OB death

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Twiggidy said:
5 should be the minimum
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I start 4 for most everyone unless they're really morbidly obese. One-sided then pull back to 3. Still one-sided then replace.

It's anecdotal, but I noticed a huge difference wrt improved efficacy and less futzing around when there's less catheter because I think there are higher odds it's midline. Of course it also means your securement method has gotta be bulletproof.
 
vector2 said:
I start 4 for most everyone unless they're really morbidly obese. One-sided then pull back to 3. Still one-sided then replace.

It's anecdotal, but I noticed a huge difference wrt improved efficacy and less futzing around when there's less catheter because I think there are higher odds it's midline. Of course it also means your securement method has gotta be bulletproof.
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And it’s that last part that worries me most. They’re big and they start sweating and the next thing you know that catheter is sitting under the foam.

I also think since our dilution is half dilute than others have mentioned (0.0625), we run at higher volumes so there’s more spread of the solution in the space. If I get LOR at 5cm, I’m always leaving it in at 11 or 12. I’ve just experienced enough “out” catheters that needed do overs to not want to leave them so shallow.
 
SaltyDog said:
Don’t use the foam.
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Now I’m going to derail the thread......

Filter or no filter

47C8874F-3566-4ED7-94C8-9EFB478F434E.gif
 
Twiggidy said:
And it’s that last part that worries me most. They’re big and they start sweating and the next thing you know that catheter is sitting under the foam.

I also think since our dilution is half dilute than others have mentioned (0.0625), we run at higher volumes so there’s more spread of the solution in the space. If I get LOR at 5cm, I’m always leaving it in at 11 or 12. I’ve just experienced enough “out” catheters that needed do overs to not want to leave them so shallow.
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Indeed, the bigger they are, more catheter in the space. But if they're under ~190-210 lb (positively svelte in my neck of the woods) then 4 cm is fine.

And as Salty say the securement method matters. I like no foam, get the site bone dry, mastisol, multiple loops under the teg, and then a couple more loops as you secure the rest of the catheter to the patient's back and shoulder. The catheter is much less likely to move when multiple distal tension sites have to be broken before the catheter insertion site gets pulled on.
 
vector2 said:
Indeed, the bigger they are, more catheter in the space. But if they're under ~190-210 lb (positively svelte in my neck of the woods) then 4 cm is fine.

And as Salty say the securement method matters. I like no foam, get the site bone dry, mastisol, multiple loops under the teg, and then a couple more loops as you secure the rest of the catheter to the patient's back and shoulder. The catheter is much less likely to move when multiple distal tension sites have to be broken before the catheter insertion site gets pulled on.
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I find the betadine to be sticky already.
 
Twiggidy said:
5 should be the minimum
Click to expand...

I have never gone further than 6 cm past LOR, and almost always less than that. Have only had 1 come out and that was an obese and very sweaty lady that managed to get everything unstuck from her back in which case threading further probably would not have helped anyway.
 
I ran into a tough situation last night on call. BMI of 60, laboring all day, comfortable after a struggle-fest epidural. Of course, once they call a section 12 hours later for FTP, she tells me her epidural is “wearing off”. It’s clearly a one sided block. I pull the catheter back a bit and try bolusing with 2% lidocaine. Got her back to the OR and still one sided after 10-15 ccs lido. At this point, only 3 cm in the space. Where I trained, we would NEVER do a SAB after bolusing an epidural. I decided to pull it and just do a reduced dose SAB (1.2cc). It worked beautifully. I was obviously worried about a high spinal but I figured it was my best chance to avoid GA. I’m sure some of you guys would have pulled it to begin with before bolusing, but I was legitimately worried a spinal would be difficult; I didn’t want to give up my epidural catheter so easily. I also debated replacing the epidural and slowly obtaining levels.

Thanks for all the discussion here. Any thoughts, tips, suggestions? How would y’all have handled that?
 
patriot6 said:
I ran into a tough situation last night on call. BMI of 60, laboring all day, comfortable after a struggle-fest epidural. Of course, once they call a section 12 hours later for FTP, she tells me her epidural is “wearing off”. It’s clearly a one sided block. I pull the catheter back a bit and try bolusing with 2% lidocaine. Got her back to the OR and still one sided after 10-15 ccs lido. At this point, only 3 cm in the space. Where I trained, we would NEVER do a SAB after bolusing an epidural. I decided to pull it and just do a reduced dose SAB (1.2cc). It worked beautifully. I was obviously worried about a high spinal but I figured it was my best chance to avoid GA. I’m sure some of you guys would have pulled it to begin with before bolusing, but I was legitimately worried a spinal would be difficult; I didn’t want to give up my epidural catheter so easily. I also debated replacing the epidural and slowly obtaining levels.

Thanks for all the discussion here. Any thoughts, tips, suggestions? How would y’all have handled that?
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if it's a crap epidural, pull it and place a spinal. I would at least read the procedure note from who placed it to see depth of LOR or hope they would have informed me if it was impossibly difficult. If you struggle with the spinal, can always use a CSE kit to get the spinal. I definitely don't dose up an epidural and then pull it and place a spinal.
 
Mman said:
if it's a crap epidural, pull it and place a spinal. I would at least read the procedure note from who placed it to see depth of LOR or hope they would have informed me if it was impossibly difficult. If you struggle with the spinal, can always use a CSE kit to get the spinal. I definitely don't dose up an epidural and then pull it and place a spinal.
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I placed it. It worked great for 12 hours. I suppose my mistake was thinking I could salvage it since it had only started being one sided in the past hour or so. I did use CSE technique to do the spinal. I regretted bolusing once I realized we weren’t making any headway.
 
patriot6 said:
I placed it. It worked great for 12 hours. I suppose my mistake was thinking I could salvage it since it had only started being one sided in the past hour or so. I did use CSE technique to do the spinal. I regretted bolusing once I realized we weren’t making any headway.
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I’m a chicken in those cases, and with a BMI 60 lady, would probably have converted to GA if the epidural bolus didn’t work. The risk of high spinal causing an emergency intubation after giving 15 mL of lido, then a spinal seems too high for me to not do a controlled setting GA.

I have had a number of BMI 60+ women where I do a beautiful spinal for C/S and then they can’t tolerate laying flat because they are too fat and can’t breath. Now I make them try it laying flat (tilted, but head flat) for me before I even attempt the spinal.

I also probably would have started with bolusing the epidural because of the difficulty you had placing it.
 
patriot6 said:
I ran into a tough situation last night on call. BMI of 60, laboring all day, comfortable after a struggle-fest epidural. Of course, once they call a section 12 hours later for FTP, she tells me her epidural is “wearing off”. It’s clearly a one sided block. I pull the catheter back a bit and try bolusing with 2% lidocaine. Got her back to the OR and still one sided after 10-15 ccs lido. At this point, only 3 cm in the space. Where I trained, we would NEVER do a SAB after bolusing an epidural. I decided to pull it and just do a reduced dose SAB (1.2cc). It worked beautifully. I was obviously worried about a high spinal but I figured it was my best chance to avoid GA. I’m sure some of you guys would have pulled it to begin with before bolusing, but I was legitimately worried a spinal would be difficult; I didn’t want to give up my epidural catheter so easily. I also debated replacing the epidural and slowly obtaining levels.

Thanks for all the discussion here. Any thoughts, tips, suggestions? How would y’all have handled that?
Click to expand...

And what would you have done if patient developed a high spinal? Would she have been a difficult intubayion?
 
pjl said:
I’m a chicken in those cases, and with a BMI 60 lady, would probably have converted to GA if the epidural bolus didn’t work. The risk of high spinal causing an emergency intubation after giving 15 mL of lido, then a spinal seems too high for me to not do a controlled setting GA.

I have had a number of BMI 60+ women where I do a beautiful spinal for C/S and then they can’t tolerate laying flat because they are too fat and can’t breath. Now I make them try it laying flat (tilted, but head flat) for me before I even attempt the spinal.

I also probably would have started with bolusing the epidural because of the difficulty you had placing
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coffeebythelake said:
And what would you have done if patient developed a high spinal? Would she have been a difficult intubayion?
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Probably. In retrospect, I lucked out. I think I’ll be pulling the next catheter if it even looks at me funny.
 
patriot6 said:
Probably. In retrospect, I lucked out. I think I’ll be pulling the next catheter if it even looks at me funny.
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When you initially placed the epidural what depth did you tape it? Also, what level did you insert the catheter. In my experience, when I personally have come across these "one sided" catheters the placement is too low (almost near sacral) and also not taped deep enough. If you said only 3 cm of catheter was in the space, in my book that catheter is out especially in obese patients.
 
Aheadbyacentury said:
You cannot be serious! I have NEVER seen anyone do that.
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I haven't done it but have wished I had a few times. Twice had to intubate big fat patients because of subjective dyspnea laying flat when the spinal got up to T6 or T4. They completely freaked out and were going to come off the OR table.
 
Twiggidy said:
When you initially placed the epidural what depth did you tape it? Also, what level did you insert the catheter. In my experience, when I personally have come across these "one sided" catheters the placement is too low (almost near sacral) and also not taped deep enough. If you said only 3 cm of catheter was in the space, in my book that catheter is out especially in obese patients.
Click to expand...

Loss at 9, taped at 15. I actually did think I was a little low, good thought. I pulled it back 1 cm with each 5 cc bolus when there was no improvement. So, I ended up at 12cm or so at the skin before pulling it. It was just really frustrating for me because I checked on her multiple times during the day to ensure a good working catheter. Then, of course, things go to hell the hour before the section is called.
 
It's sometimes worthwhile to have the really obese women lay down on their side before you tape the epidural. All that fat will shift a bit and the catheter will get sucked in another cm or two at the skin. This will make it less likely to pull back from the epidural space as they squirm and move around during labor.
 
I was spoiled with the multi orifice catheters. Even the old timers who were super proficient with the old catheters swears by them.

Until my current job, now we have the single orifice catheter. And it’s pretty stiff. The other day I had a patient with twins and started with one sided block. It was good uncomfortable 30 mins, until she finally got comfortable on both sides.

I probably would stopped at 10ml of 2%. If it ain’t working, it ain’t gonna work. I would under dose my spinal, with maybe 1cc or less of heavy bupivacaine, hoping for a quick surgeon and versed after baby’s out so she can remember at least up to meeting the baby.

Probably not kosher by some, but...
 
Mman said:
I haven't done it but have wished I had a few times. Twice had to intubate big fat patients because of subjective dyspnea laying flat when the spinal got up to T6 or T4. They completely freaked out and were going to come off the OR table.
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Why not just put the back of the table up
 
So if it’s clear your epidural is going to fail after attempting to dose it... would it be reasonable to tell your OB to put their feet up somewhere while the block wears off? ... then bring patient back later to sit for a spinal. Obviously, we’re talking non-urgent stuff here.
 
Mman said:
it will happen to you eventually, just gotta have your gameplan ready for when it does
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There was a case of failed spinal due to intrathecal digoxin in CA. Pt suffered significant disabilities.

I think it is really rare to have a failed spinal in young women (bupi does not work?). More likely to happen in the elderly for total joints.
 
patriot6 said:
Also, I’d be interested in hearing people’s approach to the failed spinal for elective sections.
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Sleepytime Tea

I'd like to caveat this by saying I think the whole "difficult airway on OB" thing is a touch overrated, especially with glidescopes. If they test and she screams ouch then it's "good night"
 
Twiggidy said:
Sleepytime Tea

I'd like to caveat this by saying I think the whole "difficult airway on OB" thing is a touch overrated, especially with glidescopes. If they test and she screams ouch then it's "good night"
Click to expand...

I agree with you. I'll try to find the study recently that showed failed intubation rates are the same with parturients as with other adults for general. It's more so the psychosocial part of it -- patients obviously wanting to be awake to see their baby.
 
Twiggidy said:
Sleepytime Tea

I'd like to caveat this by saying I think the whole "difficult airway on OB" thing is a touch overrated, especially with glidescopes. If they test and she screams ouch then it's "good night"
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dr doze said:
Take down the drapes. Sit them up. Repeat spinal at lower dose, assuming partial block.
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Now you have two completely opposite answers, what will you do?

My training we have 8-10 elective sections a day. Most of my attendings would just sit them up and redo.

My job now, 3 scheduled section a day, most of the senior partners would just put them to sleep without messing anymore.

But in my training, it was MD only with selected people that would do OB.

My job now, everyone does OB and some CRNA would place spinal, some wouldn’t.

What I am trying to say is, every place and every set up is different. As long as it’s safe, until it’s not of course.
 
Last edited:
narcotics999 said:
There was a case of failed spinal due to intrathecal digoxin in CA. Pt suffered significant disabilities.

I think it is really rare to have a failed spinal in young women (bupi does not work?). More likely to happen in the elderly for total joints.
Click to expand...

while it is rare to have one fail in obstetric population, it is not zero. It happens. You do enough of them and you will see it. I usually assume a bad batch of drugs, but then the same batch will have other vials that work.

stuff happens and we don't always have a great reason why
 
narcotics999 said:
There was a case of failed spinal due to intrathecal digoxin in CA. Pt suffered significant disabilities.

I think it is really rare to have a failed spinal in young women (bupi does not work?). More likely to happen in the elderly for total joints.
Click to expand...

Have been there multiple times. With the old, not the dig.
 
Mman said:
while it is rare to have one fail in obstetric population, it is not zero. It happens. You do enough of them and you will see it. I usually assume a bad batch of drugs, but then the same batch will have other vials that work.

stuff happens and we don't always have a great reason why
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I'm fairly certain there's a rash of failed spinals every year in July/August at academic centers.

Kinda weird, must be the drugs stored in hot temps while being shipped during the summer or something.
 
There is such a thing as bad batches of bup. I had a case I know for sure I was in, csf dripping, and no block at all. Was for a total knee so went off to sleep. Had placed duramorph and patient had minimal pain and itching with minimal opioid use no nerve block. So the duramorph worked but bup didnt.
 
IMGASMD said:
Now you have two completely opposite answers, what will you do?

My training we have 8-10 elective sections a day. Most of my attendings would just sit them up and redo.

My job now, 3 scheduled section a day, most of the senior partners would just put them to sleep without messing anymore.

But in my training, it was MD only with selected people that would do OB.

My job now, everyone does OB and some CRNA would place spinal, some wouldn’t.

What I am trying to say is, every place and every set up is different. As long as it’s safe, until it’s not of course.
Click to expand...
I just don’t have the time nor patience to sit someone up and down just so they can be awake during a laparotomy. Unless it’s a legit contraindication, we’re going to sleep.
 
Twiggidy said:
I just don’t have the time nor patience to sit someone up and down just so they can be awake during a laparotomy. Unless it’s a legit contraindication, we’re going to sleep.
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Our customers, I mean patients, are babied by their obstetricians..... unless we had a very good reason, everyone gets skin to skin......
 
pjl said:
After having a few really ****ty c/s on ladies with BMIs in the 70s, yeah, I lower the head of their bed when I preop them. Takes less than a minute, and those cases left a mark.
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How did they even get pregnant...
 
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