OB death

[Mman]

If 0.5 is enough, the epidural alone woulda been enough.

not if the epidural had some patchiness to it. The epidural space is not always free flowing and easy to spread everywhere. There can be membranes and pockets that will not get local to spread to them.

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[deleted162650]

not if the epidural had some patchiness to it. The epidural space is not always free flowing and easy to spread everywhere. There can be membranes and pockets that will not get local to spread to them.

I do agree with this, but more often than not, this is used an excuse for a crappily placed epidural.

 

[MirrorTodd]

I do agree with this, but more often than not, this is used an excuse for a crappily placed epidural.

Just like the pt that has "rolling" veins.

 

[Mman]

I do agree with this, but more often than not, this is used an excuse for a crappily placed epidural.

A catheter is either in the epidural space or is not in the epidural space. Nobody can control if the catheter ends up threading up/down/left/right (except for limiting the distance by not threading it in too far) and nobody can control how the local will spread within the space. It's up to the patient's spine to determine how that local is going to spread.

 

[deleted162650]

A catheter is either in the epidural space or is not in the epidural space. Nobody can control if the catheter ends up threading up/down/left/right (except for limiting the distance by not threading it in too far) and nobody can control how the local will spread within the space. It's up to the patient's spine to determine how that local is going to spread.

I dunno man. I replace a lotta epidurals that are just sorta crappily working/patchy/uneven that tend to be placed by the same couple people that work perfectly after I replace them.

 

[dabears505]

I dunno man. I replace a lotta epidurals that are just sorta crappily working/patchy/uneven that tend to be placed by the same couple people that work perfectly after I replace them.

I'm sorry your ob shift always follows mine

 

[Mman]

I dunno man. I replace a lotta epidurals that are just sorta crappily working/patchy/uneven that tend to be placed by the same couple people that work perfectly after I replace them.

Replacing an epidural that isn't working can let the new catheter thread somewhere else in their epidural space where it might work better. That isn't a function of the technique of placing it, just luck of the draw with where it ended up. My pain colleagues see this under fluoro all the time.

Over the years I have had to replace epidurals from 30+ colleagues and it almost always works great the second time. By my napkin calculations the odds of success on the second one are about the same as odds of success on the first unless they have a really messed up spine. So when you replace one, it usually works in the same way the first one usually works.

 

[nofliesonme]

As an old anesthesiologist... I have learned to give other anesthesiologists the benefit of the doubt.
It's very easy to criticize others when you were not in their shoes when the sh.t hit he fan!
But always try to remember these times when you were not stellar... when you could have done better... and you knew it, but you never admitted it. That's what happened here, and unfortunately this time it did not go well.
Let's not crucify the poor guy any further and maybe admit that we are all humans... we sometimes make mistakes.
We all do... it's human to make mistakes.
We are not lawyers, we are physicians and by default scientists.
Scientists know that humans are not perfect!

As a young surgeon when seeing another doctor's complication, I would think "who could have done this to the patient"........as I gained experience when seeing a complication I would think "there by the Grace of God go I".....now as a "seasoned" (old) surgeon I have had my own complications that have not been described.........when you go in the ocean enough times, you get to see everything that swims

 

[Mman]

As a young surgeon when seeing another doctor's complication, I would think "who could have done this to the patient"........as I gained experience when seeing a complication I would think "there by the Grace of God go I".....now as a "seasoned" (old) surgeon I have had my own complications that have not been described.........when you go in the ocean enough times, you get to see everything that swims

well said

 

[Southpaw]

once I started CSE most of the nonsense described here went away. Most, not all. If you don’t get +CSF you almost certainly aren’t midline. If you thread the catheter you do so knowing that catheter may very well function poorly and need replacement.

if you never try CSE to begin with you have no clue where you are within the epidural space.

 

[Southpaw]

As a young surgeon when seeing another doctor's complication, I would think "who could have done this to the patient"........as I gained experience when seeing a complication I would think "there by the Grace of God go I".....now as a "seasoned" (old) surgeon I have had my own complications that have not been described.........when you go in the ocean enough times, you get to see everything that swims

solid

 

[patriot6]

once I started CSE most of the nonsense described here went away. Most, not all. If you don’t get +CSF you almost certainly aren’t midline. If you thread the catheter you do so knowing that catheter may very well function poorly and need replacement.

if you never try CSE to begin with you have no clue where you are within the epidural space.

I haven't been doing CSEs, mostly because I want quick feedback regarding the quality of my catheter. I have been dropping a 27G Whitacre on my tray though, and I use it to confirm midline placement for anything that isn't the "one pass, crisp LOR" typical tactile feedback. I just don't put any drug through it.

 

[deleted162650]

I just don't put any drug through it.

That’s dumb.

 

[DrOwnage]

That’s dumb.

Yeah DPEs are meh. Just the tip? You going to tease them like that?

 

[woopedazz]

I find that it's mainly my junior colleagues dropping CSEs/DPEs only for the patchy epidural to slowly reveal itself just in time for the section. I prefer to just place the epidural and know the truth.

I don't really get people who Delivery Suite CSEs as default. You've got a barely monitored woman with no pressor support who'll be comfy within 10mins... And then you go and throw a surgical block into her.

I do them a lot, but defaulting to it/ pulling all epidurals for sections/ other decisions in this thread is a bit weird to me.

 

[Hoya11]

once I started CSE most of the nonsense described here went away. Most, not all. If you don’t get +CSF you almost certainly aren’t midline. If you thread the catheter you do so knowing that catheter may very well function poorly and need replacement.

if you never try CSE to begin with you have no clue where you are within the epidural space.

you can be off midline, but when you pass the spinal needle through the tuohy, you should still get CSF regardless of how far off midline you are.

if you are not getting CSF back from your spinal, you are not merely not midline, you are very likely not in the epidural space.

I cant think of a situation where you would be in the epidural space but could not get CSF due to being off midline.

its not like the sides of the epidural space dont also contain csf deep to the dura

Maybe for a transforaminal epidural but not what we are talking about here...

 

[Southpaw]

you can be off midline, but when you pass the spinal needle through the tuohy, you should still get CSF regardless of how far off midline you are.

if you are not getting CSF back from your spinal, you are not merely not midline, you are very likely not in the epidural space.

I cant think of a situation where you would be in the epidural space but could not get CSF due to being off midline.

its not like the sides of the epidural space dont also contain csf deep to the dura

Maybe for a transforaminal epidural but not what we are talking about here...

this information isn’t correct.

 

[Hoya11]

this information isn’t correct.

if you are checking that you are midline by checking for csf, thats incorrect

you can get csf back from both lateral sides of the epidural space.

your needle tip could be on the right side of the epidural space, not outside the space but not the midline, and you get csf back, and you thread the catheter into the right sided gutter and out the right foramen giving you a one sided block

 

[Southpaw]

if you are checking that you are midline by checking for csf, thats incorrect

you can get csf back from both lateral sides of the epidural space.

if you’re far enough off midline (left or right) you won’t get csf. It happens fairly often in my practice (both me and my partners). We are in the epidural space, but far enough off midline that you will not get csf. It’s understood that if you pass the catheter here you do so with risk of failure.

Usually the patient can tell us which side we are off of relative to midline.

I agree with you on the anatomy. It doesn’t make a ton of sense when you look at pictures. But in practice it occurs and honestly it isn’t rare.

if you were doing a straight epidural (no cse) and it was straightforward you’d just pass the catheter and be done. The procedure would’ve taken you 5 min and you’re out. And not shockingly you’ll get called back for one-sidedness, patchiness, poor setup, etc. this is why I’m a strong believer of the CSE for multiple reasons.

 

[anbuitachi]

off topic but anyone knows exactly what nerve causes the pressure feeling that's so hard to get rid of even with the best spinals?
im not surprised with pressure sensation for c sections since its next to all the peritoneal structures.
but i have cerclages (easy spinal + 0.75% bupi)) with patient feeling no pain but still has pressure which is surprising to me. cerclages should go no higher than t10... anyone know why?

 

[Hoya11]

if you’re far enough off midline (left or right) you won’t get csf. It happens fairly often in my practice (both me and my partners). We are in the epidural space, but far enough off midline that you will not get csf. It’s understood that if you pass the catheter here you do so with risk of failure.

Usually the patient can tell us which side we are off of relative to midline.

I agree with you on the anatomy. It doesn’t make a ton of sense when you look at pictures. But in practice it occurs and honestly it isn’t rare.

if you were doing a straight epidural (no cse) and it was straightforward you’d just pass the catheter and be done. The procedure would’ve taken you 5 min and you’re out. And not shockingly you’ll get called back for one-sidedness, patchiness, poor setup, etc. this is why I’m a strong believer of the CSE for multiple reasons.

yeah but it wouldnt feel right because im not in the epidural space if there is not CSF deep to my needle tip

ever do an epidural under fluoro?

you can be on the extreme right or left side of the interlaminar epidural space, and there is CSF there..

if you are basing if you are midline, meaning in the middle of the epidural space, not to the right or left, off of getting CSF, that is absolutely incorrect

 

[pgg]

I find that it's mainly my junior colleagues dropping CSEs/DPEs only for the patchy epidural to slowly reveal itself just in time for the section. I prefer to just place the epidural and know the truth.

I don't really get people who Delivery Suite CSEs as default. You've got a barely monitored woman with no pressor support who'll be comfy within 10mins... And then you go and throw a surgical block into her.

I do them a lot, but defaulting to it/ pulling all epidurals for sections/ other decisions in this thread is a bit weird to me.

No one is dosing the intrathecal portion of a labor CSE for a "surgical block" - that's just silly.

Reasonable choices would be something like
- 15 or 25 mcg of fentanyl
- 1 mL of 0.25% bupiv
- 2 mL of the epidural mix (maybe it's 0.125% bupiv + fentanyl)

No one is dropping surgical blocks in these patients.

There is an actual down side to labor CSEs and that's the somewhat higher incidence of transient fetal bradycardia after placement. Usually this is attributed to the sudden relief of pain --> decrease in circulating maternal catecholamines --> abrupt decrease in beta effect on uterine tone. It's not a big deal though if the labor RN knows the job (granted, not always a given).

 

[Southpaw]

yeah but it wouldnt feel right because im not in the epidural space if there is not CSF deep to my needle tip ever do an epidural under fluoro?

you can be on the extreme right or left side of the interlaminar epidural space, and there is CSF there..

if you are basing if you are midline, meaning in the middle of the epidural space, not to the right or left, off of getting CSF, that is absolutely incorrect

don’t really see the point in arguing this. I gather you don’t do CSEs. If you don’t believe you can be in the epidural space and not get CSF you’re wrong. This happens and not rarely.

I didn’t do a pain fellowship. Did plenty of fluoro guided epidurals in residency but that’s been a while.

 

[GassYous]

off topic but anyone knows exactly what nerve causes the pressure feeling that's so hard to get rid of even with the best spinals?
im not surprised with pressure sensation for c sections since its next to all the peritoneal structures.
but i have cerclages (easy spinal + 0.75% bupi)) with patient feeling no pain but still has pressure which is surprising to me. cerclages should go no higher than t10... anyone know why?

It's not about how high, it's about how low

 

[Arch Guillotti]

I cant think of a situation where you would be in the epidural space but could not get CSF due to being off midline.

It can happen.

 

[deleted162650]

you can be on the extreme right or left side of the interlaminar epidural space, and there is CSF there..

The bigger issue is when you enter the epidural space at an angle, instead of perpendicular. This can happen if positioning isn’t great, or if there is some unappreciated scoli. In this instance the CSE needle passes adjacent to the thecal sac, still within the epidural space, and you get no CSF return despite the Tuohy tip being epidural.

 

[anbuitachi]

It's not about how high, it's about how low

what? if i transect spine at t4. you shouldn't feel below t4.

 

[Mman]

what? if i transect spine at t4. you shouldn't feel below t4.

we are talking epidurals, not spinals. I mean if you place a mid or high thoracic epidural, the patient can still clearly walk around and use their legs. The local has to diffuse up and down the epidural space to get to those levels, not the same as a spinal where it is all flowing around freely with the nerves in the cauda equina.

 

[Twiggidy]

I haven't been doing CSEs, mostly because I want quick feedback regarding the quality of my catheter. I have been dropping a 27G Whitacre on my tray though, and I use it to confirm midline placement for anything that isn't the "one pass, crisp LOR" typical tactile feedback. I just don't put any drug through it.

You shouldn't be hesitant to place drug.

A) they will get almost instant pain relief
B) if your catheter isn't good then they'll call you back in about a couple hours when she's screaming

I don't believe in the "giving intrathecal drugs clouds my epidural placement" theory

 

[Twiggidy]

I find that it's mainly my junior colleagues dropping CSEs/DPEs only for the patchy epidural to slowly reveal itself just in time for the section. I prefer to just place the epidural and know the truth.

I don't really get people who Delivery Suite CSEs as default. You've got a barely monitored woman with no pressor support who'll be comfy within 10mins... And then you go and throw a surgical block into her.

I do them a lot, but defaulting to it/ pulling all epidurals for sections/ other decisions in this thread is a bit weird to me.

If you do it correctly it's not a "surgical block" but it's certainly enough to make her happy

 

[Twiggidy]

No one is dosing the intrathecal portion of a labor CSE for a "surgical block" - that's just silly.

Reasonable choices would be something like
- 15 or 25 mcg of fentanyl
- 1 mL of 0.25% bupiv
- 2 mL of the epidural mix (maybe it's 0.125% bupiv + fentanyl)

No one is dropping surgical blocks in these patients.

There is an actual down side to labor CSEs and that's the somewhat higher incidence of transient fetal bradycardia after placement. Usually this is attributed to the sudden relief of pain --> decrease in circulating maternal catecholamines --> abrupt decrease in beta effect on uterine tone. It's not a big deal though if the labor RN knows the job (granted, not always a given).

As the Mandalorian Guild says....."This is the way". I like option 3. I give 3 cc (our solutions are 0.0625%). 99% percent no itching. 99% happy patients. If they're closer to 9-10 cm and the baby is saying "ready or not" i may go cowboy and do 4-5 cc. They still are able to push with that level.

If you do the math, you see how little bupivacaine it takes to make them happy, able to labor, and able to push. It's nowhere near the 10-15 mgs they get for a "surgical block" for a c-section.

 

[pjl]

If you do it correctly it's not a "surgical block" but it's certainly enough to make her happy

When I do CSEs, I used to do 15-20 of fentanyl, but now do 2 mL of the bag mix. Definitely not a surgical block.

Both work well, but this is not routine for me. I only do it if I think delivery will be within 30-45 minutes.

Otherwise, I am a straight epidural guy. My time from in room to bolusing epidural is enough faster than my time from in room to doing a CSE spinal dose that they have 1-2 more painful contractions than they otherwise would have.
To me, having the epidural set up gives me confirmation that I won’t have to leave my bed again for her by the time I leave the room. Her 2 contractions are worth me not having to wake up again. I guess here in Lake wobegon I just dont struggle with one sided blocks enough to change my practice.

 

[Southpaw]

No one is dosing the intrathecal portion of a labor CSE for a "surgical block" - that's just silly.

Reasonable choices would be something like
- 15 or 25 mcg of fentanyl
- 1 mL of 0.25% bupiv
- 2 mL of the epidural mix (maybe it's 0.125% bupiv + fentanyl)

No one is dropping surgical blocks in these patients.

There is an actual down side to labor CSEs and that's the somewhat higher incidence of transient fetal bradycardia after placement. Usually this is attributed to the sudden relief of pain --> decrease in circulating maternal catecholamines --> abrupt decrease in beta effect on uterine tone. It's not a big deal though if the labor RN knows the job (granted, not always a given).

fetal brady occurs. Like you said, if you’re at a facility that routinely does CSE this isn’t a big deal.

 

[anbuitachi]

we are talking epidurals, not spinals. I mean if you place a mid or high thoracic epidural, the patient can still clearly walk around and use their legs. The local has to diffuse up and down the epidural space to get to those levels, not the same as a spinal where it is all flowing around freely with the nerves in the cauda equina.

i think we are takling abotu different topics. i was responding to his reply to my question about spinal pressures

 

[Mman]

i think we are takling abotu different topics. i was responding to his reply to my question about spinal pressures

my brain may have confused itself

 

[deleted126335]

No one is dosing the intrathecal portion of a labor CSE for a "surgical block" - that's just silly.

Reasonable choices would be something like
- 15 or 25 mcg of fentanyl
- 1 mL of 0.25% bupiv
- 2 mL of the epidural mix (maybe it's 0.125% bupiv + fentanyl)

No one is dropping surgical blocks in these patients.

There is an actual down side to labor CSEs and that's the somewhat higher incidence of transient fetal bradycardia after placement. Usually this is attributed to the sudden relief of pain --> decrease in circulating maternal catecholamines --> abrupt decrease in beta effect on uterine tone. It's not a big deal though if the labor RN knows the job (granted, not always a given).

One more downside. I supervise CRNAs and residents. More than once I have had a CSE where there was good analgesia with the spinal dose, but, before the epidural catheter was activated, an urgent Section became necessary. We subsequently found that the epidural cath was inadequate for Surgical anesthesia after fully dosing.

There is something very comforting about knowing that you have a well working epidural catheter in a laboring patient as opposed to an untested epidural catheter. I don't find this to be an issue with experienced and skilled practitioners. But not everyone that I work with meets that definition-so no CSEs on my patients.

 

[Southpaw]

yeah but it wouldnt feel right because im not in the epidural space if there is not CSF deep to my needle tip

ever do an epidural under fluoro?

you can be on the extreme right or left side of the interlaminar epidural space, and there is CSF there..

if you are basing if you are midline, meaning in the middle of the epidural space, not to the right or left, off of getting CSF, that is absolutely incorrect

got busy earlier so sorry if I was short. I believe you're anatomically correct. I'm not disputing that. however I am telling you that in practice it isn't rare for me or my partners to be in the epidural space, pass the spinal needle, and get no CSF return. If you've asked the patient during epidural placement they can often correctly tell you which side you're off. I believe you can be way left or way right and get no CSF. I also believe that depending on the angle of your tuohy you can get no CSF. I can 100% unequivocally tell you based on lots of experience between myself and my partners that if you don't get CSF your catheter has a higher chance of failure. it still works most of the time (and if it's been a difficult placement we skip CSE and pass the catheter) but it isn't 100%.

I imagine you'll tell me that we aren't getting CSF in those cases, or that our catheters fail in those cases, because we aren't in the epidural space. Honestly, I can't help but shrug off or ignore that. Again, in the last year I've pulled an epidural catheter and placed a spinal once for CS. All other CSs I've used the catheter. I haven't put anyone to sleep unless it's been a true stat CS and we haven't had for bolus to setup. My hospital does around 4000 deliveries a year.

I know everyone on SDN thinks everything they do works every time and it takes them 2 minutes to place every. single. time. that's not what I'm saying. If I were supervising CRNAs or residents I'd be far less hesitant to believe my own words and I'd be far less hesitant to trust the epidurals we routinely use for CS. These are all attending placed CSEs and we all have lots of experience. Many of my partners are OB fellowship trained and I know everyone here thinks that's useless. Interestingly, our OB/GYNs (and therefore our hospital....) place a very high value on it. Also, I'm not fellowship trained.

 

[OTCAwesome]

Not sure if everyone else does this or not, but generally when placing the epidural I'll thread pretty deep and then pull back. This acts to draw the catheter back to the midline if it's snaked off to one side or another. We have a decently busty OB service, prob avg 12 epidurals and 5 sections during a normal 24h call and I can't remember the last time I've been called for a one-sided epidural that I placed myself.

 

[okayplayer]

^
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Waiting for Salty on this one..

 

[Mman]

One more downside. I supervise CRNAs and residents. More than once I have had a CSE where there was good analgesia with the spinal dose, but, before the epidural catheter was activated, an urgent Section became necessary. We subsequently found that the epidural cath was inadequate for Surgical anesthesia after fully dosing.

There is something very comforting about knowing that you have a well working epidural catheter in a laboring patient as opposed to an untested epidural catheter. I don't find this to be an issue with experienced and skilled practitioners. But not everyone that I work with meets that definition-so no CSEs on my patients.

It's still an issue. I have replaced epidural catheters from colleagues that always do CSEs, even ones that have been doing it for decades. They claim it never fails, but occasionally it does. I've seen them super one sided, or totally failed, or nearly anything...you just don't find out until they are further along in labor and hurting even more than before.

Epidurals can fail. It happens. It is not a question of technique or experience or skill. Being super awesome can decrease the odds of failure compared to a brand new resident, but not eliminate it.

 

[vector2]

It's still an issue. I have replaced epidural catheters from colleagues that always do CSEs, even ones that have been doing it for decades. They claim it never fails, but occasionally it does. I've seen them super one sided, or totally failed, or nearly anything...you just don't find out until they are further along in labor and hurting even more than before.

Epidurals can fail. It happens. It is not a question of technique or experience or skill. Being super awesome can decrease the odds of failure compared to a brand new resident, but not eliminate it.

How far in the space are the catheters that you've had to replace?

 

[Aheadbyacentury]

off topic but anyone knows exactly what nerve causes the pressure feeling that's so hard to get rid of even with the best spinals?
im not surprised with pressure sensation for c sections since its next to all the peritoneal structures.
but i have cerclages (easy spinal + 0.75% bupi)) with patient feeling no pain but still has pressure which is surprising to me. cerclages should go no higher than t10... anyone know why?

your spinal is not high enought

 

[Hoya11]

got busy earlier so sorry if I was short. I believe you're anatomically correct. I'm not disputing that. however I am telling you that in practice it isn't rare for me or my partners to be in the epidural space, pass the spinal needle, and get no CSF return. If you've asked the patient during epidural placement they can often correctly tell you which side you're off. I believe you can be way left or way right and get no CSF. I also believe that depending on the angle of your tuohy you can get no CSF. I can 100% unequivocally tell you based on lots of experience between myself and my partners that if you don't get CSF your catheter has a higher chance of failure. it still works most of the time (and if it's been a difficult placement we skip CSE and pass the catheter) but it isn't 100%.

I imagine you'll tell me that we aren't getting CSF in those cases, or that our catheters fail in those cases, because we aren't in the epidural space. Honestly, I can't help but shrug off or ignore that. Again, in the last year I've pulled an epidural catheter and placed a spinal once for CS. All other CSs I've used the catheter. I haven't put anyone to sleep unless it's been a true stat CS and we haven't had for bolus to setup. My hospital does around 4000 deliveries a year.

I know everyone on SDN thinks everything they do works every time and it takes them 2 minutes to place every. single. time. that's not what I'm saying. If I were supervising CRNAs or residents I'd be far less hesitant to believe my own words and I'd be far less hesitant to trust the epidurals we routinely use for CS. These are all attending placed CSEs and we all have lots of experience. Many of my partners are OB fellowship trained and I know everyone here thinks that's useless. Interestingly, our OB/GYNs (and therefore our hospital....) place a very high value on it. Also, I'm not fellowship trained.

i do support using in situ epidural catheters for CS

my only point was to argue against the idea that CSF coming back means you are square in the middle of the epidural space.

Its hard to blindly palpate the spine and end up with a catheter 3-5cm deep and in the dead center of the epidural space. No matter what technique.

if we did fluoro images of these catheters they would be at different levels and different sides of the epidural space than we expect.

despite this, volume helps us spread the local to both sides and produce surgical anesthesia for CS very often.

But I do NOT think that doing a CSE is improving your chances of having a catheter that is more midline and therefore more likely to work for CS if needed.

It sounds like you have a good system that works for you and that you are very proficient at it - many ways to skin a cat

 

[Hoya11]

The bigger issue is when you enter the epidural space at an angle, instead of perpendicular. This can happen if positioning isn’t great, or if there is some unappreciated scoli. In this instance the CSE needle passes adjacent to the thecal sac, still within the epidural space, and you get no CSF return despite the Tuohy tip being epidural.

yes this can happen at exactly the right angulation.. but what are the chances of that happening, vs just not being in the epidural space?

i wouldnt feel confident placing a catheter and relying on a catheter in that situation - just me.

 

[Twiggidy]

yes this can happen at exactly the right angulation.. but what are the chances of that happening, vs just not being in the epidural space?

i wouldnt feel confident placing a catheter and relying on a catheter in that situation - just me.

I sort of agree. Since being in the space and seeing +CSF improves my confidence of the catheter, if I get LOR but -CSF then I'm very reluctant to even place the catheter despite the LOR. Especially in the case of scoliosis where not only is there a curvature but also a rotational component, I readjust my approach until I get LOR AND +CSF because if I get CSF I must be in the proper space.

That's just my thought and not scientifically proven

 

[anbuitachi]

your spinal is not high enought

can you go in more detail than that. you mean not high enough to cover the cranial nerves?
0.75% bupi get pretty high, yet patient still feels pressure with cerclage.

actually this week i had a spinal level go up to the neck. patient lost sensories in both arms, complained of dizziness, felt difficulty breathing, and difficulty talking. yet she still feels the pressure from the C section.

my understanding is it's the vagus nerves fault?

 

[GassYous]

can you go in more detail than that. you mean not high enough to cover the cranial nerves?
0.75% bupi get pretty high, yet patient still feels pressure with cerclage.

actually this week i had a spinal level go up to the neck. patient lost sensories in both arms, complained of dizziness, felt difficulty breathing, and difficulty talking. yet she still feels the pressure from the C section.

my understanding is it's the vagus nerves fault?

da fuq is going on with your spinals?

 

[deleted162650]

many ways to skin a cat

Ya, but my way is the best way.

 

[woopedazz]

can you go in more detail than that. you mean not high enough to cover the cranial nerves?
0.75% bupi get pretty high, yet patient still feels pressure with cerclage.

actually this week i had a spinal level go up to the neck. patient lost sensories in both arms, complained of dizziness, felt difficulty breathing, and difficulty talking. yet she still feels the pressure from the C section.

my understanding is it's the vagus nerves fault?

Peritoneum is innervated all higgly piggly. Med school teaches you that somatic is from ~T6 and visceral from ~T4 down, but in practice the innervation is quite poorly approximated by the somatic dermatomal distribution of the skin. The vagus nerve has some sensory input, which means you cannot completely get rid of the pressure/stretch, but you can normally eliminate most of the issues by hitting T4.

Problem is the vagal input is mainly upper epigastric/pelvic (including cervix obviously). So even in some decent saddle blocks/spinals the pelvic region cannot be completely eliminated. That, and over-shooting T4

 

[Mman]

How far in the space are the catheters that you've had to replace?

the same 3-5 centimeters or so as anyone else