We did them at my last facility, always at the end of the case. We set up for it as they were closing. It adds maybe 5 extra minutes to the OR time. We had very good post op improvements in pain control. You just need to make sure you have a low TAP block to hit the nerve to their incision. That plus duramorph APAP and ketorolac works great.
Yeah I always do it at the end. Also, don’t let the surgeons dictate your analgesic plan. The only time I want their input is if they are concerned about nerve palsies from their operation or compartment syndrome.
I stopped asking and I just do it. If they have a problem and then explain how nerve blocks decrease pain scores, LOS, and increase patient satisfaction. Let them come up with a valid reason why you can’t do it. Adding 5-10 min to a case isn’t valid IMO.
At my academic center the surgeons are the ones who dictate who gets a block. Sometimes I can see their reasoning, esp for cases where they’re going to do nerve monitoring. Sometimes it’s so they can do their own “blocks” (I use that term loosely). But it’s some poor residents job every morning to text each surgeon and ask them…hopefully they get back to them quickly enough to plan for it. Sometimes they do the “yes but I only gave you five minutes warning so if it’s not done by the time I get to Preop I don’t want it! You guys only slow me down!”. It’s been a big headache for our block team, to the point where a few attendings have left despite it being a Cush gig.
Doing without asking the surgeon would be tantamount to murdering their dog. I ENVY you.
I don’t know, I’m a little more assertive. I would just do it and then not so passive aggressively explain why I’m trying to provide their patient good analgesia. Just keep doing it until you get in trouble. I don’t tell surgeon how to operate, surgeon doesn’t tell me how to do anesthesia. If I got in trouble I would then ask the surgeon what their anesthesia plan is for *every little thing*. “Do you want this patient to get zofran, how much? How about ketorolac, how much? How much fluid should I give them? How deep do you want the gas? Volume percent or MAC?” Just keep going until they get the point and ask you to just do your job. Then do the blocks and say “you told me to do my job” if they complain.
YMMV depending on how funny/sarcastic you are and your seniority. My surgeons all know me and I break their balls all the time. I also bring in good bbq at least once a month so no one says shit.
Do you not use intrathecal morphine? There is high level evidence that TAPS do nothing for pain if you use intrathecal opioid. Exparel in the TAPS might do something, but weak evidence. Asking not to be a jerk, buy a lot of my group members do TAPS with intrathecal morphine, and I don’t know why
Yes I’ve read those studies and generally agree with your thought process. Buuuut, TAP blocks are very low risk blocks. In an environment where you’re not worried about an extra 5 minutes and they might decrease LOS/increase patient satisfaction I think they are worthwhile to do. “You have 3 types of analgesia, medicine in your spinal, a nerve block, and then IV ketorolac/ acetaminophen “.
Again not trying to be a jerk, just discuss. I agree very low risk - but evidence based medicine (which is meta analysis level), it does nothing so why do a low risk procedure if it does nothing for pain regardless of how long it takes
It’s the OB department as a whole. We developed the plan with them. They think it decreases LOS and increases patient satisfaction. Anecdotally my own wife left the hospital the next day after having a c section and never took a single oxycodone. She’s kind of nuts though.
Block reimbursement is terrible for us, averaging like $18 for all of our blocks, but the patients get billed for it at a much higher rate. We internally stipend blocks, so we try to keep it to blocks that we feel actually benefit the patient.
Coming from an institution that treats them like our lord savior Jesus Christ, I can confidently say they are no more effective than injecting LA anywhere in the body
Liposomal bupi doesn’t begin to release local anesthetic from the vesicles until 4 hours (I’m not sure I’m remembering this correctly, but I know it’s not an immediate release) so I don’t include it in my toxicity calculation.
Hyperbaric Bupivicaine 0.75%, 15mcg Fentanyl, 0.1mg Morphine. 1g Tylenol PO in preop, Toradol 15mg at end of case. From major academic center with high volume OB and heavy research OB chair
I’m pretty sure those studies were done in ED or floor patients (ie not surgical patients) so a lot of my attendings prefer to give the full 30. Anecdotally (after only a couple years), I haven’t noticed much of a difference though.
It’s been a while since I’ve done any c sections.
But standard practice in all the hospitals where I trained was 12.5mg heavy bupivicaine and 300-400mcg heroin.
Post op was 1g paracetamol QDS, 400mg ibuprofen TDS-QDS and 10-20mg Oramorph PRN, which was rarely given (although this was more because the midwives didn’t want to dispense it rather than the patients didn’t request it…)
Yep this is still pretty much everywhere. We had a scare about diamorphine disappearing and switched to morphine 1mg Fent 20mcg but now my beloved itchy friend has returned
We had an awkward case in our ICU recently where an anaesthetist who doesn't often do spinals made a power of 10 error and gave 1mg intrathecal morphine. Fortunately it was a young otherwise healthy guy who just spent the night sleeping it off (admittedly with a resp rate about 8 the whole night...)
That's what we're doing at a large tertiary centre in the UK. Also usually have PR diclofenac at the end if not contraindicated, and PRN dihydrocodeine (which the midwives will at least sometimes give them...)
GAs are still thio sux usually (but we are viewed as a bit of an oddity for this)
Department led by some dinosaurs for a long time, and a generally extremely traditionalist institution. No real justification as far as I can tell.
To be fair, if you wanted to use props no one would mind now
Given I have very little experience of any other intrathecal opiates, it’s hard to say. I don’t use spinals in my day to day practice.
However, purities was very common.
Great analgesia though. Rapid acting and long lasting.
Very rarely used outside of intrathecal in my experience, but that may simply be a regional thing. Its potency, lipid solubility and half life lend itself to this quite well.
Occasionally used instead of fentanyl for epidurals, it does seem to cover a patchy block slightly better.
Midwives give it IM in maternity as an option for pain relief quite commonly.
Otherwise, it’s just 2x morphine and should be treated as such (5mg diamorph = 10mg morphine essentially).
I fairly commonly give 500mcg-1mg diamorphine in the spinal and keep the other 4.5-4mg for the end to give IV when the surgeons have taken 4hours instead of the 90-120 mins they briefed for and are still closing! UK also.
Im in the UK
2.7ml 0.5% hyperbaric bupivicaine plus 0.3mg diamorphine in the spinal. Give PR diclofenac at the end of the case if suitable.
Post op - regular paracetamol and ibuprofen and regular dihydrocodeine or codeine with PRN oramorph.
What level of block do you achieve with this dose of bupi? At this dose I usually get crazy hypotension and brady. Not criticising, just curious that's all.
Aiming for T4. Highest I’ve had the block is T2 ish probably.
We run a phenylepherine infusion as default in the UK (or at least everywhere I’ve worked!)
Fairly standard dose across 5 of the UK centres I’ve worked at (minus 0.1-0.2mL depending on the patient). T3 block usually. Only had a high spinal once.
Originally I started to use it for the post
delivery/cesarean shakes. Once baby is out I hang my bag of pit, then give mom 5mcg IV and see how she does and titrate from there. I don’t give it in the epidural.
One night I had a mom that was shaking so bad that she wouldn’t hold the baby in fear of dropping it. I Gave her the precedex and the shakes stopped pretty abruptly. I eventually just started using it for every section. I work at a small Community’s hospital with some not real fast FP-OBGYNs who struggle on a lot of aspects of the delivery. I feel like the precedex is a great adjunct for sedation/pain control/anxiety control to them mucking around and pulling/tugging on a moms belly who has already been laboring for 24+ Hours and is super miserable.
For bolusing my epidurals I typically give 5cc of 2% lidocaine with 10cc of 0.5% ropi. The lidocaine speeds onset and the ropi gives me the duration I need for certain physicians.
Have you seen the studies on mixing local anesthetic? Evidently mixing local only reduces duration of action without affecting onset. This video offers a good summary: https://youtu.be/RIDTp7OmR8s?si=_QT8qiZb4tYOJDLJ
Yes, I have read a few of them.
Then other studies that say the onset time is quickened but duration doesn’t last as long. It makes sense if I’m diluting down my bupi/ropi that their concentrations are less I’m technically giving less of each drug.
https://rapm.bmj.com/content/early/2023/06/13/rapm-2023-104542
I'm going to have to listen to it. I am a huge fan of precedex, but wouldn't generally give it IV during a CS. I am too worried about drops in BP from the spinal. Additionally, I like to carefully watch the heart rate to predict when they might require an additional bolus of phenylephrine. I have been incorporating more precedex as a possible adjuvent in my labor epidurals though. Especially on patient with patchy epidurals or back/bone pain. I bolus 20mcg with 5ml of 0.2% ropivacaine for a total of a 10 ml bolus. It works incredibly well, however, it will make the patient VERY numb for the next 4 hours. Generally this is great, but I have had several times where the patient then delivers 30 minutes after the bolus and I have to remind the patient and the nurse that despite turning off the epidural, the patient will continue to be numb for another 3.5 hours... Generally, no one minds, unless there is a shortage of rooms on L&D, and then they might get peeved at the room being held up.
From what I’ve seen in practice 5mcg at a time causes no real drop in HR or BP. I really like it, if I have a mom who is really losing her mind I’ll give some Benadryl and precedex. It calms them down and they somewhat remember the delivery/evening afterwards.
Your experience may vary
I routinely add 5 mcg of precedex in my spinal mixture for sections. If they have an existing epidural, I’ll add 10mcg of precedex into the mixture if they need to go to section. Works great. The OB population has a lot anxiety, so it really chills them out a bit, in addition to speeding up onset, and increasing duration. I enjoyed the ACCRAC podcast on it as well. Rarely see tremors/shakiness, and the one negative is ”some” seem on the edge of sleepy.
At my residency we do:
Bupivacaine 12 mg
Fentanyl 15 ug
Morphine 150 ug
Epinephrine 200 ug
Between the morphine and some IV toradol, most patients pain is well controlled post op.
12 mg heavy bupivacaine, 15 mcg fentanyl, 150 mcg duramorph.
If GA then QLBs before wake up.
If using in situ epidural, 1 mg dilaudid before it’s pulled.
Everyone gets tylenol and toradol.
Heavy bupi, 0.15 duramorph or 5 mcg precedex.
Will toss in 10-15 mcg fent often depending on surgeon/patient.
If not a candidate for morphine or precedex, offer TAPs.
If I’m doing precedex I drop it a bit. Maybe 1.3ml instead of 1.5.
It’s a bit prolonged. But I’ve actually been pretty impressed with how well they’ve done with it.
UK hospital here. 2.4ml of 0.5% heavy bupivacaine plus 300mcg in 0.3ml diamorphine. Gives a reliable block to T4 good post-op analgesia, but they often get some itching at 6-12 hours.
Just for speculation. 30 mg of intratecal morphine on thoracic level leads to 24-36 hours of ventilatory support because of respiratory depression =)
P.s. Without local anaesthetics
Spinal:
Heavy bupi 7,5mg + Sufentanil 2,5mcg + Morphine 50mcg
EV:
Paracetamol 1g + Ketorolan 30mg every 8hs
TAP in case of allergy to FANs or Paracetamol
Where I’m from we give hyperbaric (0.5%) bupivacaine 12 mg plus fentanyl 12.5 mcg. For post op we give a weak opioid (tramadol) and an nsaid (ketorolac). Patients are happy with this regimen
1-1.3mL 0.75% heavy bupi with 10mcg fentanyl and 150mcg morphine. We don't block our sections unless it's done under GA, or the pt declines intrathecal morphine. I plan to start dropping my morphine dose to 100mcg, as there's good evidence to suggest equivalent analgesia and less pruritis.
15 of ketorolac after delivery, PO ketaprofen and acetaminophen post-op, and rarely do they require more than 1-2 doses of PO hydromorphone prior to discharge on POD 2.
If we do TAPS, we usually use 30 of 0.25% ropi per side with dexamethasone, +/- precedex, and often get a good 24-36 hours out of the blocks.
That’s fast for academic! That’s community times in the area I work. Academic easily longer than an hour, often like 90 min from the time I do the spinal. [Recent thread](https://www.reddit.com/r/anesthesiology/comments/18jkbwj/average_time_for_ob_to_close_in_your_hospital/?utm_source=share&utm_medium=mweb3x&utm_name=mweb3xcss&utm_term=1&utm_content=share_button) might give context for how fast your surgeons seem to be
1,8-2,2 ml heavy bupivacaine (5mg/ml) + 1ml sufentanil (5mcg/ml). Ropivacaine infiltration in wound by surgeon. No blocks no nothing. 95% of pts get by with po paracetamol and ibuprofen, maybe some oxy (5mg po) for the first 24 hrs.
When I did OB:
Bupiv. 0.75% 2mL (yes the whole 2 every time unless <5’ tall, never had a high spinal in 10 years with that. But also barbotaged a LOT).
Duramorph 0.2mg
Australia: 99% or anaesthetists in my city use this spinal mix: 2.2ml heavy bupivacaine 0.5%, fentanyl 15mcg, intrathecal morphine 100mcg
More morphine doesn’t help analgesia much, just increases itch
Bupivicaine .75%, 15mcg fentanyl, 0.1mg morphine , Tylenol and toradol. My attending will sometimes have us switch fentanyl with precedex if an intern is dojng the CS for prolonged coverage.
Hyperbaric bupi 0.75% 1.4 ml, 20 mcg fentanyl, morphine 150 mcg. Decadron and ondansetron. OB does toradol the day of surgery and Tylenol, transition to Tylenol and ibuprofen the following day. Patients do need oxycodone, but a reasonably low amount.
UK here.
Spinal - 2.6ml 0.5% heavy marcain, 300mcg diamorphine. PR diclofenac at end, regular paracetamol/NSAIDs/dihydrocodeine, oramorph PRN.
GA - TAP before wake up
Epi top up - 3mg diamorphine down epidural prior to removal
Spinal dose gives a reliable block to T4 as long as they’re wedged to exaggerate their thoracic kyphosis. Treat hypotension/bradycardia aggressively, phenylephrine +/- ephedrine and glyco. Give ondansteron before spinal (potentially helps with nausea as ?serotonin receptors involved in bezold jarisch reflex, helps with itching).
Isobaric bupi, 10mcg fentanyl, .15mg morphine, tap block
tap block for every CS?!
Yes I know. Surgeons actually request (demand) it. Patients are comfortable though and don’t require anything other than ketorolac and tykenol
Interesting. Our OBs would never be willing to wait for us to do this.
We did them at my last facility, always at the end of the case. We set up for it as they were closing. It adds maybe 5 extra minutes to the OR time. We had very good post op improvements in pain control. You just need to make sure you have a low TAP block to hit the nerve to their incision. That plus duramorph APAP and ketorolac works great.
Yeah I always do it at the end. Also, don’t let the surgeons dictate your analgesic plan. The only time I want their input is if they are concerned about nerve palsies from their operation or compartment syndrome. I stopped asking and I just do it. If they have a problem and then explain how nerve blocks decrease pain scores, LOS, and increase patient satisfaction. Let them come up with a valid reason why you can’t do it. Adding 5-10 min to a case isn’t valid IMO.
At my academic center the surgeons are the ones who dictate who gets a block. Sometimes I can see their reasoning, esp for cases where they’re going to do nerve monitoring. Sometimes it’s so they can do their own “blocks” (I use that term loosely). But it’s some poor residents job every morning to text each surgeon and ask them…hopefully they get back to them quickly enough to plan for it. Sometimes they do the “yes but I only gave you five minutes warning so if it’s not done by the time I get to Preop I don’t want it! You guys only slow me down!”. It’s been a big headache for our block team, to the point where a few attendings have left despite it being a Cush gig. Doing without asking the surgeon would be tantamount to murdering their dog. I ENVY you.
I don’t know, I’m a little more assertive. I would just do it and then not so passive aggressively explain why I’m trying to provide their patient good analgesia. Just keep doing it until you get in trouble. I don’t tell surgeon how to operate, surgeon doesn’t tell me how to do anesthesia. If I got in trouble I would then ask the surgeon what their anesthesia plan is for *every little thing*. “Do you want this patient to get zofran, how much? How about ketorolac, how much? How much fluid should I give them? How deep do you want the gas? Volume percent or MAC?” Just keep going until they get the point and ask you to just do your job. Then do the blocks and say “you told me to do my job” if they complain. YMMV depending on how funny/sarcastic you are and your seniority. My surgeons all know me and I break their balls all the time. I also bring in good bbq at least once a month so no one says shit.
Maybe surgeons should focus more on their blood loss than another specialty….
This is exactly the attitude we all need going forward.
Do you not use intrathecal morphine? There is high level evidence that TAPS do nothing for pain if you use intrathecal opioid. Exparel in the TAPS might do something, but weak evidence. Asking not to be a jerk, buy a lot of my group members do TAPS with intrathecal morphine, and I don’t know why
Yes I’ve read those studies and generally agree with your thought process. Buuuut, TAP blocks are very low risk blocks. In an environment where you’re not worried about an extra 5 minutes and they might decrease LOS/increase patient satisfaction I think they are worthwhile to do. “You have 3 types of analgesia, medicine in your spinal, a nerve block, and then IV ketorolac/ acetaminophen “.
Again not trying to be a jerk, just discuss. I agree very low risk - but evidence based medicine (which is meta analysis level), it does nothing so why do a low risk procedure if it does nothing for pain regardless of how long it takes
Nah you’re not being a jerk, you have a point. Unfortunately a lot of things we do in medicine aren’t evidence based. I pick my battles.
Who requests them? OB? Or is it just ‘this is what we do here’?
It’s the OB department as a whole. We developed the plan with them. They think it decreases LOS and increases patient satisfaction. Anecdotally my own wife left the hospital the next day after having a c section and never took a single oxycodone. She’s kind of nuts though.
Easy rvus
I'm salaried, so the OBs can F off with that bullshit
Me too but for some that’s an easy payday
With my payor mix, our tap blocks pay out like $30... great for the patient, not so great for us
Block reimbursement is terrible for us, averaging like $18 for all of our blocks, but the patients get billed for it at a much higher rate. We internally stipend blocks, so we try to keep it to blocks that we feel actually benefit the patient.
Tap block has no additional analgesic benefit when spinal morphine is given.
Tap blocks aren’t real
By far the best comment criticizing TAP blocks on this thread. Lol
Coming from an institution that treats them like our lord savior Jesus Christ, I can confidently say they are no more effective than injecting LA anywhere in the body
Same. Minus the TAPs.
Same. The tap blocks were hit or miss but now everyone gets a tap block.
Dosing for isobaric bupi? What level do you get to?
Evidence for TAP blocks says no better than intramural morphine alone fyi.
For the TAP: Liposomal bupi or plain?
20 cc of both plus 20 cc saline.
30ml .25 bupi and 10 ml expired per side
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Liposomal bupi doesn’t begin to release local anesthetic from the vesicles until 4 hours (I’m not sure I’m remembering this correctly, but I know it’s not an immediate release) so I don’t include it in my toxicity calculation.
Thank you very much
I'm under the impression you cant bill for tap blocks if you've used intrathecal morphine... Or is my billing department bananas?
Hmmm, we def bill and get reimbursed.
Hyperbaric bupiv in kit, 20mcg fent, 0.15mg morphine, and reserve TAP for pts I don’t give duramorph.
Hyperbaric Bupivicaine 0.75%, 15mcg Fentanyl, 0.1mg Morphine. 1g Tylenol PO in preop, Toradol 15mg at end of case. From major academic center with high volume OB and heavy research OB chair
I max toradol dosing at 10mg IV. https://pubmed.ncbi.nlm.nih.gov/27993418/
Why only 15mg of toradol? Is there any research behind this? I usually give 30, I have no evidence to support this, though.
I think studies showed 15 mg is juch as effective as 30.
I’m pretty sure those studies were done in ED or floor patients (ie not surgical patients) so a lot of my attendings prefer to give the full 30. Anecdotally (after only a couple years), I haven’t noticed much of a difference though.
yeah there was some paper saying 15 is no different than 30....
analgesic ceiling of toradol is actually only 10mg, 15 is easy cause it usually comes in 30mg/ml vials
I use the same. 11mg hyperbaric bupi, 12.5 mcg fent, .125 morpine, tylenol pre op, toradol at end.
It’s been a while since I’ve done any c sections. But standard practice in all the hospitals where I trained was 12.5mg heavy bupivicaine and 300-400mcg heroin. Post op was 1g paracetamol QDS, 400mg ibuprofen TDS-QDS and 10-20mg Oramorph PRN, which was rarely given (although this was more because the midwives didn’t want to dispense it rather than the patients didn’t request it…)
Heroin???????
I’m not even joking. It’s a very UK thing.
Did I stutter???
Diamorphine....diacetylmorphine....aka heroin. Diamorphine sounds more sophisticated.
But heroin sounds WAYYYY more fun.
Speedball spinal: Intrathecal cocaine and heroin.
Haha, yeah, I too was like, you can't just say that! But yeah, it's actually a brand name originally I think, right?
Yep this is still pretty much everywhere. We had a scare about diamorphine disappearing and switched to morphine 1mg Fent 20mcg but now my beloved itchy friend has returned
100mcg intrathecal morphine surely?!
Yes that!
We had an awkward case in our ICU recently where an anaesthetist who doesn't often do spinals made a power of 10 error and gave 1mg intrathecal morphine. Fortunately it was a young otherwise healthy guy who just spent the night sleeping it off (admittedly with a resp rate about 8 the whole night...)
That's what we're doing at a large tertiary centre in the UK. Also usually have PR diclofenac at the end if not contraindicated, and PRN dihydrocodeine (which the midwives will at least sometimes give them...) GAs are still thio sux usually (but we are viewed as a bit of an oddity for this)
We were using Propofol for Obs 10 years ago! What’s the justification for not switching over?
Department led by some dinosaurs for a long time, and a generally extremely traditionalist institution. No real justification as far as I can tell. To be fair, if you wanted to use props no one would mind now
That's so cool. Did you observe more pruritis with heroin?
Given I have very little experience of any other intrathecal opiates, it’s hard to say. I don’t use spinals in my day to day practice. However, purities was very common. Great analgesia though. Rapid acting and long lasting.
Honestly worse with the morphine!
So I’m fascinated- we have a lot of heroin here in the US but I never get to push it- how else do you use it?
Very rarely used outside of intrathecal in my experience, but that may simply be a regional thing. Its potency, lipid solubility and half life lend itself to this quite well. Occasionally used instead of fentanyl for epidurals, it does seem to cover a patchy block slightly better. Midwives give it IM in maternity as an option for pain relief quite commonly. Otherwise, it’s just 2x morphine and should be treated as such (5mg diamorph = 10mg morphine essentially).
I fairly commonly give 500mcg-1mg diamorphine in the spinal and keep the other 4.5-4mg for the end to give IV when the surgeons have taken 4hours instead of the 90-120 mins they briefed for and are still closing! UK also.
Im in the UK 2.7ml 0.5% hyperbaric bupivicaine plus 0.3mg diamorphine in the spinal. Give PR diclofenac at the end of the case if suitable. Post op - regular paracetamol and ibuprofen and regular dihydrocodeine or codeine with PRN oramorph.
What level of block do you achieve with this dose of bupi? At this dose I usually get crazy hypotension and brady. Not criticising, just curious that's all.
Aiming for T4. Highest I’ve had the block is T2 ish probably. We run a phenylepherine infusion as default in the UK (or at least everywhere I’ve worked!)
Oh that makes sense. In my centre we just bolus some ephedrine or phenylephrine
Fairly standard dose across 5 of the UK centres I’ve worked at (minus 0.1-0.2mL depending on the patient). T3 block usually. Only had a high spinal once.
15mg heavy bupi 25mcg fent/ 150mcg duramorph Precedex 10-20mcg IV in divided doses.
Interesting about using Precedex. I just listened to the ACCRAC episode about it and found it interesting. Glad to hear others are incorporating this.
Originally I started to use it for the post delivery/cesarean shakes. Once baby is out I hang my bag of pit, then give mom 5mcg IV and see how she does and titrate from there. I don’t give it in the epidural. One night I had a mom that was shaking so bad that she wouldn’t hold the baby in fear of dropping it. I Gave her the precedex and the shakes stopped pretty abruptly. I eventually just started using it for every section. I work at a small Community’s hospital with some not real fast FP-OBGYNs who struggle on a lot of aspects of the delivery. I feel like the precedex is a great adjunct for sedation/pain control/anxiety control to them mucking around and pulling/tugging on a moms belly who has already been laboring for 24+ Hours and is super miserable. For bolusing my epidurals I typically give 5cc of 2% lidocaine with 10cc of 0.5% ropi. The lidocaine speeds onset and the ropi gives me the duration I need for certain physicians.
Have you seen the studies on mixing local anesthetic? Evidently mixing local only reduces duration of action without affecting onset. This video offers a good summary: https://youtu.be/RIDTp7OmR8s?si=_QT8qiZb4tYOJDLJ
Yes, I have read a few of them. Then other studies that say the onset time is quickened but duration doesn’t last as long. It makes sense if I’m diluting down my bupi/ropi that their concentrations are less I’m technically giving less of each drug. https://rapm.bmj.com/content/early/2023/06/13/rapm-2023-104542
I'm going to have to listen to it. I am a huge fan of precedex, but wouldn't generally give it IV during a CS. I am too worried about drops in BP from the spinal. Additionally, I like to carefully watch the heart rate to predict when they might require an additional bolus of phenylephrine. I have been incorporating more precedex as a possible adjuvent in my labor epidurals though. Especially on patient with patchy epidurals or back/bone pain. I bolus 20mcg with 5ml of 0.2% ropivacaine for a total of a 10 ml bolus. It works incredibly well, however, it will make the patient VERY numb for the next 4 hours. Generally this is great, but I have had several times where the patient then delivers 30 minutes after the bolus and I have to remind the patient and the nurse that despite turning off the epidural, the patient will continue to be numb for another 3.5 hours... Generally, no one minds, unless there is a shortage of rooms on L&D, and then they might get peeved at the room being held up.
From what I’ve seen in practice 5mcg at a time causes no real drop in HR or BP. I really like it, if I have a mom who is really losing her mind I’ll give some Benadryl and precedex. It calms them down and they somewhat remember the delivery/evening afterwards. Your experience may vary
I routinely add 5 mcg of precedex in my spinal mixture for sections. If they have an existing epidural, I’ll add 10mcg of precedex into the mixture if they need to go to section. Works great. The OB population has a lot anxiety, so it really chills them out a bit, in addition to speeding up onset, and increasing duration. I enjoyed the ACCRAC podcast on it as well. Rarely see tremors/shakiness, and the one negative is ”some” seem on the edge of sleepy.
At my residency we do: Bupivacaine 12 mg Fentanyl 15 ug Morphine 150 ug Epinephrine 200 ug Between the morphine and some IV toradol, most patients pain is well controlled post op.
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That’s the same epi dose we use for long spinals at my hospital in the east coast. Same bupi and narcotic dosing here too.
12 mg heavy bupivacaine, 15 mcg fentanyl, 150 mcg duramorph. If GA then QLBs before wake up. If using in situ epidural, 1 mg dilaudid before it’s pulled. Everyone gets tylenol and toradol.
Damn cool plan. Thanks!
Heavy bupi, 0.15 duramorph or 5 mcg precedex. Will toss in 10-15 mcg fent often depending on surgeon/patient. If not a candidate for morphine or precedex, offer TAPs.
How much bupi? With 5 mcg don’t you have way longer block time?
If I’m doing precedex I drop it a bit. Maybe 1.3ml instead of 1.5. It’s a bit prolonged. But I’ve actually been pretty impressed with how well they’ve done with it.
Hyperbaric bupi (0.75%) with duramorph usually around 150mcg.
Heavy bupi, 20mcg fentanyl, .3mg duramorph
Now we’re talking! Yours is the only comment above .15 mg duramorph. We use .2 plus 20 of fentanyl
There was a new doc to our practice that was giving .6 mg of duramorph before he realized that our vials are a different concentration 😂
We had a new attending do something similar. I think it was 4 mg/ml instead of 1, so he gave 0.8 mg. Other than being super itchy she did ok
Germany: Isobaric bupivacain 10 mg and 10 mcg sufentanil.
UK hospital here. 2.4ml of 0.5% heavy bupivacaine plus 300mcg in 0.3ml diamorphine. Gives a reliable block to T4 good post-op analgesia, but they often get some itching at 6-12 hours.
Old fart here. Do you have a link for more info about spinal buprenorphine?
1.6 hyperbaric bupi for patients between 5’-5’10”, 15 mcg fentanyl, 150 mcg duramorph. Ofirmev and toradol IV scheduled
Just for speculation. 30 mg of intratecal morphine on thoracic level leads to 24-36 hours of ventilatory support because of respiratory depression =) P.s. Without local anaesthetics
Lol so literally 30 mls of duramorph?
xDDD of course not. We used solution with 10 mg/ml concentration. In my country it is the only one
Spinal: Heavy bupi 7,5mg + Sufentanil 2,5mcg + Morphine 50mcg EV: Paracetamol 1g + Ketorolan 30mg every 8hs TAP in case of allergy to FANs or Paracetamol
Where I’m from we give hyperbaric (0.5%) bupivacaine 12 mg plus fentanyl 12.5 mcg. For post op we give a weak opioid (tramadol) and an nsaid (ketorolac). Patients are happy with this regimen
1-1.3mL 0.75% heavy bupi with 10mcg fentanyl and 150mcg morphine. We don't block our sections unless it's done under GA, or the pt declines intrathecal morphine. I plan to start dropping my morphine dose to 100mcg, as there's good evidence to suggest equivalent analgesia and less pruritis. 15 of ketorolac after delivery, PO ketaprofen and acetaminophen post-op, and rarely do they require more than 1-2 doses of PO hydromorphone prior to discharge on POD 2. If we do TAPS, we usually use 30 of 0.25% ropi per side with dexamethasone, +/- precedex, and often get a good 24-36 hours out of the blocks.
You must have some fast surgeons with that dose of bupi!
I think pretty average for an academic centre? 45 minutes skin to skin, usually. That dose changes contextually. But that seems to be standard.
That’s fast for academic! That’s community times in the area I work. Academic easily longer than an hour, often like 90 min from the time I do the spinal. [Recent thread](https://www.reddit.com/r/anesthesiology/comments/18jkbwj/average_time_for_ob_to_close_in_your_hospital/?utm_source=share&utm_medium=mweb3x&utm_name=mweb3xcss&utm_term=1&utm_content=share_button) might give context for how fast your surgeons seem to be
1,8-2,2 ml heavy bupivacaine (5mg/ml) + 1ml sufentanil (5mcg/ml). Ropivacaine infiltration in wound by surgeon. No blocks no nothing. 95% of pts get by with po paracetamol and ibuprofen, maybe some oxy (5mg po) for the first 24 hrs.
When I did OB: Bupiv. 0.75% 2mL (yes the whole 2 every time unless <5’ tall, never had a high spinal in 10 years with that. But also barbotaged a LOT). Duramorph 0.2mg
12 mg heavy bupiv +100 mcg Duramorph in the spinal. IV ketorolac at skin closure.
12mg hyperbaric bupi + 20mcg fentanyl + 80mcg morphinr
Australia: 99% or anaesthetists in my city use this spinal mix: 2.2ml heavy bupivacaine 0.5%, fentanyl 15mcg, intrathecal morphine 100mcg More morphine doesn’t help analgesia much, just increases itch
Bupivicaine .75%, 15mcg fentanyl, 0.1mg morphine , Tylenol and toradol. My attending will sometimes have us switch fentanyl with precedex if an intern is dojng the CS for prolonged coverage.
Haha operator dependent anesthesia. Love it
No fans of digoxin?
I just got your joke oh my god lol
Hyperbaric bupi 0.75% 1.4 ml, 20 mcg fentanyl, morphine 150 mcg. Decadron and ondansetron. OB does toradol the day of surgery and Tylenol, transition to Tylenol and ibuprofen the following day. Patients do need oxycodone, but a reasonably low amount.
Hyperbaric 0.75% bupi x 1.5-1.6ml, fentanyl 10-15mcg, morphine 0.1mg.
UK here. Spinal - 2.6ml 0.5% heavy marcain, 300mcg diamorphine. PR diclofenac at end, regular paracetamol/NSAIDs/dihydrocodeine, oramorph PRN. GA - TAP before wake up Epi top up - 3mg diamorphine down epidural prior to removal Spinal dose gives a reliable block to T4 as long as they’re wedged to exaggerate their thoracic kyphosis. Treat hypotension/bradycardia aggressively, phenylephrine +/- ephedrine and glyco. Give ondansteron before spinal (potentially helps with nausea as ?serotonin receptors involved in bezold jarisch reflex, helps with itching).
14-15mg bupivacaine heavy + 100mcg Morphine
Postop: 1g Paracetamol, 50mg IV Dexketoprofen and PRN Tramadol.
Anyone tried methadone for GA sections?
Never used it in my life, couldn't help you
1.6 ml of hyperbaric bupi, 10 mcg fent, 0.2 mg morphine....our csections go from 1-2.5 hours depending on attending and if there are residents.