generic OB scenario

[gaspasser2004]

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I've gotten several different answers to this hypothetical situation and I was wondering what you all thought...

So, you got an otherwise healthy patient in labor and you place an epidural. Hours later she presents for urgent (not stat) C-section due to failure to progress/failure to dilate/non reassuring fetal heart rate, etc. In the OR, you dose the epidural and.... patchy. Too patchy in your opinion to proceed with incision. What next?

Give more local through existing cather? When do you stop?

Sit her up and do a spinal? If so, what dose?

Do another epidural? If so, what dose?

Do it under general? 😱

lets assume that the patient is stable enough that you have time to do any of the above interventions...

 

[Planktonmd]

I've gotten several different answers to this hypothetical situation and I was wondering what you all thought...

So, you got an otherwise healthy patient in labor and you place an epidural. Hours later she presents for urgent (not stat) C-section due to failure to progress/failure to dilate/non reassuring fetal heart rate, etc. In the OR, you dose the epidural and.... patchy. Too patchy in your opinion to proceed with incision. What next?

Give more local through existing cather? When do you stop?

Sit her up and do a spinal? If so, what dose?

Do another epidural? If so, what dose?

Do it under general? 😱

lets assume that the patient is stable enough that you have time to do any of the above interventions...

Unless I think that the airway is horrible my plan would be at this point GA.

 

[dfk]

I've gotten several different answers to this hypothetical situation and I was wondering what you all thought...

So, you got an otherwise healthy patient in labor and you place an epidural. Hours later she presents for urgent (not stat) C-section due to failure to progress/failure to dilate/non reassuring fetal heart rate, etc. In the OR, you dose the epidural and.... patchy. Too patchy in your opinion to proceed with incision. What next?

Give more local through existing cather? When do you stop?

Sit her up and do a spinal? If so, what dose?

Do another epidural? If so, what dose?

Do it under general? 😱

lets assume that the patient is stable enough that you have time to do any of the above interventions...

if anxious, give small doses of midaz, or some fentanyl 0.5 mcg/kg IV, perhaps some N2O via mask. even some ketamine. you could have the surgeon give 10-20 ml 0.5% lido intraperitoneally.
if analgesia is inadequate at this point, consider GA via ETT.

 

[Bertelman]

This happened to me yesterday. Tried the epidural, weren't convinced, pushed forward. She described "ripping sensation" going through fascia, peritoneum. Generally stoic disposition, so we probably delayed the inevitable longer than we should have. She got GETA, dad was asked to leave. Significant post-op pain as soon as I dropped her off.

When I asked about spinal, it was explained that a spinal may be technically difficult after injecting 25 cc into the epidural space, also as you suggested how do you dose it?

Made me want to never dose an epidural for c-sec again.

 

[periopdoc]

I've gotten several different answers to this hypothetical situation and I was wondering what you all thought...

So, you got an otherwise healthy patient in labor and you place an epidural. Hours later she presents for urgent (not stat) C-section due to failure to progress/failure to dilate/non reassuring fetal heart rate, etc. In the OR, you dose the epidural and.... patchy. Too patchy in your opinion to proceed with incision. What next?

Give more local through existing cather? When do you stop?

Sit her up and do a spinal? If so, what dose?

Do another epidural? If so, what dose?

Do it under general? 😱

lets assume that the patient is stable enough that you have time to do any of the above interventions...

I would not have dosed the epidural in the first place. If time is not a major issue, I prefer to pull the epidural and place a spinal in the usual fashion.

In this scenario, I would either go night-night or do a spinal through a Touhy ala CSE in the lateral decubitus position. Dose it normally and be prepared for a little extra hypotension.


-pod

 

[thegasman]

I've gotten several different answers to this hypothetical situation and I was wondering what you all thought...

So, you got an otherwise healthy patient in labor and you place an epidural. Hours later she presents for urgent (not stat) C-section due to failure to progress/failure to dilate/non reassuring fetal heart rate, etc. In the OR, you dose the epidural and.... patchy. Too patchy in your opinion to proceed with incision. What next?

Give more local through existing cather? When do you stop?

Sit her up and do a spinal? If so, what dose?

Do another epidural? If so, what dose?

Do it under general? 😱

lets assume that the patient is stable enough that you have time to do any of the above interventions...

GA - prop/sux/tube - no big deal

 

[Noyac]

if anxious, give small doses of midaz, or some fentanyl 0.5 mcg/kg IV, perhaps some N2O via mask. even some ketamine. you could have the surgeon give 10-20 ml 0.5% lido intraperitoneally.
if analgesia is inadequate at this point, consider GA via ETT.

Come on man. Have you ever asked an OB to do local for a c/s? I haven't?
Ketamine works great if yo give enough (read GA) but not versed and fentanyl.

I don't have faith in an OB injecting local for a c/s.


I will never be in this postition b/c I pull the epidural and place a spinal every time. But if I were to find myself in this position I'd be going the GA route. Jet just last year described a case where his pt got a high spinal from placing a spinal after dosing an epidural. He put her to sleep.

 

[Arch Guillotti]

I've gotten several different answers to this hypothetical situation and I was wondering what you all thought...

So, you got an otherwise healthy patient in labor and you place an epidural. Hours later she presents for urgent (not stat) C-section due to failure to progress/failure to dilate/non reassuring fetal heart rate, etc. In the OR, you dose the epidural and.... patchy. Too patchy in your opinion to proceed with incision. What next?

Give more local through existing cather? When do you stop?

Sit her up and do a spinal? If so, what dose?

Do another epidural? If so, what dose?

Do it under general? 😱

lets assume that the patient is stable enough that you have time to do any of the above interventions...

I will throw out a new answer out there. I would replace the epidural.

This is not a stat section and according to your scenario you have a little time to play around. If you have already dosed it up I would not place a SAB because of the risk of a high spinal. The risk is not theoretical because I have seen this happen and we had to put a snorkel in.

Once I located the epidural space I would dose some local through the Touhy so that one-sided distribution could be avoided. Then I would thread the catheter and continue dosing, either w/2% lido w/bicarb or chloroprocaine. If that doesn't work after a few minutes and I didn't think I could gimp through w/nitrous, versed, ketamine, fentanyl, morphien, etc then I would just put her to sleep.

 

[Arch Guillotti]

Come on man.
Ketamine works great if yo give enough (read GA) but not versed and fentanyl.

Ketamine is the best med in this scenario. Most would try and avoid dosing narcotics till after the cord is clamped which would limit your options.

 

[dfk]

Come on man. Have you ever asked an OB to do local for a c/s? I haven't?
Ketamine works great if yo give enough (read GA) but not versed and fentanyl.

I don't have faith in an OB injecting local for a c/s.


I will never be in this postition b/c I pull the epidural and place a spinal every time. But if I were to find myself in this position I'd be going the GA route. Jet just last year described a case where his pt got a high spinal from placing a spinal after dosing an epidural. He put her to sleep.

that's why i said could, not would. some might be a little more willing than others. perhaps not the ones you work with. like i was saying, just running thru options is all. some more favorable than others, but options nonetheless.

 

[Noyac]

that's why i said could, not would. some might be a little more willing than others. perhaps not the ones you work with. like i was saying, just running thru options is all. some more favorable than others, but options nonetheless.

Now you are playing the semantics game, nurse. I asked you if you had ever asked an OB to give local?

You can change your story but you will get more respect if you tell us what it is you WOULD do and stop the word play. Reality is not always in the books , ie what you could do.

 

[dfk]

Now you are playing the semantics game, nurse. I asked you if you had ever asked an OB to give local?

You can change your story but you will get more respect if you tell us what it is you WOULD do and stop the word play. Reality is not always in the books , ie what you could do.

nope. never did. haven't had to. if i had to make the choice, i would consider pulling epidural, and do SAB. if became more emergent, i'd go with GA.

 

[huktonfonix]

In general you can avoid this by asking the following, "has your epidural been working well for you so far?". If the answer is yes dose for section and it will be very unusual for it not to work. The "patchy" ones I have seen are the ones that havent been working especially well for labor either. Those, if I have time, I pull without dosing and do a spinal with 10.5-12 mg of bupi + narc of choice. (what I do for every other C/S). I give it one shot and if it fails (there is a chance you might get fluid from the epidural space instead of intrathecal, hasnt happened so far but possible) they go off to sleep unless there is some convincing reason for me to try another epidural (really horrific airway, etc...)

 

[MTGas2B]

I'm in the use a working epidural camp. Agreed, questioning how well its been working is key. If its patchy as I try to bring it up, or it hasn't been working that well to begin with, abandon ship. If its a solid block, just low, more lidocaine.

A couple months ago when I was on OB we had some attendings and residents who swore the 2% lidocaine wasn't working. So everyone went to chloroprocaine (we keep it around, but generally we hadn't been using it). A couple of attendings and I didn't buy. We were using the same lot #'s of 2%, worked just fine. Just have to give enough, and wait long enough. (We don't have bicarb around on OB)

What's the largest volume of 2% lidocaine some of you have used in your lumbar epidurals for c/s?

 

[2ndyear]

Once you've dosed the epidural you're done in my opinion. If it's non-urgent or even urgent but not emergent I have been pulling the epidural and doing a spinal unless the epidural has been flawless throughout labor without any boluses. I believe that the risk of high spinal is unacceptably high once 20 mL of local is in the epidural space. Here is some case report data:
http://www.usuhs.mil/ane/resident/pbls/csxepifail.pdf

The OB's I work with don't know what local is. I recently suggested this and had to hand them the bottle, and tell them how much to use. Still needed to go to sleep.

 

[dhb]

if anxious, give small doses of midaz, or some fentanyl 0.5 mcg/kg IV, perhaps some N2O via mask. even some ketamine. you could have the surgeon give 10-20 ml 0.5% lido intraperitoneally.
if analgesia is inadequate at this point, consider GA via ETT.

The surgeon could certainly do that but i don't think it would be helpful in the setting of a c-section via a low corporeal incision... (eg extra-peritoneal incision )

 

[dhb]

Getting back to the clinical scenario: it has been discussed before and i think the best thing you can do is

1- if the epidural hasn't been working properly pull it and do a spinal with your conventional dose. You have nothing to gain from performing another epidural.

2- if you have bolused the epidural, spinal is a no-go so
a- if the block is sufficient and surgery has started baby is almost out go with some K
b- if they can't cut it's off to sleep.

 

[EvoX]

Good airway goes to sleep.
Bad airway gets intrathecal catheter, building up spinal level slowly with small incremental doses.

 

[Bertelman]

Good airway goes to sleep.
Bad airway gets intrathecal catheter, building up spinal level slowly with small incremental doses.

Seems like most others here views GA as the last resort. Have you ever had an intrathecal that misbehaved, then needed to take the "bad airway" off to sleep later with the OB holding the blade? I would think that if you knew it was a bad airway, you would rather address it up front, when you have a few more minutes.

 

[numbmd]

We do about 6800 deliveries a year with about a 45% section rate, give or take. 90 to 95% epidural rate for laboring patients and over a third get sectioned. So we see a s - load of laboring patients with epi's who are going for section. Almost all get 2% lido for a section dose. Usually 10 cc. I also give 100 u of fentanyl with my section dose because it works differently than the fent in the bag.
For my patients who move easliy over to the table, or who have some question as to the location of the tip of the catheter, I check with an alice clamp. Ratchet it closed on the skin and tug like a mofo. (Gold standard test).

Let's say it's not working. The question is does the patient have a partial block or no block?

No Block: Just slightly less than a full dose. So 1.2 cc of 3/4 %.

Spotty block: 2 cc of 1/4 % Bupi. You know, the one that says in big caps "NOT FOR SPINAL ANESTHESIA" You get adequate block but much less incidence of a high spinal as the mixture is the closest to isobaric I have found.

 

[jwk]

We do about 6800 deliveries a year with about a 45% section rate, give or take. 90 to 95% epidural rate for laboring patients and over a third get sectioned. So we see a s - load of laboring patients with epi's who are going for section. Almost all get 2% lido for a section dose. Usually 10 cc. I also give 100 u of fentanyl with my section dose because it works differently than the fent in the bag.

Only 10cc to dose for a C/S? I wonder what dose the OP was using when he got a patchy block. On an average sized patient, I start with 15-20cc of Lido 2% with epi + bicarb (including the test dose). Some will get 30cc, which is generally our cutoff.

If, after 20cc we get absolutely nothing, we'll replace the epidural with a reduced dose of local. If the block is coming up with 20cc, we'll dose a little more. We NEVER add a spinal on top of an epidural - ever.

If we have issues around incision time, we'll try a little N2O or ketamine. If they're clearly not gonna make it, we'll go ahead with GA.

Our conversion rate to GA because of failed epidurals is perhaps 1 in 500.

 

[proman]

I had a strange CSE last night. 22 y/o 100kg for repeat c section (number 3). Did a routine CSE with 1.7cc 0.75% bupi and 25 mcg fentanyl, then threaded the catheter easily. Supine quickly. Got a nice sympathectomy. T4 level by cold sensation but felt pain around T11. Gave 20 cc of lidocaine 2% with epi. That brought the level to around T9. Then had to supplement with ketamine (a lot). Not a fun night. Any thoughts?

 

[Planktonmd]

I had a strange CSE last night. 22 y/o 100kg for repeat c section (number 3). Did a routine CSE with 1.7cc 0.75% bupi and 25 mcg fentanyl, then threaded the catheter easily. Supine quickly. Got a nice sympathectomy. T4 level by cold sensation but felt pain around T11. Gave 20 cc of lidocaine 2% with epi. That brought the level to around T9. Then had to supplement with ketamine (a lot). Not a fun night. Any thoughts?

Insufficient spinal dose (partial dose went intrathecal) and epidural catheter went caudad?
It happens.

 

[proman]

I had CSF at the end of injection. No way to know for sure where the catheter went but it felt like all the others.

 

[huktonfonix]

decreased potency batch of bupivicaine. Supposedly it can result from storage at improper temperature (i.e. during transport). may want to see if its happening to others with the same batch. As far as the epidural goes, like plank said, caudad migration or unusual anatomic barrier

 

[rsgillmd]

Only 10cc to dose for a C/S?

Only 2 times in 3+ years have I had to do GA because of a patchy block. Both were happy at the end of the procedure. Both were also STAT C/S's.

I do the same thing others mentioned, ask how the epidural has been working for them. Maybe a handful more have needed some support from ketamine. Basically, it's unusual to get a patchy block. Maybe, I've been lucky, but that's my experience.

Additionally I'm in numbmd's camp. If the epidural has been working well for labor analgesia, 10 ml is plenty to get to at least T6, if not T4.

I don't always give the Fentanyl 100 mcg when they get in the OR, but if it's a STAT C/S and I really want the epidural working, I give it. It's just a hassle sometimes to get into the Pyxis to get it out, especially if you are alone trying to get things started.

For the STAT C/S's I'll also give the 10 ml loading dose (with bicarb added) in the hallway (when possible) as the OB team is wheeling in the patient.

 

[jetproppilot]

Come on man. Have you ever asked an OB to do local for a c/s? I haven't?
Ketamine works great if yo give enough (read GA) but not versed and fentanyl.

I don't have faith in an OB injecting local for a c/s.


I will never be in this postition b/c I pull the epidural and place a spinal every time. But if I were to find myself in this position I'd be going the GA route. Jet just last year described a case where his pt got a high spinal from placing a spinal after dosing an epidural. He put her to sleep.

Yep.

There is not a RIGHT answer to this.

Actually the RIGHT answer is what SUCCESSFUL PLAN B you have.

NOY'S SUCCESSFUL PLAN B is to not dose the epidural but rather pull it and place a spinal.

My successful Plan B is to put her to sleep.

I feel the "potential risks of GA" are grandly overemphasized in residency for the parturient, to the point where emerging CA-3s are inappropriately intimidated by general anesthesia for a C section.

Yes, there are risks.

We all know them.

I've posted on this prolifically....where I feel residents are given a NO FLY ZONE feel for GA for a C section....

I've been doing this private practice gig for 12 years, folks.

I've done a gagillion crash C sections.

99.9999987000% of those crash sections had an airway that accepted a 7.5 ETT easily.

Which brings me to the point that YEAH, you're gonna come across the occasional parturient requiring GA thats gonna need a 6.0 tube....with airway swelling et al....

THATS THE ZEBRA.

KNOW HOW TO HANDLE IT WHEN IT HAPPENS.

In the same breath, REALIZE THIS IS A ZEBRA.

Most C sections requiring GA are relatively easy airways.

WHICH BRINGS ME TO MY POINT:

Train residents to know how to handle zebras.

But to not be intimidated by general anesthesia for a C section because of their training, which is, current day,

GENERAL ANESTHESIA FOR C SECTION MEANS SOME BAD S HIT IS GONNA HAPPEN.

The above just AIN'T TRUE.

We need to pass on this sentiment to residents so they aren't afraid to put a C section to sleep.

 

[huktonfonix]

count me in on the 10ml on a working labor epidural for C/S. in residency I used to hit almost everyone with 20. Which makes me wonder if it just happens that my current patient population needs less than my former one or if I was just majorly overdoing everyone before. I actually do the opposite on the fentanyl. Im more apt to give the fentanyl at the beginning of the C/S for electives and toward/after cord clamp for stat ones. In general (which admittedly may be paranoia on my part) any C/S for which there is some fetal indication (preemie, fetal distress, etc..) I figure I'll avoid anything extra which may depress the fetus in case of poor fetal outcome.

 

[RabbMD]

Also, be sure to watch how they react to the auto BP cuff. I have found since residency that far more patients jump off the bed and can't even tolerate the BP cuff. One kept hitting their PCEA (thankfully did not go for section) to try and relieve that BP pain every 10-15 minutes for 4-5 hours. She ended up with a high bromage block and needing the epidural off to push. Others that can't tolerate the BP cuff during section need a spinal regardless of how the epidural is working. On those I don't even bothering dosing the epidural. Just take it out and put in a new spinal.

Additionally, Jedi mind tricks work wonders. I always tell pts that they are going to feel discomfort from pulling and pushing. Right before the baby comes out as the OB pushes down on their sternum area is going to be painful no matter what I do. Jedi mind tricks work wonders

 

[numbmd]

Only 10cc to dose for a C/S?

Yeah, when I first started, everybody got 15 cc. Then I divided my dose up and found that 10 was usually enough. Sometimes they get a little wacky when you give a lot of lido, maybe from systemic absorption. One of our attendings who I gave an epi to told me this after her section. Point is, you don't need all that much.

 

[ncdoc1974]

If the epidural was patchy after my initial bolus, I would pull the epidural back (say from 5cm in the space to 3cm in the space), redose, preoxygenate, and reevaluate the patient...If this maneuver failed to help the patchy block I would proceed with a GA. I would choose a GA far before attempting a spinal on top of a dosed epidural.

 

[MTGas2B]

We need to pass on this sentiment to residents so they aren't afraid to put a C section to sleep.

My program has gone through an interesting change on this front. The old leadership on our OB anesthesia department was always down with GAs. One of our senior attendings used to argue that a patient with a legit difficult airway should probably get a GA from the get go, cause plan B may not look so pretty. He would make sure we let patient know that GA is always an option, even elective sections. That was my CA-2 year.

Move on to my CA-3 year, new director of OB anesthesia, when I make a brief return to OB as the senior on the service with the new to OB CA-2s. Paraphrasing, if a patient has to get a GA for c-section we have failed. My favorite was a woman who spent some time on antepartum, prior c-section, we had done the pre-op when I was a CA-2, she insisted that her section be under GA. Okay fine, we can do that. She eventually goes home, comes back for her section after new director had taken over. New director had long conversation with patient, from what I heard director just couldn't understand why a patient would want a GA.

Our program was very good about making sure that we weren't afraid to put patients to sleep for a section. I'm sad that is going to change, most of the senior faculty are still around, but they will be retiring, and new boss will be around for a while.

 

[Planktonmd]

My program has gone through an interesting change on this front. The old leadership on our OB anesthesia department was always down with GAs. One of our senior attendings used to argue that a patient with a legit difficult airway should probably get a GA from the get go, cause plan B may not look so pretty. He would make sure we let patient know that GA is always an option, even elective sections. That was my CA-2 year.

Move on to my CA-3 year, new director of OB anesthesia, when I make a brief return to OB as the senior on the service with the new to OB CA-2s. Paraphrasing, if a patient has to get a GA for c-section we have failed. My favorite was a woman who spent some time on antepartum, prior c-section, we had done the pre-op when I was a CA-2, she insisted that her section be under GA. Okay fine, we can do that. She eventually goes home, comes back for her section after new director had taken over. New director had long conversation with patient, from what I heard director just couldn't understand why a patient would want a GA.

Our program was very good about making sure that we weren't afraid to put patients to sleep for a section. I'm sad that is going to change, most of the senior faculty are still around, but they will be retiring, and new boss will be around for a while.

Very sad!
These people are producing new anesthesiologists who are afraid of doing GA for c sections, and they have to overcome this fear on their own later as attendings when there is no one else around to bail them out.

 

[Mman]

Spotty block: 2 cc of 1/4 % Bupi. You know, the one that says in big caps "NOT FOR SPINAL ANESTHESIA" You get adequate block but much less incidence of a high spinal as the mixture is the closest to isobaric I have found.

If I might ask, why 2 mls of 0.25% and not 1 ml of 0.5%? Both are isobaric and it's the same dose. Once you inject it into the CSF it's going to get diluted anyway and the volume of 1 ml vs 2 mls isn't going to matter.


I don't like isobaric spinals for c-sections because it's hard to get the level up to anything close to T4 so when they yank on the peritoneum the patient feels it. If they've had an epidural dosing and I'm going to use a spinal, I just cut back on the dose of the hyperbaric bupiv.

 

[Planktonmd]

I don't like isobaric spinals for c-sections because it's hard to get the level up to anything close to T4 so when they yank on the peritoneum the patient feels it. If they've had an epidural dosing and I'm going to use a spinal, I just cut back on the dose of the hyperbaric bupiv.

Are you saying that you can get a higher level with Hyperbaric spinals than what you would get with isobaric spinals?
How do you explain that?

 

[Mman]

ever see the glass spine and how isobaric and hyperbaric solutions act in the context of the curvature of the spinal column?

Put somebody in trendelenberg position after dosing a hyperbaric spinal and you can get the level up quite high.

 

[Planktonmd]

I am not sure that in real life there is any difference between isobaric and hyperbaric spinals regarding the level of anesthesia.
If you are doing your spinal in the sitting position you have to realize that no matter how fast you are, a portion of your bolus would have migrated caudad by the time you put the patient supine.
I think it's more common to see hypotension with hyperbaric spinals but I am not sure they provide better anesthesia if you use the same doses and do them in the sitting position.

 

[Noyac]

I am not sure that in real life there is any difference between isobaric and hyperbaric spinals regarding the level of anesthesia.
If you are doing your spinal in the sitting position you have to realize that no matter how fast you are, a portion of your bolus would have migrated caudad by the time you put the patient supine.
I think it's more common to see hypotension with hyperbaric spinals but I am not sure they provide better anesthesia if you use the same doses and do them in the sitting position.

I also believe that the heavy buiv gives you a higher level if you lay them down in a reasonable amount of time. This is also why you get more hypotension.

Isobaric just stays where you put it depending on the volume of course.

 

[Mman]

I agree that some hyperbaric bupiv goes caudad no matter how fast you lay them down, however it is "heavy" and going downhill to cover more cephalad dermatomes.

Isobaric bupivicaine just doesn't move much from where you put it, unless you give a big dose, because it is moving by diffusion alone without the aid of gravity.

 

[numbmd]

If I might ask, why 2 mls of 0.25% and not 1 ml of 0.5%? Both are isobaric and it's the same dose. Once you inject it into the CSF it's going to get diluted anyway and the volume of 1 ml vs 2 mls isn't going to matter.


I don't like isobaric spinals for c-sections because it's hard to get the level up to anything close to T4 so when they yank on the peritoneum the patient feels it. If they've had an epidural dosing and I'm going to use a spinal, I just cut back on the dose of the hyperbaric bupiv.

I read an article quoting good conditions with 5mg of bupi and 20 u fentanyl alone for a cesearean. Seemed like a reasonable study but a ridiculously low dosage. I tried it and it worked. But when you used it for more people, it didn't work as well for all comers. The extremely nervous, the fifteen year olds, the multiple repeats, the stupid slow surgeons. However it did have a place, as in the emergent preecclamptic, the day you have 18 patients on the floor, and for partial blocks.

Why 2.5 %? I found a larger volume had a less spotty block. One of those anecdotal pieces of my practice, go figure. Could you do 0.5% and pull back csf in your syringe until you get the same volume? No. Never. Absolutely not. Impossible. Don't even think that way.

 

[huktonfonix]

I think I read the same study. If you do this I would strongly advise using it as a combined CSE technique since the study Im thinking of did the low dose bupi + fentanyl showed a fairly high (dont quote me, but I think it was somewhere around 5-10%) incidence of inadequate block. I think its a good way to decrease hypotension and post op recovery, but I would have plan B (epidural) ready to go if you need to raise the level.