Repeat c-sections and "failed" spinal

[Twiggidy]

i approach OB from more of a customer service standpoint more than anything else, especially in private practice. They come in and not want to feel a thing so I just give them what they want.

And I think some on here sre misinterpreting the “put them to sleep”. I dont think any of us are tubing people. I just give propofol until they snore. Usually if the block is,spotty, just putting them out makes up for it. Im hesitant with the ketamine although I will use it if needed. Ive had a few too many laryngospasms for my liking

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[Planktonmd]

so you guys either recommend giving an overdose of spinal to be sure it'll work, or giving a normal dose and converting to a GA if it doesn't work out.

i recommend giving a normal dose, checking block height and pushing it up a bit with gravity if needs be before starting... and I'm the one with weak sauce -- ah ok, carry on gentlemen, I prefer my way.

"Overdose" is a strong statement implying that you actually know with certainty the right dose for each patient, and you can actually calculate the spinal dose based on what level you want to reach.

 

[deleted59964]

And I think some on here sre misinterpreting the “put them to sleep”. I dont think any of us are tubing people. I just give propofol until they snore. Usually if the block is,spotty, just putting them out makes up for it. Im hesitant with the ketamine although I will use it if needed. Ive had a few too many laryngospasms for my liking

Wait ... what?
You don’t do an rsi?

For inadequate regional for lscs I do the following

1 discuss options and offer GA
2 give nitrous
3 give some iv fentanyl
4 do rsi

 

[deleted59964]

"Overdose" is a strong statement implying that you actually know with certainty the right dose for each patient, and you can actually calculate the spinal dose based on what level you want to reach.

Language is semantics.

Academic response Minimum local anaesthetic dose (MLAD) of intrathecal levobupivacaine and ropivacaine for Caesarean section

Practical response - the finessed technique is a lower dose of heavy Bupivacaine ( I use 11mcg with 20mcg fentanyl) and use of gravity to achieve a block to T5 if necessary.

IMHO using 15mg routinely is “weak sauce”

 

[Planktonmd]

Language is semantics.

Academic response Minimum local anaesthetic dose (MLAD) of intrathecal levobupivacaine and ropivacaine for Caesarean section

Practical response - the finessed technique is a lower dose of heavy Bupivacaine ( I use 11mcg with 20mcg fentanyl) and use of gravity to achieve a block to T5 if necessary.

IMHO using 15mg routinely is “weak sauce”

If you ask 10 different anesthesiologists what's the best Bupivacaine dose for a C section you probably get 10 different numbers and non of them is wrong.
And I am sure you know that exceeding the minimal anesthetic dose of something is not an overdose. It's basically similar to saying that giving more than 1 MAC of an inhaled agent is an overdose!

 

[Twiggidy]

Wait ... what?
You don’t do an rsi?

For inadequate regional for lscs I do the following

1 discuss options and offer GA
2 give nitrous
3 give some iv fentanyl
4 do rsi

Nope....and the reason why is in bold

 

[deleted59964]

Nope....and the reason why is in bold

Sorry - I don’t follow

 

[Twiggidy]

Sorry - I don’t follow

I'm assuming when you say "Give nitrous" you mean placing a face mask over the patient and letting them breath. That's no more secure airway, than say, putting in an LMA, which actually is probably more secure of an airway. So in the words of Seinfeld, "What's the big deal with doing a RSI when you want the patient to sleep?" If they're not morbidly obese and just had some Micky D's, I just let the sleep with propofol boluses and if that's not cutting it, I slip in an LMA and let them breath some gas.

The books say we need to RSI the OB patients. The reality is you don't really need to

But residents, on the orals, do what JobsFan is saying. Secure the airway with RSI with a nurse holding cricoid so you can pass the test. And make the C/S patient take all that oral antacid crap that no one does in real life.

 

[MoMoGesiologist]

So just to clarify, since all OB patients are considered aspiration risks during delivery, no matter NPO status, are we comfortable with some sedation to get through a CSx with a patchy neuraxial block (ex. Nitrous, fent, Midaz, ketamine, prop) or are we going straight to GA w/ ETT and RSI?

 

[deleted162650]

I'm assuming when you say "Give nitrous" you mean placing a face mask over the patient and letting them breath. That's no more secure airway, than say, putting in an LMA, which actually is probably more secure of an airway. So in the words of Seinfeld, "What's the big deal with doing a RSI when you want the patient to sleep?" If they're not morbidly obese and just had some Micky D's, I just let the sleep with propofol boluses and if that's not cutting it, I slip in an LMA and let them breath some gas.

The books say we need to RSI the OB patients. The reality is you don't really need to

But residents, on the orals, do what JobsFan is saying. Secure the airway with RSI with a nurse holding cricoid so you can pass the test. And make the C/S patient take all that oral antacid crap that no one does in real life.

Careful Twig. You're essentially doing an unsecured airway general on a "known full stomach" for abdominal surgery no less. 1 aspiration and you're hosed. I'll play the propofol game if the section is almost done and mom is getting a bit squirrelly. But, if baby ain't out yet then mama gets some PVC through the cords.

 

[deleted59964]

I'm assuming when you say "Give nitrous" you mean placing a face mask over the patient and letting them breath. That's no more secure airway, than say, putting in an LMA, which actually is probably more secure of an airway. So in the words of Seinfeld, "What's the big deal with doing a RSI when you want the patient to sleep?" If they're not morbidly obese and just had some Micky D's, I just let the sleep with propofol boluses and if that's not cutting it, I slip in an LMA and let them breath some gas.

The books say we need to RSI the OB patients. The reality is you don't really need to

But residents, on the orals, do what JobsFan is saying. Secure the airway with RSI with a nurse holding cricoid so you can pass the test. And make the C/S patient take all that oral antacid crap that no one does in real life.

Ah ok I follow your criticism of me givining nitrous.
I give 50% and they must hold the mask themselves.

 

[Twiggidy]

Ah ok I follow your criticism of me givining nitrous.
I give 50% and they must hold the mask themselves.

solid.

 

[Twiggidy]

Careful Twig. You're essentially doing an unsecured airway general on a "known full stomach" for abdominal surgery no less. 1 aspiration and you're hosed. I'll play the propofol game if the section is almost done and mom is getting a bit squirrelly. But, if baby ain't out yet then mama gets some PVC through the cords.

yeah. it's one of the many reasons I'm not a fan of OB. I personally don't think anyone with a laparatomy incision should be awake, whether they have a spinal or whatever, but that's just me personally. if it were up to me I'd tube them all. Given this thread it will make me evaluate my practice a bit, because yes, the last thing I want is an aspiration.

 

[deleted59964]

So just to clarify, since all OB patients are considered aspiration risks during delivery, no matter NPO status, are we comfortable with some sedation to get through a CSx with a patchy neuraxial block (ex. Nitrous, fent, Midaz, ketamine, prop) or are we going straight to GA w/ ETT and RSI?

My practice is I will give a small amount of fentanyl and essentially entonox... equivalent to what they could reasonably have got on the labour ward administered by a midwife or nurse. I don’t give sedation, if nitrous and fentanyl don’t cut it ... rsi

 

[anbuitachi]

My practice is I will give a small amount of fentanyl and essentially entonox... equivalent to what they could reasonably have got on the labour ward administered by a midwife or nurse. I don’t give sedation, if nitrous and fentanyl don’t cut it ... rsi

cause you like nitrous and fentanyl over ketamine or midaz?

 

[deleted59964]

cause you like nitrous and fentanyl over ketamine or midaz?

well the problem is pain, so I choose analgesics over sedatives.
sedating supine patients at high risk of aspiration isn't for me.

ketamine in low dose is probably fine, but if you over do it and it depresses their level of consciousness and they aspirate the lawyers will have you (it is an IV induction agent after all). they may also get dysphoric from Ketamine.

It's very hard for 50% nitrous being held by the patient to lead to aspiration.
If they get dysphoric from nitrous, they stop using it and it passes.
also using supplemental nitrous is widely accepted practice here, so if something does go bad I will have many allies.
if it's safe enough for delivery suite it's safe enough for the OR is the thinking.

I think I've given well reasoned responses, and I'm beginning to think some of you take issue with my opinions because I'm not American - so I'll leave it at that.

 

[deleted59964]

yeah. it's one of the many reasons I'm not a fan of OB... personally. if it were up to me I'd tube them all...

On these points we agree!

 

[Twiggidy]

So just to clarify, since all OB patients are considered aspiration risks during delivery, no matter NPO status, are we comfortable with some sedation to get through a CSx with a patchy neuraxial block (ex. Nitrous, fent, Midaz, ketamine, prop) or are we going straight to GA w/ ETT and RSI?

i think it depends on who ot is and the patient number one. also as you see from the thread different people have differing approaches. in general i think the take aways is ‘patchy’ vs ‘doesnt work’. for patchy most of us chosose some form of sedating/temporizing if delivery has occurred and they’re almost finished. for ‘doesn’t work’ i personally go to GETA. i dont like sitting people back up and havent had much success with 2nd attempts (and by that i mean, i saw CSF the first time and injected but for some reason it stil didn’t work)

but JobFan and Salty and hitting excellent points home about being cautious for aspiration....per the books, anyone after 12 weeks is full stomach. whether we adhere to that in reality depends on who the patient is and who’s the anesthesiologist