Interesting OB case

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Called to the labor floor 2am (of course) Pt for C-section. Primigravada, ruptured, not progessing, non-reassuring tracing, not STAT, but need to go relatively soon. Obese, crappy airway exam, Not horrible. SLOW Obstetrician. 90 minutes typical, often worse, skin-skin for C-section. Mom is a former hydrocephalus kid, with an existing V-P shunt. Last revision 1 year ago.

Your Ball.
 
Did anyone say awake retrograde wire yet? :naughty:


Does she have a headache, any reason to believe the VP shunt is not functioning? No? CSE as well.

Lots of women with prior intracranial HTN issues will re-develop or worsen the problem during pregnancy, but a functioning shunt should make this a non-issue.

Given a functioning shunt and normal ICP, there's not much special about her. Two theoretical risks come to mind. If her CSF volume is decreased you might get a higher level than expected from your intrathecal dose. CSE with a conservative spinal dose might be prudent; you can always give more via the epidural. And maybe a higher risk of shunt infection, not from the spinal or epidural anesthesia, but at the other end in the abdomen after the OBs get into the peritoneum. But you're going to give her antibiotics anyway, so nothing special to do there.
 
What I did: my usual plain old bupivicaine spinal plus dura morph.

What happened: worked great for about 40 minutes. Did the usual temporizing with IV agents plus supplemental nitrous by mask to get through the case.

In retrospect, I wonder if the fluid dynamics of the shunt sped the offset of the spinal.

Next time CSE.
 
dr doze said:
What I did: my usual plain old bupivicaine spinal plus dura morph.

What happened: worked great for about 40 minutes. Did the usual temporizing with IV agents plus supplemental nitrous by mask to get through the case.

In retrospect, I wonder if the fluid dynamics of the shunt sped the offset of the spinal.

Next time CSE.
Click to expand...

We do cse's for cases like these at my hospital, but I think a straight epidural would have been my choice here. When you're looking at a slow OB that very well may outlast your spinal you want to make sure the epidural works before starting the case. Nice job getting through without GA.
 
What is the downside to CSE? I see none (I've never had a high spinal).
In fact, I believe this is a perfect case for a CSE.

We've all seen patchy epidurals. I'm pretty sure a patchy epidrual for 30 minutes is way better than a patchy epidural for 90 minutes in a potential dif. AW.
The spinal buys you time. If you don't have a spinal on board at the 60-80 minute mark, some people do enough IV and inhaled anesthetics to cover a patchy epidural that it becomes a near general (if not full) in a full stomach patient.

Thanks for posting Doze. I will need to look up the effect of having a shunt during placement of intrathecal meds. Def. something to consider. 👍
 
http://www.ncbi.nlm.nih.gov/pubmed/19669021

The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

Nothing here about duration of spinal anesthesia with VP shunts. These patients may benefit from an epi wash (which I personaly don't routinely do).
 
sevoflurane said:
Nothing here about duration of spinal anesthesia with VP shunts. These patients may benefit from an epi wash (which I personaly don't routinely do).
Click to expand...

We have a couple attendings that will do epi wash for like a 2nd C-section. Anecdotally it definitely prolongs the duration of the block. I guess the counter-argument could be made that if you were really concerned about the case going long, just go for the CSE.
 
sevoflurane said:
......Nothing here about duration of spinal anesthesia with VP shunts. These patients may benefit from an epi wash (which I personaly don't routinely do).
Click to expand...

Epi wash with hyperbaric spinal bupivacaine? I thought Epi didn't significantly prolong the duration of bupivacaine. At least that's what I remember reading in the books a few years ago. Do you have experience with this? Would be an interesting thought.

The only agent I've used Epi wash with for spinal is tetracaine.
 
I'm of the opinion that either you need epi or you don't. If I think I need it, I use 0.1mL. If I don't think I need it , I don't use it. I don't buy the epi wash thing. No good evidence for my opinion, just my opinion.


rsgillmd said:
The only agent I've used Epi wash with for spinal is tetracaine.
Click to expand...

What were you doing that you needed epi to go along with tetracaine? Did you need 18hrs out of your spinal?
 
TrustMe said:
I'm of the opinion that either you need epi or you don't. If I think I need it, I use 0.1mL. If I don't think I need it , I don't use it. I don't buy the epi wash thing. No good evidence for my opinion, just my opinion.
Click to expand...

I think epi wash is about .5-.1ml if you coat your entire 5 cc syringe. I'll have to check though. I haven't had to use it outside of academics as we do skin to skin in about 30-45 minutes on routine cases.
 
I am familiar with the pediatric spinal literature and epinephrine definitely does prolong spinal anesthetics with bupivacaine and tetracaine for neonates/infants undergoing lower abdominal/perineal surgeries. It seems to add approximately 20 minutes to the 60 and 100 min duration of those respective drugs.

I have only ever used hyperbaric solutions in this population.
 
CSE... haven't recalled epi-wash in a long time... will have to dwell on that and maybe try it again... nice post and replies.
 
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