Breast / Chest pain during C-section under Spinal..

[gasp]

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I have noticed this a few times with different OBGYN attendings.. I usually use 1.8cc of hyperbaric 0.75% marcaine with 0.6cc of Duramorph for my spinals and usually achieve a nice dense T3-4 level. A few times I have noticed the pt starts complaining of left breast / chest pain usually as the surgeon has put the uterus back and is doing some cleanup. All vitals WNL and normal ECG but their pain is sometimes 10/10 and I have to give Fentanyl and nitrous to keep them from freaking out. After they are closed and the pt is fully with it, they have zero chest pain. Has anyone else had this experience or have any thoughts on how to avoid it?

 

[deleted9493]

I have noticed this a few times with different OBGYN attendings.. I usually use 1.8cc of hyperbaric 0.75% marcaine with 0.6cc of Duramorph for my spinals and usually achieve a nice dense T3-4 level. A few times I have noticed the pt starts complaining of left breast / chest pain usually as the surgeon has put the uterus back and is doing some cleanup. All vitals WNL and normal ECG but their pain is sometimes 10/10 and I have to give Fentanyl and nitrous to keep them from freaking out. After they are closed and the pt is fully with it, they have zero chest pain. Has anyone else had this experience or have any thoughts on how to avoid it?

Yeah, definitely seen this too with externalization of the uterus. Air embolism with chest tightness and shortness of breath is well-described in the literature. There does seem to be a component of visceral discomfort in this population, as well...as opposed to those who have uterine repair without externalization.

 

[Idiopathic]

yes, your block isnt as dense as you think it is, especially up high. some lower thoracic sparing goes a long way toward causing pain especially at the end of the case. i feel its very hit or miss as far as pain during/after externalization of the uterus and dont really have a good way to prevent it except for having a great/dense block at the beginning and hoping it lasts long enough

 

[IlDestriero]

20mcg fentanyl in your spinal should produce a denser block.
I use 1.6cc bup, 150mcg morphine, 20mcg fent and 100mcg Epi. Works great. 1.8 cc if it's a repeat with a slower surgeon. 2.0cc if she's 6' amazon woman.

 

[pgg]

I have noticed this a few times with different OBGYN attendings.. I usually use 1.8cc of hyperbaric 0.75% marcaine with 0.6cc of Duramorph for my spinals and usually achieve a nice dense T3-4 level

.6 cc Duramorph = what? .3 mg or .6 mg? .6 is a lot, and .3 might be more than you need. Regardless, because of its slower onset, you're not getting much out of the morphine until after the surgery is done, anyway.

Adding some fentanyl will help.

I use 1.2 mL of the .75% hyperbaric bupivacaine + 15 mcg fentanyl + .2 mg morphine. If slow surgeons or a resident is operating, I'd use more bupiv.

 

[drmwvr]

You'll notice that primarily when the assistant exerts sustained caudad traction on the bladder blade.

 

[BLADEMDA]

.6 cc Duramorph = what? .3 mg or .6 mg? .6 is a lot, and .3 might be more than you need. Regardless, because of its slower onset, you're not getting much out of the morphine until after the surgery is done, anyway.

Adding some fentanyl will help.

I use 1.2 mL of the .75% hyperbaric bupivacaine + 15 mcg fentanyl + .2 mg morphine. If slow surgeons or a resident is operating, I'd use more bupiv.

I agree 100% except for slow surgeons or residents I add 0.1 mg Epi to your mixture which prolongs the block by about 30 minutes.

 

[norwood]

.6 cc Duramorph = what? .3 mg or .6 mg? .6 is a lot, and .3 might be more than you need.

Yep, was going to comment on this. For the residents, Duramorph comes in both 0.5mg/cc and 1mg/cc strengths, in identical-looking 10cc vials. One contains 5mg, the other 10mg. IMHO the factory should distinguish them in some way other than simply the number on the vial...

 

[gasp]

.6 cc Duramorph = what? .3 mg or .6 mg? .6 is a lot, and .3 might be more than you need. Regardless, because of its slower onset, you're not getting much out of the morphine until after the surgery is done, anyway.

Adding some fentanyl will help.

I use 1.2 mL of the .75% hyperbaric bupivacaine + 15 mcg fentanyl + .2 mg morphine. If slow surgeons or a resident is operating, I'd use more bupiv.

I'm using 0.3mg which is 0.6cc for our vials..

 

[BLADEMDA]

I'm using 0.3mg which is 0.6cc for our vials..

On what basis are you choosing 300 ug of duramorph? Any data? The published data supports 100 ug-250 ug with many of using 150 ug-250 ug.

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=856134

I do add Fentanyl 15 ug to the spinal these days for about 1/4 my patients. The Fentanyl makes the block a bit denser and prolongs the duration. So, the slower OB docs get the Fentanyl for certain and the real slow ones get 0.1 mg Epi as well.

In recent use of duramorph ( over the past 2 years) for C sections I have reduced the dosage to the 150 ug-175 ug with excellent results. While not scientific my anecdotal evidence at my practice seems to support 175 ug as the sweet spot. I tried 100ug and 125 ug but too many complaints of pain. Duramorph 150 ug-175 ug seemed to generate the least amount of complaints all around.

The Mercedes-Benz of postop pain relief would be an SAB with 100 ug of Duramorph followed by Bilateral Tap blocks with Exparel in the PACU.


http://onlinelibrary.wiley.com/doi/10.1111/jog.12074/abstract

http://www.ncbi.nlm.nih.gov/pubmed/22591488

 

[Planktonmd]

Give some Propofol...

 

[gasp]

On what basis are you choosing 300 ug of duramorph? Any data? The published data supports 100 ug-250 ug with many of using 150 ug-250 ug.

Not based on any data. I'm new at this institution so I'm following what these guys have been doing for a long time. I actually never used Duramorph at all (only Fentanyl) but it seems like everyone flips out here when they hear the pt didn't get any Duramorph.. Will try decreasing the Duramorph and adding some Fent. Thanks.

 

[IlDestriero]

There was an article that came out in 2003 or 4 comparing duramorph doses with pain control vs side effects.
100 or 150 seemed to be the sweet spot. I don't remember anymore. 300 works great but at the expense of N/V and pruritis.
I use 150mcg.

 

[BLADEMDA]

There was an article that came out in 2003 or 4 comparing duramorph doses with pain control vs side effects.
100 or 150 seemed to be the sweet spot. I don't remember anymore. 300 works great but at the expense of N/V and pruritis.
I use 150mcg.

The article recommended 100 ug of duramorph. I've tried that dosage and it didn't cut the mustard at my hospital. When I went to 150 ug-175 ug the complaints were low (itching, N/V, etc ) and the satisfaction fairly high. I strongly recommend the 150 ug-200 ug range for private practice.
A lot depends on your patient population so for me that means the higher end of the range (175 ug).

If you don't want to try different doses then stick with 200 ug of duramorph via SAB.

 

[pgg]

The article recommended 100 ug of duramorph. I've tried that dosage and it didn't cut the mustard at my hospital. When I went to 150 ug-175 ug the complaints were low (itching, N/V, etc ) and the satisfaction fairly high. I strongly recommend the 150 ug-200 ug range for private practice.
A lot depends on your patient population so for me that means the higher end of the range (175 ug).

If you don't want to try different doses then stick with 200 ug of duramorph via SAB.

I totally agree. This is what I did my MOCA practice improvement on ... I posted my data a while ago:

http://forums.studentdoctor.net/showthread.php?t=901829

I used 1.6 mL of 0.75% bupiv at that time, but these days I am blessed with some fast OBs and I can get away with less bupivacaine.

 

[periopdoc]

I agree with this being thoracic dermatomal sparing. 0.1 of Pi seems to be the best option for it although I wouldn't argue against a little Fentanyl for this problem.

- pod

 

[deleted162650]

So this is something I saw rarely as a resident, a whole lot as a resident rotating at the local women's hospital (PP staffed), and again not to often now as an attending. I think dosing is a big factor as previously mentioned. At the women's center guys were using 1.2mL bupi w/ 20mcg fent + duramorph compared to 1.6mL w/ the same narcotic in residency and now as well. I also saw a lot more nausea intra-op with reduced bupi dosing.

However, I have noticed that the chest pain is also very surgeon dependent and almost always at the time of vigorous uterine massage which makes me think there is something to embolic (air v. whatever else they are squeezing out of the uterus) theory

 

[Idiopathic]

So this is something I saw rarely as a resident, a whole lot as a resident rotating at the local women's hospital (PP staffed), and again not to often now as an attending. I think dosing is a big factor as previously mentioned. At the women's center guys were using 1.2mL bupi w/ 20mcg fent + duramorph compared to 1.6mL w/ the same narcotic in residency and now as well. I also saw a lot more nausea intra-op with reduced bupi dosing.

However, I have noticed that the chest pain is also very surgeon dependent and almost always at the time of vigorous uterine massage which makes me think there is something to embolic (air v. whatever else they are squeezing out of the uterus) theory

i agree with you, although i dont think i would use <10mg bupiv for a cesarean...there is just no reason to cut it that close. you dont spare hypotension and you dont spare any postop problems. why not just give 12.5 or even 15 and get a dense block? i give 12.5-13mg routinely with fentanyl and duramorph and still see this from time to time...agree with your assessment of surgical technique

 

[deleted162650]

Ya the 1.2mL bupi just wasn't quite enough from what I saw, but this was at a very busy women's hospital and they wanted pts out of PACU as fast as possible. They liked to see pts moving legs as soon as they dropped em off. I've been very happy with 1.6mL's as my standard dose with fent and morph as mentioned above.

 

[Arch Guillotti]

If you have really fast surgeons try a lidocaine spinal for c/s.