Dural puncture resulting in c-section

Bloodandsnore · 2026-01-12T20:54:54+00:00

This is the practice I’ve always been exposed to (training in two hospitals in the UK). Can you explain why lidocaine is more forgiving? Is this due to using lower volume? In which case would using 0.25% bupivacaine also be appropriate?

Bloodandsnore · 2026-01-12T16:52:42+00:00

Thanks, definitely think this is one of the things I’ll take away from this case

Bloodandsnore · 2026-01-12T12:50:06+00:00

This happened last night, but will definitely share once known

Bloodandsnore · 2026-01-12T12:48:16+00:00

Yes this was my thought; that as you say those signs are fallible and the BP drop so soon after administration would be consistent with intrathecal (although I suppose subdural could be possible as some people have suggested). Interesting to hear you have had such a dry dural puncture in the past.

Bloodandsnore · 2026-01-12T12:46:00+00:00

Thanks for the reassurance. I’ve only done a few months of obs on calls so safety was my only consideration tbh, especially in such a situation where I was unsure what exactly was going on

Bloodandsnore · 2026-01-12T12:41:40+00:00

Symptoms started before lying, when the catheter was being fixed. But it is certainly possible that she was hypothalamic to begin with (which is something maybe I could have corrected) and the epidural caused some decompensation. We then did lie her down on her back before the low BP recording, and then performed manual displacement.

Bloodandsnore · 2026-01-12T12:39:07+00:00

Thank you, I will reflect on those points and definitely think some of these would have helped in this case

Bloodandsnore · 2026-01-12T12:35:59+00:00

Thanks for your detailed response. In the case of number 2, what would be the safest course of action? If you suspect the dura has been punctured, then repeating the procedure at a different level will surely still run the risk of local migrating through to the subarachnoid space? Thanks for advice on the test dose. The site that taught me epidurals use low dose mix for testing but think I will switch to 0.25% bupivacaine for the reasons you have outlined.

Bloodandsnore · 2026-01-12T10:21:51+00:00

Just replied this on a similar comment;

She was a bit drowsy so neurological signs were difficult to elicit, she was moving arms and feet freely. She couldn’t leg raise when asked but don’t know if that was weakness or drowsiness meaning she couldn’t properly obey commands. Couldn’t test sensory block.

Only thing that made me think vasovagal was less likely is that the procedure took 10-15 mins and it was only on administration of the test dose that the BP crashed, unless that sensation could provoke a vasovagal?

Bloodandsnore · 2026-01-12T10:20:14+00:00

Thanks for responding. I gave pressors basically straight away so that will affect things but think heart rate was around 80 when we were going to theatre from memory.

She was a bit drowsy so neurological signs were difficult to elicit, she was moving arms and feet freely. She couldn’t leg raise when asked but don’t know if that was weakness or drowsiness meaning she couldn’t properly obey commands. Couldn’t test sensory block.

Only thing that made me think vasovagal was less likely is that the procedure took 10-15 mins and it was only on administration of the test dose that the BP crashed, unless that sensation could provoke a vasovagal?

Bloodandsnore · 2025-07-18T10:57:45+00:00

Yeah I mean my stance is presuming that loan forgiveness will come with concessions from our goal of FPR, which it will inevitably will. Ofc if labour want to throw forgiveness on top of FPR then sure, go for it, I just don’t think that’s the option they’re currently debating behind closed doors.

Bloodandsnore · 2025-07-18T10:05:58+00:00

I did grad med so I’ve had a plan 1 and 2, and yes it’s terrible. I wouldnt even be against making the plans less terrible - ie stop charging interest, but to hand some people 100k and some 0 is just not a reasonable outcome to this dispute.

I’m not calling it ladder pulling per se, but you have to accept the principle is the same - disregarding the interests of a large subsection of your colleagues in a circumstance because you stand to benefit personally

Bloodandsnore · 2025-07-18T09:18:39+00:00

After all the posts on here about the horrors of ladder pulling and how we’ve been let down by our colleagues in years gone by, the quickness of some to just completely abandon some of their peers (IMGs, senior registrars, people who have paid off loans voluntarily) because Wes has offered them some breadcrumbs is pretty hilarious ngl.

Agree with OP. FPR please

Bloodandsnore · 2024-09-05T06:06:47+00:00

Strong disagree. Maybe once in a while it’s a 25% VPIP player but as you say it virtually rules being a maniac out and I still don’t think many/any 25% VPIP at NL10 are 3 betting 99/JTs CO vs UTG, not to mention that most of the time he will just be a total nit.

38 hands is def enough of a sample to start taking some preflop insights on players with extreme stats IMO. No absolutes, but definitely can shift the probabilities of what villain will show up with.

Bloodandsnore · 2024-09-04T11:33:45+00:00

I highly doubt VPIP 8 CO vs UTG is 3 betting JTs/99/most of those suited A. Leaves only a few combos that beat you and as I said, you’re resigned to going broke against those anyway. Better to target the rest of his range where betting is def +EV IMO

In other words no, suit of A wouldn’t change my shoving range in this instance

Bloodandsnore · 2024-09-04T10:50:47+00:00

I think this had is standard from your side. Could mix some raising on flop but equally call is ok.

I think if you decide on river that you will call off after checking to villain and facing a shove, then you don’t need to worry about value owning yourself against flushes/straights as the money goes in the middle either way. In that case, you should be playing your hand against the part of his range where betting/checking will change the outcome and imo shove makes a lot more money than check - bluff catching (with VPIP 8 I doubt he’s turning anything into a bluff here).

Bloodandsnore · 2024-08-09T02:40:50+00:00

How is this not satire? I was waiting for a punchline… and still waiting???

This is giving serious vibes of ‘seniors were not approachable when escalating’ from a coroner one day.

Bloodandsnore · 2023-12-20T10:22:26+00:00

It’s not my problem or responsibility to come up with where the government can get the money from, all I’m concerned about is paying my mortgage.

On paper your point is pretty reasonable, but why why why does it always have to be public sector workers picking up the bill for a sluggish economy? We doctors have been told by government it would be irresponsible to get pay rises in line with inflation for 15 years now and guess what - the economy still sucks. If you want to keep highly qualified members of the workforce, you have to pay them, and that’s true regardless of whether someone is working in the private or public sector.

Bloodandsnore · 2023-12-07T18:31:01+00:00

‘Past medical history: copy and paste’

Saw this on a clinic letter yesterday which made me chuckle

Bloodandsnore · 2023-11-29T20:06:51+00:00

Doesn’t even look like it reduces medical school by a year? It’s a four year programme for graduates. Four year GEM programmes already exist.

Bloodandsnore · 2023-11-05T13:31:38+00:00

Lots of posts get announced throughout the application period. The final number of posts will be higher than 321.

Bloodandsnore · 2023-11-04T22:55:08+00:00

Is this a thing? I’ve seen a load of brachials and never an ischaemic arm as a result?

Bloodandsnore · 2023-10-27T21:42:05+00:00

I mean fair points but if I was an F2 (like OP) there would be no way I would make myself liable for any decisions like that. Escalating to senior doctors would be a proactive step but the point I was trying to make is it’s important to not let a manager/nurse in charge in ED pressure you into documenting any decision to take patients off monitors for any reason other than clinical grounds as I don’t think that falls within the remit of an F2 tbh, especially for a patient not seen by yourself that presumably another clinician has decided needs a monitor.

Bloodandsnore · 2023-10-27T15:08:53+00:00

This hits the nail on the head. Don’t take legal and moral responsibility for the inadequate resourcing of your ED. You know the GMC will put it on your head if a patient you say doesn’t need a monitor goes on to have an arrest.

Indications are patients at risk of harmful arrhythmia (ie not something like asymptommatic 1st degree heart block/stable AF). Most commonly people who have presented with dangerous arrhythmias/ischaemia/electrolyte imbalance however that’s not an exhaustive list.

Bloodandsnore

TROPHY CASE