So was curious if anyone has appreciated an intense sympathectomy with saddle anesthesia before? Done several cerclages on the ob floor with 1.6 ml isobaric .75 spinal marcaine and 20mcg fentanyl as the 'go to' dosing at the training facility I'm at...and today had to but someone on a phenyl drip (up to 20mcg/min) for the procedure and about 30min postoperative for hypotension that initially managed with frequent phenyl/ ephedrine pushes after a pressure of 60 systolic manifested after lying her down. She was sitting up a good 5min for the block to set prior to lying her down...I've not had a sympathectomy with saddle anesthesia before. Was curious about others insights...
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Saddle block sympathectomy
Started by usma05
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From your case it sounds like you guys do this dose all the time and don't have this problem very commonly. My first impression, though, is:
*** that's a f*ckload of local/narcotic for a cerclage
*** in this situation you're probably not doing the things you would normally do for a C-section spinal, e.g. immediate supine (LUD), aggressive BP correction, IVF preload and coload, etc, etc.
Did you mean isobaric?
Seriously. We use 1.2-1.4ml of .75% hyperbaric plus 15 of fentanyl and 150 of morphine for our C-sections. Our saddle blocks are more like 0.5-1.0 of 0.75% hyperbaric plus 10-15 of fentanyl.
If I'm doing a saddle block it's usually 1.0 to 1.2 mls of 0.75% bupivicaine with 10 mcg of fentanyl and I leave them in sitting position for at least 4-5 minutes before laying them back down. They still get a little leg weakness, but usually not much, and definitely don't get much of a sympathectomy.
Isobaric? I assume you are using hyperbaric. Either way, too much local.
I usually use 1 ml of 0.75% hyperbaric bupivacaine = 7.5 mg +/- 15 mcg of Fentanyl.
I saw hypotension once during residency with that dose, but in retrospect I think it was at least partly due to the fact that the degree of Trendelenburg required by the surgeon was extreme.
If you want to do a "saddle block" you need to use hyperbaric Bupiva not isobaric!
Probably gave hypobaric 😉
