Testing Levels after Spinal/Epidural

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Yangkower

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While in OB, I performed spinal/Epidurals on a lot on non-English speaking patients and sometimes find it cumbersome to evaluate the level of anesthesia. It seems like more often than not I end up jabbing the blunt needle up the abdomen and chest until the patient jumps since asking them to differentiate sharp from touch is too complicated. Any tricks, (especially with a language barrier or nervous patient)?
 
I wasn't clear in my OP. I'm talking about testIng for surgical anesthesia. I'm fluent in Spanish but we get patients who speak many other languages with limited English. 90% of the time a clear explanation of the process is sufficient. What bothers me is when I think I have a level then when surgeon tests, the patient feels pain. This has happened to me a couple times.
 
I still use a blunt needle but don't push very hard. Some of the anesthetists I work with use a nerve stimulator, which seems to work well.
 
Goldenyak2 said:
I still use a blunt needle but don't push very hard. Some of the anesthetists I work with use a nerve stimulator, which seems to work well.
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Tongue depressor broken in half works well.
Had a fellow resident use an 18 gauge cutting needle (did not realize it was a cutting filter needle) once early in his training. Looked over a couple minutes later and there was a trail of bloody spots in a straight line up the abdomen. He added it to the EBL for the case 🙂

Another option is to get the person that helped you with the consent process come in to the OR in scrubs and assist with the testing.

I would imagine it would be frightening to be in an OR awake during surgery and not speak the language being spoken in the room.

When in doubt though, to avoid surprises, the twitch monitor rarely fails you. The language is universal.
 
Twitch monitor is a good idea. I have to try that. I actually used a cutting needle once by accident. Luckily I realized it after a couple pokes (EBL negligible).
 
The situation where this comes up (that is clinically significant) is the non-emergent unplanned C-section under epidural, right?

I mean, if it's truly emergent, and you're at all unsure about your level - mom is going off to sleep (unless she's a 400 kg achondroplastic dwarf with an overbite) regardless of what your neuraxial technique is. If GA will be - under no circumstances - an option, and you must have the ability to provide emergent surgical anesthesia, then a continuous spinal can be a reasonable choice. We've used this before on an obese woman with breech-breech twins demanding a TOLAC (why this was allowed on the OB's part...is beyond me).

And while they can fail on rare occasions, SABs generally produce a consistent level adequate for a c-section (assuming you got CSF return in your syringe). It's fairly uncommon to be fretting about an adequate level if you use an appropriate dose.

So we're left with the non-emergent c-section with epidural, which I think can be the trickiest. One thing I've found that is important to bear in mind is that there's usually a large emotional component to the situation as well. Most of the time you're doing the section because the woman has been laboring for hours, baby's not dropping down, and everyone is mentally and physically exhausted. Mom did not come to the hospital to get a c-section. Here in the Bay Area, they are usually so anti-surgery (thanks to the midwife/doula culture that has permeated the region) that the fact they are in the OR at all is utterly repulsive to them.

I think that's why when you test a level on these people you can get such a variable response: they feel some component of whatever stimulus you're using, don't really know what they're supposed to feel (no matter what language they speak or how good you are at explaining it to them), and are so terrified of "feeling the surgery" that you get these inconclusive responses.

When I'm on the OB ward in these situations, I still test the level with ice (we've got a machine close to the OR). But the real test is once the drapes are up - our OBs clandestinely test the skin by pinching with clamps before incision. I've been pretty amazed that the women who report no level of anesthesia when I check them, don't react at all when the OBs pinch their skin.

Personally, I think it goes back to the emotional component thing. If you ask them about a level and they feel anything at all, you're gonna hear about it. If they don't know you're testing them, though, you may get a more accurate picture of what's truly going on.

Albeit there will be times when the OBs pinch and you hear a scream. Your choice in these situations is to either re-dose the epidural with something fast-acting (2% lido) and wait, replace the epidural, or go off to sleep.

I know the OP was asking about techniques for testing in these cases (and I will most certainly add the stimulator to my arsenal), but I also wanted to go through the thought-process I use in these situations and see how other people think through the same situations.
 
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It works or it doesn't and testing ain't going to make it work so there's no point in testing.




ps: testing is great when your NNT is 350 🙄
 
dhb said:
It works or it doesn't and testing ain't going to make it work so there's no point in testing.




ps: testing is great when your NNT is 350 🙄
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So your first indication that the block is inadequate should be with incision when your patient jumps off the table? That'll hold up in court.
 
Is off to sleep the default after a failed spinal or epidural. What about sitting the patient up and having another go at it (assuming incision hasn't happened yet)?
 
Yangkower said:
Is off to sleep the default after a failed spinal or epidural. What about sitting the patient up and having another go at it (assuming incision hasn't happened yet)?
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If you have just dumped 20-30 mls of local anesthetic in the "epidural space" over the last 30-40 minutes trying to get a level, your results of a spinal or repeat epidural may be difficult to predict and might involve a high spinal or a seizure. Those are things that I consider when faced with this situation. If it is simply a hot spot, I will sometimes consider local by the surgeon and a little N2O or ketamine for the rough spots. If it is clear the epidural is not adequate, I usually just go to GETA instead of putzing around.

The clandestine surgical clamp test is the best way and is an outstanding way to differentiate a good block from a bad. Just engage the mom in a conversation about what she will name the baby or how many kids she has at home while they do the test. If she screams out mid sentence, you know your answer. If she carries on with the conversation, you also have your answer.
 
It's pretty easy to tell if your epidural or spinal is working and then there's always plan B, be it in a C-section or in the main OR. At my residency program we just write "adequate" where the blank for level is in the regional part. Only one of our attendings asks for a level. During my anesthesia rotations as a med student we would test to get a level and document it.
At both places the OBs would do the pinch test with an ellis clamp.


As for what to do for a c-section with an existing epidural secondary to failure to progress, just from the laboring time we would know if the epidural is working or not if it is dose it appropriately, in my program that's 20ml of 3% chloroprocaine in divided doses of course, if it doesn't get you the level you want but you know that the epidural is working then I would probably either wait a little longer or give her a little more chloroprocaine. once the baby is out we would start the post-op epidural solution (0.075% bupivicaine with 5mcg/ml fentanyl) If the epidural wasn't working to begin with I would take it and do a spinal with a full dose of bupivicaine for us it's about 12mg. If you get a high spinal no big deal, recognize it, strap on a face mask and support her breathing, calmly explain to the pt what's happening and that she's okay and everything is going well. If she freaks out then drug her a little. Seizures I would think are extremely rare and you'd probably have to be intravascular. I test to make sure that neither the epidural catheter nor my spinal are intravascular before injecting, so seizures are rare, but even if you get one, give her propofol and or versed, if there's cardiac issues call for intralipids super stat, and either support or secure the pt's airway once they're done jerking.

in my residency most of our call is OB call and we pretty much work solo with a senior resident so those would be my plans of action. I think OB is pretty easy, there are only a few things that can go wrong and I know exactly what my plan B or C is and how to fix things if they go wrong.
 
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Why are you guys running an infusion post-op? Just give them 4mg of duramorph and pull the catheter as you are moving the pt to the gurney.
 
scotchnwater said:
our OBs clandestinely test the skin by pinching with clamps before incision.
Click to expand...

If only we were all so lucky. Our OBs shout out "Testing! Testing!", clamp the skin, then ask the patient (through the drape, over the clamor of the instrument count going on in the background) "DO YOU FEEL ANYTHING?!"

Real clever stuff. 👍
 
scotchnwater said:
So your first indication that the block is inadequate should be with incision when your patient jumps off the table? That'll hold up in court.
Click to expand...

There are other indicators and that's my point testing makes you look like you don't know what you're doing.
 
fakin' the funk said:
If only we were all so lucky. Our OBs shout out "Testing! Testing!", clamp the skin, then ask the patient (through the drape, over the clamor of the instrument count going on in the background) "DO YOU FEEL ANYTHING?!"

Real clever stuff. 👍
Click to expand...

We have a few who do the same thing. Very irritating.
 
Saw proof today that approaching the surgical clamp test in the wrong way can totally cloud your test and give you skewed results. Perfectly good SAB and a CRNA in the room gets in the patient's ear and says:

"Do you feel that!?! They're squeezing a clamp on your stomach!!" Do you feel it?!!! Does it hurt??!!"

It was very embarrassing.

I spent the next few minutes trying to undo what she had done as the patient now had what she thought was a failed block because she was talked into it by the poorly trained CRNA. Quite frustrating.
 
Yangkower said:
Is off to sleep the default after a failed spinal or epidural. What about sitting the patient up and having another go at it (assuming incision hasn't happened yet)?
Click to expand...

For spinals, you could drop into T-berg and try to push the LA cephalad

RussianJoo said:
At both places the OBs would do the pinch test with an ellis clamp.
Click to expand...

That would be Allis
 
Gern Blansten said:
Saw proof today that approaching the surgical clamp test in the wrong way can totally cloud your test and give you skewed results. Perfectly good SAB and a CRNA in the room gets in the patient's ear and says:

"Do you feel that!?! They're squeezing a clamp on your stomach!!" Do you feel it?!!! Does it hurt??!!"

It was very embarrassing.

I spent the next few minutes trying to undo what she had done as the patient now had what she thought was a failed block because she was talked into it by the poorly trained CRNA. Quite frustrating.
Click to expand...

:smack:


Reminds me of a story one of my attendings told me about a c-section. Don't remember all the details now but I think the patient was a homeless HIV+ schizophrenic ...

She asks "what's that smell?" as some Bovie smoke wafts over the curtain.

Resident (who's a foreign grad) leans down and says in his thickly sinister accent "they're burning you" ...

Predictable freakout followed by pent/sux/tube.
 
We had this horrible setup whereby the suction canister was positioned a few feet from the patient's head. As if the sound weren't bad enough, they could look to the right and see the exsanguination.
 
I have had good luck with our OBs testing in silence however today, coincidentally we had an attending and resident both do the look over the drape and do the "Hey, we are really pinching the crap out of you routine" at the same time. I like to silently make eye contact with the OB to acknowledge that we are about to test, they pinch, I look at the patient and give a thumbs up to proceed. There is no need to say anything.
 
I apply a glove full of ice to their arm and ask "frio?" and usually get "Si"

I then start down from the inguinal crease and work my way cranial asking "frio aqui?"

It usually works well at determining a level.
 
You don't have ever? Or just at the moment due to shortage? We had some trouble getting for awhile and got a lot more calls for post op pain although our itching complaints went down.

I would be scared to send patients to the OB floor with a catheter in place. Nurses would be injecting all kinds of crap in those things.
 
Yangkower said:
You don't have ever? Or just at the moment due to shortage? We had some trouble getting for awhile and got a lot more calls for post op pain although our itching complaints went down.

I would be scared to send patients to the OB floor with a catheter in place. Nurses would be injecting all kinds of crap in those things.
Click to expand...

So you don't have an acute pain service or run post-op epidural catheters on any of your patients?

In my experience, post-partums don't get much in the way of IV push after delivery, save some pitocin and Zofran. Several hours post-op they are separated from their IV solutions, and that PIV just sits there and rots away from lack of action. I personally wouldn't be too worried about med error into an epidural cath on the OB floors compared to every other wing of the hospital.
 
Not in OB. There would be too many patients for our pain service to watch. True the risk is low but not zero and the outcome could be catastrophic. The vast majority on the women I talk to 24 hours later are pretty comfortable.
 
Our patients want to get up and walk as soon as they get their legs back. Also, the cost of time and pumps not to mention increased PE risk is much greater than the cost of duramorph.
 
Come back the next day....

Pass go... and collect $200.

Go_space_on_Monopology.gif
 
After placement and before the prepping, ask the patient to lift his or her leg at the hip. While prepping, ask the patient if the prep is cold. I think people who do repeated testing with a sharp object look foolish.
 
dhb said:
There are other indicators and that's my point testing makes you look like you don't know what you're doing.
Click to expand...

Totally misunderstood what you were saying earlier. I see your point - why bother with the pre-testing with ice/pinprick if the real test is going to be with the surgical clamp.
 
Hey man, your post scares me. Are you a CA-1? I'm not trying to be a jerk here, but I don't think I agree with some of the positions you take.

RussianJoo said:
It's pretty easy to tell if your epidural or spinal is working
Click to expand...

I think a lot of people would argue that the picture can often be cloudy.

RussianJoo said:
and then there's always plan B, be it in a C-section or in the main OR. At my residency program we just write "adequate" where the blank for level is in the regional part. Only one of our attendings asks for a level. During my anesthesia rotations as a med student we would test to get a level and document it.
At both places the OBs would do the pinch test with an ellis clamp.


As for what to do for a c-section with an existing epidural secondary to failure to progress, just from the laboring time we would know if the epidural is working or not if it is dose it appropriately,
Click to expand...

The point is that even if your epidural is in the right place and you have some sort of level, you will rarely - if ever - get the patient to the point of being entirely numb with an epidural. They rarely work as well as a spinal. Plus you have the frustration/exhaustion of capping off a day of labor with an unexpected trip to the OR. This only serves to complicate the picture. The point is not to be able to document that you had and "adequate" block - the point is to get your patient safely (and sanely) through the procedure with a minimal amount of screaming. This is usually a bigger challenge than it may seem. Even with an "adequate" block.

RussianJoo said:
in my program that's 20ml of 3% chloroprocaine in divided doses of course, if it doesn't get you the level you want but you know that the epidural is working then I would probably either wait a little longer or give her a little more chloroprocaine.
Click to expand...

I don't know what other people's thoughts/experiences are, but I have been led to believe that 3% chloroprocaine should generally be reserved for times when you need a STAT level, as it does set faster than 2% lidocaine. The drawback with 3% chloroprocaine is that a lot of people believe it makes post-op duramorph less effective. Perhaps it's a non-issue if you're running local/fentanyl post-op, but I raise the same question about why you don't want your pts ambulating quickly post-op (which may be problematic for some pts if you are infusing local - even at such a low dose). It's definitely not our "go-to" local of choice for non-emergent C-sections. What are other places doing?

RussianJoo said:
once the baby is out we would start the post-op epidural solution (0.075% bupivicaine with 5mcg/ml fentanyl) If the epidural wasn't working to begin with I would take it and do a spinal with a full dose of bupivicaine for us it's about 12mg. If you get a high spinal no big deal,
Click to expand...

No big deal? You have an unsecured pregnant airway and it's "no big deal"?

RussianJoo said:
recognize it, strap on a face mask and support her breathing, calmly explain to the pt what's happening and that she's okay and everything is going well. If she freaks out then drug her a little. Seizures I would think are extremely rare and you'd probably have to be intravascular. I test to make sure that neither the epidural catheter nor my spinal are intravascular before injecting, so seizures are rare, but even if you get one, give her propofol and or versed, if there's cardiac issues call for intralipids super stat, and either support or secure the pt's airway once they're done jerking.

in my residency most of our call is OB call and we pretty much work solo with a senior resident so those would be my plans of action. I think OB is pretty easy, there are only a few things that can go wrong and I know exactly what my plan B or C is and how to fix things if they go wrong.
Click to expand...

This sounds like something someone would say who hasn't had a lot go wrong. Yet.
 
scotchnwater said:
I don't know what other people's thoughts/experiences are, but I have been led to believe hat 3% chloroprocaine should generally be reserved for times when you need a STAT level, as it does set faster than 2% lidocaine. The drawback with 3% chloroprocaine is that a lot of people believe it makes post-op duramorph less effective.
Click to expand...

I agree with all of that. The other quoted advantage to chloroprocaine for stat sections is that for a distressed baby, there's less chance of any LA crossing the placenta because of chloroprocaine's super fast metabolism by plasma esterases.

That said, I don't end up using it much. Usually what I see are sections that's aren't really "stat" and lidocaine is OK ... or "stat" really means "stat" and we go general.


scotchnwater said:
This sounds like something someone would say who hasn't had a lot go wrong. Yet.
Click to expand...

Most of the OB that I do is low risk, meaning everyone with a hint of a problem is turfed off to another facility. Even so - if I get an ulcer, it'll be because of OB.
 
Scotch, I agree with your posts. To say that a high spinal is no big deal is cavalier. It may have no significant consequences some of the times, but there is certainly a huge risk there and it is very unsettling. If it does not cause your sphincter to tighten, you probably don't enough to know any better.
 
Another related use of chloroprocaine -

Some people out there start off with 2% lidocaine, and if their epidural fails to augment sufficiently after they give 20 or 25 mL of it, will switch to chloroprocaine. The rational being that they don't want to push more lidocaine in there as they approach 7 mg/kg cap, but chloroprocaine is safe.


These guys talk about it and theorize that an anteriorly positioned epidural catheter might not get good posterior spread without larger volumes. (50+ mL in one of their cases.)

http://www.springerlink.com/content/x75222j5010824v0/

It's on my list of things to try someday when I get a crappy epidural, and don't mind waiting a few more minutes to try something before going to sleep.
 
RussianJoo said:
just from the laboring time we would know if the epidural is working or not if it is dose it appropriately, in my program that's 20ml of 3% chloroprocaine in divided doses of course, if it doesn't get you the level you want but you know that the epidural is working then I would probably either wait a little longer or give her a little more chloroprocaine.
...
Seizures I would think are extremely rare and you'd probably have to be intravascular. I test to make sure that neither the epidural catheter nor my spinal are intravascular before injecting, so seizures are rare, but even if you get one, give her propofol and or versed, if there's cardiac issues call for intralipids super stat, and either support or secure the pt's airway once they're done jerking.
Click to expand...

Someone once said, "the first sign of a failed epidural is denial."

Do you test your single shot spinal for intravascular? And you think 1.5ml of bupiv will give your pt a seizure?

What do you do when epidural is not working after 30ml of 2CP? I can think of at least 3 options that doesn't risk a GA or high spinal.
 
if you believe that putting the patient into T-Berg will help your low spinal "creep up" and therefore maybe save you a general or having to dose ketamine, then testing a level earlier than the clamp means you get them into T-berg sooner and may have a greater chance of the level getting higher than if you waited longer
 
RussianJoo said:
....If you get a high spinal no big deal, recognize it, strap on a face mask and support her breathing, calmly explain to the pt what's happening and that she's okay and everything is going well. If she freaks out then drug her a little.....
Click to expand...

I want to give you the benefit of the doubt by believing your intentions/thoughts may have been different in your head than what appears on the screen. Others have already voiced some of my thoughts on your post. However, I feel the need to pick on the part in bold.

With a high spinal requiring you to use a higher FiO2 and possibly assist the patient's ventilation, you are already at a point where the patient's respiratory function is seriously impaired. If you decide to add sedation on top of that, you are risking further respiratory depression and potentially necessitating an urgent/emergent intubation.

In my opinion, if you don't want to induce and intubate, your best bet in addition to supportive measures is usually to tell the surgeons to hurry up and deliver the baby. In the few high spinals I've seen, that will usually improve symptoms. The caveat is that my n is small, and the surgeons here also almost invariably exteriorize the uterus. That probably helps also, in addition to delivery of the baby.

I would not prefer to sedate the type of patient you describe in your post.
 
pgg said:
:smack:


Reminds me of a story one of my attendings told me about a c-section. Don't remember all the details now but I think the patient was a homeless HIV+ schizophrenic ...

She asks "what's that smell?" as some Bovie smoke wafts over the curtain.

Resident (who's a foreign grad) leans down and says in his thickly sinister accent "they're burning you" ...

Predictable freakout followed by pent/sux/tube.
Click to expand...

omg, you're killin me
 
pgg said:
:smack:


Reminds me of a story one of my attendings told me about a c-section. Don't remember all the details now but I think the patient was a homeless HIV+ schizophrenic ...

She asks "what's that smell?" as some Bovie smoke wafts over the curtain.

Resident (who's a foreign grad) leans down and says in his thickly sinister accent "they're burning you" ...

Predictable freakout followed by pent/sux/tube.
Click to expand...

Those damn foreign grads.
 
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