Spinal after Epidural

[deleted697535]

for C Section
Are there guidelines that say you should wait x amount of time (after last epidural bolus) for a non immediate section?

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[Arch Guillotti]

No set guidelines. Judgement, experience and clinical situation.

 

[D P356]

Not that I’m aware of. Inadequate Unilateral or bilateral block could affect SAB bupi dosage depending on level of block. ASA has a way to calculate a dosage.
Others say use a normal dose of bupi and have pt sit up a little longer or decrease SAB bupi by 20%.

Emergency, epidural not working.... Like a few months ago when I took care of that prolapsed cord with OB forearm deep, preventing immediate delivery of products of conception in the wrong order. ETT RSI. Woof!
I grew some new gray chest hair in that case.

It will be interesting to hear what more experienced docs on this board would do.

 

[deleted697535]

 

[deleted697535]

Agreed, thank you! OB can be terrifying sometimes!

 

[deleted162650]

for C Section
Are there guidelines that say you should wait x amount of time (after last epidural bolus) for a non immediate section?

How big of a bolus are you talking?

 

[deleted126335]

No set guidelines. Judgement, experience and clinical situation.

like the old saying goes, Good judgement is the result of experience. Experience is the result of bad judgment.

 

[surgndoc]

Would not do a spinal after a failed dosing of an epidural for section, as in just gave 20mL+ epidural Lidocaine.

your options are
1 - if non urgent wait 45 mins and do a spinal, possibly with a lower dose spinal
2 - if urgent but not emergent, and you have more room to go with lidocaine, just place a new epidural. Can also dose up with chloroprocaine
2b - prop sux tube
3 - emergent - prop sux tube

at academic centers issues like this come up more often than you’d think

 

[deleted126335]

Would not do a spinal after a failed dosing of an epidural for section, as in just gave 20mL+ epidural Lidocaine.

your options are
1 - if non urgent wait 45 mins and do a spinal, possibly with a lower dose spinal
2 - if urgent but not emergent, and you have more room to go with lidocaine, just place a new epidural. Can also dose up with chloroprocaine
2b - prop sux tube
3 - emergent - prop sux tube

at academic centers issues like this come up more often than you’d think

4. Do spinal and be willing to deal with the consequences of probable high spinal.

 

[okayplayer]

I probably handle this differently than some of you. Get called for section on pt with epidural. Go see pt. If she is grimacing with contractions/uncomfortable —> no epidural bolus, consent her for SAB in OR. Give 1.4 instead of 1.6ml bupi.

Obviously the opposite scenario is she is very comfortable with contractions. That patient gets 2% lido through the epidural.

This is my system based on my experiences. Works for me.

 

[Norepi]

What's the problem here? Give 1.6 of heavy bupi intrathecally, check a level and call it a day if your epidural isnt adequate. You're nowhere near toxic levels and the chances of a super high spinal (barring extreme epidural boluses like 30cc of local +) are not that significantly different either. I'd love to see some data proving the converse.

 

[GassYous]

What's the problem here? Give 1.6 of heavy bupi intrathecally, check a level and call it a day if your epidural isnt adequate. You're nowhere near toxic levels and the chances of a super high spinal (barring extreme epidural boluses like 30cc of local +) are not that significantly different either. I'd love to see some data proving the converse.

Don't have data but heard enough anecdotes to just put 'em to sleep. Ain't nothing some pvc through the cords can't fix.

 

[Volatile]

I probably handle this differently than some of you. Get called for section on pt with epidural. Go see pt. If she is grimacing with contractions/uncomfortable —> no epidural bolus, consent her for SAB in OR. Give 1.4 instead of 1.6ml bupi.

Obviously the opposite scenario is she is very comfortable with contractions. That patient gets 2% lido through the epidural.

This is my system based on my experiences. Works for me.

I have a similar approach. I have dosed several epidurals followed by a spinal for urgent c/s and have never had a high spinal (not saying it can’t happen, just haven’t experienced it). If the patient has an epidural in place that has required a lot of trouble-shooting by the anesthesia team throughout the day and she has never really gotten comfortable, I’m pretty quick to pull it and do a spinal in the room, usually 1.5cc. If she has an epidural and has partial relief, I’ll try dosing it, if she’s not getting the block I want after say 10-15cc, I’ll pull it and place a spinal, maybe ~1.2-1.4cc. Maybe I’m too quick to switch to a spinal, but I absolutely hate limping through a c/s with a sh$t epidural, so now I don’t. Never had any issues.... other than reliably comfortable patients 😉

 

[okayplayer]

I have a similar approach. I have dosed several epidurals followed by a spinal for urgent c/s and have never had a high spinal (not saying it can’t happen, just haven’t experienced it). If the patient has an epidural in place that has required a lot of trouble-shooting by the anesthesia team throughout the day and she has never really gotten comfortable, I’m pretty quick to pull it and do a spinal in the room, usually 1.5cc. If she has an epidural and has partial relief, I’ll try dosing it, if she’s not getting the block I want after say 10-15cc, I’ll pull it and place a spinal, maybe ~1.2-1.4cc. Maybe I’m too quick to switch to a spinal, but I absolutely hate limping through a c/s with a sh$t epidural, so now I don’t. Never had any issues.... other than reliably comfortable patients 😉

That is NOT my approach. If they are not super comfortable with contractions with the epidural, I don’t load it prior to the section. Just pull it and do a spinal. I think this is lower risk for high spinal.

If they are comfortable with contractions, I fully load the epidural and proceed. These patients nearly always do fine using the epidural for section. If they were still uncomfortable after loading epidural, I’d put an ETT in (thankfully very rare).

I think I have an uncommon attitude/approach to this but I HATE a patchy lousy epidural section. Miserable for everyone involved.

 

[Arch Guillotti]

What's the problem here? Give 1.6 of heavy bupi intrathecally, check a level and call it a day if your epidural isnt adequate. You're nowhere near toxic levels and the chances of a super high spinal (barring extreme epidural boluses like 30cc of local +) are not that significantly different either. I'd love to see some data proving the converse.

Probably not enough data out there to draw meaningful conclusions. Once you see it happen once or twice tends to make you very cautious.

 

[okayplayer]

Probably not enough data out there to draw meaningful conclusions. Once you see it happen once or twice tends to make you very cautious.

Same.

As one of my partners says “there are old pilots and there are bold pilots but there are no old, bold pilots.”

 

[Mman]

I probably handle this differently than some of you. Get called for section on pt with epidural. Go see pt. If she is grimacing with contractions/uncomfortable —> no epidural bolus, consent her for SAB in OR. Give 1.4 instead of 1.6ml bupi.

Obviously the opposite scenario is she is very comfortable with contractions. That patient gets 2% lido through the epidural.

This is my system based on my experiences. Works for me.

I almost always pull the epidural and do a spinal. The only people that I do under epidural for csection are those patients that are so numb from the labor infusion that you could almost do a csection already without additional bolus.

I also decrease the dose on the spinal compared to normal. Somewhere between 0.5 ml and 1.0 ml of hyperbaric bupivacaine is more than enough if they were already mostly comfortable with their epidural.

 

[Mman]

What's the problem here? Give 1.6 of heavy bupi intrathecally, check a level and call it a day if your epidural isnt adequate. You're nowhere near toxic levels and the chances of a super high spinal (barring extreme epidural boluses like 30cc of local +) are not that significantly different either. I'd love to see some data proving the converse.

nobody cares about a toxic serum level from the 10 or 15 mg of intrathecal bupivacaine. It's the gigantic load of local sitting in their epidural space (under pressure) that now has a clear path into their CSF and straight into high spinal land that is the concern. And no there isn't a study to prove it because it doesn't need to be done.

Next time you find your epidural isn't adequate, dose your spinal with < 1 ml of bupivacaine. I guarantee it will be enough to get through an hour long c-section. And yes, I've seen spinals get up to the cervical level with a 1 ml dose in a spinal in a patient that had an epidural running.

(and furiously knocking on wood) I've never had to intubate for a high spinal in OB in somewhere between 3000-5000 csections. I have had to CPAP for a few minutes here or there on patients that got awful damn close.

 

[coffeebythelake]

What's the problem here? Give 1.6 of heavy bupi intrathecally, check a level and call it a day if your epidural isnt adequate. You're nowhere near toxic levels and the chances of a super high spinal (barring extreme epidural boluses like 30cc of local +) are not that significantly different either. I'd love to see some data proving the converse.

if u are looking for a randomized control trial you aren't going to find one

 

[Gator7]

As others have mentioned pretty low threshold to pulling epi with no attempt at bolus and just doing spinal.

I used to think it was bs but I have now seen a couple high spinals from doing a spinal after an epidural bolus. Standard dose here is 1.2-1.4 of heavy so if I end up in this situation I now just give 1.0 ml

 

[Mman]

As others have mentioned pretty low threshold to pulling epi with no attempt at bolus and just doing spinal.

I used to think it was bs but I have now seen a couple high spinals from doing a spinal after an epidural bolus. Standard dose here is 1.2-1.4 of heavy so if I end up in this situation I now just give 1.0 ml

Don't get me wrong, if it's a stat c-section I am pushing the drugs in the epidural quickly. But if it is your run of the mill failure to progress sort of situation, just sit 'em up and stick in a spinal and life will be much easier. You don't get a special award for using the epidural.

 

[Hork Bajir]

Anybody feel comfortable leaving the old epidural catheter in place while you’re doing the spinal? Seems like a... ballsy... move (risk of shearing the epidural cath). But if you’re low-dosing your spinal, would be nice to have the epidural as a bail-out. Personally I would just do a new CSE in that scenario (depending on how much I had low-balled the spinal dose), but I admittedly don’t do much OB these days. Just curious if anyone out there is doing this

 

[Arch Guillotti]

Anybody feel comfortable leaving the old epidural catheter in place while you’re doing the spinal? Seems like a... ballsy... move (risk of shearing the epidural cath). But if you’re low-dosing your spinal, would be nice to have the epidural as a bail-out. Personally I would just do a new CSE in that scenario (depending on how much I had low-balled the spinal dose), but I admittedly don’t do much OB these days. Just curious if anyone out there is doing this

No

 

[Planktonmd]

Pull the catheter out and do a spinal exactly the same way you would if there was no epidural. All that other masturbatory stuff they taught you in residency is truly irrelevant.
In the unlikely situation where you get a high spinal, you know how to deal with it, don't you?

 

[Mman]

Anybody feel comfortable leaving the old epidural catheter in place while you’re doing the spinal? Seems like a... ballsy... move (risk of shearing the epidural cath). But if you’re low-dosing your spinal, would be nice to have the epidural as a bail-out. Personally I would just do a new CSE in that scenario (depending on how much I had low-balled the spinal dose), but I admittedly don’t do much OB these days. Just curious if anyone out there is doing this

there is no need to. Just need the OB to finish in < 90 minutes and preferably in < 60 minutes. A lower dose spinal with an epidural space full of local works just fine.

 

[deleted697535]

there is no need to. Just need the OB to finish in < 90 minutes and preferably in < 60 minutes.

Good luck with that!
The ivory tower i work at trains residents to take 3 hours+. Sometimes more
The locum gig i got im back in bed after around an hour

 

[Mman]

Good luck with that!
The ivory tower i work at trains residents to take 3 hours+. Sometimes more
The locum gig i got im back in bed after around an hour

a 3+ hour csection is criminal. 2 unsupervised junior residents should be able to finish in less than 2 hours.

 

[Southpaw]

Anybody feel comfortable leaving the old epidural catheter in place while you’re doing the spinal? Seems like a... ballsy... move (risk of shearing the epidural cath). But if you’re low-dosing your spinal, would be nice to have the epidural as a bail-out. Personally I would just do a new CSE in that scenario (depending on how much I had low-balled the spinal dose), but I admittedly don’t do much OB these days. Just curious if anyone out there is doing this

all risk no reward. No.

 

[Southpaw]

I have no problem doing spinal after epidural provided that the epidural hasn't been bolused in the last hour or so. If the epidural has been bolused, especially heavily, there are a couple things to keep in mind. The epidural space can get dilated, or expanded, and compressing the dura and subarachnoid space. this has a couple of issues, some of which are you can get false positive with spinal placement when you're still in the epidural space (and seeing epidural local, rather than spinal fluid, come out through your spinal needle). another issue is that once you create a 25g hole in the dura with an expanded epidural space because of your bolus(es) you'll get an unknown quantity of epidural local coming into the subarachnoid space due to pressure gradient. this in itself can lead to a high spinal. the other problem is that even if you inject a small dose spinal because the subarachnoid space is compressed by the epidural space, so your spinal dose spreads higher and quicker (again, pressure gradient from epidural space) so you're at higher risk of high spinal.

If you know all of this and are aware of it and plan for it, then go ahead. but those waters should be tread carefully. I personally am not a fan of doing a spinal after a bolused epidural, but I used to have partners do it routinely. personally I examine the epidural closely and if it hasn't worked well for labor, then I don't bolus it. I pull it and do spinal.

also, I've noticed personally that if I do a lower dose spinal after a bolused epidural (which by the way, I don't really do anymore for the reasons already stated), anecdotally speaking I believe the spinal doesn't last as long. this, in my opinion, is because the spinal space has been compressed by the epidural space, so less spinal med has spread faster both caudad and especially cephalad, but there isn't as much working on the levels that I want it working. it doesn't last nearly as long as a normal heavy bupi spinal. we better be in and out of the room in 45 min or so or I'm going to have to augment with IV meds pretty significantly.

also, since starting CSE my epidurals are better, less patchy, and I almost always am able to use the epidural for CS.

 

[fakin' the funk]

for C Section
Are there guidelines that say you should wait x amount of time (after last epidural bolus) for a non immediate section?

A) critical to decide if your epidural works before u start to bolus for CS
B) if it's sketch and there's no time -> GA

 

[woopedazz]

We have junior registrars rotate through this obstetric hospital, so more than occasionally the theatre top-up fails. Normally I remove it and do a CSE with ~1.5mL heavy + IT morphine and don't dose the epidural until the block height is establishing. Then just put a couple of extra mLs into the epidural to force the spinal up a few levels if it's too low; or hold if it's T4/higher.

Would never do a spinal alone anymore, just because I've been burnt before by high/low block and then what you gonna do? You're the player that has stuffed up. Your only escape is a GA and I personally believe that's a suboptimal outcome (albeit easier for us).

 

[narcotics999]

We have junior registrars rotate through this obstetric hospital, so more than occasionally the theatre top-up fails. Normally I remove it and do a CSE with ~1.5mL heavy + IT morphine and don't dose the epidural until the block height is establishing. Then just put a couple of extra mLs into the epidural to force the spinal up a few levels if it's too low; or hold if it's T4/higher.

Would never do a spinal alone anymore, just because I've been burnt before by high/low block and then what you gonna do? You're the player that has stuffed up. Your only escape is a GA and I personally believe that's a suboptimal outcome (albeit easier for us).

It is really uncommon to get low block for spinal unless you give a very small dose. For a typical woman of 5'4, I give 1.3ml heavy bupi+15mcg fent+0.2mg morphine (50mcg dilaudid) and it always works (knock wood).

I think T4 is not necessary. It is for the classic (barbaric ) vertical c-section.

Our OB are not slow. Skin to skin usually within an hour.

 

[DrOwnage]

With all things said I mostly agree with not doing a spinal after recent bolusing of the epidural.

I usually stay around 10 minutes in the room doing paperwork after placing and bolusing my epidurals and check to see if they're truly working before I leave. Then I can DGAF and trust it, especially if secured well. If I come on to shift and take over epidurals I make sure theyre working, especially the one that the partner put in 12 hours ago and she's still 5cm.

First thing I do when I get the call that "we're going for a section" is walk to the nourishment room and put ice in a glove. Walk over to the patient and do a quick level test, if its a tiny patchy but bilateral and similar dermatomal coverage I'm willing to hedge my bet that a good strong hand bolus of 10-20 of lido will get good enough coverage. If there's inconsistent dermatomal coverage on one side compared to the other I'm pretty hesitant. In that situation I would do a spinal if its just been running at the normal 8cc and hour with no recent boluses. However chances are if its a ****ty epidural the patient will have been bolusing it. If that's the case redo the epidural if "urgent."

If the OB says its urgent/emergent and says we gotta get baby out in the next 10, that's not enough time in my opinion to do anything safely without compromising the baby. I understand all the hubub about general anesthesia in parturients, but honestly we do this every day. General is not the devil and we have glidescopes. I'm pushing the 200 of prop to induce and getting the tube in while they cut skin, realistically not much of that medication or volatile is getting to the baby if its out in 2 minutes. God forbid if something is wrong with the kiddo and it goes to litigation, what sounds better? The anesthesiologist had his dick in his hands trying to get an epidural in while the baby was in the gray zone. Or he secured the airway and got the baby out fast.

 

[BloodySurgeon]

I think about these hypothetical situations a lot and always wonder what would I do?

Also said to myself, ive need seen a high spinal, i never met anyone who seen a high spinal until a few months ago.

I had a colleague with a high spinal after a failed epidural. 5"0 women level checked beforehand and it was below T10 after lidocaine bolus' as per report. He said he gave 1.2cc of 0.75% hyperbaric bupivicaine intrathecally (to account for his previous bolus') and patient lost consciousness with upper extremity weakness after laying patient flat.

If it were me I would just give 3.0mL of 0.5% isobaric bupivicaine intrathecally. If it was an obese lady with horrible airway, maybe a CSE with catheter for the hailmary if the spinal doesnt work.

 

[DrOwnage]

I think about these hypothetical situations a lot and always wonder what would I do?

Also said to myself, ive need seen a high spinal, i never met anyone who seen a high spinal until a few months ago.

I had a colleague with a high spinal after a failed epidural. 5"0 women level checked beforehand and it was below T10 after lidocaine bolus' as per report. He said he gave 1.2cc of 0.75% hyperbaric bupivicaine intrathecally (to account for his previous bolus') and patient lost consciousness with upper extremity weakness after laying patient flat.

If it were me I would just give 3.0mL of 0.5% isobaric bupivicaine intrathecally. If it was an obese lady with horrible airway, maybe a CSE with catheter for the hailmary if the spinal doesnt work.

Cesarean section requires a T4-T6 level. You would not get that with isobaric bupivicaine injected at the lumbar level. Isobaric spinal 0.5% bupivacaine produces sensory blockade that is reduced by two dermatomes per interspace when injection at L2–L3, L3–L4, and L4–L5 interspaces are compared. Speed of injection has been reported to affect spinal block height, but the data available in the literature are conflicting. In studies using isobaric bupivacaine, there is no difference in spinal block height with different speeds of injection.

 

[Bryan O’Blivion]

Generally would NOT place spinal after bolusing an epidural. Have pulled questionable epidurals and replaced with SAB, will continue this practice.

There are many different situations that will make this ambiguous and nuanced. Habitus of patient, patient airway, length of labor, engagement of fetal head in pelvis, skill of surgeon and assist, and of course indication for section. It’s worth getting the recent history of the course of labor, and talking to the OB. For instance, a patient can have breakthrough pain with motor block due to the fetal head making contact with the ischium, which may not be getting benefit from a lumbar labor epidural at standard dosing, but they will probably convert to a surgical block just fine, although you may want to anticipate a difficult fetal extraction.

Again, generally speaking, if it’s working well for labor, it will probably work well for surgery, and if it’s failed for labor, it has a solid probability of failure for surgery.

Although like everyone, I prefer neuraxial anesthetics for OB, I have found that General is a lot better when it’s the initial plan rather than performed when a patient is screaming with an open abdomen from a failed block, and even this is better than hurriedly after the horrific progression of a high spinal.

 

[Bryan O’Blivion]

With all things said I mostly agree with not doing a spinal after recent bolusing of the epidural.

I usually stay around 10 minutes in the room doing paperwork after placing and bolusing my epidurals and check to see if they're truly working before I leave. Then I can DGAF and trust it, especially if secured well. If I come on to shift and take over epidurals I make sure theyre working, especially the one that the partner put in 12 hours ago and she's still 5cm.

First thing I do when I get the call that "we're going for a section" is walk to the nourishment room and put ice in a glove. Walk over to the patient and do a quick level test, if its a tiny patchy but bilateral and similar dermatomal coverage I'm willing to hedge my bet that a good strong hand bolus of 10-20 of lido will get good enough coverage. If there's inconsistent dermatomal coverage on one side compared to the other I'm pretty hesitant. In that situation I would do a spinal if its just been running at the normal 8cc and hour with no recent boluses. However chances are if its a ****ty epidural the patient will have been bolusing it. If that's the case redo the epidural if "urgent."

If the OB says its urgent/emergent and says we gotta get baby out in the next 10, that's not enough time in my opinion to do anything safely without compromising the baby. I understand all the hubub about general anesthesia in parturients, but honestly we do this every day. General is not the devil and we have glidescopes. I'm pushing the 200 of prop to induce and getting the tube in while they cut skin, realistically not much of that medication or volatile is getting to the baby if its out in 2 minutes. God forbid if something is wrong with the kiddo and it goes to litigation, what sounds better? The anesthesiologist had his dick in his hands trying to get an epidural in while the baby was in the gray zone. Or he secured the airway and got the baby out fast.

Agree with your stance. Must say, from your phrasing, your epidural technique sounds odd, but bold.

 

[Southpaw]

Cesarean section requires a T4-T6 level. You would not get that with isobaric bupivicaine injected at the lumbar level. Isobaric spinal 0.5% bupivacaine produces sensory blockade that is reduced by two dermatomes per interspace when injection at L2–L3, L3–L4, and L4–L5 interspaces are compared. Speed of injection has been reported to affect spinal block height, but the data available in the literature are conflicting. In studies using isobaric bupivacaine, there is no difference in spinal block height with different speeds of injection.

you don’t need T4-T6. Nice to have, but not always required. Especially if the OB doesn’t externalize the uterus or do lots of pulling/tugging. You can do the section w isobaric but it’s not as reliable as the heavy stuff. Isobaric also takes considerably longer to fully set up than the heavy stuff which is its biggest disadvantage for CS in my opinion.

 

[Southpaw]

I think about these hypothetical situations a lot and always wonder what would I do?

Also said to myself, ive need seen a high spinal, i never met anyone who seen a high spinal until a few months ago.

I had a colleague with a high spinal after a failed epidural. 5"0 women level checked beforehand and it was below T10 after lidocaine bolus' as per report. He said he gave 1.2cc of 0.75% hyperbaric bupivicaine intrathecally (to account for his previous bolus') and patient lost consciousness with upper extremity weakness after laying patient flat.

If it were me I would just give 3.0mL of 0.5% isobaric bupivicaine intrathecally. If it was an obese lady with horrible airway, maybe a CSE with catheter for the hailmary if the spinal doesnt work.

yeah again, it’s bad idea and you’re asking for trouble if you spinal after blousing an epidural. Especially if you’re trusting all should be ok because it was a patchy or incomplete setup with the epidural bolus. You’ve still dilated the epidural space. And you’ll still get local through the dura via pressure gradient once you poke a hole in it. Especially if you do the spinal at the same level as the epidural. The spinal can get high crazy/scary fast.

 

[woopedazz]

you don’t need T4-T6. Nice to have, but not always required. Especially if the OB doesn’t externalize the uterus or do lots of pulling/tugging. You can do the section w isobaric but it’s not as reliable as the heavy stuff. Isobaric also takes considerably longer to fully set up than the heavy stuff which is its biggest disadvantage for CS in my opinion.

I'm envious of how low-dose you guys are able to go where you work. Where I work you need T4-T6 coverage for up to 2 hours. I'm not comfortable giving under 2.2mL of heavy 0.5% even for elective cases. I doubt you folk would ever get a high-spinal with the routine doses you use; even after an epidural bolus. That's just my opinion.

 

[DrOwnage]

Agree with your stance. Must say, from your phrasing, your epidural technique sounds odd, but bold.

Why odd?

 

[Bryan O’Blivion]

Probably professional jealousy. I need two hands.

 

[BloodySurgeon]

Cesarean section requires a T4-T6 level. You would not get that with isobaric bupivicaine injected at the lumbar level. Isobaric spinal 0.5% bupivacaine produces sensory blockade that is reduced by two dermatomes per interspace when injection at L2–L3, L3–L4, and L4–L5 interspaces are compared. Speed of injection has been reported to affect spinal block height, but the data available in the literature are conflicting. In studies using isobaric bupivacaine, there is no difference in spinal block height with different speeds of injection.

Anesthesiology

pubs.asahq.org

 

[GassYous]

Cesarean section requires a T4-T6 level. You would not get that with isobaric bupivicaine injected at the lumbar level. Isobaric spinal 0.5% bupivacaine produces sensory blockade that is reduced by two dermatomes per interspace when injection at L2–L3, L3–L4, and L4–L5 interspaces are compared. Speed of injection has been reported to affect spinal block height, but the data available in the literature are conflicting. In studies using isobaric bupivacaine, there is no difference in spinal block height with different speeds of injection.

wtf are you going on about

 

[DrOwnage]

Just putting in the 2 cents from Nysora. There's a reason we use hyperbaric for sections 99.9% of the time. No need to be rude.

 

[Mman]

for the people that like using epidurals for c-sections, it's worth noting that most of the time patients get far less dense of a block from an epidural compared to a spinal (even when that epidural is as perfectly functional as can be). You can usually get through the case but that doesn't always mean it was a good experience for the mother.

 

[Southpaw]

for the people that like using epidurals for c-sections, it's worth noting that most of the time patients get far less dense of a block from an epidural compared to a spinal (even when that epidural is as perfectly functional as can be). You can usually get through the case but that doesn't always mean it was a good experience for the mother.

This is true, but multifactoral. I think as of fairly recently a super high volume OB place in Atlanta did CS with exclusively epidural. At least that's what I've heard. @jwk may be able to speak to it.

Anyway, if the epidural is a solid epidural it'll almost surely be fine for CS. And unless a Mom previously had a CS under spinal she'll have nothing to compare that experience to. But a lot depends on patient psychology (is she crazy? or in a crazy place? labor can make in the most normal gal super nuts...) and OB factors (how long do they take? do they externalize the uterus? pull/tug a lot?).

If the OB is fast, doesn't externalize, and the patient is fairly normal and you have a decent epidural it'll be fine. On the flip, if the OB is slow, externalizes, tugs a lot, putzes around a lot, and your patient is going nuts, then you need spinal and likely some versed/fent post delivery.

Of course, if you really don't want think much about any of this, then just take your epidural (pre bolus) out and put a spinal in. I had an attending in residency who sort of wrote a cliff notes version on how to handle management of the patient going from labor to CS. I'm simplifying it but he basically said if you like your patient take the epidural out and place a spinal. I personally think that's a bit overkill, and believe so even more since I started doing CSEs, but it's not an unreasonable approach.

 

[Mman]

Anyway, if the epidural is a solid epidural it'll almost surely be fine for CS. And unless a Mom previously had a CS under spinal she'll have nothing to compare that experience to. But a lot depends on patient psychology (is she crazy? or in a crazy place? labor can make in the most normal gal super nuts...) and OB factors (how long do they take? do they externalize the uterus? pull/tug a lot?).

If the OB is fast, doesn't externalize, and the patient is fairly normal and you have a decent epidural it'll be fine. On the flip, if the OB is slow, externalizes, tugs a lot, putzes around a lot, and your patient is going nuts, then you need spinal and likely some versed/fent post delivery.

I agree you can usually get through the case, I'm just pointing out is a less dense block the vast majority of the time.

 

[deleted162650]

Cesarean section requires a T4-T6 level. You would not get that with isobaric bupivicaine injected at the lumbar level. Isobaric spinal 0.5% bupivacaine produces sensory blockade that is reduced by two dermatomes per interspace when injection at L2–L3, L3–L4, and L4–L5 interspaces are compared. Speed of injection has been reported to affect spinal block height, but the data available in the literature are conflicting. In studies using isobaric bupivacaine, there is no difference in spinal block height with different speeds of injection.

I gotta say, 0.5% isobaric works great for sections. During the local shortage a couple years ago we had no choice - hyperbaric bupi just wasn’t available. I was skeptical/concerned the level would not be high enough - it is. For a few months we did all sections with iso bupi. I used the same dose as with hyperbaric, 10.5 mg plus 20mcg fent, and 0.2mg duramorph. Not one failed spinal. Not one uncomfortable patient. If you blinded me, I don’t think I could tell whether I used heavy or iso. The only real difference was a much more gradual onset of hypotension with the iso. I’ve gone back to using the heavy stuff since it’s back in the kits, but a few of my partners continue to use 0.5% iso to this day.

Isobaric also takes considerably longer to fully set up than the heavy stuff which is its biggest disadvantage for CS in my opinion.

Wasn’t my experience. By the time foley was in, belly prepped and dry time, and drapes up the block was dense, and they were good to go. No extra waiting necessary.

 

[deleted162650]

Back to the OP:

Add me to the camp that thinks an SAB after a failed attempt to bolus the epidural for section is a bad idea. I’ve seen it go high. Story time:

I was outta residency for a year or 2, and a new fresh grad had just started. He was starting a section for failure to progress, and I was gonna be in the next room over doing gyn cases.

He sees me and says:
“Hey, I bolused the epidural and don’t have a great level - what should I do”

Me:
“I’d just put her to sleep”

Him:
“I think I’m just go ahead and place a spinal”

Me:
“I don’t know, be careful with that. . .”

I go to start my case.

Later that afternoon:

Me:
“Hey, how’d that section go”

Him (real casual like):
“Oh it went fine. She was only apnic for a few minutes.”

Me:


PS: @nimbus , you know this guy. PM me and I’ll tell you who it is so you can make fun of him.