Spinal after Epidural

[nimbus]

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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.

Now that I know I’m not surprised at all and I can’t stop laughing.

 

[DrOwnage]

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.




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.

Interesting Salty. Thanks for the advice, makes me feel better if I’m ever pushed to do it. Always nice to learn from your bag of tricks.

 

[Velefunt]

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.




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.

This really surprises me; I'm probably too chicken to try. Maybe next time I'll check to see how high a block my THA's get and re-evaluate.

Only other issue is block duration and whether that would be an issue for postpartum patients. Isobaric has recently become a problem with a few of our orthopedic surgeons who are convinced it adds a day to their LOS due to inability to immediately participate in PT post-op.

 

[GassYous]

This really surprises me; I'm probably too chicken to try. Maybe next time I'll check to see how high a block my THA's get and re-evaluate.

Only other issue is block duration and whether that would be an issue for postpartum patients. Isobaric has recently become a problem with a few of our orthopedic surgeons who are convinced it adds a day to their LOS due to inability to immediately participate in PT post-op.

Use less
7.5-10 with no adjuvants

 

[Velefunt]

Use less
7.5-10 with no adjuvants

We've gone to mepivicaine for those particular surgeons.

 

[deleted162650]

This really surprises me; I'm probably too chicken to try. Maybe next time I'll check to see how high a block my THA's get and re-evaluate.

Only other issue is block duration and whether that would be an issue for postpartum patients. Isobaric has recently become a problem with a few of our orthopedic surgeons who are convinced it adds a day to their LOS due to inability to immediately participate in PT post-op.

Yup, surprised me too. You have to remember that you get a higher level in a term parturient than a non-pregnant patient. Whether that’s due to “epidural vein engorgement” or not, I don’t know. Pregnant patients also have decreased anesthetic requirements which I think helps as well.

I was concerned about prolonged blocks too - even told the OB nurses to expect it. Didn’t happen (at least not to a significant enough degree for anyone to comment on it). Nobody is really pushing for early ambulation in section patients anyways. Plus, I suspect a 20-30 something metabolically hyperactive parturient clears drugs faster than your typical 60-80 something joint patient.