Spinal for C/S after epidural

[soorg]

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I'm not a big fan of doing C-sections with an epidural, simply because the block (as expected) isn't as dense at that of a spinal. However, I've been told by my former program director (ob guy) that you have to give a smaller dose for the spinal in a patient who has had a running laboring epidural if they go for section; otherwise you may get a high spinal. Point being, what is a good dose of hyperbaric bupiv. to give to get a good T4 level if you pull the epidural out prior to giving a spinal?

 

[9french]

I'm not a big fan of doing C-sections with an epidural, simply because the block (as expected) isn't as dense at that of a spinal. However, I've been told by my former program director (ob guy) that you have to give a smaller dose for the spinal in a patient who has had a running laboring epidural if they go for section; otherwise you may get a high spinal. Point being, what is a good dose of hyperbaric bupiv. to give to get a good T4 level if you pull the epidural out prior to giving a spinal?

You are gambling when you do a spinal after you have had a working epidural. The infused epidural solution may compress the meninges resulting in a smaller volume subarachnoid space. Furthermore you are placing a hole in the dura which some of the epidural medication may cross. For these reasons, most people I know suggest using 1/2 to 2/3 of their regular c/s spinal dose. Unfortunately, if the dura is not actually compressed, you may get too low of a level if you give this reduced dose. However, I suppose this beats a high spinal.

For these reasons, I prefer to use a good working epidural for c/s. If you use 10-15 mls of 2% lido w/ epi + bicarb, it can be dosed to the level needed for surgical anesthesia in about 5 minutes. If you need to dose the epidural even quicker, you can use 3% chlorprocaine which in my experience is almost as quick as a bupivicaine spinal.

If, on the otherhand, the epidural is borderline, I will often elect to do a spinal using about 2/3 the dose I normally would. If it does not provide adequate anesthesia, I would at that point go to general.

 

[2ndyear]

The biggest risk of high spinal is clearly after you've loaded the epidural space with 15-30 mL of high test lidocaine and then do a spinal. Even then it is not 100%, but it's not an unexpected complication either. I really don't worry a whole lot if the infusion has been running. I usually go for 12 mL/hr of 0.1% bupiv in the epidural as do most of you I'm sure. Very dilute. Now if you've been in there bolusing with a higher concentration of local then you've still got to be careful. I do not decrease my dose of spinal when the epidural has been running under normal circumstances.

 

[jwk]

I'm not a big fan of doing C-sections with an epidural, simply because the block (as expected) isn't as dense at that of a spinal. However, I've been told by my former program director (ob guy) that you have to give a smaller dose for the spinal in a patient who has had a running laboring epidural if they go for section; otherwise you may get a high spinal. Point being, what is a good dose of hyperbaric bupiv. to give to get a good T4 level if you pull the epidural out prior to giving a spinal?

You have a WORKING epidural. Use it. It makes absolutely no sense whatsoever to pull it and do a spinal.

We do virtually all of our 5000+ C/S each year under epidural. A couple of spinals, and zero CSE's.

 

[thegasman]

You have a WORKING epidural. Use it. It makes absolutely no sense whatsoever to pull it and do a spinal.

We do virtually all of our 5000+ C/S each year under epidural. A couple of spinals, and zero CSE's.

I still don't understand why you guys preferentially use epidurals. SAB is a better block. I will use a working labor epidural for a csection. If no epidural in place I do a spinal. If the epidural is patchy or completely one sided - I pull it and do a spinal. And if extra boluses have not been given I use my usual dose. If extra boluses have been given I will reduce it to about 2/3.

 

[jwk]

I still don't understand why you guys preferentially use epidurals. SAB is a better block. I will use a working labor epidural for a csection. If no epidural in place I do a spinal. If the epidural is patchy or completely one sided - I pull it and do a spinal. And if extra boluses have not been given I use my usual dose. If extra boluses have been given I will reduce it to about 2/3.

1 - We use them because they work - an epidural with a solid T4 level is a perfectly adequate block, easy to attain and maintain
2 - It can be redosed as needed intra-op
3 - We use it for post-op pain control for 24-36 hrs - we have an acute pain service to monitor them.
4 - As already mentioned, if you already have one in for labor, it makes no sense to pull it and replace it with a spinal. If it's a patchy or one sided block, withdraw the catheter and try dosing again, and/or replace it and use a carefully titrated dose to get an adequate level. Then it can still be used for post-op pain control.

 

[Arch Guillotti]

Similar thread recently:

http://forums.studentdoctor.net/showthread.php?t=434151&highlight=high+spinal+epidural

 

[RabbMD]

I have found it to be completely population dependent. In residency I almost always used epidurals if they were working. However in Private practice I have numerous patients that complain about how they can not tolerate the BP cuff every 5 minutes because it hurts so much. On these patients I now take out working epidurals and give a spinal. I set their expectations WAY low still and go with it. If the patient has normal expectations and anxiety levels I just use the epidural, 2% lidocaine with bicarb (10ml or so) mixed with 0.5% ropivacine (10ml or so). It usually takes 15-25ml of this mixture to get an adaquate surgical level. If I take out a working epidural I have not bolused I will do 1.0-1.2 ml of 0.75% hyperbaric bupivacaine for the spinal dose. This seems to prevent problems with pain on tugging later.

 

[jwk]

I have found it to be completely population dependent. In residency I almost always used epidurals if they were working. However in Private practice I have numerous patients that complain about how they can not tolerate the BP cuff every 5 minutes because it hurts so much. On these patients I now take out working epidurals and give a spinal. I set their expectations WAY low still and go with it. If the patient has normal expectations and anxiety levels I just use the epidural, 2% lidocaine with bicarb (10ml or so) mixed with 0.5% ropivacine (10ml or so). It usually takes 15-25ml of this mixture to get an adaquate surgical level. If I take out a working epidural I have not bolused I will do 1.0-1.2 ml of 0.75% hyperbaric bupivacaine for the spinal dose. This seems to prevent problems with pain on tugging later.

Wait - so you don't take blood pressures on your SAB patients?

 

[RabbMD]

LOL. No I do, that is my test on whether they get a spinal or an existing epidural. If they are very anxious and jump off the table from the first NIBP measurement, they sit up and get a spinal.

 

[drgopoos]

We do virtually all of our 5000+ C/S each year under epidural. A couple of spinals, and zero CSE's.

Wow that is an amazing number of C/S . Like around 14 sections per day

 

[jwk]

Wow that is an amazing number of C/S . Like around 14 sections per day

Just comes with the territory for us - 18,000+ deliveries a year. We keep 3 MD's and 4-5 anesthetists in OB on the day shift each day. We have 5 OR's in our L&D area, and it's not that unusual to be using all 5 at once. One of our docs kept track of his weekend last week - he personally did 39 epidurals in two 12-hr day shifts.

 

[Bertelman]

LOL. No I do, that is my test on whether they get a spinal or an existing epidural. If they are very anxious and jump off the table from the first NIBP measurement, they sit up and get a spinal.

Seriously? You must be working with some hyped-up ladies. I've had a couple complain about the cuff being tight (it is when it hits 180 for the first measurement), but I've never seen a physical response.

Besides, by the time the cuff is going up, I'm gloved and setting up my kit.

 

[2ndyear]

Just comes with the territory for us - 18,000+ deliveries a year. We keep 3 MD's and 4-5 anesthetists in OB on the day shift each day. We have 5 OR's in our L&D area, and it's not that unusual to be using all 5 at once. One of our docs kept track of his weekend last week - he personally did 39 epidurals in two 12-hr day shifts.

Wow, that's some seriously high volume OB! Does everyone rotate through or is there an opt-out system for those who don't want to?

 

[Monty Python]

Just comes with the territory for us - 18,000+ deliveries a year. .

I'm guessing you're at Grady ?

http://www.gradyhealthsystem.org/about.asp

 

[jwk]

I'm guessing you're at Grady ?

http://www.gradyhealthsystem.org/about.asp

Grady is nowhere near that high. 😉

 

[jwk]

Wow, that's some seriously high volume OB! Does everyone rotate through or is there an opt-out system for those who don't want to?

Pretty much everyone does there turn during the week, but both the docs and anesthetists swap shifts, so it's pretty easy to get out of if you don't like it. However, if you're on nights or weekends, you're gonna get some regardless.

 

[9french]

Grady is nowhere near that high. 😉

.

 

[PACMDA]

If I were a patient that had a good epidural, then spinal for C-Section, then a nagging positional headache on the 2nd post-op day, that didn't respond to conservative treatment, would you recommend another epidural for a blood patch? That's 2 procedures that were not really necessary and I would send a hit man after you.

 

[epidural man]

You are gambling when you do a spinal after you have had a working epidural. The infused epidural solution may compress the meninges resulting in a smaller volume subarachnoid space. Furthermore you are placing a hole in the dura which some of the epidural medication may cross.

THere is actually good data on this stuff, and the flux of meds across dura is highly dependant on the size of the spinal needle used. Chris Bernarnds at VM did some great work on this in the 90s. Recently there was an article about doing combined CSE but not putting medicine through the spinal and letting the amount that crosses the dura do the work. It was pretty interesting.

Personally, I wouldn't worry about 12 cc of fluid going in over an hour (try pushing a 12cc syringe over an hour - it is a SMALL amount of fluid) in a space that has holes all over the place for the solution to leak out. A 20 cc bolus just before placement is a different matter.

 

[thegasman]

THere is actually good data on this stuff, and the flux of meds across dura is highly dependant on the size of the spinal needle used. Chris Bernarnds at VM did some great work on this in the 90s. Recently there was an article about doing combined CSE but not putting medicine through the spinal and letting the amount that crosses the dura do the work. It was pretty interesting.

.

yeah - we had a guy come talk to us during my last year of residency - he was the ob anes chief at the Brigham. He advocated CSE for labor with a dural puncture without administering any intrathecal medication. He said there was good data that this resulted in a better block without increased pdph.

 

[cchoukal]

yeah - we had a guy come talk to us during my last year of residency - he was the ob anes chief at the Brigham. He advocated CSE for labor with a dural puncture without administering any intrathecal medication. He said there was good data that this resulted in a better block without increased pdph.

There was just an article in this month's A/A comparing epidural alone vs epidural with dural puncture with a 25g whitacre. The differences were interesting. There was a higher %-age with VAS < 30 at 20 min and S1 block at any time, but the cool one, I thought, was the lower incidence of unilateral block.

Oh, and this was a study out of Brigham

 

[militarymd]

There was just an article in this month's A/A comparing epidural alone vs epidural with dural puncture with a 25g whitacre. The differences were interesting. There was a higher %-age with VAS < 30 at 20 min and S1 block at any time, but the cool one, I thought, was the lower incidence of unilateral block.

Oh, and this was a study out of Brigham

All good and fine, but don't you think the "prevalence" of unilateral block in the "control" group is excessively high?

 

[cchoukal]

All good and fine, but don't you think the "prevalence" of unilateral block in the "control" group is excessively high?

Didn't really think about it at the time, but now that you mention it, it's greater than 50%. I'll have to look back and see how they defined "unilateral." I think it was if the level was higher by a couple dermatomes on one side or the other, rather than a true "one-sided" block.

 

[militarymd]

Didn't really think about it at the time, but now that you mention it, it's greater than 50%. I'll have to look back and see how they defined "unilateral." I think it was if the level was higher by a couple dermatomes on one side or the other, rather than a true "one-sided" block.

Like I said...all good and fine...but this all amounts to a hill of beans in PP where we know what we're doing.....

99.999% of my patients are comfortable in 10 minutes...and don't complain about anything....

that extra little hole is not helping guys like us in pp.



Now....on the other hand...if you kind of suck at epidurals, then maybe this kind of "evidence" will help you out.

 

[toughlife]

You are gambling when you do a spinal after you have had a working epidural. The infused epidural solution may compress the meninges resulting in a smaller volume subarachnoid space. Furthermore you are placing a hole in the dura which some of the epidural medication may cross. For these reasons, most people I know suggest using 1/2 to 2/3 of their regular c/s spinal dose. Unfortunately, if the dura is not actually compressed, you may get too low of a level if you give this reduced dose. However, I suppose this beats a high spinal.

For these reasons, I prefer to use a good working epidural for c/s. If you use 10-15 mls of 2% lido w/ epi + bicarb, it can be dosed to the level needed for surgical anesthesia in about 5 minutes. If you need to dose the epidural even quicker, you can use 3% chlorprocaine which in my experience is almost as quick as a bupivicaine spinal.

If, on the otherhand, the epidural is borderline, I will often elect to do a spinal using about 2/3 the dose I normally would. If it does not provide adequate anesthesia, I would at that point go to general.

Would you expect the compression of the meninges leading to a smaller subarachnoid volume to translate into sluggish CSF flow once your spinal needle is in the SA space?

 

[huktonfonix]

You are gambling when you do a spinal after you have had a working epidural. The infused epidural solution may compress the meninges resulting in a smaller volume subarachnoid space. Furthermore you are placing a hole in the dura which some of the epidural medication may cross. For these reasons, most people I know suggest using 1/2 to 2/3 of their regular c/s spinal dose. Unfortunately, if the dura is not actually compressed, you may get too low of a level if you give this reduced dose. However, I suppose this beats a high spinal.

For these reasons, I prefer to use a good working epidural for c/s. If you use 10-15 mls of 2% lido w/ epi + bicarb, it can be dosed to the level needed for surgical anesthesia in about 5 minutes. If you need to dose the epidural even quicker, you can use 3% chlorprocaine which in my experience is almost as quick as a bupivicaine spinal.

If, on the otherhand, the epidural is borderline, I will often elect to do a spinal using about 2/3 the dose I normally would. If it does not provide adequate anesthesia, I would at that point go to general.

I dunno dude, the baricity and curvature of the spinal curve should still be the main determinants of spread. I dont think that the 1.4 mg of hyperbaric bupivicaine that I normally give is gonna give a high spinal regardless. At least I've never seen it.

 

[9french]

Would you expect the compression of the meninges leading to a smaller subarachnoid volume to translate into sluggish CSF flow once your spinal needle is in the SA space?

I would not. I would be surprised if CSF pressure decreased.

 

[9french]

I dunno dude, the baricity and curvature of the spinal curve should still be the main determinants of spread. I dont think that the 1.4 mg of hyperbaric bupivicaine that I normally give is gonna give a high spinal regardless. At least I've never seen it.

That is one of the explanations that I have heard for the increased risk of high spinal after an epidural. Honestly, I have never seen primary literature which supports it and it could just be anesthesia mythology. Nonetheless, in my mind, it seems like a plausible mechanism, i.e., lower spinal CSF volume leads to decreased rate of hyperbaric bupivicaine dilution leads to increased spread.

 

[isoman2000]

here is a link that may be of some interest
http://www.developinganaesthesia.org/index.php?option=com_content&task=view&id=111&Itemid=28

As well I saw an abstract about this subject in the journal of epidural anesthesia that appered to state the normal volume of local for a spinal is safe.