C-section meds choices with spotty epidural

[Noyac]

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I'm of the school where there are no crash emergencies with patients who are super morbidly obese or who have "horrendous" airways. Where I am currently (community hospital without a lot of back up, etc). I would agitate strongly for a scheduled section. Unclaimed, 2 AM presentation to L and D, same deal. CSE or awake intubation. Bottom line, for any out lier patient you can think of, for me, is that this patient would not be allowed to labor.

I see your point but you do know that babies don’t follow plans. I was talking about you approach to dosing up a spotty epidural. And then I added, what if it was a horrendous airway?

 

[Noyac]

Wait the entire reason we are doing section under epidural is so mom can experience it?? I dont know if i agree with that. Kind of like how i do my hips/knees under spinal not because of patient wants to experience it

Yes. At least as far as the OB’s see it.

 

[drmwvr]

I see your point but you do know that babies don’t follow plans. I was talking about you approach to dosing up a spotty epidural. And then I added, what if it was a horrendous airway?

That was my point, sir...sorry for being so unclear...a horrendous airway would not have had the chance to have a spotty epidural....she'd go to section either scheduled or when she showed up at triage. I'd do everything in my power to ensure that the baby had no say in the matter.

 

[Noyac]

That was my point, sir...sorry for being so unclear...a horrendous airway would not have had the chance to have a spotty epidural....she'd go to section either scheduled or when she showed up at triage. I'd do everything in my power to ensure that the baby had no say in the matter.

So if someone has a horrendous airway you won’t place an epidural?

 

[drmwvr]

So if someone has a horrendous airway you won’t place an epidural?

Truly horrendous? Maybe we're not thinking of the same thing. Awake FOI horrendous, where I am, not unless I'm going back to the OR, no.

 

[Southpaw]

Let me begin here by saying you can do whatever you want to do. BUT, your approach to doing whatever you want to do is basically what determines how you are perceived as an anesthesiologist and doctor. If you take the approach that you just laid out then you will be viewed as dogmatic and unapproachable. You will soon find that your colleagues prefer not to work with you even if you are the best of the best. But the best of the best don’t act this way.

When it comes to what you give pts with regards to your anesthetic, just remember that that pt visits the surgeon again and not you. When they complain it is to the surgeon. I doubt you would want to field complaints from pts about how your colleagues did their job all the time. I sure you would get tied of defending that person and you would start to want to cease working with that person. It’s a two way street. So check your ego at the door. It’s not a turf war. We are all trying to do what is best for the pt. If you are so he’ll bent on giving something then at least give them the courtesy of explaining why they are against it. And this should happen long before you are in the presence of staff and pts.
You have been here a long time and you and I go way back. I’m saying this mostly for others because I know 5his isn’t your style. Cheers!
And for the record, I don’t give OB pts midaz. The entire reason we are doing regional for these cases is so mom can experience the birth of their child. You can claim that it is safer and that this is why but that’s BS. this s also why I don’t dick around with an epidural that “might” work. Sure I get burned just like everyone else. Nobody is 100%.

Will only say you interpreted my post wrong. I was more responding to a post regarding med choices for a mom, post-delivery, with a spotty/sh@tty epidural and I’m limping through. Though my post was a while back, so perhaps you’re right and on target. I’m probably a pretty average anesthesiologist. No problem admitting that. I used to think I was hot sh@t but as I’ve gotten older I’ve grown to respect those around me and admire their skills more than my own.

My lack of desire for supplementing sh@tty epidurals post delivery with versed/fent/ket/nitrous all while Mom is trying to have a ‘natural’ birthing experience in the CS room after the OB called it stat when he saw a few weird blips on the monitor,and completely freaked Mom out, is the exact reason I that I try really hard never to talk myself into using the epidural for CS, and instead trusting my instinct to take the damn thing out and place a SAB.

 

[Arch Guillotti]

That was my point, sir...sorry for being so unclear...a horrendous airway would not have had the chance to have a spotty epidural....she'd go to section either scheduled or when she showed up at triage. I'd do everything in my power to ensure that the baby had no say in the matter.

So your OB will section a patient with a bad airway if you ask them to?

 

[Arch Guillotti]

I'm of the school where there are no crash emergencies with patients who are super morbidly obese or who have "horrendous" airways. Where I am currently (community hospital without a lot of back up, etc). I would agitate strongly for a scheduled section. Unclaimed, 2 AM presentation to L and D, same deal. CSE or awake intubation. Bottom line, for any out lier patient you can think of, for me, is that this patient would not be allowed to labor.

So what do you do when there is an obese abruption, nuchal cord or ruptured vback happens when the OB is screaming that you need to put her to sleep?

 

[dannyboy1]

So what do you do when there is an obese abruption, nuchal cord or ruptured vback happens when the OB is screaming that you need to put her to sleep?

You almost always put them to sleep. Cmon people. If the patient has an anterior mediastinal mass or large oropharangeal tumor or they are truly massive (like above 500lbs and it is all in the neck) then you don’t. The usual fat OB population ? I don’t even think twice. You will be able to mask ventilate and glidescope is (or should be) ubiquitous.

 

[Noyac]

You almost always put them to sleep. Cmon people. If the patient has an anterior mediastinal mass or large oropharangeal tumor or they are truly massive (like above 500lbs and it is all in the neck) then you don’t. The usual fat OB population ? I don’t even think twice. You will be able to mask ventilate and glidescope is (or should be) ubiquitous.

You are reaching for ****.
The questions posed to you are legitimate questions. Just as your mediastinal mass but the situation “ in most circumstances” is very different.
My question was this, if you have a pt with a horrendous airway ( let’s say a true Pierre type type) who was coming in for term labor management and delivery, you would push for c/s electively? You would not place an epidural?
You stated that you would ensure that the epidural was not spotty. I’m not sure how one does this.
You see where I’m going wit( this right? And I’m not pulling out zebras because I’ve been there.

 

[Noyac]

Truly horrendous? Maybe we're not thinking of the same thing. Awake FOI horrendous, where I am, not unless I'm going back to the OR, no.

That’s not what we are trained to do.
You are being dogmatic and obstructionistic.

 

[BobLoblaw78]

Are you guys using the bupi for crash c/s? My attendings have let me use it a few times for non-emergent c/s just so I'd appreciate the difference in density & time to setup for 0.5% bupi VS. 2% lido+epi / 3% chloroprocaine. The bupi definitely created a longer acting surgical block but it also took a lot longer to setup.

No. Not for a crash. I actually mix bupivacaine when I use it now- 0.375%. Dose 10 mL immediately in patient room. Then 5 mL when we roll into C/S room. Usually don't give more, but do if I want a higher level. Never had to wait for it to set up. Never had a hot spot with it. That is with N=50. 0.5% just seemed a bit too much.

 

[drmwvr]

So what do you do when there is an obese abruption, nuchal cord or ruptured vback happens when the OB is screaming that you need to put her to sleep?

I'm not suggesting there is any equivalency between a known patient with troubling co-morbidities and an unanticipated emergency. Are you? I do the case with what I have and according to what the patient presents with. That's a big difference from seeing problems coming your way in advance.