Propofol infusion in stat c/sections

[ucsfgaspain]

So this may be an elementary question and I may look like a dumbSh*t for asking this, but oh well. When I trained, the cook book for a stat c/s was induce, relax with succ and then run them on up to a 0.75 mac of vapor. when baby is out, you can turn on nitrous, and give narcotic and dose a non depolarizer. well, is there anything wrong with running a propofol infusion so you can run your patient deeper before the baby is delivered? Also after the baby is out rather than giving relaxant just increase your propofol infusion. Anything I'm missing here? Let me know if this is stup*d or if everyone is all ready doing this and I'm riding the short bus. peace.

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[Monty Python]

So this may be an elementary question and I may look like a dumbSh*t for asking this, but oh well. When I trained, the cook book for a stat c/s was induce, relax with succ and then run them on up to a 0.75 mac of vapor. when baby is out, you can turn on nitrous, and give narcotic and dose a non depolarizer. well, is there anything wrong with running a propofol infusion so you can run your patient deeper before the baby is delivered? Also after the baby is out rather than giving relaxant just increase your propofol infusion. Anything I'm missing here? Let me know if this is stup*d or if everyone is all ready doing this and I'm riding the short bus. peace.

Just seems like a lot of steps and polypharmacy, but to each his/her own -- if it works for you and does right by the patient then press on.

My OBs are quick. Most stat C/secs with intubation are:

pentothal
sux
tube
about 0.75 mac
baby out
titrate narc to keep spont resp rate in the teens, maybe add versed
extubate about 15 minutes later

 

[Arch Guillotti]

The stat sections I have done that required a SNORKEL, didn't give any nondepolarizers. I don't see any idea why you couldn't do what you are describing.

 

[ucsfgaspain]

God I wished I had fast ob. I work at a place with a training program. The worst thing is that we aren't a true academic program, we're one of those hybrid programs. I don't have residents but the ob, ortho, and g-surg do. F*ck, 2 hour c/sections are the norm here as are 2 hour lap choles. Just shoot me please! I honestly think that you need to add another designation to ASA class. If at a training program, each case goes up 1 ASA class...if you have OB training program, ASA class goes up 2 classes. ANd the chances of a ureter getting hit and urology getting called in goes up about 10,000%

Case in point, just did a stat c-section and they got the baby out in 10 minutes (that is like a f*ing guiness book of world record here. Now get this, it took them an additional 2 f*cking hours to close! **** I think that I could see the wound reepitheliaze in front of me! I was about to hang myself at the end of the case. Another case, ankle fracture took 4 f*cking hours! 4 hours...by that time the fracture has all ready healed itself. God help me, I need a drink!

 

[jetproppilot]

God I wished I had fast ob. I work at a place with a training program. The worst thing is that we aren't a true academic program, we're one of those hybrid programs. I don't have residents but the ob, ortho, and g-surg do. F*ck, 2 hour c/sections are the norm here as are 2 hour lap choles. Just shoot me please! I honestly think that you need to add another designation to ASA class. If at a training program, each case goes up 1 ASA class...if you have OB training program, ASA class goes up 2 classes. ANd the chances of a ureter getting hit and urology getting called in goes up about 10,000%

Case in point, just did a stat c-section and they got the baby out in 10 minutes (that is like a f*ing guiness book of world record here. Now get this, it took them an additional 2 f*cking hours to close! **** I think that I could see the wound reepitheliaze in front of me! I was about to hang myself at the end of the case. Another case, ankle fracture took 4 f*cking hours! 4 hours...by that time the fracture has all ready healed itself. God help me, I need a drink!

jet scurries to the bar, gets a glass, pours a TRIPLE SHOT of Patron, cuts three limes in half and squeezes all their glory into the glass fulla Patron.

Hands the glass fulla nectar to UCSF....

"Here ya go, Dude."

"Drink up, cuz I'm at a loss."

"With the kinda times you're reporting, there isn't a model to model after."

Jet pours a double shot of his own and touches UCSF's glassa nectar......

TING.....

 

[Laurel123]

Ten minutes after induction to get the baby out? That seems to defeat the purpose of a stat C-section, doesn't it? Ten minutes after induction, the OB's are usually stapling.

I know that when we do a stat C-section, the baby is out before the induction dose has worn off (usually 30 seconds to 1 minute after induction) Do you guys induce after the patient has been prepped and draped and the OB has a knife to the patient's belly ready to cut as soon as the ET balloon is up?

Well, propofol drip seems reasonable in your situation.

 

[jetproppilot]

So this may be an elementary question and I may look like a dumbSh*t for asking this, but oh well. When I trained, the cook book for a stat c/s was induce, relax with succ and then run them on up to a 0.75 mac of vapor. when baby is out, you can turn on nitrous, and give narcotic and dose a non depolarizer. well, is there anything wrong with running a propofol infusion so you can run your patient deeper before the baby is delivered? Also after the baby is out rather than giving relaxant just increase your propofol infusion. Anything I'm missing here? Let me know if this is stup*d or if everyone is all ready doing this and I'm riding the short bus. peace.

All kidding aside, no matter how long the C section is, you're complicating your life with a propofol infusion.

Give some non depolarizer if its a 5 hour C section. 🙂lol🙂

But just turn up DA SEVO in the meantime.

There isnt anything wrong with propofol.

It is more complicated than just turning up the vaporizer.

 

[ucsfgaspain]

Jet,

Thanks for the drink🙂 My only concern about turning up my volatile is the issue of uterine tone. At what mac of vapor do you think that this becomes and issue? With nitrous on, I really shouldn't reach a mac very high but if I don't use nitrous do you think that I could reach a high enough mac to lead to uterine atony?

The only reason that I don't like using a non-depol is, that sometimes, we in the RARE instance, can get a c-section done quick. It's usually with a chief resident who's not going to stay on after residency. ....SIGH...it goes to prove the saying...Those who can't...teach...

Peace.

 

[9french]

If it is truly an emergent c/s. i.e., loss of fetal heart tones, I have the OBs cut as soon as the propofol and sux are pushed (assuming a normal airway). I do not wait for the tube to get in. This may only save a minute, but decreasing the period of fetal anoxia by even a minute can make a big difference. I have not found that placing the tube WHILE the OBs are cutting increases the degree of dificulty of the intubation by much.

 

[Planktonmd]

Jet,

Thanks for the drink🙂 My only concern about turning up my volatile is the issue of uterine tone. At what mac of vapor do you think that this becomes and issue? With nitrous on, I really shouldn't reach a mac very high but if I don't use nitrous do you think that I could reach a high enough mac to lead to uterine atony?

The only reason that I don't like using a non-depol is, that sometimes, we in the RARE instance, can get a c-section done quick. It's usually with a chief resident who's not going to stay on after residency. ....SIGH...it goes to prove the saying...Those who can't...teach...

Peace.

And this is exactly where your problem is!
Why don't you use Nitrous?
It will allow you to use less vapor and get better anesthesia without relaxing the uterus.
OB is one place where Nitrous is very useful.

 

[zippy2u]

UCSF, Induce with prop and sux and bang her with the vapors like ya mean it. Crank the flows up to 4 and 4 or 5 and 5( oxygen and nitrous) initially, with Sevo at about 3% until the baby is out. Don't worry about uterine hypotonicity until baby is out. Like Plank said gotta use nitrous. Blow off prop infusion as too much work--don't need it. If the OBs don't whine keep her spontaneously breathing and titrate in some fentanyl to lower her RR. Lower the Sevo to about 2% with 50% O2, 50% N2O once baby is out. If OBs whine, bang her with 2-3 mgs vec or 2-3 mls of zem and throw her on the vent. Regards, ----Zippy

 

[urge]

well, is there anything wrong with running a propofol infusion so you can run your patient deeper before the baby is delivered?

Babies don't like propofol too much. I wouldn't use a drip. Use nitrous like others have said.

 

[9french]

I think the concern for fetal acidosis with propofol in a C/S is a bit overblown. A competent OB will have the baby out within a minute or two of induction, which is too soon for the baby to have uptaken any significant amount of the drug. Most babies come out crying, with minimal, if any, signs of sedation. If your OB is slow, or you are doing a general for another surgery, such as an appendectomy in a pregnant woman, I would agree that propofol would best be avoided.
At least where I practice, Pentothal is kept in the pyxis, as it is controlled. It takes at least a minute to check it out, plus another minute to mix it, which is two minutes too long in an emergency. Propofol is in the drawer of our anesthesia carts, and can be drawn up and given in a matter of seconds.
Also, another vote for volatile plus nitrous once the baby is out as well as titrating in some Morphine and/or fentanyl. Keep in mind that MAC is reduced during pregnancy.