Clinical Question for the Attending Gurus

[OldManDave]

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OK...I tried to get this started way back yonder - when I had freaking free time as a CA-2. To compliment/complement (I can't freaking spell for $hit), JPP & company's clinical scenario threads, I want to throw out a series of more simplistic, yet potentially controversial clinical questions that seem steeped in mythology & pseudoscience.

How do you dose your Bupivicaine spinals for C/S?

Background: At Dartmouth, the 'range' of answers varied from the middling mythological approach of starting at "1.5ml of 0.775% bupiv for the 'standard' 5'5" lady & adding x-amount for each inch in excess of 5'5". Of course, the "...x-amt added per y-number of inches in excess..." varied by attending. The extremes were: "they all get 1.5ml of 0.75% bupiv" contrasting with "they all get the full 2ml of 0.75% bupiv" on the other end. Being a teaching facility for both anesthesia & OB/Gyn, you can imagine the c/s times were protracted vs. what you expect in the private world...please God, I hope they were protracted & NOT representative of the surgical times I expect to see in the 'real world'!

So, all of you attending-level gurus (and of course, everyone from the lowly CA-1s through the elite (wishful thinking) CA-3s) please chime in with your collective wisdom & techniques. I am all ears...and looking forward to the discussion of real-worled experience, the evidence & alternate way to skin the proverbial cat.

 

[zippy2u]

Zip's cookbook says... 1.4ccs of the hyperbaric bupiv, 25 mikes of fent and 0.2mgs of duramorph. Go down with the bupiv for 3.5 foot midgets or up for the 7+ foot amazonians. Regards, ----Zip

 

[Sevo]

1.5ml heavy marcaine with 25 mcg fentanyl and 0.3mg duramorph.

I add 0.1ml for women taller than 5'8 and go down 0.1ml for under 5'1. There's no science behind that; just anecdotal experience. I also lay them down and tilt after I empty the syringe and often give 5 to 10 mg of ephedrine off the bat.

 

[VentdependenT]

I ain't no private practice guru but here's what I use:

everyone gets 25ucg fent and 200ucg duramorph
5ft-5'8 1.5 bup.
>5'9 2.0cc bup.

Everyone gets the trendelenberg for a few minutes while the foley goes in.

 

[Planktonmd]

If you ask this question to the 30'000 practicing anesthesiologists in the U.S. you will probably get 30,000 different answers.

 

[jetproppilot]

OK...I tried to get this started way back yonder - when I had freaking free time as a CA-2. To compliment/complement (I can't freaking spell for $hit), JPP & company's clinical scenario threads, I want to throw out a series of more simplistic, yet potentially controversial clinical questions that seem steeped in mythology & pseudoscience.

How do you dose your Bupivicaine spinals for C/S?

Background: At Dartmouth, the 'range' of answers varied from the middling mythological approach of starting at "1.5ml of 0.775% bupiv for the 'standard' 5'5" lady & adding x-amount for each inch in excess of 5'5". Of course, the "...x-amt added per y-number of inches in excess..." varied by attending. The extremes were: "they all get 1.5ml of 0.75% bupiv" contrasting with "they all get the full 2ml of 0.75% bupiv" on the other end. Being a teaching facility for both anesthesia & OB/Gyn, you can imagine the c/s times were protracted vs. what you expect in the private world...please God, I hope they were protracted & NOT representative of the surgical times I expect to see in the 'real world'!

So, all of you attending-level gurus (and of course, everyone from the lowly CA-1s through the elite (wishful thinking) CA-3s) please chime in with your collective wisdom & techniques. I am all ears...and looking forward to the discussion of real-worled experience, the evidence & alternate way to skin the proverbial cat.

I give the whole thing. 15 mg HB bupiv + 25 mikes fentanyl + 200 mikes duramorph.

I'll reduce it to 12 mg if she's really short. I dont have a definition for what really short is but around 5'2" 5'3" I cut back.

 

[bullard]

Everybody at Northwestern gets 1.6 cc of 0.75% hyperbaric bupivicaine, 15 mcg of fentanyl, and 150 mcg of Duramorph (no Duramorph for BMI > 40). If our attendings change up the bupivicaine based on size, I haven't seen it yet.

 

[huktonfonix]

We almost univerally do 12mg hyperbaric bupiv + 20 fent + 200 morphine. Seems to usually last long enough. a question for JPP. Why the 15mg in private practice? Does the 12 not seem to cover most women adequately for the full C-section?

 

[johankriek]

I give 1.6cc for everyone.. I dont care how tall or short.. and I put .5mg of duramorph..

if

 

[johankriek]

I give the whole thing. 15 mg HB bupiv + 25 mikes fentanyl + 200 mikes duramorph.
.

geez.. you give the whole thing? how many high spinals have you gotten? a csection is only 20 minutes

 

[militarymd]

I give 1.6cc for everyone.. I dont care how tall or short.. and I put .5mg of duramorph..

if

you do know that it is very well documented that any dose above 0.3 mg of preservative free morphine in the CSF does not enhance analgesia but just increases side effects.

 

[urge]

nobody puts epi in their concoction?
we used during residency but I hated it.

 

[militarymd]

nobody puts epi in their concoction?
we used during residency but I hated it.

I did as a resident.

 

[jetproppilot]

geez.. you give the whole thing? how many high spinals have you gotten? a csection is only 20 minutes

Yep.

I give the whole thing, assuming they are not really vertically challenged.

You'd think one would experience more than one's share of high spinals....I havent experienced that.

I figure a spinal is a one shot deal. Ya got uno chance-oh. So I wanna minimize my chance of having a block that is inadequate for surgical analgesia.

Do you really think, if you are a 1.6 mL HB bupiv believer, that .4 more mL of HB bupiv is gonna throw parturients over the edge and suddenly youre gonna have an OB recovery room full of plastic smoking moms?

I do spinals in the sitting position. After the medicine goes in I keep her in the sitting position for 30-45 seconds, then lay her down.

Been doing that for years.

I believe it

1) helps protect from inadequate spinal

2) keeps the lady more comfortable, especially during extroversion of the uterus.

Someone asked why 15mg and not 12 in reference to time in private practice. I'm not selecting the dose based on trying to get the block to wear off quickly after the section....its not an outpatient procedure....thay are going to their room after recovery and arent getting out of bed for a while anyway. Do they go to their room a little number than others? Not sure...havent queried the nurses....but I havent had any complaints.

I give the dose I give for the above reasons.

 

[Sevo]

nobody puts epi in their concoction?
we used during residency but I hated it.

why? the average private practice c-section is 30 mins long, not a 2 hour marathon, like those commonly seen in residency.

 

[VentdependenT]

nobody puts epi in their concoction?
we used during residency but I hated it.

? PONV

I didn't think epi help prolong hyperbaric bupivicaine? I understand it has intrinsic local anesthetic properties (alpha-2 thank you) but I never use the stuff outside of labor epidurals, test doses, and peripheral nerve blocks...and codes 🙂.

 

[OldManDave]

I ain't no private practice guru but here's what I use:

everyone gets 25ucg fent and 200ucg duramorph
5ft-5'8 1.5 bup.
>5'9 2.0cc bup.

Everyone gets the trendelenberg for a few minutes while the foley goes in.

Damn! I forgot to include my own recipe...old timer's disease is acting up!

5'~5'7" --> 1.5ml bupiv
>/= 5'8" --> 2.0ml bupiv

PLUS 25mcg fentanyl + 250mcg morphine

And some slight (5~10 degrees) trendellenburg while they futz around with prep, & "time out".

 

[OldManDave]

geez.. you give the whole thing? how many high spinals have you gotten? a csection is only 20 minutes

Not to answer for JPP, but the staff who give the full 2.0ml all of the time where I am (DHMC) all swear that they have never/rarely had high-spinals & that the increased risk for them with higher volumes of interthecal injections are essentially mythology produced by mental masturbation.

 

[OldManDave]

nobody puts epi in their concoction?
we used during residency but I hated it.

We did the "epi-wash" thing for one particular OB attending. Very nice guy that the OB residents love because he is allegedly a great teacher. But, he is as SLOW as molasses in a Michagan winter! Every instance of one my spinals failing to cover the duration of a c/s was with this cat...you learn how to titrate good old ketamine! It also makes for some @$$-clench moments too!

After a few fun times with ketamine, I started placing CSEs so that I could sustain the spinal via the epidural...sad, huh?

Please God I hope that c/s in the private world do not last that long!

 

[rsgillmd]

why? the average private practice c-section is 30 mins long, not a 2 hour marathon, like those commonly seen in residency.

2 hours? I've seen that rarely (1 surgeon), and that's room in to room out. Usually we are out of the room in 1 hr 15 minutes to 1 hr 30 minutes. I guess I'm lucking.

Once I had one go about 3.5 hours -- the surgeon just kept buzzing at little bleeders, until another surgeon came in and told her to close already.

From the dosing side, we have one attending that gives 1.3 ml HB to everyone (but I haven't done a really short person with him yet), in addition to the cookbook (our institution) 15 mcg Fentanyl + 0.2 mg Duramorph. I'll go with 1.3 58-65" and 1.5 >65." I haven't had to deal with any pt. less than 58" tall yet on the OB side.

I usually find myself having to use a little trendelenburg to get the case going when I use 1.3 ml. Except for that 3.5 hour case, I haven't had my spinal wear off on me to the point that I had to supplement with ketamine.

My use of ketamine has been the occasional spinal/epidural that initially appears adequate but turns out not to be (i.e. patchy).

Regarding Duramorph my anecdotal experience has been 0.2 mg is sufficient. If I give 0.3 mg it doesn't necessarily produce better analgesia, but does produce more itching. Unless a pt. is really tall >=68" I just use 0.2 mg.

 

[pmichaelmd]

1.6-mL heavy marcaine with .200 mg morphine. I also vary the amount of marcaine depending upon extremes of height as determined by me. Under 5'? 1.5 or 1.4-mL. Over 6'6"? 1.8-mL to 2-mL. Of course, it depends on the procedure and level of expected anesthesia as well as duration of surgery.

PMMD

 

[Noyac]

I give the whole thing. 15 mg HB bupiv + 25 mikes fentanyl + 200 mikes duramorph.

I'll reduce it to 12 mg if she's really short. I dont have a definition for what really short is but around 5'2" 5'3" I cut back.

Exactly!

 

[Noyac]

Not to answer for JPP, but the staff who give the full 2.0ml all of the time where I am (DHMC) all swear that they have never/rarely had high-spinals & that the increased risk for them with higher volumes of interthecal injections are essentially mythology produced by mental masturbation.

Absolutely.

Has anyone here ever seen a total spinal with HB bupiv? My guess is no. It did occur with tetracaine but not very likely with bupiv for some reason.

I did get a pretty high one the other day with a lady that was 5'9". May have gotten one of those subarachnoid/subdural (can't remember what its called ) injections. Every so often I see some numb fingers (4th and 5th) but thats it. Pts seem to have less discomfort with the higher spinals during the externalization of the uterus, etc.

 

[coprolalia]

Pts seem to have less discomfort with the higher spinals during the externalization of the uterus, etc.

That's what the fentanyl is for. I've done plenty (at this point in my training) of each, both with and without fentanyl in the mix, and it has been my consistent observation that the women who get the fentanyl don't budge when they pull the uterus out. They just generally seem a lot more comfortably overall. When I have say (which is currently never), 25mcg of fentanyl is going into everyone of my spinals for section.

-copro

 

[dhb]

the attending covering most of OB likes bupi 10mg, sufenta 2.5mcg clonidine 37.5 mcg

 

[Planktonmd]

the attending covering most of OB likes bupi 10mg, sufenta 2.5mcg clonidine 37.5 mcg

You are training in Europe and that's a huge advantage because you guys have less lawyers, and your patients actually still trust their doctors, which allows you to try all kinds of exotic mixtures without fear of getting sued if something goes wrong.
When it comes to spinals and epidurals there is hardly any drug left that hasn't been tried by someone somewhere.

 

[DrRobert]

We have one attending who uses sufenta instead of fentanyl for all his spinals, but he doesn't seem to have a convincing reason for it.

He is also the only attending that uses isobaric bupivicaine - and yes high spinals are not that uncommon.

 

[thegasman]

all patients get 25 mcg fent and 0.2 mg astramorph. I've got 1.6 ml 0.75 hyperbaric marcaine for "nl height". If about 5'8 + I give 1.8 and if less than 5"2 than 1.4. This is how we have been trained and seems to work well. I never even considered giving all 2 cc but maybe I will give it a try sometime and see how comfortable the patient is. It sure can be a pain when the ob's have the uterus out playing around with it and the patient starts squirming/vomiting.

 

[coprolalia]

I never even considered giving all 2 cc but maybe I will give it a try sometime and see how comfortable the patient is.

Ah! The good 'ole "one size fits all" Gutsche block, a habit that all PennWee's learn and take, on average, 2 years in private practice to finally break themselves of. If you're going to do this, just make sure you have a few sticks of the purples stuff laying around.

-copro

 

[jetproppilot]

Ah! The good 'ole "one size fits all" Gutsche block, a habit that all PennWee's learn and take, on average, 2 years in private practice to finally break themselves of. If you're going to do this, just make sure you have a few sticks of the purples stuff laying around.

-copro

I think you are trying to make science of something that isnt very scientific.

 

[VentdependenT]

Before the surgeons started mandating, you heard me, that we use epidural ONLY for TKA/THA's at Rush we used to blast all the old timers with 2cc of hyperbaric.

Their pressures would eat $hit but we've never had a high spinal.

 

[Planktonmd]

Before the surgeons started mandating, you heard me, that we use epidural ONLY for TKA/THA's at Rush we used to blast all the old timers with 2cc of hyperbaric.

Their pressures would eat $hit but we've never had a high spinal.

Why are they "mandating" epidurals?

 

[VentdependenT]

Why are they "mandating" epidurals?

The big money maker ortho guy does same day TKA and THA's. He feels the pt can get out of PAR and into rehab earlier in the day because the motor block of the epidural is more easily titrated and predictible than that of a spinal.

We've (they've) tried to explain otherwise but the guy just brings in wayyyy too much money. Nevermind logic.

Now that he does it that way, all the other numbnuts want it the exact same.

 

[proman]

We have an ortho like that but takes it one step farther. No blocks of any kind. All his knees are GA.

 

[VentdependenT]

We have an ortho like that but takes it one step farther. No blocks of any kind. All his knees are GA.

Nice! I hope you cover ZERO of his post op pain crap on the floors.

 

[coprolalia]

I think you are trying to make science of something that isnt very scientific.

That was a reference to a particular attending I was working with who trained at Penn who used to always say "At Penn we did this case with..." or "At Penn we always..." and was trained by Brett Gutsche, who insisted that you did not have a good spinal block for c-section unless the patient's hands were numb. This particular attending was fresh out of residency. She always insisted on giving the 2mL of bupicaine (i.e., 15mg). And, the first few cases I did with her, we would routinely have to give at least 800-1200 mcgs of phenylephrine after the block was in. I was literally drawing up a second syringe, and sometimes a third. All in all, I did probably 4-5 cases with her this way and each time it was the same friggin' thing.

Finally, one patient vomited all over herself despite correcting the BP. After that, for the next coupla cases I would only draw-up 1.5mL (11.25 mg) of bupiv and put it in the mix. I still told her that I was giving the full 2mL/15mg when I did these cases with her. Miraculously, the patients stopped needing 2 sticks of phenylephrine, got through the entire procedure without any pain, and recovered more quickly in the PACU. By about the third case doing it this way, she said to me, "See, sometimes you just have to do more and observe that this is a good block. Not every patient's blood pressure dips."

I just smiled. 🙂

-copro

 

[Planktonmd]

That was a reference to a particular attending I was working with who trained at Penn who used to always say "At Penn we did this case with..." or "At Penn we always..." and was trained by Brett Gutsche, who insisted that you did not have a good spinal block for c-section unless the patient's hands were numb. This particular attending was fresh out of residency. She always insisted on giving the 2mL of bupicaine (i.e., 15mg). And, the first few cases I did with her, we would routinely have to give at least 800-1200 mcgs of phenylephrine after the block was in. I was literally drawing up a second syringe, and sometimes a third. All in all, I did probably 4-5 cases with her this way and each time it was the same friggin' thing.

Finally, one patient vomited all over herself despite correcting the BP. After that, for the next coupla cases I would only draw-up 1.5mL (11.25 mg) of bupiv and put it in the mix. I still told her that I was giving the full 2mL/15mg when I did these cases with her. Miraculously, the patients stopped needing 2 sticks of phenylephrine, got through the entire procedure without any pain, and recovered more quickly in the PACU. By about the third case doing it this way, she said to me, "See, sometimes you just have to do more and observe that this is a good block. Not every patient's blood pressure dips."

I just smiled. 🙂

-copro

If you were having such severe hypotension with 15mg Bupivacaine, this most likely means that your patients were dehydrated and did not receive enough IV fluids prior to placing the spinal.
I am not saying it's right or wrong to give 15 mg but the hypotnesion should not be that dramatic if the patient is well hydrated.

 

[militarymd]

If you were having such severe hypotension with 15mg Bupivacaine, this most likely means that your patients were dehydrated and did not receive enough IV fluids prior to placing the spinal.
I am not saying it's right or wrong to give 15 mg but the hypotnesion should not be that dramatic if the patient is well hydrated.

for once I agree...other point is lateral displacement of uterus

 

[coprolalia]

If you were having such severe hypotension with 15mg Bupivacaine, this most likely means that your patients were dehydrated and did not receive enough IV fluids prior to placing the spinal.
I am not saying it's right or wrong to give 15 mg but the hypotnesion should not be that dramatic if the patient is well hydrated.

for once I agree...other point is lateral displacement of uterus

Hey, guys. I'm just telling you what happened. These were elective sections. All patients were given 1-2L pre-spinal. And, of course, LUD was used. Every time I've given that much bupivicaine - EVERY TIME - I've had problems with the BP. The only other times I've had problems with the BP using less bupivicaine is when they were not pre-loaded with IVF. Likewise, each time you use that much the patient spends at LEAST an extra half-hour in the PACU. May not be a big deal in an academic center, but not how I plan to practice in the real world.

-copro

 

[jetproppilot]

Hey, guys. I'm just telling you what happened. These were elective sections. All patients were given 1-2L pre-spinal. And, of course, LUD was used. Every time I've given that much bupivicaine - EVERY TIME - I've had problems with the BP. The only other times I've had problems with the BP using less bupivicaine is when they were not pre-loaded with IVF. Likewise, each time you use that much the patient spends at LEAST an extra half-hour in the PACU. May not be a big deal in an academic center, but not how I plan to practice in the real world.

-copro

I used to wait until I saw a low BP or lady said she was nauseated until I gave a pressor.

Now I give ephedrine prophylactically when the lady lays down.

15 mg.

Not doubting your experience but I've been giving 15 mg for most C sections for years now and its rare when I have to keep giving a pressor.

Regardless of the dose you use those cases will occur....usually on big women....then I use the 50mg ephedrine IM trick.

 

[pushthesux]

Surprised to hear such large volumes since our institution's recipe is 1.2cc of heavy bupivicaine with 15mcg of fentanyl...with some attendings adding duramorph on top of this.

Have almost always seen hypotension with this (with left uterine displacement).

One thing I have noticed is that the incidence is a little higher when we lay these patients supine real quick....some attendings pull the needle out and rip the drape off in a frenzy.

Anyway, would love to see a study relating patient position in the first 10 seconds after injection and spinal block height.

I think I like the idea of prophylactic ephedrine....I hate seeing 70/40 when dad starts walking in. Luckily most of them don't have a clue!

 

[Idiopathic]

a csection is only 20 minutes

easily the funniest thing ive heard this week