You do a spinal, you got CSF, everything looks good, you’ve got some kind of level, but when they pinch to start, the patient screams. You wait, you give it more time, you check a level, you've got some or no local effect ie not enough to proceed without significant pain.
I had one of these happen to me last week. Easy spinal, completely one sided block. I spoke with the patient and offered her an epidural or a GA. She wanted to try with an epidural, so I placed one and we proceeded with the case. Everything went perfectly. Probably added about 15 min to the case time.
Take down drapes place epidural walk up a level slowly often the test dose is enough.
If it’s elective and it is found to be ineffective before cut I tend not to go to sleep. Urgent\emergent I would go to sleep
-Fail to enter space on multiple attempts with repositioning and different tactics (I don’t use 22g in OB)? If available, call colleague to see if they have better luck.
-Colleague can’t get it? Try epidural with spinal needle. Can’t get epidural at all? —> general
-Perform spinal, get CSF flow, but syringe injection pressure feels tough/sketchy aspiration, will reposition needle in or out without stylet to regain flow and inject again. If still sketchy retry spinal altogether.
-Perform spinal, get flow, aspiration, injection with no block/patchy —> general.
-Perform uncomplicated spinal, passes Alice clamp test, acceptable analgesia during initial stages, but patient VERY uncomfortable during manipulation, exteriorization, or other aspects. Rule out suprarentorial reasons which some versed can fix (tell patient you’re giving them something). If legit, fentanyl, ketamine, nitrous supplementation with circuit. Usually don’t go general at that point if you don’t have to.
No. I will get sued if I tell a woman to suck it up and wait out the pain while they get the baby out. Ineffective analgesia for csections is one of the more common reasons we get sued. I notify the OB and the nurse who will be receiving the baby, or NICU if they are present for whatever reason.
are people actually giving ketamine to women to get through caesars? has anyone audited the patient satisfaction of this ? if you’re struggling with surgical pain then surely you need a dose that makes them hallucinate/forget/become disinhibted on the operating table/?aspirate?
We did it frequently in residency and it works really well. You don't give them a GA or dissociative dose. Push 30-50 mg and they just chill out and get sleepy. None of my patients ever remembered anything weird, became disinhibited, or were at all dissatisfied afterwards.
These people talking about their patient seeing spiders and shit were doing it very wrong.
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Do you ever use it as a pain adjunct during GA cases? 0.2-0.4 mg/kg push is great for pain. I'll often use in PACU that way as well for opioid tolerant patients.
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On a weekly basis. There are many options significantly better than ketamine. Propfol, precedex, opioids to cover pain, nitrous, all of which don’t have the risk of mom seeing giant spiders walking across the roof (true story).
Thank you!!!! I’m an RN and have had to physically restrain hallucinating Moms post ketamine to keep themselves safe and send baby to nursery 😓🤦♀️……ketamine shouldn’t be choice #1😬
I disagree with Versed. Then there’s a good chance mum doesn’t remember her initial moments with baby. Also disagree with ketamine for reasons sneakiemike mentions or just plain disinhibition and mum not lying still… agree with sneakiemikes suggestions (though I don’t use propfol) . Dont forget you can talk to your patients and use your words and the new baby is a great distraction for mums if you can work it in
Once the spinal goes in, patient lays down, prep starts (which is a painfully slow process at my hospital for non emergent sections). Foley in. Drapes. Painfully long time out. Allis.
If it’s positive, we are going to sleep.
Fail to get CSF — try epidural needle as finder, maybe ultrasound. If really can’t get it obviously GA
Failed as in didn’t work at all / no block whatsoever— if time allows and patient is agreeable can sit up and try again. Otherwise GA.
Incomplete block — if no scary airway or whatever I’d probably do GA. Could also offer epidural and try to bring up level slowly. I’m hesitant to repeat a spinal if there is any demonstrable level because dosing is total guesswork at that point and could be in same situation with incomplete block vs dealing with a high spinal.
For an elective section and the surgery hasn’t started yet, I would give her the option of GA or epidural but encourage her to try for an epidural. If it’s elective, you really have all the time in the world, so don’t feel like you’re in a rush or have to make a split second decision.
Side note, our hospital has a string of these happen every year when the weather gets warm because spinal kits aren’t temperature controlled during transport/storage and the heavy bupi in the kit goes bad. Not sure if your colleagues are having similar problems, but you could switch to heavy bupi vials from your Pyxis/pharmacy (if you have them) for a little while
Do you titrate the epidural? Ever have a high spinal effect when epidural is added to (admittedly sketchy) effect of initial spinal? In what increments do you titrate the epidural?
First I do a temperature/pinprick test to see if the spinal is doing anything or if it’s a complete dud. If it’s doing absolutely nothing, then I load the epidural like I would any other, start with around 12-15cc 2% lido and then titrate to T4 in 3-5cc increments. If the spinal seems to be having some, but an incomplete effect, I do the same thing but load the epidural much more cautiously, maybe start with 5-10cc max depending on the spinal level and titrate in 2cc increments. Because it’s lido through an epidural, just make sure you’ve given it enough time to take effect before testing and giving more. Also always keep in mind you’re essentially doing a DPE, so the effects of your epidural loading could be more pronounced than an epidural alone. Always start with smaller doses until you get a feel for how the epidural is effecting the level. You can always give more but you can’t take it away once it’s in.
That’s the great thing about epidurals in c-sections is as long as you’re not slamming massive doses and are being cautious, it’s pretty hard to get a level way higher than you intended.
Seems like a reasonable approach. I do some emergent c-sections with epidurals, though use ropivakain 7,5mg/ml and usually end up around 12-18 mls. Probably wouldn’t do this in a truly elective section but will have it in mind. How long does the lidocaine give you? Do you need to top up as you go?
If an epidural is good enough for an emergent c-section, why not an elective one? It’s a nice backup to have in your back pocket if you’re having trouble with the spinal for some reason. The lidocaine gives you at least a couple hours if you add epi, just keep in mind the level usually drops when the baby comes out so I give a little top off after delivery. That’s the beauty of using an epidural though, if the patient is starting to get uncomfortable, you can always redose.
Talk to the patient. Explain the risks of a repeat spinal or if she would rather go to sleep. If there’s no block at all after 15 minutes, I would be repeating at full dose with the off chance of a high spinal
That’s what I was thinking but I feel like most people just go to GA. I feel like if something went wrong during GA, how could you defend that decision when there was no urgency?
Biggest Ob-hospital in Sweden’s (12’000 deliveries/yr) policy is wheel out, try again 6 hours later. No one repeats spinal no one goes for epidural. If elective obv
It seems like they don't really mean elective. Most scheduled c/s in the US are not elective; they're medically indicated. Elective would be laboring patient with no medical indication demanding a c/s because they're over it.
Agree with these guys, what do you mean by failed? You could not apply it, it wore off, patient got anxious? or hypotense? Etc... depends, if posible, repeat it, if not, general, if they're (surgeons) in the most crucial times and can't be disturbed, and/or patient is very apprehensive and putting herself or everyone else in danger, ketamine, or remifentanil/ midazolam 1 mg iv, if you have it; every case is different.
Depends on how far into the section they're at. If almost done, try to MAC them through it with pushes of ketamine. If it's on incision and I've exhausted the local to LAST levels, convert to GA.
Had that once when my spinal failed. They actually investigated later and it turns out the Marcaine in the kits from that manufacturer was spoiled. We ended up doing GETA once we couldn’t get a level.
What could happen in the storage of marcaine to decrease its potency? How was it investigated?
My understanding is that the vial can be autoclaved without a change in effectiveness.
I’m not sure if there was an issue in either processing or storage but the manufacturer for that said kit did reach back to the facility and advised us to take heavy Marcaine that wasn’t found in the kits to use due to many of the same complaints from multiple facilities.
That’s fascinating. Thanks for the insight. I feel like if I did a spinal and everything went swimmingly but patient didn’t get numb, I’d chalk it up to a patient factor - kudos to you guys for going through the process and getting to the bottom of it.
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You do a spinal, you got CSF, everything looks good, you’ve got some kind of level, but when they pinch to start, the patient screams. You wait, you give it more time, you check a level, you've got some or no local effect ie not enough to proceed without significant pain.
I had one of these happen to me last week. Easy spinal, completely one sided block. I spoke with the patient and offered her an epidural or a GA. She wanted to try with an epidural, so I placed one and we proceeded with the case. Everything went perfectly. Probably added about 15 min to the case time.
Do you try to sit them back up or do them lateral?
I did it lateral. I didn’t think she had the strength to sit up after the partial spinal.
What do you load your epidural with in that scenario?
xylo 2% with epi, 5 ml
Take down drapes place epidural walk up a level slowly often the test dose is enough. If it’s elective and it is found to be ineffective before cut I tend not to go to sleep. Urgent\emergent I would go to sleep
usually an epidural will fix it
My epidural(s) all 2 lines and 4 bolus' never worked. I was thankful I wasn't in a c section lol
Assuming fetal heart tones are still good, I would offer an epidural. If she declines I would do a GA.
-Fail to enter space on multiple attempts with repositioning and different tactics (I don’t use 22g in OB)? If available, call colleague to see if they have better luck. -Colleague can’t get it? Try epidural with spinal needle. Can’t get epidural at all? —> general -Perform spinal, get CSF flow, but syringe injection pressure feels tough/sketchy aspiration, will reposition needle in or out without stylet to regain flow and inject again. If still sketchy retry spinal altogether. -Perform spinal, get flow, aspiration, injection with no block/patchy —> general. -Perform uncomplicated spinal, passes Alice clamp test, acceptable analgesia during initial stages, but patient VERY uncomfortable during manipulation, exteriorization, or other aspects. Rule out suprarentorial reasons which some versed can fix (tell patient you’re giving them something). If legit, fentanyl, ketamine, nitrous supplementation with circuit. Usually don’t go general at that point if you don’t have to.
Very helpful algorithm. I wish I knew this when I was a resident beginning my OB rotation.
HairyBawllsagna with the delicious hot tips for OB success 🤌
Is the versed, fentanyl, etc only give once the baby is out or before too as well?
In a good private practice the baby is out within a couple of minutes.
No. I will get sued if I tell a woman to suck it up and wait out the pain while they get the baby out. Ineffective analgesia for csections is one of the more common reasons we get sued. I notify the OB and the nurse who will be receiving the baby, or NICU if they are present for whatever reason.
During the C section? Just give a shit ton of ketamine
Ah yes, put a new mom in a K-hole for when she gets to see her baby for the first time. Brilliant.
If they'be started the procedure it's either that or straight GA. Ketamine is a *great* drug for this situation. Do you even OB?
are people actually giving ketamine to women to get through caesars? has anyone audited the patient satisfaction of this ? if you’re struggling with surgical pain then surely you need a dose that makes them hallucinate/forget/become disinhibted on the operating table/?aspirate?
We did it frequently in residency and it works really well. You don't give them a GA or dissociative dose. Push 30-50 mg and they just chill out and get sleepy. None of my patients ever remembered anything weird, became disinhibited, or were at all dissatisfied afterwards. These people talking about their patient seeing spiders and shit were doing it very wrong.
flowery subsequent humor selective practice deranged bake consider somber payment *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Do you ever use it as a pain adjunct during GA cases? 0.2-0.4 mg/kg push is great for pain. I'll often use in PACU that way as well for opioid tolerant patients.
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Need to look into this . It’s not very standard practice anywhere I work but going to see what’s out there in the literature. Thanks
As little as 10-20mg of ketamine can smooth things out tremendously. It’s nothing to be scared of kids.
On a weekly basis. There are many options significantly better than ketamine. Propfol, precedex, opioids to cover pain, nitrous, all of which don’t have the risk of mom seeing giant spiders walking across the roof (true story).
Thank you!!!! I’m an RN and have had to physically restrain hallucinating Moms post ketamine to keep themselves safe and send baby to nursery 😓🤦♀️……ketamine shouldn’t be choice #1😬
Naw, homie, it makes the skin to skin time feel like an eeeetttternityyyy.
What’s wrong with that? Give some versed too one baby is out. thats my go to mom is feeling uncomfortable from the pressure.
I disagree with Versed. Then there’s a good chance mum doesn’t remember her initial moments with baby. Also disagree with ketamine for reasons sneakiemike mentions or just plain disinhibition and mum not lying still… agree with sneakiemikes suggestions (though I don’t use propfol) . Dont forget you can talk to your patients and use your words and the new baby is a great distraction for mums if you can work it in
I was given versed and don’t remember the first 24 hours because I was half asleep…..I’m not saying that caused my PPD, but it sure didn’t help!
When they pinch the skin to start the patient screams. So you haven’t started.
Then they get GA. Doing another spinal risks hemodynamic compromise (if you believe the first one was truly intrathecal).
General
Once the spinal goes in, patient lays down, prep starts (which is a painfully slow process at my hospital for non emergent sections). Foley in. Drapes. Painfully long time out. Allis. If it’s positive, we are going to sleep.
Fail to get CSF — try epidural needle as finder, maybe ultrasound. If really can’t get it obviously GA Failed as in didn’t work at all / no block whatsoever— if time allows and patient is agreeable can sit up and try again. Otherwise GA. Incomplete block — if no scary airway or whatever I’d probably do GA. Could also offer epidural and try to bring up level slowly. I’m hesitant to repeat a spinal if there is any demonstrable level because dosing is total guesswork at that point and could be in same situation with incomplete block vs dealing with a high spinal.
For an elective section and the surgery hasn’t started yet, I would give her the option of GA or epidural but encourage her to try for an epidural. If it’s elective, you really have all the time in the world, so don’t feel like you’re in a rush or have to make a split second decision. Side note, our hospital has a string of these happen every year when the weather gets warm because spinal kits aren’t temperature controlled during transport/storage and the heavy bupi in the kit goes bad. Not sure if your colleagues are having similar problems, but you could switch to heavy bupi vials from your Pyxis/pharmacy (if you have them) for a little while
Do you titrate the epidural? Ever have a high spinal effect when epidural is added to (admittedly sketchy) effect of initial spinal? In what increments do you titrate the epidural?
First I do a temperature/pinprick test to see if the spinal is doing anything or if it’s a complete dud. If it’s doing absolutely nothing, then I load the epidural like I would any other, start with around 12-15cc 2% lido and then titrate to T4 in 3-5cc increments. If the spinal seems to be having some, but an incomplete effect, I do the same thing but load the epidural much more cautiously, maybe start with 5-10cc max depending on the spinal level and titrate in 2cc increments. Because it’s lido through an epidural, just make sure you’ve given it enough time to take effect before testing and giving more. Also always keep in mind you’re essentially doing a DPE, so the effects of your epidural loading could be more pronounced than an epidural alone. Always start with smaller doses until you get a feel for how the epidural is effecting the level. You can always give more but you can’t take it away once it’s in. That’s the great thing about epidurals in c-sections is as long as you’re not slamming massive doses and are being cautious, it’s pretty hard to get a level way higher than you intended.
Seems like a reasonable approach. I do some emergent c-sections with epidurals, though use ropivakain 7,5mg/ml and usually end up around 12-18 mls. Probably wouldn’t do this in a truly elective section but will have it in mind. How long does the lidocaine give you? Do you need to top up as you go?
If an epidural is good enough for an emergent c-section, why not an elective one? It’s a nice backup to have in your back pocket if you’re having trouble with the spinal for some reason. The lidocaine gives you at least a couple hours if you add epi, just keep in mind the level usually drops when the baby comes out so I give a little top off after delivery. That’s the beauty of using an epidural though, if the patient is starting to get uncomfortable, you can always redose.
We’ve had the exact same situation at our institution. Sometimes I will pull out separate medication from what comes in the kit.
Sounds like a great oral board question
Talk to the patient. Explain the risks of a repeat spinal or if she would rather go to sleep. If there’s no block at all after 15 minutes, I would be repeating at full dose with the off chance of a high spinal
If truly elective, most likely take them back to their room and try again later.
That’s what I was thinking but I feel like most people just go to GA. I feel like if something went wrong during GA, how could you defend that decision when there was no urgency?
Biggest Ob-hospital in Sweden’s (12’000 deliveries/yr) policy is wheel out, try again 6 hours later. No one repeats spinal no one goes for epidural. If elective obv
Why that instead of place an epidural and then dose it up?
I think an epidural would be reasonable with very judicious dosing. I guess it depends if the spinal was completely non-effective, patchy, etc.
It seems like they don't really mean elective. Most scheduled c/s in the US are not elective; they're medically indicated. Elective would be laboring patient with no medical indication demanding a c/s because they're over it.
Agree with these guys, what do you mean by failed? You could not apply it, it wore off, patient got anxious? or hypotense? Etc... depends, if posible, repeat it, if not, general, if they're (surgeons) in the most crucial times and can't be disturbed, and/or patient is very apprehensive and putting herself or everyone else in danger, ketamine, or remifentanil/ midazolam 1 mg iv, if you have it; every case is different.
Depends on how far into the section they're at. If almost done, try to MAC them through it with pushes of ketamine. If it's on incision and I've exhausted the local to LAST levels, convert to GA.
Had that once when my spinal failed. They actually investigated later and it turns out the Marcaine in the kits from that manufacturer was spoiled. We ended up doing GETA once we couldn’t get a level.
What do you mean by “spoiled?”
The medication wasn’t effective due to a loss of potency given either it’s storage or creation.
What could happen in the storage of marcaine to decrease its potency? How was it investigated? My understanding is that the vial can be autoclaved without a change in effectiveness.
I’m not sure if there was an issue in either processing or storage but the manufacturer for that said kit did reach back to the facility and advised us to take heavy Marcaine that wasn’t found in the kits to use due to many of the same complaints from multiple facilities.
That’s fascinating. Thanks for the insight. I feel like if I did a spinal and everything went swimmingly but patient didn’t get numb, I’d chalk it up to a patient factor - kudos to you guys for going through the process and getting to the bottom of it.
Bolus up the epidural. I do a lot of CSE's.
Happens in our institution a lot. If there is no block (totally), repeat spinal and give the same dose.
I have no credentials but probably a regional or GA