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    You enter a room where are 23 y/o patient is requesting an epidural. This is her first baby and she is having alot of pain. Her birth plan included an epidural and she is glad you are here. She has no other history and this is an uncomplicated pregnancy.

    You notice as you are localizing her she is dodging the needle, not uncommon but it will make insertion more challenging. At one point during a contraction she literally stand bolt upright. This stuff can happen, it makes you work harder but the best you can do is verbally reassure her.

    One she stops moving you get a quick loss of resistance without difficulty. You inject the 3 cc test dose and wait a minute for a response, there isnt any.

    You grab your 8cc of 0.2% bolus with 100 mcg of fentanyl in it and start a slow injection. Between pushing this in you tape your epidural in.

    Over a period of a minute or 2 the whole bolus is in. As you are preparing to claim victory and lay her back down she starts to tell you she cannot breathe. She looks like it too. Then she immediately passes out.

    What do you do?
    This article was originally published in forum thread: OB Mishap and You started by MmacFN View original post
    Comments 34 Comments
    1. Bluegoldcrna's Avatar
      Bluegoldcrna -
      Call for help. Quick assessment, is she moving air? Is there a pulse? Differential diagnosis here includes high spinal, pulmonary embolism, vasovagal response, etc. with most likely cause (giving what I just did) the high spinal. I'm most worried about the ABC's here. If the patient is not ventilating I would first attempt to intubate, as this patient is at risk of aspiration and will likely require PPV for some length of time. If unsuccessful with intubation, I would attempt mask ventilation with cricoid pressure and, failing that, fall back on a LMA. I would have high suspicion for hypotension and bradycardia as a result of the high spinal. Since the damage is already done, I would have no problem placing the patient in a Trendelenburg position to augment venous return, also ensuring to place a wedge under the right hip to minimize aortocaval compression. I would have vasopressors at the ready and would have a low threshold for titrating in epinephrine due to possible bradycardia. If patient was hypotensive but without bradycardia, I could opt for phenylephrine. I would open the fluids wide open in an effort to offset any relative hypovolemia.
    1. MmacFN's Avatar
      MmacFN -
      Ok!

      To add some more info!

      VS are stable, she does appear to be apenic and she is also unresponsive with pin point pupils.

      You are easily bagging her. Sats normal.

      The OB/GYN is already in the room as they happened to by on the floor. They notice a rash on her arms and chest. Its small.
    1. rjkt's Avatar
      rjkt -
      The local was to much 0.5% bupivicaine a lil much, high epidermal. Support airway, intubation if necessary, maintain hemodynamics with pressors or and fluids if unstable. Make sure it wasn't intravascular had some LA tox but that would have been seen in the test dose. Test dose would have shown if u were intrathecal. So IMHO epidermal too high with local too dense and excessive sympathectomy and you were able to block her C4!!! Impressive!!!
    1. Bluegoldcrna's Avatar
      Bluegoldcrna -
      I still think the catheter migrated and is intrathecal; apnea with 40mg of marcaine and after only a minute or two is a pretty profound response if this stayed epidural. Seems like the patient is stable now, but I'm concerned about that rash. I guess it could be sensitivity to the local or the fentanyl, but allergies to amide LA's are relatively rare (this one is preservative free) and fentanyl frequently presents with pruritus but not normally a rash. I tried looking this up but couldn't find anything right away...I though PE could present with a rash across the chest but I'm not sure. Can someone help me out?

      Does the OB want to do a section? I would maintain the catheter and dose like a spinal for the interim.
    1. MmacFN's Avatar
      MmacFN -
      Sorry that was supposed to be 0.2% i fixed it nice catch tho!

      Quote Originally Posted by rjkt View Post
      The local was to much 0.5% bupivicaine a lil much, high epidermal. Support airway, intubation if necessary, maintain hemodynamics with pressors or and fluids if unstable. Make sure it wasn't intravascular had some LA tox but that would have been seen in the test dose. Test dose would have shown if u were intrathecal. So IMHO epidermal too high with local too dense and excessive sympathectomy and you were able to block her C4!!! Impressive!!!
    1. pdsr's Avatar
      pdsr -
      Quote Originally Posted by MmacFN View Post
      Sorry that was supposed to be 0.2% i fixed it nice catch tho!
      Thought maybe you were just going "Old School" on us...
    1. MmacFN's Avatar
      MmacFN -
      The baby is doing fine but the crew is getting ready for a section.

      Currently pt remains unintubated. Ventilates easy and after a 10 minutes appears to be breathing on her own. Still unresponsive.

      OB is not rushing the section since baby is perfect.

      What are your differentials. Keep in mind the vitals have not changed during this entire time.
    1. LouisiAnimal's Avatar
      LouisiAnimal -
      Tell her to quit playing around and you don't need this shit today
    1. LightsOut's Avatar
      LightsOut -
      Quote Originally Posted by Bluegoldcrna View Post
      I still think the catheter migrated and is intrathecal;
      are you saying you give a test dose before you thread the catheter?
    1. Bluegoldcrna's Avatar
      Bluegoldcrna -
      Quote Originally Posted by LightsOut View Post
      are you saying you give a test dose before you thread the catheter?
      No, that's not what I'm saying. The test dose was fine. The catheter could have migrated while the epidural was being taped/bolused. I'm not sure how else you can explain the test dose being fine but then getting symptoms very similar to a high spinal. I guess a sub-dural injection is possible, but it's still not in the epidural space.
    1. J-Dubya's Avatar
      J-Dubya -
      Tube. No VS changes probably means it's not a simple high spinal. Either way, an unresponsive pregnant lady needs a secure airway while you sort things out. Could give narcan too
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by J-Dubya View Post
      Tube. No VS changes probably means it's not a simple high spinal. Either way, an unresponsive pregnant lady needs a secure airway while you sort things out. Could give narcan too
      The patient is breathing on her own, without assist, vital signs stable, fetus stable, no signs of decline. Is intubation really necessary here? I support patient as needed, trouble-shoot the cause, and fix accordingly. Of course, any change (for the worse) in mom or baby, move to stat-CS, prop sux tube. Business as usual. Oh, and what LouisiAnimal says would be my first go-to!
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by MmacFN View Post
      Sorry that was supposed to be 0.2% i fixed it nice catch tho!
      I've never used (nor seen) 0.2% bupivacaine. Did you mean ropivacaine?

      My differential would be related to fentanyl (pin-point pupils), or latex (gloves/medication rubber stopper/other epidural equipment used).
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by ethernaut View Post
      The patient is breathing on her own, without assist, vital signs stable, fetus stable, no signs of decline. Is intubation really necessary here? I support patient as needed, trouble-shoot the cause, and fix accordingly. Of course, any change (for the worse) in mom or baby, move to stat-CS, prop sux tube. Business as usual. Oh, and what LouisiAnimal says would be my first go-to!
      She's totally unresponsive for no reason, I would have moved to immediately intubate her, if she aspirates everyone is screwed.
      Maybe one(SMALL) dose of narcan first
    1. RAYMAN's Avatar
      RAYMAN -
      Quote Originally Posted by J-Dubya View Post
      Tube. No VS changes probably means it's not a simple high spinal. Either way, an unresponsive pregnant lady needs a secure airway while you sort things out. Could give narcan too
      Agree. If it was a high spinal you'd see symptoms of a sympathectomy. If she's unconscious then I would assume she doesn't have protective reflexes intact.
    1. armygas's Avatar
      armygas -
      Neurocardiogenic syncope






      If you want to "talk anesthesia" email me at armygas@gmail.com
    1. J-Dubya's Avatar
      J-Dubya -
      Quote Originally Posted by armygas View Post
      Neurocardiogenic syncope






      If you want to "talk anesthesia" email me at armygas@gmail.com
      With apnea though? And wasn't she monitored during the epidural? Sounds very slow to come back too?

      But. I guess it could it be, young, anxious, needle phobic.
    1. MmacFN's Avatar
      MmacFN -
      Nope its ropivicaine

      Comes like this in a 100 cc bottle.

      Attachment 4268

      Quote Originally Posted by ethernaut View Post
      I've never used (nor seen) 0.2% bupivacaine. Did you mean ropivacaine?

      My differential would be related to fentanyl (pin-point pupils), or latex (gloves/medication rubber stopper/other epidural equipment used).
    1. MmacFN's Avatar
      MmacFN -
      So

      After 30 minutes the patient is now fully awake. The epidural was never running.

      She is numb from waist down and says she is ready to push

      She has no memory of any of the events that transpired.

      Here are the questions to answer:

      1) Give the 3 main differential diagnosis.

      2) What was the rash from?

      3) Why was she apenic?


      Just so you all know there is no actual final diagnosis it is a total mystery. However, there are some very good possibilities based on the information presented.
    1. pdsr's Avatar
      pdsr -
      Sitting here babysitting an epidural and thinking "I'm glad this happened to someone else".

      Differentials: High Spinal; Intravascular injection; intraneural injection. Possible anomalous epidural space as well. Also, could be some combination of these.

      Rash: this has me stumped. I've seen mild rash on occasion with epidural and spinal narcotics.

      Apnea: I've seen pt's get respiratory depression from high dose lidocaine in the CCU without seizure, but this wouldn't explain why she was blocked when she woke up. I've not seen a significant intravascular injection with ropivicaine, so I don't know if it behaves in a similar fashion.

      Was the epidural catheter a single port, or multiple port? If multiport, then the cath could have been half in spinal, and half in a vein and could explain some of this.

      Glad she's better, baby's safe, and it didn't happen to me. Mine just delivered, so I'm out of here...