly, leave them sitting for a minute, lie down slowly.
 
pgg said:
It's wild that people think a difference of a couple TENTHS of a cc can affect the phsycial spread of local in the CSF to the point of inducing hemodynamic collapse.
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I mean I'm a fair few years out from exams but I do recall something somewhere that said spread of spinal had a lot to do with dose, more so than the volume of the drug itself?
Am I wrong?

Re high spinal after epidurals. Personally I've not seen it but I've heard enough from experienced good people that I believe it's true... just be aware of time since last bolus and volume of that bolus. I don't change my spinal dose much. Always 1.4mls heavy with opioid... but I do employ a lot of bed tilt and manipulation to "get my level🙂 idk if that's ridiculous or no
 
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I would have given the same dose with a few caveats. If she is less then 5 feet and obese potentially reduce the dose. I had a 5 footer that had a crappy epidural after 10cc of 2% lido. Sat her up used 1cc of heavy bupi. Perfect spinal.
 
Discussed as nauseum. I see. Two new case reports here - though.
 
pgg said:
I do not adjust my spinal dose in such cases.

I do not believe 1.2 mL of heavy 0.75% bupi caused a high spinal.

Symptomatic hypotension, maybe. You didn't mention her vitals. I'm just guessing she needed more vasopressor than you gave.
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Vitals were remarkably unimpressive, no hypotension no bradycardia.

Pt inaudibly mouthed “I can’t breathe” before going apneic and had recall of the same.
 
NeedleJockey said:
Vitals were remarkably unimpressive, no hypotension no bradycardia.

Pt inaudibly mouthed “I can’t breathe” before going apneic and had recall of the same.
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Maybe drug error since it can’t be a high spinal.

Never go ass to mouth or epidural to spinal.
 
cytocide said:
There is plenty of literature and case reports on this topic, but please educate me, professor.
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Educate yourself buddy. You applied a blanket statement to all instances... of course case reports exist of bad scenarios... we discussed this a tonne in residency. But there's also literally millions of instances when spinal after epidural was totally safe...

Of course you give a big topup to a short fat lady, 2 second before a spinal then lay her flat you're asking for trouble... but if the last bolus is a while ago and low volume, you're probably fine to do a spinal

So get on... and don't do or say stupid stuff
 
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Replace an epidural if your epidural sucks. It’s so simple. If you have time to wait for the last top off to recede, you have time for an epidural. If you have time to place a spinal, you have time for an epidural.
 
cytocide said:
Replace an epidural if your epidural sucks. It’s so simple. If you have time to wait for the last top off to recede, you have time for an epidural. If you have time to place a spinal, you have time for an epidural.
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Disagree. Spinal is generally easier and quicker to place. Sometimes an epidural is just as quick to place but what’s the purpose of your epidural? It’s not gonna be as quick to set up if your goal if for c-section.
 
Onefellswoop87 said:
Disagree. Spinal is generally easier and quicker to place. Sometimes an epidural is just as quick to place but what’s the purpose of your epidural? It’s not gonna be as quick to set up if your goal if for c-section.
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Well some OBs are terribly slow, so that's probably the point...
 
PpfSuxTube said:
Well some OBs are terribly slow, so that's probably the point...
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No, cytocide stated you should NEVER do a spinal after an epidural has been in which is just plain wrong. If you need an epidural bc your surgeon is slow that is a different story, but I don’t want other newer anesthesiologists reading this board to think this can’t/shouldn’t be done.
 
Had a high spinal about a year ago. Place epidural, patient comfortable for hours. C/S called, patient now says epidural spotty. No recent boluses so I did spinal with 1.4 ml heavy. Keeps creeping higher and around time baby coming out patient getting voice changes and trouble breathing. I ask if she wants to go to sleep and she says yes. Prop, sux intubate her no issues. I see her in recovery, expecting her to be angry. She says "thank you so much much for putting me to sleep" haha.
 
rick roller pump said:
Had a high spinal about a year ago. Place epidural, patient comfortable for hours. C/S called, patient now says epidural spotty. No recent boluses so I did spinal with 1.4 ml heavy. Keeps creeping higher and around time baby coming out patient getting voice changes and trouble breathing. I ask if she wants to go to sleep and she says yes. Prop, sux intubate her no issues. I see her in recovery, expecting her to be angry. She says "thank you so much much for putting me to sleep" haha.
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Way too much.
 
The thing isbfor those saying way too much, what happens when you do 1.0 for the spinal and then it's not dense enough or wears out. You end up putting them to sleep anyway.
 
cytocide said:
Replace an epidural if your epidural sucks. It’s so simple. If you have time to wait for the last top off to recede, you have time for an epidural. If you have time to place a spinal, you have time for an epidural.
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This is bizarre. Epidurals are markedly inferior anesthetics for c-sections, compared to spinals.

The main reason we put up with augmenting labor epidurals for c-sections is because the catheter is already there. I can't imagine putting in a new epidural for a section instead of doing a spinal.
 
pgg said:
This is bizarre. Epidurals are markedly inferior anesthetics for c-sections, compared to spinals.

The main reason we put up with augmenting labor epidurals for c-sections is because the catheter is already there. I can't imagine putting in a new epidural for a section instead of doing a spinal.
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Yeah it’s bizarre. It’s almost as if there was a reason I did it - perhaps the three events in this thread and the ones in countless other threads were the reason.

I can’t recall the last time I’ve had an issue with using a working epidural for c section.
 
pgg said:
This is bizarre. Epidurals are markedly inferior anesthetics for c-sections, compared to spinals.

The main reason we put up with augmenting labor epidurals for c-sections is because the catheter is already there. I can't imagine putting in a new epidural for a section instead of doing a spinal.
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Pgg
Please remember their was one OB that we did mostly cse’s for… If the c section was expected to be longer pull the patchy epidural and do a quick cse 1.2 heavy bupi max, 10 fent 200 duramorph. If the spinal is good the epidural will likely be good too.
 
narcusprince said:
Pgg
Please remember their was one OB that we did mostly cse’s for… If the c section was expected to be longer pull the patchy epidural and do a quick cse 1.2 heavy bupi max, 10 fent 200 duramorph. If the spinal is good the epidural will likely be good too.
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Oh sure, for an academic c-section in which the pgy1 does the case and teaches the ms3 to close the skin, or one with that clown we had who claimed the bair hugger caused her kidney failure because standing next to it for three hours made her overheat ... an epidural catheter that you can dose after the 15 mg of intrathecal bupi wears off, is a great thing. 🙂

I'm just saying, there's a list of reasons we do SPINALS for elective c sections and not EPIDURALS, and it's mainly because a spinal provides a denser, more even, more reliable block than an epidural.

Pulling out a flaky labor epidural when a section is called, and replacing it with another epidural, as Mr Cytocide here advocates, is ridiculous and I have literally never in my life seen anyone do it.
 
gunnershow said:
If you load up an epidural and it fails Allis then it's reasonable to do a repeat epidural instead of putting them to sleep. But as long as you're not loading spotty epidurals, this should be a very rare occurrence.
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Careful 🙂

Boluses of 2% lido add up fast and the epidural space is the next best thing to IV administration.

For all the debate in this thread most of the time the real world best answer (if there's any urgency to the section) is general anesthesia.
 
Have never seen anyone replace a patchy epidural with a epidural for a section. We would all consider that person nuts if we ever saw that.

Hey, this person’s epidural space sucks. Let’s repeat the exact same thing that sucks in a similar manner. Brilliant!
 
Maz777 said:
Have never seen anyone replace a patchy epidural with a epidural for a section. We would all consider that person nuts if we ever saw that.

Hey, this person’s epidural space sucks. Let’s repeat the exact same thing that sucks in a similar manner. Brilliant!
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Seems fairly reasonable. You’ve never replaced a labor epidural? It’s likely not the epidural space that sucks but the epidural. If you’ve fully bolused an epidural for a CS and you aren’t getting adequate levels, it’s fine to place anyone epidural if you want to avoid GETA. You’re limited by local dose but that’s it.
 
Southpaw said:
Seems fairly reasonable. You’ve never replaced a labor epidural? It’s likely not the epidural space that sucks but the epidural. If you’ve fully bolused an epidural for a CS and you aren’t getting adequate levels, it’s fine to place anyone epidural if you want to avoid GETA. You’re limited by local dose but that’s it.
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This is just plain wrong. I could see replacing the epidural with a CSE. CSE to confirm that your actually in the right spot the spinal to provide adequate anesthesia and the epidural catheter to extend the anesthesia.
 
narcusprince said:
This is just plain wrong. I could see replacing the epidural with a CSE. CSE to confirm that your actually in the right spot the spinal to provide adequate anesthesia and the epidural catheter to extend the anesthesia.
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I do a lot of ob and do almost exclusively CSEs. Read closely. No need to CSE. If you want to CSE/spinal a non-working epidural after stopping the infusion once a CS is called, that’s fine. But if you go poking holes in the dura after fully dosing an epidural for a CS you’re going to find trouble at some point.

There’s nothing wrong with replacing a non-working epidural with another epidural.
 
narcusprince said:
This is just plain wrong. I could see replacing the epidural with a CSE. CSE to confirm that your actually in the right spot the spinal to provide adequate anesthesia and the epidural catheter to extend the anesthesi
Southpaw said:
I do a lot of ob and do almost exclusively CSEs. Read closely. No need to CSE. If you want to CSE/spinal a non-working epidural after stopping the infusion once a CS is called, that’s fine. But if you go poking holes in the dura after fully dosing an epidural for a CS you’re going to find trouble at some point.

There’s nothing wrong with replacing a non-working epidural with another epidural.
Click to expand...
For a labor yes no problem replacing the catheter. But for c/s its a spinal or cse for me. Replacing the epidural catheter and bolusing up seems dumb.
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