Preventing C section wrenching/nausea?

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Hawaiian Bruin said:
Prophylactic phenylephrine.
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This. If I don't have a drip, I check the BP every minute. If the BP drops, even by a point, I give phenylephrine (as long as it's not ridiculous, like >160). I see so many people sit on BPs of 120 when the last one was 140 (why give neo when the BP's normal, right?) then the next thing you know you're trying to scoop mom's "secret breakfast" out of her hair.
 
After spinal and positioning I always give Ephedrine and Zofran. Not 100% but helps.
 
In the days when I did OB, I would give 25 mg of ephedrine IM after the spinal.

If that didn't work, I gave dad a pair of gloves and an emesis basin. It is partially his fault for impregnating her in the first place.
 
A touch of pressor with spinal, wide open fluids. After the baby is out they get zofran and Benadryl. Maybe versed depending. 20mg of propofol as a last resort. Mine never almost never get sick. If they do its bc I thought I was out of the woods n was too slow with repeat pressor doses
 
preop zofran, reglan, bicitra, pepcid

as you inject the opiate/local anesthetic mix into the intrathecal space, inject it slowly and smoothly. i find it keeps the BP pretty stable rather than injecting it quickly. not sure if there are studies out there showing this, but just an anecdote.

following spinal - load IV LR bag with a vial of phenylephrine, run it wide open. I've not given ephedrine IM in these patients, but I have in other cases. It's a good thought.

no need for anything thereafter.
 
LOAD IV BAG WITH VIAL OF NEO!???!?!?!?
Almost all the vials of phenylephrine I've ever seen are 10mg. I hope one of us is off somewhere. If not, you might back off the 500mg Bupiv Spinal. 😉
J/K. (Sorta)
 
CaliDreamin4Life said:
We've all been there. Section, baby is out, OB is closing. Patient is wrenching. Any tips in your regimen, prophylactic antiemetics, etc?
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Zofran pre spinal.

I posted this article in another posting (neo infusion)

NNT to prevent nausea/vomiting = 3. Pretty good.

NNT to prevent hypotension = 1.4. Pretty damn good.

NNH for hypertension = 6. However, I would argue people tolerate hypertension much better than they do hypotension.
 

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for my c-sections I do this:
Odansetron/metoclopramide before spinal.
20 mg ephedrine/300 mcg phenylephrine in 1 L of LR
Spinal with 12 mg isobaric Bupivicaine, Fentanyl 10 mcg, Morphine PF 0.1 mg.

It's taken me some time to get here but the main reasons are:
1) prevention of N/V... it's been a long long time since I've had vomiting
2) prevention of B!tch!ng and moaning during externalization of the uterus. The fentanyl here really helps with that.

I find I do have to give diphenhydramine about 2-3 times a year for itching... which is fine by me because it usually knocks the patient asleep...

Just curious, and maybe I missed this.. what's the reasoning for waiting on the odansetron till the baby's out?
 
Obs here freak if u give them anything.... I'll give it if she's sick but not routinely. I'm more aggressive w narcs - 25 fentanyl 200 morphine. They don't get sick but they itch..... Hence Benadryl which makes em snooze once baby is gone and I like sleepy pts 🙂
 
Spinal then
100mcg neo in a minute or two
Repeat neo if the heart rate trends up
Don't need zofran, benadryl, gloves, or puke bag
 
Our OB nurses load all our patients with 1liter LR prior to all elective Csections and Epidural. This helps a crapload as in residency, I had so many patient's puke due to no preloading and in practice, hardly ever.
Once I get them laying down after the spinal I give Reglan and Zofran
Always have a stick of Neosynephrine ready in case B/P drops. Sometimes inject, sometimes squirt some in LR.
Yesterday I put 2mg EPI from the spinal tray in the liter of fluid and ran it almost wide open. Worked well. Thought I would use it since I always throw those vials away. Maybe I will keep trying this.
 
So much Reglan in this thread. I hate that stuff. Dirty med IMO. But whatever floats your boat.
 
drccw said:
for my c-sections I do this:


Just curious, and maybe I missed this.. what's the reasoning for waiting on the odansetron till the baby's out?
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Good question!

5 reasons to give zofran pre-spinal.

1. Helps blunt or prevent hypotension
2. Prevents shivering
3. Prevents/treats pruritis
4. Prevents/treats nausea
5. May help prevent the cardiac arrest rarely seen with spinals.
 
I agree. No need to wait for the Zofran. It doesn't hurt the baby. Hyperemesis gravidarum is treated with a Zofran pump. Give it before incision. I've seen some pretty bad akathisia and one time even some funky dysrhythmias with Reglan so I'm +/- with that one.

Also manipulating the uterus is what causes a lot of "wrenching" by the mom. Put fentanyl in your spinal. I use 20 mcg. I'm familiar with the data about it being no different than putting it in the IV. I don't care. I still put it in the spinal and the only time I have a problem is when I can't get it. Site of action and whatnot.

Also if the SBP goes below 100 mmHG and stays there, they're going to puke. I don't put phenylephrine in the IV bag because you lose control. Put I do use boluses even before they are hypotensive. And don't play around - start with 200 mcg. I haven't had a c-section puke on me in God knows when doing this.
 
chocomorsel said:
Yesterday I put 2mg EPI from the spinal tray in the liter of fluid and ran it almost wide open. Worked well. Thought I would use it since I always throw those vials away. Maybe I will keep trying this.
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That's a sh*tload of epi to be giving routinely.
 
For a C-Section...

1) Pre-load everybody. If they haven't had a minimum of a liter of fluid in the last 30 minutes, don't call us for the epidural.
2) Don't be a wimp with phenylephrine - my bolus dose starts at 200mcg. I still see people starting with 50...pointless.
3) At the first hint of nausea, give phenylephrine. 99.99% of nausea after an epidural/spinal is from hypotension. I don't need to see the BP - I can fix the problem before the cuff cycles.
4) If BP normalizes and still nauseated, ondansetron any time is just dandy.

We've pretty much dropped ephedrine and use almost exclusively phenylephrine, a total flip-flop from 20 years ago. That means we've also almost stopped IM ephedrine to ward off evil spirits, but a few still use it.

I would never squirt an amp or two of pressor-du-jour of any type in the IV bag. What happens when the pressure normalizes? Ya gotta toss the bag and hang an uncontaminated fluid. Use boluses to effect. If you need a pressor drip, you need more fluid on board.
 
jwk said:
I would never squirt an amp or two of pressor-du-jour of any type in the IV bag. What happens when the pressure normalizes? Ya gotta toss the bag and hang an uncontaminated fluid.
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Nah, you just slow or stop the drip. Don't overthink it. It's easy. About 500 mcg of phenylephrine in the IV bag works great. Completely smooth, flat train-track vitals, no nausea. HR doesn't bounce between 70 and 100 as the phenylephrine boluses peak and trough. It's easy. It just works ... and there's not so much of it in the bag that anyone ever gets hypertensive.


jwk said:
If you need a pressor drip, you need more fluid on board.
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Totally disagree. You don't "need" a drip of about 50 mcg/min any more than you "need" boluses of 100 mcg every two minutes. A "pressor drip" isn't just for patients in extremis. It's a smooth elegant way to deliver smaller amounds of a drug that has a rapid onset and short half-life ... like phenylephrine. Putting it on a pump and programming it is a hassle. Squirting it in the IV bag and thumbing the wheel thingy is easy.
 
pgg said:
Nah, you just slow or stop the drip. Don't overthink it. It's easy. About 500 mcg of phenylephrine in the IV bag works great. Completely smooth, flat train-track vitals, no nausea. HR doesn't bounce between 70 and 100 as the phenylephrine boluses peak and trough. It's easy. It just works ... and there's not so much of it in the bag that anyone ever gets hypertensive.



Totally disagree. You don't "need" a drip of about 50 mcg/min any more than you "need" boluses of 100 mcg every two minutes. A "pressor drip" isn't just for patients in extremis. It's a smooth elegant way to deliver smaller amounds of a drug that has a rapid onset and short half-life ... like phenylephrine. Putting it on a pump and programming it is a hassle. Squirting it in the IV bag and thumbing the wheel thingy is easy.
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I LIKE IT!!!!
 
pgg said:
Credit to Noyac for the idea, way back when.
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Again, I don't do this. And I don't have problems doing it my way. I can't remember the last time a c-section puked on me. Seriously. It was probably residency.
 
The OP ain't talking about nausea and retching from hypotension. This is at the end of the case when vitals have pretty much stabilized out.

At this point of the case, the nausea is caused by stimulation of the visceral peritoneum, either through washing or traction, or a hand mucking around in the belly. The spinal has started to wear off at it's highest and weakest level, and the signals from the visceral peritoneum are getting through to the brain.

If your block is perfect (4th and 5th fingers numb bilaterally at the start of the case) or slightly higher than perfect then you won't get the nausea at this point unless the OB's have taken a super long time.

0.1 mg epi will help prolong the upper segments of the block and reduce the incidence of nausea from peritoneal stimulation at the end of the case.

- pod
 
periopdoc said:
The OP ain't talking about nausea and retching from hypotension. This is at the end of the case when vitals have pretty much stabilized out.

At this point of the case, the nausea is caused by stimulation of the visceral peritoneum, either through washing or traction, or a hand mucking around in the belly. The spinal has started to wear off at it's highest and weakest level, and the signals from the visceral peritoneum are getting through to the brain.

If your block is perfect (4th and 5th fingers numb bilaterally at the start of the case) or slightly higher than perfect then you won't get the nausea at this point unless the OB's have taken a super long time.

0.1 mg epi will help prolong the upper segments of the block and reduce the incidence of nausea from peritoneal stimulation at the end of the case.

- pod
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Good god how long are your OBs taking to do their sections? I've never seen this in private practice. Even on the beached whales.
 
BuzzPhreed said:
Good god how long are your OBs taking to do their sections? I've never seen this in private practice. Even on the beached whales.
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When I was a resident, I'd do CSEs for the repeat sections in large patients, because the full vial of bupivacaine wouldn't last long enough, even with an epi wash.
Now, I have the opposite problem - minimizing the bupivacaine dose because the case is done in 20 minutes, but still having enough there to get a reliable block (fentanyl's the key there).
 
The morbidly obese are pharmacologically easier to block than the thin, fit ones and usually don't experience this problem even with the typical slightly longer operative times.

The upper level of the block is the first to wear off. If you have a ~2 hour block with plain bupi, the block of the highest dermatome may only last 30-45 min. Check it out sometime. Right when the OB's are on skin, check to see if your block has receded. I bet it has. Epi helps prolong the block on these upper dermatomes and fentanyl will theoretically help as well just like it will when you are trying to reduce bupi to the minimum possible dose (yes, PGG, I just admitted that, for this particular problem anyway, intrathecal fentanyl makes sense).

I previously had the pleasure of working in an institution where c-sections were scheduled at 8,9,10,11,13,14,15,16 on the hour. Not every day was full mind you, but it was common to do 4 scheduled c-sections in 4 hours in the morning and another 1 or 2, usually unscheduled, in the afternoon. I never experienced this late nausea from block recession issue there.

I sure missed those days when I first moved here and was taking OB call.

- pod
 
pgg said:
When I was a resident, I'd do CSEs for the repeat sections in large patients, because the full vial of bupivacaine wouldn't last long enough, even with an epi wash.
Now, I have the opposite problem - minimizing the bupivacaine dose because the case is done in 20 minutes, but still having enough there to get a reliable block (fentanyl's the key there).
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Yes! Residents pay attention.
 
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