Failed Epidural for C section-Now What?

[jwk]

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I guess I'm just skeptical that the average patient really prefers being anchored to a bed with numb legs and a tube in her back for 24 hours, vs ambulating with a heplocked IV and intrathecal narcotics.

I'm one of those rare guys who likes doing OB, and although my patients are pretty consistently satisfied, I'm always looking for ways to make their experience better. I'm trying to convince myself to give this 24 hr post-c-section epidural thing a shot, but I don't see it.

Fentanyl 5mcg/cc / bupiv 0.04% with a rate of 5cc/hr if I remember the pre-printed orders correctly. They're not numb. They ambulate 4-6hrs postop per whatever "pathway" or protocol is set up by the hospital. We have acute pain NP's that round on all our post-op pain patients twice a day and a doc once a day. Since we have in-house anesthesia, someone is always available to see these patients if needed, day or night. The epidural cath is pulled 24-36 hrs postop as soon as the patient is taking PO.

 

[IlDestriero]

Back in the day, I would do CSEs on everyone. Leave the epidural off and go home to bed, or out to dinner, the store, the gym, walk the dog, etc. We had to be there, by policy, for a running epidural. I think my spinal solution was 1.2cc 0.25% bupiv with 20mcg fent, 0.2mg morphine and epi. It would free me up for 2-4 hours, occasionally longer. Worked fine. Rarely there was transient fetal bradycardia, less after I switched from sufenta to fentanyl.

 

[sevoflurane]

Back in the day, I would do CSEs on everyone. Leave the epidural off and go home to bed, or out to dinner, the store, the gym, walk the dog, etc. We had to be there, by policy, for a running epidural. I think my spinal solution was 1.2cc 0.25% bupiv with 20mcg fent, 0.2mg morphine and epi. It would free me up for 2-4 hours, occasionally longer. Worked fine. Rarely there was transient fetal bradycardia, less after I switched from sufenta to fentanyl.

Daannng...!

That is supah ninja.

 

[Mman]

Back in the day, I would do CSEs on everyone. Leave the epidural off and go home to bed, or out to dinner, the store, the gym, walk the dog, etc. We had to be there, by policy, for a running epidural. I think my spinal solution was 1.2cc 0.25% bupiv with 20mcg fent, 0.2mg morphine and epi. It would free me up for 2-4 hours, occasionally longer. Worked fine. Rarely there was transient fetal bradycardia, less after I switched from sufenta to fentanyl.

Can I at least point out the stupidity of a policy that requires you to be there if the epidural is running but couldn't give a rat's behind if you leave after bolusing the spinal? Nonclinical person came up with that bright idea.

 

[IlDestriero]

Can I at least point out the stupidity of a policy that requires you to be there if the epidural is running but couldn't give a rat's behind if you leave after bolusing the spinal? Nonclinical person came up with that bright idea.

Well, in theory, a running epidural or pcea could do something bad, cause hypotension, etc etc. the spinal shouldn't act up after it sets up. At least that's my thinking, and how things went down. Obviously this it's only useful in a low volume service, and once there was one running, I was stuck there. It was actually the OB service's addition to the policy. We can blame the midwives though.😉
I should have added some clonidine to that soup.😀

 

[pgg]

Just because you have an epidural running doesn't mean you need to be stuck in the hospital.

Our hospital policy is that anesthesia stays in house so long as an epidural is running. The OB is required to be there too.

We allow our (experienced) nurses to give pressors under strict preset orders. We also allow them to give a small bolus over 10 minutes (on pump of course). Everyone is happy. Patient, doc, nurse.

Yeah, that wouldn't fly here. 🙂

I've never heard of a "long acting labor spinal". They better be there monitoring the patients... that sounds like a disaster waiting to happen if they are using more than 1cc of .25% marcaine... which as you know, doesn't last 2 hours.

One of the guys I knew who used to work there said he used 1 cc of the .75% bupiv in the spinal kits. If delivery was imminent he'd cut back. It's an odd setup for sure.

 

[foshizzo]

If you're a SOAP member, there's a nice video of a pro/con debate addressing this issue here:

http://www.anesthesiaillustrated.com/portfolio/debate-urgent-cs-and-the-failed-epidural/

 

[pillowhead]

Our peak year about 3-4 years ago, before we added OB services at a new hospital in our system, was 18,000 deliveries at a single community hospital. We have the largest non-academic OB practice in the country. A few years ago we added a second hospital (same system) doing OB, and now have a third. For the three hospitals, we're now probably at 20-21k total. At the biggest hospital, I was guessing the C/S rate at about 33% - we do a TON of repeat C-Sections and a minimum of VBAC's, even with in-house OB and anesthesia.

As you might imagine, the logistics are crazy sometimes, particularly at our main hospital which has 5 C/S OR's. There are 3 MD's and 4-5 anesthetists that do nothing but OB on weekdays, and 24/7 MD and anesthetist coverage at all three hospitals with additional backup on call. Our OB anesthetists do only sections and manage labor epidurals when assigned to OB - they have no surgical OR responsibilities. The anesthesiologists place all the epidurals. On a busy day, an anesthesiologist might put in 20 epidurals. I think our single day-record at one hospital is near 80 deliveries. That hospital has about 75 labor rooms. BTW, our group is approaching 150 docs, AA's, and CRNA's.

Delivered there a couple of years ago. Will be there again sometime soon (38 weeks now). Would never deliver where I work.

 

[pgg]

Fentanyl 5mcg/cc / bupiv 0.04% with a rate of 5cc/hr if I remember the pre-printed orders correctly. They're not numb. They ambulate 4-6hrs postop per whatever "pathway" or protocol is set up by the hospital. We have acute pain NP's that round on all our post-op pain patients twice a day and a doc once a day. Since we have in-house anesthesia, someone is always available to see these patients if needed, day or night. The epidural cath is pulled 24-36 hrs postop as soon as the patient is taking PO.

OK this is more in line with the post-delivery narcotic-only epidurals we were talking about here a while ago, doesn't look as wacky as I initially thought. 🙂 Sounds like a nice setup. 👍

 

[HollywdAnesth]

If you have a patchy epidural and a terrible airway, why not break out an ultrasound and do some TAP blocks?

They take very little time to do and will cover most of the procedural pain?

 

[sevoflurane]

If you have a patchy epidural and a terrible airway, why not break out an ultrasound and do some TAP blocks?

They take very little time to do and will cover most of the procedural pain?

Great idea for a patchy block....! 👍

I'll keep that in mind.

But in general....

Tap blocks:

Epidural:

Spinal:

😉

😀

 

[sevoflurane]

They are great for GA C/S.... and I think I'll Tap my next patchy block (honeslty can't remember the last time I had a patchy block for C/S).

That is a great idea if you just bolused and don't want to do a spinal.

 

[BobBarker]

Epidural infusion fentanyl=intravenous fentanyl

If the anesthesiologists place all of the epidurals what role are your midlevels playing?

 

[IlDestriero]

Epidural infusion fentanyl=intravenous fentanyl

If the anesthesiologists place all of the epidurals what role are your midlevels playing?

Scribe for billing, and c/s biatch probably.

 

[BLADEMDA]

They are great for GA C/S.... and I think I'll Tap my next patchy block (honeslty can't remember the last time I had a patchy block for C/S).

That is a great idea if you just bolused and don't want to do a spinal.

Evidence based medicine doesn't really support TAP blocks vs adding a little duramorph for post op pain relief.
Sorry

http://www.ncbi.nlm.nih.gov/pubmed/20488929

CONCLUSION:

As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.


http://www.ncbi.nlm.nih.gov/pubmed/22410586

CONCLUSIONS:

In this trial, the TAP block was associated with greater supplemental morphine requirements and higher pain scores than intrathecal morphine but fewer opioid-related side effects. The TAP block may be a reasonable alternative when intrathecal morphine is contraindicated or not appropriate.

 

[BLADEMDA]

Br J Anaesth. 2011 May;106(5):706-12.
Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.

McMorrow RC, Ni Mhuircheartaigh RJ, Ahmed KA, Aslani A, Ng SC, Conrick-Martin I, Dowling JJ, Gaffney A, Loughrey JP, McCaul CL.
Source

Department of Anesthesia, Rotunda Hospital, Parnell Square, Dublin 1, Ireland.

Abstract

BACKGROUND:

Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial.
METHODS:

Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 µg (S(M)) or saline (S(S)) and a postoperative bilateral TAP block with either bupivacaine (T(LA)) 2 mg kg(-1) or saline (T(S)).
RESULTS:

Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: S(M)T(LA) (20 mm)<S(M)T(S) (27.5 mm)<S(S)T(S) (51.5 mm)<S(S)T(LA) (52.0 mm) (P<0.05, highest vs lowest). The rank order of median morphine consumption at 6 h was: S(M)T(S) (4.0 mg)<S(M)T(LA) (5.0 mg)<S(S)T(LA) (8.0 mg)<S(S)T(S) (12.0 mg) and at 24 h was: S(M)T(LA) (5.0 mg)<S(M)T(S) (6.0 mg)<S(S)T(S) (9.5 mg)<S(S)T(LA) (15.0 mg) (P<0.05, highest vs lowest). Sedation scores and patient satisfaction did not differ between groups. Anti-emetic use and pruritus were highest in the S(M)T(LA) group.
CONCLUSIONS:

Spinal morphine-but not TAP block-improved analgesia after Caesarean section. The addition of TAP block with bupivacaine 2 mg kg(-1) to spinal morphine did not further improve analgesia.

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/19916252

CONCLUSIONS:

The TAP block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve the quality of post-CD analgesia

 

[Mman]

If you have a patchy epidural and a terrible airway, why not break out an ultrasound and do some TAP blocks?

They take very little time to do and will cover most of the procedural pain?

Let's say you just bolused 400 mg of lidocaine in the epidural and it's still too patchy to do a c-section. How much local are you going to use for your TAP blocks? When I do them for postop pain it's 20mls on each side. That's a lot of local to give someone who just had a bunch of local in their epidural.

 

[BLADEMDA]

Let's say you just bolused 400 mg of lidocaine in the epidural and it's still too patchy to do a c-section. How much local are you going to use for your TAP blocks? When I do them for postop pain it's 20mls on each side. That's a lot of local to give someone who just had a bunch of local in their epidural.

1. I'm going to do GA 99% of the time here
2. I would just re-do the epidural (faster than a TAP block)
3. I could do a spinal but would want to wait 30 min.

TAP block for section? Ain't gonna happen in 99% plus of private practices.

 

[jwk]

Scribe for billing, and c/s biatch probably.

Gee thanks for that!

We do labor boluses as needed and all the C-Sections. I can't begin to tell you how many "miracles of birth" I've seen over the years.

 

[doctron]

Prop
Sux
Tube

End of discussion

Seriously...

You guys need to get a life

 

[HollywdAnesth]

Evidence based medicine doesn't really support TAP blocks vs adding a little duramorph for post op pain relief.
Sorry

http://www.ncbi.nlm.nih.gov/pubmed/20488929

CONCLUSION:

As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.


http://www.ncbi.nlm.nih.gov/pubmed/22410586

CONCLUSIONS:

In this trial, the TAP block was associated with greater supplemental morphine requirements and higher pain scores than intrathecal morphine but fewer opioid-related side effects. The TAP block may be a reasonable alternative when intrathecal morphine is contraindicated or not appropriate.

Is this a discussion of post op pain or intraoperative anesthesia? Nobody would argue with you that 24 hour acting duramorph gives better post op pain relief than the local anesthetic used for a TAP block.

I thankfully don't do OB anymore, but I would rather do a controlled intubation at the beginning rather than putz around underneath the drapes during the case.

Put a tube in her, you and the patient will both rest easier.

 

[sevoflurane]

Evidence based medicine doesn't really support TAP blocks vs adding a little duramorph for post op pain relief.
Sorry

http://www.ncbi.nlm.nih.gov/pubmed/20488929

CONCLUSION:

As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.


http://www.ncbi.nlm.nih.gov/pubmed/22410586

CONCLUSIONS:

In this trial, the TAP block was associated with greater supplemental morphine requirements and higher pain scores than intrathecal morphine but fewer opioid-related side effects. The TAP block may be a reasonable alternative when intrathecal morphine is contraindicated or not appropriate.

Let me first refer you to post # 161 to let you know how I compare tap blocks to epidurals and spinals.

Now take a good look at what I said:

They are great for GA C/S.... and I think I'll Tap my next patchy block (honeslty can't remember the last time I had a patchy block for C/S).

That is a great idea if you just bolused and don't want to do a spinal.

Tap blocks are the bomb when it comes to patients who get general anesthesia for their C-sections. That means failed or no neuraxial 99% of the time.

I'm going to do a 3 minute bilateral TAP block right after the last stich goes in... every single time... and while they are under GA.

Adding a TAP block to a GA section (usually stat or failed neuraxial) is way better than GA by itself. Plenty of studies out there supporting this. Just look it up.

You can go ahead and place an intrathecal dose of duramorph after you prop/sux tube a stat C/S patient, turn on the nitrous/vapors, paralyze them, reverse them , wake them up and then kindly ask them to sit for their spinal morphine because it's better than a TAP block. I'll tap &#8216;em in 3 minutes and get 24 hours of analgesia.

Depending on how big of a area you have, you can easily get away with the surgeon adding local at the hot spot. Adding dilute LA via a TAP block near the incision dermatome is icing on the cake.

 

[BLADEMDA]

Let me first refer you to post # 161 to let you know how I compare tap blocks to epidurals and spinals.

Now take a good look at what I said:




Tap blocks are the bomb when it comes to patients who get general anesthesia for their C-sections. That means failed or no neuraxial 99% of the time.

I'm going to do a 3 minute bilateral TAP block right after the last stich goes in... every single time... and while they are under GA.

Adding a TAP block to a GA section (usually stat or failed neuraxial) is way better than GA by itself. Plenty of studies out there supporting this. Just look it up.

You can go ahead and place an intrathecal dose of duramorph after you prop/sux tube a stat C/S patient, turn on the nitrous/vapors, paralyze them, reverse them , wake them up and then kindly ask them to sit for their spinal morphine because it's better than a TAP block. I'll tap &#8216;em in 3 minutes and get 24 hours of analgesia.

Depending on how big of a area you have, you can easily get away with the surgeon adding local at the hot spot. Adding dilute LA via a TAP block near the incision dermatome is icing on the cake.

In the same 3-5 min you can roll the patient on her side and place an SAB thereby adding the Duramorph. This could be done at the end of the case prior to extubation. The studies show Duramorph is superior to bilateral TAP blocks. I've placed hundreds of SABs/Epidurals on asleep patients without any complications.

The main reason for bilateral TAP blocks after a C Section over a single injection of subarachnoid Duramorph is billing. You can bill and collect really good money doing bilateral TAP blocks compared to a single SAB injection.

 

[sevoflurane]

In the same 3-5 min you can roll the patient on her side and place an SAB thereby adding the Duramorph. This could be done at the end of the case prior to extubation. The studies show Duramorph is superior to bilateral TAP blocks. I've placed hundreds of SABs/Epidurals on asleep patients without any complications.

The main reason for bilateral TAP blocks after a C Section over a single injection of subarachnoid Duramorph is billing. You can bill and collect really good money doing bilateral TAP blocks compared to a single SAB injection.

There is NO WAY I'm going to do a spinal under GA if I can do a TAP block instead.

All it takes is to be a little off midline and your spinal needle goes right into a nerve root... and you loose your best monitor. Patient feedback.

No thanks.

 

[sevoflurane]

The main reason for bilateral TAP blocks after a C Section over a single injection of subarachnoid Duramorph is billing. .

This is a bold statement.

When I round on my patients, often times they can tell me around what time the block wore off.

 

[sevoflurane]

It may help with chronic pain as well:

"The purpose of this randomized, double-blinded study is to evaluate the ability of an established anesthetic technique called the transversus abdominis plane (TAP) block to reduce the amount of hyperalgesia women develop around their incision after CS."

http://clinicaltrials.gov/ct2/show/NCT01015807 (this study is being completed this month)

"We conclude that the TAP block holds considerable promise as part of a multimodal analgesic regimen for postcesarean delivery analgesia. The TAP block was easy to perform, and provided reliable and effective analgesia in this study, and no complications due to the TAP block were detected."

http://www.anesthesia-analgesia.org/content/106/1/186.full

 

[BLADEMDA]

There is NO WAY I'm going to do a spinal under GA if I can do a TAP block instead.

All it takes is to be a little off midline and your spinal needle goes right into a nerve root... and you loose your best monitor. Patient feedback.

No thanks.

Really? My group's N is well over 10,000 fully anesthetized patients who got needles in their back. In addition, this technique is widely utilized in pediatrics.

The fact remains is a single shot of subarachnoid Duramorph is superior to bilateral TAP blocks for post c Section pain relief. But, reimbursement is much better for the Anesthesiologist who chooses TAP blocks.

 

[BLADEMDA]

Anesth Analg. 2003 Jun;96(6):1547-52, table of contents.
Small risk of serious neurologic complications related to lumbar epidural catheter placement in anesthetized patients.
Horlocker TT, Abel MD, Messick JM Jr, Schroeder DR.
Source
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA. [email protected]
Abstract
Previous studies have identified pain during needle/catheter placement or during the injection of local anesthetic as a risk factor for the development of persistent paresthesias after regional anesthetic techniques. The performance of regional blockade on anesthetized patients theoretically increases the risk of postoperative neurologic complications, because these patients are unable to respond to painful stimuli. In this study, we evaluated the frequency of neurologic complications in 4298 thoracic surgical patients undergoing lumbar epidural catheter placement while under general anesthesia. Catheters were placed immediately after the induction and tracheal intubation or on completion of the surgical procedure, before emergence. Most epidural catheters (4220, or 98.2%) were used solely for postoperative analgesia; only 78 (1.8%) epidural catheters were used for intraoperative anesthesia. In 4239 (98.6%) patients, an opioid alone was administered. The remaining 56 (1.3%) patients received a local anesthetic or local anesthetic/opioid mixture epidurally. Analgesia was graded as excellent or good in 92.2% of patients. Side effects included sedation in 455 (10.6%), nausea or emesis in 328 (7.6%), pruritus in 116 (2.7%), and respiratory depression (pH <or=7.3 and PaCO(2) >or=50 mm Hg) in 308 (7.2%) patients. The mean duration of epidural analgesia was 2.4 +/- 0.8 days (range, 0-10.7 days). There were no neurologic complications, including spinal hematoma, epidural abscess or catheter site infections, radicular symptoms, or persistent paresthesias (95% confidence interval, 0%-0.08%). In one patient, the epidural catheter broke during removal, and a portion was retained. The patient was notified; no long-term sequelae were noted. Six patients developed new neurologic symptoms or postoperative worsening of a previous neurologic condition unrelated to epidural catheterization. We conclude that the risk of neurologic complications associated with lumbar epidural catheter placement in anesthetized patients is small. However, the relative risk of this practice, compared with epidural catheter placement in awake patients, is unknown. IMPLICATIONS: We report no neurologic complications in 4298 patients undergoing epidural catheter placement while under general anesthesia. Although the risk of neurologic complications associated with lumbar epidural catheter placement in anesthetized patients is small, the relative risk compared with epidural catheterization in awake patients is unknown.
Comment in
Epidural insertion in anesthetized adults: will your patients thank you? [Anesth Analg. 2003]
PMID: 12760972 [PubMed - indexed for MEDLINE] Free full text
Publication Types, MeSH Terms, Substances

LinkOut - more resources

 

[BLADEMDA]

In 2008 McDonnell et*al. [1] published a study demonstrating that the transversus abdominis plane (TAP) block reduced morphine requirements following elective caesarean section. Patients in this study received subarachnoid anaesthesia without a long acting opioid. In our unit we use spinal diamorphine for our elective caesarean sections [2]. We wished to establish whether the TAP block should be introduced into our routine practice.


Methods
Following Research Ethics Committee approval, we recruited 48 elective caesarean section parturients who were randomly assigned to undergo TAP block with either bupivacaine (n*=*23) or saline (n*=*25). All patients received a spinal anaesthetic with 0.5% heavy bupivacaine and 300*&#956;g diamorphine. On completion of surgery, bilateral TAP blocks were performed under ultrasound guidance. All patients received a loading dose of rectal diclofenac and paracetamol. Standard postoperative analgesia comprised regular diclofenac and paracetamol, and subcutaneous morphine on request. A blinded investigator assessed each patient postoperatively 2, 6, 24 and 48*h postoperatively.


Results
There were no statistically significant differences in postoperative morphine requirement (Fig.*1) or visual analogue pain scores between the two groups. The incidence of side effects was similar.


Figure*1. &#8194;Proportion of patients not receiving morphine after TAP block with either bupivacaine or saline.


Discussion
The TAP block does not improve analgesia following elective caesarean section under subarachnoid block with intrathecal diamorphine. The multimodal analgesic regimen used in our unit means that routine implementation of the TAP block for elective caesarean section would not be beneficial.


References
1
McDonnell JG, Curley G, Carney J, et*al. The analgesic efficacy of transversus abdominis plane block after caesarean delivery: a randomised controlled trial. Anesthesia and Analgesia 2008; 106: 186&#8211;92.
CrossRef,PubMed,CAS,Web of Science® Times Cited: 25
2
Wrench IJ, Sanghera S, Pinder A, Power L, Adams MG. Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard. International Journal of Obstetric Anesthesia 2007; 16: 17&#8211;21.
CrossRef,PubMed,CAS,Web of Science® Times Cited: 3

 

[sevoflurane]

Really? My group's N is well over 10,000 fully anesthetized patients who got needles in their back. In addition, this technique is widely utilized in pediatrics.

The fact remains is a single shot of subarachnoid Duramorph is superior to bilateral TAP blocks for post c Section pain relief. But, reimbursement is much better for the Anesthesiologist who chooses TAP blocks.

I've placed tons of epidruals and caudals under GA in the pediatric population. I've never placed a spinal under GA in the pediatrics population.

Doing a spinal in an adult patient that is undergoing GA is not something I don't see myself ever doing.

The OB population have a lot of back issues anyways.. They can develop neruopathies prior, during and after their c/s. What happends then? Pain in the arse.

TAP blocks are certinaly inferior to spinals... I said that in post #161, but in my book spinals are not worth the risk while the patient is asleep.

No thanks. I'll pass.

 

[BLADEMDA]

I've placed tons of epidruals and caudals under GA in the pediatric population. I've never placed a spinal under GA in the pediatrics population.

Doing a spinal in an adult patient that is undergoing GA is not something I don't see myself ever doing.

The OB population have a lot of back issues anyways.. They can develop neruopathies prior, during and after their c/s. What happends then? Pain in the arse.

TAP blocks are certinaly inferior to spinals... I said that in post #161, but in my book they are not worth the risk of placing one while the patient is asleep.

No thanks. I'll pass.

That's fine. But, my hunch is that with heavy sedation and/or IV propofol being utilized for many SABs in private practice that hundreds of thousands of spinals have been placed under essentially "GA" without complications. I know that my group uses heavy sedation for SAB blocks and I estimate at least 50,000 or more SABs with minimal patient feedback (if you know what I mean).

 

[sevoflurane]

While I respect your point of view, at this point in my career, I love patient feedback when I'm performing neuraxial techniques.

"Ouch... I felt that go down my leg"... these are not words that are unfamiliar to us.

I don't even find sedation necessary. Skin is the only painful part. 1/2 a cc of 2% lido takes care of that.

 

[BLADEMDA]

While I respect your point of view, at this point in my career, I love patient feedback when I'm performing neuraxial techniques.

"Ouch... I felt that go down my leg"... these are not words that are unfamiliar to us.

I don't even find sedation necessary. Skin is the only painful part. 1/2 a cc of 2% lido takes care of that.

That's fine. In Ob it is just local. In the main OR it is heavy sedation. My point is that single injection spinals are extremely safe and the data supports that statement. Every day spinal injections are placed across the USA under heavy sedation/GA.

 

[fakin' the funk]

This thread is awesome.

For a second, based on Blade's reactions, I thought someone had proposed using TAP blocks as a surgical anesthetic for CS.

Then, I saw sevo's clarification, and thought, "whew," and realized Blade was just Pubmed-blasting us like usual.

As I continued to scroll up, there ya go, HollywoodAnesth suggesting TAP as surgical anesthetic.

And now we're doing spinals on patients under GA! So awesome!

 

[BobBarker]

This thread is awesome.

For a second, based on Blade's reactions, I thought someone had proposed using TAP blocks as a surgical anesthetic for CS.

Then, I saw sevo's clarification, and thought, "whew," and realized Blade was just Pubmed-blasting us like usual.

As I continued to scroll up, there ya go, HollywoodAnesth suggesting TAP as surgical anesthetic.

And now we're doing spinals on patients under GA! So awesome!

I find the fact that the largest OB practice in the country doesn't do spinals even more odd. It has to be pure billing motivated.

 

[dhb]

Superior pain control with more side effects does not equate higher patient satisfaction: i'd rather have a TAP block than IT morphine

 

[BLADEMDA]

I've placed tons of epidruals and caudals under GA in the pediatric population. I've never placed a spinal under GA in the pediatrics population.

Doing a spinal in an adult patient that is undergoing GA is not something I don't see myself ever doing.

The OB population have a lot of back issues anyways.. They can develop neruopathies prior, during and after their c/s. What happends then? Pain in the arse.

TAP blocks are certinaly inferior to spinals... I said that in post #161, but in my book spinals are not worth the risk while the patient is asleep.

No thanks. I'll pass.

TAP blocks after a GA for a C-Section are fine. I've got no issues with your excellent care. That said, I really don't believe there are any isues to doing an Epidural or SAB under GA provided all you inject is Morphine. But, your time and effort will be better rewarded in our current health system by placing bilateral TAP blocks.

 

[BLADEMDA]

I find the fact that the largest OB practice in the country doesn't do spinals even more odd. It has to be pure billing motivated.

Absolutely. It is all about Billing,convenience and efficiency. With the payer mix in JWK's Group I would be happy to do bilateral TAP blocks after every Section along with a dilute epidural mixture for 24 hours.

 

[IlDestriero]

One of the other local groups doesn't do IT opiates at all for c/s. Bupiv spinal, and a post op pca. I think dilaudid. They say calls about opiate side effects went away and pt satisfaction improved. Though I suspect it was nursing satisfaction that improved. I just write generous prn orders. They NEVER call. I suspect that it is the culture here vs there. The only time they would bother us is for hypotension, intractable N/V, or an urgent concern.

 

[BLADEMDA]

One of the other local groups doesn't do IT opiates at all for c/s. Bupiv spinal, and a post op pca. I think dilaudid. They say calls about opiate side effects went away and pt satisfaction improved. Though I suspect it was nursing satisfaction that improved. I just write generous prn orders. They NEVER call. I suspect that it is the culture here vs there. The only time they would bother us is for hypotension, intractable N/V, or an urgent concern.

If you keep the IT Mso4 in the 150-200 microgram range the side-effects are very manageable. About 90% of my C sections get an SAB with Duramorph or an existing Epidural with Duramorph (3 mg).

 

[HollywdAnesth]

As I continued to scroll up, there ya go, HollywoodAnesth suggesting TAP as surgical anesthetic.

If you had bothered to read my post, it said in a patient with a patchy epidural with an anticipated difficult airway.

I've had anesthesiologists from Australia tell me that they do all of their "Caesars" under just bilateral TAP blocks. I told them that I think they're crazy, and that they're patients probably do too if the OBs exteriorize the uterus.

Chalk me up for being another person that would never place a neuraxial block on a patient already under GA or a spinal after a bolus in the epidural space.

 

[jwk]

I find the fact that the largest OB practice in the country doesn't do spinals even more odd. It has to be pure billing motivated.

Patients are happy, the surgeons are happy, we're happy, the hospital is happy. Those who don't place epidurals and keep them in for post-op pain seem odd to me. Much of what we do is enabled simply due to our high volume of patients. Having a dedicated NP or other staff solely tasked to an acute pain service doesn't make good economic sense if you only have a couple patients a day with post-op epidurals or PCA's. However, if you have 40+ patients to manage at any given time (both OB and OR postops) then the economics are more reasonable.

 

[IlDestriero]

Chalk me up for being another person that would never place a neuraxial block on a patient already under GA or a spinal after a bolus in the epidural space.

You should never say never, but I understand your concerns. Just be aware that some of us do regional and neuraxial blocks in children under GA every day with no problems.
I might not want to do it blind on a beached whale, but if they had good landmarks or I worked it out with the ultrasound, I wouldn't give it a second thought.

 

[BobBarker]

200mcg of duramorph intrathecal, 30mg Ketorolac q 8 routine x 3. They don't hurt and aren't numb.

 

[HollywdAnesth]

You should never say never, but I understand your concerns. Just be aware that some of us do regional and neuraxial blocks in children under GA every day with no problems.
I might not want to do it blind on a beached whale, but if they had good landmarks or I worked it out with the ultrasound, I wouldn't give it a second thought.

I hardly do Peds anymore, so this slipped my mind. Thanks.

 

[Mman]

Patients are happy, the surgeons are happy, we're happy, the hospital is happy. Those who don't place epidurals and keep them in for post-op pain seem odd to me. Much of what we do is enabled simply due to our high volume of patients. Having a dedicated NP or other staff solely tasked to an acute pain service doesn't make good economic sense if you only have a couple patients a day with post-op epidurals or PCA's. However, if you have 40+ patients to manage at any given time (both OB and OR postops) then the economics are more reasonable.

your patients might be happier if they had a CSE for the c-section compared to an epidural. It's an inferior anesthetic to a spinal, even when freshly placed in the OR. There is no combination of meds you can place into the epidural space that will provide as reliable or as dense an anesthetic as a spinal.

 

[Mman]

200mcg of duramorph intrathecal, 30mg Ketorolac q 8 routine x 3. They don't hurt and aren't numb.

why 30 of ketorolac? that's the IM dose, but plenty of evidence that you need less for IV doses.

 

[BobBarker]

Honestly, probably just the dose they have always used. Nubain for duramorph itching, I give buprenex as my prn breakthrough pain med of choice. Always works in my limited personal n.

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/7893022

After this article came out many began switching from Epidural to Spinal Anesthesia for C-Section. By the late 1990's almost everyone was doing a spinal for an elective or scheduled C section.

I started my career doing Epidurals for scheduled sections and gradually began moving to spinals. By the late 1990's I had almost completely abandoned the Epidural for a scheduled C section. There is no doubt a spinal is a superior anesthetic compared to an Epidural for a C Section.