Spinal for post-partum tubal ligation

[Cookie]

Just wondering if you have any ideas for spinals for tubal ligation, currently I use Bupi 0.75% (1.4-1.6 cc) but the procedure is fairly short and the pts get stuck in PACU ! thanks

---

Members don't see this ad.

 

[jwk]

Just wondering if you have any ideas for spinals for tubal ligation, currently I use Bupi 0.75% (1.4-1.6 cc) but the procedure is fairly short and the pts get stuck in PACU ! thanks

Why not use the epidural they probably had during labor and delivery?

 

[Idiopathic]

our epidurals either get pulled immediately or they clot off overnight, even when we run saline through. lidocaine spinal is great like 70 mg of heavy lidocaine although we had to convert one when they couldnt even find the tube in the first hour.

 

[Arch Guillotti]

heavy lido. much better than epidural

 

[Planktonmd]

Here is the answer: Propofol Sux Tube!
I can't even remember the last time I did a spinal for PPBTL.

 

[periopdoc]

chloroprocaine

- pod

 

[bigdan]

I did my first PPTL today, and we "activated" the epidural...which meant we put in a 20 cc stick of Lidocaine + Epi, watched her squirm, and then made the case into a MAC.

She may have been better off with a spinal, but I hear these horror stories of long ass tubals...maybe GA is the way to go

 

[Cookie]

How often do you guys use lido for spinals , I have never used it b/c of the possibility of TNS . What concentration do u use and how much to give ?thanks

 

[dA pilot]

how bout TNS with lido?
i use 1.3 cc of .75% marcaine with 10 mcg of fentanyl.

 

[Idiopathic]

Here is the answer: Propofol Sux Tube!
I can't even remember the last time I did a spinal for PPBTL.

i dont like to put peripartum women to sleep for elective procedures

 

[TrustMe]

We use the epidural that was intentionally left in place after delivery for the PPTL. If pt. doesn't have an indwelling epidural we usually tell them and the OB to come back in 6 wks and we will do it however the pt. likes (spinal, GA). We will not proceed with elective PPTL if pt. needs GA.

 

[jwk]

our epidurals either get pulled immediately or they clot off overnight, even when we run saline through. lidocaine spinal is great like 70 mg of heavy lidocaine although we had to convert one when they couldnt even find the tube in the first hour.

We leave the epidural in, and they come down for their tubals the day after delivery. The longer the epidural has been in, the higher the chance that it doesn't work. If we can still inject through the catheter, we dose them with 20cc of Lido 2% +/- epi. If it works (generally 50-60% of the time) then we use it. If not, off to sleep. I don't think you've lost anything by attempting to redose the epidural. Post partum tubals in our shop are a 10 minute case.

 

[Idiopathic]

I did my first PPTL today, and we "activated" the epidural...which meant we put in a 20 cc stick of Lidocaine + Epi, watched her squirm, and then made the case into a MAC.

She may have been better off with a spinal, but I hear these horror stories of long ass tubals...maybe GA is the way to go

you made it into a room-air general is what you mean

 

[TrustMe]

I like 5% lido (70mg) but only a couple of our attendings will let us use this because of the TNS issue. Usually use this for cerclage's as they are quick. Works great, although I may have a different opinion if I ever have a pt. get TNS.

 

[jwk]

i dont like to put peripartum women to sleep for elective procedures

So which is more invasive/dangerous/cost effective? GETT and making a 1cm or so incision at the only time the tubes will be easily visible (while the woman is already in the hospital, or coming back 6 weeks later and doing a potentially life threatening laparoscopic procedure?

My opinion is somewhat colored by the fact that I've never had a patient aspirate or have any other complications doing a PPTL - but I have seen total catastrophes (non-anesthesia related) from elective laparoscopic tubal ligations (as in trocar straight into the aorta).

 

[TrustMe]

Most of our OB's are doing hysteroscopic tubal occlusion as opposed to laparoscopic TL for elective procedures.

 

[rsgillmd]

Just wondering if you have any ideas for spinals for tubal ligation, currently I use Bupi 0.75% (1.4-1.6 cc) but the procedure is fairly short and the pts get stuck in PACU ! thanks

Assuming you don't have an epidural in place/don't feel like inserting one I would give 1-1.2 ml of hyperbaric Bupi 0.75% + Fentanyl 15 mcg, because it sounds like you have relatively fast surgeons. If they are quick about starting the case after the spinal goes in, then I would stick with 1.2-1.4 ml of Bupivacaine. I routinely use 1 ml of Bupivacaine for my C/S + Fentanyl and rarely have to bolus the epidural (they like to CSE's at my hospital for C/S). However, I know from residency that 1-1.2 ml sometimes hasn't reached a peak level before the surgeons are ready to begin.

I think the narcotic is important. It allows you to reduce your dose of the spinal, and there are studies that show pinching of the tube (visceral pain) is the most painful part of the procedure and sometimes requires a higher block for adequate pain relief if using pure local.

I've had a long day so if I'm unclear feel free to ask any questions.

 

[Idiopathic]

So which is more invasive/dangerous/cost effective? GETT and making a 1cm or so incision at the only time the tubes will be easily visible (while the woman is already in the hospital, or coming back 6 weeks later and doing a potentially life threatening laparoscopic procedure?

My opinion is somewhat colored by the fact that I've never had a patient aspirate or have any other complications doing a PPTL - but I have seen total catastrophes (non-anesthesia related) from elective laparoscopic tubal ligations (as in trocar straight into the aorta).

neither, treat the case like you would an elective cesarean and put in a spinal or epidural

 

[Idiopathic]

or 70 mg IT demerol

 

[Corwin29]

Had a pertinent situation just yesterday, 33 y/o pp HIV +, mentally challenged, with some kind of rash all over her derm didn't know and wanted biopsy but pt refused saying they were mosquito bites. OB wants to do pp TL on labor floor b/c we weren't busy at the time. After seeing pt not convinced she could even consent herself but that aside, she had this unknown rash, (no epidural as she delivered at home prior to hospital, and reluctant to do spinal through rash) after some research in chestnut the book claims that 75% of these done under local, talked with OB they had never heard that and said no spinal then GA, my staff declined as this was elective OB staff agreed and case cancelled. Question is who is doing local and what techinique are the OB people using.

 

[pd4emergence]

neither, treat the case like you would an elective cesarean and put in a spinal or epidural

I give them the option for a spinal. They almost never want to be stuck in the back again, I don't blame them and I don't push it unless I have a good reason. Do you cancel a ppbtl in patients that refuse to have a regional anesthetic? Honestly, in alot of the patients I see they need to get the tubal or they will be back in their ob's office in a few months pregnant with #5 at age 21. Normal, healthy patient with no airway issues, I'll sleep them if they don't want the spinal. I've never seen one of these aspirate. I also agree with jwk, some of the worst OR disasters I've seen have been laparoscopic cases gone bad.

 

[Idiopathic]

look, no rule is hard and fast. you dont mysteriously lose all the risk factors of pregnancy after one day post partum. if you are the type that puts lots of c-sections to sleep, then happy hunting. but where i am thats probably not the most defensible plan of action.

i tell people,"its safer for you" because it is, and in some cases, i would probably refuse to anesthetize someone who wouldnt agree to spinal/epidural for PPTL.

 

[pgg]

I don't offer GA to PP tubals. I don't fear the pregnant GA, but neither do I go looking for it electively, either.

Spinal it is. Their labor epidurals are not reliable enough 12-24 hours later, so I don't bother trying them anymore.

Mepivacaine spinals were popular for cerclages and PP tubals at a hospital where I did some OB time as a resident. 3 cc 1.5% mepivacaine + 2 cc D10 to make it hyperbaric. They work and they're reasonably short acting.

 

[RabbMD]

Of course if you look at the albeit very limited data mepivacaine spinals have almost the same tns rate as lidocaine.

I used to use procaine, but we cant get it anymore...

 

[wee eng]

The success rate of using a labor epidural for a post partum tubal ligation is about 75-80% according to the literature. It is quicker and more effective to pull the epidural and do a spinal, if that is your choice. As for the choice of agent, I have used 5% lidocaine for any surgery in which the surgeon is fast enough to finish. I always withdraw an equal volume of CSF with barbotage of local and have never had an issue. Chloroprocaine, lidocaine, or bupivicaine may all be used, the choice being mostly dependent on the speed of the surgeon

 

[dhb]

Wow didn't know it was so complicated to do a short acting spinal!!
If i need a 1h spinal i take 1.5ml of 0.5% hyperbaric bupivacaine (we don't have 0.75%here) and dilute to 0.25% with csf and squirt it in

 

[Surfer]

propofol - lma or prop-sux-tube. this isn't rocket science. If you can't get the airway you can wake her up and cancel. but with proper pre-oxygenation and sux, you really aren't at great risk here despite her recent delivery. spinals and epidurals have risks too, remember.

 

[Colba55o]

To the OP, won't the patient have to be "stuck in PACU" even if you do GETA? I guess if you are discharging right after the procedure you could send her home at most a couple of hours early but she just had a baby. I don't think she will be itching to get out the door.

I vote for spinal with hyperbaric bupi.