centrino

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After the incidence of my first failed spinal (before that my spinals actually worked well) I have been showered with more failed spinal. I'm really frustrated. What am I doing wrong? For more that a week I have been spending all my time in thinking what goes wrong.

I would appreciate the help of all of you experienced anaesthetists in this regard. I have asked the question from my seniors but I haven't gotten a single satisfactory answer. I searched a few books and the internet but to no avail.

I get the needle (25 G Quincke) in. In some cases when I feel an increased resistance for some distance, I stop, take the stylete out, get a free flowing CSF, connect the syringe, aspirate CSF confirm and inject 15 mg/2ml of bupivacaine. After a 1 ml injection a recheck by aspiration and then inject the remaining 1 ml. Put the patient supine immediately and wait. Even after 10 minutes the patient is able to move the legs. Skin pinch over lower abdomen seems painless so the surgery is started and as soon as the skin is started to cut, the patient feels pain. Now in this scenario I thought this is what made it go wrong: May be I felt the resistance, stopped a little too soon and my needle bevel was halfway into the subarachniod so that CSF could flow freely but while injecting the drug, not all of it was injected into the space resulting in a lower dose. I've read in a book that this is a possible explanation.

Most of failed spinals had partial effect and some had no effect. A few spinals that failed were repeated by a senior, two of the repeated ones worked ok but one of the repeat spinal was partial (done by a senior anaesthetist) and patient had to be heavily sedated.

Some factors (that may be contributory) that also changed since my spinals started to fail are:

1. In the hospital pharmacy (where most of the local anaesthetics are bought), there was a change of contract and a new group started running the pharmacy. (some tell me there is a problem in new stock but some spinals are successful and others fail, so this doesnt seem to be a problem.

2. Since a week or two the internal heating system in the OR has been started and the OR is really warm, I sometime feel sweaty in the gown cap n mask. The drug amouple stays in the OR for sometime atleast 15 min before the injection. Some of the old/experienced Anaesthesia Technicians tell me that if we cool down the drug, so that its cold right before injection it works and a reason of failed spinal is higher temperature of the drug. (Research goes against it, the hyperbaric bupicaine at 37 C has higher block than the one with lower temperature)


3. I have heard that one or two spinals have also failed in the hands of much experienced persons than me over the past two weeks.

4. Reaspiration at 1 cc injection and then injecting the last 1cc mixed with CSF, could this be causing variable effect?


Today I did a spinal and keeping my own judged mistake stated above in mind, I tried to appericiate the loss of resistence and I actually lost it and then removed the stylete and got clear CSF flowing and finally injected after confirmation. Everything went well. The patient appreciated the heaviness in her legs, skin pinch was painless, the surgeon started with Pfannensteil incision, cut the skin, the fat the rectus and reached the uterus (it was a case of abdominal hystrectomy). on touching the uterus the patient started shouting with pain and the surgeons complained of the patient being too tight. We had to stop the surgery, intubate the patient and continue under general anaesthesia. Now I'm further confused. Why did she felt no somatic pain but shouted with pain on visceral touch?

Why Why why.
There are so many whys I cannot answer. Please help me. Could it be that the drug was warm and didn't work. One drug that was kept in cold water before injection actually worked. But was it that my technique that was changed or was it actually the temperature of the drug that matter. What do I do wrong? Why after a satisfactory spinal injection, the block fails or gets partial

One more thing. All of my spinals I performed under direct supervision.
 

toughlife

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After the incidence of my first failed spinal (before that my spinals actually worked well) I have been showered with more failed spinal. I'm really frustrated. What am I doing wrong? For more that a week I have been spending all my time in thinking what goes wrong.

I would appreciate the help of all of you experienced anaesthetists in this regard. I have asked the question from my seniors but I haven't gotten a single satisfactory answer. I searched a few books and the internet but to no avail.

I get the needle (25 G Quincke) in. In some cases when I feel an increased resistance for some distance, I stop, take the stylete out, get a free flowing CSF, connect the syringe, aspirate CSF confirm and inject 15 mg/2ml of bupivacaine. After a 1 ml injection a recheck by aspiration and then inject the remaining 1 ml. Put the patient supine immediately and wait. Even after 10 minutes the patient is able to move the legs. Skin pinch over lower abdomen seems painless so the surgery is started and as soon as the skin is started to cut, the patient feels pain. Now in this scenario I thought this is what made it go wrong: May be I felt the resistance, stopped a little too soon and my needle bevel was halfway into the subarachniod so that CSF could flow freely but while injecting the drug, not all of it was injected into the space resulting in a lower dose. I've read in a book that this is a possible explanation.

Most of failed spinals had partial effect and some had no effect. A few spinals that failed were repeated by a senior, two of the repeated ones worked ok but one of the repeat spinal was partial (done by a senior anaesthetist) and patient had to be heavily sedated.

Some factors (that may be contributory) that also changed since my spinals started to fail are:

1. In the hospital pharmacy (where most of the local anaesthetics are bought), there was a change of contract and a new group started running the pharmacy. (some tell me there is a problem in new stock but some spinals are successful and others fail, so this doesnt seem to be a problem.

2. Since a week or two the internal heating system in the OR has been started and the OR is really warm, I sometime feel sweaty in the gown cap n mask. The drug amouple stays in the OR for sometime atleast 15 min before the injection. Some of the old/experienced Anaesthesia Technicians tell me that if we cool down the drug, so that its cold right before injection it works and a reason of failed spinal is higher temperature of the drug. (Research goes against it, the hyperbaric bupicaine at 37 C has higher block than the one with lower temperature)


3. I have heard that one or two spinals have also failed in the hands of much experienced persons than me over the past two weeks.

4. Reaspiration at 1 cc injection and then injecting the last 1cc mixed with CSF, could this be causing variable effect?


Today I did a spinal and keeping my own judged mistake stated above in mind, I tried to appericiate the loss of resistence and I actually lost it and then removed the stylete and got clear CSF flowing and finally injected after confirmation. Everything went well. The patient appreciated the heaviness in her legs, skin pinch was painless, the surgeon started with Pfannensteil incision, cut the skin, the fat the rectus and reached the uterus (it was a case of abdominal hystrectomy). on touching the uterus the patient started shouting with pain and the surgeons complained of the patient being too tight. We had to stop the surgery, intubate the patient and continue under general anaesthesia. Now I'm further confused. Why did she felt no somatic pain but shouted with pain on visceral touch?

Why Why why.
There are so many whys I cannot answer. Please help me. Could it be that the drug was warm and didn't work. One drug that was kept in cold water before injection actually worked. But was it that my technique that was changed or was it actually the temperature of the drug that matter. What do I do wrong? Why after a satisfactory spinal injection, the block fails or gets partial

One more thing. All of my spinals I performed under direct supervision.
possibly subdural.
 
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Jeff05

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it is possible that you pull the needle out slightly during your re-aspiration placing the tip subdurally/epidurally, etc.
 

militarymd

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According to one of my former Navy attendings....the guy who put in Bill Clinton's epidural for his patellar tendon repair.....

the most common cause of neuraxial blockade failure is related to the proximal end of the needle.
 

coprolalia

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Yeah, gotta agree with Mil here. You're undoubtedly moving the needle somehow before you inject. You gotta hold that sucker really still.

-copro
 

Planktonmd

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According to one of my former Navy attendings....the guy who put in Bill Clinton's epidural for his patellar tendon repair.....

the most common cause of neuraxial blockade failure is related to the proximal end of the needle.
They did the surgery under epidural anesthesia??
 

Noyac

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According to one of my former Navy attendings....the guy who put in Bill Clinton's epidural for his patellar tendon repair.....

the most common cause of neuraxial blockade failure is related to the proximal end of the needle.
:slap: (this is how I picture Mil's attending teaching him or whomever)
 
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toughlife

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According to one of my former Navy attendings....the guy who put in Bill Clinton's epidural for his patellar tendon repair.....

the most common cause of neuraxial blockade failure is related to the proximal end of the needle.
In other words, if the operator sucks..... :D
 

toughlife

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I think a general would have even been fine. But the last thing I would have done is an epidural but thats my opinion.

Knowing you, you'd have prolly gone with some slick regional block besides spinal or epi. Or not.
 

militarymd

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I think a general would have even been fine. But the last thing I would have done is an epidural but thats my opinion.
In general, one tries to not give general anesthesia to the president of the United States when possible....
 

Hawaiian Bruin

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Some guys around here have started getting a fresh vial of marcaine for spinals rather than use the vial that comes in our kits, cuz they've seen this happen a couple times when they were SURE they were intrathecal throughout injection, and figure that some of the spinal kits must have bad drug in them.

Some others say that's a buncha crap.

Since I haven't had it happen to me yet I'm skeptical, but the ones who claim this are people whose clinical judgment I definitely trust.
 

Monty Python

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Bad lot of bupivicaine?

Are several other people having problems?

I believe there is the occasional bad lot of ineffective bupi. At my local VA, (staffed by me, another CRNA, and one anesthesiologist) most of the hernias are done under spinal. We have a very high success rate.

The three of us ran into a week-long stretch where not a single spinal (N=8) worked. On the last one I wanted a witness to my technique, which had never been a problem prior. I inserted the spinal, got CSF, then turned it over to the anesthesiologist who performed his own confirmation tests. He injected and we both saw CSF aspirate before and after injection.

Didn't work.

This was in the middle of the Louisiana summer, and it wasn't uncommon for boxes to sit in the sunlight on the delivery dock for hours. Who knows if the bupi was affected by the heat before the spinal trays finally wound up in the OR ?
 

Bertelman

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Some guys around here have started getting a fresh vial of marcaine for spinals rather than use the vial that comes in our kits, cuz they've seen this happen a couple times when they were SURE they were intrathecal throughout injection, and figure that some of the spinal kits must have bad drug in them.

Some others say that's a buncha crap.

Since I haven't had it happen to me yet I'm skeptical, but the ones who claim this are people whose clinical judgment I definitely trust.
The bupiv is separate from our kits. Maybe that's why.
 
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