c-section case

[leaverus]

No, you don't. The #1 reason for not doing a regional anesthetic is patient refusal.

agree. i'm a strong proponent of regional, esp for OB but it's not worth "convincing" someone to have regional when they specifically request general. not that i wouldn't have made an attempt at explaining the benefits of a neuraxial but i wouldn't insist.

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[deleted162650]

When she started whining after the 2nd needle pass, I just would pushed a little prop. As she slumped forward a little (thereby opening up her spinous processes) pop that 25g whit through the dura, dose her up, and when she's lucid again she'll be in LUD with some prep on her belly.

 

[Urzuz]

When she started whining after the 2nd needle pass, I just would pushed a little prop. As she slumped forward a little (thereby opening up her spinous processes) pop that 25g whit through the dura, dose her up, and when she's lucid again she'll be in LUD with some prep on her belly.

I'm all for trying new things, but giving propofol to a morbidly obese, pregnant patient who is in the sitting position while I'm doing a spinal on them definitely isn't something I'm going to try. Ever.

Some of these OB patients need to learn to put their big girl pants on and clam up while you do your best to guide them safely through a surgery while minimizing the risks that a lifetime of eating cheeseburgers has conferred on them. Emotional drama queens who are challenging need a little extra TLC and/or a pep talk as you make other passes. The women who are totally flying off the handles get a general.

 

[deleted162650]

a morbidly obese, pregnant patient

Unless she's 4'11", a 200lb term parturient is not even close to what I would consider morbidly obese. And I practice in the land of pilates and juice clenses.

 

[Urzuz]

Unless she's 4'11", a 200lb term parturient is not even close to what I would consider morbidly obese. And I practice in the land of pilates and juice clenses.

For some reason I thought the post said she was 300 lbs. In any event, I personally would never give propofol to any pregnant patient in the above situation...and I'm fairly certain our practices are pretty much next door to one another

 

[vector2]

I'm all for trying new things, but giving propofol to a morbidly obese, pregnant patient who is in the sitting position while I'm doing a spinal on them definitely isn't something I'm going to try. Ever.

The look on the OB nurse's face as you push prop on a sitting parturient would almost make it worth it.

 

[fakin' the funk]

In any event, I personally would never give propofol to any pregnant patient in the above situation...and I'm fairly certain our practices are pretty much next door to one another

Why not? You wouldn't give 10mg...20mg...0.5/kg? What are you afraid of? The patient sitting up, already having received bicitra, pepcid, and reglan, still with an intact cough and gag...somehow aspirating? Fetal depression when the baby is delivered 20-30 minutes later?

 

[fakin' the funk]

Has anybody ever used the FOB and Glidescope at the same time? Only had to do this once, but worked beautifully when the airway was so edematous/anterior that an ETT couldn't be directed towards the cords with the Glidescope by itself

Yes.

But Glidescope-Bougie works more quickly, with fewer hands.

 

[fakin' the funk]

Apparently, I am still living in the dark ages. I regularly go to 10 hospitals and none of them are stocking it.

Major hospital system in a major American city; we don't have it.

 

[fakin' the funk]

Would you A) keep trying to intubate, B) wake patient up and tell her she's getting a spinal. C) wake patient up for an awake fiberoptic D) wake patient up and schedule for a different day when you are on vacation. E) place an LMA and proceed. F) Other

Option F: intubating LMA (Fastrach, Cookgas) --> FOB --> ETT
Option G: Regular LMA --> FOB/airway exchange catheter --> ETT

 

[fakin' the funk]

I love regional and any chance that I get I will do regional over general, but at the same time I think patient selection is important and it can't be every patient gets regional or else.

True dat.

The last GA for C/S that I did (quite a few months ago) was a patient who flatly refused to be awake in any capacity during the surgery. Not anxious, not fearful per se, just couldn't even fathom the idea of being awake while having abdominal surgery. The nurses approached me like this: "The patient in room 1 says she refuses spinal, you have to talk to her into it." Riiiiiiight. R/b/a explained and fully understood. Easy GA. Next case.

 

[Urzuz]

Why not? You wouldn't give 10mg...20mg...0.5/kg? What are you afraid of? The patient sitting up, already having received bicitra, pepcid, and reglan, still with an intact cough and gag...somehow aspirating? Fetal depression when the baby is delivered 20-30 minutes later?

No, I wouldn't. The risk/benefit isn't worth it. At all.

The risk of: giving enough to make them disinhibited but not enough to "sedate" them, them hypoventilating and/or desaturating, even if you give enough you may have a huge pregnant lady start slumping off to one side or another and having a tiny nurse trying to support them, having to take my sterile gloves off to even administer the propofol, etc etc etc...the list goes on and on. And the most important reason is that it ISN'T NECESSARY.

And all that for what potential benefit? You get her to shut up for a minute? If having a pregnant lady overdramatize an epidural/spinal by hooting and hollering scares you into giving them propofol then you must not do a lot of OB. Most patients will stop moving if you're firm enough with them. They may continue yelling and screaming like the sky is falling on their heads, but you shouldn't let that scare you into administering them a medicine for it.

Again, if you've found that administering propofol to your patients while doing a spinal is effective, more power to you. I still can't fathom any sort of situation where I would do it though.

 

[Planktonmd]

I'm all for trying new things, but giving propofol to a morbidly obese, pregnant patient who is in the sitting position while I'm doing a spinal on them definitely isn't something I'm going to try. Ever.

Some of these OB patients need to learn to put their big girl pants on and clam up while you do your best to guide them safely through a surgery while minimizing the risks that a lifetime of eating cheeseburgers has conferred on them. Emotional drama queens who are challenging need a little extra TLC and/or a pep talk as you make other passes. The women who are totally flying off the handles get a general.

You should try it ... it makes your life easier!

 

[Planktonmd]

The look on the OB nurse's face as you push prop on a sitting parturient would almost make it worth it.

Is that really such an unusual practice? You don't have to induce GA, just give a little!

 

[fakin' the funk]

The risk of: giving enough to make them disinhibited but not enough to "sedate" them, them hypoventilating and/or desaturating, even if you give enough you may have a huge pregnant lady start slumping off to one side or another and having a tiny nurse trying to support them, having to take my sterile gloves off to even administer the propofol, etc etc etc...the list goes on and on. And the most important reason is that it ISN'T NECESSARY.

Have you given 10mg of propofol to a parturient? It doesn't make them hypoventilate, desaturate, or get disinhibited. It makes them close their eyes for 2-3 minutes.