SAB or epidural for morbidly obese c/section

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Monty Python

Monty Python

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I've been reading conflicting articles lately on the best way to approach an elective primary c/section in a morbidly obese patient. Mine tomorrow is G1P0, 65 inches, 322 pounds. Haven't seen her yet for assessment. Some articles call for reducing SAB dosage due to potential higher spread versus what's seen in thin patient with same dosage; other articles conflict with that recommendation. Some articles call for epidural due to easier placement of Tuohy versus flimsier spinal needle along with the availability to redose epidural if needed, yet other articles find a higher failure rate with epidural versus SAB. What are others currently doing for obese c/sections? Thanks.
 
Dose does not need to be reduced. Obese people tend to get higher levels because their abundant posteriors effectively put their spines in Trendelenberg and hyperbaric bupiv sinks north. You can control the height of your block with the table control.

Use whichever needle you need to get the drug in the right place.
 
A CSE might be a more attractive option in some of these patients because it will make placing the spinal needle easier and you will have a catheter to augment your spinal if things take longer than anticipated.
 
In PP it's SAB all the way. I could see epidural in academia where the case is gonna take 2.5x's as long as it should. I just go straight to a 24g for the fluffy ones. I've also used a tuohy as along introducer sort of like a CSE. I think taking the extra time to thread the cath allows the IT dose to sink resulting in a lower level that may end up inadequate especially if the OB likes to shake out the uterus like a dusty rug.
 
How about doing a true CSE to get the best of both worlds? At my institution we use straight 0.5% bupivicaine (not hyperbaric) and I haven't had any issues getting an adequate spinal level. For that patient I'd give Bupivicaine 0.5% 12mg plus fentanyl 15mcg IT.
 
Interesting, this was one of my oral board questions, many years ago. Short morbidly obese lady MP3 airway for urgent but not stat C-section. I said epidural and the examiner made it a wet tap. So I said I'd put a catheter and slowly dose it up with .5% isobaric bupivacaine. She ended up with difficulty breathing, impossible to intubate and an LMA full of puke in a cant intubate or ventilate scenario. I passed, because I did follow a reasonable order in management of the anesthetic. The examiner was RK Stoelting.


Sent from my iPad using Tapatalk
 
SaltyDog said:
I think taking the extra time to thread the cath allows the IT dose to sink resulting in a lower level that may end up inadequate especially if the OB likes to shake out the uterus like a dusty rug.
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Good points.
My take is, if you are using a touhy to place the SAB then why not just thread the catheter but you say the "heavy" bupiv will not ridges enough. This is a very important point. I use isobaric bupiv for these cases.
With that being said, I haven't used a touhy strictly for SAB and I've done some bigguns.
My thought process would be, who is the surgeon and can they possibly get in trouble causing the case to go longer than usual. If so then the pt either gets a CSE or a GA. This is rare in PP. In academics, I'd probably do a GA just because I am no longer tolerant of slow surgeons.

Btw, this is a routine SAB in my practice.
 
This woman honestly isn't that big. I had a calculated BMI of 75 a few months back. My average patient lately is 5'4" and >350. It's really starting to piss me off. Had one last week who was 5'8" (a friggin giant for these parts) and last weight a month ago was 342 because she maxed out the scale we had on L&D. Airway was horrible. I got an epidural in her and she eventually ended up a section.


My take on SABs in these patients is to do your standard dose. I only ever adjust for height, never weight. If this woman shows up in labor then I ask the OBs to call for the epidural early so I know what I am dealing with. Nothing worse than getting called stat for a section and finding a woman who is large.
 
SaltyDog said:
In PP it's SAB all the way. I could see epidural in academia where the case is gonna take 2.5x's as long as it should. I just go straight to a 24g for the fluffy ones. I've also used a tuohy as along introducer sort of like a CSE. I think taking the extra time to thread the cath allows the IT dose to sink resulting in a lower level that may end up inadequate especially if the OB likes to shake out the uterus like a dusty rug.
Click to expand...
Ummmm, no, it's not. We do epidurals on these types of patients every single day. Virtually all our sections get epidurals, along with PCEA for 24 hours after. Perhaps 1/10 of 1% might get a spinal or CSE.
 
jwk said:
Ummmm, no, it's not. We do epidurals on these types of patients every single day. Virtually all our sections get epidurals, along with PCEA for 24 hours after. Perhaps 1/10 of 1% might get a spinal or CSE.
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Ya, I know you guys do it that way (I remember you posting about it quite a while back). I know you guys deliver truckloads of babies too, so obviously it works out well for you to do it like that. I think you have to recognize though that your practice is an anomaly. I've never heard of another institution (private or academic for that matter) that does their C/S's that way. My guess is it's a relic from the days when everyone did epidurals for sections because small bore pencil point needles weren't readily available (those things are a bitch to manufacture compared to a Quincke). Either that or some billing gymnastics makes it better for you to do that although a post-op epidural check should bill the same as IT Duramorph. I firmly believe though that an SAB is a superior anesthetic for a C-Section compared to an epidural. This is something that every colleague I know agrees with as well as every pt I've taken care of that has had one of each.

I'm curious though, why do a small fraction get SAB's in your practice? What is the indication for an SAB or CSE for you guys??
 
PainDrain said:
This woman honestly isn't that big. I had a calculated BMI of 75 a few months back. My average patient lately is 5'4" and >350. It's really starting to piss me off. Had one last week who was 5'8" (a friggin giant for these parts) and last weight a month ago was 342 because she maxed out the scale we had on L&D. Airway was horrible. I got an epidural in her and she eventually ended up a section.


My take on SABs in these patients is to do your standard dose. I only ever adjust for height, never weight. If this woman shows up in labor then I ask the OBs to call for the epidural early so I know what I am dealing with. Nothing worse than getting called stat for a section and finding a woman who is large.
Click to expand...

It's a special kind of obesity when your BMI surpasses your height in inches.
 
Monty Python said:
I've been reading conflicting articles lately on the best way to approach an elective primary c/section in a morbidly obese patient. Mine tomorrow is G1P0, 65 inches, 322 pounds. Haven't seen her yet for assessment. Some articles call for reducing SAB dosage due to potential higher spread versus what's seen in thin patient with same dosage; other articles conflict with that recommendation. Some articles call for epidural due to easier placement of Tuohy versus flimsier spinal needle along with the availability to redose epidural if needed, yet other articles find a higher failure rate with epidural versus SAB. What are others currently doing for obese c/sections? Thanks.
Click to expand...

Jwk aside, spinal is the anesthetic of choice for C section. Don't overthink it.
 
SaltyDog said:
Ya, I know you guys do it that way (I remember you posting about it quite a while back). I know you guys deliver truckloads of babies too, so obviously it works out well for you to do it like that. I think you have to recognize though that your practice is an anomaly. I've never heard of another institution (private or academic for that matter) that does their C/S's that way. My guess is it's a relic from the days when everyone did epidurals for sections because small bore pencil point needles weren't readily available (those things are a bitch to manufacture compared to a Quincke). Either that or some billing gymnastics makes it better for you to do that although a post-op epidural check should bill the same as IT Duramorph. I firmly believe though that an SAB is a superior anesthetic for a C-Section compared to an epidural. This is something that every colleague I know agrees with as well as every pt I've taken care of that has had one of each.

I'm curious though, why do a small fraction get SAB's in your practice? What is the indication for an SAB or CSE for you guys??
Click to expand...
A couple of our docs (out of about 65) will do spinals on occasion for urgent/emergent sections. Strictly personal preference on a case-by-case basis. I couldn't tell you the last time I've seen one done that way. The hospital and our group made their "claim to fame" 40+ years ago by being the first in our area to offer 24/7/365 in-house OB epidural anesthesia coverage. The post-op PCEA got added to the mix 25+ years ago when the CADD-style pumps first came on the market. I would assume that it's pretty much a "don't mess with success" thing - it works well for us in a very high-volume practice, the patients are happy, the OB's are happy.
 
I agree with the above statements, the epidural is really an inferior technique when compared to the SAB for c/s in my experience.
I also don't understand leaving it in place for 24hrs. We have very little issues with post c/s pts with regards to pain control.
JWK, I have to wonder if your pt population is something different? I'm sure their size is different from my "usual" pt size but is there something else that is different. I remember when I worked in south La the pts were more eager to get an epidural. It was like they wanted to feel nothing. Now my pts think they want to go "natural" right up until it hurts. So I get called once the screaming starts to hit a fever pitch. I almost prefer the previous.
 
jwk said:
A couple of our docs (out of about 65) will do spinals on occasion for urgent/emergent sections. Strictly personal preference on a case-by-case basis. I couldn't tell you the last time I've seen one done that way. The hospital and our group made their "claim to fame" 40+ years ago by being the first in our area to offer 24/7/365 in-house OB epidural anesthesia coverage. The post-op PCEA got added to the mix 25+ years ago when the CADD-style pumps first came on the market. I would assume that it's pretty much a "don't mess with success" thing - it works well for us in a very high-volume practice, the patients are happy, the OB's are happy.
Click to expand...
Fair enough and I hope you don't take my criticisms the wrong way but I think it's more a institution bias than a superior approach. Plus if you are so busy why do a procedure that takes more time? Doesn't make sense to me.
 
I would put my two sense in. Where I trained we would intervene as early as possible and place epidurals. Usually when moms were not in much pain and coast the epidural until delivery. Where I currently practice they place the epidurals as late as possible and the inhaled nitrous has made things a lot worse in that once the nitrous stops being effective moms are writhing in pain. Some of my partners will just place a spinal with 25mcg of fentanyl and 1cc of .25% and walk away and come back and place the epidural. If they are super jumpy I will place a spinal with the spinal kit, I won't place a CLE with her jumping all over the place with the thouy needle. In my practice over 4 years have not had a wet tap or headache.
 
I think it's silly to do a spinal and come back later for the epidural. Just do a CSE.

As for moving ... she either holds mostly still or she doesn't get the epidural. I find that if I stand back there doing nothing, telling her that I'll start when she can hold still, somehow even the most histrionic and dramatic patients conjure the ability to hold still. I can play the patience game longer than they can play the lookit-me-I'm-suffering game.

And it is a game. Or rather, a performance. I find at the places where the husband/SO isn't allowed to stay in the room for the epidural, the patients are a lot less ... demonstrative.

We just got nitrous on L&D. I haven't seen it in action enough to form an opinion on it yet.
 
If the airway is really concerning or super obese:

Take your Touhy, bury it until you get a nice loss of resistance. Then go a little further until you get Niagara falls. Place that catheter right there in that spot. Its a good spot, trust me. Very few people are accustom to doing it this way. Throw a tegaderm on it, lay her down and bolus a dose like 10 mg heavy bup and titrate from there.

Rebolus all your heart desires and give a little duramorph while you're at it (i prefer 150 mcg). End of case, pull it, throw it in the trash, and move on. If you want to be fancy, cap it and leave it for 24 hrs then pull it and throw it in the trash. But I keep it simple cause fancy things have fancy problems.

Why risk a PDPH you ask?????? Cause Id take a headache over a dead patient any day.

And guess what?? Really obese woman almost never get that headache. Maybe cause ICP is higher in the spinal cord or maybe they never get up to begin with, I really dont know. But I won't lie to you, 330 lb is your average Sally in my neck of the woods. 450 is when i start thinking obese. For your sally Id probably just do your average Joe spinal, especially if its 2 am.
 
RxBoy said:
If the airway is really concerning or super obese:

Take your Touhy, bury it until you get a nice loss of resistance. Then go a little further until you get Niagara falls. Place that catheter right there in that spot. Its a good spot, trust me. Very few people are accustom to doing it this way. Throw a tegaderm on it, lay her down and bolus a dose like 10 mg heavy bup and titrate from there.

Rebolus all your heart desires and give a little duramorph while you're at it (i prefer 150 mcg). End of case, pull it, throw it in the trash, and move on. If you want to be fancy, cap it and leave it for 24 hrs then pull it and throw it in the trash. But I keep it simple cause fancy things have fancy problems.

Why risk a PDPH you ask?????? Cause Id take a headache over a dead patient any day.

And guess what?? Really obese woman almost never get that headache. Maybe cause ICP is higher in the spinal cord or maybe they never get up to begin with, I really dont know. But I won't lie to you, 330 lb is your average Sally in my neck of the woods. 450 is when i start thinking obese. For your sally Id probably just do your average Joe spinal, especially if its 2 am.
Click to expand...
How far do you tread the spinal catheter in these patients?
 
narcusprince said:
How far do you tread the spinal catheter in these patients?
Click to expand...
3 to 4 cm as long as they are not having paresthesia's. Cause of that multi-orifice cath and giant fat pad, I dont want to be too shallow. Also youre average epidural catheter prime is about 0.3 cc's, I measured it. But I just aspirate till i get csf then push syringe with local, usually covers that prime and tells you that you're still in.
 
RxBoy said:
If the airway is really concerning or super obese:

Take your Touhy, bury it until you get a nice loss of resistance. Then go a little further until you get Niagara falls. Place that catheter right there in that spot. Its a good spot, trust me. Very few people are accustom to doing it this way. Throw a tegaderm on it, lay her down and bolus a dose like 10 mg heavy bup and titrate from there.

Rebolus all your heart desires and give a little duramorph while you're at it (i prefer 150 mcg). End of case, pull it, throw it in the trash, and move on. If you want to be fancy, cap it and leave it for 24 hrs then pull it and throw it in the trash. But I keep it simple cause fancy things have fancy problems.

Why risk a PDPH you ask?????? Cause Id take a headache over a dead patient any day.

And guess what?? Really obese woman almost never get that headache. Maybe cause ICP is higher in the spinal cord or maybe they never get up to begin with, I really dont know. But I won't lie to you, 330 lb is your average Sally in my neck of the woods. 450 is when i start thinking obese. For your sally Id probably just do your average Joe spinal, especially if its 2 am.
Click to expand...

That would be my technique for the super obese + disaster airway + full stomach crash section nightmare scenario we have all pondered. Gets more fun to think about if you throw in a PLT count of 70K.
 
BTW SAB vs Epidural is not even a question.
SAB>>>>>>>>Epidural

Epidurals suck a$$ for SURGICAL anesthesia. They are amazing for post op pain analgesia. As a matter of fact, if a labor epidural is even slightly questionable, I refrain from bolusing, pull the catheter and do a spinal.

Ive even left questionable epidurals in place. I take off the dressing while prepping all around it, do a spinal underneath it and pop a fresh tegaderm back on. I usually reserve this strategy for those anticipated difficult spinals. That way Im not burning a bridge if I dont hit the spinal. Also, I can always rebolus the epidural if the case takes too long.
 
RxBoy said:
BTW SAB vs Epidural is not even a question.
SAB>>>>>>>>Epidural

Epidurals suck a$$ for SURGICAL anesthesia. They are amazing for post op pain analgesia. As a matter of fact, if a labor epidural is even slightly questionable, I refrain from bolusing, pull the catheter and do a spinal.

Ive even left questionable epidurals in place. I take off the dressing while prepping all around it, do a spinal underneath it and pop a fresh tegaderm back on. I usually reserve this strategy for those anticipated difficult spinals. That way Im not burning a bridge if I dont hit the spinal. Also, I can always rebolus the epidural if the case takes too long.
Click to expand...
This is master ninja level teaching here......Do not tell all the tricks!
 
pgg said:
I think it's silly to do a spinal and come back later for the epidural. Just do a CSE.

As for moving ... she either holds mostly still or she doesn't get the epidural. I find that if I stand back there doing nothing, telling her that I'll start when she can hold still, somehow even the most histrionic and dramatic patients conjure the ability to hold still. I can play the patience game longer than they can play the lookit-me-I'm-suffering game.

And it is a game. Or rather, a performance. I find at the places where the husband/SO isn't allowed to stay in the room for the epidural, the patients are a lot less ... demonstrative.

We just got nitrous on L&D. I haven't seen it in action enough to form an opinion on it yet.
Click to expand...
I am surprised your chairman did not put an end to Nitrous. L+D where you are at is run far better then most of our L+D practices. Also a seasoned L+D nurse is worth her weight in gold. I have seen a case where the patient was transferred to the OR for fetal deceleration and the nurse loses the IV during the transport with no epidural and an abruption. Case morphed from a straightforward case to a super master level ninja case. Crash c-section under local cutting into an abruption.
 
narcusprince said:
I am surprised your chairman did not put an end to Nitrous. L+D where you are at is run far better then most of our L+D practices. Also a seasoned L+D nurse is worth her weight in gold. I have seen a case where the patient was transferred to the OR for fetal deceleration and the nurse loses the IV during the transport with no epidural and an abruption. Case morphed from a straightforward case to a super master level ninja case. Crash c-section under local cutting into an abruption.
Click to expand...

That sounds like a total **** show. Why not just take 30s to pop in a new IV --> GA????
 
Self-administered Nitrous Oxide for labor is a fantastic idea and it is used routinely in other parts of the world, I expect it to become more common in the US as reimbursement for epidurals keeps dropping.
 
Its a good idea for the early stages of labor. But as they start progressing it loses its effectiveness. Pgg just wait when you start placing the epidurals after nitrous the moms are jumping all over the place. Also the nurses here need to learn that its not okay to place a patient with pulmonary htn on inhaled nitrous.
 
RxBoy said:
If the airway is really concerning or super obese:

Take your Touhy, bury it until you get a nice loss of resistance. Then go a little further until you get Niagara falls. Place that catheter right there in that spot. Its a good spot, trust me. Very few people are accustom to doing it this way. Throw a tegaderm on it, lay her down and bolus a dose like 10 mg heavy bup and titrate from there.

Rebolus all your heart desires and give a little duramorph while you're at it (i prefer 150 mcg). End of case, pull it, throw it in the trash, and move on. If you want to be fancy, cap it and leave it for 24 hrs then pull it and throw it in the trash. But I keep it simple cause fancy things have fancy problems.

Why risk a PDPH you ask?????? Cause Id take a headache over a dead patient any day.

And guess what?? Really obese woman almost never get that headache. Maybe cause ICP is higher in the spinal cord or maybe they never get up to begin with, I really dont know. But I won't lie to you, 330 lb is your average Sally in my neck of the woods. 450 is when i start thinking obese. For your sally Id probably just do your average Joe spinal, especially if its 2 am.
Click to expand...
I totally disagree with this approach but it is an option I guess.
Also, could you provide evidence that fattie don't get PDPH's?
 
narcusprince said:
Also the nurses here need to learn that its not okay to place a patient with pulmonary htn on inhaled nitrous.
Click to expand...

Does your practice see many pregnant women with pulm HTN? I remember a few mod to severe cases in residency. Always concern for disaster in those patients.
 
RxBoy said:
BTW SAB vs Epidural is not even a question.
SAB>>>>>>>>Epidural

Epidurals suck a$$ for SURGICAL anesthesia. They are amazing for post op pain analgesia. As a matter of fact, if a labor epidural is even slightly questionable, I refrain from bolusing, pull the catheter and do a spinal.

Ive even left questionable epidurals in place. I take off the dressing while prepping all around it, do a spinal underneath it and pop a fresh tegaderm back on. I usually reserve this strategy for those anticipated difficult spinals. That way Im not burning a bridge if I dont hit the spinal. Also, I can always rebolus the epidural if the case takes too long.
Click to expand...
Do you feel Fentanyl makes your epidural c sections better than 2% lidocaine by itself. I have found adding 100 Mcg epidurally makes it a much denser analgesic but maybe it is all in my head...
 
It's pretty well accepted that the addition of narcotic is synergistic and creates a superior block/analgesia.

100mcg fent has been part of every C/S under epidural I've ever done. That's what we did in residency, and I've never had a reason to omit it.
 
SaltyDog said:
It's pretty well accepted that the addition of narcotic is synergistic and creates a superior block/analgesia.

100mcg fent has been part of every C/S under epidural I've ever done. That's what we did in residency, and I've never had a reason to omit it.
Click to expand...
I agree completely. I was taught to give fentanyl & morphine via the epidural after cord clamp.

I'm not sure if I've ever not given them both, except in the rare morphine-allergic patient.

For non-urgent c-sections with epidurals, I chase the lidocaine in with 100 mcg of fentanyl and 3 mg of morphine. I don't wait for cord clamp.

For c-sections that involve a question of fetal well-being, I don't give the fentanyl until after delivery. The argument is that since systemic uptake from epidural fentanyl is awful close to that of IV fentanyl, one doesn't need the headache of defending the early administration when someone says the newborn was down because of the fentanyl. I know that's weak CYA medicine. But those sections are usually skin-to-delivery of a minute or two, so I don't think she's missing out on a ton of fentanyl benefit if I wait.
 
One word of advice, if you are using your Tuohy as a finder for the SAB, you get CSF with it, and you decide to dose through it, don't forget the dead space is huge. Did this once on a non-urgent section. Decided to just dose through the Tuohy. Just as I was pulling the syringe off the needle, what was about to happen dawned on me. Too late. I watched half of my IT dose get flushed out onto the floor.

No biggie. Threaded a catheter and dosed it with isobaric. Since I only use 100 mcg Duramorph in my spinals, I didn't feel to nervous about administering a second dose through the catheter.

Hadn't really thought about withholding the 100mcg fent from the epidural on those urgent sections for ugly tracings. Probably will start doing that.

-pod
 
Wiscoblue said:
Interesting, this was one of my oral board questions, many years ago. Short morbidly obese lady MP3 airway for urgent but not stat C-section. I said epidural and the examiner made it a wet tap. So I said I'd put a catheter and slowly dose it up with .5% isobaric bupivacaine. She ended up with difficulty breathing, impossible to intubate and an LMA full of puke in a cant intubate or ventilate scenario. I passed, because I did follow a reasonable order in management of the anesthetic. The examiner was RK Stoelting.


Sent from my iPad using Tapatalk
Click to expand...

Oh my.
 
Planktonmd said:
Self-administered Nitrous Oxide for labor is a fantastic idea and it is used routinely in other parts of the world, I expect it to become more common in the US as reimbursement for epidurals keeps dropping.
Click to expand...

I've used it a handful of times since our institution got it and in my limited n it sucks. All those except the true diehard gave up after a few whiffs and just asked for an epidural.
 
Planktonmd said:
That's a great business idea!
Click to expand...

Nah. Too easy for people to just take an empty whip cream can into the salon.

Now if your seriously interested in starting up a sedation tattoo/piercing/tattoo removal business shoot me PM.
 
SaltyDog said:
Nah. Too easy for people to just take an empty whip cream can into the salon.

Now if your seriously interested in starting up a sedation tattoo/piercing/tattoo removal business shoot me PM.
Click to expand...

Heh, I was just having this discussion a couple of weeks ago with an attending. Untapped market, logistics would be a pain though.
 
Ok, same patient from OP. Private practice. Hct is 35. Bad veins, nurses got a 20g. Do you roll with that?
 
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