Routine C Section?

[Licoricestick]

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About 5 minutes after getting the single shot spinal the patient developed the following:

1) Nausea

2) Junctional rhythm with a rate of 38

4) BP=58/32

5) Sat=99%

What do you do now? Patient is still awake and talking but not feeling well. What is your plan?

If surgeons have started - tell them to stop whatever they're doing (yes I know you said 5min, but some surgeons can get started that quickly - although I'm sure many will say it is certainly less likely in academia!).

Give atropine 0.6mg
IVT open fully (mainly to run drugs in - I don't think 200mL of fluid in the next couple of min is going to change her BP all that much)
high flow O2 by facemask
Draw up adrenaline whilst waiting for atropine to work (should have an effect in <60sec - although it will feel like a lot longer) - give if atropine doesn't have an adequate response
Consider percussion pacing

 

[BLADEMDA]

If surgeons have started - tell them to stop whatever they're doing (yes I know you said 5min, but some surgeons can get started that quickly - although I'm sure many will say it is certainly less likely in academia!).

Give atropine 0.6mg
IVT open fully (mainly to run drugs in - I don't think 200mL of fluid in the next couple of min is going to change her BP all that much)
high flow O2 by facemask
Draw up adrenaline whilst waiting for atropine to work (should have an effect in <60sec - although it will feel like a lot longer) - give if atropine doesn't have an adequate response
Consider percussion pacing

The "surgeon" is a 32 year female OB Doc that Copro would like a lot. While nice to look at she isn't the type of person that will be much help.

Since this is a C section she is busy getting ready to cut the uterus. You want her to stop?

Your first choice here is atropine? Ever use much atropine in OB? What will her heart rate be after the atropine most likely? If the atropine fails you want an external pacer? By the way the patient is still awake and not sedated. Do you plan on letting the patient know her predicament?

If you decide upon the atropine why choose 0.6 mg dose? Is there a reason for this dosage?

 

[BLADEMDA]

Of the now 48 posts on this thread, you have made 32 of them. That's 2/3rds.

Dude... just... dude.

-copro

Once I start a case discussion I finish it. The data presented here is both valid and interesting. The number of posts is less important than the quality of those posts.

The case needs to concluded and I will do so over the next few days. While many post their opinions few support them with published data and/or decades of experience.

Blade

 

[pgg]

Since this is a C section she is busy getting ready to cut the uterus. You want her to stop?

No. Hypotension is bad for the baby, and a gravid uterus is bad for CPR.

Your first choice here is atropine?

No. Epi is the board and real life answer.

By the way the patient is still awake and not sedated. Do you plan on letting the patient know her predicament?

And a great big no to that too.

 

[BLADEMDA]

If you decide to give Epi what dosage will you use? Anyone else willing to give some Ephedrine I.V. and hope it works in time?

 

[BLADEMDA]

After you get the BP and HR back to normal the BP starts drifting down again. Assuming the Baby has NOT been delivered yet what is the best choice for hypotension? The vitals are 83/56 HR=95 Sat=99%

A. Ephedrine 5 mg I.V.

B. Phenylephrine 50 ug I.V.

C. Epi 5 ug I.V.

D. Vasopressin 5 units I.V.

E. Any of the above A-D


Data strongly suggests that there really may be a BEST CHOICE to minimize fetal acidosis at delivery.

 

[coprolalia]

The "surgeon" is a 32 year female OB Doc that Copro would like a lot.

Okay... YEAH!... tell me more... preferably post some pictures.

-copro

 

[BLADEMDA]

After you get the BP and HR back to normal the BP starts drifting down again. Assuming the Baby has NOT been delivered yet what is the best choice for hypotension? The vitals are 83/56 HR=95 Sat=99%

A. Ephedrine 5 mg I.V.

B. Phenylephrine 50 ug I.V.

C. Epi 5 ug I.V.

D. Vasopressin 5 units I.V.

E. Any of the above A-D


Data strongly suggests that there really may be a BEST CHOICE to minimize fetal acidosis at delivery.

Abstract:

Background: Use of ephedrine in obstetric patients is associated with depression of fetal acid-base status. The authors hypothesized that the mechanism underlying this is transfer of ephedrine across the placenta and stimulation of metabolism in the fetus.
Methods: A total of 104 women having elective Cesarean delivery under spinal anesthesia randomly received infusion of phenylephrine (100 [mu]g/ml) or ephedrine (8 mg/ml) titrated to maintain systolic blood pressure near baseline. At delivery, maternal arterial, umbilical arterial, and umbilical venous blood samples were taken for measurement of blood gases and plasma concentrations of phenylephrine, ephedrine, lactate, glucose, epinephrine, and norepinephrine.
Results: In the ephedrine group, umbilical arterial and umbilical venous pH and base excess were lower, whereas umbilical arterial and umbilical venous plasma concentrations of lactate, glucose, epinephrine, and norepinephrine were greater. Umbilical arterial Pco2 and umbilical venous Po2 were greater in the ephedrine group. Placental transfer was greater for ephedrine (median umbilical venous/maternal arterial plasma concentration ratio 1.13 vs. 0.17). The umbilical arterial/umbilical venous plasma concentration ratio was greater for ephedrine (median 0.83 vs. 0.71).
Conclusions: Ephedrine crosses the placenta to a greater extent and undergoes less early metabolism and/or redistribution in the fetus compared with phenylephrine. The associated increased fetal concentrations of lactate, glucose, and catecholamines support the hypothesis that depression of fetal pH and base excess with ephedrine is related to metabolic effects secondary to stimulation of fetal [beta]-adrenergic receptors. Despite historical evidence suggesting uteroplacental blood flow may be better maintained with ephedrine, the overall effect of the vasopressors on fetal oxygen supply and demand balance may favor phenylephrine.
(C) 2009 American Society of Anesthesiologists, Inc.

Go to Full Text of this Article

http://journals.lww.com/anesthesiol...ansfer_and_Fetal_Metabolic_Effects_of.15.aspx

 

[ssmallz]

Why are we proceeding with the case with platlets of 56k and doing a spinal? While its true that its only a relative contraindication to get do neuraxial anesthesia on a pt w/platlets this low, this is an elective case and I'm going to to tx 5 units and re check. C-s patients lose blood and I certainly don't want to proceed untill the platlets are geater than 100k. If the section has to go now, it's GA for me.

HR of 38 and low bp? Atropine 1 mg, Neo/Ephedrine boluses as needed. Alert ob doing the surgery about whats going on and handle it. I wouldn't break out the epi just yet. Oh yeah, and get the puke bucket out

 

[dhb]

Data strongly suggests that there really may be a BEST CHOICE to minimize fetal acidosis at delivery.

B. Phenylephrine 50 ug I.V

Phenylephrine has been shown to give better chord blood gases on delivery but no difference in Apgar or outcome. Epi, neo , ephedrine are all equal imho

 

[BLADEMDA]

Why are we proceeding with the case with platlets of 56k and doing a spinal? While its true that its only a relative contraindication to get do neuraxial anesthesia on a pt w/platlets this low, this is an elective case and I'm going to to tx 5 units and re check. C-s patients lose blood and I certainly don't want to proceed untill the platlets are geater than 100k. If the section has to go now, it's GA for me.

HR of 38 and low bp? Atropine 1 mg, Neo/Ephedrine boluses as needed. Alert ob doing the surgery about whats going on and handle it. I wouldn't break out the epi just yet. Oh yeah, and get the puke bucket out

Wow. I am glad you don't work for me. I hope you gain more insight into OB before graduating Residency.

No need for type and cross. Hgb is normal. While platelet count is low they work just fine. I produced plenty of data to support a single shot spinal in this patient. In fact, I have done about ten of these cases under SAB so far in PP without any transfusions whatsoever.

Want to do a GA that is fine with me. But, a 100K requirement for a single shot spinal in this patient (healthy gestational thrombocytopenia) seems excessive; however, as JPP likes to point out there is nothing wrong with a GA.

The Atropine dose of 1 mg seems excessive. This is likely to cause a raging tachycardia; in addition, atropine is probably NOT the best choice here as the high spinal is causing the bradycardia. The correct Board Answer is low dose Epi although I escaped in this case with Ephedrine 30 mg I.V. and Robinul 0.4 mg I.V.

I didn't alert "OB" about anything because I "just handled it."

Blade

 

[ssmallz]

Wow. I am glad you don't work for me. I hope you gain more insight into OB before graduating Residency.

No need for type and cross. Hgb is normal. While platelet count is low they work just fine. I produced plenty of data to support a single shot spinal in this patient. In fact, I have done about ten of these cases under SAB so far in PP without any transfusions whatsoever.

Want to do a GA that is fine with me. But, a 100K requirement for a single shot spinal in this patient (healthy gestational thrombocytopenia) seems excessive; however, as JPP likes to point out there is nothing wrong with a GA.

The Atropine dose of 1 mg seems excessive. This is likely to cause a raging tachycardia; in addition, atropine is probably NOT the best choice here as the high spinal is causing the bradycardia. The correct Board Answer is low dose Epi although I escaped in this case with Ephedrine 30 mg I.V. and Robinul 0.4 mg I.V.

I didn't alert "OB" about anything because I "just handled it."

Blade

A little tachycardia in an otherwise healthy young patient is NOT going to kill her. OTOH, low bp is gonna create a problem for both her and the kid. I would certainly start with ephedrine but have no problem moving to something else. Epi may be the board answer but it is not routinely drawn up in our c/s rooms. Maybe this is different in your practice. Atropine, Ephedrine, and Neo are so I would choose one of those first as they are readily available

 

[BLADEMDA]

SRNA asks how much Duramorph you give C section patients? Also, if Fentanyl or Sufenta should be given as well? What are the side effects of these drugs and how long do they last?

 

[pgg]

Wow. I am glad you don't work for me. I hope you gain more insight into OB before graduating Residency.

Geez man, that's a great way to encourage people to post in your threads.

SRNA asks how much Duramorph you give C section patients? Also, if Fentanyl or Sufenta should be given as well? What are the side effects of these drugs and how long do they last?

Different people use different doses. I use
1) 15 mcg fentanyl, 0.2 mg morphine for spinals (usually added to 1.4-1.6 mL of 0.75% hyperbaric bupivacaine)
2) 3 mg morphine, 100 mcg fentanyl for epidurals (up front for non-urgent sections)
3) 3 mg morphine, +/- 100 mcg fentanyl (after delivery for urgent/emergent sections)

I'm not aware of any data showing a benefit to more than 3.75 mg of epidural morphine for postcesarean pain. As for spinals, the sweet spot appears to be in the 0.1 - 0.25 mg range ... equivalent analgesia but less pruritis than modestly higher doses.

Some of my attendings in residency vehemently forbade giving fentanyl prior to umbilical cord clamping, but doses of 100 mcg and less prior to delivery haven't been shown to cause significant neonatal depression. I give both fentanyl and morphine up front because there's a substantial lag in the onset of epidural morphine and the pharmacokinetics of fentanyl complement it nicely. Without the fentanyl, they'd have minimal or no neuraxial opiate effect until the postoperative period.

For urgent/emergent sections in which fetal well being is questionable, I hold off giving the opiates until after cord clamping, not because I believe there's any chance that a significant portion of a 3 mg dose of hydrophilic morphine administered epidurally will reach and harm the baby, but because I don't ever want to have the above discussion if a baby turns out bad. Someone's always looking to blame anesthesia, and opiates prior to cord clamping are just controversial enough that someone out there will blame me.

Most common side effect is pruritis which is easily treated with a small dose of naloxone (without reversing its antinociceptive effects) but for some reason everyone tries Benadryl first, which in my experience only "works" if you wait long enough for the itching to go away by itself. At one hospital where I trained, the epidural itchies were routinely treated with an ampule of Narcan in 1000 mL infusing at 100/hr (so 40 mcg/hr) - worked every time, and without compromising its analgesic effects.


Incidentally, that property of naloxone (reversal of undesired side effects BEFORE analgesia) was on the ITE last year.

 

[dhb]

epidural itchies were routinely treated with an ampule of Narcan in 1000 mL infusing at 100/hr (so 40 mcg/hr) - worked every time

Thanks for the that. Nice way of doing it.

 

[BLADEMDA]

Geez man, that's a great way to encourage people to post in your threads.



Different people use different doses. I use
1) 15 mcg fentanyl, 0.2 mg morphine for spinals (usually added to 1.4-1.6 mL of 0.75% hyperbaric bupivacaine)
2) 3 mg morphine, 100 mcg fentanyl for epidurals (up front for non-urgent sections)
3) 3 mg morphine, +/- 100 mcg fentanyl (after delivery for urgent/emergent sections)

I'm not aware of any data showing a benefit to more than 3.75 mg of epidural morphine for postcesarean pain. As for spinals, the sweet spot appears to be in the 0.1 - 0.25 mg range ... equivalent analgesia but less pruritis than modestly higher doses.

Some of my attendings in residency vehemently forbade giving fentanyl prior to umbilical cord clamping, but doses of 100 mcg and less prior to delivery haven't been shown to cause significant neonatal depression. I give both fentanyl and morphine up front because there's a substantial lag in the onset of epidural morphine and the pharmacokinetics of fentanyl complement it nicely. Without the fentanyl, they'd have minimal or no neuraxial opiate effect until the postoperative period.

For urgent/emergent sections in which fetal well being is questionable, I hold off giving the opiates until after cord clamping, not because I believe there's any chance that a significant portion of a 3 mg dose of hydrophilic morphine administered epidurally will reach and harm the baby, but because I don't ever want to have the above discussion if a baby turns out bad. Someone's always looking to blame anesthesia, and opiates prior to cord clamping are just controversial enough that someone out there will blame me.

Most common side effect is pruritis which is easily treated with a small dose of naloxone (without reversing its antinociceptive effects) but for some reason everyone tries Benadryl first, which in my experience only "works" if you wait long enough for the itching to go away by itself. At one hospital where I trained, the epidural itchies were routinely treated with an ampule of Narcan in 1000 mL infusing at 100/hr (so 40 mcg/hr) - worked every time, and without compromising its analgesic effects.


Incidentally, that property of naloxone (reversal of undesired side effects BEFORE analgesia) was on the ITE last year.

Many people read these threads. So, while I encourage responses and hope many will give input I believe "wild" posts need an appropriate response. Atropine at 1.0 mg is likely to cause a HR of 130 or greater in this patient for a good 15 minutes. I have seem a few CRNAs give atropine and it is NOT the best choice here.

Your response to the question about Duramorph/Fenatnyl was spot on.

FYI, I keep this simple KISS. For Spinals I give around 0.25 mg duramorph (half cc of 0.5 mg/cc ampule) and for Epidurals around 4 mg.


"One randomized dose-response study (43) allowed patients free access to IVPCA after epidural administration of saline or 1 of 4 doses of morphine (1.25, 2.5, 3.75, or 5 mg). Quality of analgesia improved as the dose of epidural morphine increased to 3.75 mg. Beyond that, there was no difference in analgesic effect as measured by IVPCA use. All women given epidural morphine experienced pruritus, but there was no correlation with the dose of epidural morphine. Analgesia lasted for 18&#8211;26 h. "

http://www.anesthesia-analgesia.org/cgi/content/full/101/5S_Suppl/S62

Spinals:

"A meta-analysis (33) demonstrated excellent efficacy of morphine doses of 0.1 to 0.2 mg but no additional pain relief with doses >0.2 mg. Median time to first request for supplemental analgesics in that study was 27 h. In contrast, doses smaller than 0.1 mg had little effect on pain relief. "

 

[BLADEMDA]

Anesth Analg. 2000 Jul;91(1):172-5. Links

Prophylactic intravenous ondansetron reduces the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery.

Yeh HM, Chen LK, Lin CJ, Chan WH, Chen YP, Lin CS, Sun WZ, Wang MJ, Tsai SK.
Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
Pruritus is a common side effect of intrathecal morphine injection for postoperative pain control. Its incidence is especially high in patients undergoing cesarean delivery. We investigated the effectiveness of ondansetron in preventing intrathecal morphine-induced pruritus in such patients. We included 60 consecutive nonbreastfeeding women who were scheduled for elective cesarean delivery. After the administration of spinal anesthesia with bupivacaine and intrathecal morphine 0.15 mg injection, the patients were randomly divided into three groups. Group 1 received placebo (normal saline) IV injection, Group 2 diphenhydramine 30 mg IV injection, and Group 3 ondansetron 0.1 mg/kg IV injection. The incidence of pruritus was significantly lower in the ondansetron group (25%) when compared with that in the placebo group (85%) and in the diphenhydramine group (80%) (both P < 0.05). The postoperative pain score and time to flatus passage were not significantly different among the three groups. There were no headache or extrapyramidal signs associated with ondansetron use. In conclusion, ondansetron prophylaxis significantly reduced the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery. IMPLICATIONS: Ondansetron prophylaxis significantly decreases the incidence of pruritus, a common side effect of intrathecal morphine used to treat postcesarean delivery pain.

 

[BLADEMDA]

There are other studies which show Zofran doesn't work to decrease itching in this group of patients.

http://www.ncbi.nlm.nih.gov/pubmed/...nkpos=3&log$=relatedarticles&logdbfrom=pubmed


http://www.ncbi.nlm.nih.gov/pubmed/...inkpos=4&log$=relatedreviews&logdbfrom=pubmed

What do you think?

 

[coprolalia]

What do you think?

They only get Nubain from me. Everything else is suboptimal.

-copro

 

[BLADEMDA]

1: Anesth Analg. 1996 Mar;82(3):641-7. Links

Naloxone versus nalbuphine infusion for prophylaxis of epidural morphine-induced pruritus.

Kendrick WD, Woods AM, Daly MY, Birch RF, DiFazio C.
Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA.
This randomized, double-blind study compared the efficacy of two mu-receptor antagonists, naloxone and nalbuphine, in the prophylactic management of pruritus in postcesarean section patients receiving epidural morphine. Dosages of study drugs were individualized by the use of a patient self-administration (PSA) device. All 51 patients were healthy women who received a uniform epidural anesthetic and epidural morphine (5 mg). Coded solutions were infused for 24 h, with 5-min PSA lockout times: Group A (n = 17), nalbuphine 2.5 mg/h, PSA nalbuphine 1 mg; Group B (n = 16), naloxone 50 micrograms/hr, PSA saline; Group C (n = 18), naloxone 50 micrograms/h, PSA naloxone 40 micrograms. Patients were assessed for pruritus and pain every 8 h for 24 h. Both naloxone and nalbuphine provided good relief for pruritus; median pain and pruritus scores were in the none-to-mild range (0-3) for all groups at all assessment intervals. The pruritus scores of the PSA saline group were higher during the 16- to 24-h period (P < 0.05) than the scores of either group receiving A-receptor antagonist by PSA. There was evidence of shortening of the duration of analgesia in patients receiving naloxone who required treatment for pruritus after 16 h. Patients who self-administered large doses of nalbuphine over the first 8 h also reported pain scores consistent with reversal of analgesia. The potency ratio for naloxone:nalbuphine for antagonism of the pruritic effects of epidural morphine was approximately 40:1. Intervention to treat either unrelieved pruritus or pain, respectively, was necessary in the following numbers of patients: Group A, 0/1; Group B, 1/1; Group C, 2/2. Prophylactic infusions offer the potential for labor cost savings by minimizing the need for episodic therapeutic interventions to treat pruritus.

 

[BLADEMDA]

They only get Nubain from me. Everything else is suboptimal.

-copro

So, do you put 20 mg of Nubain in a 1 liter bag and run at 100 per hour? Then, titrate the rate up as needed based on patient input?

I have limited experience with Nubain; instead I use Narcan (low dose) as an infusion as described by PGG. That said, there may be theoretical advantages of Nubain over Narcan.

 

[BLADEMDA]

In obstetric patients, the incidence of pruritus after epidural or intrathecal administration of hydrophilic opioids such as morphine is frequent and may limit their use (6). This vulnerability to pruritus, thought to be caused by the altered binding of opioids at receptor sites, may be caused by competition by estrogens (7). The increased cephalad spread of spinally administered drugs in a pregnant woman at term as compared with the general population may also play a role (8). This study demonstrated a 35% incidence of intrathecal morphine-induced pruritus requiring treatment (pruritus score

3), and this is consistent with previously reported values (5,9,10). The parturients were observed for four hours in the postanesthesia care unit, because pruritus usually occurs within a few hours of intrathecal morphine injection (11,12). The onset of pruritus in this study ranged from 25 to 180 minutes, which is also consistent with the previous results (10).
The mechanism of pruritus after the neuraxial administration of opioids is not fully understood. It is probably not related to histamine release, because histamine blockers are ineffective in the therapy of pruritus caused by spinal morphine (13). Another theory is that the opioid receptors in the central nervous system are activated by morphine. Opioid receptors are located both supraspinally and at the spinal cord level. Spinal opioids activate the opioid receptors in the substantia gelatinosa of the spinal cord’s dorsal horn (14). The µ receptor is responsible for pain modulation and some side effects, especially pruritus (14). This would explain the antipruritic effect of nalbuphine or naloxone, specific µ antagonists (3,5). A third theory is that the pruritus from neuraxial opioids may be related to the excitatory effects of opioids on the nocifensive and nonnocifensive neurons in the anterior and posterior spinal horns (15). Propofol may relieve pruritus related to neuraxial opioids because it has an inhibitory effect on the dorsal horn of the spinal cord (15). Recently, there has been evidence that opioids and the serotoninergic system interact closely in the central nervous system; ondansetron, a specific 5-hydroxytryptamine-3 receptor antagonist, has an antipruritic effect (10,16).