Optimal fentanyl and morphine dose for CS spinal.

[deleted875186]

Can some OB experts update me on the “optimal doses”. Too many papers, all over the place. I will typically do 100-200 mcg morphine and 10-25 mcg fentanyl.

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[Arch Guillotti]

15 mcg fentanyl and 150 mcg duramorph.

 

[Modoc]

I use 25mcg fentanyl and 100 mcg duramorph

 

[Lashler9054]

300 mcg duramorph and 20 mg fentanyl

 

[linkin06]

A 2020 meta-analysis of 14 randomized trials (700 patients) of the effects of adding fentanyl to bupivacainefor spinal anesthesia for CD found that intrathecal fentanyl (10 to 15 mcg) reduced the need for supplemental intraoperative analgesia (4.5 percent versus 29.6 percent, RR 0.18, 95% CI 0.11-0.27) and reduced the incidence of intraoperative nausea and vomiting (10 percent versus 25.8 percent, RR 0.41, 95% CI 0.24-0.74)

Efficacy of Intrathecal Fentanyl for Cesarean Delivery: A... : Anesthesia & Analgesia

it, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS: Key electronic databases...

journals.lww.com

Doses above 150 mcg do not improve pain scores in the first 24 hours after CD

Neuraxial morphine and respiratory depression: finding the right balance - PubMed

Morphine is a drug commonly administered via the epidural or intrathecal route, and is regarded by many as the 'gold-standard' single-dose neuraxial opioid due to its postoperative analgesic efficacy and prolonged duration of action. However, respiratory depression is a recognized side effect of...

pubmed.ncbi.nlm.nih.gov

In a 2016 meta-analysis of 11 randomized trials (480 patients) that compared low dose (50 to 100 mcg) to high dose (>100 to 250 mcg) intrathecal morphine, time to first request for analgesia was longer after high dose morphine (mean difference 4.5 hours, 95% CI 1.85-7.13 hours)

The Effect of Intrathecal Morphine Dose on Outcomes After Elective Cesarean Delivery: A Meta-Analysis - PubMed

This meta-analysis shows that HDs of intrathecal morphine prolong analgesia after cesarean delivery compared with lower doses. The MD of 4.5 hours (95% CI, 1.9-7.1 and 99% CI, 1.0-8.2 hours) of pain relief must be balanced against the increased risk of maternal pruritus and vomiting. Results...

pubmed.ncbi.nlm.nih.gov

 

[med2010]

15 mcg fentanyl 100 mcg Duramorph

 

[woopedazz]

15 mcg fentanyl 100 mcg Duramorph

This. Don't @Me

 

[deleted875186]

So I’ve heard many people say 150 mcg duramorph is the ceiling for analgesia and the optimal dose, but it seems studies are all over the place. Anywhere from 100-300 seems reasonable for analgesia with little side effects, but I will occasionally get the patient that itches all day for 24 hours. Does anyone individualize their dose? Any way to predict who needs a smaller dose?

 

[Gator7]

I keep it simple 1.4 heavy, 20mcg fent, 200mcg duramorph. I have all three vials lined up and draw in 1 syringe. Comes out to 2 ml

 

[yerhuckleberry]

w/ repeat c/s, I typically ask the patient what their preference is...longer analgesia (125mcg) or minimal/no pruritus (75mcg).

 

[sevoflurane]

100 mcg morphine
15 mcg fent
Just under 2 mls

 

[LivetoTell]

As an aside, anyone adding dexmedetomidine (5 mcg) to their spinals?

 

[Arch Guillotti]

As an aside, anyone adding dexmedetomidine (5 mcg) to their spinals?

No

 

[IlDestriero]

1.4-1.6 Bupi, 20 Fent, 150 Morphine

 

[linkin06]

100 mcg morphine
15 mcg fent
Just under 2 mls

Dang 2 ml sounds high. They’re able to hold baby and do skin to skin??

 

[deleted875186]

I inject 2ml total volume all the time, never had a high block.

 

[sevoflurane]

Dang 2 ml sounds high. They’re able to hold baby and do skin to skin??

Nah. It’s just right.
2 CSF swirls on the way in and you are good to go.
Never had a high spinal.

 

[surgndoc]

I do 12.5mg bupi, 10mcg fentanyl, 200mcg duramorph but I’ve had a lot of N/V…so based on that and reading these numbers I’m going to start doing 100-150mcg duramorph. 200 was just the standard where I’m at but I seem to be having a lot of nausea.

Interestingly in residency we did 130mcg PF dilaudid and N/V was never a problem but it’s hard to get at my current spot

 

[DocVapor]

Anyone just not use fentanyl?

 

[Sleeplessbordernights]

As an aside, anyone adding dexmedetomidine (5 mcg) to their spinals?

Never for C/S but I often use it for long orthopedic surgeries

 

[brominator]

Clonidine 30
Mcg in spinal to extend another 40
Mins

 

[deleted875186]

Anyone just not use fentanyl?

I wouldn’t. Helps intraop significantly, helps reduce nausea intraop, and pretty minimal side effects.

 

[OptionOffense]

I inject 2ml total volume all the time, never had a high block.

not 2cc of marcaine though?

 

[abolt18]

For those afraid of 2cc (15mg) of heavy bupivacaine, I have administered this exact dose to countless women for c-sections in my residency at the direction of an OB Anesthesia big-wig, without regard for patient height, and have had zero issues with it. He gives them all 2cc due to our exceptionally slow OBs. At most, they sometimes have had their hands start to tingle.

 

[Katheudontas parateroumen]

For those afraid of 2cc (15mg) of heavy bupivacaine, I have administered this exact dose to countless women for c-sections in my residency at the direction of an OB Anesthesia big-wig, without regard for patient height, and have had zero issues with it. He gives them all 2cc due to our exceptionally slow OBs. At most, they sometimes have had their hands start to tingle.

Do you also include the cc’s of fent, epi, duramorph too?

 

[nimbus]

For those afraid of 2cc (15mg) of heavy bupivacaine, I have administered this exact dose to countless women for c-sections in my residency at the direction of an OB Anesthesia big-wig, without regard for patient height, and have had zero issues with it. He gives them all 2cc due to our exceptionally slow OBs. At most, they sometimes have had their hands start to tingle.

We love to debate A LOT about things that don’t matter.

 

[Planktonmd]

Just don't give too much!

 

[abolt18]

Do you also include the cc’s of fent, epi, duramorph too?

2.6cc total. 0.3cc fentanyl, 0.3cc PF morphine (0.5mg/ml)

 

[deleted875186]

I’m thinking of changing my practice to lower dose duramorph, perhaps 0.1 or 0.15 mg after this thread.

 

[vector2]

For those afraid of 2cc (15mg) of heavy bupivacaine, I have administered this exact dose to countless women for c-sections in my residency at the direction of an OB Anesthesia big-wig, without regard for patient height, and have had zero issues with it. He gives them all 2cc due to our exceptionally slow OBs. At most, they sometimes have had their hands start to tingle.

Yeah, I only realized after residency that 1.4 or 1.6 being a soft upper limit was just academic dogma

 

[NitroS]

As an aside, anyone adding dexmedetomidine (5 mcg) to their spinals?

I’ve been doing this and seems to have good results. I don’t put fentanyl on my spinal anymore. 5 mcg dex+100 mcg duramorph

 

[deleted875186]

I’ve been doing this and seems to have good results. I don’t put fentanyl on my spinal anymore. 5 mcg dex+100 mcg duramorph

What is the advantage? I do think fentanyl helps significantly, and it’s pretty clean at low doses.

Does dexmedetonidine have the same incidence of hypotension and nausea as clinidine??

 

[abolt18]

Yeah, I only realized after residency that 1.4 or 1.6 being a soft upper limit was just academic dogma

Alternatively, you could double or triple that 15mg like these guys in Iowa and intentionally achieve a high spinal!

Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study | Regional Anesthesia & Pain Medicine

 

[sevoflurane]

“Conclusions HSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only.”

They left out the poor outcomes due to combined vasoplegia with high spinal under GA. 🎃🎃

 

[NitroS]

What is the advantage? I do think fentanyl helps significantly, and it’s pretty clean at low doses.

Does dexmedetonidine have the same incidence of hypotension and nausea as clinidine??

I find precedex increases the duration of the block that I can give less marcaine, usually 1.2-1.4mg is enough. Less hypotension, less nausea, less shivering

 

[abolt18]

“Conclusions HSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only.”

They left out the poor outcomes due to combined vasoplegia with high spinal under GA.

No, they prophylactically started all of them on NE infusion, gave zero IV narcotic, and ran a light volatile anesthetic. Maybe you're right, but I actually loved reading about their methods. This unorthodox approach doesn't seem half bad.

 

[sevoflurane]

Def. interesting. I think there were some places doing thoracic epidurals under conscious sedation 10-15 years ago. Def. a cool read, but not something I would personally try. Same with a high spinal pump run under GA. Once you give it, you can’t take it back. Doesn’t sound very titratable, but def interesting to see other people doing it.