OB Anesthesia Hot Topics

[Crash cart]

I've had really mixed results using 0.25% ISO bupivicaine for CSE. it seems that there is modest, if any sacral spread of the isobaric solution which can be problematic if the patient is rapidly progressing and the fetus is descending. Anyone else have this issue?

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[agammaglobulin]

How often do you run into shivering during C-sections? Seems to happen ~1/3 of the time for me, usually shortly after baby is out. I assume this is from decreased thermoregulation after sympathetic block from spinal. I've started trying some Meperidine if it's severe with good effect.

 

[Noyac]

How often do you run into shivering during C-sections? Seems to happen ~1/3 of the time for me, usually shortly after baby is out. I assume this is from decreased thermoregulation after sympathetic block from spinal. I've started trying some Meperidine if it's severe with good effect.

I just let them shiver.
Meperidine will make them puke on occasion. I'd rather watch them shiver than have them puke.

 

[Noyac]

Anyone using an etoh wipe for nausea?

 

[pgg]

Anyone using an etoh wipe for nausea?

Our PACU nurses do. I wish they wouldn't.

 

[Random Anesthesiologist]

Anyone using an etoh wipe for nausea?

I find ephedrine or phenylephrine is more effective

 

[deleted162650]

I'll try it if BP is normal and they are still a little quesy. Sometimes they feel better and occasionally they'll say the smell is making it worse. I think for those that it helps it's really just the cooling effect that does it and a cool damp towel/gauze would be just as effective (kinda like a cup of sea water on the head for sea sickness).

 

[deleted162650]

Shivering is a side effect of delivering a baby. Happens for vag births with or without anesthesia as well. I'll tell mom it's normal and that I can give her something if it gets too annoying but it might make her sleepy. Can't remember the last time I actually gave anything for it.

 

[deleted171991]

I find ephedrine or phenylephrine is more effective

Because you're treating the cause, while the alcohol wipe treats the symptom, and thus it's less effective.

 

[Noyac]

I agree, it's mostly a waste of time and just an annoying nursing tactic.

 

[kazuma]

Does anyone give IM ephedrine? I've done it a few times and had train track BP even with the 40 unit pitocin bolus the OB requests.

 

[Noyac]

Does anyone give IM ephedrine? I've done it a few times and had train track BP even with the 40 unit pitocin bolus the OB requests.

Yes. I give it on occasion. I can't recall ever having any negative effects or wishing that I hadn't given it. So,I guess I should use it more but personally I like my neo laced IV fluids.

 

[kazuma]

Yes. I give it on occasion. I can't recall ever having any negative effects or wishing that I hadn't given it. So,I guess I should use it more but personally I like my neo laced IV fluids.

The OB usually asks whats up with the blood spot is on the patients thigh. Its less hassle to just throw some phenylephrine the bag.

 

[deleted171991]

Ann Emerg Med. 2015 Nov 21. pii: S0196-0644(15)01361-X. doi: 10.1016/j.annemergmed.2015.09.031. [Epub ahead of print]
Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial.
Beadle KL1, Helbling AR1, Love SL1, April MD2, Hunter CJ1.
Author information
Abstract
STUDY OBJECTIVE:
We compare nasal inhalation of isopropyl alcohol versus placebo in treating nausea among emergency department (ED) patients.

METHODS:
A convenience sample of adults with chief complaints of nausea or vomiting was enrolled in a randomized, double-blind, placebo-controlled trial conducted in an urban tertiary care ED. Patients were randomized to nasally inhaled isopropyl alcohol versus nasally inhaled normal saline solution. Patient nausea and pain were measured with previously published 11-point verbal numeric response scale scores; patient satisfaction was measured by a 5-point Likert scale. The primary outcome was reduction in nausea 10 minutes poststart. Secondary outcomes included patient satisfaction and pain reduction measured at 10 minutes poststart.

RESULTS:
Of 84 recruited patients, 80 (95.2%) completed the study. Thirty-seven (46.3%) received nasally inhaled isopropyl alcohol and 43 (53.8%) received nasally inhaled normal saline solution. At 10 minutes postintervention, median nausea verbal numeric response scale score was 3 in the isopropyl alcohol arm versus 6 in the placebo arm, for an effect size of 3 (95% confidence interval 2 to 4). Median satisfaction score was 4 in the isopropyl alcohol arm versus 2 in the placebo arm, for an effect size of 2 (95% confidence interval 2 to 2). There were no significant differences between the 2 arms in median pain verbal numeric response scale scores or subsequent receipt of rescue antiemetics.

CONCLUSION:
We found that nasally inhaled isopropyl alcohol achieves increased nausea relief compared with placebo during a 10-minute period.

Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

http://www.ncbi.nlm.nih.gov/pubmed/26679977

http://stemlynsblog.org/26596-2/

 

[pgg]

I sort of wonder if the mechanism for the alcohol pad "cure" for PONV is just that it's so annoying that it jolts the patient more awake. Kind of like if you start to feel carsick, closing your eyes isn't helpful but focusing on something can help you keep the burrito in your stomach.

If someone waved an alcohol pad under my nose I'd tell them my nausea was better just to get them to stop. Maybe someone should do a study comparing getting kicked in the shins compared to placebo. I bet the shin-kicking group would be less bothered by nausea too.

 

[deleted162650]

I sort of wonder if the mechanism for the alcohol pad "cure" for PONV is just that it's so annoying that it jolts the patient more awake. Kind of like if you start to feel carsick, closing your eyes isn't helpful but focusing on something can help you keep the burrito in your stomach.

If someone waved an alcohol pad under my nose I'd tell them my nausea was better just to get them to stop. Maybe someone should do a study comparing getting kicked in the shins compared to placebo. I bet the shin-kicking group would be less bothered by nausea too.

I tried to do that study but couldn't get it past the IRB.

 

[RxBoy]

For the CSE guys... DO you guys give test dose??

I got into the habit of doing CSE's until I had a run of hypotensive patients. One resulting in fetal bradycardia and c/s. I treated her hypotension very quickly too, usually roll with a neo stick in pocket on call (we have premade syringes).

I was giving no more than 1.5 mg bupivacaine and 10 mcg fentanyl IT. My guess was that the test dose through the epidural catheter was causing the issue. I probably did about 50 up until I had a run of hypotension, then I just stopped. THey did work great though. It was probably just bad luck.

A better test dose would probably be nothing but 45 mcg epi.

 

[deleted162650]

No test dose for me. I'm confident that the soft arrow cath will NOT go intravascular. I do aspirate on the cath both before and after pushing 3-5cc of the 1/8% bupi + fent infusion solution through it though.

 

[pgg]

I do not test dose CSEs for labor. I just start the infusion.

If the catheter is intravascular, I'll know it in an hour when the patient has pain.

If the catheter is intrathecal, I'll know it in 30-60 minutes when the patient gets something approaching a surgical block.


Also, I have never had an accidental intravascular or intrathecal catheter with the soft Arrow catheters.

 

[wickedskillz]

just wanted to chime in and say thanks for sharing your experiences everyone

 

[Libertas]

CSE can also result in uterine tetany after rapid withdrawal of maternal catacholamines. Abrupt pain relief allows the uterus to go gangbusters with contractions. Is it possible the hypotension was a red herring or confounding factor and uterine tachy systole was missed? Can treat this with terbutaline to try and reduce the change of a crash section if it happens. I've seen it a few times with cse.

For the CSE guys... DO you guys give test dose??

I got into the habit of doing CSE's until I had a run of hypotensive patients. One resulting in fetal bradycardia and c/s. I treated her hypotension very quickly too, usually roll with a neo stick in pocket on call (we have premade syringes).

I was giving no more than 1.5 mg bupivacaine and 10 mcg fentanyl IT. My guess was that the test dose through the epidural catheter was causing the issue. I probably did about 50 up until I had a run of hypotension, then I just stopped. THey did work great though. It was probably just bad luck.

A better test dose would probably be nothing but 45 mcg epi.

 

[pgg]

CSE can also result in uterine tetany after rapid withdrawal of maternal catacholamines. Abrupt pain relief allows the uterus to go gangbusters with contractions. Is it possible the hypotension was a red herring or confounding factor and uterine tachy systole was missed? Can treat this with terbutaline to try and reduce the change of a crash section if it happens. I've seen it a few times with cse.

Nitroglycerin works too.

 

[painstop]

8mls of 0.25% Bup with 100 ug Fentanyl. I place the catheter. I secure it. By the time I finish my note the patient is comfortable. All I can say is that I can feel when something isn't quite right. I know by "feel" whether there is even a possible dural "rent" or the catheter isn't going in smoothly. When in doubt (1/20 or so) I resort to the "standard" technique of Epidural placement and utilize 5-6 mls of saline instead of the bolus dose of 0.25% Bup.
I'd say after 300 or so Epidurals you probably have a good sense of what I'm talking about here. After 1,000 you definitely know what I'm talking about.

So logistically, are you emptying 8 mL of bupivacaine and 2 mL of fentanyl into an empty well/pocket in your epidural kit before you put your sterile gown on or do you have a nurse hold it up for you to draw up in a sterile manner...or do you have a syringe of this stuff in a 10 mL syringe in your scrub pocket? I only ask because I currently pre-draw a syringe and place it in my pocket but only bolus my "loading dose" through the catheter after I have slapped on a Tegaderm over the insertion site because I feel more comfortable about sterility since any subsequent boluses (for example, if I were to get called back to the patient's room for a "top-off") would be through the epidural catheter with aspetic technique anyway (simple glove and syringe) as opposed to the stage you are at with the Touhy needle still in the patient's back, at which point I would still maintain sterile technique since the catheter has not been advanced into the epidural space yet and so sterility is key...just curious.

 

[pgg]

Never in my life have I seen a person don a gown to place an epidural. Sounds like something a JC or CMS good-idea-fairy would come up with.

I do CSEs, and mix then squirt the intrathecal dose into a well on the epidural tray before getting my gloves on. If I bolused catheters (or bolused through the Tuohy) I'd do the same. Easy enough.

 

[painstop]

Never in my life have I seen a person don a gown to place an epidural. Sounds like something a JC or CMS good-idea-fairy would come up with.

I do CSEs, and mix then squirt the intrathecal dose into a well on the epidural tray before getting my gloves on. If I bolused catheters (or bolused through the Tuohy) I'd do the same. Easy enough.

oops meant sterile GLOVE not gown

 

[fakin' the funk]

The OB usually asks whats up with the blood spot is on the patients thigh. Its less hassle to just throw some phenylephrine the bag.

If you think answering your colleague's question about your entirely justified therapy is a "hassle" then you should grow a pair.

 

[fakin' the funk]

For the CSE guys... DO you guys give test dose??

Yes. Doing a test dose is still useful to rule out IT and IV catheter placement even in a CSE.

I do CSE's < 10% of the time. I do them less and less. When I do, I use 1 cc 0.25% bupiv. It is a wimpy dose but I would rather it be a weak spinal dose than be rushing back for C/S because a bigger intrathecal dose worked too well. (For me, that's an ultimate anesthesia fail.)

If you've ever had a test dose be positive for intrathecal placement -- or if you've ever intentionally done a lidocaine spinal -- you'll know that 45 mg of IT lidocaine produces a PROFOUND motor and sensory and autonomic block almost immediately. 2.5mg of bupiv doesn't (nor does 5 or 10mg for that matter).

So, the test dose still has value ruling out IT placement, plus the obvious value in ruling out IV placement.

 

[fakin' the funk]

How often do you run into shivering during C-sections? Seems to happen ~1/3 of the time for me, usually shortly after baby is out. I assume this is from decreased thermoregulation after sympathetic block from spinal. I've started trying some Meperidine if it's severe with good effect.

Most women having C-section under epidural (i.e., at the end of labor) will shiver.

Some having C-section under spinal will shiver.

Your theory is a good one, and the one I've read.

Sometimes I give the rest of whatever morphine I have around. I'd rather give that than f*cking meperidine.

 

[kazuma]

If you think answering your colleague's question about your entirely justified therapy is a "hassle" then you should grow a pair.

I don't have any problems answering a colleagues question. It does get annoying when they make a big deal about it and make the circulator document the blood spot was from the anesthesiologist as they continue to mumble about how they hope they don't get blamed for the mark. With an awake patient.

 

[Libertas]

I don't have any problems answering a colleagues question. It does get annoying when they make a big deal about it and make the circulator document the blood spot was from the anesthesiologist as they continue to mumble about how they hope they don't get blamed for the mark. With an awake patient.

What the *%+#???

 

[Urzuz]

I don't have any problems answering a colleagues question. It does get annoying when they make a big deal about it and make the circulator document the blood spot was from the anesthesiologist as they continue to mumble about how they hope they don't get blamed for the mark. With an awake patient.

I give IM ephedrine not infrequently and I use the deltoid. Alcohol swab, small gauge needle, aspirate+inject. Obviously tell the patient before you do it, but they tolerate it without a problem. Hold pressure for 10 seconds and there is no spot, and no one knows any different. If for whatever reason you feel the need, put a band-aid on it. Never had anyone ask me about it, patients haven't complained, everyone is happy.

 

[deleted171991]

I just love when people ask me to give stuff into the deltoid, when the patient is under neuraxial anesthesia and the thigh is available. They must be obsessed with patient satisfaction.

I know a surgeon who insists that his patients get subcutaneous heparin pre-induction. Five minutes later, when the patient is already under GA, is unacceptable. Because exactly in those five minutes... You can't fix stupid.

 

[pgg]

Blood spot? How big a needle are you using? We stock 27g needles in our carts.

 

[Urzuz]

I just love when people ask me to give stuff into the deltoid, when the patient is under neuraxial anesthesia and the thigh is available. They must be obsessed with patient satisfaction.

I know a surgeon who insists that his patients get subcutaneous heparin pre-induction. Five minutes later, when the patient is already under GA, is unacceptable. Because exactly in those five minutes... You can't fix stupid.

Get down on my hands and knees and tunnel my way under the drapes during a C-section to save the patient a shot with a 25g needle? Thanks, but no thanks

 

[deleted171991]

Get down on my hands and knees and tunnel my way under the drapes during a C-section to save the patient a shot with a 25g needle? Thanks, but no thanks

Not you. There is a nurse called circulator in the room.

 

[jwk]

Get down on my hands and knees and tunnel my way under the drapes during a C-section to save the patient a shot with a 25g needle? Thanks, but no thanks

"Hold still Mrs Jones - Dr. Smith, your OB, wants me to give you a shot in the arm."

 

[Noyac]

Are you guys/gals really discussing this ****? A blood spot on the thigh. WTF?

And are you seriously "too good" to crawl under the drapes to give an injection? I do it all the time.

 

[McPoyle]

Where I'm at we do predominately CSEs for laboring women.
- IT: 15mcg fentanyl and 2.5mg 0.5%bupi
- Epidural: 1/16% bupi with fentanyl

Occasionally need to be redosed, generally with 10cc 1/8% bupi. Seems like a good regimen that works well. I like the instant relief with the IT dose while waiting for the epidural to take effect. C sections get spinals with fent, MS, epi, bupi.

 

[fakin' the funk]

I don't have any problems answering a colleagues question. It does get annoying when they make a big deal about it and make the circulator document the blood spot was from the anesthesiologist as they continue to mumble about how they hope they don't get blamed for the mark. With an awake patient.

This OB sounds like the worst person ever.

Yes I get under the drapes to give IM stuff (methergine > ephedrine) without a moment's hesitation.

Incidentally, IM ephedrine during GETA is awesome

 

[deleted171991]

Incidentally, IM ephedrine during GETA is awesome

How much do you use? Same question for those who give IM phenylephrine.

 

[Urzuz]

Are you guys/gals really discussing this ****? A blood spot on the thigh. WTF?

And are you seriously "too good" to crawl under the drapes to give an injection? I do it all the time.

If I need to crawl under the drapes to give an injection I don't have a problem doing it. But my question is, WHY would you crawl under the drapes when you can inject it in their deltoid? Not only is giving it in the deltoid much cleaner, easier, faster, and safer (no risk of contaminating the sterile field, no risk of drapes contaminating the site of injection, and most importantly you can go back to monitoring the patient rather than ****ing around under the drapes since clearly they are having some degree of hypotension), but you have to ask yourself what are you gaining by injecting it in their thigh? You save them from feeling the poke from a 25/27 gauge needle? I have literally never had a patient even so much as wince when giving them a shot in the deltoid. And let's be real, if that's the biggest complaint they have after having their uterus sliced open and a human being ripped out of it, then I think they've had a fairly easy peripartum course.

I understand why some may inject it in the thigh, and to each his own. But it's just not my choice of practice.

 

[Urzuz]

How much do you use? Same question for those who give IM phenylephrine.

I give anywhere between 25-50 mg of IM ephedrine. Never have used IM phenylephrine.

 

[deleted162650]

Why are you giving IM ephedrine when there's an IV staring you in the face?? If you're sick of bolusing throw some neo in the bag.

 

[Urzuz]

Why are you giving IM ephedrine when there's an IV staring you in the face?? If you're sick of bolusing throw some neo in the bag.

I do put neo in the bag when I feel like it's warranted, but there are occasions where IM ephedrine is better IMO:

1) if the patient is persistently hypotensive at the end of the surgery and you need something longer acting to keep their pressure up while they continue to get resuscitated/the spinal wears off. I don't feel comfortable leaving a PACU nurse with a bag of saline of phenylephrine in it, and it's clunky to bring them to the PACU on a phenylephrine infusion.

2) when you want to know exactly how much you're giving. The effects of IM ephedrine are very reproducible and you will see similar effects across all patients. When you just throw neo in the bag, sure you can titrate to effect but realistically you have no idea what your drip rate correlates to (is your drip giving neo at 25 mcg/min? 50? 200?).

3) if for whatever reason you want to give long acting ephedrine more than phenylephrine. Maybe you're still an old-timer that believes ephedrine is superior to phenylephrine when the fetus is still in utero (if you do think that, let me update you: it's not), or maybe you prefer ephedrine for one reason or another. In that case, IM ephedrine > neo in bag

4) I can turn the question on you: why are you putting neo in the IV when you have a deltoid muscle staring you in the face? Are you uncomfortable giving an intramuscular injection? Obviously all things being equal, IV is the preferred route since it spares them the 25/27 gauge poke and it's easier and quicker...but as I've laid out above there are scenarios where all things aren't equal, and sparing the patient a poke from such a fine needle falls way to the bottom of issues to consider when picking your medication and delivery method.

 

[Noyac]

2) when you want to know exactly how much you're giving. The effects of IM ephedrine are very reproducible and you will see similar effects across all patients. When you just throw neo in the bag, sure you can titrate to effect but realistically you have no idea what your drip rate correlates to (is your drip giving neo at 25 mcg/min? 50? 200?).

So please excuse my ignorance here but why does this matter? You are going for effect, not a number aren't you?

 

[Urzuz]

So please excuse my ignorance here but why does this matter? You are going for effect, not a number aren't you?

I like to know what my vasopressor requirements are, don't you? 25 mcg/min of phenylephrine is a lot different than 200 mcg/min. And if your patient is requiring such a heavy infusion to maintain an adequate blood pressure, you should probably start investigating other causes of hypotension rather than "this is just from the spinal," and even potentially think about switching vasopressors...

 

[Noyac]

I like to know what my vasopressor requirements are, don't you? 25 mcg/min of phenylephrine is a lot different than 200 mcg/min. And if your patient is requiring such a heavy infusion to maintain an adequate blood pressure, you should probably start investigating other causes of hypotension rather than "this is just from the spinal," and even potentially think about switching vasopressors...

You give a pretty extreme example there. How often are your pts on 200 mcg/min? I don't think I have ever gone that high. And I am pretty damn sure when the requirements are going up I have a grasp on it. I don't need some number to tell me this.
So let me take it back down to a typical everyday c/s type example. What does the number matter? If you want to get nitpicky then do the math. You squirt 1000mcg in a liter and let it run. Pretty sure that without a pressure bag you won't get it in in under 20 minute. That would be 50mcg/min at 20 min. But again so what?

 

[Urzuz]

You give a pretty extreme example there. How often are your pts on 200 mcg/min? I don't think I have ever gone that high. And I am pretty damn sure when the requirements are going up I have a grasp on it. I don't need some number to tell me this.
So let me take it back down to a typical everyday c/s type example. What does the number matter? If you want to get nitpicky then do the math. You squirt 1000mcg in a liter and let it run. Pretty sure that without a pressure bag you won't get it in in under 20 minute. That would be 50mcg/min at 20 min. But again so what?

In the case you present the number doesn't matter. As I say in the first line of that post, I am someone who puts phenylephrine in the bag during a C-section and will let it drip in. The numbered list I gave were the advantages IM ephedrine has over putting phenylephrine in a bag and dripping it in.

 

[fakin' the funk]

How much do you use? Same question for those who give IM phenylephrine.

Either 25 or 50, depending on how much oomph I need. Have never given more than 50 though it would probably be appropriate to dose something like 0.5-1mg/kg. The effect seems to come on within 5-10 minutes and last about an hour.

Salty, it's an alternative to a neo gtt because it's simply easier than mixing, putting on the pump, etc, or by blindly doing it with LR/NS as the carrier if you don't want to give a lot of fluid. A lot of our rooms don't have Alaris pumps in them, so I have to call, etc... Sometimes if I'm running a propofol gtt on a Baxter or Alaris pump I'll use it like a carrier, mix some concentrated neo from the 1ml vial into the propofol and do the math, most patients (as you know) if they need it, need something like 20-50mcg/min