1. The SDN iPhone App is back and free through November! Get it today and please post a review on the App Store!
    Dismiss Notice
  2. Dismiss Notice

Epidural Man's uselss (but maybe not SO useless) problem based learning. 5 cases

Discussion in 'Anesthesiology' started by epidural man, Aug 19, 2011.

  1. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    So,

    Case #1 -

    32 y/o female presents for C/S. She has no contraindication for a spinal anesthetic. After all the appropriate measures are taken, a routine spinal anesthetic is flawlessly placed. Shortly after recumbancy, she complains of nausea, and SBP is in the low 80's. What might have been done to prevent this? (The low SBP, and besides the obvious of doing a general:p)

     
  2. Note: SDN Members do not see this ad.

  3. silvester78

    2+ Year Member

    Joined:
    Jun 26, 2009
    Messages:
    22
    Likes Received:
    0
    -pre spinal fluid bolus (colloid or crystalloid)
    -not entirely recumbant (left tilt) to avoid caval compression until the operation starts
    -Put 10 mg of ephedrine in R/L after spinal (Our hospital doesn't have obstetric cases, but i met many - old - anesthesiolgists, who routinely do this in every C/S spinal to avoid hypotension and never failed)
     
    #2 silvester78, Aug 19, 2011
    Last edited: Aug 19, 2011
  4. bigdan

    bigdan SDN Donor
    15+ Year Member

    Joined:
    Dec 30, 2002
    Messages:
    2,368
    Likes Received:
    232
    Status:
    Attending Physician
    Some of our attendings are putting a Phenylephrine gtt up on pump, and beginning low dose infusion at the time of spinal needle insertion...this has seemed to completely remove hypotension (and thus nausea) from our ORs.
     
  5. sevoflurane

    15+ Year Member

    Joined:
    Jul 16, 2003
    Messages:
    4,708
    Likes Received:
    1,373
    Status:
    Attending Physician
    LUD (always document)
    Head down during initial spinal set up
    Pre-spinal fluids + concomitant fluid administration during spinal anesthetic
    If trending down, pre-emptive pressors
    Lower LA dose + use narcotic vs. local only
    Later on, don't push oxytocin. Slow it up once the uterus contracts.
     
  6. IlDestriero

    IlDestriero Ether Man
    Physician Faculty 10+ Year Member

    Joined:
    Nov 24, 2007
    Messages:
    7,352
    Likes Received:
    6,653
    Status:
    Attending Physician
    This is what I do. Listen for increasing HR after spinal placement while you are placing leads, etc. If it's starting to go up, give neo. By the time you get a pressure, it's back up.
    When I do a potentially longer case I add some clonidine now. Very smooth, no nausea.
     
  7. MTGas2B

    MTGas2B Cloudy and 50
    Physician Faculty 10+ Year Member

    Joined:
    Sep 22, 2004
    Messages:
    897
    Likes Received:
    27
    Status:
    Attending Physician
    I don't do this now, but one of my staff in residency would make up a pressor mix we called snake oil. In a 250 ml saline bag add 2 mg of phenylephrine and 100 mg of ephedrine. Put it on a dial a flow microdripper and let it rip.

    I think he liked because the amount of phenylephrine was so small it would be hard for a resident to overshoot.

    Every now and then some resident would chart it as snake oil. :confused:
     
    #6 MTGas2B, Aug 19, 2011
    Last edited: Aug 19, 2011
  8. IlDestriero

    IlDestriero Ether Man
    Physician Faculty 10+ Year Member

    Joined:
    Nov 24, 2007
    Messages:
    7,352
    Likes Received:
    6,653
    Status:
    Attending Physician
    Neo drip I get. It's an old school, pre pump technique. You can count drips and document a dose if you want. 10 mg of ephedrine in 250 cc? Piss in the wind. Are you sure it wasn't 100?
     
  9. amyl

    amyl ASA Member
    10+ Year Member

    Joined:
    Aug 19, 2006
    Messages:
    1,752
    Likes Received:
    125
    Status:
    Attending Physician
    ha ha, now thats funny :) i hope none of those patients ever wanted to see their chart or god forbid a lawyer or the media get a hold of one of those charts.... snake oil would be a little hard to explain
     
  10. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    :laugh:

    Although I would say to the overshooting statement - the human body tolerates hypertension much better than hypotension.
     
  11. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    Good answers,

    But nobody suggested the answer I was looking for.

    The 'guess what I am thinking answer' is pretreat with a 5-HT3 antagonist.

    WHAT!!!??? you say?

    View attachment Picture1.jpg

    36 patients in each arm - so not a 'tiny' study.
     

    Attached Files:

    #10 epidural man, Aug 19, 2011
    Last edited: Aug 19, 2011
  12. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    Case #2

    A healthy 24 y/o physically fit professional soccor player presents for a knee scope. Spinal anesthetic is planned. His resting heart rate is 43 bpm. A perfect spinal anesthetic is performed and surgery procedes. 20 minutes after the anesthetic was placed, his heart rate dips to 32, than quickly to 17, than all the lines on the monitor go flat.

    What (or why) has this happened? What do you do?
     
  13. sevoflurane

    15+ Year Member

    Joined:
    Jul 16, 2003
    Messages:
    4,708
    Likes Received:
    1,373
    Status:
    Attending Physician
    Cuz you placed a spinal for a knee scope?

    ;)
     
  14. silvester78

    2+ Year Member

    Joined:
    Jun 26, 2009
    Messages:
    22
    Likes Received:
    0
    An attending of mine said that ondasetron prevents also spinal induced bradycardia and syncope. He cited an article from france. he always pretreat syncope-prone patients (young, with a history of vague mediated LOC etc) with 4 mg of ondasetron before doing the spinal.

    For case 2#
    probably a little of midazolam or an atropine pretreatment would have prevent this .
    I have seen this scenario once, the patient had two subsequent monitors flat line, and all started when the anestheiologist informed him that the operation had just started. From his past history he admitted several episodes of fear induced LOC.
     
    #13 silvester78, Aug 19, 2011
    Last edited: Aug 19, 2011
  15. btbam

    7+ Year Member

    Joined:
    Jan 16, 2011
    Messages:
    424
    Likes Received:
    143
    Status:
    Non-Student
    25-50 mg Ephedrine IM for case #1
     
  16. PreciousDex

    PreciousDex ASA Member
    5+ Year Member

    Joined:
    Aug 19, 2011
    Messages:
    6
    Likes Received:
    0
    Status:
    Resident [Any Field]
    Just a med student but here goes :laugh::

    2nd patient already has high vagal tone from being an athlete (as evidenced by the low resting heart rate); sympathectomy from the spinal left this vagal tone uninhibited and pt went asystolic. Treat with atropine?
     
  17. MTGas2B

    MTGas2B Cloudy and 50
    Physician Faculty 10+ Year Member

    Joined:
    Sep 22, 2004
    Messages:
    897
    Likes Received:
    27
    Status:
    Attending Physician
    Yeah, brain fart. 100 mg of ephredrine. I'll change that.
     
  18. sevoflurane

    15+ Year Member

    Joined:
    Jul 16, 2003
    Messages:
    4,708
    Likes Received:
    1,373
    Status:
    Attending Physician
    Atropine is no longer recommended for asystole.

    Epi is your friend.
     
  19. MTGas2B

    MTGas2B Cloudy and 50
    Physician Faculty 10+ Year Member

    Joined:
    Sep 22, 2004
    Messages:
    897
    Likes Received:
    27
    Status:
    Attending Physician
    True, but I think the thing he worried about would be some resident leaving a neo drip wide open inadvertantly. Especially since they had been using this mix since the days when it wasn't cool yet to use neo in OB.
     
  20. sevoflurane

    15+ Year Member

    Joined:
    Jul 16, 2003
    Messages:
    4,708
    Likes Received:
    1,373
    Status:
    Attending Physician
    I like your thought process. :thumbup:
     
  21. sevoflurane

    15+ Year Member

    Joined:
    Jul 16, 2003
    Messages:
    4,708
    Likes Received:
    1,373
    Status:
    Attending Physician
    Thanks for this dude. :horns:

    Honestly, I've never heard of zofran attenuating drops in BP with spinals. Interesting. It would be nice to have a bigger N, but nontheless, little harm to give it pre-spinal if your OB's can do skin to skin in less than an hour. If you are at a university setting, you may loose some of your anti nausea effects.
     
  22. IlDestriero

    IlDestriero Ether Man
    Physician Faculty 10+ Year Member

    Joined:
    Nov 24, 2007
    Messages:
    7,352
    Likes Received:
    6,653
    Status:
    Attending Physician
    Bezold-Jarisch... :laugh: You must be hanging out with Rhodel. He's been spouting that BS for >10 years now.
     
  23. PreciousDex

    PreciousDex ASA Member
    5+ Year Member

    Joined:
    Aug 19, 2011
    Messages:
    6
    Likes Received:
    0
    Status:
    Resident [Any Field]
    Thanks:)

    Good to know. So even if you're attributing the asystole to excessive vagal tone, you still use epi first?
     
  24. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    Case #2 -

    So cardiac arrest after a spinal is not unheard of - and there are many reports in the literature, and probably a ton more not reported (one at our hospital).

    Risk factor seems to be a bradycardic rythm prior to spinal, and probably some others.

    This is imporantant because the question may be on your boards in some form, AND, you should think about it when doing spinals.

    The answer for treatment, as sevo points out, is NOT atropine. Atropine has not been shown to work in this scenario. So grab the epi. I had this question on an ACE exam, so it's likely to show on the test.

    It has been described to the Bezold-Jerasch reflex, but others disagree with this idea. Who cares what you call it. Nonetheless, it is thought to be due to an low preload state - an undefilled ventricle and the ventricle walls slap together, there are receptors there that when activated set up an arc that produces a HUGE parasympathetic discharge - enough to cause cardiac arrest, and it isn't reversed with atropine. It needs epi.

    This reflex arc can be demonstrated nicely in animals. The cool thing is, the arc is completely reversed or abolished with 5-HT3 inhibitors. But what about in humans?

    Well as someone mentioned, there was an 'article..' Actually, it wasn't an article, but a case report, and it wasn't from France, but it was written in French (Canadians...:rolleyes:)

    They tried atropine (but remember, atropine doesn't work), then gave zofran. The cardiac arrest reversed.

    View attachment Picture2.jpg

    by the way, if you do have a guy with a low heart rate and you are going to do a spinal, I would pretreat to get his heart rate up a little bit.
     

    Attached Files:

  25. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    Case #3

    32 y/o had an uneventful spinal placed for a C/S. Because you didn't read the data regarding the fact that any dose greater than 100mcg morphine in the intrathecal space does not increase efficacy, but increases pruritis, you went ahead and put 250 mcg.

    Anyway, in the PACU, she is horribly pruritic.

    What could have been done to help prevent this annoying side effect of intrathecal opioids? Oh, besides the obvious of NOT using opioids, or less of a dose.
     
  26. Oggg

    2+ Year Member

    Joined:
    May 2, 2011
    Messages:
    962
    Likes Received:
    21
    case3:zofran!!!
     
    #25 Oggg, Aug 19, 2011
    Last edited: Aug 19, 2011
  27. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician

    Attached Files:

  28. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    Case 4# -

    33 y/o presents for cesarean delivery. She has no contraindications for a spinal anesthetic. AFter all the appropriate measures are taken, a routine spinal is flawlessly delivered. Shortely after delivery, she starts to shiver. What can be done to treat this?

    I know you know the answer now,

    So....


    View attachment Picture4.jpg
     

    Attached Files:

  29. dhb

    dhb Member
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,586
    Likes Received:
    790
    Status:
    Attending Physician
    Case #5: 83 y/o patient with ischemic cardiomyopathy sp CABG x4 stent x3 EF 25% sp PM for 3rd degre AV block, DM type 2 with CKD dialysis for 10y, peripheral arteriopathy sp bilateral LE amputation and chronic MRSA infection, COPD Gold 4 still active smoker presents with sepsis due to pneumonia huge ulcerated neck tumor.

    BP 75/34 HR 115 Temp 101, GCS 8

    What could be done to save this patient?

    You know the answer:
    attach 1834
     
  30. pgg

    pgg Laugh at me, will they?
    Moderator Physician Faculty 10+ Year Member

    Joined:
    Dec 14, 2005
    Messages:
    11,566
    Likes Received:
    6,667
    Status:
    Attending Physician
    I almost code browned myself a few months ago when, after giving 100 mcg of phenylephrine after a low post-spinal BP the patient abruptly complained of a crushing severe headache and the next BP came back SBP >200. 50 mcg of NTG fixed the BP and the headache.

    (No chance that I OD'd her with 1000 mcg; I don't do the double-dilution in one syringe thing to mix my neo. Always 10 mg into a 100 mL bag and drawn from there.)
     
  31. imfrankie

    imfrankie Anesthesiologist
    7+ Year Member

    Joined:
    Feb 22, 2011
    Messages:
    1,010
    Likes Received:
    98
    Status:
    Attending Physician
     
  32. Lightwand

    5+ Year Member

    Joined:
    Apr 5, 2011
    Messages:
    64
    Likes Received:
    9
    Status:
    Attending Physician
    Don't worry. It's an ESRD patient. Nearly impossible to kill, even without Zofran.
    Responded to a code the other day on the floor. Asystole upon discovery, down time unknown- don't think he was on tele. Tubed him, team got a pulse back. From asystole. With unknown down time. He was an ESRD patient.

    Granted, the family withdrew care the next day, but still...
     
  33. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,858
    Likes Received:
    105
    :laugh::laugh::laugh::laugh:

    Thats some funny sh i t!!!:laugh:
     
  34. Monty Python

    10+ Year Member

    Joined:
    Apr 5, 2005
    Messages:
    1,305
    Likes Received:
    97
    Putting down his smokes about six decades prior.
     
  35. IlDestriero

    IlDestriero Ether Man
    Physician Faculty 10+ Year Member

    Joined:
    Nov 24, 2007
    Messages:
    7,352
    Likes Received:
    6,653
    Status:
    Attending Physician
    Yo trinity! The avatars a bit too big pal.
    Much love for the Mercy though!
     
  36. MTGas2B

    MTGas2B Cloudy and 50
    Physician Faculty 10+ Year Member

    Joined:
    Sep 22, 2004
    Messages:
    897
    Likes Received:
    27
    Status:
    Attending Physician
    West coast Navy. Nice. Looking forward to getting back to the Mercy's home port.
     
  37. pgg

    pgg Laugh at me, will they?
    Moderator Physician Faculty 10+ Year Member

    Joined:
    Dec 14, 2005
    Messages:
    11,566
    Likes Received:
    6,667
    Status:
    Attending Physician
    Have either of you heard anything about decommissioning those ships and turning an older LHA or LHD into more capable, less shipwreck-waiting-to-happen hospital ships?
     
  38. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    love it.

    Anyway to summarize what we have learned

    zofran does 5 things peri-spinal.

    1. Anti-yack
    2. Anti shiver
    3. Anti pruritus
    4. Anti drop in systolic post placement
    5. May prevent or treat the so called bezold-jarasch


    Also, we have learned that Medicare made a huge mistake years ago by including dialysis in part of it's coverage.
     
  39. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,858
    Likes Received:
    105
    Sorry man I'm not buying it. Would love to try it tho....

    Don't do OB anymore so can't do an anecdotal trial.

    What I can add that I know works

    FO SURE

    is giving

    ephedrine 10-20mg IV immediately after spinal placement.

    Pretty much

    eliminates nausea/vomiting.

    Be aggressive with keeping the blood pressure up.

    Don't wait for a

    ninety systolic to treat and

    your parturients won't

    BARF.
     
  40. epidural man

    epidural man ASA Member
    10+ Year Member

    Joined:
    Jun 3, 2007
    Messages:
    2,858
    Likes Received:
    582
    Status:
    Attending Physician
    yeah maybe.

    And I agree that preventing hypotension in whatever method is the best NV prevention.

    I do find it fascinating that zofran in the setting of spinals has been shown, in some form of research, to do all that stuff I mentioned.

    I'll give it to my spinal patients and I try to get all my residents to do it also. I know zofran isn't completely benign, but realistcally has such a low downside.
     
  41. silvester78

    2+ Year Member

    Joined:
    Jun 26, 2009
    Messages:
    22
    Likes Received:
    0
    I read somewhere (i think is in "avoiding common anesthesia errors" but i'm not sure), "that every patient in the OR must recieve TWO drugs. ONE is oxygen the OTHER is ondasetron. But even them have contraindications"
     
  42. MTGas2B

    MTGas2B Cloudy and 50
    Physician Faculty 10+ Year Member

    Joined:
    Sep 22, 2004
    Messages:
    897
    Likes Received:
    27
    Status:
    Attending Physician
    I haven't heard anything about it. Then again I've been green side in the sand since January.
     
  43. Robert Loblaw

    Robert Loblaw Junior Member
    5+ Year Member

    Joined:
    Apr 18, 2006
    Messages:
    216
    Likes Received:
    1
    Status:
    Non-Student
    this.

    soap on board with this strategy as well. has virtually eliminated intraop nausea in all my cases. 50 mcg/min and generally never needs titration.
     
  44. Monty Python

    10+ Year Member

    Joined:
    Apr 5, 2005
    Messages:
    1,305
    Likes Received:
    97

    I used this same avatar several years ago and it was the normal size. When I re-uploaded it last night (same .jpg from same thumb drive) it came out huge. I don't have a clue as to why or how ??????

    When I was doing my dockside lifeboat refresher training on the Comfort (in freezing Baltimore harbor) we were hearing conflicting rumors about replacing/not replacing the two hospital ships. Some politicos in DC think the PR value of MEDRETES and humanitarian missions outweights the cost.

    Sorry about the thread hijack.
     
  45. MTGas2B

    MTGas2B Cloudy and 50
    Physician Faculty 10+ Year Member

    Joined:
    Sep 22, 2004
    Messages:
    897
    Likes Received:
    27
    Status:
    Attending Physician
    Did you have Navy verified status a few years ago? I think you get bigger avatars with a military account.
     
  46. hoyden

    10+ Year Member

    Joined:
    Oct 6, 2004
    Messages:
    869
    Likes Received:
    1
    Status:
    Attending Physician

    ... except that it has been shown to produce the same complications as FDA-blackboxed droperidol ( love the latter) ;)
     
  47. W222

    W222 2K Member
    10+ Year Member

    Joined:
    Aug 24, 2003
    Messages:
    4,244
    Likes Received:
    1
    Good reasoning for being "just a med student". The only thing I would change would be to treat with epi which gives you a HR and pressure boost. Epinephrine is now first line for total sympathetic blockade with high spinal.
     
  48. Femtochemistry

    Femtochemistry Skunk Works
    10+ Year Member

    Joined:
    May 13, 2002
    Messages:
    663
    Likes Received:
    21
    Status:
    Attending Physician
    I love this! And I know who the attending who taught me this trick, bigD ;)

    I have started using this on most my c/s cases unless they are known hypertensive or pre eclamptic. I have yet to see a case of hypotension or n/v w/ this. Although some attending will freak the F out if they see a phenylephrine gtt, so choice wisely.
     
  49. Mman

    Mman Senior Member
    10+ Year Member

    Joined:
    Mar 22, 2005
    Messages:
    4,243
    Likes Received:
    1,817
    Status:
    Attending Physician
    having used this technique myself, it frequently needs titration to keep the BP within 20% of baseline and avoiding bradycardia.

    I think a phenylephrine gtt is good for OB spinals, but it's certainly not cookie cutter and needs some titration to be effective.
     

Share This Page