High Spinal
Started by epidural man
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deleted87051
No
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deleted171991
No. Btw, is there any other spinal than a lumbar-placed one? 🙂
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deleted171991
The question was more like: should there be one? 😉
The spinal cord ends in the lumbar area. Anything higher risks damage to it. Even lumbar spinals can cause cauda equina syndrome.
I've heard of a few academic cardiac places doing purposely high spinals and using very little narcotic for the case.
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That sounds safe.
I had a patient describe a high spinal to me once. Exquisitely large gentleman (6' 7", 300+lbs) who had a spinal done for a hernia repair in Japan. Took a little longer for the spinal to set in so they turned him over and repeated the spinal. Said he almost immediately started feeling flushed all over and began having difficulty breathing.
I knew a CRNA that experienced a high spinal for an elective case (I believe something with his knee). Initial spinal wasn't working with incision, the person doing his case repeated the spinal. He said within a minute of being turned back supine, he started having trouble breathing, then returned to conciseness in PACU.
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How do you repeat a spinal after the incision has been made?!?
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Yes. I've performed a few high lumbar spinals in the L1-L2 range accidentally. Sometimes I'll try for L2-L3 in the morbidly obese patients.
The odds of permanent neurological damage with a non cutting needle is extremely remote. But, these days we anticoagulate patients a lot more aggressively postop. I would never purposely do a SAB above the L2-L3 interspace.
The length of the spinal cord varies according to age. In the first trimester, the spinal cord extends to the end of the spinal column, but as the fetus ages, the vertebral column lengthens more than the spinal cord. At birth, the spinal cord ends at approximately L3 and in the adult, the cord ends at approximately L1 with 30% of people having a cord that ends at T12 and 10% at L3. Figure 4 shows a cross section of the lumbar vertebrae and spinal cord. The position of the conus medullaris, cauda equina, termination of the dural sac, and filum terminale are shown. A sacral spinal cord in an adult has been reported, though this is extremely rare.[37] The length of the spinal cord must always be kept in mind when a neuraxial anesthetic is performed, as injection into the cord can cause great damage and result in paralysis.[38]
NYSORA - The New York School of Regional Anesthesia - Spinal Anesthesia
NYSORA - The New York School of Regional Anesthesia - Spinal Anesthesia
If this thread is about a total spinal secondary to a large dose Of subarachnoid bupivacaine then the answer is yes. We have had 2 "high spinals" after injection of 15 mg of hyperbaric bupivacaine. That's not a lot of patients over 25 years considering the volume performed at my facility.
Both of these cases were elderly patients. I suspect injection occurred at the L2-L3 interspace with 15 mg of hyperbaric bupivacaine.
https://oatext.com/Complete-spinal-...-with-low-dose-bupivacaine-in-the-elderly.php
Both of these cases were elderly patients. I suspect injection occurred at the L2-L3 interspace with 15 mg of hyperbaric bupivacaine.
https://oatext.com/Complete-spinal-...-with-low-dose-bupivacaine-in-the-elderly.php
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The how is not that hard. I imagine it involved covering the incision with a sterile towel, rolling him on his side, repeating the spinal, then prepping again once repositioned. He never did tell that part of the story.
It's the 'why?' I never understood.
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. Several studies have shown that analgesia levels obtained after subarachnoid injection of hyperbaric local anesthetic solution are approximately 3–4 spinal segments higher in elderly compared with young adult patients.[8,9] Possible reasons include decreased leakage of local anesthetic through intervertebral foramina, decreased compliance of the epidural space in elderly resulting in greater spread or an increased sensitivity of the nerves in elderly.[10] Precipitous arterial hypotension due to high levels of sympathetic block remains a common and acute problem associated with spinal anesthesia in geriatric patients. Despite prophylactic measures such as fluid preload, it may be difficult to maintain a near normal blood pressure in these patients.
Thanks. This is good gouge. Everyone always says - "I've never heard of it."
This case makes no sense at all!
They are suggesting that the patient had a complete spinal following 5 mg Bupivacaine and 20 mcg Fentanyl that manifested as respiratory arrest and loss of consciousness without hypotension and only mild bradycardia!
Further, they say that the patient actually became hypertensive and they had to treat that hypertension.
My humble opinion here: This was an overdose of intrathecal Fentanyl and what they thought was 20 mcg maybe was more.
Only a high dose intrathecal fentanyl would logically produce this respiratory arrest without hemodynamic compromise.
Now even 20mcg of fentanyl could be too much for a tiny 80 Y/O lady but most likely they inadvertently gave more and then they came up with this fantastic theory and case report.
We all have seen these type of cases where people try to come up with magical explanations to justify a stupid error.
They could have inadvertently used sufenta instead of fentanyl. I've seen this happen. Not in a spinal but for a sedation case. The pt was given 2cc of sufenta but anesthesiologist thought it was fentanyl and the pt immediately became apneic and had a rigid chest. Unable to ventilate until paralyzed.
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deleted162650
Anyone ever heard of/seen a high spinal from Isobaric?
One of the old timer attendings in residency said that back in the dark ages, their anesthetic of choice for a splenectomy was a continuous total spinal. He said if BP got too high you just tilt the table into a little reverse T, and you almost hear all the blood slosh to their feet. BP too low - just put the head back down and hear all the blood slosh back to their head.
One of the old timer attendings in residency said that back in the dark ages, their anesthetic of choice for a splenectomy was a continuous total spinal. He said if BP got too high you just tilt the table into a little reverse T, and you almost hear all the blood slosh to their feet. BP too low - just put the head back down and hear all the blood slosh back to their head.
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I had my spleen removed in the 80's. I sure hope this isn't how they did it.Anyone ever heard of/seen a high spinal from Isobaric?
One of the old timer attendings in residency said that back in the dark ages, their anesthetic of choice for a splenectomy was a continuous total spinal. He said if BP got too high you just tilt the table into a little reverse T, and you almost hear all the blood slosh to their feet. BP too low - just put the head back down and hear all the blood slosh back to their head.
Sorry to point this out but thoracic rigidity is a myth, vocal cord closure more likely
How can you make the difference?
A couple of nice studies handled that for our benefit...
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deleted162650
All I'm gonna say is: if you've never seen anyone get total body rigidity from narcotics (I'm talking arm flexion, chest wall, neck, etc.) then you haven't given enough narcotic. I've seen this multiple times in residency when we would titrate in 15-25cc of fentanyl for crani inductions. Man those people woke up smooooooooth though.
Case Question - Aortic Stenosis
Prone spine case intubated. Narcotic bolus and inability to ventilate until relaxants given. Presented at the ASA circa 2010.
I will admit that I am more in the laryngeal muscle spasm camp than I am in the skeletal muscle rigid chest camp. It just makes more sense to me.
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deleted162650
Brussels sprout emoji?
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deleted162650
Because it's the truth.
Okay,
So I asked the question for this reason.
Would you do a spinal in someone who you knew you couldn't intubate - knowing the risk of a high spinal is extremely low.
The case is a inguinal hernia repair.
So I asked the question for this reason.
Would you do a spinal in someone who you knew you couldn't intubate - knowing the risk of a high spinal is extremely low.
The case is a inguinal hernia repair.
Yes, the alternatives are all rather poor. You already said he cannot be intubated (why?), so GETA is out, unless you plan on adding a trach to his planned surgery. I wouldn't do just sedation with local, as the probability of needing to convert to GA with that is higher than the probability of a total spinal. You could try a combination of TAP, ilioinguinal, lumbar PVB, or low ESB, with supplementation by the surgeon, but that could be a lot of local and carry a decent likelihood of failure. If you're really concerned with high spinal, a slowly titrated intrathecal catheter is also an option. I've done a few of them for the OR, they work great, and only take a few extra minutes.
Cancelling is also an option. How bad is the hernia?
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Absolutely. Hyperbaric Bupivacaine 10 mg. You could get away with a lower dosage but why bother when 10-12 mg is guaranteed to work and provide sufficient coverage.
Other Options include a Lumbar Plexus block, a QL block or an Erector Spinae Block at T9 or T10. A Neuraxial technique is the typical approach most providers would choose to perform.
A TAP Block isn't a good option because it misses the L1 dermatome so a QL or TFP would be required.
FYI, I'd be prepared to bet you 100K and give 20:1 odds that a spinal with hyperbaric 10 mg of bupivacaine would not lead to a "high spinal."
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So wait, you guys are all saying this is one of those 100% on the boards but never in real life entities?
And in regards to your case, the answer is yes, this logic essentially rules over the entire realm of OB with an iron fist.
I've already posted I had seen 2 "high spinals" in my career (non OB high spinals).. But, based on the fact that these 2 patients had large doses of IT Bupivacaine 15 mg and were elderly I consider the odds of a high spinal with a typical dosage of bupivacaine to be in the 1:10,000 range. Those are some good odds.
I knew I couldn't intubate the guy. Here is the story.
Moonlighting at a ASC with no fiberoptic capabilities. We do have a glidescope however. On preop, guy his healthy, young dude with no medical problems. Large face and jowls, but looks like an easy mask and intubation - except he couldn't open his mouth an inch. No history of jaw fracture.
At this point, I was about 75% sure I could open his mouth more after paralysis, so I proceeded with a general - but after sux, couldn't budge his mouth. I couldn't get an oral airway in. CRNA attempted a Mac blade, I told her to abandon immediately and I was able (scrapping his poor dentition all the way down) to place the glidesope blade, but for the first time ever for me, all I could see was blurred pink. I think I couldn't get the tongue out of the way enough to get the blade over it - despite me trying to push the tongue down with a depressor. Anyway, we messed around a little bit more until we abandoned the case and proceeded to wake him up. interestingly, at this point, he was very difficult to mask. That was stressful until he finally could support his own airway.
Anyway, in the PACU, we offered him a spinal for that day or the next day, or told him to go to hospital where they have fiberoptic optic availability. He had no desire to do a spinal. He also said this jaw problem was getting worse. We also told him he needed to get this fixed or looked at, and if he did that, he could come back to us.
Moonlighting at a ASC with no fiberoptic capabilities. We do have a glidescope however. On preop, guy his healthy, young dude with no medical problems. Large face and jowls, but looks like an easy mask and intubation - except he couldn't open his mouth an inch. No history of jaw fracture.
At this point, I was about 75% sure I could open his mouth more after paralysis, so I proceeded with a general - but after sux, couldn't budge his mouth. I couldn't get an oral airway in. CRNA attempted a Mac blade, I told her to abandon immediately and I was able (scrapping his poor dentition all the way down) to place the glidesope blade, but for the first time ever for me, all I could see was blurred pink. I think I couldn't get the tongue out of the way enough to get the blade over it - despite me trying to push the tongue down with a depressor. Anyway, we messed around a little bit more until we abandoned the case and proceeded to wake him up. interestingly, at this point, he was very difficult to mask. That was stressful until he finally could support his own airway.
Anyway, in the PACU, we offered him a spinal for that day or the next day, or told him to go to hospital where they have fiberoptic optic availability. He had no desire to do a spinal. He also said this jaw problem was getting worse. We also told him he needed to get this fixed or looked at, and if he did that, he could come back to us.
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Need a bit more data. Does "knew you couldn't intubate" mean you have evidence that FOI wouldn't/ hasn't worked in the past? My first choice is to take a look with FOI without any respiratory depressants on board. Drown them in topical lido and a stiff precedex bolus. Don't burn any airway bridges, and be okay with walking away (don't push it).
If the airway is a confirmed flog based on patient history/ previous fiber optic failure, then yes, spinal anesthetic would be a reasonable option. Would still have a parachute (cric kit, give ENT a heads up and ascertain their ETA in the event you needed a friend with a knife). Ultrasound in the room would also be a good idea, as this is gaining traction to help guide needle placement into trachea for emergent cric in known difficult airway/neck anatomy.
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Sorry just saw your post about how the original attempt with glide went. I do think spinal would be your best bet.
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I've had quite a few "failed glidescopes" during my career. Anyone who thinks the glidescope is always the answer to a difficult airway is a fool. The failure rate for glidescopes/Cmac, McGrath, etc is in the 5-8% range. That means you better have a backup plan ready to go besides the glidescope.
I agree with how you handled the case. If he had declined a spinal I would have likely suggested a Block such an Erector Spinae Block at T10. The block plus Ketafol would have worked nicely for this surgical case.
Did you every try to insert an LMA? If not, why not?
This patient needs a Fiberoptic intubation for his "jaw surgery" much more than he needs his hernia fixed.
Success for Glidescope intubation after failed direct laryngoscopy was 94%
Routine Clinical Practice Effectiveness of the Glidescope in Difficult Airway Management:An Analysis of 2,004 Glidescope Intubations, Complications, and Failures from Two Institutions | Anesthesiology | ASA Publications
GlideScope®‐assisted awake fibreoptic intubation: initial experience in 13 patients
Routine Clinical Practice Effectiveness of the Glidescope in Difficult Airway Management:An Analysis of 2,004 Glidescope Intubations, Complications, and Failures from Two Institutions | Anesthesiology | ASA Publications
GlideScope®‐assisted awake fibreoptic intubation: initial experience in 13 patients
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Blade,
I don't think I could have squeezed an LMA in there - but didn't try. I had recently read about a lawsuit in a plastic surgery center where the anesthesiologist (or CRNA - don't remember) couldn't intubate, and decided to do the case under LMA instead, and lost the airway in the case and it turned out bad. I had that fresh in my mind, so didn't consider an LMA an option since I knew I couldn't intubate. Had I not been able to ventilate while waking them up, I would have attempted to place an LMA just for ventilation purposes. We had one ready and set up.
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deleted697535
One of my staff cardiac anaesthesics regular shopping list for me to prepare in the morning was 2mg of fentanyl. He gave almost every single cabg about 30ccs in the 20 mins it took me to do the neck line and art line. I personally didn't see this rigidity nor did he say it was much of an issue
The first time he did it with me I nearly passed out with shock!
I'm not questioning the validity of cancelling the case. I'm just asking whether an LMA was utilized at all during the induction. I've been in all kinds of disasters and by no means am I implying that the LMA would have solved your problem. But, I have done cases under LMA where the glidescope failed provided the patient was an easy mask. That was not the situation in your case.
Big boluses will result in vocal cord closure, slow titration not so much even if the dose is huge.
That's an old school cardiac technique, hemodynamically stable but turns out not amnestic (opioid alone) and has fallen out of favor because of the progress towards fast track cardiac surgery.
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deleted87051
Yep that's how I learned in residency. Was combined with 20mg of versed. Old school TIVA. Not very elegant. And when I got out, the PP guys were using low dose inhalation agent and propopol. They were ahead of academics.
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