Vasovagal reaction?

[pgg]

You start a phenylephrine infusion on most of the C sections? Really?

Yes. I squirt a bunch of phenylephrine in the IV bag (roughly 100 mcg for every 100 mL left in the bag) and let it drip wide open.

It takes about 4 seconds to do an infusion this way. No pump needed, it just works. BP is very stable, HR typically hangs out in the 70-80 range, and the patients don't puke. It's much smoother and more elegant than chasing highs and lows with boluses of phenylephrine or ephedrine.

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[fakin' the funk]

Most bupivicaine spinals for c-section, which require a high thoracic level, need a phenylephrine infusion (+/- chronotropic support) for the duration of the case.

No they don't.

I'm typically using no more than 200-300mcg phenylephrine in the first liter bag that finishes within 15-20 minutes after spinal placement. (Pts are preloaded with another liter before coming to OR). Usually they're off this cheapo infusion well before baby's out and the pit is running

 

[pgg]

It also depends on the spinal dose.

There's the 15 mg bupiv with epi "academic spinal" when residents are operating, and there's the 9-10.5 mg bupiv "fast surgeon spinal" ... the degree of hypotension varies between the two.

 

[scudrunner]

No they don't.

I'm typically using no more than 200-300mcg phenylephrine in the first liter bag that finishes within 15-20 minutes after spinal placement. (Pts are preloaded with another liter before coming to OR). Usually they're off this cheapo infusion well before baby's out and the pit is running

I'm surprised that's all you need. We titrate our infusions for MAPs > 60, and fluid is running open the whole time. I would say we typically run the the infusions for an hour or so, but it is variable. Will be interesting to see how things change in PP.

 

[Arch Guillotti]

If the hypotension and bradycardia were due to a sympathetic blockade that reached T1-T4 then this is a high spinal isn't it?

Lots of folks aim for T4 for c/s, do you consider this a high spinal?

 

[fakin' the funk]

Lots of folks aim for T4 for c/s, do you consider this a high spinal?

IMO (n < 100) it seems like T5-6 is plenty. Our OB's don't reach up into the foregut with laps and tickle the stomach/diaphragm, like they did in residency.

Routinely I am doing 1.4-1.6ml heavy bupi, 20mcg fent, 150mcg morphine. Our C/S's skin to skin usually 30-40 minutes, total anesthesia time 60 minutes. I am running fluid the whole time, neo/ephed in the first bag usually only the first 15-20 minutes.

I was very proud of my labor epidural the other day that gave a lady a Horner's syndrome

 

[deleted162650]

I was very proud of my labor epidural the other day that gave a lady a Horner's syndrome

Maybe some sub-dural action??

 

[Arch Guillotti]

IMO (n < 100) it seems like T5-6 is plenty. Our OB's don't reach up into the foregut with laps and tickle the stomach/diaphragm, like they did in residency.

Routinely I am doing 1.4-1.6ml heavy bupi, 20mcg fent, 150mcg morphine. Our C/S's skin to skin usually 30-40 minutes, total anesthesia time 60 minutes. I am running fluid the whole time, neo/ephed in the first bag usually only the first 15-20 minutes.

I was very proud of my labor epidural the other day that gave a lady a Horner's syndrome

The ones I work with pull the uterus up to the ears.

 

[pgg]

Lots of folks aim for T4 for c/s, do you consider this a high spinal?

Barash is so bold as to unequivocally state "Blockade to the T4 dermatome is necessary to perform cesarean delivery without maternal discomfort."

I guess that gentler more proficient surgeons (like fakin' the funk's) can let you get away with something a bit lower, but I still aim for T4.

 

[Planktonmd]

Maybe some sub-dural action??

Yes very likely!

 

[Planktonmd]

Lots of folks aim for T4 for c/s, do you consider this a high spinal?

The bradycardia becomes an issue once you reach above T4, actually around T1 since that means you have basically blocked all the sympathetic nerves including all the cardiac ones (T1 - T4), and that would definitely be a high spinal.
The hypotension and bradycardia in a spinal that reaches that level would require treatment for more than just a few minutes, actually until the spinal starts receding, and the sensory block would be high as well (maybe 1 or 2 dermatoms lower than the sympathetic block).

 

[Shouldawouldacouldas]

I dont think I have ever used a Neo gtt in a C-sec. I guess that might be a "smoother" approach than bolusing 25 -50 mcg at a time. However, I don't see myself adapting that approach.

Basically, if you have life threatening hypotension and bradycardia after a spinal, you better be injecting 10-100 mcg of epi before your patients code.

 

[risnwb]

IMO (n < 100) it seems like T5-6 is plenty. Our OB's don't reach up into the foregut with laps and tickle the stomach/diaphragm, like they did in residency.

Routinely I am doing 1.4-1.6ml heavy bupi, 20mcg fent, 150mcg morphine. Our C/S's skin to skin usually 30-40 minutes, total anesthesia time 60 minutes. I am running fluid the whole time, neo/ephed in the first bag usually only the first 15-20

Agree that a T6 level is adequate. I'm using 1.2 of heavy bupi, 25 much of fent (they don't have adequate monitoring for us to use morphine pf) and block is more than adequate. Also requiring much less phenylephrine than I did in residency when cases lasted longer and doses of bupi were higher. Haven't even been changing doses when it's a 2nd or 3rd section, and we are always done well before block begins to recede (no residents operating;-)