OB death

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dannyboy1 said:
Last I checked this is the anesthesia forum. If the OB says we need to section, then we need to section. I’m certainly not going to throw my 2 cents in.....
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100% If they say it's a STAT, it's a STAT. I used to have an attending that would say "never be the reason a baby cannot get delivered on time."
 
If a labor epidural is even the least bit sketchy I'll pull it and do a spinal for the c-section. It's just not worth screwing around with encouraging words about "yeah it's just gonna be some pressure" or ketamine or propofol or nitrous, when the gold standard of c-section anesthesia and satisfied customers is a 25 g needle and 3 minute procedure away.

Of course, since I post on SDN, all of MY labor epidurals are magnificent so I never have to do this. It's only epidurals placed by my colleagues who don't have SDN accounts that I can't trust.
 
pgg said:
If a labor epidural is even the least bit sketchy I'll pull it and do a spinal for the c-section. It's just not worth screwing around with encouraging words about "yeah it's just gonna be some pressure" or ketamine or propofol or nitrous, when the gold standard of c-section anesthesia and satisfied customers is a 25 g needle and 3 minute procedure away.

Of course, since I post on SDN, all of MY labor epidurals are magnificent so I never have to do this. It's only epidurals placed by my colleagues who don't have SDN accounts that I can't trust.
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I think if everyone just did CSEs for their labor epidurals we’d have a lot less questionable blocks and more satisfied laboring mothers.....and my unresearched opinion, less C sections after labor. Again my theory
 
sevo00 said:
that means your epidurals suck. Ive used labor epidurals for C sections by giving 20cc of 2% lidocaine and they always work great.
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I'm not getting into the penis measuring size portion of the competition, but as anesthesiologists all we can do is get the catheter into the epidural space. It is up to the drugs and their spine to determine how efficacious it will be.

But even absolutely perfectly functioning labor epidurals where the mom does not know they are contracting provide inferior surgical anesthesia more often than spinals. A lot more often. Spinals work perfect almost every single time. Labor epidurals converted to spinal anesthesia work great maybe 75% of the time. Spinals never need IV sedatives to get through the case, epidurals occasionally do.

This is from my n of >5000.

Spinals are easy and usually take less than 60 seconds in someone that already has a catheter showing you their interspace and documented depth to LOR and make the moms more comfortable.
 
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Twiggidy said:
Then the epidural placed isn’t working the vast majority of the time.

Working epidurals can get surgical anesthesia with 15-20 cc 2% lidocaine 99% of the time. Pulling an epidural to do a spinal in a “working” catheter is adding an unnecessary procedure. There are institutions I know of that strictly do their elective c-sections with 20 cc 2% epidural lidocaine.
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I define a good working epidural as a comfortable patient with good bilateral epidural levels. That's a working epidural. There is no way to get >90% of those patients through a c-section comfortably without nitrous or IV meds.

The reason you can do an elective c-section with an epidural is usually that those places are bolusing through the needle and not a catheter that has been in place for 6-18 hours.
 
Mman said:
I define a good working epidural as a comfortable patient with good bilateral epidural levels. That's a working epidural. There is no way to get >90% of those patients through a c-section comfortably without nitrous or IV meds.

The reason you can do an elective c-section with an epidural is usually that those places are bolusing through the needle and not a catheter that has been in place for 6-18 hours.
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I haven’t done OB in a long time, but when I did, I never pulled a functioning epidural for a CS. I’d always bolus the epidural with lido 2%x20ml, bicarb 2ml, and fent 100mcg. Those patients were very numb, sometimes up to their fingers. I never had to give nitrous or IV meds.
 
Mman said:
I define a good working epidural as a comfortable patient with good bilateral epidural levels. That's a working epidural. There is no way to get >90% of those patients through a c-section comfortably without nitrous or IV meds.

The reason you can do an elective c-section with an epidural is usually that those places are bolusing through the needle and not a catheter that has been in place for 6-18 hours.
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Not true, we use in situ epidurals all the time. Sometimes you need to give them more than the 20 cc of lido but they almost always have a good block by 30. I can confidently say that more than 90% of c/s can be done under epidural alone and probably more than that.
 
Mman said:
I define a good working epidural as a comfortable patient with good bilateral epidural levels. That's a working epidural. There is no way to get >90% of those patients through a c-section comfortably without nitrous or IV meds.

The reason you can do an elective c-section with an epidural is usually that those places are bolusing through the needle and not a catheter that has been in place for 6-18 hours.
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This is the craziest and most incorrect thing I’ve read on here in a long time, and that includes all the recent Trump supporting posts.

A good working epidural will work well for a c section 99% of the time, period.
 
JoelJoel84 said:
This is the craziest and most incorrect thing I’ve read on here in a long time, and that includes all the recent Trump supporting posts.

A good working epidural will work well for a c section 99% of the time, period.
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a spinal leaves them more comfortable 99% of the time
 
Mman said:
a spinal leaves them more comfortable 99% of the time
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Funny enough I did a spinal today for a knee that sucked and needed to be supplemented with opioid. But I think that says more about me than the technique...
 
Mman said:
I define a good working epidural as a comfortable patient with good bilateral epidural levels. That's a working epidural. There is no way to get >90% of those patients through a c-section comfortably without nitrous or IV meds.

The reason you can do an elective c-section with an epidural is usually that those places are bolusing through the needle and not a catheter that has been in place for 6-18 hours.
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Then what alternative universe, where I can count on my hands when I had to stop a c section because she’s feeling my epidural loaded with 2% lidocaine, do I work in?

seriously, count on my hands and not get to my pinky. And I’m talking about taking over mostly catheters placed by others

This not a direct attack on anyone, but i would ask if someone really thinks they need to pull epidurals and place a spinals for c-section after labor they either need to be a little more confident in their epidurals or evaluate their placement technique or the drugs they use for either labor or c-section. we didn't even do this as residents with slow OB residents doing the c-sections.
 
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haven’t don’t OB in a while but chloroprocaine for real stat c-section and 2% lido with bicarbonate for walk slowly to the suite.
If in-situ is bilateral, 15cc -20cc of either local is sufficient for a c-section. However a combined spinal epidural sometimes can cause false sense of a good epidural block
 
Mman said:
I will never use an indwelling labor epidural for a c-section unless they basically have surgical anesthesia in their labor room or I do not have time to place a spinal. Inferior the vast majority of the time.
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What? WHy? You can get a good block out of an epidural...
 
Maybe I like OB because I only work with a special city full of tough women.

I do the bulk of my non-emergency C/S conversions under epidural, and most of the time (70%?) are fine with 10 mL 2% lido. Some (20%?) need 5 mL more.
I bolus in the room prior to pushing back though, I think a lot of people don’t wait long enough for it to work (12 +/-2 min).

For that other 10% they typically had crappy epidurals to begin with. If they don’t have good bilateral coverage prior to the decision to section, I will pull it and do a spinal when we get to the room.
 
jpgoodie said:
Interesting this is re-surfacing now, given recent events. I'm sure we're going to see more and more of this, where complications related to minors or people of color are going to start being called race issues. I hope not, but I won't be surprised. Sad because we treat all patients the same, i.e. none of us want negative or adverse outcomes for any of our patients.
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Yes, none of us want negative or adverse outcomes for any of our patients. However, that does not mean - or justify - that we treat all patients the same.
 
Adding to the echo chamber that if you're routinely pulling epidural to do a spinal for sections then your epidural was **** to begin with. I don't do much OB since I've been out but as a resident we dosed >95% of epidurals for a section without issue.

The question here is how is your epidural placed and assessed? I leave 4 cm, not 5 in the space to start. I don't like CSEs because it delays the diagnosis of one sided or a non-functioning catheter. I check levels with ice to make damn sure each side is numb. If it's one-sided then I pull the catheter back to 3 cm in. If it's still one-sided then I pull the catheter and replace it.

At the end of the day, if one is meticulous in making sure the epidural is not just functioning but functioning well, then the probability of a successful dose up for section is extremely high.
 
I totally agree with >95% effectiveness of labor to csection epidurals; check a level before bolusing, bolus accordingly , don’t go by the book of LA pharmacokinetics to rebolus because u will be burnt.

what I have found very interesting is the huge interpatient variability regarding response to LA dose and type. You can be easily fooled by that eg. I won’t never forget a pt that I placed an epidural on (1st shot with elective Duran puncture with confirmed CSF) who would continue be in pain after usual LA administration (most of the time I bolus via bupi/fent epidural with 10 cc and the let the epidural run); she required x4 times that and then was perfect till she delivered. I kept bolusing because I was sure about my epidural.

another observation I have made is that once in a while u will get a pt who responds to lidocaine but not as well to bupivacaine so before u consider the epidural a failure, bolus with both lol
 
I want to circle back around to the beginning of this thread to really hit some issues home in case the casual observer comes through lurking. While all of us professionals can certainly come to a conclusion as to what may have happened in this case, we all know there are many reasons, including those unrelated to epidural or spinal anesthesia, why an L&D patient may arrest. The important issue is that it's quickly recognized and you do everything you can do help the patient. Again, given that the public isn't aware of the full details of the case, I'm don't think there needs to be "Justice for *blank*" protests outside of hospitals.

Having said the above and addressing a few posts on the first page we can't write off bias in medicine but I do think, with regard to OB anesthesia, there's a learning point that can help moving forward. Yes, it bothers me that there is a higher maternal mortality for African American women and Ive certainly wondered if there is something that we as anesthesiologists can do to address that. It's also been studied that it isn't normalized when socioeconomic status is used as a factor (see: Beyonce/Serena Williams, also this )We're obviously mostly involved with only pain control during labor so that's where we need to reflect on our own biases. As said above and I think this needs to be hammered home:

On Labor and Delivery, no two patients are the same.

It's in my opinion that you can't just walk into every laboring patient's room, drop an epidural, start the infusion, and expect to get the same result. We're talking about the subjective issue of pain with a regional anesthetic that isn't meant to achieve surgical anesthesia. Again, I have hot takes, but you will have patients that need the epidural just to take the edge off so they can get the bite block for their delivery while in the very next room you may have a patient that needs a general anesthetic just for the skin local. This varies person to person, and I'll just say it, culture to culture. You'd be surprised who I perceive are the "toughest women" and the ones you need to hit with an epidural nuclear weapon. l

So, again, I'm not ready to say "bias" contributed to this situation, but I really do think this is something that people who cover L&D need to be aware of. I genuine think all anesthesiologists have the best intentions when placing epidurals and spinals for laboring mothers but I personally feel we all need to remember that no two patients are the same.
 
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Twiggidy said:
But you just proved my point. An inferior block needing a spinal is a bad block. Plain and simple. I’ve certainly placed spinals in ladies who have said “this block isn’t great” prior to me dosing the epidural only to turn them and see the catheter basically out.
If they arrive somewhat comfortable and need a section for failure to progress or fetal intolerance, people shouldn’t make a habit of pulling catheters to do spinals. They should either place better or better secure their epidurals.

moreover, my problem with the statement was saying “surgical anesthesia” was needed in the labor room. That’s the false statement
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Wow, lots of replies before I got back.

I'll explain further as I think we're probably not that far off from our practice as what our posts might indicate, and I want to hear everyone's thoughts. I'm not far out of residency so welcome feedback.

1. C/S Called in epidural patient due to failure to progress or something where nursing is going to drag their feet and take an hour to get them into the OR.
2. My first step is to evaluate the epidural.
a.Not working great/patchy? Plan to pull and SAB. Turn pump off asap so best chance to absorb as much epidural solution as possible before attempting spinal. I don't think anyone here disagrees with this.
-or-
Perfectly working epidural - i.e. evaluate with ice test to get good levels, patient at 0 or 1/10 pain with contractions whereas before was 8+, etc. Like most have said, yes this will likely work and be an adequate surgical epidural with 2% Lidocaine +/- bicarb. I always dose this in the room before heading back with 10 cc, then 5 more once on table, reserving 5 more CC for later if needed. This works fine obviously, but in my experience, unless the mom has the proper psychological affect - the epidural just isn't going to work as well as a spinal would. It does require supplementation with versed/ketamine/nitrous etc more frequently than SAB (generally this becomes necessary around exteriorizing the uterus - so if the first part of the C/S isn't perfect I'll push that last 5 of lido as they are incising the uterus.)

Generally I give the mom the choice - give the epidural a shot, or pull and do the SAB. +'s and -'s to both. I do explain that the backup, if either fails, is GA - they don't get to attempt using the epidural, then if not getting an adequate level before incision, sit them up for spinal.

Truthfully probably 75% elect to use the epidural when given the option. Most do fine. All of the 25% that elect for the SAB do fine though.

Then there's the rock-and-a-hard place patients that are case by case, i.e.:
1. Obese + Very difficult placement of epidural + Epidural is "ok"
2. Raging anxiety where just brushing their arm unexpectedly causes them to jump off the table
3. Drug abusers or those on methadone/buprenorphine therapy


There ya have it.
 
Twiggidy said:
While I agree with this in theory, we all know L&D floor is full of ticking time bombs. 100% health patients can suddenly code for a handful of reasons including some that have nothing to do with performing an elective proced
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Twiggidy said:
You should never need to pull a working epidural to do a spinal for a c-section. 15-20cc of 2% lidocaine will last a good 2hrs. Even if she starts to " feel" just give 5 more ccs, see where they are in the case progress, and use the other drugs at your disposal (Prop, midaz, etc) Now you mentioned "residency" so I understand things are slower but when you get to "the real world" you dont need to make that part of your practice.
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Thanks for all the advice. And yes, the longest uncomplicated section I’ve endured thus far was just a hair over 3 hours. Not to mention that our OBs would prefer to hold the uterus at eye level to suture, if it were possible. Currently I pull the catheter if any of the following are present:

1. Being called to the room previously for a bolus.
2. Epidural placed >12 hrs ago (or by an intern)
3. Any inkling that the pt is crazy

I just can’t stand doing near-general anesthetics with half a dozen adjuncts, while OB is treating the uterus like a bagpipe and looking at me like I’m the mean one for not jumping to convert to general.

But overall, put me in the camp of enjoying OB
 
we do CSEs and use the epidural for c sections. I've pulled the catheter and done a spinal approximately once in the last year. we (and I...) do a ton of OB in our practice.

Relative to my residency experience (where we did not do CSEs) I've been surprised how much better and more even a CSE makes the epidural, and how much better it makes doing a CS with an epidural. Yes, generally speaking a spinal for CS is a denser block than an epidural for CS. Always? No. Generally? Yes.

The judgment of using the labor epidural for CS is tricky. Not all babies descend in the same manner and in the same position. The baby descending OP tends to give Mom a lot more back pain and sacral pain, even with an otherwise well working epidural. While all of your bolusing, catheter pulling back and catheter replacing, etc. won't relieve Mom of that pain totally, bolusing that epidural for CS when the time comes usually works fine. Moms can continue to have back labor/back pain through the epidural. It'll still work fine for CS. Moms who have been admitted for induction and end up with a CS two days later - well they're almost always miserable for multiple reasons and in my experience it doesn't matter if you use the epidural or pull it and do a spinal, they'll still want/need a little IV supplement because they've been in labor laying in a hospital bed for 2 days and they're freaking miserable. I don't blame them.

The only catheters I pull to place spinal are obviously one-sided catheters and catheters that just have failed due to poor placement. The former occurs, but rarely in my experience. The latter also occurs, but so long as you confirmed your position with +CSE, and you aren't stupid, then more often than not that catheter works fine for both labor and CS.
 
Southpaw said:
we do CSEs and use the epidural for c sections. I've pulled the catheter and done a spinal approximately once in the last year. we (and I...) do a ton of OB in our practice.

Relative to my residency experience (where we did not do CSEs) I've been surprised how much better and more even a CSE makes the epidural, and how much better it makes doing a CS with an epidural. Yes, generally speaking a spinal for CS is a denser block than an epidural for CS. Always? No. Generally? Yes.

The judgment of using the labor epidural for CS is tricky. Not all babies descend in the same manner and in the same position. The baby descending OP tends to give Mom a lot more back pain and sacral pain, even with an otherwise well working epidural. While all of your bolusing, catheter pulling back and catheter replacing, etc. won't relieve Mom of that pain totally, bolusing that epidural for CS when the time comes usually works fine. Moms can continue to have back labor/back pain through the epidural. It'll still work fine for CS. Moms who have been admitted for induction and end up with a CS two days later - well they're almost always miserable for multiple reasons and in my experience it doesn't matter if you use the epidural or pull it and do a spinal, they'll still want/need a little IV supplement because they've been in labor laying in a hospital bed for 2 days and they're freaking miserable. I don't blame them.

The only catheters I pull to place spinal are obviously one-sided catheters and catheters that just have failed due to poor placement. The former occurs, but rarely in my experience. The latter also occurs, but so long as you confirmed your position with +CSE, and you aren't stupid, then more often than not that catheter works fine for both labor and CS.
Click to expand...

This guy knows what the F he is talking about. Spot on.
 
Comfort increases chances of success. Get them comfortable. I’ve actually used pearls learned on this forum (shout out @SaltyDog ) for getting these laboring patients more comfortable and thus more successful and I really think it’s been a benefit to the patients.
 
Twiggidy said:
Comfort increases chances of success. Get them comfortable. I’ve actually used pearls learned on this forum (shout out @SaltyDog ) for getting these laboring patients more comfortable and thus more successful and I really think it’s been a benefit to the patients.
Click to expand...

Friendly reminder that 10mcg of precedex after the baby is out is magic for discomfort, nausea, and shaking (disclaimer: probably wouldn’t use if patients hemorrhaging as it may confuse assessment of hypotension)
 
ER doc here. Love this forum. This convo is over my head. I briefly read up on epidural vs spinal but can’t seem to conceptualize the differences and roles pragmatically. Any good links or quick explanations available?
 
Twiggidy said:
I want to circle back around to the beginning of this thread to really hit some issues home in case the casual observer comes through lurking. While all of us professionals can certainly come to a conclusion as to what may have happened in this case, we all know there are many reasons, including those unrelated to epidural or spinal anesthesia, why an L&D patient may arrest. The important issue is that it's quickly recognized and you do everything you can do help the patient. Again, given that the public isn't aware of the full details of the case, I'm don't think there needs to be "Justice for *blank*" protests outside of hospitals.

Having said the above and addressing a few posts on the first page we can't write off bias in medicine but I do think, with regard to OB anesthesia, there's a learning point that can help moving forward. Yes, it bothers me that there is a higher maternal mortality for African American women and Ive certainly wondered if there is something that we as anesthesiologists can do to address that. It's also been studied that it isn't normalized when socioeconomic status is used as a factor (see: Beyonce/Serena Williams, also this )We're obviously mostly involved with only pain control during labor so that's where we need to reflect on our own biases. As said above and I think this needs to be hammered home:

On Labor and Delivery, no two patients are the same.

It's in my opinion that you can't just walk into every laboring patient's room, drop an epidural, start the infusion, and expect to get the same result. We're talking about the subjective issue of pain with a regional anesthetic that isn't meant to achieve surgical anesthesia. Again, I have hot takes, but you will have patients that need the epidural just to take the edge off so they can get the bite block for their delivery while in the very next room you may have a patient that needs a general anesthetic just for the skin local. This varies person to person, and I'll just say it, culture to culture. You'd be surprised who I perceive are the "toughest women" and the ones you need to hit with an epidural nuclear weapon. l

So, again, I'm not ready to say "bias" contributed to this situation, but I really do think this is something that people who cover L&D need to be aware of. I genuine think all anesthesiologists have the best intentions when placing epidurals and spinals for laboring mothers but I personally feel we all need to remember that no two patients are the same.
Click to expand...
Toughest women are Hmong women, anyone who tries to convince me otherwise is a soy boy.
 
The Duck Knows said:
Thanks for all the advice. And yes, the longest uncomplicated section I’ve endured thus far was just a hair over 3 hours. Not to mention that our OBs would prefer to hold the uterus at eye level to suture, if it were possible. Currently I pull the catheter if any of the following are present:

1. Being called to the room previously for a bolus.
2. Epidural placed >12 hrs ago (or by an intern)
3. Any inkling that the pt is crazy

I just can’t stand doing near-general anesthetics with half a dozen adjuncts, while OB is treating the uterus like a bagpipe and looking at me like I’m the mean one for not jumping to convert to general.

But overall, put me in the camp of enjoying OB
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Disagree with #2. I'll bolus a catheter that's been in for 24 hours as long as its still working.
 
jw3600 said:
ER doc here. Love this forum. This convo is over my head. I briefly read up on epidural vs spinal but can’t seem to conceptualize the differences and roles pragmatically. Any good links or quick explanations available?
Click to expand...
Nysora.com will give you all the info you want on spinals or epidurals and then some
 
I love using ketamine in 10-20 mg boluses for difficult patients. BUT, any time I have to sedate the mom I chalk it up as a failure (obviously the patients failure- LOL). As much as I don't want to talk them through, I suck it up and do it b/c that is the job. I really can't remember the last epidural that I had to convert to general. It seems like I use words when people use sedation. And I use sedation when people use general. I prefer them asleep, but try do what I would want for me/my wife.

If you talk to people and take their mind off it does wonders. And so does skin to skin with the newborn. I truly opposed the skin to skin movement, but had to admit I was wrong b/c it does take their mind off of everything else. I stupidly find myself getting the nurse to bring the baby over.

Another trick I use is using Bupiv 0.25-0.375% in 5 mL boluses instead of Lido. No need to rebolus and really good block if you have the time!
 
BobLoblaw78 said:
LOL. How would they know!

I have learned the most about ketamine from my sedated C/S cases. When they start tripping, I can't help but ask them what is going on
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Man I gave some ketamine for a block in an old lady the other day and she started this creepy high pitched giggling. Haunts my nightmares.
 
How long should you wait after stopping your epidural to place a spinal for a C-section? Afraid of possible high spinals.
 
As an old anesthesiologist... I have learned to give other anesthesiologists the benefit of the doubt.
It's very easy to criticize others when you were not in their shoes when the sh.t hit he fan!
But always try to remember these times when you were not stellar... when you could have done better... and you knew it, but you never admitted it. That's what happened here, and unfortunately this time it did not go well.
Let's not crucify the poor guy any further and maybe admit that we are all humans... we sometimes make mistakes.
We all do... it's human to make mistakes.
We are not lawyers, we are physicians and by default scientists.
Scientists know that humans are not perfect!
 
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LivetoTell said:
How long should you wait after stopping your epidural to place a spinal for a C-section? Afraid of possible high spinals.
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time not relevant, just give smaller dose. Depending on how numb from the epidural I will back off my spinal dose significantly. Also crank their head up a smidge. Still have not gotten a high spinal doing it this way.
 
Mman said:
time not relevant, just give smaller dose. Depending on how numb from the epidural I will back off my spinal dose significantly. Also crank their head up a smidge. Still have not gotten a high spinal doing it this way.
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So what do you give the average spinal after epidural? I use 1.2 mL of 0.75% Bupiv (or full dose of 1.6 mL if I was able to stop if for > 1 hr and level is essentially gone). I am amazed about the 0.5 mL dose after epidural and may need to rethink my dose if that works great...
 
BobLoblaw78 said:
So what do you give the average spinal after epidural? I use 1.2 mL of 0.75% Bupiv (or full dose of 1.6 mL if I was able to stop if for > 1 hr and level is essentially gone). I am amazed about the 0.5 mL dose after epidural and may need to rethink my dose if that works great...
Click to expand...

Higher risk of failure due to inadequate level. I'd like to see at least 7 mg of bupi but I guess having the epidural dose helps things.
 
Planktonmd said:
As an old anesthesiologist... I have learned to give other anesthesiologists the benefit of the doubt.
It's very easy to criticize others when you were not in their shoes when the sh.t hit he fan!
But always try to remember these times when you were not stellar... when you could have done better... and you knew it, but you never admitted it. That's what happened here, and unfortunately this time it did not go well.
Let's not crucify the poor guy any further and maybe admit that we are all humans... we sometimes make mistakes.
We all do... it's human to make mistakes.
We are not lawyers, we are physicians and by default scientists.
Scientists know that humans are not perfect!
Click to expand...
true. But could this catastrophe have been avoided?
 
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