Low spinals in c-sections

[castafari]

We are getting fairly frequent low spinals at my shop. Probably several a month in L&D. I thought it may have been a bad batch of bupi but now it’s been going on for several years. How frequently do you see this in OB? What do you think is the cause? I noticed our CRNAs tend to under dose spinals 1.2-1.4 bupi with fent/morphine vs 1.6 is what I trained on. Also noticing a real lack of urgency to get the patient supine (excess time cleaning back/pulling down drape ect ). Not sure the cause, could be bad bupi but thought these issues could contribute

---

Members don't see this ad.

 

[okayplayer]

We are getting fairly frequent low spinals at my shop. Probably several a month in L&D. I thought it may have been a bad batch of bupi but now it’s been going on for several years. How frequently do you see this in OB? What do you think is the cause? I noticed our CRNAs tend to under dose spinals 1.2-1.4 bupi with fent/morphine vs 1.6 is what I trained on. Also noticing a real lack of urgency to get the patient supine (excess time cleaning back/pulling down drape ect ). Not sure the cause, could be bad bupi but thought these issues could contribute

How do you handle these?

 

[pgg]

1.2 mL of the heavy bupivacaine in the kit is enough for a c-section if and only if the surgeon is fast, and you add 15 or 25 mcg of fentanyl to supplement the less-dense block. Even then there are sometimes a couple of uncomfortable minutes. I think the only reason to ever taunt that beast with 1.2 is if you have fast surgeons and PACU throughput must be fast too lest the days cases stack up as you wait for a PACU bed. Otherwise just use 1.6 and call it good.

It looks like you know the answer - use more bupiv and lay them down faster to get up to T4 - but the CRNAs want to do it their way? If you're directing them just choose the dose for them.

 

[abolt18]

I cannot imagine using 1.2mL. We regularly use 1.6-2.0mL depending on if it's a repeat section. Works great. Occasionally they comment on their hands tingling a bit. My OB anesthesia attending (who is a boss and I trust him more than most physicians) would respond "perfect! That means it's working just like we want!" He would also tell us to just do 2.0mL for everyone unless they're really short; <5'. Overkill? Not here it's not. Slow surgeons.

We also add a little fentanyl and duramorph.

 

[GassYous]

I do 1.6 and 20 of fent

 

[PainDrain]

About five years ago I had a run of failed/low spinals for sections. I was beginning to doubt my skills and couldn’t figure out what was going on but several others in my group also had issues around the same time. We assumed the bupi was garbage and it probably was because it resolved after a few months without doing anything differently. I literally used 3.5 mls of heavy in one patient (two spinals due to morbid obesity, full stomach and terrible airway) and she barely got a level.

I will also say adding fentanyl 20-30mcg to a low dose spinal can make all the difference.

 

[Beeftenderloin]

1.4ml heavy bupi, plus fentanyl and duramorph. 1.6ml if they’re really tall. The OB nurses at my shop understand the need to lay them down ASAP. Once I finish injecting they’re typically supine within 10-15 seconds. A few have totally failed, can’t really recall ever having a low block, though with the fentanyl and duramorph it’s over 2ml total volume.

 

[BobLoblaw78]

1.6 ml of 0.75% hypobaric Bupiv for every patient with Duramorph 200 mcg. I would defend using 2 ml in most patients. Sometimes add fentanyl or hydromorphone.

What is the downside of 1.6 mL? What is the downside of 1.2 mL? That is why I go with 1.6 mL and you're proving it at your shop. I would have that discussion and hopefully once they understand the why, it will get better.

 

[castafari]

Had a full stomach the other night full of pizza 3 am low spinals after crna 1.4. I sat her up and gave additional 0.4 and had ok spinal. We are slow as hell here teaching ob residents. Giving ketamine on the back end a lot. We have a culture of 1.4 for everyone here and I noticed slow to lay them down too. Interesting to hear some of you guys giving 2.0 and not getting high spinals.

 

[Southpaw]

Had a full stomach the other night full of pizza 3 am low spinals after crna 1.4. I sat her up and gave additional 0.4 and had ok spinal. We are slow as hell here teaching ob residents. Giving ketamine on the back end a lot. We have a culture of 1.4 for everyone here and I noticed slow to lay them down too. Interesting to hear some of you guys giving 2.0 and not getting high spinals.

you’re not going to get high spinals with 2ml unless your patients are all less than 5’0 and even then you’ll probably be fine.

I don’t understand a culture of 1.2-1.4 in a teaching place with slow cases. It’s honestly a complete lack of any thought whatsoever in my opinion.

 

[Urzuz]

Had a full stomach the other night full of pizza 3 am low spinals after crna 1.4. I sat her up and gave additional 0.4 and had ok spinal. We are slow as hell here teaching ob residents. Giving ketamine on the back end a lot. We have a culture of 1.4 for everyone here and I noticed slow to lay them down too. Interesting to hear some of you guys giving 2.0 and not getting high spinals.

Unless you’re literally taking 10+ minutes to lay them down, that’s not the issue. Your nurses are underdosing them relative to how slow your surgeons are. Do what you’re paid to do and direct your nurses.

 

[GassYous]

Lay them down right away. No need for ketamine but we start neo drips on everyone cause a lot of people get hypotensive and nauseous.

There were reports here of failed spinals due to heavy bupi from kit. Resolved by using iso from the bottle, they thought it had to do with storage or transport of the kits and it got better after a few months.

 

[dabears505]

What is happening with the low blocks. Are you having to convert to a general?

 

[DrOwnage]

Had a full stomach the other night full of pizza 3 am low spinals after crna 1.4. I sat her up and gave additional 0.4 and had ok spinal. We are slow as hell here teaching ob residents. Giving ketamine on the back end a lot. We have a culture of 1.4 for everyone here and I noticed slow to lay them down too. Interesting to hear some of you guys giving 2.0 and not getting high spinals.

Stomach full of pizza and ketamine boluses sound like a bad idea to me. Not to mention because most people freak out and overdose ketamine in these situations. I had a patient once where I asked her if she had an epidural or a spinal for her last section and she said she had no recollection of her delivery. I looked in the record and someone gave her a bolus of 200mg of ketamine, lol...

 

[woopedazz]

We are getting fairly frequent low spinals at my shop. Probably several a month in L&D. I thought it may have been a bad batch of bupi but now it’s been going on for several years. How frequently do you see this in OB? What do you think is the cause? I noticed our CRNAs tend to under dose spinals 1.2-1.4 bupi with fent/morphine vs 1.6 is what I trained on. Also noticing a real lack of urgency to get the patient supine (excess time cleaning back/pulling down drape ect ). Not sure the cause, could be bad bupi but thought these issues could contribute

That's not bad Bupiv. That's a low-dose spinal behaving as expected.

Take my anecdotal observations below with a grain of salt as I work in teaching hospitals, and obviously, our cases run longer and we need less theatre throughput than private venues:

I've done about 400 sections under spinal in the past 2 years and have never once used less than 1.9mL of heavy.
The majority get ~2.2mL (This is in addition to ~100mcg morphine and ~15mcg fentanyl - so the syringe has 2.7mL in it on average, sometimes 3). My procedure is exactly the same as what you guys do: Spinal in --> lie down immediately (table flat) and add lateral tilt (if they need it) --> Start the pressor --> IDC in --> ice test --> Either: block at T8ish = proceed, it will reach T6 by the knife-to-skin (happens 90% of time); block at T9 or below = tilt head slightly down and proceed (more than 5% of time); block at T7 or above = slight head up and proceed, ice check again later on.

If there's a slow-as **** resident on overnight I'll give even more.
I've never had a high spinal.
I've had to convert to GA twice for them being unable to tolerate the pressure sensation. Maybe another 3 have received N2O and a lick of IV fentanyl and are fine.
This is standard at the hospitals I work (~7,000 deliveries/year)
There has been like 2 high spinals at my workplace(s) in the past few years (One was a hip. One was a LSCS where they blasted the spinal in at force and it immediately went high and they arrested - it was less than 2mL, just bolused at speed).

I'm not saying give 2.2-2.4mL for your sections. I'm saying that it's safe and works well in other parts of the world.
The question I pose (and the answer is obvious) is why are we accepting the outcomes of GA conversions/ketamine/miserable patients in such a high number of patients? It certainly isn't for safety/patient satisfaction reasons. And does it actually save money if your rate of conversions/sad mums is so high?

 

[CodeBlu]

What's the complication of giving too low a dose? Convert? Give basically a MAC?

I heavy hand also with 1.8-2.0 of hyperbaric bupi, 150 of epimorph and 15 of fentanyl. Reliable and it just works. Complication? Low BP sometimes. Tx with phenylephrine and fluid and good to go.

An olde attending told me... do you think anyone is that good to ensure that all 10mg of bupi went intrathecal? Depending on your needle... how do you know you're not riding the dura? Some in, some out. Less is more usually, unless it comes to spinals for L&D. Failed spinals suck.

 

[vector2]

My understanding a few years ago from academics is that 1.2-1.4 ml should be used based on the notion that gravid women and especially fatty gravida have increased cephalad spread due to increased abdominal pressures getting referred to the intrathecal space. I thought that sounded silly at the time.

 

[BobLoblaw78]

That's not bad Bupiv. That's a low-dose spinal behaving as expected.

Take my anecdotal observations below with a grain of salt as I work in teaching hospitals, and obviously, our cases run longer and we need less theatre throughput than private venues:

I've done about 400 sections under spinal in the past 2 years and have never once used less than 1.9mL of heavy.
The majority get ~2.2mL (This is in addition to ~100mcg morphine and ~15mcg fentanyl - so the syringe has 2.7mL in it on average, sometimes 3). My procedure is exactly the same as what you guys do: Spinal in --> lie down immediately (table flat) and add lateral tilt (if they need it) --> Start the pressor --> IDC in --> ice test --> Either: block at T8ish = proceed, it will reach T6 by the knife-to-skin (happens 90% of time); block at T9 or below = tilt head slightly down and proceed (more than 5% of time); block at T7 or above = slight head up and proceed, ice check again later on.

If there's a slow-as **** resident on overnight I'll give even more.
I've never had a high spinal.
I've had to convert to GA twice for them being unable to tolerate the pressure sensation. Maybe another 3 have received N2O and a lick of IV fentanyl and are fine.
This is standard at the hospitals I work (~7,000 deliveries/year)
There has been like 2 high spinals at my workplace(s) in the past few years (One was a hip. One was a LSCS where they blasted the spinal in at force and it immediately went high and they arrested - it was less than 2mL, just bolused at speed).

I'm not saying give 2.2-2.4mL for your sections. I'm saying that it's safe and works well in other parts of the world.
The question I pose (and the answer is obvious) is why are we accepting the outcomes of GA conversions/ketamine/miserable patients in such a high number of patients? It certainly isn't for safety/patient satisfaction reasons. And does it actually save money if your rate of conversions/sad mums is so high?

Thanks for sharing. Is the Bupivacaine 0.5% or 0.75%?

 

[DrZzZz]

I've never used more than 1.6mL for a c-section, not in residency with slow residents/surgeons, nor in my current gig which has family med OB "fellows" doing some of the csections. They aren't quick, but I've never needed more than 1.6mL. Honestly shocked to read how many people give 2+ for a c-section.

 

[okayplayer]

Been awhile since I reviewed the literature on intrathecal fentanyl. I’ve been putting in 15mcg for years because my understanding is it helps with visceral discomfort. Is that still what you all are doing?

Have observed a ton of variation on whether anesthesiologists include it or not.

 

[PainDrain]

I started out using large doses for sections 1.8-2mls in PP with slowwwww (horrible) surgeons. I have switched to 1.2-1.4mls with fentanyl because the current OBs are incredibly fast (20-25 min for most sections).

I have had two high-ish spinals. One patient went into a junctional rhythm and briefly went unconscious. The other reported that she couldn’t move her arms and she was hypotensive but she did fine with some neo and repositioning. I always get a little nervous when their baseline HR is in the 50s and they tell me they run 30 miles a week. Those are historically (from closed claims and studies) the ones who experience cardiovascular collapse.

 

[DrZzZz]

Been awhile since I reviewed the literature on intrathecal fentanyl. I’ve been putting in 15mcg for years because my understanding is it helps with visceral discomfort. Is that still what you all are doing?

Have observed a ton of variation on whether anesthesiologists include it or not.

Yea, I use 15mcg fentanyl and 150mcg duramorph for c-section spinals. No narcotic for spinals for total joints.

 

[LifeofGas]

1.2-1.4 ml seems too little. I only give this on surgeons I know are blazing fast with their sections (staple closure etc). On majority I give 1.6ml of 0.75% Hyperbaric Bupivacaine and 200mcg Duramorph. I do ice test to t4. I think there was a few times the spinal wore off faster than expected, and I had to supplement with IV narcs (Baby out at this point). In residency, I remember using 1.6ml with duramorph and fentanyl. I think sometimes we even put in CSE’s just as backup.

 

[MirrorTodd]

Our cocktail in residency is like 1.6ml heavy bup, 15mcg fent, 200mg duramorph, and 10mcg epi. Residency program so longish sections, mostly over an hour. 45min is like the fastest time your gonna get.

 

[Mman]

I give about 1.5-1.6 ml of hyperbaric bupi + 15 mcg of Fentanyl and lay them down right away. Works fine. Only spinals I have ever come close to intubating were after epidurals that had been pulled, not a primary spinal. If someone is really short like < 5 ft I drop it down to 1.3 or 1.4 mls.

 

[Angus Avagadro]

We are getting fairly frequent low spinals at my shop. Probably several a month in L&D. I thought it may have been a bad batch of bupi but now it’s been going on for several years. How frequently do you see this in OB? What do you think is the cause? I noticed our CRNAs tend to under dose spinals 1.2-1.4 bupi with fent/morphine vs 1.6 is what I trained on. Also noticing a real lack of urgency to get the patient supine (excess time cleaning back/pulling down drape ect ). Not sure the cause, could be bad bupi but thought these issues could contribute

1.2 is too light for most cases. If Iso, then it won't move if you need it to come up a little. 3rd problem is CRNA doing it.

 

[Blockit]

I have been hearing allegations of “a bad batch of bupi” for 20 years now. That’s a lot of bad bupivacaine. In my opinion, the true answer here is usually partitioning secondary to not lying the patient down quickly enough. Also, I can say I have never really used less than 1.4 mls. Maybe 1.2 mls if she was a dwarf. 🤣

 

[IlDestriero]

1.4-1.6 for almost everyone. 1.8 for 6’ folks or some concern about it taking a while. Our surgeons are not slow, no trainees.
Also 20mcg Fent, 150mcg Duramorph, and 50mcg Epi.
Some of my partners give everyone 2cc. I bet they have more hypotension and vomiting.

 

[IlDestriero]

I have been hearing allegations of “a bad batch of bupi” for 20 years now. That’s a lot of bad bupivacaine. In my opinion, the true answer here is usually partitioning secondary to not lying the patient down quickly enough. Also, I can say I have never really used less than 1.4 mls. Maybe 1.2 mls if she was a dwarf. 🤣

I actually did an epidural on a dwarf a few months ago. I took a few min thinking about a spinal dose for her. I was going to go 1.2!
She did fine with my mad epidural skills.

 

[Blockit]

I actually did an epidural on a dwarf a few months ago. I took a few min thinking about a spinal dose for her. I was going to go 1.2!
She did fine with my mad epidural skills.

You made a wise choice my friend, no way of knowing what the intrathecal space volume is in them.

 

[GassYous]

1.2 is too light for most cases. If Iso, then it won't move if you need it to come up a little. 3rd problem is CRNA doing it.

Yeah I don't understand why anesthesiologists get crnas on labor floors and then let them do the spinals and epidurals. Why let them do the fun stuff and still take the responsibility? Makes no sense to me, why wouldn't you let them do the topoffs and consents?

 

[jwk]

Yeah I don't understand why anesthesiologists get crnas on labor floors and then let them do the spinals and epidurals. Why let them do the fun stuff and still take the responsibility? Makes no sense to me, why wouldn't you let them do the topoffs and consents?

This is a large component of the "we don't need anesthesiologists" mantra of CRNAs. Far too many practices cede the entire OB anesthesia operation to CRNAs (their own or a separate group) simply because they don't want to mess with OB.

 

[Aether2000]

We have had a run of several consecutive C/S spinals recently in one of our hospitals using 1.6ml heavy with 200mcg MS and some with fentanyl that gave a dense block early, but after the baby was out had to supplement with fentanyl, ketamine, or propofol, and even had to convert to general in one case. We don't have epi in our kits and it is not easy to obtain in ampules. Perhaps we will need to increase to 2ml heavy???

 

[Katheudontas parateroumen]

OB sometimes feels like voodoo medicine. Basically all seems like “expert opinion”. There is so much variety of what people do and I’m not sure there’s any consensus of how much any of these drugs are needed. We use 1.4-1.6ml 0.75 bupi with 10mcg fent, 150mcg duramorph and 100mcg epi. It’s based on this article I believe. Stanford study.

ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery​

METHODSForty-two parturients undergoing elective cesarean delivery with use of combined spinal-epidural anesthesia received intrathecal hyperbaric bupivacaine in doses of 6, 7, 8, 9, 10, 11, or 12 mg in equal volumes with an added 10 microg intrathecal fentanyl and 200 microg intrathecal morphine
RESULTS ED50 for success(induction) and success(operation) were 6.7 and 7.6 mg, respectively, whereas the ED95 for success(induction) and success(operation) were 11.0 and 11.2 mg.

 

[abolt18]

OB sometimes feels like voodoo medicine. Basically all seems like “expert opinion”. There is so much variety of what people do and I’m not sure there’s any consensus of how much any of these drugs are needed. We use 1.4-1.6ml 0.75 bupi with 10mcg fent, 150mcg duramorph and 100mcg epi. It’s based on this article I believe. Stanford study.

ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery​

METHODSForty-two parturients undergoing elective cesarean delivery with use of combined spinal-epidural anesthesia received intrathecal hyperbaric bupivacaine in doses of 6, 7, 8, 9, 10, 11, or 12 mg in equal volumes with an added 10 microg intrathecal fentanyl and 200 microg intrathecal morphine
RESULTS ED50 for success(induction) and success(operation) were 6.7 and 7.6 mg, respectively, whereas the ED95 for success(induction) and success(operation) were 11.0 and 11.2 mg.

Maybe you're hitting the ED99 when you put in the whole 15mg.

 

[linkin06]

link for above

ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery - PubMed

The ED95 of intrathecal bupivacaine under the conditions of this study is considerably in excess of the low doses proposed for cesarean delivery in some recent publications. When doses of intrathecal bupivacaine less than the ED95, particularly near the ED50, are used, the doses should be...

pubmed.ncbi.nlm.nih.gov

 

[linkin06]

OB sometimes feels like voodoo medicine. Basically all seems like “expert opinion”. There is so much variety of what people do and I’m not sure there’s any consensus of how much any of these drugs are needed. We use 1.4-1.6ml 0.75 bupi with 10mcg fent, 150mcg duramorph and 100mcg epi. It’s based on this article I believe. Stanford study.

ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery​

METHODSForty-two parturients undergoing elective cesarean delivery with use of combined spinal-epidural anesthesia received intrathecal hyperbaric bupivacaine in doses of 6, 7, 8, 9, 10, 11, or 12 mg in equal volumes with an added 10 microg intrathecal fentanyl and 200 microg intrathecal morphine
RESULTS ED50 for success(induction) and success(operation) were 6.7 and 7.6 mg, respectively, whereas the ED95 for success(induction) and success(operation) were 11.0 and 11.2 mg.

i use the same fentanyl and duramorph, but don't need epi in private practice. <1 hour c sections

 

[pgg]

My understanding a few years ago from academics is that 1.2-1.4 ml should be used based on the notion that gravid women and especially fatty gravida have increased cephalad spread due to increased abdominal pressures getting referred to the intrathecal space. I thought that sounded silly at the time.

I figure obese women get higher spinals (with hyperbaric drugs) because the fat is mostly on their buttocks and not upper back, so even laying supine their spine is in trendelenburg.

I don't find that pregnant women who aren't obese get higher spinals than non-pregnant women. Though granted I don't do a lot of spinals on non-pregnant young women.

 

[deleted162650]

I figure obese women get higher spinals (with hyperbaric drugs) because the fat is mostly on their buttocks and not upper back, so even laying supine their spine is in trendelenburg.

I don't find that pregnant women who aren't obese get higher spinals than non-pregnant women. Though granted I don't do a lot of spinals on non-pregnant young women.

I think you can still expect a higher spinal in a thin pregnant patient due to the enhanced lordosis in late pregnancy. And don’t forget that mythical epidural vein engorgement.

I agree with you on the obese ones though.

 

[Hoya11]

Yeah I don't understand why anesthesiologists get crnas on labor floors and then let them do the spinals and epidurals. Why let them do the fun stuff and still take the responsibility? Makes no sense to me, why wouldn't you let them do the topoffs and consents?

in our case it was because you covered the MAIN OR all day, youve been up to OB 4 times already for minor issues, your working tomorrow morning and you just want to sleep at night..

 

[Katheudontas parateroumen]

i use the same fentanyl and duramorph, but don't need epi in private practice. <1 hour c sections

Academics so spinal to out the room is usually 2 hours or more.

 

[woopedazz]

Thanks for sharing. Is the Bupivacaine 0.5% or 0.75%?

0.5%

 

[YadaYadaNext]

What is the advantage of using a lower dose ie 1.2cc of .75 bupi? Do you really care that much if your L&D nurses get held up for another hour at most to recover the patient? Serious question.

 

[Angus Avagadro]

What is the advantage of using a lower dose ie 1.2cc of .75 bupi? Do you really care that much if your L&D nurses get held up for another hour at most to recover the patient? Serious question.

I don't see one. Imo, I think many low spinals are due to insufficient mg's of drug to thoroughly anesthetized the nerves. I believe 1.2 cc is too little to anesthetize the majority of patients adequately. Just my $0.02.

 

[abolt18]

0.5%

I think everyone else on here is talking about 0.75% so you're really talking pretty similar doses.

 

[deleted697535]

never had a low spinal, never had a high spinal important enough to do anything about

the spinal dose is 1.6mls heavy with whatever opiod. Everyone gets the same

 

[NoodleIncident]

1.2-1.6 ml with Fent and Duramorph. I have never gone above 1.6ml. Wheels in to wheels out typically 50-75 min, private practice setting. I have had a few with dwarfism and I’ve been fortunate not to over or underdose them when guesstimating how much to use.

 

[Arch Guillotti]

never had a low spinal, never had a high spinal important enough to do anything about

You haven’t done enough cases tehn.

 

[deleted697535]

You haven’t done enough cases tehn.

Definitely not, i agree 100%. But like the neurologist trader said on the other thread dont hate the player... ;-)

 

[woopedazz]

I think everyone else on here is talking about 0.75% so you're really talking pretty similar doses.

Oh... now I feel silly. 0.75 isn't avaliable here