Just a quick question to get a sense for what others are doing -- do you add fentanyl into your spinals for C-sections? Why or why not? And how much do you add?
Anybody using isobaric bupic? How much?
We typically do 100mcg epi, 10mcg fentanyl & 150mcg duramorph at my training program
To reiterate what everyone has already been saying we use 1.6cc of .75% bupi with 200mcg of duramorph (+/- 20mcg of fentanyl depending on the attending). Several attendings I have worked with say the fentanyl does nothing but add pruritis.
If you don't trust the epidural to load for the section and pull it in favor of single shot spinal?Typically, I don't add fentanyl. Haven't needed it and they start to itch during the c/s when it's added. No itching with just morphine until later. Fentanyl may add some visceral component but I don't think it is reproducable enough to consider using it.
But if a pt comes for c/s that had an epidural running and maybe hit the PCEA button a coup,e of times or got a bolus then I will cut the Bupiv from 1.6cc to 1.2 and add 20mcg of Fent.
Oh yeah, I should have my mentioned that I don't use the epidurals. I always pull them.If you don't trust the epidural to load for the section and pull it in favor of single shot spinal?
I think I'm going to start leaning this way more if there is any chance that epidural isn't golden. It's pretty easy to pull it and bang in a spinal vs loading a questionable epidural where you have now burned some bridges potentially.
100mcg of epi is a huge dose and it might produce longer anesthesia by causing cord ischemia!We typically do 100mcg epi, 10mcg fentanyl & 150mcg duramorph at my training program
Oh yeah, I should have my mentioned that I don't use the epidurals. I always pull them.
100mcg of epi is a huge dose and it might produce longer anesthesia by causing cord ischemia!
Think about it: your typical premixed Bupivacaine with epi commercial solution is usually 1/200,000 epinephrine which translates into 100mg/200,000 ml ---> 5mcg/ml
You are basically giving an epinephrine solution that is 20 times more concentrated!
Did some one actually teach you to use that concentration or is it a typo?
You pull out the epidural and give a normal dose of spinal for a C/S? A good working epidural is more than adequate for a C/S. If you do that every time, have you ever had a high spinal? If you did that and patient ended up with a high spinal, intubated in the ICU, you'd be buried by any attorney and a long line of "expert" witnesses who would say that is bad practice (no offense).
100mcg of epi is a huge dose and it might produce longer anesthesia by causing cord ischemia!
Think about it: your typical premixed Bupivacaine with epi commercial solution is usually 1/200,000 epinephrine which translates into 100mg/200,000 ml ---> 5mcg/ml
You are basically giving an epinephrine solution that is 20 times more concentrated!
Did some one actually teach you to use that concentration or is it a typo?
100mcg of epi is a huge dose and it might produce longer anesthesia by causing cord ischemia!
Think about it: your typical premixed Bupivacaine with epi commercial solution is usually 1/200,000 epinephrine which translates into 100mg/200,000 ml ---> 5mcg/ml
You are basically giving an epinephrine solution that is 20 times more concentrated!
Did some one actually teach you to use that concentration or is it a typo?
Really? Unless an epidural is working GREAT, I pull it and do a spinal.
As a fresh attending this is something I still struggle with (deciding to pull the epidural or bolus it up for section). I'm having a hard time determining what constitutes a great block vs an ok block. If it's been in 6 hours and you have had no calls and the pt appears comfortable? Demonstrable dermatomal block (not always consistent or easily identifitable with a weak infusate running)? Good initial analgesic effect when you placed it?
Lots of gray areas I feel like. Seems like if time allows just pulling it and doing a spinal is less risky often.
Really? Unless an epidural is working GREAT, I pull it and do a spinal. Anything other than a perfect epidural and you end up telling the patient that it's pressure, not pain that you are feeling for the entire case. Epidurals SUCK for c-sections in many instances. Spinals don't. If the epidural is iffy, I pull it and do a spinal with a 0.8-1.0 ml dose of hyperbaric bupivicaine. Personal incidence of high spinal from it is zero, though I have a low threshold for putting the patient in reverse T-berg if the level is coming up fast.
I'd bet that if you tend to use most epidurals for c-sections, you have a higher incidence of having to convert to GA than the incidence of high spinals from doing a low dose spinal in a patient with a previously running epidural.
We have quite a few "FTP" and urgent C/S on laboring patients with epidurals. It is not very often any of us have had to convert to GETA with an epidural. A few times I've replaced an epidural for a patient who needs a C/S that can wait for a new one and it's worked well for me. We do about 3000 deliveries a year so I am not at some po dunk community hospital that sees 20 a month.
Sorry if I struck a bad nerve. My Attending always trained us not to do a spinal after an epidural. If you have perfect success with it, more power to you. I also don't like the idea of pulling out an adequate epidural and doing an extra, unnecessary (IMO, not yours obviously) procedure on the patient. I've never tried to do a spinal after epidural so maybe I'm the ignorant one, just how I was trained I suppose.
I know it "isn't very often" you have to convert to GA. You can usually get by with Midazolam and Fentanyl and Nitrous and Ketamine and any other number of things people use on half working epidurals half way through a c-section.
That's why I said I've never had to intubate a patient I put a spinal in after an epidural. Zero. Out of hundreds or perhaps thousands of times I've done it. I don't put in a full normal dose as that'd just be stupid. Only takes a little to get their current block denser.
The only thing that strikes a nerve with me is trying to get by with an epidural that isn't perfect. The patient suffers and we try to tell them "it's OK, it's just pressure" while they are writhing in pain. I'd much rather take the 30 seconds to put the spinal in and then they have a perfect experience with no IV sedation needed. I'm sorry you never learned how to do that. It's quite safe and like I said I think fewer patients get intubated after a spinal than not doing the spinal and trying to get by with the epidural.
Easy big fella.You pull out the epidural and give a normal dose of spinal for a C/S? A good working epidural is more than adequate for a C/S. If you do that every time, have you ever had a high spinal? If you did that and patient ended up with a high spinal, intubated in the ICU, you'd be buried by any attorney and a long line of "expert" witnesses who would say that is bad practice (no offense).
In terms of the epi, I agree with Plankton. That's a big, whopping dose when there is no real added benefit of epi to marcaine.
You started this debate.Ok, the holiness and God of anesthesia has spoken. I have no defense for that. Man, I really suck for using our half working epidurals. I always thought them screaming in pain was just being a whiny, pregnant patient. You've enlightened me in so many ways, THANK YOU!
Ok, the holiness and God of anesthesia has spoken. I have no defense for that. Man, I really suck for using our half working epidurals. I always thought them screaming in pain was just being a whiny, pregnant patient. You've enlightened me in so many ways, THANK YOU!
Let's say you think you have a good epidural and go ahead and dose it up for C/S but fail to get an adequate level or it ends up patchy, or whatever. Would you still go ahead with a spinal after a fresh epidural bolus or do you consider the risk of a high block too great at that point? I ask bc this happened to a partner of mine recently who went ahead with an SAB after a failed epidural bolus. He ended up with an unconscious pt for about 10 min.
Since I've been out of training I've really contemplated switching to Noy's approach, but just haven't had any epidurals fail to be plenty adequate for a C/S yet so I haven't been able to justify the extra step in my head. I definitely agree though that an SAB is a superior block for a C/S.
Mman,
I agree with your approach to using epidural for CS in general. Though it seems like you have a low threshold to pull one if it's iffy, i.e., you don't want to deal with or don't feel it's appropriate to do the "pain vs pressure" dance. Which is really just, awful.
What do you do about dosing intrathecal morphine? You didn't mention it in your spinal dose.
Yep, all the OB faculty use it at my program. We've never had problems with it100mcg of epi is a huge dose and it might produce longer anesthesia by causing cord ischemia!
Think about it: your typical premixed Bupivacaine with epi commercial solution is usually 1/200,000 epinephrine which translates into 100mg/200,000 ml ---> 5mcg/ml
You are basically giving an epinephrine solution that is 20 times more concentrated!
Did some one actually teach you to use that concentration or is it a typo?
Makes you wonder if the enhanced anesthesia is not actually caused by spinal cord ischemia!Yep, all the OB faculty use it at my program. We've never had problems with it
You would take a FTP pt and make her wait 4-6 hrs to have a spinal? That is insanity in my opinion and I'm sure in the pts and OBs opinions as well. Please explain this line of reasoning?To answer the question regarding failed epidural and proceeding with spinal. First it would depend on the status of baby and m0m. If the section was urgent IE fetal bradycardia, fetal distress. I would proceed with general anesthesia after failed bolus of epiduiral. If the section was due to failure to progress I would wait 4-6 hrs and pull the epidural catheter and redose with a spinal. How about the other way what if you had a failed spinal(bad bupi) would you place an epidural and proceed? Or straight to general anesthesia?
If the section was due to failure to progress I would wait 4-6 hrs and pull the epidural catheter and redose with a spinal.
Spinal after epidural is tricky. You have to be cognizant of the EVE effect IE epidural volume expansion and reduce the dose of bupi to 1.2ml of .75% bupivicaine.
Not tricky from a tactical standpoint more so that you have to be aware the EVE effect. How compressed is the intrathecal sac from the full bolus of lidocaine? How much CSF has been spread cephalad? I have seen a handful of these cases in training, these patients often required greater vasopressor support. Placing a spinal in a patient without an expanded epidural space is different then placing a spinal with and expanded epidural space.
Makes you wonder if the enhanced anesthesia is not actually caused by spinal cord ischemia!
100mcg of epi is a huge dose and it might produce longer anesthesia by causing cord ischemia!
Think about it: your typical premixed Bupivacaine with epi commercial solution is usually 1/200,000 epinephrine which translates into 100mg/200,000 ml ---> 5mcg/ml
You are basically giving an epinephrine solution that is 20 times more concentrated!
Did some one actually teach you to use that concentration or is it a typo?
All this is fantastic and sounds great but unfortunately we still don't really know what exactly happens when you add epinephrine to local anesthetics intrathecally, and we don't know how it spreads or where it acts.Very different applied pharmacology. 100 mcg is a completely appropriate intrathecal dose and is well within published guidelines. Bridenbaugh recommends 200 mcg in his Neural Blockade text.
When you administer Lido + Epi 1:100,000 (10mcg/mL) or Bupi+ Epi 1:200,000 (5mcg/mL), you are either testing for IV placement, in which case a small dose of dilute epi is optimal, or you are applying it to an enclosed, nerve containing space with only the local anesthetic volume as the diluent. Your typical 30cc bupivacaine block would contain 150 mcg of epinephrine bathing the nerves in a very confined area. (Ok, there is also infiltration, but I think we can ignore that for this discussion)
Epinephrine administered intrathecally, spreads rapidly throughout the spinal portion of the csf, much like the lipophillic opiods. Typical adult total CSF volumes range from 120-150mL with 25-35mL of that volume being in the spinal portion of the CSF. Pregnant and obese individuals occupy the lower end of the spectrum. So, your 100mcg of epinephrine is being diluted in 25 mL of CSF for a final concentration of 4mcg/mL. This is comparable to the 5-10 mcg/mL concentration used in peripheral nerve block.
In addition to prolonging the block due to reduced clearance (vasoconstriction or decreased metabolism?), epinephrine has intrinsic anesthetic action through alpha-2 agonism, and may carry some of the local anesthetic with it as it spreads higher in the spinal column. The alpha-2 agonism and higher spread may explain the nausea someone mentioned in this thread.
Although spinal cord ischemia has long been brought up as a concern, to date there is little evidence to support the concern. Animal studies show blood flow reduction from intrathecal epinephrine is primarily and preferentially in the dura, as opposed to the cord itself. There are reductions in spinal cord blood flow when bupivacaine and epi are administered, but this is likely explained by decreased metabolic activity resulting in decreased demand for blood flow. Epinephrine added to a low-dose bupi spinal reduces the spinal cord blood flow to a greater magnitude than epinephrine added to a higher-dose bupi spinal. This supports the supposition that the reduction in blood flow results from decreased metabolic activity instead of direct vasoconstriction.
- pod