How much Bupivacaine to put in a spinal for C section

[Doughy315]

Hey, anyone look at the patient height when it comes to how much Bupivacaine to put in the spinal or does everyone put 10.5 mg and 12 mg?

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[Hoya11]

Hey, anyone look at the patient height when it comes to how much Bupivacaine to put in the spinal or does everyone put 10.5 mg and 12 mg?

yes. 1.6 -1.8 ml depending on height

 

[abolt18]

15mg for everyone at my exceptionally slow institution. 2+hr c-sections on the regular. This was taught to me by Bob Gaiser, a very prominent physician in OB anesthesia. Obviously if we had fast OBs, I'd adapt.

Edit: just to add, these also get 15mcg fentanyl and 150mcg duramorph.

 

[MirrorTodd]

Roughly 1.4-1.8. Like <5'4 might get 1.4 if we know the surgeon is looking to be fast. Almost always putting duramorph, fent, epi anyway which seems to leave plenty of wiggle room.

 

[IMGASMD]

Wow. I must be underdosing a lot then. I’ve done 1-1.5 ml of 0.75%. All those with fent and duramorph. Some of the ob’s where I trained, regular c-section is half hour.

 

[Guillemot]

12mg in PP with 20mcg fent & .15 morph.

cs are about 60min (nothing special)

If you have exceptionally slow or fast surgeons goin up or down with bupi could be considered.

 

[abolt18]

Wow. I must be underdosing a lot then. I’ve done 1-1.5 ml of 0.75%. All those with fent and duramorph. Some of the ob’s where I trained, regular c-section is half hour.

If they're getting through without you needing to support with IV meds, then you're not underdosing.

 

[pgg]

Height doesn't matter. Prowess of the surgeon does.

Usually 1.6 mL, sometimes 2.0, rarely 1.2 if the surgeon is fast. For faster surgeons and lower bupivacaine doses, adding fentanyl is a must.

 

[Doughy315]

Out of curiosity, let say you have someone that 5’2” and you put Bupivacaine 12mg, Fentyl 15 mcg and Duramorph 0.2 mg, do you put the the patient reverse Tberg to prevent the spinal from going to high

 

[Guillemot]

Out of curiosity, let say you have someone that 5’2” and you put Bupivacaine 12mg, Fentyl 15 mcg and Duramorph 0.2 mg, do you put the the patient reverse Tberg to prevent the spinal from going to high

Watch the glass spine videos on youtube

 

[abolt18]

Out of curiosity, let say you have someone that 5’2” and you put Bupivacaine 12mg, Fentyl 15 mcg and Duramorph 0.2 mg, do you put the the patient reverse Tberg to prevent the spinal from going to high

Never done such a thing. If their fingers start tingling, it's perfect.

 

[Skribbles]

Out of curiosity, let say you have someone that 5’2” and you put Bupivacaine 12mg, Fentyl 15 mcg and Duramorph 0.2 mg, do you put the the patient reverse Tberg to prevent the spinal from going to high

Hey, anyone look at the patient height when it comes to how much Bupivacaine to put in the spinal or does everyone put 10.5 mg and 12 mg?

Someone please correct me if I'm wrong, but I recall being told in fellowship that there's no data to support dose reductions / increases to account for extremes in height. Now whether that was in the context of a isobaric vs hyperbaric discussion I can't recall, but I took from that discussion to mean all baricities. That being said, just the other day I gave 12 mg of hyperbaric bupi to a patient who's 4'11" without any problems. Level was just under T5/6. I normally don't check levels but in this case I was curious.

To address the topic here, I think volume is much more important than actual bupi dose (to some degree oc). I have partners that get away with 9 mg of Bupi, but put 20 mcg of fent and 0.2 mg of duramorph. That equates to about 1.8 cc volume. I do 12 mg of bupi, 0.1 mg duramorph, and 10 mcg Fent which equates to 1.9 cc. I've had partners attempt 9 mg bupi, no fent, and 0.1 duramorph (1.3 cc) with levels that failed Allis and required redosing. I of course would never test this, but I think had they just increased the volume with saline it would have spread high enough to be effective.

Ultimately, what are we gaining by limiting the dose of Bupi for "fast" surgeons? Is it that uncomfortable for patients to have an effective spinal for 30-45 minutes longer with a higher dose that's guaranteed not to "fail"? People will often cite the hypotension and n/v as a reason to limit the dose, but I have no issues with this by infusing phenylephrine proactively instead of being reactionary to the symptoms of hypotension.

 

[DrZzZz]

Someone please correct me if I'm wrong, but I recall being told in fellowship that there's no data to support dose reductions / increases to account for extremes in height. Now whether that was in the context of a isobaric vs hyperbaric discussion I can't recall, but I took from that discussion to mean all baricities. That being said, just the other day I gave 12 mg of hyperbaric bupi to a patient who's 4'11" without any problems. Level was just under T5/6. I normally don't check levels but in this case I was curious.

To address the topic here, I think volume is much more important than actual bupi dose (to some degree oc). I have partners that get away with 9 mg of Bupi, but put 20 mcg of fent and 0.2 mg of duramorph. That equates to about 1.8 cc volume. I do 12 mg of bupi, 0.1 mg duramorph, and 10 mcg Fent which equates to 1.9 cc. I've had partners attempt 9 mg bupi, no fent, and 0.1 duramorph (1.3 cc) with levels that failed Allis and required redosing. I of course would never test this, but I think had they just increased the volume with saline it would have spread high enough to be effective.

Ultimately, what are we gaining by limiting the dose of Bupi for "fast" surgeons? Is it that uncomfortable for patients to have an effective spinal for 30-45 minutes longer with a higher dose that's guaranteed not to "fail"? People will often cite the hypotension and n/v as a reason to limit the dose, but I have no issues with this by infusing phenylephrine proactively instead of being reactionary to the symptoms of hypotension.

Was taught the same regarding height. That being said, most of my attendings still dropped the dose a touch if under 5 ft tall. No one increased it for tall people though.

And as for dropping the dose for fast surgeons, the only realistic reason is to move the meat patient through pacu faster.

 

[Arch Guillotti]

Never understood for the life of me all these dose adjustments based on height. Pure silliness.

 

[gcc322]

15mg for everyone at my exceptionally slow institution. 2+hr c-sections on the regular. This was taught to me by Bob Gaiser, a very prominent physician in OB anesthesia. Obviously if we had fast OBs, I'd adapt.

Edit: just to add, these also get 15mcg fentanyl and 150mcg duramorph.

Thoroughly enjoyed learning from Dr Gaiser. 15mg for everyone. “When they ask you on oral boards what your dose is, paused and act like you’re really contemplating the situation, then just say 15mg.”

 

[Guillemot]

Someone please correct me if I'm wrong, but I recall being told in fellowship that there's no data to support dose reductions / increases to account for extremes in height. Now whether that was in the context of a isobaric vs hyperbaric discussion I can't recall, but I took from that discussion to mean all baricities. That being said, just the other day I gave 12 mg of hyperbaric bupi to a patient who's 4'11" without any problems. Level was just under T5/6. I normally don't check levels but in this case I was curious.

To address the topic here, I think volume is much more important than actual bupi dose (to some degree oc). I have partners that get away with 9 mg of Bupi, but put 20 mcg of fent and 0.2 mg of duramorph. That equates to about 1.8 cc volume. I do 12 mg of bupi, 0.1 mg duramorph, and 10 mcg Fent which equates to 1.9 cc. I've had partners attempt 9 mg bupi, no fent, and 0.1 duramorph (1.3 cc) with levels that failed Allis and required redosing. I of course would never test this, but I think had they just increased the volume with saline it would have spread high enough to be effective.

Ultimately, what are we gaining by limiting the dose of Bupi for "fast" surgeons? Is it that uncomfortable for patients to have an effective spinal for 30-45 minutes longer with a higher dose that's guaranteed not to "fail"? People will often cite the hypotension and n/v as a reason to limit the dose, but I have no issues with this by infusing phenylephrine proactively instead of being reactionary to the symptoms of hypotension.

classic textbook knowledge would state that volume has little impact on block height for spinal. lack of fentanyl can decrease block duration and density though.

 

[Skribbles]

classic textbook knowledge would state that volume has little impact on block height for spinal. lack of fentanyl can decrease block duration and density though.

I agree, the studies I've looked at however have shown mixed results. But the boards answer is still no difference.

 

[Skribbles]

And as for dropping the dose for fast surgeons, the only realistic reason is to move the meat patient through pacu faster.

Should have clarified, my thought was in the context of using bupi for csections, so I have little motivation to time the spinal to the surgery. I generally haven't used Bupi for anything else these days. Isobaric Chloro/Mepi/Ropi covers pretty much everything else I do.

 

[DrZzZz]

Should have clarified, my thought was in the context of using bupi for csections, so I have little motivation to time the spinal to the surgery. I generally haven't used Bupi for anything else these days. Isobaric Chloro/Mepi/Ropi covers pretty much everything else I do.

Ok. Yea, 99.9% of my C-sections get 12mg hyperbaric bupi. Don't care what OB is holding the scalpel.

 

[narcotics999]

Roughly 1.4-1.8. Like <5'4 might get 1.4 if we know the surgeon is looking to be fast. Almost always putting duramorph, fent, epi anyway which seems to leave plenty of wiggle room.

This. No epi though. I work in a community hospital and the skin to skin time is around 30-45mins.

 

[pgg]

Ultimately, what are we gaining by limiting the dose of Bupi for "fast" surgeons? Is it that uncomfortable for patients to have an effective spinal for 30-45 minutes longer with a higher dose that's guaranteed not to "fail"? People will often cite the hypotension and n/v as a reason to limit the dose, but I have no issues with this by infusing phenylephrine proactively instead of being reactionary to the symptoms of hypotension.

PACU time.

If it's a slow surgeon who needs all day to get through 2 or 3 sections then it doesn't matter if the patient sits in PACU for 2 hours.

If it's a fast surgeon and you've got 6 or 8 sections to do before afternoon tea, and one PACU nurse to recover them all, plus the odd PP tubal or version to throw in, a three hour spinal is a problem.

 

[deleted697535]

Ok. Yea, 99.9% of my C-sections get 12mg hyperbaric bupi. Don't care what OB is holding the scalpel.

Same.
This is a very heavily researched topic guys. Standard exam fodder. Full chapters in Miller, chestnut etc
Most import fx for block height is dose, baricity and position if you are taking about about avoiding high block

 

[deleted126335]

Thoroughly enjoyed learning from Dr Gaiser. 15mg for everyone. “When they ask you on oral boards what your dose is, paused and act like you’re really contemplating the situation, then just say 15mg.”

Just say "One amp"

 

[Skribbles]

PACU time.

If it's a slow surgeon who needs all day to get through 2 or 3 sections then it doesn't matter if the patient sits in PACU for 2 hours.

Your sections go to PACU? At the institutions I've been at they always just go straight back to their L&D room where they're recovered by their nurse. Limiting the number of rocks in PACU is certainly an incentive to time the spinal to the surgery.

 

[pgg]

Your sections go to PACU? At the institutions I've been at they always just go straight back to their L&D room where they're recovered by their nurse. Limiting the number of rocks in PACU is certainly an incentive to time the spinal to the surgery.

Yes

Maybe I've just been unlucky in the places I've worked, but I'd have some reservations about a floor L&D nurse watching an immediately-postop c-section patient.

 

[deleted697535]

Yes

Maybe I've just been unlucky in the places I've worked, but I'd have some reservations about a floor L&D nurse watching an immediately-postop c-section patient.

Likewise.
But i think the rough ones, i get push to get pacu nurse for or ICU *shudder*
Is there anything worse than a really bloody Csection?

 

[BobLoblaw78]

Thoroughly enjoyed learning from Dr Gaiser. 15mg for everyone. “When they ask you on oral boards what your dose is, paused and act like you’re really contemplating the situation, then just say 15mg.”

My response was "how much is in the vial"

Edit: Dang you DrDoze!!!

 

[Ezekiel2517]

I remember an older attending once telling me, "The only thing worse than a high spinal is one that's too low." And an epidural isn't technically a spinal but the same adage applies in those situations where you have a subpar epidural in a patient going for c-section.

 

[Doughy315]

So I have a scheduled primary C section for a lady that is 4’11” otherwise healthy. How much 0.75% Bupivicaine would you put in ? 1.4 ml or 1.6 ml ? It take the surgeon 1.0 hour to do the C section.

 

[Arch Guillotti]

So I have a scheduled primary C section for a lady that is 4’11” otherwise healthy. How much 0.75% Bupivicaine would you put in ? 1.4 ml or 1.6 ml ? It take the surgeon 1.0 hour to do the C section.

For gods sake man does it really matter? 😎 Just flip a coin! If it's the higher dose and her fingers start to tingle, tilt the bed some!

 

[Gator7]

1.2 to 1.4 of heavy, 0.2 duramorph, 20 fent for near everyone

I’ll do 1.6 if they’re only like 26wks

 

[2Fast2Des]

I have been doing 1.6ml heavy bupi,
20mcg fent, 200mcg morphine for my sections. I've noted that they are numb for at least an hour or 2 after, so almost like a 2.5 to 3hr spinal. Maybe I'll cut back to 1.4ml and try to decrease my total duration, as our slowest OBs are like 1.5 hrs in and out of room and the quick ones about an hour total time. That being said our LnD is super slow and so there is zero impetus to get the patient out of the LnD PACU any quicker, and plus they have no pain for a little longer...

 

[JWebar]

Dose should be adjusted based on gestational age (Kim H. Reg Anesth Pain Med 2019;44:793–795) and surgical time, not patient's height.

If surgery is ≤ 1 hr, 1.3 mL of 0.75% with Fentanyl should be enough. I've never had a problem with 1 mL for crash sections (25-30 minutes).

What dose you guys use if there is ****ty working epidural (meaning you'll take the catheter out and put a spinel) running at ~8–12 mL/hr)?

 

[Arch Guillotti]

Dose should be adjusted based on gestational age (Kim H. Reg Anesth Pain Med 2019;44:793–795) and surgical time, not patient's height.

If surgery is ≤ 1 hr, 1.3 mL of 0.75% with Fentanyl should be enough. I've never had a problem with 1 mL for crash sections (25-30 minutes).

What dose you guys use if there is ****ty working epidural (meaning you'll take the catheter out and put a spinel) running at ~8–12 mL/hr)?

“Crash” c/s with spinal? No thanks.

 

[JWebar]

“Crash” c/s with spinal? No thanks.

I would argue that when the indication is fetal distress without maternal issues a fast–track spinal doesn't really take much longer than a GA induction, in a patient with normal anatomy

 

[Arch Guillotti]

I would argue that when the indication is fetal distress without maternal issues a fast–track spinal doesn't really take much longer than a GA induction, in a patient with normal anatomy

I would argue that is fine if it is urgent but a true “crash” c/s is almost always a general, not a spinal.

 

[JWebar]

I would argue that is fine if it is urgent but a true “crash” c/s is almost always a general, not a spinal.

Ohhh my apologies. Most of my anesthetic OB practice is in a different language. You're right, I meant urgent, not "crash".

 

[lane]

Private hospital with slick surgeons - 1.2mL (9mg) with 20mcg fent + 0.2mg morphine.