Failed Spinal for C-section

[PainDrain]

I am sure this has been covered before but I need some advice. Been out a few years and I do OB from time to time. In residency I did alot of OB and we were a busy medical center with alot of high risk OB, etc. I never once had a spinal completely fail to the point where an allis test failed or was patchy. I had only a handful of blocks wear off prior to completion of the section (an this was academics so you can imagine what a typical section ran). In residency our typical dose was 1.6 (rarely 1.8) mls of 0.75% hyper bupi combined with 200mcg morphine and epi wash.

Fast forward to present day, I have had several (between 5-8 that I can recall) where the allis test failed or the patient was clearly uncomfortable and required a significant amount of IV meds or conversion to GA. I have now resorted to increasing my bupiv dose to 1.8-2mls and getting rid of the epi wash. It still happened the other day. My technique has not changed any since residency: I place at L3-4, aspirate at the beginning and end, lay the patient flat and test the level, tilt head up slightly when level reaches T6ish and re-test. I am not alone because I can think of atleast two instances where failures occurred to colleagues. I am suspicious that our kits are **** or that they are being degraded by something but I can't figure it out. I am also noticing that I am not always getting a sympathectomy.

Thoughts, commments......

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[urge]

Maybe your bupivacaine is bad.

 

[deleted126335]

Maybe your bupivacaine is bad.

We have had a lot of failed spinals over the past year or so. We suspect bad bupivicaine as well. These are mostly experienced practitioners. Even contacted the manufacturer who denied a problem.

 

[PainDrain]

I am very suspicious because I had a cluster and then one other guy had one, then things normalized for 3-4 months and then I just had another last week.

 

[urge]

I used to work in a place where the experienced OB anesthesiologist would use a separate bupivacaine vial over the one that came with the kit because they believed the drug in the kit didn't work.

 

[ZzzPlz]

I covered OB last week and had two epidural kits (in a row!) that were missing the test dose solution entirely. I can understand how your faith in these kits is questionable...

 

[narcusprince]

Write down the lot number. I have had this happen to myself, never had a failed spinal in residency had roughly 2-3 as an attending. If that happens I place an epidural and slowly bolus up the epidural. Interestingly enough you can test if your spinal was truly intrathecal. Original spinal had 1.4ml of .75% bupi pt was 5^0 with 200mcg duramorph and 20mcg fentanyl great swirl and it failed I then placed an epidural bolused it up with 2% lido with 1-200 thousand epi with 2meq of bicarb. Worked like a charm. Interestingly enough the effects of the narcotic in the original spinal were evident no pain meds needed in the first 24 hrs and the patient had some itching in the postop period I used 200mcg of duramorph and 20 mcg of fentanyl. So if the bupivicaine is bad and or degraded is this a contamination issue or storage. My thought was it may not be shipped at the appropriate temperature on the ampule.

 

[Noyac]

Bad bupiv. Get used to it or switch to your own stash of bupiv.
Other comments as I see it.
-ditch the epi. Your in PP and if the OBs can't do a c/s in under an hour then they suck.
-consider cutting down your MS dose but this is just my impression and 200mcg is not a bad dose but I find 100-150 does just as good but slightly less SEs. You will inevitably see larger and larger pts with OSA etc. no need to introduce resp depression if not necessary. I'm sure others might have a different opinion here.
-if the pt is greater than 5'2" then give a full 2cc (this includes your MS which means your adding 1.8-1.9 cc bupiv). If you go to isobaric which I haven't gone to yet with c/s then give a full 15 Mg. With that being said, I use 1.6 cc if they had an epidural running. And I add some Fent to it.
- finally, don't be afraid to put an OB pt to sleep. Your Duramorph will still work.

 

[Triple AAA]

Does anybody here routinely place CSEs for their C/S? Not that I do, but it may save a lot of headache, especially in the scenario described above. Never know when a spinal could go bad...

 

[Noyac]

That's a awful lot of work for something that might happen once or twice a year.

 

[nimbus]

Do you live/work in a hot climate? Years ago we had a cluster when I worked in the desert. Multiple doctors all during a 2-3 month period. We suspected our kits were sitting in delivery trucks and loading docks in 110-120degree weather.

 

[narcusprince]

Do you live/work in a hot climate? Years ago we had a cluster when I worked in the desert. Multiple doctors all during a 2-3 month period. We suspected our kits were sitting in delivery trucks and loading docks in 110-120degree weather.

Nimbus, I work in a very very equatorial hot enviorment and our bupivicaine comes in on a barge. My thoughts exactly.

 

[pjl]

I had a recent complete failure of kit Bup, but obvious narcotic effect. 100% reliable patient, absolutely no change. Perfect easy spinal. This was my first total failure of bup, but ~1.5 years ago I had 2 in a row with minimal effectiveness.

It seems a lot of guys on this board have had failures over past month or so based on comments. Wonder if they changed something in their processing.

BTW for dosing 1.6 mL should be more than enough, unless you have brand new resident OBs with med students closing and pause to watch a movie in the middle. Tell your OBs to quit sucking.

 

[pgg]

I had a recent complete failure of kit Bup, but obvious narcotic effect. 100% reliable patient, absolutely no change. Perfect easy spinal. This was my first total failure of bup, but ~1.5 years ago I had 2 in a row with minimal effectiveness.

We had a run of bad local in kits about a year ago. All from the same lot. 4 or 5 different anesthesiologists, including me, had perfect easy spinals and NO effect. We think the shipment probably sat on a pallet in the 110 degree central CA sun for an afternoon.

Also had a bad batch of succinylcholine in Afghanistan, for what we assume is the same reason.

BTW for dosing 1.6 mL should be more than enough, unless you have brand new resident OBs with med students closing and pause to watch a movie in the middle. Tell your OBs to quit sucking.

I used to do CSEs for repeat sections with a certain attending OB in residency, after getting burnt a couple times by her being slow, her talking a lot, her resident being slow, and her med student closing. Hard to believe a routine c-section can take hours ... god I think I'm getting PTSD just thinking about it.

Post residency it was a matter of seeing how little local I could get away with, in order to minimize recovery time. Spinal fentanyl helped.

Now I'm back at the teaching hospital where I trained, so I'll probably go full circle to CSEs for some patients, I mean OBs.

 

[Gimlet]

Does anybody here routinely place CSEs for their C/S? Not that I do, but it may save a lot of headache, especially in the scenario described above. Never know when a spinal could go bad...

I've adopted the approach of my favorite OB anesthesia attending in residency who considers CSEs a setup for fulfilling their own prophecy. The extra time the pt spends sitting up while you thread and secure the catheter equals more caudad spread of the hyperbaric intrathecal dose and shorter duration of adequate anesthesia at the higher dermatomes. I.E. if you just laid them down right away after dosing the spinal you wouldn't have needed the epidural anyway.

For 3rd or 4th time repeat sections that may go long I just give all 15mg of the bup in the kit and support the blood pressure liberally. I've had a few 3hr long sections (including cytso-ing for urethral injuries and calling gen surg for bowel lacs) where the patients were perfectly comfy the whole time using this approach.

 

[twoliter]

I was involved in a 4 hour c-section a few weeks ago (from skin to skin; ok, maybe 3.5 hours + waiting on x-ray 2/2 OR staff turnover and/or BMI -- I can't remember for sure). It was a combination of training facility, "extensive lysis of adhesions (one prior c-section)" per the most important reason for the long case -- a notoriously slow surgeon, etc. But no bowel/bladder injuries requiring repair or any other good reason for such a lengthy case. I let "the new guy" do the spinal before he left. Fortunately, I didn't end up having to regret that decision. A magical spinal with the routine 1.6 ml 0.75% bupivacaine, 20 mcg fentanyl, 200 mcg Duramorph. She started getting a little uncomfortable at the end, but no significant pain requiring treatment.

 

[Oggg]

I had at least two weak spinals where it got patchy and pt needed some extra sedation. Never a total failure. But at least two were able to move legs the whole surgery. Eek. And then a partner had the same problem. But it's been a while now. This was probably a few months ago.

 

[ranvier]

During residency, if the OB rotation was during summer, we were advised to use the heavy marcaine out of the pyxis not the vial in the spinal kit. The head of OB anesthesia was convinced that bad marcaine causing failed spinals was from the spinal kits sitting out in the sun (program in southwest) The meds in the pyxis were supposedly handled and shipped in a more controlled manner.

I had two failed spinals in the same week and I used marcaine from the kit. (2/300 or so)

 

[deleted171991]

That might be it. It's supposed to be stored between 68 and 77F.

 

[chmd]

I use 1.2cc of the heavy stuff or 1.4 if "tall." Plus 0.15 of duramorph. It's a lot less than I used in residency but I've had no problems yet -- n approx 100.

 

[narcusprince]

Makes sense I have not seen a day here under 80 degrees here.

 

[sevoflurane]

I'm sorry. Haven't read the entire thread...but what does "bad" marcaine actually do? Nothing at all? Missed dermatomes?

Here is my experience. Happened to me 3x and another time to a partner.

Good CSF, inject 1/2, pull more CSF, then inject the rest. No block after 15 minutes. 2nd (lower) dose... Nothing.

Patient wakes up after GA. Happy as a clam cuz she's got t10 levels.

I'm guessing my phenomena is totally different. Intrathecal space anatomy vs weird/bad marcaine? I'm going w/ #1.

 

[RxBoy]

I am sure this has been covered before but I need some advice. Been out a few years and I do OB from time to time. In residency I did alot of OB and we were a busy medical center with alot of high risk OB, etc. I never once had a spinal completely fail to the point where an allis test failed or was patchy. I had only a handful of blocks wear off prior to completion of the section (an this was academics so you can imagine what a typical section ran). In residency our typical dose was 1.6 (rarely 1.8) mls of 0.75% hyper bupi combined with 200mcg morphine and epi wash.

I had a failed spinal couple months ago. The spinal was textbook. One poke, double pop, excellent flow. Test was a no go, put her to sleep.

I personally think its the needle. I hate the pencan needle in all our trays. Actually I hate pencil point needles altogether. Yeah I know, literature says PDPH 8% cutting vs 2% pencil. But I swear the flow and injection of a quincke is amazing. Pencil points flow always seems shotty and I never feel confiendent after I inject. For the obese I go straight to the 25g Q. For the 65+ ortho club I go straight to the 22g Q. Everyone else gets the standard issue pencan in the kit. The only failed spinals Ive seen or performed were with the pencil points. Ironically the only PDPH incidents Ive had were after the pencil points (of course this has to do more with pt population). Of course my evidence is all ancedotal, but something worth considering.

 

[RxBoy]

One other point. One of my OB Anesthesia trained attendings used to aspirate in 4 positions while turning the needle in place. Sometimes he would have to advance or withdraw a mm to get the flow in all 4 positions. He always had the best spinals. The "my legs cant move" within a minute kind.

 

[RxBoy]

I guess I wasnt as crazy as I thought:

"Tip displacement must be guarded against with any type of spinal needle, but it is a particular issue with the ‘pencil point’ needles now used widely to minimize the incidence of post-dural puncture headache. The opening at the end of these needles is proximal to the tip, so only a minor degree of ‘backward’ movement during syringe attachment may result in epidural injection as was recognized at an early stage in the widespread use of such needles.12 The distances involved are of the order of a millimetre or two, but (as with leakage) misplacement of only a small amount of solution can have significant effects. An additional issue with pencil-point needles is that the opening, being much longer than the bevel of a Quincke needle, may ‘straddle’ the dura so that some solution reaches the CSF, and some the epidural space (Fig. 2).41 This may be exaggerated by the dura acting as a ‘flap’ valve across the needle opening. Initially, CSF pressure pushes the dura outwards so that aspiration is successful (Fig. 3A), but subsequent injection pushes the dura forward and the solution is misplaced (Fig. 3B)."

Just read this article.... Its a great read on this subject:
http://bja.oxfordjournals.org/content/102/6/739.full

 

[Gimlet]

So aspirate with the hole at 12, 3, 6, and 9 o'clock positions before injecting? Interesting...I may have to try that. Any issues with paresthesias with all that twisting of the needle or advancement after already in the subarachnoid space?

 

[dhb]

Not only that, sometimes you might be entering the subarachnoid space at a slight lateral angle giving the same result of partial injection into the csf

 

[Depakote]

While I'm all for working on my technique, I can say that we had a run of bad bupivicaine in our spinal kits where I did my OB training. This was consistent across multiple providers at that institution, plenty with years/decades of experience.

 

[ZzzPlz]

Seems to me like the best way to avoid a partial block 2/2 getting the eye stuck in the dura is to just drive the needle home until you meet bone and just back up a bit.

 

[Orin]

Could be, but that is a heat stable drug. They use bupivicaine in the tropics with no climate controlled storage.

http://apps.who.int/medicinedocs/pdf/h1808e/h1808e.pdf
WHO has studied it and found it to be stable at ~120 F for 30 d followed by ~160 F for 3 days.

 

[pgg]

Could be, but that is a heat stable drug. They use bupivicaine in the tropics with no climate controlled storage.

http://apps.who.int/medicinedocs/pdf/h1808e/h1808e.pdf
WHO has studied it and found it to be stable at ~120 F for 30 d followed by ~160 F for 3 days.

That's an interesting read.

Guess I should stop blaming FedEx and the loading dock crew for those failed spinals. I'm still blaming them for the bad succinylcholine though.