OB case.

[sevoflurane]

... Wrong thread.

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[Mman]

Seems like a pretty average case to me. Prior spinal fusion is the only real complicator, but spinals are usually easy and work well in those patients. It's an epidural that probably is impossible to place or get to function well.

I'd talk to the OB and figure out what sort of time frame this baby needs to be delivered in. Wait for some labs if possible. Take her in the OR and put in a spinal, maybe with an epi wash if I'm thinking this OB is going to be slow. If we got a spinal creeping up high? Tilt the bed. Crank up her head. The odds of getting a spinal so high you'd have to intubate is probably < 1:5000. If you have to intubate, not all MP4 airways are the same and airway management depends on the situation.

 

[BuzzPhreed]

All of this reminds me of a case not that long ago where the parturient was full-term and was febrile with RSV. She couldn't lay flat without uncontrollable coughing. Had been delayed with SROM, and needed to go for a c-section not emergently but ASAP.

Any guesses what happened and what I did? (The consultants seeing her before me where talking intubation, prolonged ICU stay, etc.)

 

[Mman]

All of this reminds me of a case not that long ago where the parturient was full-term and was febrile with RSV. She couldn't lay flat without uncontrollable coughing. Had been delayed with SROM, and needed to go for a c-section not emergently but ASAP.

Any guesses what happened and what I did? (The consultants seeing her before me where talking intubation, prolonged ICU stay, etc.)

Let me guess. You put in a spinal and they delivered a baby.

 

[BuzzPhreed]

Let me guess. You put in a spinal and they delivered a baby.

Yep.

Multiple people masturbated over that case for >36 hours. I had her breathe some 4% lidocaine and gave her 0.2 of hydromorphone IV (as an antitussive). Put the spinal in. Laid her down. She didn't cough once. Baby came out screaming.

You should have seen the pre-op pulmonology consult they got. The guy basically told her she was going to die. Terrified the OB/GYN. I told her and the patient not to worry. In the end who looked like a rockstar? Not the pulmonologist.

(Of course, we were loaded for elephant in that room. Didn't need any of it, but were ready. Which is the point I tried to make earlier... in a nutshell... be ready, but trust your skills and training.)

 

[Mman]

Yep.

Multiple people masturbated over that case for >36 hours. I had her breathe some 4% lidocaine and gave her 0.2 of hydromorphone IV (as an antitussive). Put the spinal in. Laid her down. She didn't cough once. Baby came out screaming.

You should have seen the pulmonology consult. The guy basically told her she was going to die. Terrified the OB/GYN. I told her and the patient not to worry. In the end who looked like a rockstar? Not the pulmonologist.

(Of course, we were loaded for bear in that room. Didn't need any of it, but were ready. Which is the point I tried to make earlier... in a nutshell... be ready, but trust your skills and training.)

I'd tell the pulmonologist that coughing isn't a contraindication to having a spinal for a c-section. It might be mildly annoying to the OB at times, but BFD. I mean they manage to get babies out in moms that are retching and puking during the procedure.

 

[Noyac]

excuse my ignorance ... why is this patient at increased risk of a high spinal?
I know she's short and fat and pregnant ... am I missing something here? it seems like most of our obstetric population fits that description.

I don't think anyone is overly concerned of a high spinal happening in reality but the discussion went there more as a board question due to previous spinal instrumentation/fusion. Theoretically, I could happen so we discussed it.

 

[Mac4]

I would ask what kind of anesthetics she had for her previous C/S and in what kind of setting (post spinal fusion? Pre-clamp?). If her airway history sounds reasonable, I would do RSI/GETA with pre-indction a line. I would wait as long as possible though. If she had a difficult airway history, I would start working on a spinal catheter right now.


I

 

[Ignatius J]

One thing that has not been mentioned that I would question as I have little experience in NA techniques w/ lumbar fusions- would anyone hesitate because of potential scar tissue/adhesions within the dura/IT space making a NA block unreliable? I think I would. I've seen Neuro guys struggle with anatomy on lumbar redos enough to stay away from it.

The difficult airway is my concern here, and I would attack this head on and not try and dance around it and have to confront it under non-ideal circumstances.

For labor epidural, sure go ahead and see if you can make the patient comfy with an epidural. For an urgent/emergent case in which a surgical block is needed, no thank you.

 

[Mman]

One thing that has not been mentioned that I would question as I have little experience in NA techniques w/ lumbar fusions- would anyone hesitate because of potential scar tissue/adhesions within the dura/IT space making a NA block unreliable? I think I would. I've seen Neuro guys struggle with anatomy on lumbar redos enough to stay away from it.

The difficult airway is my concern here, and I would attack this head on and not try and dance around it and have to confront it under non-ideal circumstances.

For labor epidural, sure go ahead and see if you can make the patient comfy with an epidural. For an urgent/emergent case in which a surgical block is needed, no thank you.

The scar tissue is within the epidural space, not intra-thecal. The patient still has free flowing CSF. They presumably still have bowel and bladder function and the ability to walk. The postop abnormal anatomy is all external to the dura. They aren't going subdural on their lumbar fusion, although occasionally they can accidentally tear the dura which would be the same as you causing a hole in the dura with a touhy needle. We do spinals on patients that have had a lumbar fusion all the time without difficulty.

 

[Ignatius J]

The scar tissue is within the epidural space, not intra-thecal. The patient still has free flowing CSF. They presumably still have bowel and bladder function and the ability to walk. The postop abnormal anatomy is all external to the dura. They aren't going subdural on their lumbar fusion, although occasionally they can accidentally tear the dura which would be the same as you causing a hole in the dura with a touhy needle. We do spinals on patients that have had a lumbar fusion all the time without difficulty.

Good stuff. Thanks Mman. Great information that will change my approach to these patients.

Hypothetical- If a patient with a history of lumber fusion comes in for vaginal delivery after uncomplicated pregnancy, would you do an epidural, CSE, or continuous spinal? I like the idea of a continuous spinal, but I am pretty sure no hospitals I go to have anything other than the 18G Tuohys.

 

[Mman]

Good stuff. Thanks Mman. Great information that will change my approach to these patients.

Hypothetical- If a patient with a history of lumber fusion comes in for vaginal delivery after uncomplicated pregnancy, would you do an epidural, CSE, or continuous spinal? I like the idea of a continuous spinal, but I am pretty sure no hospitals I go to have anything other than the 18G Tuohys.

You can try an epidural, just no guarantee you can get it in without a wet tap and no guarantee it will work that well (as in a very patchy block). Continuous spinal is a possibility, but if they get a PDPH, good luck fixing that headache. My first try would be to do an epidural either above or below their fused levels and if that didn't work I'd give them a remifentanil PCA until they get close to delivery and then a single dose spinal with a 25 g needle to get them over the hump.

 

[deleted59964]

i wouldn't try epidural, would go straight to PCA (fentanyl or remifentanil depending on institution) -- would hope they got by with entonox (it isn't the devil) and pca ... would swear a little under my breath - but would do spinal at end as Mman would, if necessary.

 

[CaliDreamin4Life]

Out of curiosity guys, do you need a special spinal catheter to place an ingrate cal catheter or can you use the epidural catheter? Do you use the epidural kit...can you elaborate?

 

[RxBoy]

Out of curiosity guys, do you need a special spinal catheter to place an ingrate cal catheter or can you use the epidural catheter? Do you use the epidural kit...can you elaborate?

I use the epidural catheter. We have 2, the 17g t and the 18g t... I use the 18g with the thinner, non spring loaded catheter in the spinal space mainly because its a smaller needle. The 17g t is made to facilitate the larger spring bound atraumatic catheters. Decades ago they made microcatheters for continuous spinals but they were associated with a higher incidence of TENS and cauda equina syndrome so they were discontinued.

As for PDPH... Significant risk reduction will occur just based on the fact they are usually used for the obese pregnant pts. In my personal experience, obese pts rarely get PDPH. 2 other risk reduction strategies are leaving the catheter in for minimal 24-48 hrs before removing (jury is still out on the evidence) and giving a long acting neuroaxial narcotic like duramorph.

In any case... In high risk pts, Ill take a PDPH over a total spinal any day.

 

[deleted59964]

In my personal experience, obese pts rarely get PDPH.

interesting observation ... is there any supporting evidence beyond your observation?

*not trying to be a smart ass

 

[Mman]

interesting observation ... is there any supporting evidence beyond your observation?

*not trying to be a smart ass

Yes. I'm not sure of any large studies (pun intended), but there have been several smaller case series reported in the literature and at meetings. Basically the fatter you are, the less likely you are to get PDPH. Why? We don't know. Plenty of theories. Increased intra-abdominal pressure, increased fat in epidural space, being less likely to actually be up walking to get the in the first place headache, etc.

 

[CaliDreamin4Life]

Thanks RxBoy. So you just wet tap with the 18g Touhy and thread the epidural catheter? What's yr infusion of choice and at what rate?

 

[pgg]

Thanks RxBoy. So you just wet tap with the 18g Touhy and thread the epidural catheter? What's yr infusion of choice and at what rate?

It's been a while but my recipe is -

For labor with an IT catheter bolus 1 + 1 mL of 0.125% bupiv with 2 mcg/mL fentanyl then start the pump at 1 mL/hr.

For a c-section incrementally dose 0.5% bupiv to about 15 mg, plus 15 mcg fent and 0.2 mg morphine.


Someday I hope we get microcatheters back. The problems that got them pulled from the market were surely due to the high concentrations of lidocaine people put through them. I would love to have a low-PDPH-risk option for continuous spinals ...