Spinal Anesthesia

Lately, I have forced myself to overcome my fear of leaving the somewhat comfortable zone of general anesthesia and head to other types of anesthesia such as neuraxial. I have had a chance to work in OB for a couple of days now and feel better about administering spinals and epidurals even with such limited experience.

Yesterday, I had a 15 and a half hour day in the OB department. Yes, it was really long! Part of it was sitting in the surgeon lounge waiting for the doctor to come or patient to be prepped, but still...it was too long! Regardless, I had plenty of opportunities to try out spinal anesthesia for C-section.

Here is a quick run-down on how I was taught and other necessary tidbits.

• A my clinical site, a tech preps your spinal site usually and sets up the tray for you. I managed to do a few myself. The first thing before doing anything is to make sure the patient is connected to the monitors. A baseline set is needed as you will have to keep a close eye on vitals immediately after injecting spinal anesthesia. Be sure to adequately preload the patient with fluids to prevent hypotension and nausea/vomiting related to that. 
• Basic things needed: Duramorph, Spinal Kit (we use Pencan 25g), sterile gloves. 
• The next step is to ensure proper positioning. Inform nurse that the patient needs to be in a "Mad cat" position and it helps demonstrating this to the patient. Ask the patient to drop shoulders forward and push lower back outwards. Another thing that I missed was ensure the patient was not leaning to a side. I was a working with an obese patient and it was hard to tell but I was aiming my spinal needle off centered because she was leaning slightly to one side. It was easy once my preceptor made me realize that.
• Before prep it is good to identify the landmark for L3-L4 interspace. For some reason if you did not get an opportunity to find the landmarks prior to them prepping the site. Use the drape to feel for iliac crest to keep everything sterile. It is also important to follow the spine with one's fingers to make sure it is not off midline as one would notice with scoliosis. 
• Be sure to collect everything before donning sterile glove. I used duramorph so, I had to open and place the unsterile syringe standing upwards on the table so I could draw up having my sterile gloves on without touching. 
• After getting everything ready, palpate for the insertion site again and mark with a little indentation using your thumb nail. 
• Open the glass vials in the spinal kit one at a time to keep things simple. 
• #1: Lidocaine 1 % for infiltration=  3ml
• Infiltrate the insertion site, create a skin wheal and injected at the site. Skin wheal helps identify the site you choose.
• # 2: Bupivacaine 0.75% = 1.6ml and inject 250mcg Duramorph (0.5ml for me). Be sure everything is meant for spinals and is preservative free!
• By the time your spinal meds are drawn up, local infiltration gets a chance to work
• Insert the introducer straight in. Deviate as necessary to avoid bone. 
• Insert the Pencan spinal needle. Feel for pop 1, keep going and then feel for pop # 2.
• After second pop, remove stylet and check for CSF.
• Connect the syringe with medicine and check for clear CSF and aspirate to check for swirl
• Then slowly but steadily inject the medication and pull all the needles out together!
• immediately rest the patient back.
• I have been told that 1.6 can work for everyone under 6 feet as you can make it go higher or lower based on patient's bed positioning.
• And assess level to be a T4.
• If it is too low, trend the patient for sometime and reassess. If patient starts having numbness or tingling to the fingers. Straighten the bed to avoid further increase in spinal. Vice versa.
• Let patient know that it IS OK to feel pressure and touch!
• But NOT OK for pain.

This is it for now...I will keep adding to this as I learn more. Please let me know your experiences and what else I should add.   Be sure to Comment, "Like" ,Subscribe and "Follow"  for more useful info! Thanks!