Failed Epidural for C section-Now What?

[BLADEMDA]

No, if I have to continue with a regional plan (still a bad choice) I would place an intrathecal catheter and bolus very slowly.
That is the safest way to approach this situation.

Not for me. Her headache will become my headache. I would rather re-do the Epidural or go with 6 mg Bupivicaine (if Regional is Insisted upon) via the spinal route.

However, if she is a known difficult intubation then intrathecal catheter sounds very prudent.

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[InGasWeTrust]

As stated before this is clearly GA. Had a jr attending try the same thing and got your same result! Go figure

What happens when your 6mg bupi is insufficient or flat out fails?

Interesting that you cite that Birnbach et al article from Da U. As a former Birnbach disciple nothing made me happier then going to board rounds post call and telling Birnbach I put to sleep some 400lb eclamptic lady with a horrid airway........I would always get a rise out of him!

I was known as the resident with the lowest threshold to sleep em, I was always beloved by my jr residents for my "cowboy"ways

 

[Planktonmd]

Not for me. Her headache will become my headache. I would rather re-do the Epidural or go with 6 mg Bupivicaine (if Regional is Insisted upon) via the spinal route.

However, if she is a known difficult intubation then intrathecal catheter sounds very prudent.

I would take the risk of PDPH over the risk of high spinal.
The intrathecal catheter at least allows you to titrate your dose to desired level.

 

[BLADEMDA]

As stated before this is clearly GA. Had a jr attending try the same thing and got your same result! Go figure

What happens when your 6mg bupi is insufficient or flat out fails?

Interesting that you cite that Birnbach et al article from Da U. As a former Birnbach disciple nothing made me happier then going to board rounds post call and telling Birnbach I put to sleep some 400lb eclamptic lady with a horrid airway........I would always get a rise out of him!

I was known as the resident with the lowest threshold to sleep em, I was always beloved by my jr residents for my "cowboy"ways

Not afraid of GA my friend. Not at all. We are discussing possible options. Any trained monkey can do a GA here. The real expertise is looking for the alternatives; admittedly, there simply may not be a good one here.

But, I am not afraid if trying to honor patient's requests when they are reasonable. Do you believe that a patient wanting you to try a spinal or Epidural AGAIN is unreasonable?

Whatever our opinions may be on this case the LITERATURE clearly supports an Anesthesiologist ATTEMPTING neuraxial anesthesia after a failed epidural.

Now, in PP land you will be MUCH better off putting this patient to sleep 99% of the time.

But, this case is as much about options as it is about real world practice.

 

[BLADEMDA]

I would take the risk of PDPH over the risk of high spinal.
The intrathecal catheter at least allows you to titrate your dose to desired level.

Sure,

1. We agree GA is the best route here.

2. If coerced I am willing to attempt SAB with the understanding GA is likely anyway.

3. IF difficult airway known or expected then intrathecal catheter

We only disagree on number 2. Is that correct?

 

[jetproppilot]

Not afraid of GA my friend. Not at all. We are discussing possible options. Any trained monkey can do a GA here. The real expertise is looking for the alternatives; admittedly, there simply may not be a good one here.

But, I am not afraid if trying to honor patient's requests when they are reasonable. Do you believe that a patient wanting you to try a spinal or Epidural AGAIN is unreasonable?

Whatever our opinions may be on this case the LITERATURE clearly supports an Anesthesiologist ATTEMPTING neuraxial anesthesia after a failed epidural.

Now, in PP land you will be MUCH better off putting this patient to sleep 99% of the time.

But, this case is as much about options as it is about real world practice.

HUH?

Sorry Slim.

That aint true.

Actually I think a trained monkey would sit there trying to make some kinda regional work when what the mom needs is a THROAT FULLA PLASTIC.

 

[ProRealDoc]

No one has mentioned adding more local to the existing epidural. Give another 5cc, check a level. If the block is improved fine. If it's improved and not high enough, give another After that, it's sleepy time. We don't do spinals or CSE's for C-sections anyway, but in no event would we ever place a spinal after a dosed epidural.

even after 20cc did not produce surgical anesthesia?

 

[BLADEMDA]

Anesth Analg 2006;103:187-190
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000220877.70380.6e

OBSTETRIC ANESTHESIA

Combined Spinal-Epidural Anesthesia for Cesarean Delivery: Dose-Dependent Effects of Hyperbaric Bupivacaine on Maternal Hemodynamics

Marc Van de Velde, MD, PhD, Dominique Van Schoubroeck, MD, Jacques Jani, MD, An Teunkens, MD, Carlo Missant, MD, and J. Deprest, MD, PhD

[SIZE=-1]From the Department of Anesthesiology and of Obstetrics and Gynaecology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium. [/SIZE]
[SIZE=-1]Address correspondence and reprint requests to Marc Van de Velde, MD, PhD., Director Obstetric Anesthesia and Extra Muros Anesthesia, Department of Anesthesiology, University Hospitals Gasthuisberg, Herestraat 49, B - 3000 Leuven, Belgium. Address e-mail to [email protected] .[/SIZE]
Hypotension remains an important side effect of spinal anesthesia for cesarean delivery. There is limited evidence that reducing the spinal dose has a favorable effect on maternal hemodynamic stability. We designed the present randomized trial to test the hypothesis that reducing the spinal dose of local anesthetics results in equally effective anesthesia and less maternal hypotension. Fifty term pregnant patients were randomly assigned to two study groups. In the HIGH-group combined spinal-epidural anesthesia was performed using 9.5 mg hyperbaric bupivacaine combined with 2.5 µg sufentanil. In the LOW-group combined spinal-epidural anesthesia was performed using 6.5 mg hyperbaric bupivacaine combined with 2.5 µg sufentanil. Demographic data, obstetrical data, visual analog scale score for pain, number of medical interventions for pain, maternal hemodynamics, and neonatal outcome were recorded. Patients in the HIGH-group experienced more pronounced and longer hypotensive periods as compared with the LOW-group. The mean lowest recorded systolic blood pressure was higher in the LOW-group (102 ± 16 versus 88 ± 16 in the HIGH-group; P < 0.05). More patients in the HIGH-group experienced hypotension compared with the LOW-group (68% versus 16%; P < 0.05). In the HIGH-group 15 patients required pharmacological treatment for hypotension compared with 5 in the LOW-group. Duration of effective anesthesia (block to cold sensation above or at T3) was longer in the HIGH-group as compared with the LOW-group (95 ± 25 versus 68 ± 18 min, respectively, P < 0.05). We conclude that small-dose spinal anesthesia (6.5 mg hyperbaric bupivacaine combined with sufentanil) better preserves maternal hemodynamic stability with equally effective anesthesia that is of shorter duration.

 

[Planktonmd]

Sure,

1. We agree GA is the best route here.

2. If coerced I am willing to attempt SAB with the understanding GA is likely anyway.

3. IF difficult airway known or expected then intrathecal catheter

We only disagree on number 2. Is that correct?

If difficult airway is known or expected and we already had a failed epidural then my choice would be awake intubation.

 

[BLADEMDA]

Note: No supplementation required before delivery.

 

[BLADEMDA]

HUH?

Sorry Slim.

That aint true.

Actually I think a trained monkey would sit there trying to make some kinda regional work when what the mom needs is a THROAT FULLA PLASTIC.

Only tried two spinals in this situation in my entire career. The rest get GA but even then that is only a few patients because the REGIONAL works.

Sure, the young ones shouldn't be afraid of GA. But, they shouldn't be afraid to think and challenge the status quo either.

 

[jetproppilot]

note: No supplementation required before delivery.

reread post number 38.

 

[BLADEMDA]

Anyone ever used 6 mg bupivicaine in this situation?

 

[jetproppilot]

Anyone ever used 6 mg bupivicaine in this situation?

I seriously think your bong water has been laced.

 

[BLADEMDA]

Okay,

Plankton or JPP please provide any reference to a PEER reviewed study claiming Neuraxial Anesthesia after a failed Epidural is "a bad idea."

I have provided many showing that Regional is perfectly acceptable in this situation. But, so is doing a GA with "da plastic."

Published literature does not show that high spinals after failed epidurals are "inevitable" or anywhere near 50%.

The Residents should know the published facts AS WELL as the opinions.

 

[jwk]

even after 20cc did not produce surgical anesthesia?

Labor Epidural has worked pretty well.

CRNA doses Epidural with 20 cc of 2% lidocaine, HCO3 and epi 1:200,000.
7 minutes later block is still patchy.

The epidural has worked, and after only 7 minutes, she has a "patchy block". She needs either more time, more local, or both. You could also pull the catheter back 1cm before additional dosing. If I got NOTHING after that first20cc, we would replace the epidural with a decreased dose, maybe 6-10cc and see what the level is. A total volume of about 30-35cc would be my absolute max.

 

[Planktonmd]

I think I am going to use the data you provided

1: J Clin Anesth. 1995 Feb;7(1):71-4. Links

Risk of high spinal anesthesia following failed epidural block for cesarean delivery.

Furst SR, Reisner LS.
Department of Anesthesiology, University of California, San Diego 92103, USA.
Recent case reports suggest there may be an increased risk of abnormally high blockade ("high spinal") from subarachnoid anesthesia if it is performed immediately after epidural anesthesia. We describe two cases of high spinal anesthesia following failed epidural block in obstetric patients scheduled for cesarean delivery. Using a retrospective chart review, we estimate the incidence of high spinal anesthesia to be 11% in patients after prior failed epidural blockade versus fewer than 1% in patients undergoing spinal anesthesia alone.
PMID: 7772363 [PubMed - indexed for MEDLINE]

Okay,

Plankton or JPP please provide any reference to a PEER reviewed study claiming Neuraxial Anesthesia after a failed Epidural is "a bad idea."

I have provided many showing that Regional is perfectly acceptable in this situation. But, so is doing a GA with "da plastic."

Published literature does not show that high spinals after failed epidurals are "inevitable" or anywhere near 50%.

The Residents should know the published facts AS WELL as the opinions.

 

[jetproppilot]

Okay,

Plankton or JPP please provide any reference to a PEER reviewed study claiming Neuraxial Anesthesia after a failed Epidural is "a bad idea."

I have provided many showing that Regional is perfectly acceptable in this situation. But, so is doing a GA with "da plastic."

Published literature does not show that high spinals after failed epidurals are "inevitable" or anywhere near 50%.

The Residents should know the published facts AS WELL as the opinions.

You incessantly speak of your experience.

Thousands of spinals/epidurals.

ME TOO.

I respect your experience.

I've been in private practice 12 years so I've got a little experience as well.

As far as the studies go you keep falling back on published by academic dudes concerning this UNSCIENTIFIC subject of how much subarachnoid local anesthetic can/might/should be used after bolusing an epidural,

REREAD POST NUMBER 38.

 

[BLADEMDA]

I think I am going to use the data you provided

Thank you. The figure quoted is 11% but that seems low based on our limited experiences. In addition, the dosage was NOT 6 mg bupivicaine.

Again, I am not disputing your "opinion" here. I am examining the facts as we know them today.

Ultimately, the decision is yours to make.

 

[BLADEMDA]

You incessantly speak of your experience.

I respect your experience.

I've been in private practice 12 years so I've got a little experience as well.

As far as the studies go you keep falling back on published by academic dudes concerning this UNSCIENTIFIC subject of how much subarachnoid local anesthetic can be used after bolusing an epidural,

REREAD POST NUMBER 38.

Not arguing with you. I hear your opinion loud and clear. My 50% high spinal rate was with 10 mg bupivicaine. I am just asking if anyone else here has any personal experience with this same scenario using a lower dosage. Perhaps, they have something to add?

 

[Planktonmd]

Thank you. The figure quoted is 11% but that seems low based on our limited experiences. In addition, the dosage was NOT 6 mg bupivicaine.

Again, I am not disputing your "opinion" here. I am examining the facts as we know them today.

Ultimately, the decision is yours to make.

My friend, there is no FACTS.
No one has done a real study on doing a spinal after 20 cc Of concentrated local injected in the epidural space and I don't think anyone will.
So, we have to depend on opinions and case reports.
I do appreciate your case and your expertise though.

 

[jetproppilot]

My friend, there is no FACTS.
No one has done a real study on doing a spinal after 20 cc Of concentrated local injected in the epidural space and I don't think anyone will.
So, we have to depend on opinions and case reports.
I do appreciate your case and your expertise though.

"UHHHHHHH, DID ANYONE READ POST NUMBER THIRTY EIGHT?"

"HUH? NUMBER 38? THE POST NUMBER? TRENTE OCHO?"

 

[Lonestar]

well, this little anesthesiologist is putting his pt to sleep following a bolus of a patchy epidural.

Gas is your friend.

Crazy pt with good epidural going for c/s...extremely nervous...afraid of someone touching her....possible psychosis....no problem...gas to the rescue. Problem solved.

 

[BLADEMDA]

Most academic OB anesthesiologists are affraid of GA and this fear is reflected in thier literature and in the BS they teach the residents.
I have seen a couple of new grads who literally don't know how to do a c section under GA.

Here it is again (post number 38 by Plankton)

 

[BLADEMDA]

As stated before this is clearly GA. Had a jr attending try the same thing and got your same result! Go figure

What happens when your 6mg bupi is insufficient or flat out fails?

Interesting that you cite that Birnbach et al article from Da U. As a former Birnbach disciple nothing made me happier then going to board rounds post call and telling Birnbach I put to sleep some 400lb eclamptic lady with a horrid airway........I would always get a rise out of him!

I was known as the resident with the lowest threshold to sleep em, I was always beloved by my jr residents for my "cowboy"ways

So, for my case scenario what do you think Birnbach would say?

 

[Planktonmd]

Here it is again (post number 38 by Plankton)

You disagree?

 

[jetproppilot]

So, for my case scenario what do you think Birnbach would say?

He'd say

"Dude, you need to read post number thirty eight."

 

[Planktonmd]

He'd say

"Dude, you need to read post number thirty eight."

I think this deserves the helicopter laughing smiley:

 

[SleepIsGood]

Hey guys-

Good discussion. BLADE, interesting concept you brought to the table. I wish they would allow us to try this in academia, but likely wont.

But here's a question for Plank et al that would consider putting a catheter in the subarachnoid space.

So for this I take it you would get the epidural kit's toughy needle and purposely get a wet tap. Then thread the cath from the kit into the SA space. How would you go about dosing the cath?

I assume you would use hyperbaric bupi? Or would you use the 1.5% lido that comes in the kit (yah yah i know there's the risk of cauda eq syndrome..but that's with 5% and with a diff cath). My question really is though, how much local would you put in the cath. I'm assuming you can just put 1 or 2 ml of whatever solution. However, because of the 'dead space' in the cath, how would you know how much actually got into the space? Would you flush some sterile normal saline through the cath after the med was put in to 'get it in'?

 

[ProRealDoc]

Hey guys-

Good discussion. BLADE, interesting concept you brought to the table. I wish they would allow us to try this in academia, but likely wont.

But here's a question for Plank et al that would consider putting a catheter in the subarachnoid space.

So for this I take it you would get the epidural kit's toughy needle and purposely get a wet tap. Then thread the cath from the kit into the SA space. How would you go about dosing the cath?

I assume you would use hyperbaric bupi? Or would you use the 1.5% lido that comes in the kit (yah yah i know there's the risk of cauda eq syndrome..but that's with 5% and with a diff cath). My question really is though, how much local would you put in the cath. I'm assuming you can just put 1 or 2 ml of whatever solution. However, because of the 'dead space' in the cath, how would you know how much actually got into the space? Would you flush some sterile normal saline through the cath after the med was put in to 'get it in'?

The dead space in the epidural catheter is negligible. How do I know? One of my resident buddies and I tried to figure it out. It was like 0.1cc. I think the dosing is 1/10 of the epidural dose.

 

[ProRealDoc]

He has spanked all of us with the data to back up his claim. Yeah I know in PP things are done differently but still. We should aspire to be like him. Reminds me of MMD who would always back his claims up with literature.

At any rate, it appears to me that the threshold in PP is lower than in academia and since time and money are of the essence, no one wants to monkey around with anything besides what is guaranteed to work.

Excellent discussion.

 

[jetproppilot]

He has spanked all of us with the data to back up his claim. Yeah I know in PP things are done differently but still. We should aspire to be like him. Reminds me of MMD who would always back his claims up with literature.

At any rate, it appears to me that the threshold in PP is lower than in academia and since time and money are of the essence, no one wants to monkey around with anything besides what is guaranteed to work.

Excellent discussion.

This isnt about time/money/convenience.

Its about RISK.

I truly believe its better for the mom to go sleepytime if you find yourself in this situation.

 

[Planktonmd]

He has spanked all of us with the data to back up his claim. Yeah I know in PP things are done differently but still. We should aspire to be like him. Reminds me of MMD who would always back his claims up with literature.

At any rate, it appears to me that the threshold in PP is lower than in academia and since time and money are of the essence, no one wants to monkey around with anything besides what is guaranteed to work.

Excellent discussion.

I do give him credit and I appreciate his sincere effort to inject more clinical content in this forum.
On the other hand I am not sure that he presented any literature that is specifically relevant to the situation he was trying to discuss:
Doing a spinal after a full dose concentrated local has been injected epidurally.
We just have no clue how this spinal would behave and there is no literature to support it.
So, He presented a case report that we do appreciate but I am not sure if we could draw any conclusions from this case report.

 

[Planktonmd]

Hey guys-

Good discussion. BLADE, interesting concept you brought to the table. I wish they would allow us to try this in academia, but likely wont.

But here's a question for Plank et al that would consider putting a catheter in the subarachnoid space.

So for this I take it you would get the epidural kit's toughy needle and purposely get a wet tap. Then thread the cath from the kit into the SA space. How would you go about dosing the cath?

I assume you would use hyperbaric bupi? Or would you use the 1.5% lido that comes in the kit (yah yah i know there's the risk of cauda eq syndrome..but that's with 5% and with a diff cath). My question really is though, how much local would you put in the cath. I'm assuming you can just put 1 or 2 ml of whatever solution. However, because of the 'dead space' in the cath, how would you know how much actually got into the space? Would you flush some sterile normal saline through the cath after the med was put in to 'get it in'?

If I have to do continuous spinal anesthesia I would inject 0.5 cc increments of 0.75% hyperbaric Bupivacaine because it's readily available.
It's probably better to use 0.5% if you have it.
Put the patient in slight revers trendelenberg and check the sensory level 3-4 minutes after each bolus.

 

[BLADEMDA]

This isnt about time/money/convenience.

Its about RISK.

I truly believe its better for the mom to go sleepytime if you find yourself in this situation.

I do agree with JPP's conclusion for failed Neuraxial Anesthesia in this situation. Until we get some good data showing extremely high success rate with spinal anesthesia after failed Epidural, GA is the way to go.

Right now, the data isn't there and our personal experiences show the patient is probably going to get GA anyway.

 

[BLADEMDA]

I do give him credit and I appreciate his sincere effort to inject more clinical content in this forum.
On the other hand I am not sure that he presented any literature that is specifically relevant to the situation he was trying to discuss:
Doing a spinal after a full dose concentrated local has been injected epidurally.
We just have no clue how this spinal would behave and there is no literature to support it.
So, He presented a case report that we do appreciate but I am not sure if we could draw any conclusions from this case report.

Someimes the literature doesn't have the answer and that is what this case revealed.

The conclusion we can draw from the case is that doing a spinal after failed Epidural is risky; sort of like a roll of the dice. Even with low dose bupivicaine the patient may still get a GA.

 

[CambieMD]

Based on these findings, when time permits repeat epidural anesthesia should be initiated after failed epidural conversion rather than spinal anesthesia. I agree. I replaced a bad epidural two days ago and was glad that I did. The pt had a c/s.

I feel the same way epidurals as I do IVs . if it is questionable replace it.

cambie

 

[dhb]

Yes. I got it. But, if the patient understands the risks and wants to give it a shot why not try it? Most spinals only take 5 minutes.

I bet 6 mg would have done the trick in my case. But, I won't be as enthusiastic next time to test my hypothesis.

That's what i was getting to with "dose reduction" 6mg vs 12mg is not going to make a difference what's causing the high spinal is the local anesthetic in the epidural space entering the sub-arachnoid space through your dural puncture. This principle is being studied with the dural puncture epidural where you do a CSE without putting anything in the CSF.
If you wait enough for the local to diffuse you should be ok. In your case 10min is a bit short.

 

[dhb]

Guys i think you are misinterpreting the thread this is not about post #38 (although is a true observation) it's about option experience and what can be backed by scientific data.

So as I said i would wait a good 15min before performing the spinal:

[The distribution of solutions in the epidural space][Article in Japanese]


Nishimura N, Fujimaki T, Oshibuchi M, Yoshikawa I, Aida M.
Department of Anesthesiology, Hakuji-kai Memorial Hospital, Tokyo.

In 21 patients the distribution within the epidural space of epidurally injected 99mTc-DTPA was assessed. The gamma emissions from the epidural space were measured externally with the patients in supine position by use of a gamma camera. The recordings over the patient's back were stored in digital computer for 60 min. The results were as follows; 1) The spread of the radionuclide was mainly to cephalad direction, and seldom crossed the L5 level to sacral region. 2) The solution injected in the epidural space would distribute to less resistant compartments and the spread depends on the power of injection, negative pressure in the high epidural space and capillary pressure. 3) The elimination half-life of the injected radionuclide was between 1 to 17 min depending on the region in the epidural space. 4) The solution injected in the epidural space may penetrate dura mater at the ink cuff area and local anesthetic agents may affect the spinal nerve roots in the subarachnoid space rather than at the extra-dural space. 5) With continuous infusion technique the diffusion and penetration of the local agent through the dura mater are facilitated and more profound anesthetic effects would

 

[dhb]

what's causing the high spinal is the local anesthetic in the epidural space entering the sub-arachnoid space through your dural puncture.

Effect of needle puncture on morphine and lidocaine flux through the spinal meninges of the monkey in vitro. Implications for combined spinal-epidural anesthesia.Bernards CM, Kopacz DJ, Michel MZ.
Department of Anesthesiology, University of Washington, Seattle 98195.

BACKGROUND: Combined spinal-epidural anesthesia is a technique growing in popularity. However, there have been no attempts to investigate the risk of epidural drug reaching the subarachnoid space in high concentration by passing through the meningeal hole left by the spinal needle. This study begins to address this question by quantitating the flux of morphine and lidocaine through the spinal meninges of the monkey in vitro after puncture with three different-sized needles. METHODS: Spinal meningeal tissue from anesthetized monkeys was mounted in a diffusion cell and drug flux was measured through intact tissue and through tissue punctured with a 27-G Whitacre, a 24-G Sprotte, and an 18-G Tuohy needle. RESULTS: The flux of morphine through the meningeal tissue was significantly increased by puncture with each of the study needles. The flux of lidocaine was significantly increased only by puncture with the 24-G Sprotte and 18-G Tuohy needles. The flux of morphine through intact tissue was less than the flux of lidocaine through intact tissue. In contrast, the flux of morphine and lidocaine were the same through tissue punctured with the study needles. The magnitude of the drug flux through the needle puncture was a function of the diameter of the study needle. CONCLUSIONS: Epidural anesthesia after accidental or intentional puncture of the spinal meninges has occasionally resulted in high spinal blocks and total spinal anesthesia. This study suggests that drug movement through the meningeal hole is responsible for this complication and that the risk may be decreased by using the smallest possible needle to puncture the meninges.


Consistent with the studies showing no benefit of a dural puncture epidural with a 27g spinal needle.

In order to achieve maximal safety you could wait 20min after bolusing the epidural and use a 27g spinal needle.

 

[Planktonmd]

Effect of needle puncture on morphine and lidocaine flux through the spinal meninges of the monkey in vitro. Implications for combined spinal-epidural anesthesia.Bernards CM, Kopacz DJ, Michel MZ.
Department of Anesthesiology, University of Washington, Seattle 98195.

BACKGROUND: Combined spinal-epidural anesthesia is a technique growing in popularity. However, there have been no attempts to investigate the risk of epidural drug reaching the subarachnoid space in high concentration by passing through the meningeal hole left by the spinal needle. This study begins to address this question by quantitating the flux of morphine and lidocaine through the spinal meninges of the monkey in vitro after puncture with three different-sized needles. METHODS: Spinal meningeal tissue from anesthetized monkeys was mounted in a diffusion cell and drug flux was measured through intact tissue and through tissue punctured with a 27-G Whitacre, a 24-G Sprotte, and an 18-G Tuohy needle. RESULTS: The flux of morphine through the meningeal tissue was significantly increased by puncture with each of the study needles. The flux of lidocaine was significantly increased only by puncture with the 24-G Sprotte and 18-G Tuohy needles. The flux of morphine through intact tissue was less than the flux of lidocaine through intact tissue. In contrast, the flux of morphine and lidocaine were the same through tissue punctured with the study needles. The magnitude of the drug flux through the needle puncture was a function of the diameter of the study needle. CONCLUSIONS: Epidural anesthesia after accidental or intentional puncture of the spinal meninges has occasionally resulted in high spinal blocks and total spinal anesthesia. This study suggests that drug movement through the meningeal hole is responsible for this complication and that the risk may be decreased by using the smallest possible needle to puncture the meninges.


Consistent with the studies showing no benefit of a dural puncture epidural with a 27g spinal needle.

In order to achieve maximal safety you could wait 20min after bolusing the epidural and use a 27g spinal needle.

Correct me if I am wrong but the study is saying that a puncture with a # 27 needle is the safest because lidocaine flow did not increase when the needle was a 27??

 

[dhb]

My read is that a hole from a 27g needle does not significantly increase flux compared to standard diffusion through an intact membrane.

And: "The magnitude of the drug flux through the needle puncture was a function of the diameter of the study needle."

 

[InGasWeTrust]

So, for my case scenario what do you think Birnbach would say?

He would spout off about 4 or 5 recent studies regarding failed/patchy epidurals. Then get all dramatic and drill the team chief at the board for about 10-15 minutes about pharmacology/pharmocodynamics of LA in the epidural/spinal space. Then tell a about a case that he served as an expert witness on regarding a similar situation. Then he would say that if the airway is questionable, which at da U, everyone has and say that you place an intrathecal catheter and dose slowly. Tell the pt. they will get a HA but this is the safest type of anesthesia for you and the baby.

Im confident that this would be his chosen pathway. Why? Cause I got hammered by him everytime for putting people to sleep and always being told of the "alternatives"...........good times indeed!

 

[Planktonmd]

He would spout off about 4 or 5 recent studies regarding failed/patchy epidurals. Then get all dramatic and drill the team chief at the board for about 10-15 minutes about pharmacology/pharmocodynamics of LA in the epidural/spinal space. Then tell a about a case that he served as an expert witness on regarding a similar situation. Then he would say that if the airway is questionable, which at da U, everyone has and say that you place an intrathecal catheter and dose slowly. Tell the pt. they will get a HA but this is the safest type of anesthesia for you and the baby.

Im confident that this would be his chosen pathway. Why? Cause I got hammered by him everytime for putting people to sleep and always being told of the "alternatives"...........good times indeed!

I don't know the guy personally but you make me think that I was lucky to leave Miami before he became the man.

 

[BLADEMDA]

He would spout off about 4 or 5 recent studies regarding failed/patchy epidurals. Then get all dramatic and drill the team chief at the board for about 10-15 minutes about pharmacology/pharmocodynamics of LA in the epidural/spinal space. Then tell a about a case that he served as an expert witness on regarding a similar situation. Then he would say that if the airway is questionable, which at da U, everyone has and say that you place an intrathecal catheter and dose slowly. Tell the pt. they will get a HA but this is the safest type of anesthesia for you and the baby.

Im confident that this would be his chosen pathway. Why? Cause I got hammered by him everytime for putting people to sleep and always being told of the "alternatives"...........good times indeed!

Thanks. and thanks to dhb. but, in my practice waiting even 5 minutes is a long time after a failed epidural. I will continue to do what I usually do 99% of the time in this situation: ET tube

 

[dhb]

Thanks. and thanks to dhb. but, in my practice waiting even 5 minutes is a long time after a failed epidural. I will continue to do what I usually do 99% of the time in this situation: ET tube

In that case the cortico-subcortical block is a must.

While browsing pubmed i landed these articles: anybody heard of this?

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Long-lasting epidural sensory blockade by n-butyl-p-aminobenzoate in the terminally ill intractable cancer pain patient.

http://www.ncbi.nlm.nih.gov/pubmed/1741516?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed

 

[furfur]

If the patient's airway looks manageable(i.e., appears that can ventilate and/or intubate relatively easily) and one is ready for airway management then there is very little drawback to attempting an SAB. Namely, you may get a high spinal requiring emergent intubation. Again, if the airway appears easy and you have your equipment, this is only minimally more risky than "controlled" induction/intubation. So, you give the spinal a chance and avoid the 16x increased risk for airway morbidity/mortality associated with GETA in parturients. That would be my board answer(come April) and what I would do faced with this difficult scenario. If the airway looks at all difficult, I would proceed w/ GETA(+/- awake FOB if it looks really hairy).

 

[BLADEMDA]

If the patient's airway looks manageable(i.e., appears that can ventilate and/or intubate relatively easily) and one is ready for airway management then there is very little drawback to attempting an SAB. Namely, you may get a high spinal requiring emergent intubation. Again, if the airway appears easy and you have your equipment, this is only minimally more risky than "controlled" induction/intubation. So, you give the spinal a chance and avoid the 16x increased risk for airway morbidity/mortality associated with GETA in parturients. That would be my board answer(come April) and what I would do faced with this difficult scenario. If the airway looks at all difficult, I would proceed w/ GETA(+/- awake FOB if it looks really hairy).

Thanks for your answer. Unfortunately, there is no ONE correct response to this scenario. Everyone who has responded provided valuable input.

1. Redoing the Epidural may be the safest course of action if Neuraxial Anesthesia for the C section is desired. The exact dose needed for this patient is undetermined by peer reviewed data. Perhaps, starting with 10 ml's of 2% Lido with Hco3, EPi may be prudent. Always easier to give more

2. Spinal- No good data on how much to give this patient after failed Epidural. Perhaps, 6-7 mg hyperbaric bupivicaine? Also, DHB provided excellent data that waiting 15 minutes after a FULL 20 ml dose of the Epidural may be prudent. This would be difficult in my practice and in other real world situations.

3. Just go the JPP route- mouth fulla plastic.

Remember, the Oral Board Examiner wants to evaluate your Critical thinking and make sure you are a safe practitioner. It doesn't hurt to discuss all the available options before deciding on your choice.

 

[CambieMD]

The parturient airway carries with it challenges that increase the frequency of failed intubation from 1/3000 to 1/300. The o2sat drops like a rock. Now two lives are on the line. You have a thick neck,massive breast,secretions, an airway that is bleeding and sats in the toilet. When I was a resident a thin parturient came in with a fetus that was severely bradycardic. We tubed her and it well.The cord was wrapped around the babys neck.That pt had good protoplasm. Now, a 300 pounder who is bearly 5 ft tall and I have time. RA is my choice.

There is a study out of Michigan that showed that a certain population of pt is very sensative to the resp depressant effects of narcotics. They make it out of the OR but can arrest in the PACU if not properly monitored.

Cambie
p.s. I realize that there are several ways to skin a cat.

 

[BLADEMDA]

CAmbie,

With all due respect, the academic studies regarding the intubation of Pregnant patients are over-blown. An experienced, competent Anesthesiologist will intubate the airway of 99% pregnant patients with normal anatomy.

I understand your caution in choosing GA as a route. But, when Neuraxial Anesthesia fails the FIRST time it is a reasonable choice. However, I respect your reluctance to choose GA; but in PP EXPEDIENCE is part of the game. So, you better be real quick with re-doing that Neuraxial block.