Bicitra for elective c-sxn

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From the ASA Practice guidelines on Obstetric Anesthesia:

"...The consultants and ASA members agree that the administration of a nonparticulate antacid before operative procedures reduces maternal complications"
 
okayplayer said:
Do you guys routinely give Bicitra for elective c-sxns prior to spinal?
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Yes.

And I'm occasionally amazed at the volume of vomit some pregnant ladies that have been NPO for 12 hours for an elective c-section can puke up during the case. For those ladies I'm sure the 1 oz of bicitra is like pissing in the wind, but if they aspirate during the case I'll be damn glad I gave it.
 
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I've seen so many yack that crap up the moment they swallow it. Tastes quite awful.

I gave it since they're all full bellies. Quite frankly, for a elective c/s via spinal, I don't understand the need for it. Airway reflexes are intact and they are awake, they aren't going to aspirate.

If this was a GA or urgent/emergent case - then I would totally use it without questions.
 
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Doctor4Life1769 said:
I've seen so many yack that crap up the moment they swallow it. Tastes quite awful.

I gave it since they're all full bellies. Quite frankly, for a elective c/s via spinal, I don't understand the need for it. Airway reflexes are intact and they are awake, they aren't going to aspirate.

If this was a GA or urgent/emergent case - then I would totally use it without questions.
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I am always happy when I see them vomit. Less crap in the stomach.
 
dr doze said:
I am always happy when I see them vomit. Less crap in the stomach.
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The spinal will take care of that most times. Although, I rarely had them vomit as I would give zofran preop. Keep BP stable and I would only have to give a few squirts (if any) of phenylephrine.

Again, I don't understand why it matters if the patient is awake with intact airway reflexes.
 
Well, when your spinal fails even though it looks perfect before they started or the kid takes a terminal dump when you sit her up and start the prep, it's an emergent general. That's when the bicitra comes in handy. I've seen both in my career.
I've also seen an amnionic fluid embolism and uncontrolled bleeding with a young patient where a hysterectomy was very very undesirable. They also bought a snorkel.
 
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I am really surprised that people would choose not to do such a low risk intervention that is specifically endorsed by the practice guidelines.
 
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Doctor4Life1769 said:
I've seen so many yack that crap up the moment they swallow it. Tastes quite awful.

I gave it since they're all full bellies. Quite frankly, for a elective c/s via spinal, I don't understand the need for it. Airway reflexes are intact and they are awake, they aren't going to aspirate.

If this was a GA or urgent/emergent case - then I would totally use it without questions.
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If you have no chance of a high spinal and no chance of converting to GA during a c-section, then you obviously don't need to give bicitra. In my experience, the chances of either scenario are > 0. In those situations, I'm quite glad I gave bicitra ahead of time because you can't give it during the case.

Besides, the taste isn't that bad. I actually like it.
 
I give it to all my c-sections. I have had to convert a spinal to general anesthetic a couple of times in my short career and was very glad we gave bicitra preop. Incidentally I have found that the patients who drink the bicitra without making a disgusted face often have much happier husbands and lower incidence of pre-eclamspia(wasnt their a study on this).
 
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Mman said:
If you have no chance of a high spinal and no chance of converting to GA during a c-section, then you obviously don't need to give bicitra. In my experience, the chances of either scenario are > 0. In those situations, I'm quite glad I gave bicitra ahead of time because you can't give it during the case.

Besides, the taste isn't that bad. I actually like it.
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The only time I have ever had a high spinal in my relatively short career was following the hat-trick per my attending's recommendations as a CA-1
dose up a patchy epidural (and yes, I did tell said attending it was patchy, I didn't trust it) ---> spinal with low dose ----> high spinal ----> RSI GETA --- luckily the pt was tiny with a super easy airway.

For the pros -- what was the likelihood of you converting from spinal to GA during an elective case vs. an urgent case? If it's urgent/emergent, I would always give. If it's elective, I gave as required by my attendings, but if I were out in practice I probably would not unless the patient could be a potential difficult airway if I could not get the spinal or had a failed spinal.
 
Doctor4Life1769 said:
The only time I have ever had a high spinal in my relatively short career was following the hat-trick per my attending's recommendations as a CA-1
dose up a patchy epidural (and yes, I did tell said attending it was patchy, I didn't trust it) ---> spinal with low dose ----> high spinal ----> RSI GETA --- luckily the pt was tiny with a super easy airway.
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This has been discussed here before extensively and I had the same thing happen to me as a resident.
 
narcusprince said:
I give it to all my c-sections. I have had to convert a spinal to general anesthetic a couple of times in my short career and was very glad we gave bicitra preop. Incidentally I have found that the patients who drink the bicitra without making a disgusted face often have much happier husbands and lower incidence of pre-eclamspia(wasnt their a study on this).
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Heh, there have been a few studies. To my knowledge, no randomized prospective controlled trials however. That'd be a shoo-in for an IgNobel.
 
5000+ C/S a year in our practice and every one gets Bicitra.
 
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A while ago I noticed that the patients who receive Bicitra are the only ones who actually vomit, so I stopped giving it routinely to C sections for more than 7 years now with no regrets.
 
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Thats why we stopped, more vomiting with bicitra than without it. I see this debate kind of like ETT vs LMA , or RSI with sux for everyone vs Normal induction. If I thought the incidence was of aspiration was so high in my practice then every csection patient would get it. Kind of like if I thought the risk of aspiration and untoward events under general with LMA was so high I would just put ETT in everyone.

High spinals, converstaions to GA after spinal are so rare in my practice that I dont see the need to make patients want to vomit.
 
seinfeld said:
High spinals, converstaions to GA after spinal are so rare in my practice that I dont see the need to make patients want to vomit.
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So none of your patients vomit during a c-section?
 
My experience lately, as a Bicitra nonbeliever, is that nausea is common, but actual vomiting not common. I know that if incision hasn't been made that I need to give them some purple syringe because they dropped their pressure, otherwise it's traction/vagal and it'll pass (maybe, give Benadryl or atropine or whatever). Everyone gets Zofran.
 
seinfeld said:
Thats why we stopped, more vomiting with bicitra than without it.
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That doesn't match up with my experience. To be honest, I don't think I've ever seen a patient vomit from the Bicitra. From spinals (hypotension)? Sure. Uterus getting dragged out and aired out on her belly? Sure. And lots of women are drama queens who make faces, but honestly the stuff isn't that bad. I'm all for being sensitive to patient comfort and not needlessly inflicting discomfort or indignities on them, but singling out Bicitra as so offensive that ignoring the ASA guideline to give it just seems a little odd to me.

Granted, a guideline is not a standard.



Also, there's a lot of discussion of irrelevancies here.

The point of giving Bicitra has absolutely nothing to do with nausea or vomiting. Counting how many patients puke or don't puke after a spinal, or how good we are at preventing that with purple syringes or Zofran, isn't relevant. That tree isn't even in this forest.

The point of the Bicitra is to raise the pH of gastric contents in case conversion to GA is necessary, in order to reduce the severity of the aspiration pneumonitis that can occur following induction of general anesthesia, passive regurgitation, and aspiration of stomach acid. The patients Bicitra is intended to protect aren't nauseous because they're unconscious, and they're not vomiting because they're unconscious.


I gave it routinely to everyone in residency. For a long while afterwards, I didn't, figuring the NNT might be a million or a billion. I'm not doing any OB these days but I will again soon. I'll probably go back to giving it unless or until the ASA guideline changes.
 
pgg said:
That doesn't match up with my experience. To be honest, I don't think I've ever seen a patient vomit from the Bicitra. From spinals (hypotension)? Sure. Uterus getting dragged out and aired out on her belly? Sure. And lots of women are drama queens who make faces, but honestly the stuff isn't that bad. I'm all for being sensitive to patient comfort and not needlessly inflicting discomfort or indignities on them, but singling out Bicitra as so offensive that ignoring the ASA guideline to give it just seems a little odd to me.

Granted, a guideline is not a standard.



Also, there's a lot of discussion of irrelevancies here.

The point of giving Bicitra has absolutely nothing to do with nausea or vomiting. Counting how many patients puke or don't puke after a spinal, or how good we are at preventing that with purple syringes or Zofran, isn't relevant. That tree isn't even in this forest.

The point of the Bicitra is to raise the pH of gastric contents in case conversion to GA is necessary, in order to reduce the severity of the aspiration pneumonitis that can occur following induction of general anesthesia, passive regurgitation, and aspiration of stomach acid. The patients Bicitra is intended to protect aren't nauseous because they're unconscious, and they're not vomiting because they're unconscious.


I gave it routinely to everyone in residency. For a long while afterwards, I didn't, figuring the NNT might be a million or a billion. I'm not doing any OB these days but I will again soon. I'll probably go back to giving it unless or until the ASA guideline changes.
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It makes people vomit!
And the ASA and its guidelines are full of crap half the time!
 
I was addressing the point Mman was asking with regard to seinfeld's statement that vomiting during C-section increases if you give Bicitra. My experience is that it does.

To your point, do keep in mind that the level of evidence to support routine administration of Bicitra to all partruients is pretty weak. Obviously it has an effect on gastric pH- it's a buffer. We know sufficiently acidic pH liquid in sufficient quantity in the lungs is bad. But just like routine use of the Sellick maneuver (which, incidentally, was described in conjunction with head down positioning), nobody has ever proven it actually makes a difference in the incidence of severe/fatal aspiration pneumonitis. Especially in the flat position we use today. And in any case the very thing that's more likely to cause gastric contents to be expelled during a RSI intubation is inadequate paralysis and depth of anesthesia and thus active vomiting with laryngoscopy, I don't think concerns about routine administration of a med that causes upset stomach in this setting are unwarranted. The clinical situation is multifactorial and to say that one study in rats is the only thing that matters in this situation is a little simplistic.
 
So... people decided to give the disgusting Bicitra to all parturients getting a c section in anticipation of the feared conversion to GA.
Because if you convert to GA it is so scary... it is so bad... and they will all aspirate!
That's the stupid dogma they teach residents!
Be afraid of GA in pregnant women ... be very afraid...
They have swollen soft tissue... big boobs... decreased FRC... increased oxygen consumption... they are so scary and they will all die if you don't follow the holy ASA dogmatic guidelines.
The only way to save their lives and your ass is by giving them Bicitra...
Not only they will die but the holy ASA experts who invented this crap will come to testify against you if you don't follow their teachings.
That's basically what we are discussing here.
 
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I've never seen a woman vomit from Bicitra that wasn't also hypotensive from a spinal at the same time. I've had to convert to GA during several c-sections over the years. Am I afraid of GA? Of course not. I'd prefer to avoid it for the sake of the baby if possible as well as small decreased morbidity to the mother but it's not that big of a deal. Will bicitra make the mom have a warm fuzzy outcome if she aspirates 2L of gastric contents? Uhh, no. But the lawyer on the other team will have no shortage of witnesses that have textbooks on OB anesthesia lined up to testify against you and you'll be hard pressed to find much support on your side from a legal perspective other than somebody saying that the guidelines really don't matter and the textbook answer isn't important.

Bicitra causes no real harm. It can provide a small actual benefit. To me that's the end of the story. Plus I like the taste so it isn't that bad.
 
Planktonmd said:
It makes people vomit!
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No it doesn't. Again I don't believe I've ever seen any woman yak after drinking the Bicitra. The drama queens screw up their noses and gripe, but I've never seen one puke it up after drinking it.

It's not a shot of $6/gallon tequila.

Maybe there are drama queen anesthesiologists out there telling their patients "this stuff is SOOOO awful it's gonna make you puke!" :)


Planktonmd said:
And the ASA and its guidelines are full of crap half the time!
Click to expand...

I agree, guidelines aren't standards, and the evidence isn't always compelling. In the case of Bicitra, the ASA guideline (ie "the consultants and ASA members agree") is just expert opinion, the weakest possible category of evidence.

It sounds like most of your entire argument comes down to: I don't have to do what those stupid ivory tower busybodies say I should do, because out here in the private practice real world, I know how things really are.

So what are you really objecting to, specifically?

The high NNT, cost, time, being nice and not asking patients to drink something that tastes sorta funny ... or are you really sticking to the claim that it induces vomiting ipecac-style?

If you had a pregnant patient come in, and she needed a c-section, and for whatever reason she refused a spinal, would you give her Bicitra? Why or why not?
 
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I'm with pgg on this, even if the Bicitra increases nausea that doesn't necessarily imply an increased risk of aspiration when inducing GA.

In residency I had an elective C section, with a God awful new attending who breathed down my shoulder as I placed the spinal which ultimately failed as we made incision. Emergent conversion to GA.

Prop + Sux given ->> before I put the blade in, the ladys mouth filled up with green juice. After aggressive suctioning, I quickly got the ETT in (while actively seeing said green juice dripping out of the trachea as the tube went in). I commenced to freak out but my attending calmly replied "simmer down we gave bicitra before the spinal"

Patient didnt desat much and after aggressive suctioning through the tube before emergence, we extubated at the end of the case. Mom coughed a lot but did fine.

I think the risk of facing a tragic outcome with a new mom in the ICU with ARDS from aspiration PNA, though a tiny risk is worth the increased risk of N/V.

Anyone know of evidence that Bicitra actually improves outcomes when patient aspirates? Does it increase aspiration risk? Hmm
 
pgg said:
No it doesn't. Again I don't believe I've ever seen any woman yak after drinking the Bicitra. The drama queens screw up their noses and gripe, but I've never seen one puke it up after drinking it.

It's not a shot of $6/gallon tequila.

Maybe there are drama queen anesthesiologists out there telling their patients "this stuff is SOOOO awful it's gonna make you puke!" :)




I agree, guidelines aren't standards, and the evidence isn't always compelling. In the case of Bicitra, the ASA guideline (ie "the consultants and ASA members agree") is just expert opinion, the weakest possible category of evidence.

It sounds like most of your entire argument comes down to: I don't have to do what those stupid ivory tower busybodies say I should do, because out here in the private practice real world, I know how things really are.

So what are you really objecting to, specifically?

The high NNT, cost, time, being nice and not asking patients to drink something that tastes sorta funny ... or are you really sticking to the claim that it induces vomiting ipecac-style?

If you had a pregnant patient come in, and she needed a c-section, and for whatever reason she refused a spinal, would you give her Bicitra? Why or why not?
Click to expand...
I am objecting based on my personal observation during the past 14 years... this medication makes people vomit and it serves no purpose!
 
pgg said:
No it doesn't. Again I don't believe I've ever seen any woman yak after drinking the Bicitra. The drama queens screw up their noses and gripe, but I've never seen one puke it up after drinking it.

It's not a shot of $6/gallon tequila.

Maybe there are drama queen anesthesiologists out there telling their patients "this stuff is SOOOO awful it's gonna make you puke!" :)




I agree, guidelines aren't standards, and the evidence isn't always compelling. In the case of Bicitra, the ASA guideline (ie "the consultants and ASA members agree") is just expert opinion, the weakest possible category of evidence.

It sounds like most of your entire argument comes down to: I don't have to do what those stupid ivory tower busybodies say I should do, because out here in the private practice real world, I know how things really are.

So what are you really objecting to, specifically?

The high NNT, cost, time, being nice and not asking patients to drink something that tastes sorta funny ... or are you really sticking to the claim that it induces vomiting ipecac-style?

If you had a pregnant patient come in, and she needed a c-section, and for whatever reason she refused a spinal, would you give her Bicitra? Why or why not?
Click to expand...
You didn't call me a drama queen... did you?
 
Colba55o said:
I'm with pgg on this, even if the Bicitra increases nausea that doesn't necessarily imply an increased risk of aspiration when inducing GA.

In residency I had an elective C section, with a God awful new attending who breathed down my shoulder as I placed the spinal which ultimately failed as we made incision. Emergent conversion to GA.

Prop + Sux given ->> before I put the blade in, the ladys mouth filled up with green juice. After aggressive suctioning, I quickly got the ETT in (while actively seeing said green juice dripping out of the trachea as the tube went in). I commenced to freak out but my attending calmly replied "simmer down we gave bicitra before the spinal"

Patient didnt desat much and after aggressive suctioning through the tube before emergence, we extubated at the end of the case. Mom coughed a lot but did fine.

I think the risk of facing a tragic outcome with a new mom in the ICU with ARDS from aspiration PNA, though a tiny risk is worth the increased risk of N/V.

Anyone know of evidence that Bicitra actually improves outcomes when patient aspirates? Does it increase aspiration risk? Hmm
Click to expand...
I don't give Bicitra to anyone because I am not convinced it serves any purpose... remember this statement because I can assure you in a couple of years some guy who wants to achieve academic glory will publish a study showing that Bicitra is actually Voodoo!
 
Colba55o said:
Anyone know of evidence that Bicitra actually improves outcomes when patient aspirates? Does it increase aspiration risk? Hmm
Click to expand...

Multiple animal studies show increase survival after aspiration when non particulate antacid given in quantity to increase pH to above 2.5.
 
pgg said:
:) Just messing with you.

So, is there no circumstance in which you'd ever give anyone Bicitra?

edit - Just saw your last post in which you said you wouldn't - fair enough.
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I actually give it maybe once a month when I get a patient who takes antacids or PPI's but forgot to take them the day of surgery.
 
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We stopped giving it 4 years ago. I don't see N/V nearly as much.
 
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Planktonmd said:
It makes people vomit!
And the ASA and its guidelines are full of crap half the time!
Click to expand...
I wanna see if you'd said it in court. Dear jury, ASA is crap, I know better.
 
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Nurses give it. I don't. However, if I catch it in time I will stop them from giving it.

Btw, I like the taste. Somewhat.
 
:clap:
narcusprince said:
I give it to all my c-sections. I have had to convert a spinal to general anesthetic a couple of times in my short career and was very glad we gave bicitra preop. Incidentally I have found that the patients who drink the bicitra without making a disgusted face often have much happier husbands and lower incidence of pre-eclamspia(wasnt their a study on this).
Click to expand...
 
Planktonmd said:
I thought that as a consultant in this field you should be entitled to use your clinical judgement and do what you feel is better for your patient...
Apparently I was wrong!
Click to expand...

You can do whatever you want. If something bad happens the plaintiffs attorney is free to use whatever evidence they want. Juries tend to like things like practice guidelines.
 
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