C Section

[jetproppilot]

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Just did a C section on a skinny lady...easy spinal...she was tiny so I used 12 mg HB bupiv....

she gets a motor block, sympathectomy requiring about halffa stick of ephedrine, but still feels the Alice test. Wait a little longer. She still feels it. 😡

So she bought a tube.

Did fine.

Aggravating.

 

[militarymd]

I wonder why that happens.

 

[Noyac]

I wonder why that happens.

Me too

I sit them back up and place an epidural at this time. Or if your OB is quality, they can infiltrate with local at the incision site and hope that the deep fibers are numb as they may well be.

 

[MDEntropy]

I hate that.

Expired bupivicaine? Doubtful. Sounds like you really had a sympathectomy.

Did she have a block post op?

Was the spouse already in the room with the camcorder fired up?

 

[militarymd]

Me too

I sit them back up and place an epidural at this time. Or if your OB is quality, they can infiltrate with local at the incision site and hope that the deep fibers are numb as they may well be.

Noy,

why the reluctance with GA for C-sections?

 

[zippy2u]

That little tiny thang was prolly yellin' for the 25 mikes of fentanyl to be added to that spinal. Now if ya had only done that high fallutin' CSE technique you're famous for ya wouldn't have had to sleep her.... Regards, ---Zip

 

[jetproppilot]

I hate that.

Expired bupivicaine? Doubtful. Sounds like you really had a sympathectomy.

Did she have a block post op?

Was the spouse already in the room with the camcorder fired up?

No babydaddy in sight.

Young medicaid girl spittin out babies.

She had a post op block too.

 

[Monty Python]

Just did a C section on a skinny lady...easy spinal...she was tiny so I used 12 mg HB bupiv....

she gets a motor block, sympathectomy requiring about halffa stick of ephedrine, but still feels the Alice test. Wait a little longer. She still feels it. 😡

So she bought a tube.

Did fine.

Aggravating.

I was doing a week of makeup reserve drill by passing gas at my local VA. Over the week's time, I had two spinals fail, another CRNA has one fail, and the anesthesiologist had two fail. We were all using standard kits, same manufacturer, same lot number, containing heavy marcaine. All of us swore up and down we had perfect drip x 4, easy CSF swirl before injection, and easy aspiration of CSF after injection.

On Friday afternoon of that week I used a kit from the same lot, but checked out powdered tetracaine, epi, and astromorph separately from the pyxis, getting a four hour block for a total hip. We're all thinking we had a bad batch of marcaine.

Had the spinal trays sat in the sun for hours on the VA loading dock? Were the trays counterfeit (it happens)? Bad karma?

 

[jetproppilot]

I was doing a week of makeup reserve drill by passing gas at my local VA. Over the week's time, I had two spinals fail, another CRNA has one fail, and the anesthesiologist had two fail. We were all using standard kits, same manufacturer, same lot number, containing heavy marcaine. All of us swore up and down we had perfect drip x 4, easy CSF swirl before injection, and easy aspiration of CSF after injection.

On Friday afternoon of that week I used a kit from the same lot, but checked out powdered tetracaine, epi, and astromorph separately from the pyxis, getting a four hour block for a total hip. We're all thinking we had a bad batch of marcaine.

Had the spinal trays sat in the sun for hours on the VA loading dock? Were the trays counterfeit (it happens)? Bad karma?

Wish I had an explanation, Trin.

Wouldda wrote it off to bad bupiv except physiologically everything happened like you'd expect except for the analgesia part.

 

[jetproppilot]

Me too

I sit them back up and place an epidural at this time. Or if your OB is quality, they can infiltrate with local at the incision site and hope that the deep fibers are numb as they may well be.

I differ in opinion with you, friend.

She had a motor block, transient nausea from the sympathectomy-induced-hypotension (until the ephedrine kicked in)...no way to predict how a subsequent block will react IMHO.

I think its safer to go to sleep after neuraxial block fails. At least I feel more comfortable doing it that way.

 

[sdn1977]

Aaaaaahhhh.....I do love a good drug thread - may I join?

Anesthetics are very heat labile - if the temp during storage or in transit rose too high - yes, you would get less effectiveness. My hospital pharmacy was not air conditioned & during the summer we would sometimes measure the temp above 100 for days! Most drugs should be stored at 85 or less. (Don't even think about the antibiotics!!) It does happen more often than it should.

Now....for a really, really obscure possibility. You did say she was skinny - was she perhaps asian (I hesitate to even mention this because I don't want to offend, but it does affect drug metabolism)?

Bupivicaine is a racemic mixture of levobupivacaine & dextrobupivacaine. Very little kinetic work has been done on bupivacaine - the literature just says its metabolized by the CYP3AY enzyme of the P450 system. But...it is 50% levobupivacaine & that has been studied more - it utilizes the CYP1A2 in addition to others.

Now...there is a group working on ethnic variation among the CYP enzymes - they have found there is no variability with regard to drug metabolism within the CYP3A polymorphs. However, there are HUGE differences in the CYP2 enzymes and ethnicity. Depending on the allele, asians are rapid metabolizers within some subsets. The CYP1A system has not been studied yet (which is the one we know metabolizes levobupivacaine), but one can speculate there might be variation. There are more than 80 alleles just in the CYP2 enzymes, so its a huge job to study especially since kinetic study data is normally obtained from IV use & that doesn't apply to these.

So...your clinical effect could have been due to the drug being rapidly metabolized.

Certainly, none of this matters when you need to make this girl comfy, but I figure if you're grasping at straws for an explanation - you might as well grasp them all! 😉

 

[jetproppilot]

Aaaaaahhhh.....I do love a good drug thread - may I join?

Anesthetics are very heat labile - if the temp during storage or in transit rose too high - yes, you would get less effectiveness. My hospital pharmacy was not air conditioned & during the summer we would sometimes measure the temp above 100 for days! Most drugs should be stored at 85 or less. (Don't even think about the antibiotics!!) It does happen more often than it should.

Now....for a really, really obscure possibility. You did say she was skinny - was she perhaps asian (I hesitate to even mention this because I don't want to offend, but it does affect drug metabolism)?

Bupivicaine is a racemic mixture of levobupivacaine & dextrobupivacaine. Very little kinetic work has been done on bupivacaine - the literature just says its metabolized by the CYP3AY enzyme of the P450 system. But...it is 50% levobupivacaine & that has been studied more - it utilizes the CYP1A2 in addition to others.

Now...there is a group working on ethnic variation among the CYP enzymes - they have found there is no variability with regard to drug metabolism within the CYP3A polymorphs. However, there are HUGE differences in the CYP2 enzymes and ethnicity. Depending on the allele, asians are rapid metabolizers within some subsets. The CYP1A system has not been studied yet (which is the one we know metabolizes levobupivacaine), but one can speculate there might be variation. There are more than 80 alleles just in the CYP2 enzymes, so its a huge job to study especially since kinetic study data is normally obtained from IV use & that doesn't apply to these.

So...your clinical effect could have been due to the drug being rapidly metabolized.

Certainly, none of this matters when you need to make this girl comfy, but I figure if you're grasping at straws for an explanation - you might as well grasp them all! 😉

She was black.

 

[sdn1977]

Well....for over 70 alleles of the CYP2 enzyme, 1-2% asians & blacks & 21% Saudi Arabians (???) are considered ultra-rapid metabolizers. Probably not a factor...Who will ever know - just an interesting addition to a situation without an explanation....I'm just partial to good drug mysteries!

Thanks for putting up with my instrusion!

 

[jetproppilot]

Well....for over 70 alleles of the CYP2 enzyme, 1-2% asians & blacks & 21% Saudi Arabians (???) are considered ultra-rapid metabolizers. Probably not a factor...Who will ever know - just an interesting addition to a situation without an explanation....I'm just partial to good drug mysteries!

Thanks for putting up with my instrusion!

No intrusion.

Nice educational post.

 

[militarymd]

Aaaaaahhhh.....I do love a good drug thread - may I join?

Anesthetics are very heat labile - if the temp during storage or in transit rose too high - yes, you would get less effectiveness. My hospital pharmacy was not air conditioned & during the summer we would sometimes measure the temp above 100 for days! Most drugs should be stored at 85 or less. (Don't even think about the antibiotics!!) It does happen more often than it should.

Now....for a really, really obscure possibility. You did say she was skinny - was she perhaps asian (I hesitate to even mention this because I don't want to offend, but it does affect drug metabolism)?

Bupivicaine is a racemic mixture of levobupivacaine & dextrobupivacaine. Very little kinetic work has been done on bupivacaine - the literature just says its metabolized by the CYP3AY enzyme of the P450 system. But...it is 50% levobupivacaine & that has been studied more - it utilizes the CYP1A2 in addition to others.

Now...there is a group working on ethnic variation among the CYP enzymes - they have found there is no variability with regard to drug metabolism within the CYP3A polymorphs. However, there are HUGE differences in the CYP2 enzymes and ethnicity. Depending on the allele, asians are rapid metabolizers within some subsets. The CYP1A system has not been studied yet (which is the one we know metabolizes levobupivacaine), but one can speculate there might be variation. There are more than 80 alleles just in the CYP2 enzymes, so its a huge job to study especially since kinetic study data is normally obtained from IV use & that doesn't apply to these.

So...your clinical effect could have been due to the drug being rapidly metabolized.

Certainly, none of this matters when you need to make this girl comfy, but I figure if you're grasping at straws for an explanation - you might as well grasp them all! 😉

We're in the 21st century....only a racist would say a thing like that.......You can't suggest that there may be differences due to genetics.....the different metabolism rates MUST be due to the subjugation the Asians experienced in the 20's building the railroads out west.

 

[The_Sensei]

Subdural block?

 

[stephend7799]

I wonder why that happens.

spinal not in..

thats why it happens

 

[sdn1977]

We're in the 21st century....only a racist would say a thing like that.......You can't suggest that there may be differences due to genetics.....the different metabolism rates MUST be due to the subjugation the Asians experienced in the 20's building the railroads out west.

aaaargh! I knew someone would go there (altho I think - perhaps hope - you're being sarcastic!, but I don't know you well enough to know that or not....) I'm not (at least I hope I'm not) a racist, but there are different ethinic allele dominants with regard to metabolic gene expression which can reflect in drug metabolism. I do not infer one is better nor worse than any other - just different, so expectations of drug effects should be different.

I do give all my sincere apologies - in no way did I mean to be demeaning by any racial inference. However, this research is out there with genetic differences in metabolism. We already knew they exist- particularly with regard to the metabolism of alcohol & omeprazole.

I heartily apologize for any offensive I may have inadvertenly given!

I do specifically apologize to you Mil if I gave any offense directly - it was not my intent.

 

[zippy2u]

Damm SDN, that's some serious backpedalin' ya doin' there. I think Militaryman done owned you! ----Bukuboy

 

[sdn1977]

Damm SDN, that's some serious backpedalin' ya doin' there. I think Militaryman done owned you! ----Bukuboy

Well....I support everything I said...there is lots of data to support it. I'll provide refererences if you want. However, I don't know Mil....if I offended an individual, it was not my intent. After what has gone on the last few months on this forum, I am very hesitant to post at all since the welcome is defintely a cold one. He (altho he could be a she????) did not respond in an academic/clinical manner. But then...perhaps I just don't get your banter. It was never my intent to offend anyone....just to explain how drugs could be metabolized differently.

I'm just coming from a pharmacist's perspective who not only handles the drugs you get from when they are delivered by the wholesaler to when they appear on your tray or in your pyxis, but as one who also reads & tries to understands why drugs are handled differently by different patients so I can explain it to providers and patients when they don't work as expected. But...if you really wanted to know...this is written in the pediatric anesthesia literature, with the primary literature in the pharmacology, pharmacogenetic & toxicology literature....but then I guess you all knew that. my bad!!!!

But...you've all changed the focus of your forum.......with that, I'll say good night. Again...sorry to have intruded....

 

[Gimlet]

Well....I support everything I said...there is lots of data to support it. I'll provide refererences if you want. However, I don't know Mil....if I offended an individual, it was not my intent. After what has gone on the last few months on this forum, I am very hesitant to post at all since the welcome is defintely a cold one. He (altho he could be a she????) did not respond in an academic/clinical manner. But then...perhaps I just don't get your banter. It was never my intent to offend anyone....just to explain how drugs could be metabolized differently.

I'm just coming from a pharmacist's perspective who not only handles the drugs you get from when they are delivered by the wholesaler to when they appear on your tray or in your pyxis, but as one who also reads & tries to understands why drugs are handled differently by different patients so I can explain it to providers and patients when they don't work as expected. But...if you really wanted to know...this is written in the pediatric anesthesia literature, with the primary literature in the pharmacology, pharmacogenetic & toxicology literature....but then I guess you all knew that. my bad!!!!

But...you've all changed the focus of your forum.......with that, I'll say good night. Again...sorry to have intruded....

SDN, you are a great example of why pharmacists rock. You definitely are not "intruding" on the forum...any rational posts based on solid evidence are welcome here. MilMD and Zippy are just razzin' ya a little...I guarantee you didn't offend. If I remember correctly, they have both caught flak from other posters for making comments about the differences between races, hence the snippy comment. When you're talking about differences in P450 metabolism of drugs it's a lot less controversial than, say, talking about differences in IQ. [NOT trying to bring that topic up again, though!]

 

[zippy2u]

Andy is spot on, I tend to be a razzer at times but seriously SDN, that is some good info concerning the CYP enzymes to throw in the hopper. Always appreciate the pharm perspectives on anesthesia. I think Jet handled the case well. I would have induced GETA after a failed spinal and not sat her back up for an epidural. Regards, ----Zip

 

[jwk]

spinal not in..

thats why it happens

Then where did the motor and sympathetic blocks come from?

 

[jwk]

Just did a C section on a skinny lady...easy spinal...she was tiny so I used 12 mg HB bupiv....

she gets a motor block, sympathectomy requiring about halffa stick of ephedrine, but still feels the Alice test. Wait a little longer. She still feels it. 😡

So she bought a tube.

Did fine.

Aggravating.

Ketamine - God's gift to regional anesthesia.

 

[zippy2u]

Always have to factor in the psyche of the OB patient in the equation. A lot of these women have it in their mind that they want to be asleep for their C section despite the risks. Some don't understand the difference between pressure and sharp pain. Zip's got no time to play Dr. Phil especially if it's midnight on call and I don't get the next day off. If regional fails she'll get GETA-- quick, furious and always guaranteed 100% not to fail. Regards, ---Zip

 

[militarymd]

aaaargh! I knew someone would go there (altho I think - perhaps hope - you're being sarcastic!, but I don't know you well enough to know that or not....) I'm not (at least I hope I'm not) a racist, but there are different ethinic allele dominants with regard to metabolic gene expression which can reflect in drug metabolism. I do not infer one is better nor worse than any other - just different, so expectations of drug effects should be different.

I do give all my sincere apologies - in no way did I mean to be demeaning by any racial inference. However, this research is out there with genetic differences in metabolism. We already knew they exist- particularly with regard to the metabolism of alcohol & omeprazole.

I heartily apologize for any offensive I may have inadvertenly given!

I do specifically apologize to you Mil if I gave any offense directly - it was not my intent.

it was a joke.....AND don't apologize for giving it to us straight...if that is the data, then that is the data......don't sugar coat it.

 

[Noyac]

Noy,

why the reluctance with GA for C-sections?

No reluctance with GETA here. Just offering another option.

 

[sdn1977]

it was a joke.....AND don't apologize for giving it to us straight...if that is the data, then that is the data......don't sugar coat it.

ok - a joke...at my expense...hopefully there were others who laughed. I can laugh about a lot of things & did make fun of the obscurity of my original post. However, where I come from (SF) we not only embrace diversity, we celebrate it so its very hurtful to be called a racist and rarely does anyone laugh when being called one. At one of my institutions, UCSF, we do drug studies on how ethnic, gender, age, concurrent illness differences affect all aspects of drug utilization by the body & I felt it might be a relevant addition to this topic. The only sugar coating I did was to simplify to not bore you with the tedium of subsets of the P450 enzyme system. If you think I was trying to spare your sensibilities, you're mistaken.

My apology was to you, zippy & any others who may not have been as vocal as the two of you were, not for the data. I will still let that stand since I never intend to deliberately hurt someone.

Apparently I should have heeded my hesistation all the times I thought to post but was afraid of the backlash since I seem to be getting bashed with the same broom you used to sweep away your trolls.

This has gotten way off the original topic of the young woman who did not receive sufficient anesthesia with bupivicaine....

 

[Idiopathic]

Whoa, sdn. Please dont let mil's little sarcastic comment keep you from remarking on these things. I think you took it way too seriously.

 

[Lizard1]

I think/know that Zip has got it spot on. Seen it too many times where the pt needs reassurance which is often difficult in the setting of an urgent but not emergent c/s. Often times the OB will do an Alice test by not only clamping on the skin but also pulling up ever so softly. The pt does not feel sharp pain but feels a dull sensation and immediate freaks thinking they should not feel anything.

b/c of the sypathectomy & motor block - spinal WAS in. for the above reason, i ask the ob's to just go ahead and do the alice test but i don't specifically ask the pt if they feel anything - just kinda keep going with getting everything ready and casually look at the pt's face when the pt is not aware that they are "testing". if they do grimace, i let them know that they will feel alot of pulling/tugging/dull ache but nothing sharp and reassure them that this is how every c/s is done. IF that doesn't help them AND reassurance from a family member in the OR doesn't help - only then will i titrate Ketamine accordingly.

Unfortunately, I come from an over-conservative residency where i've been taught indxn of a GA on a c/s WILL result in aspiration and be a VERY difficult airway. Also reinforced to me that all GA's will lead to a boggy uterus and significant PPH requiring extensive resuscitation. That being said, I've done 3-4 GA c/s's that everything was OK 😀

 

[jetproppilot]

I think/know that Zip has got it spot on. Seen it too many times where the pt needs reassurance which is often difficult in the setting of an urgent but not emergent c/s. Often times the OB will do an Alice test by not only clamping on the skin but also pulling up ever so softly. The pt does not feel sharp pain but feels a dull sensation and immediate freaks thinking they should not feel anything.

b/c of the sypathectomy & motor block - spinal WAS in. for the above reason, i ask the ob's to just go ahead and do the alice test but i don't specifically ask the pt if they feel anything - just kinda keep going with getting everything ready and casually look at the pt's face when the pt is not aware that they are "testing". if they do grimace, i let them know that they will feel alot of pulling/tugging/dull ache but nothing sharp and reassure them that this is how every c/s is done. IF that doesn't help them AND reassurance from a family member in the OR doesn't help - only then will i titrate Ketamine accordingly.

Unfortunately, I come from an over-conservative residency where i've been taught indxn of a GA on a c/s WILL result in aspiration and be a VERY difficult airway. Also reinforced to me that all GA's will lead to a boggy uterus and significant PPH requiring extensive resuscitation. That being said, I've done 3-4 GA c/s's that everything was OK 😀

I did all the tricks....distracting her right before the pinch test, asking her if its a boy or a ....

"OUCH!!"

The OB even did a sharp vs dull stuff.

Believe me when I tell you she was discerning sharpness accurately. Wasnt histrionics.

As an aside,

I'm still trying to figure out where the "high" risk-of-GA-in-parturients arose, which academecians "back up" with scary stories of definite aspiration and definite difficult airway.

Where are the outcome studies showing improved maternal/fetal outcome with neuraxial blockade?

I'm not implying there is no risk because we are all aware of physiologic/hormonal changes in pregnancy that affect gastric emptying, edema, etc.

But again, the academic milleau is not doing anyone (clinician or patient) any favors by exaggerating said risk to the point of a resident emerging from training scared sh i t less of a safe (in most situations) alternative.

Don't misunderstand my post.

I'm a regional advocate as you all know.

But as you emerge from residency you should feel comfortable putting a pregnant lady to sleep, if you have to.

Unfortunately thats not the case, and new clinicians everywhere are inserting the Miller 2 into the lady's mouth with a shaky hand and urine-soaked tighty whities.

 

[sdn1977]

Whoa, sdn. Please dont let mil's little sarcastic comment keep you from remarking on these things. I think you took it way too seriously.

Perhaps......however, as a nonanesthesiologist (nor an ASA member), the rants on here have made the environment for the rest of us less than inclusive. Those of us who look, lurk, etc..in related fields such as mine are very cautious for fear of inciting an attack in the event we have something to contribute from our own fields. We've actually shared pms about the need to walk on eggshells here.

Fortunately, in my real life, myself & others in my field who also read these threads do get along very well with all those who work in the OR/cath lab - from the anesthesiologists & surgeons to the porters who clean the rooms while we restock the trays. Our physicians & pharmacists enjoy the ability to share drug related issues & stories back & forth which is mentally stimulating for me & I'm guessing interesting for them since they seek me out.

Yes Idiopathic...you may be right & I am too sensitive, but I can't see where I'll ever find being called a racist other than offensive - just me I guess. I will point out though....you've all won the battle....but did you win the war & at what price?

 

[sdn1977]

Whoa, sdn. Please dont let mil's little sarcastic comment keep you from remarking on these things. I think you took it way too seriously.

Perhaps......however, as a nonanesthesiologist (nor an ASA member), the rants on here have made the environment for the rest of us less than inclusive. Those of us who look, lurk, etc..in related fields such as mine are very cautious for fear of inciting an attack in the event we have something to contribute from our own fields. We've actually shared pms about the need to walk on eggshells here.

Fortunately, in my real life, myself & others in my field who also read these threads do get along very well with all those who work in the OR/cath lab - from the anesthesiologists & surgeons to the porters who clean the rooms while we restock the trays. Our physicians & pharmacists enjoy the ability to share drug related issues & stories back & forth which is mentally stimulating for me & I'm guessing interesting for them since they seek me out.

Yes Idiopathic...you may be right & I am too sensitive, but I can't see where I'll ever find being called a racist other than offensive - just me I guess. I will point out though....you've all won the battle....but did you win the war & at what price?

 

[militarymd]

Perhaps......however, as a nonanesthesiologist (nor an ASA member), the rants on here have made the environment for the rest of us less than inclusive. Those of us who look, lurk, etc..in related fields such as mine are very cautious for fear of inciting an attack in the event we have something to contribute from our own fields. We've actually shared pms about the need to walk on eggshells here.

Fortunately, in my real life, myself & others in my field who also read these threads do get along very well with all those who work in the OR/cath lab - from the anesthesiologists & surgeons to the porters who clean the rooms while we restock the trays. Our physicians & pharmacists enjoy the ability to share drug related issues & stories back & forth which is mentally stimulating for me & I'm guessing interesting for them since they seek me out.

Yes Idiopathic...you may be right & I am too sensitive, but I can't see where I'll ever find being called a racist other than offensive - just me I guess. I will point out though....you've all won the battle....but did you win the war & at what price?

You ARE being too sensitive. This is anonymous. I don't know you. You don't know me. Just express yourself.

And BTW, read through my threads. I have never swatted at "trolls", except other anesthesiologists or those pretending to be anesthesiologists.

And I never "swatted" at them, I have disagreed with them....and only called names in responses to derogatory comments about me.

I have essentially ignored all the NiteCaps out there.

 

[jetproppilot]

Yes Idiopathic...you may be right & I am too sensitive, but I can't see where I'll ever find being called a racist other than offensive - just me I guess. I will point out though....you've all won the battle....but did you win the war & at what price?

There have been several posts above that have said your opinion is valued and appreciated here.

Mil posted he was joking....ASIAN SUBJUGATION..... .....

HORY CRAP ....prease tell me you're over it, continue with your informative posts, and move on.

 

[militarymd]

SDN,

I have always recognized that there are genetic differences between the races....ability to metabolize drugs, size of weiners, and OTHER differences that we cannot go into because it is not politically correct to accept these differences.

So........bottom line...I was just joking with you... I am sorry if I offended YOU.

 

[militarymd]

There have been several posts above that have said your opinion is valued and appreciated here.

Mil posted he was joking....ASIAN SUBJUGATION..... .....

HORY CRAP ....prease tell me you're over it, continue with your informative posts, and move on.

Dammit Jet,

It's you White people subjugating us yellow people all these years, that we can't drive as well as you guys.😉

 

[sdn1977]

You ARE being too sensitive. This is anonymous. I don't know you. You don't know me. Just express yourself.

And BTW, read through my threads. I have never swatted at "trolls", except other anesthesiologists or those pretending to be anesthesiologists.

And I never "swatted" at them, I have disagreed with them....and only called names in responses to derogatory comments about me.

I have essentially ignored all the NiteCaps out there.

This is an entirely inappropriate way & place to carry this out & I will take responsibility for that & not continue to hijack this thread...however, you did call me a name - you called me a racist. I don't see how this was in response to a derogatory comment I made to you. I have publicly apologized to you for any offense I may have given. However, even when I have pointed out how hurtful your comment was to me, you just indicated it was a joke.

You are so right - I don't know you, but I do know now it is not in your nature, at least on a public forum, to apologize when you have done something which has obviously been pointed out as being hurtful to someone - me. But...I'm just a pharmacist - pffft!

I am expressing myself! How much more clearly can I say this forum is not inclusive to anyone who is not an ASA member, even if they do have relationships with those in your fields in the real world. OK - enjoy your eclusivity. I'm off to work - oh....with the weekend surgical staff!!!

 

[militarymd]

........I'm still trying to figure out where the "high" risk-of-GA-in-parturients arose, which academecians "back up" with scary stories of definite aspiration and definite difficult airway.

Where are the outcome studies showing improved maternal/fetal outcome with neuraxial blockade?

I'm not implying there is no risk because we are all aware of physiologic/hormonal changes in pregnancy that affect gastric emptying, edema, etc.

But again, the academic milleau is not doing anyone (clinician or patient) any favors by exaggerating said risk to the point of a resident emerging from training scared sh i t less of a safe (in most situations) alternative.

I believe this is all historical. Anesthesia for C-sections used to be all done under mask....and by junior "anesthetist"....essentially interns....in the UK...and guess what..there were many bad outcomes.....and that historical data is continuing to influence our practice today.

Anyone who knows better, please correct me.

Putting a pregnant women to sleep is safer than putting anyone of the 300+ lb 70 year old fatties that I see everyday to sleep for their Medicare gastric bypasses.

 

[sdn1977]

SDN,

I have always recognized that there are genetic differences between the races....ability to metabolize drugs, size of weiners, and OTHER differences that we cannot go into because it is not politically correct to accept these differences.

So........bottom line...I was just joking with you... I am sorry if I offended YOU.

Thank you!! You post this while I was writing. I do appreciate your ability to apologize more than you can imagine!

 

[militarymd]

This is an entirely inappropriate way & place to carry this out & I will take responsibility for that & not continue to hijack this thread...however, you did call me a name - you called me a racist. I don't see how this was in response to a derogatory comment I made to you. I have publicly apologized to you for any offense I may have given. However, even when I have pointed out how hurtful your comment was to me, you just indicated it was a joke.

You are so right - I don't know you, but I do know now it is not in your nature, at least on a public forum, to apologize when you have done something which has obviously been pointed out as being hurtful to someone - me. But...I'm just a pharmacist - pffft!

I am expressing myself! How much more clearly can I say this forum is not inclusive to anyone who is not an ASA member, even if they do have relationships with those in your fields in the real world. OK - enjoy your eclusivity. I'm off to work - oh....with the weekend surgical staff!!!

Uhhhh....read above post.

 

[jetproppilot]

Dammit Jet,

It's you White people subjugating us yellow people all these years, that we can't drive as well as you guys.😉

subjugate....

I'm gonna use that word the next time my wife and I have a.....uhhhhhhh....disagreement.

 

[Noyac]

Back to the topic at hand.
I mentioned in another post not to long ago that I had a case in residency of an oriental female G1P0 for epidural. I placed what felt to be an accurate working epidural cath and dosed it up without getting a level. So I replaced it and got the same. I called my attending who got the same results. Don't remember exactly the next chain of events but she ended up going to a c/s. I sat her up placed a spinal without difficulty and dosed it. I got nothing. She went to sleep for her c/s.
Now I have an explanation. Don't know if it is the right explanation for this pt but none the less it is a explanation.

Thanks SDN for your input.

 

[TheSandMan]

Aaaaaahhhh.....I do love a good drug thread - may I join?

Anesthetics are very heat labile - if the temp during storage or in transit rose too high - yes, you would get less effectiveness. My hospital pharmacy was not air conditioned & during the summer we would sometimes measure the temp above 100 for days! Most drugs should be stored at 85 or less. (Don't even think about the antibiotics!!) It does happen more often than it should.

Now....for a really, really obscure possibility. You did say she was skinny - was she perhaps asian (I hesitate to even mention this because I don't want to offend, but it does affect drug metabolism)?

Bupivicaine is a racemic mixture of levobupivacaine & dextrobupivacaine. Very little kinetic work has been done on bupivacaine - the literature just says its metabolized by the CYP3AY enzyme of the P450 system. But...it is 50% levobupivacaine & that has been studied more - it utilizes the CYP1A2 in addition to others.

Now...there is a group working on ethnic variation among the CYP enzymes - they have found there is no variability with regard to drug metabolism within the CYP3A polymorphs. However, there are HUGE differences in the CYP2 enzymes and ethnicity. Depending on the allele, asians are rapid metabolizers within some subsets. The CYP1A system has not been studied yet (which is the one we know metabolizes levobupivacaine), but one can speculate there might be variation. There are more than 80 alleles just in the CYP2 enzymes, so its a huge job to study especially since kinetic study data is normally obtained from IV use & that doesn't apply to these.

So...your clinical effect could have been due to the drug being rapidly metabolized.

Certainly, none of this matters when you need to make this girl comfy, but I figure if you're grasping at straws for an explanation - you might as well grasp them all! 😉

SDN, correct me if i'm wrong, but I dont think the cytochrome p450 system would effect metabolism of epidurals to any significant extent since this is predominantly an hepatic mechanism of metabolism. I would imagine that the predominant decrease in metabolically active drug at the epidural site would be due to diffusion of the drug away from this site. By the time it reaches the liver, it has already diluted to the point of having a clinically insiginificant effect.

 

[sdn1977]

SDN, correct me if i'm wrong, but I dont think the cytochrome p450 system would effect metabolism of epidurals to any significant extent since this is predominantly an hepatic mechanism of metabolism. I would imagine that the predominant decrease in metabolically active drug at the epidural site would be due to diffusion of the drug away from this site. By the time it reaches the liver, it has already diluted to the point of having a clinically insiginificant effect.

You'd think so...most of the pharmcokinetic & pharmacodynamic work has been done on levobupivacaine, but the British have done work on bupivacaine epidurals. It appears there is a biphasic distribution pattern after epidural injection. The initial phase is from rapid uptake from the epidural space into the blood draining the epidural space. The second phase, apparently, is the tissue uptake within the epidural space, particularly epidural fat, then distributed into the subarachnoid space. (As an aside...I didn't even know there was epidural fat 😱 !)

These distribution processes are more rapid & extensive with agents with the greatest lipophilicity & tissue affinity. The time to maximum serum concentration of bupivacaine after epidural administration is 0.4 hr. So...if you have a pt who rapidly metabolizes a drug, it will continue to require redistribution from the epidural space to maintain equilibrium. Since you need the drug in the epidural space..and the drug is not ever able to get to equilibrium between all its "compartments"...it appears the drug is not working or not being delivered to the right place. The epidural space is not the terminal compartment, rather the initial compartment.

Researchers in France have similar results in children (age 1-7) with maximum serum concentrations at 19.2 +/-3.9min after epidural bupivicaine which are not that far different from adult populations.

 

[Noyac]

You'd think so...most of the pharmcokinetic & pharmacodynamic work has been done on levobupivacaine, but the British have done work on bupivacaine epidurals. It appears there is a biphasic distribution pattern after epidural injection. The initial phase is from rapid uptake from the epidural space into the blood draining the epidural space. The second phase, apparently, is the tissue uptake within the epidural space, particularly epidural fat, then distributed into the subarachnoid space. (As an aside...I didn't even know there was epidural fat 😱 !)

These distribution processes are more rapid & extensive with agents with the greatest lipophilicity & tissue affinity. The time to maximum serum concentration of bupivacaine after epidural administration is 0.4 hr. So...if you have a pt who rapidly metabolizes a drug, it will continue to require redistribution from the epidural space to maintain equilibrium. Since you need the drug in the epidural space..and the drug is not ever able to get to equilibrium between all its "compartments"...it appears the drug is not working or not being delivered to the right place. The epidural space is not the terminal compartment, rather the initial compartment.

Researchers in France have similar results in children (age 1-7) with maximum serum concentrations at 19.2 +/-3.9min after epidural bupivicaine which are not that far different from adult populations.

Very Nice Post SDN. 👍

 

[satyr]

jwk,
are you giving the small, frequent ketamine doses until the kid is out, or are you using it for induction of geta

 

[jwk]

jwk,
are you giving the small, frequent ketamine doses until the kid is out, or are you using it for induction of geta

Hopefully I can hold the IV drugs until the baby is out. I use ketamine mainly after the baby is out and my fentanyl and valium haven't got mom under control. If I think mom is mainly feeling discomfort from pressure, I'll sometimes go with a little N2O. But if we've made the incision and we're clearly not blocked (very rare at our place) they'd buy the tube. When I do give Ketamine, it's usually just one or two 10mg bumps. And we never use Ketamine for C/S inductions - always pentothal.

In JPP's case as he has described, I probably would have gone night-night. And it truly is not as big a deal as many think it is. My previous gig was probably >50% GA for C-Sections. Never had an aspiration personally, although I have seen it happen.

 

[militarymd]

Hopefully I can hold the IV drugs until the baby is out. I use ketamine mainly after the baby is out and my fentanyl and valium haven't got mom under control. If I think mom is mainly feeling discomfort from pressure, I'll sometimes go with a little N2O. But if we've made the incision and we're clearly not blocked (very rare at our place) they'd buy the tube. When I do give Ketamine, it's usually just one or two 10mg bumps. And we never use Ketamine for C/S inductions - always pentothal.

In JPP's case as he has described, I probably would have gone night-night. And it truly is not as big a deal as many think it is. My previous gig was probably >50% GA for C-Sections. Never had an aspiration personally, although I have seen it happen.

What were the particulars of the cases where the patients did aspirate?

 

[Noyac]

What were the particulars of the cases where the patients did aspirate?

They were pregnant!