Hyperbaric bupivicaine shortage

[Gas]

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https://soap.org/2018-bupivacaine-shortage-statement.pdf

I give at least 2.6cc plus fentanyl.

 

[Ezekiel2517]

Are you using larger doses then? If so, are you using fentanyl and duramorph still?

For c/s with iso bupi, I always use between 2.5 - 3cc depending on height, and I typically use 15 mcg fentanyl and .15 mg duramorph.

 

[deleted162650]

I was impressed with iso bupi when we were forced to use it for C/S. I only gave 10mg (2cc) with 20 fent and 0.2 duramorph. No problems. I bet if you blinded me, I couldn’t tell you if was using the heavy stuff or isobaric. For total hips and knees we are down to giving just 7.5mg (1.5cc) iso bupi. No inadequate blocks so far with most cases falling in the 2.5-3hr range.

I’m amazed at some of the big doses you guys are giving.

 

[Twiggidy]

I was impressed with iso bupi when were forced to use it for C/S. I only gave 10mg (2cc) with 20 fent and 0.2 duramorph. No problems. I bet if you blinded me, I couldn’t tell you if was using the heavy stuff or isobaric. For total hips and knees we are down to giving just 7.5mg (1.5cc) iso bupi. No inadequate blocks so far with most cases falling in the 2.5-3hr range.

I’m amazed at some of the big doses you guys are giving.

I think some are in denial that their technique may not be great and that could be the reason for inadequate blocks. I'll admit that Ive come across some patchy blocks when the spinal seemed otherwise normal, but who knows where some of the medicine ends up when you have a slightly uncooperative patient who's "ooh-ing and ahh-ing" and shifthing constantly while you're placing the block. Unless your OB service has WNBA players, you really shouldn't need more than 12 mg intrathecal, unless your OBs are slow and terrible.

 

[Ezekiel2517]

The 2.5 to 3 ml dosing is actually what was recommended in the recent SOAP advisory in response to the bupivicaine shortage, if you guys even care. Sure, you can get by with smaller doses, even less than 2 ml, but I prefer to err on the side of a little excess for c sections

 

[deleted162650]

The 2.5 to 3 ml dosing is actually what was recommended in the recent SOAP advisory in response to the bupivicaine shortage, if you guys even care. Sure, you can get by with smaller doses, even less than 2 ml, but I prefer to err on the side of a little excess for c sections

The lit showed no failures in patients receiving at least 10mg with no adjustments for height.

 

[pgg]

The 2.5 to 3 ml dosing is actually what was recommended in the recent SOAP advisory in response to the bupivicaine shortage, if you guys even care. Sure, you can get by with smaller doses, even less than 2 ml, but I prefer to err on the side of a little excess for c sections

I prefer smaller doses of local (with fentanyl to cover those sins) to keep the L&D PACU moving.

That said, at the academic day job, there's no real need for prompt PACU discharges, and the surgeons (residents) aren't speedy, so 15 mg and no fentanyl works too.

 

[Twiggidy]

I prefer smaller doses of local (with fentanyl to cover those sins) to keep the L&D PACU moving.

That said, at the academic day job, there's no real need for prompt PACU discharges, and the surgeons (residents) aren't speedy, so 15 mg and no fentanyl works too.

Any issues with patients getting slightly panic from difficulty breathing? I feel like it I use big doses that starts to happen but maybe I'm also a level up from where I think I am

 

[deleted126335]

Any issues with patients getting slightly panic from difficulty breathing? I feel like it I use big doses that starts to happen but maybe I'm also a level up from where I think I am

Yeah, but it’s ok. They are too weak to put up much of a fight.

 

[pgg]

Any issues with patients getting slightly panic from difficulty breathing? I feel like it I use big doses that starts to happen but maybe I'm also a level up from where I think I am

Not really. I mean, some patients are a touch crazy / high maintenance, but that's not really dose dependent. With the hyperbaric stuff, I just control the level by tilting the table. First hint of tingling in the fingers the head goes up. I also coach everyone ahead of time by telling them that the spinal may make their chest feel a little numb and create the sensation of difficult breathing, but not to worry.

Isobaric stuff just doesn't seem to go very high. One of the reasons I like it for hips so much, the patients don't get as hypotensive.

I don't think it matters where the needle goes in. (Within reason. I watched someone do what I'm convinced was a T10 or T11 spinal the other day.)

 

[deleted162650]

I watched someone do what I'm convinced was a T10 or T11 spinal the other day.

I love the density you get out of an intramedullary block 😉

 

[d9sccr]

I think some are in denial that their technique may not be great and that could be the reason for inadequate blocks. I'll admit that Ive come across some patchy blocks when the spinal seemed otherwise normal, but who knows where some of the medicine ends up when you have a slightly uncooperative patient who's "ooh-ing and ahh-ing" and shifthing constantly while you're placing the block. Unless your OB service has WNBA players, you really shouldn't need more than 12 mg intrathecal, unless your OBs are slow and terrible.

That's sorta the concern I'm having. We didn't do many spinals in residency bc the average CS was easily 2-2.5 hours. I'm not sure how else to improve my technique though.

+CSF through the IT needle. I let it drip some, then stabilize hand on back/needle and let it drip some more, then connect and aspirate, looking for a swirl and then aspirate once more at the end to make sure I have CSF coming back still. I push the aspirate back in and come out with everything. Maybe I shouldn't draw back at the end but I always did that with the 0.75% bupi using 12-15mg doses w/o ever having an issue

 

[deleted162650]

+CSF through the IT needle. I let it drip some, then stabilize hand on back/needle and let it drip some more, then connect and aspirate, looking for a swirl and then aspirate once more at the end to make sure I have CSF coming back still. I push the aspirate back in and come out with everything. Maybe I shouldn't draw back at the end but I always did that with the 0.75% bupi using 12-15mg doses w/o ever having an issue

I do exactly that. Not sure why you still suck?

😉

 

[Twiggidy]

That's sorta the concern I'm having. We didn't do many spinals in residency bc the average CS was easily 2-2.5 hours. I'm not sure how else to improve my technique though.

+CSF through the IT needle. I let it drip some, then stabilize hand on back/needle and let it drip some more, then connect and aspirate, looking for a swirl and then aspirate once more at the end to make sure I have CSF coming back still. I push the aspirate back in and come out with everything. Maybe I shouldn't draw back at the end but I always did that with the 0.75% bupi using 12-15mg doses w/o ever having an issue

That’s just about right. If you’re in PP with fast OBs you’ll learn that you don’t need 15 mg of LA if they can usually finish in an hour. If you’re still dealing with OB resident then that larger dose can be helpful, as well as a stick of propofol/ketafol/sedative of your liking

 

[Psai]

Any issues with patients getting slightly panic from difficulty breathing? I feel like it I use big doses that starts to happen but maybe I'm also a level up from where I think I am

Not with 3 mL at L3 level. We do a ton of ortho spinals like that and never any issue. It's probably anxiety causing a sensation of difficulty breathing.