OB intrathecal cath

[XRanger]

Had a recent OB case:

Pt has scoliosis, semi difficult epidural placement but was able to get good LOR. No CSF coming out of tuohy, threaded the cath, little difficult but able to get it in, test dose with 3ml 1.5% lido w/ epi negative. Gave loading dose 8ml 0.2% ropi. Nurse called me 10 min later cause pt had hypotension. Pt is completely numb with motor block. I aspirated from the catheter and got CSF back so I suspected intrathecal cath. Stopped the infusion. Pt is comfortable and refused replacement of epidural. The block lasted about 3 hours before pt started feeling contraction again, still refused replacing the epidural. I bolused 3ml 0.25% bupi through the catheter (in 1ml increments, waited 10 min between doses). Pt got comfortable again and luckily delivered the baby shortly after this.

Some thoughts:
-Have you guys ever had suspected intrathecal cath after negative test dose/aspiration? Did I not wait long enough (waited about 2-3min before giving loading dose. My guess is I might’ve nicked the dura with the tuohy and somehow the catheter migrated in?
-how would you dose the intrathecal cath in this case for labor analgesia? How about if pt goes to csection?


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[chocomorsel]

Would have done same thing you have done. Minimally dosed it.

If you suspected intrathecal you would dose at 1/10th the epidural rate.
I suspect it wasn’t quite intrathecal, maybe subdural if no CSF. Has she had previous surgery?

And I suspect if you gave that much intrathecally you would have more than complete motor block and hypotension.

Things would be way more severe, more like a total spinal.

 

[DocVapor]

I personally have never had intrathecal catheter after negative aspiration and test dose (I have had positive test dose after negative aspiration), but one of my co-residents did. I don't remember the exact bolus amount but it was likely a similar amount of .25% bupi. Patient immediately got SOB and they went straight to the c/s suite down the hall and called the OB on the way. Mental status and respiratory drive deteriorated rapidly so they intubated without further meds. Once everything was stabilized they aspirated the catheter and had free flow CSF. They managed to get everyone through ok. I'm with @chocomorsel on her suspicions, but I suppose it's also possible catheter was still epidural but you made a big enough knick in dura that you essentially did a mega-DPE.

 

[deleted697535]

This thread makes me think I should start giving a test dose again. Meh

 

[deleted162650]

What kind of catheter was it?

 

[IMGASMD]

I ran 1/10 rate from our bag. 0.125% little fent. End up being 1.2cc/hr. Never heard from the patient again.


Until a day or two later, asking for a patch.

 

[deleted875186]

I think the amount of motor block you got is appropriate for a spinal catheter. 8ml of 0.2 ropi is like 4mL 0.25 bupi, it’s about 2/3 a total dose for a spinal. I doubt it was epidural, subdural, or there was just a nick and you got a DPE like thing going on.

it’s interesting the test dose was negative. Maybe you didn’t wait ling enough. Did you ask her how her legs felt after the test dose?

 

[nimbus]

Catheter was initially subdural, then migrated intrathecal.

Epidural and Combined Spinal-Epidural: Pharmacology, Technique, and Side Effects - OpenAnesthesia

www.openanesthesia.org

 

[XRanger]

What kind of catheter was it?

The epidural cath that comes with the kit


I was just thinking if pt were to go for csection, would you still use the hyperbaric 0.75% bupi? How would you dose it? Give 1.6ml at once? Divide it to smaller dose?

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[AdmiralChz]

The epidural cath that comes with the kit

Captain Obvious here!

Seriously, though. The catheters they come in a typical Arrow (multiorificed for ours), Portex (styletted) and BBraun kits are all very different. Our intrathecal rates are quite different for the first two (We don’t have BBraun at my current shop)

 

[Lecithin5]

The epidural cath that comes with the kit


I was just thinking if pt were to go for csection, would you still use the hyperbaric 0.75% bupi? How would you dose it? Give 1.6ml at once? Divide it to smaller dose?

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although I forgot what the deadspace of the catheter is, definitely divide the dose into smaller doses (perhaps 1cc to start with). You can always give more

 

[Maverikk]

Captain Obvious here!

Seriously, though. The catheters they come in a typical Arrow (multiorificed for ours), Portex (styletted) and BBraun kits are all very different. Our intrathecal rates are quite different for the first two (We don’t have BBraun at my current shop)

What are your rates? I always prefer the springwound Braun, it's not included in our kit so I have to open a new needle/cath kit but it's much less intravascular/intrathecal imho.

This is a good scenario to review as I've seen a lot of different approaches to initial bolusing/injecting and I've had colleagues get total spinals before. I bolus 8-10cc off the bag, it gives the test dose time to work as I set up the pump if the test dose is subdural going intrathecal. Plus it's much less concentrated (0.1% bupi/2fent) so if it is intrathecal and not detected by the test dose they get a small dose spinal. I've seen people give 10cc 0.25%+100fent through the catheter and through the needle, maybe their patients are getting faster/better relief but I just don't see the advantage compared with the results if it goes intrathecal

 

[deleted875186]

Perhaps the “difficulty threading the catheter” should be a clue to be careful.

Honestly if I have any difficulty threading a catheter, any questionable LOR, etc, I just come out and repeat the procedure. It doesn’t take a lot of time. A good LOR and a catheter that threads easily is a very sensitive test for a good functioning epidural in my opinion.

 

[Wkrdoc]

Captain Obvious here!

Seriously, though. The catheters they come in a typical Arrow (multiorificed for ours), Portex (styletted) and BBraun kits are all very different. Our intrathecal rates are quite different for the first two (We don’t have BBraun at my current shop)

Why are you such a whiner?

 

[deleted162650]

The epidural cath that comes with the kit

I was going to shed a little insight and knowledge on you, but this response is so pants-on-head ret***ed that I’ve decided it’s not worth my effort.

 

[dhb]

I was going to shed a little insight and knowledge on you, but this response is so pants-on-head ret***ed that I’ve decided it’s not worth my effort.

I thought it was funny

 

[deleted162650]

I thought it was funny

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