SaltyDog

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Had this come up recently, and I'm wondering if any of you guys do this regularly (or ever for that matter).

Otherwise healthy labor pt with a solid epidural. Vag delivery complicated by high grade lac and subsequent repair. Anybody ever shoot some duramorph through the cath before it gets pulled?? Seems reasonable to me since high grade lacs can be equally or more painful than a C/S, but I've never seen or heard of this being done.
 

sigrhoillusion

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Had this come up recently, and I'm wondering if any of you guys do this regularly (or ever for that matter).

Otherwise healthy labor pt with a solid epidural. Vag delivery complicated by high grade lac and subsequent repair. Anybody ever shoot some duramorph through the cath before it gets pulled?? Seems reasonable to me since high grade lacs can be equally or more painful than a C/S, but I've never seen or heard of this being done.
In residency when we used a labor epidural for a c-section, we used to give Dilaudid through the epidural right before we pulled it at the end of the case. I know I read on these forums one group left the epidurals in an extra day for pain control which seems like overkill (And probably over billing...) And as I'm finishing this response I realized you were talking about lacerations not sections... but same philosophy I guess.
 

caligas

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Had this come up recently, and I'm wondering if any of you guys do this regularly (or ever for that matter).

Otherwise healthy labor pt with a solid epidural. Vag delivery complicated by high grade lac and subsequent repair. Anybody ever shoot some duramorph through the cath before it gets pulled?? Seems reasonable to me since high grade lacs can be equally or more painful than a C/S, but I've never seen or heard of this being done.
Legit. Don't think there is any extra $, but reasonable to do for a "blowout" tear.
 
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SaltyDog

SaltyDog

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In residency when we used a labor epidural for a c-section, we used to give Dilaudid through the epidural right before we pulled it at the end of the case. I know I read on these forums one group left the epidurals in an extra day for pain control which seems like overkill (And probably over billing...) And as I'm finishing this response I realized you were talking about lacerations not sections... but same philosophy I guess.
We always give epidural Duramorph for sections done under epidural.

Legit. Don't think there is any extra $, but reasonable to do for a "blowout" tear.
I would imagine it's reimbursable provided you round on them the following day just like after a section. That's something I'll have to look into though.
 

urge

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How much would you put in?
 
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SaltyDog

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How much would you put in?
I would probably just give the same dose we do for sections which is 3mg at my shop. I know women who have had both lacs and sections and the lacs were more painful.
 

sevoflurane

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Had this come up recently, and I'm wondering if any of you guys do this regularly (or ever for that matter).

Otherwise healthy labor pt with a solid epidural. Vag delivery complicated by high grade lac and subsequent repair. Anybody ever shoot some duramorph through the cath before it gets pulled?? Seems reasonable to me since high grade lacs can be equally or more painful than a C/S, but I've never seen or heard of this being done.
Don't do it regularly as I'm not around when these lacs happen. I wouldn't have a problem giving some epidural duramorph to try and help out the situation.
 

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Yup. 3 mg of PF morphine through the epidural then take it out afterwards. Do it for all regular C-sections too.
 

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Sounds like a reasonable option for rare cases, would not make it routine practice.


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polar403

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One study in 2000 showed that doses of duramorph post c-section had analgesia increase up to doses as high as 3.75 mg. A more recent study in 2013 showed that 1.5 mg was not inferior to 3 mg when combined with scheduled ketorolac and acetaminophen and PRN oxycodone.

I have generally given 3 mg post c-section and have also given it if there was a major laceration repair after SVD.
 

Hoya11

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Had this come up recently, and I'm wondering if any of you guys do this regularly (or ever for that matter).

Otherwise healthy labor pt with a solid epidural. Vag delivery complicated by high grade lac and subsequent repair. Anybody ever shoot some duramorph through the cath before it gets pulled?? Seems reasonable to me since high grade lacs can be equally or more painful than a C/S, but I've never seen or heard of this being done.
I personally dont understand the allure of intrathecal or epidural opiods. Just give it IV, or give more powerful/longer acting oral opioids. I would bolus with dilute bupi before pulling if you want to be extra nice...
 

fakin' the funk

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Had this come up recently, and I'm wondering if any of you guys do this regularly (or ever for that matter).

Otherwise healthy labor pt with a solid epidural. Vag delivery complicated by high grade lac and subsequent repair. Anybody ever shoot some duramorph through the cath before it gets pulled?? Seems reasonable to me since high grade lacs can be equally or more painful than a C/S, but I've never seen or heard of this being done.
Yes. For high grade perineal lacs we are commonly asked by the OBs to do so. I do 2mg.
 
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Random Anesthesiologist

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Do you still follow after you pull the epidural if you give duramorph? We are on the hook for 24h.
 
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SaltyDog

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I personally dont understand the allure of intrathecal or epidural opiods. Just give it IV, or give more powerful/longer acting oral opioids.
I can't say I ever felt real strongly about it until I got to experience it (second hand) after my wife's recent C-section. She felt so much better for the 24H of Duramorph and was able to get out of bed and ambulate much easier with significantly less pain than on days 2-5. Also factor in that PO opioids make a lot of people nauseous (especially in the OB demographic). Then there's the lactation issue as well. All together, I think neuraxial opioids are excellent for post-op pain control, especially in the OB crowd.

I would bolus with dilute bupi before pulling if you want to be extra nice...
Sorry, but I think that's a lousy plan. If you're gonna do that, you'd be better off just continuing the epidural infusion.
 

Hoya11

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I can't say I ever felt real strongly about it until I got to experience it (second hand) after my wife's recent C-section. She felt so much better for the 24H of Duramorph and was able to get out of bed and ambulate much easier with significantly less pain than on days 2-5. Also factor in that PO opioids make a lot of people nauseous (especially in the OB demographic). Then there's the lactation issue as well. All together, I think neuraxial opioids are excellent for post-op pain control, especially in the OB crowd.



Sorry, but I think that's a lousy plan. If you're gonna do that, you'd be better off just continuing the epidural infusion.
Disagree about neuraxial opiates. They can cause severe itch (not often but when it occurs nasty) and are less effective than IV narcs. If there weren't the opportunity to bill for the duramorph would we even be having this conversation? I bet IV dilaudid/oxycontin would have worked just as well for your wife on POD 1. As far as lactation I doubt there would be any difference if a few doses of IV dilaudid/some other opiate is given vs PO percocet. In short, I'd worry that some women would develop severe itching/other side effect for 24hrs in order to treat pain less effectively than the IV would have. Maybe epidural fentanyl makes more sense. At least if there is nausea or itch after IV it wears off soon. Different strokes for different folks though. I dont think giving duramorph for lacs is unreasonable, its just unnecessary IMO and a set up for a complaint from a patient and the inevitable: why the F is he giving duramorph for lacs anyway?

Also as far as leaving catheters in post op for pain control that is a great way to do it, but you cant do this for everybody practically, and eventually every catheter comes out and i have seen success with the "one for the road" dilute bupi bolus.
 
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SaltyDog

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Disagree about neuraxial opiates. They can cause severe itch (not often but when it occurs nasty) and are less effective than IV narcs. If there weren't the opportunity to bill for the duramorph would we even be having this conversation? I bet IV dilaudid/oxycontin would have worked just as well for your wife on POD 1. As far as lactation I doubt there would be any difference if a few doses of IV dilaudid/some other opiate is given vs PO percocet. In short, I'd worry that some women would develop severe itching/other side effect for 24hrs in order to treat pain less effectively than the IV would have. Maybe epidural fentanyl makes more sense. At least if there is nausea or itch after IV it wears off soon. Different strokes for different folks though. I dont think giving duramorph for lacs is unreasonable, its just unnecessary IMO and a set up for a complaint from a patient and the inevitable: why the F is he giving duramorph for lacs anyway?

Also as far as leaving catheters in post op for pain control that is a great way to do it, but you cant do this for everybody practically, and eventually every catheter comes out and i have seen success with the "one for the road" dilute bupi bolus.
I agree that any clinically significant concerns regarding lactation are minute, but in this day and age (and with my hoity toity pt population) they are there.

My wife got Percocet and dilaudid after the 24h of Duramorph. They were NOT as effective, but more importantly they caused significant nausea which made her reluctant to take them which meant she dealt with more pain.

I agree a small percentage really itch, but with modern dosing it's not a huge issue for the vast majority of pts.

When you look at the chart of IV v PO v neuraxial opioid administration in any anesthesia txt you will see that each has its own pros and cons. I think for the OB pts the pros vastly outweigh the cons. The opposite is probably true for the frail old man with urinary retention.