Repeat c-sections and "failed" spinal

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leaverus

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Did a spinal anesthetic (1.7cc 0.75% bup + 5mcg fent + 250mcg morph) recently, went in as easy as any other spinal I've done for a c-section. This lady was having her 4th c-section. Surgeon tested with aliss and pt felt nothing; and no response to incision either but once theyre inside working to get baby out, she starts moaning and squirming her shoulders around and when I inquire she insists that she feels pressure, not pain. Remainder of the surgery is pretty much the same, especially when they externalize the uterus; eventually I gave her some nitrous for closure. even in pacu she kept saying it was the pressure that was uncomfortable but obviously she was not as insensate as a typical C-section spinal pt.
Ive had this happen a few times before in the past several years with repeat C-sections especially multi-repeat surgery. When I was in residency, an OB attending had a theory that some pts have "spinal cord remodeling" as a result of previous laparotomies and perhaps this causes an abnormal response to later neuraxial anesthetics. anyone else notice this phenomenon or other thoughts? and what else could you do for this woman intraop?
 
leaverus said:
Did a spinal anesthetic (1.7cc 0.75% bup + 5mcg fent + 250mcg morph) recently, went in as easy as any other spinal I've done for a c-section. This lady was having her 4th c-section. Surgeon tested with aliss and pt felt nothing; and no response to incision either but once theyre inside working to get baby out, she starts moaning and squirming her shoulders around and when I inquire she insists that she feels pressure, not pain. Remainder of the surgery is pretty much the same, especially when they externalize the uterus; eventually I gave her some nitrous for closure. even in pacu she kept saying it was the pressure that was uncomfortable but obviously she was not as insensate as a typical C-section spinal pt.
Ive had this happen a few times before in the past several years with repeat C-sections especially multi-repeat surgery. When I was in residency, an OB attending had a theory that some pts have "spinal cord remodeling" as a result of previous laparotomies and perhaps this causes an abnormal response to later neuraxial anesthetics. anyone else notice this phenomenon or other thoughts? and what else could you do for this woman intraop?
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I've had some spinal blocks not work the best even though I swear they should work great. This can be frustrating. I'd consider giving more like 15-20 fent and stick with 100mcg duramorph. This will help you intra op and reduce pruritis and nausea the next day.

1st thought is always that the patient might be cray cray. Anything less than a high spinal will be inadequate in this population. This being her 4th c/s makes this somewhat less likely. Luckily, whether this is a legit inadequate spinal or just anxiety, my treatment is the same!

I've found that a mix of versed and ketamine works for a crappy block AND for supratentorial issues. I start with 1 and 30. Repeat the dose as needed and I'll bet after the third dose she's purring like a kitten regardless of the cause.

Nitrous is a good call as well. I'll add this to the versed and ketamine at times unless they're already puking.
 
Blame it on the surgeon: Adhesions. probably tugging on the abdominal contents/wall and perhaps displacing the diaphragm with all the movement.
 
ZzzPlz said:
I've had some spinal blocks not work the best even though I swear they should work great. This can be frustrating. I'd consider giving more like 15-20 fent and stick with 100mcg duramorph. This will help you intra op and reduce pruritis and nausea the next day.
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i'd be one of the first to admit that the spinal simply wasn't a good one or maybe my needle moved if I thought that was case. and i'm not looking for changes to my recipe - it works fine for me. and I've never seen this occur in a pt having her first laparotomy so i'm not sure it can be simply explained away as psych / bad spinal.
 
If you don't mind me saying that's an odd mix. Very high bupiv, low fent and massssssive morphine.

Have you audited your pruritis rate with that?

Other than that, we've all had spinals that are wierd despite seemingly perfect technique etc. Especially exteriorised. That is pure bs by the surgeons. They shouldn't do it, without asking you. Tbh they shouldn't do it at all and they should know that.

But anyway...
My usual spiel is I get the nurse over beside me and I tell the lady if she can't tolerate it shes going to sleep. That usually settles them.
Then give 10s of ketamine and tell the surgeon to hurry the **** up.

If the patient is going too bananas just tube her
 
Doesn't seem to be what you are saying, but i frequently have patients complain of pain/discomfort when there's tugging or wiping of any sort during the C section. They dont grimace or complain when the surgeon bovies or sutures, but when the surgeon presses on the abdomen or wipes or retracts patient complains of lot of pain. If it happens, usually happens in the 2nd half of the case so could be spinal wearing off (Generally use 1.5 ml bupi, 15 mcg fent, 250 duramorph) and becoming less dense of a block. It happens like every few days.. Possibly cause C sections are taking upwards of 2 hrs... Usually helps w midaz + ketamine.

And just my theory, maybe this type of pain is due to phrenic nerve/vagus nerve stimulation since they aren't covered. Obviously before the baby is out, they are cutting way down, and all the abdominal contents are pushed up. But once baby is out, organs come down, and they are in there playing around w the uterus, peritoneum and stuff, and it hurts when they do that since those 2 nerves are not covered... Idk if anyone has actually studied this
 
What was the sensory level of the block to light touch prior to starting?

Simplest explanation is level wasn’t high enough to cover innervation of the peritoneum.
 
If patient is squirming prior to baby being out, I give ketamine. If it's after delivery I usually just give 50-100mcgs of fentanyl or some versed or more ketamine if it was working before. Haven't tried benadryl but ill keep that in mind. Nitrous rarely used but I know others like it. 1.7 of 0.75% is pretty standard for me. We give 200mcg of PF morphine.
 
OP, just curious- did you train giving 5mcg fent or is that something your partners do? Rapid acting neuraxial opioid is likely synergistic with LA and can help cover a patchy or too low of a block or some of the visceral pain. I know you don't want to change your recipe but others are right. Give less local, less duramorph, more fentanyl.
 
People should not be so afraid of intrathecal narcotics. There is always naloxone. 5 mcg of fentanyl? That's nothing.

On these forums, posters tend to confirm that 15-25 mcg of fentanyl in the spinal cocktail protects from the visceral pain produced by externalizing the uterus.

We all know that multimodal analgesia is usually much better, regardless of the type of pain. Mixing LA with both rapid onset/short-acting and late onset/long-acting opioids seems like the logical solution, especially when the latter two are reversible.
 
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I'm gonna side with the OP. I think your spinal was probably fine. There are some patients that don't get the concept of "you won't feel pain, but you may feel them moving the stomach around, etc". When they feel that "pressure" they interpret it as pain and the freak out begin. If you spinal wasn't working she would've been screaming, but, I think she just "felt things happening" and couldn't grasp the concept. Perfect anesthetics.....blame the patient.
 
Twiggidy said:
I'm gonna side with the OP. I think your spinal was probably fine. There are some patients that don't get the concept of "you won't feel pain, but you may feel them moving the stomach around, etc". When they feel that "pressure" they interpret it as pain and the freak out begin. If you spinal wasn't working she would've been screaming, but, I think she just "felt things happening" and couldn't grasp the concept. Perfect anesthetics.....blame the patient.
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So you're saying that if my post-op patient (in general, not OB) is complaining about cramping pain, despite me having given her tons of dilaudid, it's the patient's fault? I would say that maybe I should have given the patient a mixture of analgesics which cover all the different kinds of painful stimuli, not just opiates.

Not much different with any analgesia, including intraop. The OP's mix is probably missing the proper dose of short-acting opiates.
 
FFP said:
So you're saying that if my post-op patient (in general, not OB) is complaining about cramping pain, despite me having given her tons of dilaudid, it's the patient's fault? I would say that maybe I should have given the patient a mixture of analgesics which cover all the different kinds of painful stimuli, not just opiates.

Not much different with any analgesia, including intraop. The OP's mix is probably missing the proper dose of short-acting opiates.
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ok ffp i'm gonna single you out but it seems none of you actually read my original post. where did I ever say that the pt complained of "crampy pain?" in fact, I asked her multiple times whether she was feeling pain or pressure (unless she was being stoic and simply didn't want to admit to pain but that's on her) and she was lying comfortably in bed in pacu; the only times she appeared to be experiencing discomfort (which she confirmed was "pressure") were with manipulation. and you guys actually think after several years in practice I haven't already tried various combinations of spinal recipe?? in fact, I've done many a C-section with no short acting opioid at all in the past and they've worked just fine. I get it, no one else on sdn has less than 100% success on their procedures, but I do; in THIS case however, I don't think it was me or what I injected but maybe.
 
leaverus said:
ok ffp i'm gonna single you out but it seems none of you actually read my original post. where did I ever say that the pt complained of "crampy pain?" in fact, I asked her multiple times whether she was feeling pain or pressure (unless she was being stoic and simply didn't want to admit to pain but that's on her) and she was lying comfortably in bed in pacu; the only times she appeared to be experiencing discomfort (which she confirmed was "pressure") were with manipulation. and you guys actually think after several years in practice I haven't already tried various combinations of spinal recipe?? in fact, I've done many a C-section with no short acting opioid at all in the past and they've worked just fine. I get it, no one else on sdn has less than 100% success on their procedures, but I do; in THIS case however, I don't think it was me or what I injected but maybe.
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Of course I read your post. It was you who didn't read mine carefully. I just used the cramping postop pain as an example to point out that analgesia (and anesthesia) should be multimodal.

I have done C-sections with just bupivacaine and duramorph myself, and, in every single case, the patient complained during uterine externalization. Just my 2 cents.
 
Everyone gets spinals that are sometimes disappointing.
I have seen this before too, I think it relates to the height of the block ... which is not an exact science based on the dose administered.

What was the height of your block prior to starting?
 
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We are trained to use 1.6mL 0.75% bupi, 15mcg fentanyl, and 150mcg morphine. The morphine dose was decreased after a somewhat recent paper showed equivalent efficacy with less pruritis.

Also: an amazing ace up the sleeve is intraperitoneal chloroprocaine. Give the surgeons 40mL 3-CP and tell them to dump it into the peritoneum and swish it around. Instantly resolves visceral pain and nausea from all that manipulation the moment it contacts tissue, I kid you not. One of our attendings is working on studying it more. It's definitely coming with me in my future career!
 
leaverus said:
ok ffp i'm gonna single you out but it seems none of you actually read my original post. where did I ever say that the pt complained of "crampy pain?" in fact, I asked her multiple times whether she was feeling pain or pressure (unless she was being stoic and simply didn't want to admit to pain but that's on her) and she was lying comfortably in bed in pacu; the only times she appeared to be experiencing discomfort (which she confirmed was "pressure") were with manipulation. and you guys actually think after several years in practice I haven't already tried various combinations of spinal recipe?? in fact, I've done many a C-section with no short acting opioid at all in the past and they've worked just fine. I get it, no one else on sdn has less than 100% success on their procedures, but I do; in THIS case however, I don't think it was me or what I injected but maybe.
Click to expand...

That’s why i sided with you. From how you described it I felt like the patient just needed a bit more hand-holding the the usual normal C-section patient. I’m not sure why people started thundering down on your mix (which was fine btw)......but SDN tho
 
FFP said:
So you're saying that if my post-op patient (in general, not OB) is complaining about cramping pain, despite me having given her tons of dilaudid, it's the patient's fault? I would say that maybe I should have given the patient a mixture of analgesics which cover all the different kinds of painful stimuli, not just opiates.

Not much different with any analgesia, including intraop. The OP's mix is probably missing the proper dose of short-acting opiates.
Click to expand...

We’re talking about THIS OB patient

I’m not sure why you decided to introduce random hypothetical post-op patient.
 
ethilo said:
Also: an amazing ace up the sleeve is intraperitoneal chloroprocaine. Give the surgeons 40mL 3-CP and tell them to dump it into the peritoneum and swish it around. Instantly resolves visceral pain and nausea from all that manipulation the moment it contacts tissue, I kid you not. One of our attendings is working on studying it more. It's definitely coming with me in my future career!
Click to expand...
Interesting, I’ll have to remember that.


JobsFan said:
Everyone gets spinals that are sometimes disappointing.
Click to expand...

This is true. I think intrathecal fentanyl covers a lot of disappointing spinal sins though.

JobsFan said:
What was the height of your block prior to starting?
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I would have no idea. I check my c-section spinal levels via the cranial nerve 8 pathway, i.e. I listen for the surgeon to call out “Allis” ... 🙂
 
Put me in the camp that thinks your IT fent dose is a bit homeopathic, but I'm with Twig - I think this patient was just a wimp. I haven't noticed any difference between repeats and primaries. Just wimps and non-wimps.
 
Twiggidy said:
That’s why i sided with you. From how you described it I felt like the patient just needed a bit more hand-holding the the usual normal C-section patient. I’m not sure why people started thundering down on your mix (which was fine btw)......but SDN tho
Click to expand...

Vague, hard to describe, hard to localize discomfort during a c-section is where the intrathecal fentanyl shines.

Per other threads on the subject, lots of SDN’ers don’t use it at all, because they feel the higher pruritis rate makes it a hassle, but there’s no denying its benefit. And 5 mcg is IMO a why’d-you-bother homeopathic dose. 😉

I don’t mean to be thunderous about it. 🙂
 
pgg said:
they feel the higher pruritis rate makes it a hassle
Click to expand...

I'm not convinced 15-20mcg of IT fent causes much pruritus at all. They never itch until rolling to PACU and hour later when - surprise surprise - the IT morph is taking effect.

I've added the same dose of IT fent to orthopedic spinals without duramorph (cuz' we don't have the proper post-op monitoring set-up) and not one of them ever itched.
 
pgg said:
Vague, hard to describe, hard to localize discomfort during a c-section is where the intrathecal fentanyl shines.

Per other threads on the subject, lots of SDN’ers don’t use it at all, because they feel the higher pruritis rate makes it a hassle, but there’s no denying its benefit. And 5 mcg is IMO a why’d-you-bother homeopathic dose. 😉

I don’t mean to be thunderous about it. 🙂
Click to expand...
what’s really strange and i have no explanation for is that if i do intrathecal opioid during labor, the patients itch, but when i give duramorph/fentanyl for C/S ive gotten next to zero calls for itching

my theory was thst once the block sets in the LA blocks the itching (because the labor patients stop complaining of after epidural reacbes a good level) i admit im just guessing, but its one of those strange things ive noticed
 
pgg said:
...

This is true. I think intrathecal fentanyl covers a lot of disappointing spinal sins though.


I would have no idea. I check my c-section spinal levels via the cranial nerve 8 pathway, i.e. I listen for the surgeon to call out “Allis” ... 🙂
Click to expand...

Agree on fentanyl being useful, I routinely add 20mcg
Weird that you don’t know block level, it’s routine to test block height here prior to allowing the surgeon to prep. Testing allows us to add in a little head down while they scrub if necessary.

8th nerve testing ... you sure you’re not listening for your patients scream?:nailbiting:
 
JobsFan said:
Agree on fentanyl being useful, I routinely add 20mcg
Weird that you don’t know block level, it’s routine to test block height here prior to allowing the surgeon to prep. Testing allows us to add in a little head down while they scrub if necessary.

8th nerve testing ... you sure you’re not listening for your patients scream?:nailbiting:
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I don't check a level either. To me, hypotension is an adequate marker of a mid-thoracic block (and by hypotension I mean the absence of hypertension with neo running).

JobsFan said:
btw a colleague got sued here for not treating “pressure”
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Inadequate pain control is the #1 reason to get sued on OB. If a pt seems uncomfortable, I'm always very sympathetic and offer if they would prefer to go to sleep. I let them make the call. Im not gonna talk someone into just grinning and bearing it. I'm not a fan of limping through a section on nitrous/ketamine/whatever. Neuraxial ain't cuttin' it - nighty night. The exception would be if they are super close to being done.
 
JobsFan said:
Ok but why not just check the level and tip them head down a bit if necessary befor3 you start?
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Exactly!
That's why I check levels.
No such thing as a high spinal from a high dose (or indeed low) just poor bed positioning!
 
anbuitachi said:
Do you check a level for orthopedic case? Hips, knees?
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no because they don't get a lumbar epidural that needs to spread to cover mid thoracic dermatome.

just to be really clear a small percentage of my patients get head down, which raises the level of the block (heavy bupivicaine) -- which prevents the patient feeling discomfort from a block that isn't high enough ... of course you can just tell them "it isn't pain ... it's just pressure" or offer them a GA conversion -- but I prefer spending 20 seconds to check block height.
 
so strange given the litigious environments you guys work in... you're making it easy for the lawyers.
 
JobsFan said:
no because they don't get a lumbar epidural that needs to spread to cover mid thoracic dermatome.

just to be really clear a small percentage of my patients get head down, which raises the level of the block (heavy bupivicaine) -- which prevents the patient feeling discomfort from a block that isn't high enough ... of course you can just tell them "it isn't pain ... it's just pressure" or offer them a GA conversion -- but I prefer spending 20 seconds to check block height.
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I don’t do scheduled c-sections with lumbar epidurals either, and I would look askance at anyone who did.

Now, bolusing a labor epidural to get a surgical block for a c-section? Yes, I check levels and titrate to effect. That’s a wholly different scenario.
 
sure, of course I don't choose epidural for elective sections either.

so to answer anbuitachi's question, if I do any case under spinal (or lumbar epidural) that requires a block to T5 ... yes I check the block.
 
Planktonmd said:
If you want your spinal to work better give the whole 15 mg of Bupi (unless the patient is really short), and skip the Fentanyl.
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Yes. I give all the bupi and 0.1mg duramorph 90% of the time. Control level by tilting table.

I've found where fentanyl is really nice is when patient is laboring with a sub par epidural and you want to SAB for the c section. I can usually get by with 7.5mg or less bupi. Without the fent they have high risk of being uncomfortable or not being able to breathe 🙂
 
Planktonmd said:
If you want your spinal to work better give the whole 15 mg of Bupi (unless the patient is really short), and skip the Fentanyl.
Click to expand...

Most accurate response and while you're at it, wash the syringe with epi (probably does nothing, but I saw a chief do it during residency and I was convinced)
 
SaltyDog said:
I don't want the spinal to last that long though. An anesthetic tha lasts 3.5 hours for a 45 min case is poor form IMO.
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But that's 4 hrs of a patient with no pain which will pretty much get you to the end of your OB shift it the section is at 12pm.

Plus I think it's easier to convince a patient after a section that "you'll be able to move in a few hours" than "are your hurting? maybe? well let's go to sleep" because I do agree with your other tactic.....if they feel something....."Goodnight ma'am"
 
so you guys either recommend giving an overdose of spinal to be sure it'll work, or giving a normal dose and converting to a GA if it doesn't work out.

i recommend giving a normal dose, checking block height and pushing it up a bit with gravity if needs be before starting... and I'm the one with weak sauce -- ah ok, carry on gentlemen, I prefer my way.
 
Twiggidy said:
But that's 4 hrs of a patient with no pain which will pretty much get you to the end of your OB shift it the section is at 12pm.
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Good point. In fact, I'm gonna start keeping all my pts intubated in PACU until I leave for the day so I don't have to deal with any post-op pain issues. :poke:
 
JobsFan said:
so you guys either recommend giving an overdose of spinal to be sure it'll work, or giving a normal dose and converting to a GA if it doesn't work out.

i recommend giving a normal dose, checking block height and pushing it up a bit with gravity if needs be before starting... and I'm the one with weak sauce -- ah ok, carry on gentlemen, I prefer my way.
Click to expand...

to be honest, i do about 1.6-1.8 bupiv with duramorph with my epi wash voodoo that does the trick. unless they're Bernadette from Big Bang Theory (she's short btw) you can do 2 cc and they'll probably just have a heavy chest. and yes, if things are iffy, I go straight to GA because, at least in the population I work with, they're already scared to death of a c-section and moving the table/hand holding doesn't do much for them if the spinal isn't the bees knees, therefore, yes, i have them go to sleep so the surgeons can work and the OR remains to be a sane place. It's much easier to explain to the husband "I put her to sleep so she could be comfortable" instead of a "what are you feeling now" battle in the OR
 
SaltyDog said:
Good point. In fact, I'm gonna start keeping all my pts intubated in PACU until I leave for the day so I don't have to deal with any post-op pain issues. :poke:
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tenor.gif
 
narcusprince said:
Along the same lines.... we should keep patients eyes taped until they get in the Pacu to stop corneal abrasions.
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Haha. Don't forget that pre induction tape.

But regarding spirals, I honestly see both sides of the argument above. Being in private practice, I'd rather give a little extra bupi and be sure I don't have to sit her up again for a little more or put her to sleep. Forget the epi wash--thank god the Fmed docs aren't allowed to do sections alone where I work.

BUT... I'm still waiting to see the parturient that wants to get up and walk around before the block wears off... not sure it's a fair comparison to leaving patients in the pacu intubated.

As long as their arms are strong enough to hold baby back in the recovery room I consider it a good anesthetic
 
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