Options after Failed Spinal

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Metalblade

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Occasionally a spinal doesn't take effect or comes out patchy even with good CSF return, re-aspiration of CSF, etc. I convert to GA in those cases. The other day, it happened and a Bupiv spinal came out patchy. One of the other anesthesiologists suggested I redo the spinal with tetracaine.

Does anyone do this on a regular basis? Do you use another local anesthetic or the same one? I'm afraid of getting a high spinal in case the original dose takes a while to take effect. Can one get a high spinal if another local anesthetic, like tetracaine, is used, and both the original dose and the second dose take effect?
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Planktonmd said:
Crappy spinal ----> GA
Why would any one try to redo a spinal?
Click to expand...

Plank's got a good point. On the frail desiccated fossils that you really, really would prefer a SAB on, a high spinal would be infinitely worse than just doing a gentle balanced, opiate heavy, GA. I have redosed a SAB for a planned repeat c/s that inexplicably never set up at all, even with CSF barbotage. The second set up as usual.
 
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If you did a CSE, you wouldn't have this problem. You could just dose the epidural.

But since you are talking about spinals only, I would have to agree with the others: barring some strong reason to avoid GA, I would probably just put the patient to sleep -- mainly for efficiency's sake. But also because it is incredibly rare for spinals to be patchy. In my experience they are usually an all or none technique. So if it is patchy, I would suspect a repeat spinal may also be patchy.

If it just didn't seem to work and I have the time, I would consider redoing it as a CSE and just cutting my spinal dose by half. I can make up the difference with the epidural catheter.
 
redo with intrathecal catheter if you are so worried about GA, otherwise chalk it up and go to sleep. more than likely the block will set up while they are asleep.
 
Metalblade said:
The other day, it happened and a Bupiv spinal came out patchy. One of the other anesthesiologists suggested I redo the spinal with tetracaine.
Click to expand...

Why? Was he thinking resistance to amide LAs, and thought switching to an ester would work? Did the patient have any history of problems during dental procedures or other regional anesthetics or anything to suggest a problem with amides?


You didn't say what the case was or what the airway looked like or why you chose a spinal in the first place so it's hard to really take a stand here.

Failed spinal for a knee scope in a healthy thin young person? No brainer, go to sleep.

Failed spinal for an elective c-section? The "correct" answer in my residency was that a failed spinal for elective c-section --> wait a couple hours and try again. The idea being that
  • there's no urgency
  • it probably failed because the needle driver boned up the procedure, not because the patient's anatomy is goofy or the LA is from a bad batch
  • the GA risk outweighed the scheduling inconvenience
  • the pissed-off-mom-who-missed-the-birth risk outweighed the scheduling inconvenience
These days, after a spinal that failed outright, for an elective section I'd probably just try again right away with an incrementally dosed epidural. I wouldn't ordinarily go for an intrathecal catheter as plan B for an elective section (though there are times when it should be plan A), and I wouldn't just go GA unless they'd already started the surgery.
 
pent sux tube
 
this happens to me a couple times a year on ob (about the only place we routinely do spinals) I repeat the spinal with a reduced dose. If the spinal didn't set up at all I might not reduce it much, if it is just low I go with about 1 cc bupiv 0.75. Works well no problems.
 
Planktonmd said:
Crappy spinal ----> GA
Why would any one try to redo a spinal?
Click to expand...

Most embarrassing one for me:

Nobel Laureate wants a spinal, great cus I get to chat him/her up.
Perfect CSF flow, inject, wait, wait, wait, wait, nothing? ahem.
Sit up again, same textbook look, failed effect. ( omg you've got to be kidding)

Crappy spinal-->crappy spinal-->GA. Man was I bummed. It still smarts.
 
imfrankie said:
Most embarrassing one for me:

Nobel Laureate wants a spinal, great cus I get to chat him/her up.
Perfect CSF flow, inject, wait, wait, wait, wait, nothing? ahem.
Sit up again, same textbook look, failed effect. ( omg you've got to be kidding)

Crappy spinal-->crappy spinal-->GA. Man was I bummed. It still smarts.
Click to expand...

Not your fault.

We practice an imperfect science.

Next time tho you will eliminate the 2nd spinal and elect for PVC IN THE THROAT, I'm sure. :D
 
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