Testing Levels after Spinal/Epidural

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I may be in the minority, but I rarely check levels that objectively. Oftentimes, it is very cumbersome explaining to them the level check test and they still don't get it. "Okay, was it more OR less on your stomach compared to your arm?....I know it's the same TYPE of touch, but is it the same INTENSITY???....Yes, it's supposed to be less.....Okay now let's go up...."

If I do a spinal, oftentimes the patient's blood pressure drops. That's a good sign. If it doesn't, I'll ask them to move their feet and toes. I'll see if their lower body is getting numb, etc.

For epidurals, I'll ask them straight up if they're contractions have gotten better. You can also just see for yourself- the "visual analogue scale" so to speak.

If there is any doubt, and to be honest, not very often is there, I'll take out a blunt tip needle and give them the test. But all in all, I think it's a waste of time. Especially, if you're trying to get a section rolling and your by yourself with monitors/oxygen to put on, drugs to give, drapes to put up, Pitocin to have ready, and the patient may vomit from a drop in BP at any given time.

Just my .02.
 
Hate the vomiting. Pt looks miserable, OBs with their dirty looks. I keep my N/V kit ready. Kidney basin filled with with 4x4, gloves and phenylephrine right beside the suction.
 
RussianJoo said:
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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I think it seems pretty easy because most of the time it is. You haven't had enough time to run into very hairy situations. You are a CA1, correct? Give it some time. I finished residency within the past few years and I have already accumulated my fair share of OB war stories.
 
Yangkower said:
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.
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I don't think NOYAC was kidding, and I agree. stop testing.
 
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.
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Sorry for the late reply. I was away for the weekend, but no we don't ever have duramorph, the 48hr morphine... I guess it's too expensive for our hospital. We do spinals with Astramorph, our epidurals for vag. deliveries that get sectioned are left in for 12 to 24 hours and we use our standard OR epidural solution for them.
 
scotchnwater said:
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.



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



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.



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?



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



This sounds like something someone would say who hasn't had a lot go wrong. Yet.
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yes I am a CA-1, yes I haven't had a lot go wrong. But I've done about half a dozen stat c-sections where I rsi intubated them, most were very easy grade 1 views, some where harder with DL but the glidescope helped with that. granted I haven't had a high spinal yet, and hopefully I don't, but I would just either bag them or put them to sleep and secure their airway.
 
RussianJoo said:
Sorry for the late reply. I was away for the weekend, but no we don't ever have duramorph, the 48hr morphine... I guess it's too expensive for our hospital. We do spinals with Astramorph, our epidurals for vag. deliveries that get sectioned are left in for 12 to 24 hours and we use our standard OR epidural solution for them.
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Astramorph is a name brand of preservative free morphine, just like duramorph is. While it may be true that your hospital does not use duramorph, it is a bit misleading to say that and then say that you use astramorph, essentially the same drug as everyone else was talking about.
 
RussianJoo said:
granted I haven't had a high spinal yet, and hopefully I don't, but I would just either bag them or put them to sleep and secure their airway.
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If you have a high spinal and an unconscious apneic patient, do you really need to "put them to sleep?"
 
Gern Blansten said:
Astramorph is a name brand of preservative free morphine, just like duramorph is. While it may be true that your hospital does not use duramorph, it is a bit misleading to say that and then say that you use astramorph, essentially the same drug as everyone else was talking about.
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ok, I didn't realize that, thought one was longer acting then the other. Pt's at the place where I rotated as a med student had fall risk precautions for 48hrs after a duramorph spinal, I specifically remember the anesthesiologists placing signs on the chart and the room to alert the nurses of this. At our hospital we use astramorph with spinals and we don't place any fall risk precautions on these patients and they're walking the fallowing day sometimes a few hours after the c-section. So that's why I thought they were two different drugs, sorry for the confusion.
 
Gern Blansten said:
If you have a high spinal and an unconscious apneic patient, do you really need to "put them to sleep?"
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no if they're unconscious i wouldn't need to give them anything else except for the tube between the vocal cords, just like I wouldn't give any drugs to an unresponsive pt that's getting chest compressions on the floor.
 
RussianJoo said:
ok, I didn't realize that, thought one was longer acting then the other. Pt's at the place where I rotated as a med student had fall risk precautions for 48hrs after a duramorph spinal, I specifically remember the anesthesiologists placing signs on the chart and the room to alert the nurses of this. At our hospital we use astramorph with spinals and we don't place any fall risk precautions on these patients and they're walking the fallowing day sometimes a few hours after the c-section. So that's why I thought they were two different drugs, sorry for the confusion.
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When the neuraxial use of PF MSO4 first started, I think it was fairly commonplace to place them in the ICU or monitored bed for concerns of late respiratory depression. While still a minor concern, it is definitely a rare issue. Prob same with falls.
 
RussianJoo said:
no if they're unconscious i wouldn't need to give them anything else except for the tube between the vocal cords, just like I wouldn't give any drugs to an unresponsive pt that's getting chest compressions on the floor.
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Not trying to be a jerk, just pointing out a concept that is not intuitive to those who may have never seen it in real life.
 
as for the chlorprocaine, at my hospital if the OB needs to take a pt back that's been laboring and who has an epidural they call them either urgent or stat before taking them back and usually rush to get the baby out.

We know that half the time it's bull**** but we can't argue with them.

In fact funny story or maybe you guys won't find it funny but, we had a case where the lady was laboring for a sometime and the OB decided to call it a stat c-section and bring her back to the OR, by the time he walked in ready to start she was asleep with a tube in her mouth. He questioned it, and the attending anesthesiologist replied to him, you called it stat, stat c-sections go to sleep with a tube in their mouth. You'd think this would teach the OB to actually think and not call stat c-sections unless they were truly stat but no not the case.

The OB/GYN department at my hospital is terrible, the residents have no surgical skills and there are almost always complications with their post-op patients or intra-op complications like perforating the uterus on hysteroscopy d&c happened to me multiple times, or cutting the bowel or bladder during one of their cases, which I've also seen a few times in my short time in the OR.
 
RussianJoo said:
Sorry for the late reply. I was away for the weekend, but no we don't ever have duramorph, the 48hr morphine... I guess it's too expensive for our hospital. We do spinals with Astramorph, our epidurals for vag. deliveries that get sectioned are left in for 12 to 24 hours and we use our standard OR epidural solution for them.
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Duramorph = Astromorph = plain preservative free morphine

Are you thinking of Depodur?
 
Gern Blansten said:
Not trying to be a jerk, just pointing out a concept that is not intuitive to those who may have never seen it in real life.
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I know you're not. I am on this forum to learn, I realize that my residency program isn't the best in terms of teaching, however, we do have sick patients, surgeons that screw up often and attendings who most of the time don't care as long as the patient doesn't die and they don't get sued, this means we're left on our own to figure $hit out and that sucks and is frustrating that's why i go on here to see what others are doing and to share my experiences and see other peoples reactions. I know I should be reading more from text books but this is more entertaining. I know there are a lot of great attendings and residents here from well respected programs so this is i guess my way of trying to learn from them.
 
pgg said:
Duramorph = Astromorph = plain preservative free morphine

Are you thinking of Depodur?
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maybe? I did my anesthesia rotations late in my 3rd year, so that could be it. If it is then I apologize for the confusion.
 
RussianJoo said:
In fact funny story or maybe you guys won't find it funny but, we had a case where the lady was laboring for a sometime and the OB decided to call it a stat c-section and bring her back to the OR, by the time he walked in ready to start she was asleep with a tube in her mouth. He questioned it, and the attending anesthesiologist replied to him, you called it stat, stat c-sections go to sleep with a tube in their mouth. You'd think this would teach the OB to actually think and not call stat c-sections unless they were truly stat but no not the case.
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At most places, the standard of care is to have the surgeon scrubbed and ready to cut before administering meds for an RSI. At my place, there is better communication to determine if it is stat or urgent or if they would just like to get it done asap.
 
The OB attending is a douche but your attending is a fool. It's hard to believe that an anesthesiologist would put a pregnant lady to sleep just to prove a point. If the patient had aspirated, the baby had a bad outcome or there was airway difficulty I would guess that the Ob attending would throw anesthesia under the bus in a second.

RussianJoo said:
In fact funny story or maybe you guys won't find it funny but, we had a case where the lady was laboring for a sometime and the OB decided to call it a stat c-section and bring her back to the OR, by the time he walked in ready to start she was asleep with a tube in her mouth. He questioned it, and the attending anesthesiologist replied to him, you called it stat, stat c-sections go to sleep with a tube in their mouth. You'd think this would teach the OB to actually think and not call stat c-sections unless they were truly stat but no not the case.
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Gern Blansten said:
Did depodur catch on anywhere? It certainly did not at our place.
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It was around for a while where I trained. The only time I saw it used was as part of an overly complex multi-arm TKA pain protocol study that never got finished. I don't believe they have it any place I work now.
 
RussianJoo said:
as for the chlorprocaine, at my hospital if the OB needs to take a pt back that's been laboring and who has an epidural they call them either urgent or stat before taking them back and usually rush to get the baby out.

We know that half the time it's bull**** but we can't argue with them.

In fact funny story or maybe you guys won't find it funny but, we had a case where the lady was laboring for a sometime and the OB decided to call it a stat c-section and bring her back to the OR, by the time he walked in ready to start she was asleep with a tube in her mouth. He questioned it, and the attending anesthesiologist replied to him, you called it stat, stat c-sections go to sleep with a tube in their mouth. You'd think this would teach the OB to actually think and not call stat c-sections unless they were truly stat but no not the case.

The OB/GYN department at my hospital is terrible, the residents have no surgical skills and there are almost always complications with their post-op patients or intra-op complications like perforating the uterus on hysteroscopy d&c happened to me multiple times, or cutting the bowel or bladder during one of their cases, which I've also seen a few times in my short time in the OR.
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I'm pretty sure that's just called being an OB/GYN :laugh:

There's a story floating around about an OB being asked how a surgery went and her replying "Awesome! We got to oversew the bladder and close some enterotomies!" Only half-kidding. Some of the old school gyn onc guys seem like legit surgeons, but the younger crop of attendings will consult gen surg, vascular, or urology at the drop of a hat.
 
Arch Guillotti said:
The OB attending is a douche but your attending is a fool. It's hard to believe that an anesthesiologist would put a pregnant lady to sleep just to prove a point. If the patient had aspirated, the baby had a bad outcome or there was airway difficulty I would guess that the Ob attending would throw anesthesia under the bus in a second.
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My thoughts exactly. If the baby comes out weak or has low Apgars, someone will almost assuredly blame exposure to anesthetic gas.

Like Gern said in his post, we don't put patients to sleep until the surgeons are prepped, draped, and ready to cut.

About the only exception I've had is during residency when a patient came in after syncopal episode in the street and abruption was suspected. OB wanted to do a STAT C/S. She was alert when we saw her and would not let the nurses put a Foley in her. So we put her to sleep, and then everything else was done. But the OB team was in the OR and no significant time was wasted.

What RussianJoo is describing is clearly atypical/unusual behavior of his attending.
 
Well the residents do most c-sections by themselves especially this time of the year and the OB attending almost never scrubs. I don't know exactly what happened with that case. But all I know is that OB residents have no clue about anesthesia so when we tell them something they don't argue. I am guessing what happened was that they tried to sit the lady up for a spinal but the anesthesia attending told them she's going to sleep and they couldn't say no. They usually don't overhead their attending until they're gloved, gowned, draped and prepped with knife in hand. .
 
RussianJoo said:
as for the chlorprocaine, at my hospital if the OB needs to take a pt back that's been laboring and who has an epidural they call them either urgent or stat before taking them back and usually rush to get the baby out.

We know that half the time it's bull**** but we can't argue with them.

In fact funny story or maybe you guys won't find it funny but, we had a case where the lady was laboring for a sometime and the OB decided to call it a stat c-section and bring her back to the OR, by the time he walked in ready to start she was asleep with a tube in her mouth. He questioned it, and the attending anesthesiologist replied to him, you called it stat, stat c-sections go to sleep with a tube in their mouth. You'd think this would teach the OB to actually think and not call stat c-sections unless they were truly stat but no not the case.
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Just want to emphasize that a "stat" section doesn't have to be a GA if she has a working epidural. There are usually enough lines and wires and hectic nurses around the patient/bed that it takes at least 5 minutes to free her up, wheel her to the OR, transfer, prep, drape, before the knife. That's plenty of time to bolus up with 3% 2CP. The OBs may not know this, but we should know better. Putting someone on L&D to sleep should never be taken lightly or as a "teaching point" to the OBs. The argument with the OBs shouldn't occur after she's asleep.
 
DrN2O said:
Just want to emphasize that a "stat" section doesn't have to be a GA if she has a working epidural. There are usually enough lines and wires and hectic nurses around the patient/bed that it takes at least 5 minutes to free her up, wheel her to the OR, transfer, prep, drape, before the knife. That's plenty of time to bolus up with 3% 2CP. The OBs may not know this, but we should know better. Putting someone on L&D to sleep should never be taken lightly or as a "teaching point" to the OBs. The argument with the OBs shouldn't occur after she's asleep.
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That's interesting. At my institution, all STAT sections go to sleep. What do you do amidst the melee if you have given the 2CP and you have an inadequate surgical block? Or wouldn't it lend to a high block if you haven't turned off the pump and allowed the level to go down before bolusing?

Also, how long do you wait before filling it up with a longer local anesthetic? Just curious, I don't have a lot of experience with 2CP. We do .0625%-.25% Bupivicaine for labor epidurals and 2% lidocaine with or without bicarb/epi/fentany for non-STAT c-sections with epidurals in place.
 
Ignatius J said:
That's interesting. At my institution, all STAT sections go to sleep. What do you do amidst the melee if you have given the 2CP and you have an inadequate surgical block? Or wouldn't it lend to a high block if you haven't turned off the pump and allowed the level to go down before bolusing?

Also, how long do you wait before filling it up with a longer local anesthetic? Just curious, I don't have a lot of experience with 2CP. We do .0625%-.25% Bupivicaine for labor epidurals and 2% lidocaine with or without bicarb/epi/fentany for non-STAT c-sections with epidurals in place.
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These are fine questions. I'm not saying you should do that with every epidural. The easiest call would be if I just put one in, , bolused it with 5-10ml of 0.1 bupiv, and FHR tanks for whatever reason. While they are getting the terb, after I gave NTG and neo, I'm drawing up 2CP if I haven't already. Amidst the scramble to the OR, I sneak in 5ml of 2CP at a time, by the time I get to OR, I'm at 10-15mL on top of that first 10mL, ready to go. The epidurals that don't work are the ones that have been going for days, and no one got around/wanted to replace it. Of course, right now I have a resident or attending back up, so I may just tube all of them when I'm by myself in the future. Even when the epidural works, it's never as good as a spinal. I just rebolus after 45min with CP, but remind the OB to hurry up before the "spinal" wears off.
 
more tubes = more chances for bad airway & mortality.

if it's a "soft" stat I ask the mom - epidural working? "not at all!" or "only one side" - i pull it out and pop in a spinal, no bolusing the catheter before hand and waiting for a crap catheter to magically start working.

if mom says it's been working like a charm, bolus with 2-CP or 2% Lido. Usually enough time with all the nonsense and transport for that to work just fine. Patchy after delivery? Hello ketamine, goodbye any reasonable conversation with the patient while you are charting.

As someone already mentioned, if it's truly a "holy ****, flying through the OR doors stat, prolapsed cord, blah blah", you're going to sleep, hoping for a forgiving airway, and encouraging the surgeon to use the stapler because The Walking Dead starts in 20 minutes and you want to see if that b|tch Lori gets killed this week..
 
Last edited:
Trisomy13 said:
and encouraging the surgeon to use the stapler because The Walking Dead starts in 20 minutes and you want to see if that b|tch Lori gets killed this week..
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That kid needs to go first. He pissed me off when he droped the gun he had swiped when taunting the zombie stuck in the mud... 😡
 
If they follow the graphic novels at all, he'll get a piece of the action. Things should start picking up and getting interesting again next season. The farm was a drag.
 
😀 I encourage this Zombie talk to come over to the TV thread. SPOILER WARNINGS as well.
😀
 
DrN2O said:
Just want to emphasize that a "stat" section doesn't have to be a GA if she has a working epidural. There are usually enough lines and wires and hectic nurses around the patient/bed that it takes at least 5 minutes to free her up, wheel her to the OR, transfer, prep, drape, before the knife. That's plenty of time to bolus up with 3% 2CP. The OBs may not know this, but we should know better. Putting someone on L&D to sleep should never be taken lightly or as a "teaching point" to the OBs. The argument with the OBs shouldn't occur after she's asleep.
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Agree with your points here. There are degrees of "stat"ness to C-sections, and when you are called for such a thing you just have to establish, by having a direct conversation with the OB, how "stat" it is, based on the indication and the clinical situation.

Even if it's true "stat" and they already wheeled the patient into the room, sometimes your labor epidural is badass enough that it's only 5 or 10 ml of 2CP or 2% lido away (+/- epidural fentanyl) from a surgical block. ...Sometimes.
 
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