ropiv for csection epidural

[thegasman]

So tell me if anybody else is doing this or if it makes any sense. A few of the anesthesiologists and crnas are bolusing labor epidurals for csection with ropiv 0.5-0.75% and swear by it. The alternative is mostly 2% lido plain. In training I almost always used 2% lido with epi/hco3 and I put in some fent too( I would use chloroprocaine for a stat). At this practice I have been mixing my own 2% with epi. Does ropiv make any sense? It seems to me this would take too long to set up. The proponents say that the lido doesn't last long enough, but I would think this is b/c no one else is putting the epi in. They also say the ropiv covers extrusion of the uterus pain better. Any feelings?

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[Planktonmd]

So tell me if anybody else is doing this or if it makes any sense. A few of the anesthesiologists and crnas are bolusing labor epidurals for csection with ropiv 0.5-0.75% and swear by it. The alternative is mostly 2% lido plain. In training I almost always used 2% lido with epi/hco3 and I put in some fent too( I would use chloroprocaine for a stat). At this practice I have been mixing my own 2% with epi. Does ropiv make any sense? It seems to me this would take too long to set up. The proponents say that the lido doesn't last long enough, but I would think this is b/c no one else is putting the epi in. They also say the ropiv covers extrusion of the uterus pain better. Any feelings?

Using Ropvacaine in this setting does not make much sense.
I have always used Lido + Epi + Bicarb and it is usually fast enough that you have a surgical block in 5 minutes if you give a good bolus.
Ropivacaine would definitely be slower and possibly more cardiotoxic than lidocaine if a big bolus goes intra-vascular.

 

[jwk]

So tell me if anybody else is doing this or if it makes any sense. A few of the anesthesiologists and crnas are bolusing labor epidurals for csection with ropiv 0.5-0.75% and swear by it. The alternative is mostly 2% lido plain. In training I almost always used 2% lido with epi/hco3 and I put in some fent too( I would use chloroprocaine for a stat). At this practice I have been mixing my own 2% with epi. Does ropiv make any sense? It seems to me this would take too long to set up. The proponents say that the lido doesn't last long enough, but I would think this is b/c no one else is putting the epi in. They also say the ropiv covers extrusion of the uterus pain better. Any feelings?

2% Lido with epi plus bicarb is gold. Ropiv seems OK for labor, but the few times I've tried it, it was lousy for c-sections. Unless you've got some fast staff and surgeons, 2% plain lido doesn't last long enough. We generally place/dose the epidural about 30 minutes prior to cut time - if you add at least 15 more minutes for the procedure itself, you're already well on the way to losing your block if you've just used plain lidocaine.

 

[coprolalia]

A few of the anesthesiologists and crnas are bolusing labor epidurals for csection with ropiv 0.5-0.75% and swear by it.

Do they like to waste money?

-copro

 

[Gator05]

2% lido + HCO3 + fentanyl + duramorph = a block lasting plenty long enough, especially if dosed to ~T5 initially. If it doesn't last long enough, why not simply redose?!?!? (FTR, never had to do this.)

At an academic setting, usually our block's presence is the limiting factor in recovery after c-section. A hefty amount of ropiv seems like it might stick around for a while.

 

[SleepIsGood]

2% lido + HCO3 + fentanyl + duramorph = a block lasting plenty long enough, especially if dosed to ~T5 initially. If it doesn't last long enough, why not simply redose?!?!? (FTR, never had to do this.)

....

took the words out of my fingers.

 

[huktonfonix]

sure, why not? If they dont mind the longer set up time then go ahead. No different than using 0.5 bupivicaine for an intraop anesthetic. I personally like the lido combo with rebolusing as needed, but there are many ways to skin a cat.

 

[coprolalia]

I'll ask again...

Do people like to waste money?

-copro

 

[thegasman]

I'll ask again...

Do people like to waste money?

-copro

these same people are very concerned about cost in other areas - such as remifentanil. I personally don't understand why anyone would use ropiv for this, and I think their dissatisfaction with 2% lido is because they are too slack to put epi in it.

 

[KungPOWChicken]

20-25 cc's of 0.5% bupivacaine works like a charm. 20minutes to setup tops.

 

[pgg]

The proponents say that the lido doesn't last long enough, but I would think this is b/c no one else is putting the epi in. They also say the ropiv covers extrusion of the uterus pain better. Any feelings?

I feel this is silly. They're using a more expensive and cardiotoxic drug, and they have to wait longer for it to set up.

Lido doesn't last long enough because your OB can't cut? It's an epidural - give more. Want longer postop analgesia? Add 3 mg morphine once the kid's out, schedule some Toradol, and be done with it. As for covering "extrusion of the uterus pain better" there's no reason why lidocaine can't produce a block that's dense enough and high enough.

I'm not usually one to criticize another way of doing things, but I don't really see a compelling up side to using ropivacaine, and there are a few nontrivial down sides.

 

[ProRealDoc]

I'll ask again...

Do people like to waste money?

-copro

exactly what our pharmacist said,.

 

[BLADEMDA]

sure, why not? If they dont mind the longer set up time then go ahead. No different than using 0.5 bupivicaine for an intraop anesthetic. I personally like the lido combo with rebolusing as needed, but there are many ways to skin a cat.

Rebolusing in PP? Not 2% Lido with Epi. Probably in some real deep doggy doo if the OB can't do a C section in an hour. In fact, if you need to rebolus the OB needs to get better and not your anesthesia.

 

[BLADEMDA]

20-25 cc's of 0.5% bupivacaine works like a charm. 20minutes to setup tops.

But, the whole case takes some OB's 20 minutes!

 

[KungPOWChicken]

I wish our sections were that fast. Unfortunately im at a teaching hospital.

 

[huktonfonix]

Rebolusing in PP? Not 2% Lido with Epi. Probably in some real deep doggy doo if the OB can't do a C section in an hour. In fact, if you need to rebolus the OB needs to get better and not your anesthesia.

no argument there. I was stating that Im sure that ropivicaine works just fine for an epidural. I personally dont see any point in using it for my practice, but that doesnt mean Im going to say someone else is wrong for doing it (unless its a crash, then obviously its a bad choice).

 

[BLADEMDA]

no argument there. I was stating that Im sure that ropivicaine works just fine for an epidural. I personally dont see any point in using it for my practice, but that doesnt mean Im going to say someone else is wrong for doing it (unless its a crash, then obviously its a bad choice).

No. Not wrong. Just slower to set up and more expensive. If your OB can do the case in under 75 minutes why do you need ropivicaine?