Inadequate Spinal

[Green Chimneys]

Hey guys, mostly a lurker here. Had a case today of an inadequate spinal for C-Section. Was interested in soliciting thoughts from the gurus here as to potential causes and how to avoid them in the future. Here's the case:

23 yo for repeat C/S #3 and BTL. PMHx morbid obesity (5'4" 276#), pregnancy induced hypertension. Epidural for C/S#1 and spinal for #2. I was told "It took them over 30 minutes of poking me to get it last time." OB expects this to be tricky, but still less than an hour and a half skin to skin.

I had no trouble accessing CSF at L2-3 (I think, landmarks were practically non existant) with a midline approach and a 25G sprotte. Rotated needle 180 degrees before injecting 12mg hyperbaric bupiv + 10mcg Fent + 0.2mg duramorph. Easy to aspirate CSF before, halfway, and after the injection. 100% sure that I did not mix up the skin vs intrathecal medications. Layed her supine with left-uterine displacement. Block set up nicely with good level. Surgery started with no problem or discomfort. Long and complicated with lots of scar tissue. Took almost 50 minutes just to get the baby. At about 60 minutes, the patient started getting some discomfort which responded well to 50mcg of fentanyl. More surgical difficulty as ovarian artery nicked. 10 minutes later more pain, fentanyl less effective this time. Anxiety seemed to be playing a component so I dosed some versed with no effect, and more fentanyl with no effect. By 80 minutes after placement of spinal, patient had a boatload of narcs and was about to sit up off the table, so we went to sleep. Smooth sailing from there. Total skin-skin was just over 2 hours.

I've never had a spinal wear off that quickly with that cocktail. Considering the block initially set up as expected and with easy CSF aspiration before and after injection, it presumably made it to the right place. The only thing I could come up with was that perhaps the opening in my spinal needle actually straddled the dura, wasting a chunk of the medicine in the epidural space (see here: http://www.csen.com/failed.pdf ). Any other thoughts? If this situation was my problem, does anyone have any tips for preventing that from happening? The article suggests perhaps rotating the needle, but I did that. Anything else? Is this just one of those s**t luck situations I may not be able to predict? Thanks again for any insight to any other residents and everybody else killin' it out there in the "real" world.

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[Idiopathic]

Hey guys, mostly a lurker here. Had a case today of an inadequate spinal for C-Section. Was interested in soliciting thoughts from the gurus here as to potential causes and how to avoid them in the future. Here's the case:

23 yo for repeat C/S #3 and BTL. PMHx morbid obesity (5'4" 276#), pregnancy induced hypertension. Epidural for C/S#1 and spinal for #2. I was told "It took them over 30 minutes of poking me to get it last time." OB expects this to be tricky, but still less than an hour and a half skin to skin.

I had no trouble accessing CSF at L2-3 (I think, landmarks were practically non existant) with a midline approach and a 25G sprotte. Rotated needle 180 degrees before injecting 12mg hyperbaric bupiv + 10mcg Fent + 0.2mg duramorph. Easy to aspirate CSF before, halfway, and after the injection. 100% sure that I did not mix up the skin vs intrathecal medications. Layed her supine with left-uterine displacement. Block set up nicely with good level. Surgery started with no problem or discomfort. Long and complicated with lots of scar tissue. Took almost 50 minutes just to get the baby. At about 60 minutes, the patient started getting some discomfort which responded well to 50mcg of fentanyl. More surgical difficulty as ovarian artery nicked. 10 minutes later more pain, fentanyl less effective this time. Anxiety seemed to be playing a component so I dosed some versed with no effect, and more fentanyl with no effect. By 80 minutes after placement of spinal, patient had a boatload of narcs and was about to sit up off the table, so we went to sleep. Smooth sailing from there. Total skin-skin was just over 2 hours.

I've never had a spinal wear off that quickly with that cocktail. Considering the block initially set up as expected and with easy CSF aspiration before and after injection, it presumably made it to the right place. The only thing I could come up with was that perhaps the opening in my spinal needle actually straddled the dura, wasting a chunk of the medicine in the epidural space (see here: http://www.csen.com/failed.pdf ). Any other thoughts? If this situation was my problem, does anyone have any tips for preventing that from happening? The article suggests perhaps rotating the needle, but I did that. Anything else? Is this just one of those s**t luck situations I may not be able to predict? Thanks again for any insight to any other residents and everybody else killin' it out there in the "real" world.

while its tough to say, this could have burned you. what ive been told (although i dont do it) is rotation of the needle through 360 degrees, followed by aspiration, allows you some reassurance that you are invested in the intrathecal space. all you are theoretically doing by rotating 180 is forcing more of your heavy marcaine down into the sacral area, where it does you little, if any, good, in an abdominal surgery. id wager that you had a great level that receded, either because you left the patient upright too long or because you "shoved" more of your local to the lower dermatomes, for lack of a better phrase. however this is purely conjecture.

i wonder if the patients legs were still weak, and if her perineum was insensate, while this was going on?

 

[Green Chimneys]

A good point, idio, and one I didn't consider. I rotated the needle initially because CSF to gravity seemed a little sluggish and perhaps that did me in. Whether that was the culprit here or not, it's the last time I think I'll be doing that.

 

[Robert Loblaw]

A good point, idio, and one I didn't consider. I rotated the needle initially because CSF to gravity seemed a little sluggish and perhaps that did me in. Whether that was the culprit here or not, it's the last time I think I'll be doing that.

Just parenthetically, for a 3rd time redo elective c/s--irrespective of morbid obesity--you might as well place an epidural catheter after your spinal. I wouldn't care what the obstetrician says...

 

[Green Chimneys]

Just parenthetically, for a 3rd time redo elective c/s--irrespective of morbid obesity--you might as well place an epidural catheter after your spinal. I wouldn't care what the obstetrician says...

Oh believe me, I was on board with that plan. Attending said nah. So I suggested if not to place an epidural catheter then how about just to make the SAB easier since she was a wrecking ball with a history of a difficult spinal placement? We elected to just go with the introducer and the sprotte. Lessons to be learned from this one...

 

[Idiopathic]

Just parenthetically, for a 3rd time redo elective c/s--irrespective of morbid obesity--you might as well place an epidural catheter after your spinal. I wouldn't care what the obstetrician says...

certainly you can argue that

 

[Dejavu]

From 35 yrs experience I say this was just a crap case on an obese pt that you handled quite well.

Kudos for even getting a spinal in her. One thing you could have tried along with your Fent/Versed is Ketamine, from 10 to 30 mg or so. That may have stretched your spinal a little longer, but there was nothing wrong with easing her off to GA land either. It is what I would have done if the Ketamine didn't help.

S**t happens, I say.

I think you handled this case exactly like a board examiner would expect you to.

 

[Planktonmd]

From 35 yrs experience I say this was just a crap case on an obese pt that you handled quite well.

Kudos for even getting a spinal in her. One thing you could have tried along with your Fent/Versed is Ketamine, from 10 to 30 mg or so. That may have stretched your spinal a little longer, but there was nothing wrong with easing her off to GA land either. It is what I would have done if the Ketamine didn't help.

S**t happens, I say.

I think you handled this case exactly like a board examiner would expect you to.

Agree!
You will see that there are spinals that will just not work as you want them.
It's just not an exact science and occasionally you get unexpected results.
Maybe 15 mg would have been a better dose here but who knows...

 

[jwk]

What you need is to finish residency and get out into private practice and the land of 15 minute sections. 50 minutes just to get to the baby? I've never seen one take that long, even in training.

 

[imfrankie]

What you need is to finish residency and get out into private practice and the land of 15 minute sections. 50 minutes just to get to the baby? I've never seen one take that long, even in training.

Yes, it is an amazing and beautiful revelation--fast surgeons. Makes private practice fun. (Nice job hanging in there, btw. She was lucky to have you.)

 

[Robert Loblaw]

What you need is to finish residency and get out into private practice and the land of 15 minute sections. 50 minutes just to get to the baby? I've never seen one take that long, even in training.

Wow, even for third c/s?

 

[BLADEMDA]

From 35 yrs experience I say this was just a crap case on an obese pt that you handled quite well.

Kudos for even getting a spinal in her. One thing you could have tried along with your Fent/Versed is Ketamine, from 10 to 30 mg or so. That may have stretched your spinal a little longer, but there was nothing wrong with easing her off to GA land either. It is what I would have done if the Ketamine didn't help.

S**t happens, I say.

I think you handled this case exactly like a board examiner would expect you to.

For Sections lasting over 70 minutes I add Epi to the mix. Just a little epi goes a long way in getting a reliable 90 minute surgical block.

Ketamine is fine provided the end is in sight. I agree that GA in the case described her was the right decision.

 

[Green Chimneys]

For Sections lasting over 70 minutes I add Epi to the mix. Just a little epi goes a long way in getting a reliable 90 minute surgical block.

Ketamine is fine provided the end is in sight. I agree that GA in the case described her was the right decision.

How much epi do you add? The spinal kit we use comes with a vial of 1ml of 1:1000 and some attendings have had me draw it up and squirt it out before adding the local, but I've never added any measurable amount to the cocktail.

With regards to the ketamine, that is something that multiple people I've run the case by suggested and have had success with. To be quite honest I didn't think of it at the time. My question to Special K supporters, how deeply do you think it is safe to sedate a patient at high risk for aspiration? She really needed to stop moving and tensing up for OB to finish, and I was nervous that getting her to that point (be it with fentanyl, versed, propofol, or what have you) could have brought a load of puke in to the equation. I did end up suctioning about 20-30cc of bilious junk from her stomach after conversion.

And JWK, 15 minute sections? That...Is...Awesome! But hey I'm a resident too, and while I try, I know I'm not ROKKSTARR fast at everything yet either. Willing to play the game and keep my head down while I hone those mad skills.

 

[dhb]

My question to Special K supporters, how deeply do you think it is safe to sedate a patient at high risk for aspiration? She really needed to stop moving and tensing up for OB to finish, and I was nervous that getting her to that point (be it with fentanyl, versed, propofol, or what have you)

K is not a great sedative, at low doses 0.5mg/kg you will not take away airway reflex provided you haven't already given other medications. I think it can work if you need to buy a little time but not if you have a long way to go before the end of the case.

 

[jwk]

And JWK, 15 minute sections? That...Is...Awesome! But hey I'm a resident too, and while I try, I know I'm not ROKKSTARR fast at everything yet either. Willing to play the game and keep my head down while I hone those mad skills.

My personal favorite is C/S twins with a tubal ligation in 10 minutes flat. No wasted motion, great assistant, impressive to watch. I'd guess about 80% of our sections are under the 30 minute mark from incision to dressing on.

We still have our slow guys too - I start to get really antsy after about 40 minutes, and on the couple guys that take an hour +, I'm ready to pull my hair out.

 

[Dejavu]

"She really needed to stop moving and tensing up "

One reason Ketamine may have helped is that it is analgesic, so she may have quit wiggling.

Whenever surgeons complain about pt movement in a case like this, one does wonder if the surgeon was starting to blame you for their lack of surgical prowess.

 

[BLADEMDA]

For slow surgeons I add 0.1 mg epi to the Bup. It adds about 20-30 minutes of surgical anesthesia to the spinal.

 

[dhb]

My personal favorite is C/S twins with a tubal ligation in 10 minutes flat. No wasted motion, great assistant, impressive to watch. I'd guess about 80% of our sections are under the 30 minute mark from incision to dressing on.

Impressive, my personal best for c/s is 20min in & out of the room w GA