ob anesthesia

[dr kozlov]

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i d like to bring couple of things we do in our place that rarely or not done at all
1) block 2nd stage of labor---cse 0.5ml 0.75% bup hyperbaric , then epid catheter, let them sit for 7 min---intense sacral block-- nicely blocks 2nd stage of labor, plus all lacerations,episotomies,repairs painless,even placement of foley after epidural is painless
2)all cs --cse..kepp epid catheter for whole time in the hospital (usualy 3 days) give duramorph 2mg epid bid----supergood pain relief

does antbody do something similar ?😉

 

[Bertelman]

2)all cs --cse..kepp epid catheter for whole time in the hospital (usualy 3 days) give duramorph 2mg epid bid----supergood pain relief

does antbody do something similar ?😉

That sounds like a lot of work.

 

[Planktonmd]

i d like to bring couple of things we do in our place that rarely or not done at all
1) block 2nd stage of labor---cse 0.5ml 0.75% bup hyperbaric , then epid catheter, let them sit for 7 min---intense sacral block-- nicely blocks 2nd stage of labor, plus all lacerations,episotomies,repairs painless,even placement of foley after epidural is painless
2)all cs --cse..kepp epid catheter for whole time in the hospital (usualy 3 days) give duramorph 2mg epid bid----supergood pain relief

does antbody do something similar ?😉

1) You don't need a saddle block and surgical anesthesia of the sacrum for labor!
It's not wrong but it's not necessary.
2) If you are keeping the catheter in then why not just give a continuous infusion of Fentanyl? this will allow you to titrate the analgesia to the patient's need and just before you pull the catheter out give a dose of Morphine to get a few more hours of analgesia.
In my practice C sections are done with a single shot spinal with a small dose of intrathecal morphine added and this gives you a good 12-18 hours of analgesia.

 

[dhb]

Weired that we are getting first time posters with funky stuff fishing for some anesthesia tidbits..
pgg it's a mission for you and your new superpowers

 

[pgg]

Weired that we are getting first time posters with funky stuff fishing for some anesthesia tidbits..
pgg it's a mission for you and your new superpowers

I wouldn't do either of the things dr kozlov mentioned in his OP, but he doesn't smell like a troll or midlevel looking to stir up crap. Bertelman's answer echoed what I was thinking and planktonmd put some good old North American anesthesia reality into the thread. No modding needed.

In any case, trollban guns in 30-06 like the one Mod Emeritus Gunslinger JPP once carried to defend the forum aren't available to outer circle assistant mod lackeys like me. I've been issued an array of carrots but few sticks. 🙂

 

[tucker27705]

OP stated:

"i d like to bring couple of things we do in our place that rarely or not done at all"

What does this mean? That you do that and want to share it? Or are you mentioning things that you rarely or never do?

And someone stated you don't need sacral block for labor? I thought the perineum was S2-4. Maybe not labor, but definitely involved in delivery and repairs.

We don't do anything unconventional in our practice. Epidurals for L&D, spinals with duramorph for c/s unless a good epidural is already in place. A couple of MDs do CSEs, most don't.

There is a reason things are not done "rarely or not done at all."

Tuck

 

[Jeff05]

i d like to bring couple of things we do in our place that rarely or not done at all
1) block 2nd stage of labor---cse 0.5ml 0.75% bup hyperbaric , then epid catheter, let them sit for 7 min---intense sacral block-- nicely blocks 2nd stage of labor, plus all lacerations,episotomies,repairs painless,even placement of foley after epidural is painless
2)all cs --cse..kepp epid catheter for whole time in the hospital (usualy 3 days) give duramorph 2mg epid bid----supergood pain relief

does antbody do something similar ?😉

that dose spinal only lasts for an hour or so - so not sure how it would cover repairs, etc. what you're seeing is probably just your epidural working. placement of foley is painless even if you put 0.5cc of 0.25% +/- 25 mcg fent.

i think dosing heavy bupiv does pose a risk of a much higher block than desired, leading to profound hypotension in the LandD room.

also, for visceral pain IT/EPI opioid would be preferable.

duramorph for 3 days? it's impressive that you can have that frequent respiratory checks for all postpartum patients for 3 days.
also a typical postpartum admission is 3 days - so are you sending patients out the same day s/p epi mso4 dose?

 

[Planktonmd]

And someone stated you don't need sacral block for labor? I thought the perineum was S2-4. Maybe not labor, but definitely involved in delivery and repairs.

I said you don't need "surgical anesthesia of the sacrum" because what we do for labor is not surgical anesthesia, and that's why you don't really need to do a saddle block using hyperbaric Bupivacaine as the OP mentioned.

 

[dr kozlov]

thank u for replies
but some of them a little strange (im saying it with all due respect of course)
for example jeff05 stays:spinal only an hour----actually sacral block lasts 5 h at least ,but in our case its indefinite--its supported by ebidural pump thru dural puncture (please look up harvard studies dp technique)
jeff05 mentions "profound hypotension" --if sacral block is done with hyperbaric bup its not possible to have hypotension---pt sits up for 7 min

jeff05 "for visceral pain"---sacral block for 2nd stage of labor ,not for visceral pain
u can not get respiratory depression on this dose of epidural morphine-(by the way does anybody know on what dose of epidural morphine we can expect resp dep ? )
last dose of epid morphine is safe because it is actually discontinuation of 3 days regimen that was observed for 3 days, not a new dose for opioid naive pt

jeff05 sounds like a student

 

[dr kozlov]

That sounds like a lot of work.

typical anesthesia thinking---to do 30 min cs and leave...but pt in pain for 3 days after , what about that? pca on oral opioid suck---pts can not cough or laugh or move bowels --too much pain
anesthesia never sees pt 1,2,3 days after cs --they do not know how bad it is

 

[dr kozlov]

1) You don't need a saddle block and surgical anesthesia of the sacrum for labor!
It's not wrong but it's not necessary.
2) If you are keeping the catheter in then why not just give a continuous infusion of Fentanyl? this will allow you to titrate the analgesia to the patient's need and just before you pull the catheter out give a dose of Morphine to get a few more hours of analgesia.
In my practice C sections are done with a single shot spinal with a small dose of intrathecal morphine added and this gives you a good 12-18 hours of analgesia.

how u block 2nd stage of labor?
u probably do not at all

typical anesthesiologist is not aware that most unpleasant part of labor ---vaginal examination ---sacral block works for it

 

[dr kozlov]

OP stated:

"i d like to bring couple of things we do in our place that rarely or not done at all"

What does this mean? That you do that and want to share it? Or are you mentioning things that you rarely or never do?

And someone stated you don't need sacral block for labor? I thought the perineum was S2-4. Maybe not labor, but definitely involved in delivery and repairs.

We don't do anything unconventional in our practice. Epidurals for L&D, spinals with duramorph for c/s unless a good epidural is already in place. A couple of MDs do CSEs, most don't.

There is a reason things are not done "rarely or not done at all."

Tuck

i mean to share what done in our place

and what r the reasons for "things not done"?

 

[dr kozlov]

I said you don't need "surgical anesthesia of the sacrum" because what we do for labor is not surgical anesthesia, and that's why you don't really need to do a saddle block using hyperbaric Bupivacaine as the OP mentioned.

how do u block 2nd stage of labor?
do u think about very uncomfortable vaginal examination when obs stick there fist into vagina ?
repairs needed in 50% of cases ---r u prepared for that ?

sounds u do not even thought about that-----typical anesthesia thinking----we just do not want to get involved

 

[dr kozlov]

did anybody thought how we anesthesiologists think----(some of the examples r answers to my post)---
"i went to residency in columbia(or other place) that why i do it this way"
"things not done because they r not done"
"too much work"----about epidural vs spinal (is it really more work if we keep in prospective 3 days superior pain relief and not 30 min cs only)

most anesthesiologist have business or scientific attitude---it does not cross mind of most people that science is not a priority--care and healing shuold come first

 

[lane]

nm

 

[Planktonmd]

how do u block 2nd stage of labor?

With a properly working epidural!
There is a difference between analgesia for labor and surgical anesthesia, we can't induce surgical anesthesia in every patient in anticipation of repairs.

do u think about very uncomfortable vaginal examination when obs stick there fist into vagina ?

Again, a properly working epidural is more than enough for this too, you DO NOT NEED SURGICAL ANESTHESIA for a pelvic exam!
Women get pelvic exams everyday with nothing!
Have you thought about that?

repairs needed in 50% of cases ---r u prepared for that ?

I am not sure you have any understranding of what you are trying to teach us here but My answer is yes, we are prepared for that!
And by the way, if you are doing surgical anesthesia of the pelvis for all your patients then it is not surprising that 50% are needing repairs, I actually would expect 100% because you are abolishing any protective muscle tone and exposing these poor patients to painless ruptures that could have been avoided if they had some muscle tone.

sounds u do not even thought about that-----typical anesthesia thinking----we just do not want to get involved

Here is what I suggest:
Read about this specialty, then maybe get a residency spot, then start practicing Anesthesiology, then work a little bit on your ability to write full sentences, then at that time, and at that time ONLY, come back here and discuss Anesthetic techniques.
Until then you need to listen and try to learn something!

 

[ssmallz]

Why do CSE's for c/s? Just do a spinal and then add a PCA or some PO meds for post op pain control. Why the need for the epidural? Worried about a c/s taking so long just place an epidural to begin with and dose it up w/Lido 2%. Worried about how long it takes for an epidural to kick in? Just add a cc or 2 of bicarb. We do plenty of c/s and rarely if ever have a problem with inadequate analgesia intra op or post op. For epidural pt's we pull the catheter at the end of the procedure and start them on PCA. We round on them post op and I rarely have complaints of post op pain. Sure its sore but not OMG I want to kill myself pain.

FWIW, one of the best ways to make enemies here is to ask a good faith question and then tell the responders they are wrong when thats what works for them day in and day out.

 

[jwk]

Clearly Dr. Kozlov doesn't work in a high volume non-academic real-world practice.

 

[Bertelman]

typical anesthesiologist is not aware that most unpleasant part of labor ---vaginal examination ---sacral block works for it

Have you ever experienced a vaginal exam? Then your anecdotes are no different from mine. I can tell you from the exams I have seen, the vaginal exam is no comparison to delivery.

typical anesthesia thinking---to do 30 min cs and leave...but pt in pain for 3 days after , what about that? pca on oral opioid suck---pts can not cough or laugh or move bowels --too much pain
anesthesia never sees pt 1,2,3 days after cs --they do not know how bad it is

We were all med students once, and we all rotated on the service seeing these patients POD #1 and 2. They're not so miserable that they required a neuraxial analgesic. They are probably some of the more pleasant abdominal post-ops in the hospital, because they have something positive to show for it.

how do u block 2nd stage of labor?
do u think about very uncomfortable vaginal examination when obs stick there fist into vagina ?
repairs needed in 50% of cases ---r u prepared for that ?

I think your OBs are doing something wrong. It only takes two fingers.

jeff05 sounds like a student

You're a student too, right?

did anybody thought how we anesthesiologists think----(some of the examples r answers to my post)---
"i went to residency in columbia(or other place) that why i do it this way"
"things not done because they r not done"
"too much work"----about epidural vs spinal (is it really more work if we keep in prospective 3 days superior pain relief and not 30 min cs only)

most anesthesiologist have business or scientific attitude---it does not cross mind of most people that science is not a priority--care and healing shuold come first

Science is a priority. There is a reason the practice in your hospital is "rarely done at all". And it's not because none of us care.

 

[lfesiam]

 

[Mman]

i d like to bring couple of things we do in our place that rarely or not done at all
1) block 2nd stage of labor---cse 0.5ml 0.75% bup hyperbaric , then epid catheter, let them sit for 7 min---intense sacral block-- nicely blocks 2nd stage of labor, plus all lacerations,episotomies,repairs painless,even placement of foley after epidural is painless

Is this implying that the patient does not receive an epidural (or CSE) until they are 10 cm dilated and pushing? 2nd stage of labor doesn't start until they are fully dilated and unless they are a grand multip you are going to have a tough time judging how long it will be exactly until they are in 2nd stage to put your spinal (saddle block) ahead of time and have it still be functional.

I'd be shocked if patients weren't allowed to get an epidural before 10 cm. It would be horrible for the patients. My epidurals work fine for 2nd stage of labor and if it doesn't, a little bolus of epidural fentanyl tends to do the trick nicely.

And anybody that thinks you can't get respiratory depression from 2 mg of morphine BID via epidural hasn't taken care of enough patients. Slap a pulse ox and some noninvasive capnometry on them overnight and I bet you see some.

 

[Jeff05]

thank u for replies
but some of them a little strange (im saying it with all due respect of course)
for example jeff05 stays:spinal only an hour----actually sacral block lasts 5 h at least ,but in our case its indefinite--its supported by ebidural pump thru dural puncture (please look up harvard studies dp technique)
jeff05 mentions "profound hypotension" --if sacral block is done with hyperbaric bup its not possible to have hypotension---pt sits up for 7 min

jeff05 "for visceral pain"---sacral block for 2nd stage of labor ,not for visceral pain
u can not get respiratory depression on this dose of epidural morphine-(by the way does anybody know on what dose of epidural morphine we can expect resp dep ? )
last dose of epid morphine is safe because it is actually discontinuation of 3 days regimen that was observed for 3 days, not a new dose for opioid naive pt

jeff05 sounds like a student

not that it matters, but i'm an attending. lets address some of your basic disconnects with actual clinical practice (harvard studies aside).
#1. 3.75mg of bupiv definitely does NOT last for 5 hours. I do spinals with 15mg for c/s and patients have complete regression of the block within 2-3 hours.

#2. "you can't get respiratory depression on this dose of morphine?" well, i would hate to disclose that i'm also pain fellowship trained. You can absolutely get respiratory depression with those doses of epidural morphine. At our institution we have 24 frequent respiratory checks after a one time dose of 4mg. in your situation, there may be a cumulative effect in some slow metabolizers and opiate sensitive patients. it only takes ONE respiratory arrest of an otherwise healthy postpartum patient to change a liberal policy.

#3. you mean the harvard study that showed increased rates of c/s, increased rates of instrumented delivery, and decreased rate of SVD? As well as no statistical difference in most meaningful categories.
Oh, as well as the complete non-real world approach of using a larger spinal needle and NOT actually doing a spinal (which in any world achieves faster analgesia vs epi).

#4. you are right that dose of bupiv is unlikely to cause hypotension. But, again, it may. Bupiv spinals take longer than 7 minutes to set (anyone who has done a significant amount of OB anes knows this as everyone is standing around and you're putting the table in Trend to get the drug to a higher thoracic level.

#5. visceral pain is usually discussed as being primarily an issue during the 1st stage of labor, however it is absolutely an issue during the second stage, as well. adding opioid to local anesthetic during the second stage helps to: decrease risk of systemic toxicity, decreased plasma concentrations in neonate, decrease motor block, decreases motor block (prolongs second stage and possibly instrumentation).

#6. not sure why your OBs are fisting their patients...(50% repair rate!?)

#7. based on your poor command of the english language, would you mind sharing what 2nd -world- eastern- european- pseudo-communist poly-clinic you work in?

 

[Bertelman]

most anesthesiologist have business or scientific attitude---it does not cross mind of most people that science is not a priority--care and healing shuold come first

Furthermore, you may be surprised to find out the docs before you that established the standard of care at your institution may very well have been blinded by the business side of their practice when they implemented a 3-day epidural injection practice for pain that is otherwise controlled by PO meds.

 

[jwk]

Furthermore, you may be surprised to find out the docs before you that established the standard of care at your institution may very well have been blinded by the business side of their practice when they implemented a 3-day epidural injection practice for pain that is otherwise controlled by PO meds.

👍

Our epidurals are out in 24-30 hours because

1) Patients are on PO meds POD #1 and sometimes DOS.
2) Patients can't get a shower until the epidural is out.
3) They go home on POD #3 most of the time.

Nothing like the real world for a perspective on how things really are. Clearly the good Dr. Kozlov doesn't know about it - have we scared him away?

 

[sevo85288]

OP: Get real. Most women in the world don't use epidurals for delivery; so come of your high horse. "anesthesia" doesn't know how much pain there is...wtf is that??? Why offend ask a question if you already dislike "anesthesia" in an anesthesia forum?

C/S pain does not last 3 days. After one dose of Pf morphine most pt's don't require anything but oral analgesics. How about the risk of leaving a catheter in for 3 days! I would never want an epid in my back for 3 days. You don't need an epidural catheter for 3 days! People go home after hernia repairs, same day.

This is not rocket science. Pt needs labor analgesia; place epidural. Pt needs c/s analgesia give epid/iv/po opioid. I don't think you have spent time in the real world.

 

[dr kozlov]

OP: Get real. Most women in the world don't use epidurals for delivery; so come of your high horse. "anesthesia" doesn't know how much pain there is...wtf is that??? Why offend ask a question if you already dislike "anesthesia" in an anesthesia forum?

C/S pain does not last 3 days. After one dose of Pf morphine most pt's don't require anything but oral analgesics. How about the risk of leaving a catheter in for 3 days! I would never want an epid in my back for 3 days. You don't need an epidural catheter for 3 days! People go home after hernia repairs, same day.

This is not rocket science. Pt needs labor analgesia; place epidural. Pt needs c/s analgesia give epid/iv/po opioid. I don't think you have spent time in the real world.

"most of the women in the world do not use epidurals"----
all ob anesthesiologist should be at least offended by this logic----to refuse only effective pain relief for labor because most of the world population has no access to this
am i wrong ?
"for 3 days!!!"--post thoracic cases epidural can stay for couple of weeks safely

"people go home after hernia repairs same day"--not after cs......may be cs is a little different from hernia repair?

"cs pain does not last for 3 days!"-----its usually for 7 days that u ll need po meds

 

[dr kozlov]

thank you everybody for replies
please forgive my english--its a second (or should i say 3rd)language---please be forgiving
if i offended anybody ---my appologies it was not my intention

lets examine fine anesthesia logic:
how many of you use duramorph in spinals for cs? i hope a lot..
how many respiratiory arrests did you have? i guess none...
if we have no problem monitoring pts for first 24 h why shoud be problem monitoring them for another day?(except my personal fears?)
if we agree that duramorph is far superior too pca or oral meds (is it?)
why not to make 2nd day to another 1st day? (i started doing that when my pt said "why second day is much worse then first?)
do we use objective test for pain evaluation ? (except lovely 1 to 10 score that means nothing)
are there any objective tests?
how do i know that duramorph superior to pca ?
ask them to cough strongly--they will have no problem to do it on 1st day on duramorph and they will not be able to cough without pain on po meds when duramorph wears out
did anybody noticed that woman on po meds ---family do not want to visit her --she is too high and sedated ?
did anybody from anesthesia ever talked to pt post cs on day 3? we rarely doing that...
do we know that post cs on po meds woman can not cough,laugh,move her bowels without pain?
did we really take a good look at whole picture ?

 

[dr kozlov]

How much pruritis and nausea/vomiting are you getting?

the same as with spinal duramorph (blah blah blah)
and with oral opioids

 

[dr kozlov]

Have you ever experienced a vaginal exam? Then your anecdotes are no different from mine. I can tell you from the exams I have seen, the vaginal exam is no comparison to delivery.






We were all med students once, and we all rotated on the service seeing these patients POD #1 and 2. They're not so miserable that they required a neuraxial analgesic. They are probably some of the more pleasant abdominal post-ops in the hospital, because they have something positive to show for it.



I think your OBs are doing something wrong. It only takes two fingers.



You're a student too, right?





Science is a priority. There is a reason the practice in your hospital is "rarely done at all". And it's not because none of us care.

care and healing is priority not science,pts are not guinea pigs...
(lovely anesthesia logic!)

 

[dr kozlov]

is there consensus that regular labor epidural does not provide pain relief for 2nd stage of labor?
do i have to quote literature for that?

 

[pgg]

if we have no problem monitoring pts for first 24 h why shoud be problem monitoring them for another day?(except my personal fears?)

Sorry, are you saying that

a) Since there were no problems in first 24 hours, you don't need to monitor them for the next 48 even if you keep giving epidural morphine?

or

b) Since you've monitored them for 24 hours, you might as well keep monitoring them for another 48?

did anybody noticed that woman on po meds ---family do not want to visit her --she is too high and sedated ?

What?

is there consensus that regular labor epidural does not provide pain relief for 2nd stage of labor?

What? Of course it does. That's the point.

care and healing is priority not science,pts are not guinea pigs...
(lovely anesthesia logic!)

What?



PO analgesics are fine starting POD 1 and monitored beds are an expensive limited resource. I don't know where you're getting the idea that patients need epidural opioids for 3 days after a c-section. Most are going HOME on POD 3; some even leave late POD 2. It's not a Whipple.

 

[Bertelman]

care and healing is priority not science,pts are not guinea pigs...
(lovely anesthesia logic!)

ur ridiculous

 

[Planktonmd]

care and healing is priority not science,pts are not guinea pigs...
(lovely anesthesia logic!)

😕
Are you even in medical school?
You are starting to sound more like a nurse or a student nurse.

 

[Jeff05]

kozlov, to better gauge where you're coming from - where are you in your training?

 

[nitroglycerine]

Furthermore, you may be surprised to find out the docs before you that established the standard of care at your institution may very well have been blinded by the business side of their practice when they implemented a 3-day epidural injection practice for pain that is otherwise controlled by PO meds.

I must admit I have been seeing a lot of North American anesthetists that would swear that every lower abdominal incision including transverse absolutely needs a low thoracic epidural cath.

 

[fakin' the funk]

#6. not sure why your OBs are fisting their patients

Most intriguing part of this thread so far.

 

[Yo GabbaPentin]

nm

 

[veetz]

would you mind sharing what 2nd -world- eastern- european- pseudo-communist poly-clinic you work in?