OB Case

[Mman]

an awful plan is going to section with an epidural in her

another awful plan is to try to impress everyone with your unbelievable epidural skills at the detriment to the patient.

remi is effective and might be more reliable than epidural analgesia in her for labor

epidurals in super fat OB patients are rarely difficult and remi is not remotely as effective at providing analgesia for labor.

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[Hoya11]

I'm amazed you think this. Do you have any literature to support it?

Any ob obese literature I've seen supports early epidural.

I've had probably 5 BMI 65 to 75 parturients cs in the last 8 years and they all did fine with an epidural. Not exactly stellar numbers but Imo it's ok for me to keep doing it. The epidurals weren't all even that harder than say BMI 40s

I've never heard of 1st line Remi in a supermorbid obese lady

I dont buy that BMI 77 is "routine" anywhere in the world

Of course a remi drip is not your first option, but what is the plan after 30 minutes of poking for an epidural? walk away with nothing?

Remi drip for laboring OB patients who cannot have neuraxial is well supported in the literature and standard where i trained

We all deal with morbidly obese patients. BMI 77!? come on, we are deep into plan B and C for that, and one consideration is what do I offer if I cant get an epidural? how long do i struggle for an epidural before I offer something else?

Seems like most are assuming they will get the epidural with their super skills and then have the nurses applaud,

 

[Twiggidy]

I dont buy that BMI 77 is "routine" anywhere in the world

Of course a remi drip is not your first option, but what is the plan after 30 minutes of poking for an epidural? walk away with nothing?

Remi drip for laboring OB patients who cannot have neuraxial is well supported in the literature and standard where i trained

We all deal with morbidly obese patients. BMI 77!? come on, we are deep into plan B and C for that, and one consideration is what do I offer if I cant get an epidural? how long do i struggle for an epidural before I offer something else?

Seems like most are assuming they will get the epidural with their super skills and then have the nurses applaud,

I see your point, but I also think you're underrating your own skills as an anesthesiologist. BMI 77 is a big and brassy woman but I'm gonna say that if you can hit bone you can get that epidural in the space. As others suggest, it doesn't have to be blind either ie, use the ultrasound. I feel like the Remi situation is reserved those platelet count of 20 labors or maybe someone with full back Harrington rods or wild stuff like that. Quite honestly, someone my hardest epidurals have been on little ladies with narrow spaces.

 

[NoodleIncident]

I dont buy that BMI 77 is "routine" anywhere in the world

Haha, you need to move down South and see for yourself. It’s common and accepted enough that there’s been more of a push to classify morbidly obese patients as ASA 2’s.

 

[deleted162650]

Haha, you need to move down South and see for yourself. It’s common and accepted enough that there’s been more of a push to classify morbidly obese patients as ASA 2’s.

BMI 77 = ASA 4.

 

[Mman]

I dont buy that BMI 77 is "routine" anywhere in the world

Nobody said a patient with a BMI of 77 is normal or routine, but if you've done a few epidurals on patients that size you will realize they usually are not difficult. I'd wager you would have a <50% chance of needing anything more than a 3.5" tuohy needle. They very rarely have much fat over the lumbar spine.

 

[NoodleIncident]

Yes, just because they are big doesn’t mean that they will be a difficult epidural. Just as they aren’t necessarily difficult intubations either.

I’ve had a number or patients with BMIs in the 70s and my biggest so far was 86 (who was a prime that delivered vaginally with an epidural by the way) and although I’ve hubbed the 9cm needle before, I have never had to use the harpoon Touhy.

 

[Arch Guillotti]

an awful plan is going to section with an epidural in her

another awful plan is to try to impress everyone with your unbelievable epidural skills at the detriment to the patient.

remi is effective and might be more reliable than epidural analgesia in her for labor

This is nonsense. The epidural may be a heroic struggle. Once you place there is no reason to believe it won’t work for a c/s.

 

[woopedazz]

an awful plan is going to section with an epidural in her

Personally, I would think that's better than going to section without an epidural? Wouldn't it be better to do under epidural top-up than GA?

 

[ethilo]

I did the case yesterday, I essentially encouraged the patient to refuse an induction with potential for middle of the night emergency in favor of a controlled schedule c section during the day time. It went super well!

Here's what I did:

-I placed an A-line to take NIBP misreadings out of the equation. Best decision ever.
-I did an epidural, performed a dural puncture for confirmation of touhy position without dosing it (a DPE). Epidural was incredibly easy, LOR 9cm. Done in <2 mins, straight shot without adjusting angle.
-I opted to not test dose or do a CSE so that the patient would pick up her own legs onto the table and positioned herself for surgery. She got positioned up on top of a bariatric ramp, in case of conversion to GA, then I dosed up the epidural in 5cc increments with lido 2%+epi+bicarb. This essentially doubled as my test dose.
-Titrated epidural dosing to pinprick. Had a lot of time to get a good level.
-OB team used Velcro straps up over her shoulders to keep her pannus up.
-No duramorph, I was concerned about long acting opioids, decided to keep it clean with just a PCA post op.
-The rest of case was routine c-section care.
-Epidural pulled out on transfer to gourney, as per routine.
-Continuous pulse oximetry post op while on a PCA.

The a-line was also a bit of a blessing bc I could respond very fast to hypotension and thus I had a few instances that she got nauseated but aborted vomiting with phenylalanine.

I feel like the epidural was so successful because I really worked hard on getting perfect positioning: her feet were on a stack of standing stools to try to flex her hips, I told her to shift her butt Chris to make them sit evenly. That was a key instruction that made her back as symmetrical as possible. Then I maintained alignment with the touhy as much as possible, focusing on symmetry. It was truly an easy epidural without the long touhy. I was a little flabbergasted, but it worked.

 

[woopedazz]

-No duramorph, I was concerned about long acting opioids, decided to keep it clean with just a PCA post op.

I'm pretty meh at obs, but if we were so against opioids what do people think about using 0.75% Ropivacaine via epidural once test/loading dose was completed. I.e. 5-10mL lignocaine + adrenaline --> block starting to form --> transition to ropivacaine for what we expect to be a longer case. I've found this works well in heavy drug addicts; especially the multiparous skinny ones where LA toxicity can be an issue.
Overall aim to reduce LA toxic dosing and allow for an iTAP single-shot +/- TAP catheter at the end; hopefully avoiding opioids post-op all together.

 

[sevoflurane]

I'm pretty meh at obs, but if we were so against opioids what do people think about using 0.75% Ropivacaine via epidural once test dosing was done with Lignocaine 2% + adrenaline. I.e. 5-10mL lignocaine + adrenaline --> block starting to form --> transition to ropivacaine for what we expect to be a longer case. Overall reducing LA dose and allowing for TAP single-shot +/- catheter at the end and hopefully avoiding opioids post-op all together.

No, no, no.... especially tap cath in a BMI of 77.

 

[woopedazz]

No, no, no.... especially tap cath in a BMI of 77.

Why not though? The obstetricians can insert under direct vision if the placement is the quandary. If it doesn't work it doesn't work, but I don't like post-delivery PCAs all that much.

 

[sevoflurane]

Why not though? The obstetricians can insert under direct vision if the placement is the quandary. If it doesn't work it doesn't work, but I don't like post-delivery PCAs all that much.

I don’t think I’ve ever seen an OB place any catheters. I think an OB dealing with a 77 kg patient has other things in mind... like get in and get out.
Personally placing a Tap catheter in a BMI of 77 is just something I would not even try.

Why .75% rop? Is that what you usually do?

 

[woopedazz]

I don’t think I’ve ever seen an OB place any catheters. I think an OB dealing with a 77 kg patient has other things in mind... like get in and get out.
Personally placing a Tap catheter in a BMI of 77 is just something I would not even try.

Yeah fair. I wouldn't put it in myself if they refused. If you tell them where to aim they can do it and the direct approach has better effect than US guided in the LSCS studies.

Why .75% rop? Is that what you usually do?

Not always, I'm still experimenting with what I like as I don't do much obs. I just feel that when it mixes with the 2% lignocaine test/loading dose it ends up being ~0.5% and gives a nice block at the surgical site without needing the large volumes and ultra-extended duration. What do you guys use?

 

[ethilo]

I'm pretty meh at obs, but if we were so against opioids what do people think about using 0.75% Ropivacaine via epidural once test/loading dose was completed. I.e. 5-10mL lignocaine + adrenaline --> block starting to form --> transition to ropivacaine for what we expect to be a longer case. I've found this works well in heavy drug addicts; especially the multiparous skinny ones where LA toxicity can be an issue.
Overall aim to reduce LA toxic dosing and allow for an iTAP single-shot +/- TAP catheter at the end; hopefully avoiding opioids post-op all together.

I'd love to see someone try performing a TAP block on this patient. Curvilinear and a block needle wouldn't be enough. You'd have a better chance with sonar and a sharpened crazy straw.

 

[pgg]

I'd love to see someone try performing a TAP block on this patient. Curvilinear and a block needle wouldn't be enough. You'd have a better chance with sonar and a sharpened crazy straw.

Consult IR.