C/S #7

[caligas]

No other issues, for 7th C/S.

Epidural?

CSE?

tetracaine spinal?

Isobaric bupiv with Epi? (Especially interested in folks that have done this for long c/s)

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[NoodleIncident]

I think a tetracaine SAB would be too aggressive. What if there are few adhesions and you’re in and out of the OR in under an hour? I would just do a CSE.

 

[facted]

I think a tetracaine SAB would be too aggressive. What if there are few adhesions and you’re in and out of the OR in under an hour? I would just do a CSE.

True, though I've never met someone who regretted the spinal lasted too long. But I doubt time would be the issue. More worried about damage to other organs, possibility of accreta or worse. But I would also do a CSE (1.6 0.75% and 100mcg epi).

 

[NoodleIncident]

A spinal lasting too long at the facilities I work mean that L&D loses a nurse for X number of additional hours, elective cases to follow may get backed up, and the patient may have to wait that much longer before getting to see her baby. For these reasons, I lean much more toward a CSE than tetracaine.

 

[Psai]

A spinal lasting too long at the facilities I work mean that L&D loses a nurse for X number of additional hours, elective cases to follow may get backed up, and the patient may have to wait that much longer before getting to see her baby. For these reasons, I lean much more toward a CSE than tetracaine.

Its number 7

 

[caligas]

So no thoughts on isobaric with Epi?

 

[facted]

So no thoughts on isobaric with Epi?

Never done it for OB though, though I'm sure it could be done. If you used something like 3ml 0.5% bupi, you don't need epi. That's a solid 4 hours, and I've seen up to 5+ in the elderly with slower clearance. I still would use hyperbaric / epi and CSE though.

 

[AdmiralChz]

So no thoughts on isobaric with Epi?

Won’t last long enough, might be ok for number 2 or 3 but definitely not 7. Adding clonidine might help squeak out a little more time but probably not enough. Plus the increasing risk of accreta necessitating a hysterectomy...

What are your thoughts on using a single shot only for this? You seem very interested to try it.

 

[caligas]

Won’t last long enough, might be ok for number 2 or 3 but definitely not 7. Adding clonidine might help squeak out a little more time but probably not enough. Plus the increasing risk of accreta necessitating a hysterectomy...

What are your thoughts on using a single shot only for this? You seem very interested to try it.

Nah, I agree I need the catheter.

 

[acidbase1]

Hey do you guys prophylactically give patient TXA on high risk PPH pts such as this one? We did in residency, but the PP OBs are reluctant to do so

 

[Twiggidy]

A spinal lasting too long at the facilities I work mean that L&D loses a nurse for X number of additional hours, elective cases to follow may get backed up, and the patient may have to wait that much longer before getting to see her baby. For these reasons, I lean much more toward a CSE than tetracaine.

sounds like a bunch of “not my problem” and i cant think of a reason why a lady with some residual spinal not being able to hold her baby other than good pain relief

 

[facted]

Hey do you guys prophylactically give patient TXA on high risk PPH pts such as this one? We did in residency, but the PP OBs are reluctant to do so

Definitely. Plenty of literature to support this, even in OB patients.

 

[acidbase1]

Definitely. Plenty of literature to support this, even in OB patients.

Have one in mind you refer to? I’d like to present it to them

 

[IlDestriero]

This was just in a journal in the last month or 2. I just saw it.


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Il Destriero

 

[acidbase1]

This was just in a journal in the last month or 2. I just saw it.


--
Il Destriero

I’ll do a lit search, thx buddy

 

[Southpaw]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext

Highlighted in current issue of APSF newsletter

 

[Scotty_G]

I have done isobaric bup a few times for c-section. It can be done w/o problems. How big is the patient? This is in pp right?

 

[caligas]

I have done isobaric bup a few times for c-section. It can be done w/o problems. How big is the patient? This is in pp right?

Not super big. PP yes.

Did CSE. Actually pretty short case, didn’t need the catheter ultimately.

I will say with CSE and a full C/S dose, you have to be pretty fast with threading the cath and slapping on the tegaderm.

I suppose it’s nice she wasn’t numb for 3 hours after the case.

 

[deleted59964]

i’ve never done isobaric for a section, do you reliably get a high enough block? T5 is a long way from where you put it

 

[caligas]

i’ve never done isobaric for a section, do you reliably get a high enough block? T5 is a long way from where you put it

Haven’t tried but:

Spinal anesthesia for cesarean section: comparative study between isobaric and hyperbaric bupivacaine associated to morphine. - PubMed - NCBI

 

[deleted697535]

Not super big. PP yes.

Did CSE. Actually pretty short case, didn’t need the catheter ultimately.

I will say with CSE and a full C/S dose, you have to be pretty fast with threading the cath and slapping on the tegaderm.

I suppose it’s nice she wasn’t numb for 3 hours after the case.

Some of the guys here do full Epidural first (bar the tape), then 2 levels down and do the spinal.

 

[deleted697535]

Haven’t tried but:

Spinal anesthesia for cesarean section: comparative study between isobaric and hyperbaric bupivacaine associated to morphine. - PubMed - NCBI

Interesting
1 - all done in left lateral. Very important i think!
2 - Spinal injection was 1ml every 15 seconds!!! What?
3 - Pity they didnt include time for return of pin prick below T5/6. Isobaric should last about 30 mins longer right?

 

[caligas]

Some of the guys here do full Epidural first (bar the tape), then 2 levels down and do the spinal.

Interesting but too complicated. The more I think about it the more I like (for these situations) just doing an epidural and firing in 20 cc of 2% lido. Dense block before the chloroprep is dry.

 

[NoodleIncident]

Interesting but too complicated. The more I think about it the more I like (for these situations) just doing an epidural and firing in 20 cc of 2% lido. Dense block before the chloroprep is dry.

Outside of a stat section on a patient with an epidural catheter in situ, I would be hesitant to do this. With an epidural you just placed in the OR, you may have a delayed positive test dose for an intrathecal cath and that 20ml of 2% can be devastating. Assuming that the epidural is in place, 20ml given in the 6-7 minutes between when you lay them down and when the Chloraprep is dry may lead to a slowly creeping high epidural. If your level is perfect, it still won’t be as dense of a block as a spinal.

 

[deleted697535]

Interesting but too complicated. The more I think about it the more I like (for these situations) just doing an epidural and firing in 20 cc of 2% lido. Dense block before the chloroprep is dry.

They used do that here too but abandoned it (not exactly sure why). Ob at my place are witheringly slow. 2 hour sections are common.

I would like to try the iso bupiv. It should last longer right?

0.5 vs 0.75 shouldn't have much affect should it? As long as the mg are the same and your not giving some crazy large volume or barbotage

 

[Noyac]

Not sure if anyone has said this yet, but the last thing I want to do is babysit an OB pt for more than two hours while the surgeons struggle to do a c/s.
I would place my usual spinal and convert to GETA if they needed more time assuming the airway is manageable.

 

[deleted59964]

Not sure if anyone has said this yet, but the last thing I want to do is babysit an OB pt for more than two hours while the surgeons struggle to do a c/s.
I would place my usual spinal and convert to GETA if they needed more time assuming the airway is manageable.

agree GA highly under rated, especially once baby’s out

 

[jwk]

Interesting but too complicated. The more I think about it the more I like (for these situations) just doing an epidural and firing in 20 cc of 2% lido. Dense block before the chloroprep is dry.

Ditto - 1st or 7th C/S - doesn't matter for us. All ours get post-op epidural pain pumps. Obviously the concern for accreta is higher (although this should already be known ahead of time) as well as the likely longer surgery time.

 

[deleted162650]

Take a look at the record from C/S #6. How long did it take? I wouldn't expect much different out of C/S #7. Maybe factor in a couple more minutes for the "accidental" BTL.

 

[Arch Guillotti]

With an epidural you just placed in the OR, you may have a delayed positive test dose for an intrathecal cath and that 20ml of 2% can be devastating.

What kind of delay are you referring to?

If a test dose for spinal block is done properly you should recognize it fairly quickly, whatever you use.

jwk has said in the past that his place does a crapload of c/s and they all get an epidural that is dosed up in the OR. It sounds sort of dumb to me to do an epidural for a normal c/s instead of a spinal but I don't think his place has an overabundance of unrecognized intrathecal catheters causing high spinals.

 

[Arch Guillotti]

I will say with CSE and a full C/S dose, you have to be pretty fast with threading the cath and slapping on the tegaderm.

And hoping that the catheter doesn't go in a vein.

 

[NoodleIncident]

What kind of delay are you referring to?

If a test dose for spinal block is done properly you should recognize it fairly quickly, whatever you use.

I’ve seen those test doses where the patient has some numbness in the feet a minute after a 3ml 1.5% Lido with Epi test dose. It’s not convincing and their vitals are fine. Then you lay them down, skip the loading dose because of the equivocal test dose, start the pump, and 10 minutes later they are numb up to their nipples and can’t move their legs. I can’t explain why this happens, but it can. A colleague of mine had as two instances of this happening to the point that they had to mask ventilate. I’d like to attribute it to just impatience on their part had I not see a positive test dose take a long time to declare itself.

 

[Planktonmd]

I am not sure why this C section is supposed to be longer than other C sections.
Why do you need to do anything different for C section # 7?

 

[anbuitachi]

I am not sure why this C section is supposed to be longer than other C sections.
Why do you need to do anything different for C section # 7?

usually a lot of adhesions that they have to clear. it's not like a untouched belly with uterus easily accessible. and like above posters mentioned, more likely of cretas

 

[Arch Guillotti]

I’ve seen those test doses where the patient has some numbness in the feet a minute after a 3ml 1.5% Lido with Epi test dose. It’s not convincing and their vitals are fine. Then you lay them down, skip the loading dose because of the equivocal test dose, start the pump, and 10 minutes later they are numb up to their nipples and can’t move their legs. I can’t explain why this happens, but it can. A colleague of mine had as two instances of this happening to the point that they had to mask ventilate. I’d like to attribute it to just impatience on their part had I not see a positive test dose take a long time to declare itself.

Did they aspirate for spinal fluid?

 

[Ronin786]

Why does isobaric last longer than hyperbaric? Is it the fact that you can't prevent it from heading down after injection?

 

[anbuitachi]

Why does isobaric last longer than hyperbaric? Is it the fact that you can't prevent it from heading down after injection?

I think the main reason is they are giving 3ml of .5% instead of 1.5ml of 0.75%. basically you are giving more

 

[caligas]

And hoping that the catheter doesn't go in a vein.

Good point, that’s a problem

 

[Twiggidy]

What kind of delay are you referring to?

If a test dose for spinal block is done properly you should recognize it fairly quickly, whatever you use.

jwk has said in the past that his place does a crapload of c/s and they all get an epidural that is dosed up in the OR. It sounds sort of dumb to me to do an epidural for a normal c/s instead of a spinal but I don't think his place has an overabundance of unrecognized intrathecal catheters causing high spinals.

i trained at a place where one of the hospitals the director didn't allow C/S under spinal. his reasoning was he didn't want ANY spinal headaches. at our city hospital is where we got our spinal experience for C/S

don't kill the messenger

 

[anbuitachi]

i trained at a place where one of the hospitals the director didn't allow C/S under spinal. his reasoning was he didn't want ANY spinal headaches. at our city hospital is where we got our spinal experience for C/S

don't kill the messenger

Was the director an anesthesiologist ..? Director of what?

 

[Planktonmd]

usually a lot of adhesions that they have to clear. it's not like a untouched belly with uterus easily accessible. and like above posters mentioned, more likely of cretas

The pregnant uterus at term should not be difficult to access regardless of how many C sections she had. The real risk here is uterus atony and excessive bleeding but that should not make a c section last more than 2-3 hours even if a hysterectomy is needed, and a simple Bupivacaine spinal should cover that.

 

[Noyac]

i trained at a place where one of the hospitals the director didn't allow C/S under spinal. his reasoning was he didn't want ANY spinal headaches. at our city hospital is where we got our spinal experience for C/S

don't kill the messenger

That makes no sense whatsoever.
The greatest risk of PDPH in the OB population is from a wet tap with an epidural needle. This director just increased the risk of headache but not knowing the actual risks of the care provided.

 

[facted]

The pregnant uterus at term should not be difficult to access regardless of how many C sections she had. The real risk here is uterus atony and excessive bleeding but that should not make a c section last more than 2-3 hours even if a hysterectomy is needed, and a simple Bupivacaine spinal should cover that.

Well, adhesions certainly play a role. Also, can have undiagnosed placental issues (percreta, accreta, etc) which are much higher incidence with each section.

 

[Twiggidy]

Was the director an anesthesiologist ..? Director of what?

sorry. yeah, he's an anesthesiologist. again, that was his BBQ....i was just there for a plate

 

[Twiggidy]

That makes no sense whatsoever.
The greatest risk of PDPH in the OB population is from a wet tap with an epidural needle. This director just increased the risk of headache but not knowing the actual risks of the care provided.

very true.....i guess he didn't expect people to hit the dura with the Touey, but we all know that if you haven't wet tapped someone you haven't done enough epidurals

 

[Arch Guillotti]

Good point, that’s a problem

That's why I think dosing it up with 20 ml of 2% lidocaine with bicarb is probably better.