Failed spinal or epidural

[loveumms]

I know what our texts and literature say but I'm wondering what others do in clinical practice.

You are on OB and have the following scenarios:

- ASA 1, thin female with good airway: you injected 1.6ml 0.75% bupi and have a patchy spinal block. Completely elective c-section. Do you put more bupi in or do you go to GA?

- What about if this pt was super morbidly obese and MP IV?

- ASA 1, thin female with epidural that is patchy, been running for 12 hours and you need to do c-section for failure to progress. Do you place a spinal or try and bolus epidural?

- ASA 1, thin female with good functioning epidural and MP II with otherwise decent airway. C/S for failure to progress. 20ml of 2% lido given and patchy block. Do you do a spinal or do you convert to GA?

- What about if the above pt was large and poor airway?

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[lane]

I know what our texts and literature say but I'm wondering what others do in clinical practice.

You are on OB and have the following scenarios:

- ASA 1, thin female with good airway: you injected 1.6ml 0.75% bupi and have a patchy spinal block. Completely elective c-section. Do you put more bupi in or do you go to GA?

- What about if this pt was super morbidly obese and MP IV?

- ASA 1, thin female with epidural that is patchy, been running for 12 hours and you need to do c-section for failure to progress. Do you place a spinal or try and bolus epidural?

- ASA 1, thin female with good functioning epidural and MP II with otherwise decent airway. C/S for failure to progress. 20ml of 2% lido given and patchy block. Do you do a spinal or do you convert to GA?

- What about if the above pt was large and poor airway?

Patchy spinal?

Ketamine + N2O can be magic if you have a partially inadequate block. If that doesn't work then they buy a tube.

 

[IlDestriero]

QUOTE=loveumms;14542027]I know what our texts and literature say but I'm wondering what others do in clinical practice.

You are on OB and have the following scenarios:

- ASA 1, thin female with good airway: you injected 1.6ml 0.75% bupi and have a patchy spinal block. Completely elective c-section. Do you put more bupi in or do you go to GA?
GA or wait 10 min, reassess and repeat spinal w/o opioid.

- What about if this pt was super morbidly obese and MP IV?
Spinal catheter with epidural cath or wait a few min and redo w/o opioid. I'm leaning towards catheter.
What's a patchy spinal BTW?

- ASA 1, thin female with epidural that is patchy, been running for 12 hours and you need to do c-section for failure to progress. Do you place a spinal or try and bolus epidural?
Spinal

- ASA 1, thin female with good functioning epidural and MP II with otherwise decent airway. C/S for failure to progress. 20ml of 2% lido given and patchy block. Do you do a spinal or do you convert to GA?
Wait and do a spinal. GA for fetal issues.

- What about if the above pt was large and poor airway?
Wait and do a spinal. How long to wait?
I say an hour. You just bolused 20cc of lido and you don't want a high spinal. With an hour to redistribute I think the risk is low. This happened to my wife BTW. No fetal distress, thin with EZ airway. Epidural seemed fine and failed with the bolus. Waited an hour and did spinal.
I've seen this a few times.

 

[RxBoy]

I know what our texts and literature say but I'm wondering what others do in clinical practice.

You are on OB and have the following scenarios:

- ASA 1, thin female with good airway: you injected 1.6ml 0.75% bupi and have a patchy spinal block. Completely elective c-section. Do you put more bupi in or do you go to GA?

GA

- What about if this pt was super morbidly obese and MP IV?

IT cath with low dose bupivicaine. Titrate slowly. IT morphine and pull at end of case. HA I can deal with, lost airway I can't.

- ASA 1, thin female with epidural that is patchy, been running for 12 hours and you need to do c-section for failure to progress. Do you place a spinal or try and bolus epidural?

Pull epidural. Spinal with IT morphine

- ASA 1, thin female with good functioning epidural and MP II with otherwise decent airway. C/S for failure to progress. 20ml of 2% lido given and patchy block. Do you do a spinal or do you convert to GA?


Rebolus 10-20 cc lido 2% + epi and wait 5 minutes. Still inadequate then GA. Been taught doing a spinal after bolusing an epidural is high risk for total/high spinal.

- What about if the above pt was large and poor airway?

IT cath with low dose bupivicaine. Titrate slowly to avoid total spinal. IT morphine and pull at end of case.

 

[IlDestriero]

Rebolus 10-20 cc lido 2% + epi and wait 5 minutes. Still inadequate then GA. Been taught doing a spinal after bolusing an epidural is high risk for total/high spinal.

- What about if the above pt was large and poor airway?

IT cath with low dose bupivicaine. Titrate slowly to avoid total spinal. IT morphine and pull at end of case.

You won't repeat a spinal but you'll drive a 17g touhy needle in there and assume the flimsy catheter will somehow seal the hole and keep the lido from your epidural bolus from going IT and causing a high spinal? I'm not so sure about that one.

 

[loveumms]

Thanks.

Patchy spinal is one where you get a partial block. Had a chick the other day where we got excellent CSF return at beginning and end of injection. Thought we had good levels, negative alice on bottom left and top right; negative the opposite. Made incision and as they were dissecting down, she started complaining of pain.

I converted to GA because she had easy airway and they had already made incision. The resident said some other staff would do another spinal. I was just curious what others would do.

 

[IlDestriero]

Thanks.

Patchy spinal is one where you get a partial block. Had a chick the other day where we got excellent CSF return at beginning and end of injection. Thought we had good levels, negative alice on bottom left and top right; negative the opposite. Made incision and as they were dissecting down, she started complaining of pain.

I converted to GA because she had easy airway and they had already made incision. The resident said some other staff would do another spinal. I was just curious what others would do.

Once they've cut it's game over. GA.
If she's 400 lbs with micrognathia and a full beard and a hx of inability to intubate, I'd probably awake fiber otherwise just DL +/- glide.

 

[RxBoy]

You won't repeat a spinal but you'll drive a 17g touhy needle in there and assume the flimsy catheter will somehow seal the hole and keep the lido from your epidural bolus from going IT and causing a high spinal? I'm not so sure about that one.

redo epidural: Who knows if it will work 2nd time around. If it doesn't work, your forced into GA.

GA: Airway disaster. Highest risk of death.

IT cath: Sure, risk of lidocaine entering space. But like I said, titrate really slowly. IT 5 mg bupivacaine + little fentanyl. then maybe 2.5 mg increments. Thats the advantage of the catheter. A straight single shot, you'll probably overdose and cause high spinal. Beauty of catheter, you know it will work and since she is obese, you can always re-bolus if it takes too long.


Question for you: Lets say you bolus epidural lidocaine 2% 20 cc. THen you take touhy and puncture dura then immediately withdraw needle. Without adding any meds in the space, would you get a total spinal?

 

[deleted9493]

Once they've cut it's game over. GA.
If she's 400 lbs with micrognathia and a full beard and a hx of inability to intubate, I'd probably awake fiber otherwise just DL +/- glide.

Do you ever or would you ever consider a topicalized, awake DL in a cooperative patient? (e.g. hurricane spray and a touch of midazolam)

 

[Idiopathic]

redo epidural: Who knows if it will work 2nd time around. If it doesn't work, your forced into GA.

GA: Airway disaster. Highest risk of death.

IT cath: Sure, risk of lidocaine entering space. But like I said, titrate really slowly. IT 5 mg bupivacaine + little fentanyl. then maybe 2.5 mg increments. Thats the advantage of the catheter. A straight single shot, you'll probably overdose and cause high spinal. Beauty of catheter, you know it will work and since she is obese, you can always re-bolus if it takes too long.


Question for you: Lets say you bolus epidural lidocaine 2% 20 cc. THen you take touhy and puncture dura then immediately withdraw needle. Without adding any meds in the space, would you get a total spinal?

i dont think so. i believe that the lumbar csf pressure, especially in the upright position, is higher than the pressure exerted against the dura from an epidural injection already given and i think it is the rare case where you get translocation of epidural volume into the intrathecal space. there will be some mixture, but i dont think it is clinically that significant.

 

[urge]

Do you ever or would you ever consider a topicalized, awake DL in a cooperative patient? (e.g. hurricane spray and a touch of midazolam)

I have only seen that done once in a hospital with no advanced airway equipment. It wasn't pretty.

 

[urge]

Thanks.

Patchy spinal is one where you get a partial block. Had a chick the other day where we got excellent CSF return at beginning and end of injection. Thought we had good levels, negative alice on bottom left and top right; negative the opposite. Made incision and as they were dissecting down, she started complaining of pain.

I converted to GA because she had easy airway and they had already made incision. The resident said some other staff would do another spinal. I was just curious what others would do.

I don't do spinal over spinal. I don't know how much local is needed. There is a good chance you can over do it and end up intubated anyway or maybe not give enough the 2nd time around either. It's a lose lose scenario for me.

 

[Idiopathic]

the literature ive read reports close to 10% incidence of high spinal when IT is attempted following failed epidural bolus (this is the most common failure ive had), so I need to plan to go to sleep in those patients if i choose to redo the spinal. if the airway is tragic, they get delayed (a viable option) and another block is placed, or they get appropriate airway management. i do not want to get in a situation with a high spinal while the drapes are up. its an awful position to be in.

regarding patchy spinal, ive had this a few times too, and unfortunately you usually find out as they are delivering the baby...the discomfort persists through closure. I supplement with IV ketafol, midaz, nitrous, whatever it takes. i try not to put the patient to sleep at that point unless its just miserable.

like with so many things, you can be right or wrong and still have a good plan. the key is to have a backup and a backup for your backup.

 

[OB1🤙]

Patchy spinal is a red flag for me for a possible subdural (rather than subarachnoid) block. Tread carefully, these can track high.

http://www.ncbi.nlm.nih.gov/pubmed/19258982

 

[Idiopathic]

never had a spinal that i suspected of being subdural, had about 10 or 15 epidurals that i would have bet on it

 

[fakin' the funk]

You are on OB and have the following scenarios:

- ASA 1, thin female with good airway: you injected 1.6ml 0.75% bupi and have a patchy spinal block. Completely elective c-section. Do you put more bupi in or do you go to GA?

GA

- What about if this pt was super morbidly obese and MP IV?

IT cath with low dose bupivicaine. Titrate slowly. IT morphine and pull at end of case. HA I can deal with, lost airway I can't.

- ASA 1, thin female with epidural that is patchy, been running for 12 hours and you need to do c-section for failure to progress. Do you place a spinal or try and bolus epidural?

Pull epidural. Spinal with IT morphine

- ASA 1, thin female with good functioning epidural and MP II with otherwise decent airway. C/S for failure to progress. 20ml of 2% lido given and patchy block. Do you do a spinal or do you convert to GA?


Rebolus 10-20 cc lido 2% + epi and wait 5 minutes. Still inadequate then GA. Been taught doing a spinal after bolusing an epidural is high risk for total/high spinal.

- What about if the above pt was large and poor airway?

IT cath with low dose bupivicaine. Titrate slowly to avoid total spinal. IT morphine and pull at end of case.

+5 out of 5. No issues with any of your decisions.

#1, no brainer.
#2, would probably do awake FOI/GA or if a/w reassuring other than MP4, i.e. no edema, decent jaw and neck mobility, prop/sux/tube, glidescope and LMAs in room
#3, who the hell is letting an epidural be patchy for 12 hours? If patchy but I "believe" in the epidural, I bolus. If someone dodgy put it in or it's been bolused already, spinal vs GA.
#4 GA
#5 see #2

 

[Spinach Dip]

Do you ever or would you ever consider a topicalized, awake DL in a cooperative patient? (e.g. hurricane spray and a touch of midazolam)

Why? Are you looking for volunteers?