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C section nausea

Discussion in 'Anesthesiology' started by huktonfonix, May 25, 2008.

  1. huktonfonix

    huktonfonix board certified!
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    Had a couple of cases the other night during which both pts. had nausea with traction on the peritoneum/fascia. Both did ok during externalization of the uterus. Both were done with a labor epidural that had been running 8-10 hours and dosed with 20ml of 2% lido +epi +HCO3. I've noticed my nausea rate during C/S is highest with converted labor epidurals. Im guessing its because of a lower block density. I rarely have nausea with spinals and primarily placed epidurals. Does anyone have any tips how to decrease the incidence of the nausea or successfully treat it when it happens? (different local solutions, anti vagal drugs, etc?) I have tried experimenting with all kinds of stuff (glyco, propofol, antiemetics, etc...). Nothing consistently successful.
     
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  3. Gaseous Clay

    Gaseous Clay ASA Member
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    I hadn't noticed a difference between whether a patient had an epidural or whether I placed a spinal. I remember my 1st day of OB, my senior didn't tell me to give prophylaxis, so of course the first 2 C/S, they were throwing up all over the place and the OB docs were glaring at me while the bowel was hanging out.

    I almost always put reglan 10 and zantac 50 in the IV bag while they are in the birthing room or pre-op area. Once they hit the OR, I give zofran 4 for the epidural or after the spinal is placed. I will give another zofran 4 if they get nauseous during the procedure.

    We also put fentanyl in both the spinal and the epidural. Even though fentanyl can cause nausea, the decreased pain, especially when tugging and externalizing the uterus can offset this and lead to less nausea.

    Hope that helps, I still get the occasional nauseous patient even with all of that but most of those times, it is because the BP is creeping down.
     
  4. gas4all

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    I discovered this technique quite by accident some years ago. In my experience (extensive) it prevents nausea and vomiting aprox 90% of the time in patients undergoing c-section. The only problem is you may not have access to droperidol at your institution. (one of the finest pharmaceuticals ever to enter the world of anesthesia) If you are lucky enough to get your hands on some, you will be a believer after your next 5 cases! Here it is:

    After the baby is out and the cord clamped, IMMEDIATELY push 2.5 mg droperidol and 50mcg fentanyl (bolus it for heavens sake). YOU MUST ADMINISTER BOTH.

    YES, you can get some mild sedation, NO it will not compromise the airway or leave the mother unable to see the kid.....why a fentanyl and droperidol combination works wonders in this patient population I am too stupid to postulate.
     
  5. Noyac

    Noyac ASA Member
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    That's the biggest dose of drop that I've seen in some time. At least not since I would use this size dose for awake intubations. I'm not sure I'm a fan of this technique. Your concoction (fentanyl and Droperidol) is very familiar to many seasoned veterans. But not used any longer.

    My technique for nausea. Pull that epidural and place a spinal every time. Much less nausea. My incidence is below 10% which I think is pretty good for c-sections. THe force with which the person assisting the obstetrician uses on the externalized uterus also matters.
     
  6. coprolalia

    coprolalia Bored Certified
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    Do not use droperidol, especially that dose, in these patients. If you are even remotely thinking about droperidol use, give it to yourself first and see how sh*tty you feel after.

    The key here is two-fold: (1) volume - they need to have two liters of crystalloid on board, and (2) effective anti-nausea prophylaxis - give 10mg of metoclopramide and 4mg of ondansetron before they cut. Ephedrine has also been demonstrated to be effective against nausea (not sure exactly why unless it's related to increased BP/decreased splanchnic blood flow). Even if their pressure is okay, 5mg increments will help you out.

    You can top-up the epidural so they can cut. The volume and the anti-emetic strategy will help. Moving the viscera around during the procedure is going to bug some patients even with the prophylaxis, but you tell them it's coming. The anti-nausea meds and the volume should keep them from puking.

    -copro
     
  7. snowman8

    snowman8 ASA Member
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    Are there any issues with placing a spinal after you have had a continuous labor epidural? Change in dosing of the spinal? Higher risk for high spinal?
     
  8. Planktonmd

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    Neuroleptanesthesia for PONV prophylaxis?

    I have a better idea: give small doses of Propofol.
     
  9. huktonfonix

    huktonfonix board certified!
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    I also had a concern about an unpredictable spread of the spinal following a labor epidural. I think that topics been covered here before, though. I have also tried hydration, ephedrine, propofol, etc.. I dont usually give prophylactic antiemetics (partially culture and because my nausea rate is usually fairly low except for these converted labor epidurals). maybe I'll start using more prophylaxis for these cases. However, come to think of it a lot of my nausea is seen with a certain surgeon. hmm......

    Also, in regards to reglan. I've had a couple of friends who had C/S that received it and had rather marked dysphoric reactions. I dont use it anymore unless the patients under general.
     
  10. Noyac

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    I give full dose and have not had a problem in over 7 yrs. Remember, these pts didn't have a large bolus and then figure out that the epidural didn't work. They had a labor epidural. I pull it without ever bolusing it.

    As far as antiemetics go I don't give them b/c they don't work. Ephedrine and Neo are better. And it does depend on the surgeon. These pts aren't vomiting when they come into the room and they aren't getting gas or narcotics except for the miniscul dose in the spinal. So why are you giving antiemetics. It's either BP related, uterine traction or oxytocin.
     
  11. Arch Guillotti

    Arch Guillotti Senior Member
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    Yeah I don't give antiemetics much either, maybe some zofran. Do treat BP liberally w/ephedrine.
     
  12. Trisomy13

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    I'm in the "liberal use of ephedrine" camp when it comes to C/S nausea and vomiting. Almost invariably I see the nausea correlate with a BP drop.

    I'm quickly becoming a fan of Ephedrine 50 mg IM in the patient's quad after the spinal has set up, before the OB preps.

    When/if she starts saying she feels sick, IVF bolus, propofol 10mg IV, ephedrine 5-10mg IV.


    And dad holds the puke basin. He's the reason we're all there in the first place ;)
     
  13. Noyac

    Noyac ASA Member
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    I still can't believe someone is giving 2.5 mg of Droperidol.
     
  14. SleepIsGood

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    I've done OB for two months. Have done over 100 c/s. I had one case of some nausea.

    What do I like to do?

    I give them TONS of fluids (they get 1L of LR easy before even going into the OB OR suite). After my spinal/epidural I give them all 5mg ephedrine upfront.

    No zofran, no reglan. Like someone mentioned, the nausea in ob is usually from hypotension. I also warn the pts there will be a lot of pushing and pulling and they will fell that (ie after the uterine incision). Give them pts a heads up and I think they generally do very well without all the added extra meds.
     
  15. SleepIsGood

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    LOL....dude ur dad's the reason that you're a trisomy!

    I like that trick, totally going to use it from now on. He cant say no either:laugh:
     
  16. dhb

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    Does 2.5mg make a big difference compared to 0.625?
    I don't give droperidol to awake patients. Good drug but probably not in the OB setting...
    Since Jet recommended it i started giving 5mg of ephedrine post spinal which has abolished the post spinal BP dip and i don't get nauseated patients...
     
  17. Jeff05

    Jeff05 Senior Member
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    every patient gets metoclopramide 10mg en route to OR.

    drop 0.625 mg is a great rescue drug for ponv.

    i find if BP is ok, they do not vomit. ephedrine 10mg iv goes in as soon as the spinal is in.

    if pt does feel sick after baby is out, i will give zofran.
     
  18. Noyac

    Noyac ASA Member
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    Is nobody using neo here?

    I haven't given ephedrine in 4 years in a c/s. Well maybe one or two times.
     
  19. Lonestar

    Lonestar Senior Member
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    i'll use phenylephrine. ephedrine has its own issues in OB. Neither is bad (we can argue fetal acidosis, blah blah blah) but i'll primarily give phenylephrine.
     
  20. foshizzo

    foshizzo Junior Member
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    I agree completely with Noyac. Most of these women are already tachy in the 90's-100's. I don't even think about reaching for ephedrine unless the HR<55.

    Phenylephrine has several advantages over ephedrine in cesereans: 1) quicker onset, 2) more effective pressor, 3) easier to titrate, 4) less likely to cause fetal acidosis

    It's ok to go through several sticks of neo if necessary, and it won't cause uterine hypoperfusion. That was disproved years ago.
     
  21. Noyac

    Noyac ASA Member
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    Here's my potion.
    Mom in the room without any premeds. Not even Bicitra.
    Sitting position, BP measured, IV fluids wide open. If epidural in place I pull it and place a spinal otherwise just put in a spinal. I give bupiv 13 - 15 g with 200mcg PFMS in the spinal. I found with the bigger bupiv dose I get less pain, nausea with uterine retraction as long as I manage hypotension.
    Supine pos with LUD. I squirt 5 - 10 cc's of neo (100mcg/cc) into IV bag depending on how much fluid is still in the bag. I manage hypotension with the thumb wheel and occasional bumps of neo from the syringe.
    I also tell every mom about chest/shoulder pain during uterine retraction and this way they rarely say "I can't breath" "I'm having a heart attack". They expect it and it fine.
    I usually get 2-3 L IV fluid in during the case. NO ANTIEMETICS.
    These pts are not throwing up from narcotics or volatiles or reversal agents etc. They throw up b/c of hypotension, uterine retraction, and pitocin.
     
  22. huktonfonix

    huktonfonix board certified!
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    None of my attendings have been too enthusiastic about pulling labor epidurals and placing a spinal. I plan to try it out next year though. In my opinion a spinal is a superior anesthetic to an epidural for a C/S. I also agree with aggresively hydrating and liberal use of phenylephrine. However, its not the C/S or even newly placed epidural C/S that I've seen nausea in. Its usually the ones I try to use the labor epidurals for. Since I feel I account for hydration and hypotension my assumption is that it is uterine traction in the face of a block thats not dense enough. Does anyone know of a good way to provide a reliably denser block when dosing a previously running labor epidural? I've heard suggestions from reverse trendelenberg position when dosing to adding some tetracaine to the usual 2% lido.

    Another question: I've never used more than 12mg hyperbaric bupivicaine for a C/S. Do you tend to get more hypotension or a higher block with this? I assume because of the spinal curvature that the spread is still fairly self limited, but I've never tried it.
     
  23. Planktonmd

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    Exactly.
    I almost never give any antiemetics to c sections.
     
  24. coprolalia

    coprolalia Bored Certified
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    So, are you saying that those drugs are ineffective at blocking the nausea/vomiting response resultant from those maneuvers?

    I had an attending like you early in my training. I "learned" from him never to put fentanyl in the spinal or to give antiemetics. I probably did my first 30-40 c-sections thinking it was fairly normal (not every time, mind you) for the patient to get nauseous, then give pressor and/or wait until they dry-heaved or, worse, vomited.

    Then, another attending showed me the reglan/zofran trick, as well as putting fentanyl in the spinal. Probably in the subsequent 100-120 c-sections I've done, I haven't had one patient even complain of nausea even when their pressure starts to drift down before it can be effectively treated.

    -copro
     
  25. jwk

    jwk CAA, ASA-PAC Contributor
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    Same here.
     
  26. Planktonmd

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    The antiemetics you mentioned are good drugs but don't address the mechanism of nausea and vomiting in this population.
    I never give antiemetics and my patients don't vomit.
    I make sure they don't get hypotensive, they are well hydrated and that they have a good anesthetic.
    I also work with OB's who can do a c section in 20 minutes skin to skin.
     
  27. jetproppilot

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    This is what works best for nausea prevention IMHO.

    Long ago I usta wait, after placing a spinal for a c section, until the BP dropped.

    Now I push 10-20 mg ephedrine right after placement regardless of starting BP.

    Then when it inevitably creeps down, even a little, I'll hitt'em again.

    Saw a much lower incidence of N/V after I started doing this.

    Same would go for a labor epidural I spose....but I do CSE so rarely see a BP drop.
     
  28. Trisomy13

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    I had to clean my screen from a spit-take. We occasionally get a fatty (definition being > 300lb .. anything else is just a healthy eater here) that the OB takes almost 20 minutes just to get from skin to baby. I think the fastest I've been involved in was around 45 minutes skin to skin, and it was stat with general.

    To the people who give Reglan to "every patient", do you inquire about a h/o seizure or dystonia? I know the incidence is very rare, but there are reported cases of permanent dystonic disorders associated with a single dose of Reglan.
     
  29. InductionAgent

    InductionAgent Senior Member
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    C-section patients are a population at moderately high-risk for PONV -young, female, non-smoking (at least they all claim to be), and undergoing abdominal surgery with traction on the uterus. To me it makes sense to provide nausea/vomiting prophylaxis after baby is delivered with at least a 2-drug regimen.

    I agree that adequate hydration and maintenance of BP is essential for preventing and treating nausea/vomiting. However, if some antiemetics are on board I feel the patient is less likely to start retching with minor swings in BP that I will be aggressively treating anyway.
     
  30. MTGas2B

    MTGas2B Cloudy and 50
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    Do any of you guys use any dilute homemade pressors? At our University Hospital (the only hospital within system with OB) we frequently mix up a bag of "snake oil". 50 mg of ephedrine and 2 mg of phenylephrine added to 250 ml of NS. Put it on a microdripper and titrate to effect. Seems to work pretty well. Patients give me a funny look when my attending looks at me and asks if I've started the snake oil yet.
     
  31. coprolalia

    coprolalia Bored Certified
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    While I appreciate and respect Plank's opinion, I agree wholeheartedly with this statement. And, it has repeatedly been proven to me through my own practice and empiricism.

    -copro
     
  32. Noyac

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    If this were true everyone would be doing it. But unfortunately it is not. My bet is that you are doing a good job of getting them numb and keeping their pressure up.

    When they start to want to puke, I use small doses of propofol.

    Think about this. How many times do these pts go to the PACU throwing up? Never unless you try to sit them up to soon or if you haven't tanked them up enough and their BP is saggy. If this were a "anesthesia" related nausea, they would still be pukey. But they are not. Once the c/s is over, they are fine. Just some of my observations. I don't think there are any "GOOD" studies supporting antiemetics in the routine c/s. If I'm wrong, let me see it.
     
  33. 2win

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    The same technique. I never tried droperidol - maybe in the future.
    "In a randomized, double-blinded, controlled trial, we investigated the prophylactic infusion of IV phenylephrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. Immediately after intrathecal injection, phenylephrine was infused at 100 microg/min (n = 26) for 3 min. From that point until delivery, phenylephrine was infused at 100 microg/min whenever systolic arterial blood pressure (SAP), measured each minute, was less than baseline. A control group (n = 24) received IV bolus phenylephrine 100 microg after each measurement of SAP <80% of baseline. Phenylephrine infusion decreased the incidence (6 [23%] of 26 versus 21 [88%] of 24; P < 0.0001), frequency, and magnitude (median minimum SAP, 106 mm Hg; interquartile range, 95-111 mm Hg; versus median, 80 mm Hg; range, 73-93 mm Hg; P < 0.0001) of hypotension compared with control. Heart rate was significantly slower over time in the infusion group compared with the control group (P < 0.0001). Despite a large total dose of phenylephrine administered to the infusion group compared with the control group (median, 1260 microg; interquartile range, 1010-1640 microg; versus median, 450 microg; interquartile range, 300-750 microg; P < 0.0001), umbilical cord blood gases and Apgar scores were similar. One patient in each group had umbilical arterial pH <7.2. Prophylactic phenylephrine infusion is a simple, safe, and effective method of maintaining arterial blood pressure during spinal anesthesia for cesarean delivery. IMPLICATIONS: In patients receiving spinal anesthesia for elective cesarean delivery, a prophylactic infusion of phenylephrine 100 microg/min decreased the incidence, frequency, and magnitude of hypotension with equivalent neonatal outcome compared with a control group receiving IV bolus phenylephrine"
     
  34. jwk

    jwk CAA, ASA-PAC Contributor
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  35. Noyac

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  36. coprolalia

    coprolalia Bored Certified
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    Please elaborate. I have some attendings who refuse to place a spinal after an epidural has been in. I've been quoted that there are "too many case reports of high-spinal after epidural" for it to be safely done. Assuming that the spinal creates a hole that can entrain what's in the epidural space, causing an excessive block.

    Thanks!

    -copro
     
  37. jwk

    jwk CAA, ASA-PAC Contributor
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  38. Noyac

    Noyac ASA Member
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  39. Noyac

    Noyac ASA Member
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    Well, I have never had a problem with a high spinal in this situation. I believe the risk is present when the epidural has been recently bolused then found to are be working adequately and then converted to spinal. But I feel the risk is not as high after an epidural that has been running for some time. The volume in the epidural space is not as much.
     
  40. Arch Guillotti

    Arch Guillotti Senior Member
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    I have seen a high spinal in this scenario. It was a crappy catheter (placed by another resident of course), we dosed it up but it wasn't gonna cut it for section. So we placed a spinal w/10 mg or so (I think) of bupi. Shortly thereafter she got a tube. The risk is not nearly as great when you just yank the cath and do the spinal from the get go.
     
  41. Noyac

    Noyac ASA Member
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    Thats what I'm talking about. The ones that are topped up are at risk for high spinal. I don't top them up.
     
  42. huktonfonix

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    I always assumed it was due to fluid compression of the intrathecal space causing a smaller volume to rise higher, although I never considered this theory. Seems reasonable also.
     
  43. Noyac

    Noyac ASA Member
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    THis is my impression of the cause as well. I don't think its been proven either way though. I'm sure someone will correct me if I am wrong.
     
  44. 2win

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    Do you speel Greek? The name is absolutely a hit.
    When I was a resident I had the same BS. There are studies to see that is safe to place a spinal after an epidural . I gor more than 200 cases done with a spinal after epid. and patien did great. I will pull the epid. cath out and place a SAB at any time.
     
  45. 2win

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  46. Noyac

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    These quotes are backwards.

    2win, I don't follow your questions.
     
  47. coprolalia

    coprolalia Bored Certified
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    I don't follow them either.

    If we're going to bolus an epidural, we always start from the patient's birthing room on the way to the OR. Usually it's 2% lidocaine with NaHCO3 +/- epi (5mcg/mL). Sometimes we use Nesacaine 3%. You don't push the whole syringe in the hallway. But, if you wait until you get into the OR and get all the monitors set-up, you're going to have to sit there twenty minutes (or so) for an adequate block.

    "Inheriting" epidurals? Happens all the time. There's no reason to believe that an epidural is inappropriately placed if it has been infusing and you have a level before you push-back to go to the OR. It's about trust of your colleagues, and if you push 5mL of lidocaine 2% in the hallway and get a total block, that'll be enough to do the whole case. And, you always test before you inject. If you pull back on the syringe and get CSF, or the resistance doesn't feel "right" when you're pushing, then you hold-off.

    -copro
     
  48. 2win

    10+ Year Member

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    I was just bringing the point that although is common practice to bolus an epidural in patient room and leave for OR, this approach place the anesthesiologyst at risk for malpractice. During transportation the vitals of the mother are not recorded, neither the fetal activity. A bolus is likely to change BP with possible consequences. I would like to know how you'll justify a bad outcome in a trial. just my 2 cents
     
  49. coprolalia

    coprolalia Bored Certified
    2+ Year Member

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    First, left uterine displacement. Amazing how well this works. And, a little phenylephrine or ephedrine if the patient starts to get symptomatic in the hallway (perish the thought for the purists) can also work wonders.

    Second, how would you justify a bad outcome related to anesthesia for a 20-minute delay in the OR when OB is ready to cut?

    -copro
     

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