Failed Epidural for C section-Now What?

[sevoflurane]

Anybody ever experience a pain doc not being able to access CSF for an intrathecal catheter placed @T12-L1...under GA... WITH FLOURO? diving deeper and deeper... They don't like that feeling... and nor do I. Some of those fluoro images look like you are intrathecal... but you are not.

No thanks. I'm not placing a spinal in a C/S patient that is paralyzed and under general anesthesia (even if I asked for fluoro).

IMHO, Not worth it. Not for this case.

TAP blocks have nothing to do with billing. They are a fantastic modality of analgesia when a specific situation arises ie: stat C/S under GA, midline incisions that need immediate anticoagulants post op, laparoscopic procedures that turn into wide midline incisions when you didn't place a pre-op epidural...

They are easy if you know what you are doing, and a clear effect is seen. Billing has nothing to do with it. Sheez.

I don't know if I'm in the minority here, but please think twice before performing spinals under GA in the adult population.

Maybe I'm unaware of the great benefits of GA spinals, but I would hate for a patient to wake up with a deficit.

I've had a single shot awake block last 38 hours. I hated it.
Long turniquet time... but still... the relief when he regained full function. Honestly scared me.

You'd be ripe for lawyer picking. Seriously. Simple USG peripheral nerve blocks (TAP, saphenous, forearm, ankle, hand, even femorals) are SO MUCH less risky than neuraxials under GA (USD ain't THAT helpful compared to peripheral NB's). I don't need a study to tell me this.

To me, it's obvious if you understand the anatomy and the (minute but very possible) consequences. It only takes one.

My 2 cents to all the residens reading this thread.

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[BLADEMDA]

Anybody ever experience a pain doc not being able to access CSF for an intrathecal catheter placed @T12-L1...under GA... WITH FLOURO? diving deeper and deeper... They don’t like that feeling... and nor do I. Some of those fluoro images look like you are intrathecal... but you are not.

No thanks. I'm not placing a spinal in a C/S patient that is paralyzed and under general anesthesia (even if I asked for fluoro).

IMHO, Not worth it. Not for this case.

TAP blocks have nothing to do with billing. They are a fantastic modality of analgesia when a specific situation arises ie: stat C/S under GA, midline incisions that need immediate anticoagulants post op, laparoscopic procedures that turn into wide midline incisions when you didn't place a pre-op epidural...

They are easy if you know what you are doing, and a clear effect is seen. Billing has nothing to do with it. Sheez.

I don't know if I'm in the minority here, but please think twice before performing spinals under GA in the adult population.

Maybe I’m a unaware of the great benefits of GA spinals, but I would hate for a patient to wake up with a deficit.

I’ve had a single shot awake block last 38 hours. I hated it.
Long turniquet time... but still... the relief when he regained full function. Honestly scared me.

You’d be ripe for lawyer picking. Seriously. Simple USG peripheral nerve blocks (TAP, saphenous, forearm, ankle, hand, even femorals) are SO MUCH less risky than neuraxials under GA (USD ain't THAT helpful compared to peripheral NB's). I don’t need a study to tell me this.

To me, it’s obvious if you understand the anatomy and the (minute but very possible) consequences. It only takes one.

My 2 cents to all the residens reading this thread.

We have been doing "asleep" Spinals and Epidurals for decades. Decades. The N is well over 50,000 if not 100,000. Not a single lawsuit related the block. If it ain't broke don't fix it.

These are lumbar injections and single shots for spinals while the epidurals were mostly Duramorph or Dilaudid infusions.

Too bad there is a false believe that being "awake" is any safer than being heavily sedated or under GA. I'm not criticizing anyone who prefers awake Neuraxial blocks as that is the way DA U teaches you to do things.

 

[BLADEMDA]

So why is it safe to do Neuraxial Blocks in Children under GA or heavy seadtion but not adults? We have doing Neuraxial blocks in children since the 1980s and don't you think we would know if there are serious, frequent complications? The fact is Neuraxial blocks placed in the Lumbar area (below L2) by a skilled practitioner is very safe and I have the evidence to back that up.

I was discussing U/S guided blocks under GA with a guy who writes Regional textbooks. He seems to feel the same way about Peripheral nerve blocks under GA or SAB (still numb) provided the nerve is avoided and U/S is utilized.

Dogma is just that..Dogma.

 

[sevoflurane]

We have been doing "asleep" Spinals and Epidurals for decades. Decades. The N is well over 50,000 if not 100,000. Not a single lawsuit related the block. If it ain't broke don't fix it.

These are lumbar injections and single shots for spinals while the epidurals were mostly Duramorph or Dilaudid infusions.

Too bad there is a false believe that being "awake" is any safer than being heavily sedated or under GA. I'm not criticizing anyone who prefers awake Neuraxial blocks as that is the way DA U teaches you to do things.

Ok...

So what do you do with a psudo loss?

You know.. the one you get @ 6cm in a adipose rich patient...

The plunger goes in on your 5 cc glass syringe... and it feels right... Maybe you grab some more saline and dilate the space another 2 ccs just to make sure...?

But you didn't hear the cruch prior....?

Oh.. and you can't thread the catheter?

Do you dive further... ?

She's under GA.

Or will you start over?

These are my questions for the patient that is asleep, paralyzed and under GA.

What is your risk tolerance?

 

[BLADEMDA]

A Numb extremity after a long tourniquet time or high tourniquet inflation pressure is due to the tourniquet. A liteature search will clearly show that nerve injury occurs in Orthopedics when a tourniquet is utilized.

I did a GA with Femoral Block (no Sciatic, No SAB) and the patient had a foot drop. The Ortho immediately assumed it was my fault until he realized that I NEVER did an SAB or Sciatic block.
Only then did he finally realize the tourniquet needs to be less than one hour and under 250 mmhg.
This guy routinely utilized 300 mmhg (not any longer).

 

[sevoflurane]

So why is it safe to do Neuraxial Blocks in Children under GA or heavy seadtion but not adults? We have doing Neuraxial blocks in children since the 1980s and don't you think we would know if there are serious, frequent complications? The fact is Neuraxial blocks placed in the Lumbar area (below L2) by a skilled practitioner is very safe and I have the evidence to back that up.

I was discussing U/S guided blocks under GA with a guy who writes Regional textbooks. He seems to feel the same way about Peripheral nerve blocks under GA or SAB (still numb) provided the nerve is avoided and U/S is utilized.

Dogma is just that..Dogma.

Blocks on little ones are so much easier than adults (when paralyzed).

Beautiful anatomy.

You ever do a TAP block on a 4 y/o? You can easily see and FEEL the 2 pops....

 

[BLADEMDA]

Ok...

So what do you do with a psudo loss?

You know.. the one you get @ 6cm in a adipose rich patient...

The plunger goes in on your 5 cc glass syringe... and it feels right... Maybe you grab some more saline and dilate the space another 2 ccs just to make sure...?

But you didn't hear the cruch prior....?

Oh.. and you can't thread the catheter?

Do you dive further... ?

She's under GA.

Or will you start over?

These are my questions for the patient that is asleep, paralyzed and under GA.

What is your risk tolerance?

Your risk tolerance is quite clear: Don't do an awake Neuraxial block. I have no issues with that stand. You seems unconcerned about U/S guided blockers under GA or SAB. I've got no issues with that either.

Perhaps, you could just consider "heavily sedated" for some Neuraxial blocks. I know many Anesthesiologists across the USA who "heavily sedate" their patients for SAB or a Lumbar Epidural. Does this make you feel better? I bet between our practices there have been a MILLION Neuraxial blocks placed over our careers by our respective groups under HEAVY SEDATION.

 

[BLADEMDA]

Blocks on little ones are so much easier than adults (when paralyzed).

Beautiful anatomy.

You ever do a TAP block on a 4 y/o? You can easily see and FEEL the 2 pops....

Most of my blocks are all quite easy especially Neuraxial. I don't feel pops any longer because I utilize U/S. I leave the pops for my soda.

 

[sevoflurane]

Most of my blocks are all quite easy especially Neuraxial. I don't feel pops any longer because I utilize U/S. I leave the pops for my soda.

Ummm... Ok. Always easy... so you don't have any soliosis patinets in your practice.. or the 48 y/o mother with ankylosing spondolytis. I've had some tough ones I've had to put to sleep.

Pops thorugh facial planes are such a NICE reasuring FEEL you get when using USD for a TAP block.

It is almost confirmatory of your LA placement and beautiful whe you see a TEG like picture when you bolus.

 

[sevoflurane]

That is just what it reminds me of...

 

[BLADEMDA]

Ummm... Ok. Always easy... so you don't have any soliosis patinets in your practice.. or the 48 y/o mother with ankylosing spondolytis. I've had some tough ones I've had to put to sleep.

Pops thorugh facial planes are such a NICE reasuring FEEL you get when using USD for a TAP block.


It is almost confirmatory of your LA placement and beautiful whe you see a TEG like picture when you bolus.

I rarely bother with a Neuraxial block on Scoliosis or Ankylosing Spondylitis in the main O.R. In OB I don't sedate at all for Neuraxial blocks and I have personally placed SABs in all of the above plus Harrington Rods to boot.

I'm glad you like your pops. I'll keep mine in my soda can and use the U/S image to guide my injection.

 

[BLADEMDA]

 

[sevoflurane]

Blade... dude...

Do we have a misuderstanding? I think so... but just in case:

Your risk tolerance is quite clear: Don't do an awake Neuraxial block.

No.

My risk tolerance is clear with GA C/S and spinals.


Awake?

Please refer to post/picture #161.

 

[sevoflurane]

I'm glad you like your pops. I'll keep mine in my soda can and use the U/S image to guide my injection.

Huh....??

I said confirmatory. Sheez man... C'mmon.

 

[BLADEMDA]

 

[BLADEMDA]

Winchester of BlockJocks.com calls this the 3 pencil eraser sign. Each muscle represents an eraser. The needle is placed at the upper fascial plane of the Transverse Abdomonis muscle. If you take your time the bowel can be seen moving on U/S (peristalsis). You never want your needle to hit bowel.

 

[BLADEMDA]

Huh....??

I said confirmatory. Sheez man... C'mmon.

Just kidding. I've got no issues with "pops" as that is old school.

 

[sevoflurane]

Winchester of BlockJocks.com calls this the 3 pencil eraser sign. Each muscle represents an eraser. The needle is placed at the upper fascial place of the Transverse Abdomonis muscle. If you take your time the bowel can be seen moving on U/S (peristalsis). You never want your needle to hit bowel.

Ummm.. thanks for that advice.

You seem to think I do these just with feel?

Do you fail to realize that USD AND FEEL are superior to USD alone?

Keep your pops in the soda can... tha's cool. But that is like telling someone to look with their eyes and cut off their hands. IMHO.