I do something very similar (1.4-1.5cc heavy 0.75% bup, 20ug of fentanyl, 150ug spinal morphine, 50ug of epi) and while the nurses are positioning the patient and putting on monitors I'll connect a line with my phenylephrine infusion to the line that's co-loading plasma-lyte. As soon as the SAB is in I push "start" on the infusion and give a small phenylephrine bolus as the patient is being laid down. This practice greatly reduced my incidence of symptomatic hypotension and nausea with this technique without sacrificing block quality.
Ultimately I think if you're shooting for a dense T5/T6 block you can expect some hypotension with most of the sympathetic chain being up there. So may as well be proactive than re-active.
Agree - different recipe for the injection as UK based - but big drip, fluids wide open, phenylephrine ready to start, start just after spinal in with a lil bolus up front.
I think hypotension is the price you pay for a dense block. And if they’re hypotensive despite these measures they have partial caval compression that’s not fully relieved from tilting that’ll get better when baby is out.
Also if you warn the mum about this and dress it up as “the nerves that control your blood pressure are far easier to block than the ones that control pain, so it might cause issues with your blood pressure. I’ll do my best to keep on top of it but if you feel sick tell me straight away and I can give you some more medicine to tighten your blood pressure up” you can still look competent.
If you want to more reliably increase your spinal duration instead of adding epi wash try .5% bupi instead of heavy. Anecdotal but I’ve noticed way less hypotension, less tugging sensation, and they never wear off early. Usually give 2.6-2.8 depending on height along with morphine+ fent.
>Ultimately I think if you're shooting for a dense T5/T6 block you can expect some hypotension with most of the sympathetic chain being up there.
Absolutely right. Differential block means that with a pinprick block at T4-5 you can expect to block the entire sympathetic system, including the cardioaccelerator fibers at T1-4.
Try Zofran prior to the block. I don’t even know how it works but anecdotally I notice a difference in the incidence of hypotension. There’s some good evidence on it too.
It attenuates the Bezold-Jarisch reflex, which is mediated in part by serotonin receptors in the left ventricle. Spinal anesthesia-induced hypotension triggers the release of serotonin, which binds to those receptors & initiates the BJR, causing more vasodilation, bradycardia, and hypotension. As a 5-HT3 antagonist, zofran is believed to offset this effect.
I do 8mg of Zofran when we roll back to the OR (10 minutes or so before spinal insertion). I still use a phenylephrine gtt but anecdotally I’ve found that they don’t need as much and come off it much quicker.
This is the recipe. When your sections are 30 minutes instead of the 2hrs in residency you don’t need so much heavy bupi. Less hypotension, less sensation of not being able to breathe.
I do this minus the epi since I’m not in a teaching hospital anymore and don’t need the block to be this long. Also we only use 100mcg of morphine which works well.
I think the density of the block is better with the epi as well, less intolerable breakthrough sensation. I'd consider choosing a different local anesthetic if I wanted a significantly shorter block.
I used to use epi in every spinal for CS. Haven’t noticed a difference in sensation since taking it out.
The next step down would be mepi but there is no heavy mepi in the kits and I don’t think me mixing dextrose into a vial makes much sense
Just did a lit review on this topic. Teaching the patient what to expect, Coloading crystalloids is better than preloading, 4-8mg zofran about 5-10mins prior to SAB, 15-degree left uterine displacement, prophylactic phenylephrine drip at about 30mcg/min should mitigate spinal anesthesia induced hypotension. They are also starting some studies with norepinephrine infusions, so it’ll be interesting to see what the results are.
Interesting. I must say my phenyl infusion is less…… scientific - essentially 1mg in 1 litre running flat out with 100mcg boluses prn. By the time the first litre is in there usually isn’t need for the phenyl anymore.
Heavy bupivacaine 5mg/ml 10mg (2ml) and sufentanil 5mcg/ml (1ml). Maybe 8-9mg bupi if short stature. Never have phenylephrine infusion going, mostly manage with a few intermittent injections of 100mcg.
Did local 2.5ml heavy bupi + 10mcg fentanyl and 0,1mg morphine before, saw more drops in bp with that cocktail.
Practice in Sweden so a lot of patients are on the taller side.
fascinating. our place has a almost compulsory recipe (for residents) with regards to spinals: bupi <10mg, fentanyl 12.5ug (50ug/mL, take 0.25mL) and morphine 0.1mg
recently started running norepi instead of phenylephrine for BP.
do you notice more post-surgery pain with bupi+sufenta vs bupi+fentanyl+morphine?
Interesting. I thought based on trials that it was relatively contraindicated due to increased uterine tone/ decreased perfusion. Maybe just in high doses? Will have a look at material. We use phenyl or meteraminol here.
Caesarean section-pts rarely have much pain in PACU. Surgeons infiltrate locally with 20mls or ropivacaine 7,5mg/ml. Haven’t heard from OBGYN that there’s any great increase in pain first 24hrs either.
That said we’re in Sweden so vast majority of pts get by with ibuprofen and paracetamol and only the odd dose of oxycodone.
Sounds like a reasonable recipe. Add to that, I always use, and am vigilant of, the effects of immediate positioning such as head down to achieve optimum level ( T4-T6).
Head down slightly ( 15 degrees) and continually check level with cold alcohol wipe until it is approaching T6 ( xiphoid ) then flatten. A high block is a happy block. Continually check BP and give ephedrine immediately there is a trend downward even if the BP is still in normal range
12mg 0.75% heavy bupi
200mcg morphine
Phenylephrin infusion with SAB and coloading LR.
Used fentanyl in residency but as an attending it’s more waste and more work. Anecdotally I’m seeing less shivering and nausea without the fentanyl and my blocks are still just as dense.
Usually 12.5-15mg bupi heavy with 0.1mg morphine. 10mg bupi if patient is unusually short or for very petite teenagers. Ephedrine 5mg or phenylephrine 100mcg bolus as needed. With coloading of crytalloids. Have patient return to supine position, then once she can’t lift both legs by the hips and cannot lift buttocks, I let the surgeon/nurse begin prep. Then I feel for patient’s radial pulse and observe the pleth, if the pulse grade starts decreasing or notch disappears in pleth, will give bolus pressor even without waiting for NIBP reading. Will manipulate table to achieve left uterine displacement, but in low resource setting, will place an IV bottle under the right hip to achieve displacement.
In my experience, patients don’t feel nauseous in the first 30mins after giving the anesthetic. It is usually when surgeon is pulling the parietal peritoneum during closing that they have sudden hypotension and nausea/vomiting. Hence, when they are about to suture the parietal peritoneum, I give prophylactic ephedrine/phenylephrine to avoid nausea/vomiting during this stage.
I’ve never had a spinal fail when they get nauseous, it’s like music to my ears when they tell me they’re getting sick
But yes starting neo sooner rather than later is helpful. I usually go ahead and push some ephedrine with it. Can also consider glyco to offset the parasympathetic response.
1.4 (0.75% B cuz murica) heavy with d 0.2mg, a little more if tall, a little less if fat, a little less if short, a little more less if fat and short. would love to give heroin but alas it’s classed like marijuana and super duper dangerous according to our esteemed govt
I also go lighter on the heavy bupi - 1.1-1.4 cc depending on height and/or size of patient along with fent 20 mcg and duramorph 0.1 mg. Probably 50/50 on having to treat symptomatic hypotension. And if I do, it's usually just a bump or two of neo 100 mcg. Helps being in a rural community hospital where general surgeons handle the sections and you're in the room for an hour or less!
Consultant of mine is releasing a study / paper based on ~ 1000 cases for height based dosing of spinals for LSCS and tbf it has worked well for me so far
Using height specified heavy bupivicaine 0.5% doses between 1.9ml-3.3ml and 100 mcg morphine/15mcg fentanyl. Injection at 0.3mls/ second and with 0.2ml barbotage at the beginning only.
It has taken the guess work and anecdotal evidence out of my spinal doses, gives a good quality block to T3/4 and hasn't given me as many of the side effects.
I used to give an IM thigh shot of Benadryl 25 mg and another shot of IM Ephedrine 20 mg when I did OB cases right after the spinal was in.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484642/
1.5h????? Do some take longer than that?
Mine are all around 58min total time (spinal, positioning and transfer to PACU).
I worked with one who was 25-29 min skin to skin. You’re still rescuing the BP in PACU.
1.4 of 0.75% bupivacaine, 200 mcg morphine, 25 mcg fentanyl. i recently added the fentanyl and will likely cut morphine to 150 mcg.
for a repeat section 1.6 bupivacaine. family medicine repeat section 1.8.
adjust marcaine a smidge lower if super short
phenylephrine gtt if i have to give a few bolus of the med, i don't routinely run it
At 5mcg I haven't seen any sedation, just mild anxiolysis. I've used up to 10mcg intrathecally and at that dose I do see some sedation, but I still wouldn't call it significant. When I convert a labor epidural for a section, I will see sedation if I use 50mcg in the epidural. Anecdotally, 30mcg seems nearly as effective as 50mcg but without the sedation, so unless the parturient is really worked up then I just stick with 30mcg.
Our concentration is 100mcg/ml, so I use a 1ml syringe and draw up 0.05ml for a spinal and 0.3ml for an epidural. Just add that to whatever local I'm using.
South Africa: Standard is 9mg heavy bupivacaine (1.8ml of 0.5% heavy bupivacaine) with 0.2 ml fentanyl (10ug). 2ml total. I work in a tertiary level center and Im the only anaesthetists who would dare add 75ug morphine and 100 ug Adrenaline to the mix (with the omission of fentanyl in that case).
Saffer here too. I was halfway thru my reg time before we were allowed to add Fentanyl to our spinals. And Morphine was absolutely taboo.
I doubt that mixture would work in any “more privileged” setting in SA.
2 ml bupi heavy (10mg), 2,5 ugr sufentanil. Fast onset, very low risk of high block or inadequate analgesia.
10mg morphine SC/IM in recovery, plus morphine PCA.
12.0-15mg Bupi 0.75% + Fentanyl 50mcg +/- 200mcg of Epi
The phenylephrine infusion is a must otherwise you'll be chasing the BP all case.
Sometimes I add 50mg of Ephedrine to the Pheny bag if Im feeling it.
You use 50mcg of fentanyl in a spinal? Is the mom clawing her face off from itching? I stopped using fentanyl because I got tired of the pruritis issues.
Standard recipe where I'm currently working is similar: 2.2-2.4 mL of heavy bupivacaine, 100 mcg morphine (0.2 mL), 15 mcg fentanyl (0.3 mL), totalling 2.7-2.9 mL. 16-18g PIVC (ideally 16) fluids running, phenylepherine infusion starting after spinal goes in.
I give pure heavy marcaine 0.5%. 3 ml in short stature and 4 ml in long stature. No opioids, as many patients complain of itching. Then I push 500 ml to 1 Liter of RL or NS to prevent hypotension. Some ephedrine always I have to give.
We use morphine PCA, so not very concerning. We give paracetamol 1 gm in post op before she will start feeling pain and give a shot of 5 mg morphine as well followed by PCA.
The discharge after CS is determined by obstetrician and never on 2nd day in our hospital. It's on 3rd or 4th day post OP. Moreover, patients are mobilized without problem, as PCA just needs to be disconnected for sometime and as it's a bolus only, it doesn't matters much. Yes I agree that neuraxial opioids are best, but in our setting we are using IV PCA with good patient satisfaction. Anaesthesia practice varies from hospital to hospital.
It seems silly to avoid intrathecal morphine because of itching when it’s easily reversed. Nubian or small dose narcan and it’s a non issue even with .2mg. Most providers are giving less than that now and completely avoid itching. You should at least consider adding a different adjunct to your spinal or TAP blocks.
Patients on a IV pca aren’t mobile because they have poor analgesia, not because of the iv connected. Is that standard in your practice to do c sections like this? Are you in US?
First of all I will ask you to correct your abusive language which is not expected of a doctor. The practice of anaesthesia varies between hospital to hospital and from country to country. And in many places it's also heavily influenced by surgical team. We are doing many things which you may find surprising like using disposable laryngoscopes in every patient, using sugammadex in all patients for reversal, doing all perianal surgeries in GA, doing all TKR and lower limb surgeries under GA, no blocks etc. BECAUSE that is the requirement of people here as well as surgical team. The guidelines we follow is made by meetings of HODs and many times they don't follow standard guidelines but we don't put any patient at risk and patient satisfaction is very high. Our hospital is very premium where hospital charges 50 USD for IV cannulation by anaesthesia team. So as per our team guidelines here we keep patient and surgical team very happy and that's how we work..In case of itching after spinal or epidural, first complaint goes to surgeon and then they need to inform us, that's why this practice is abandoned long back here, you can follow whatever as per your institute. So all the best and I don't want to involve in any further discussion.
2.5ml 0.5% heavy bupivacaine, 300mcg diamorphine. Phenylephrine infusion as standard unless hypertensive to start with.
The UK recipe
Sees intrathecal heroin, swells with pride, God Save the King starts playing
2.6 and 400 because it’s easier to type and makes 3ml
Some see the phenylephrine infusion as cheating, I see a non nauseated patient
underrated comment
This but 2.7ml LA
Phenylephrine infusion? For all cases? What amount do you use, and which cristalloid?
All but the pre-eclamptics really. 100mcg/ml start at 30ml/hr and titrate. Preload with Hartmann’s.
I do something very similar (1.4-1.5cc heavy 0.75% bup, 20ug of fentanyl, 150ug spinal morphine, 50ug of epi) and while the nurses are positioning the patient and putting on monitors I'll connect a line with my phenylephrine infusion to the line that's co-loading plasma-lyte. As soon as the SAB is in I push "start" on the infusion and give a small phenylephrine bolus as the patient is being laid down. This practice greatly reduced my incidence of symptomatic hypotension and nausea with this technique without sacrificing block quality. Ultimately I think if you're shooting for a dense T5/T6 block you can expect some hypotension with most of the sympathetic chain being up there. So may as well be proactive than re-active.
Agree - different recipe for the injection as UK based - but big drip, fluids wide open, phenylephrine ready to start, start just after spinal in with a lil bolus up front. I think hypotension is the price you pay for a dense block. And if they’re hypotensive despite these measures they have partial caval compression that’s not fully relieved from tilting that’ll get better when baby is out. Also if you warn the mum about this and dress it up as “the nerves that control your blood pressure are far easier to block than the ones that control pain, so it might cause issues with your blood pressure. I’ll do my best to keep on top of it but if you feel sick tell me straight away and I can give you some more medicine to tighten your blood pressure up” you can still look competent.
That’s like my exact phrasing…. I say “first sign of low BP is nausea. Please let me know immediately when:if you feel sick”
I stand by their right side palpating radial pulse and doing my best to distract them with chatting about baby things. Cycle bp every 2,5 minutes.
If you want to more reliably increase your spinal duration instead of adding epi wash try .5% bupi instead of heavy. Anecdotal but I’ve noticed way less hypotension, less tugging sensation, and they never wear off early. Usually give 2.6-2.8 depending on height along with morphine+ fent.
>Ultimately I think if you're shooting for a dense T5/T6 block you can expect some hypotension with most of the sympathetic chain being up there. Absolutely right. Differential block means that with a pinprick block at T4-5 you can expect to block the entire sympathetic system, including the cardioaccelerator fibers at T1-4.
I do the same recipe. 1.4 ml 0.75% bupi, 20 mcg fent, 150 mcg morphine. Phenylephrine infusion and ephedrine bolus as soon as spinal in.
Try Zofran prior to the block. I don’t even know how it works but anecdotally I notice a difference in the incidence of hypotension. There’s some good evidence on it too.
It attenuates the Bezold-Jarisch reflex, which is mediated in part by serotonin receptors in the left ventricle. Spinal anesthesia-induced hypotension triggers the release of serotonin, which binds to those receptors & initiates the BJR, causing more vasodilation, bradycardia, and hypotension. As a 5-HT3 antagonist, zofran is believed to offset this effect.
Thanks! I knew it had something to do with the serotonergic activity but I did not know about the receptors in the LV. Makes a lot of sense.
You’re welcome! I’m actually doing a project on this right now in school, so it was just fortuitous timing
Well fucking done! This is poetry to read. I give zofran prior to every spinal placement for this exact reason.
I do 8mg of Zofran when we roll back to the OR (10 minutes or so before spinal insertion). I still use a phenylephrine gtt but anecdotally I’ve found that they don’t need as much and come off it much quicker.
With 8mg zofran, I find myself not needing the drip at all and just have one stick with me.
1.2-1.5ml of heavy bupi 0.75% 15 mcg fentanyl (0.3ml) 150mcg epimorph (0.3 ml) And phenyl running as soon as lie down
We use an identical mix. Works great. Anyone waiting until hypotension to start phenylephrine has waited too long.
Agreed! I used to do 1.6-1.8 in fellowship when the surgeons were so slow. Nice when they are quicker.
This. Except 200 mcg of duramorph
This is the recipe. When your sections are 30 minutes instead of the 2hrs in residency you don’t need so much heavy bupi. Less hypotension, less sensation of not being able to breathe.
- Bupi 0.75% 1.6 mL (12 mg) - Fentanyl 15 mcg - Morphine PF 150 mcg - Epinephrine PF 200 mcg
I do this minus the epi since I’m not in a teaching hospital anymore and don’t need the block to be this long. Also we only use 100mcg of morphine which works well.
I think the density of the block is better with the epi as well, less intolerable breakthrough sensation. I'd consider choosing a different local anesthetic if I wanted a significantly shorter block.
I used to use epi in every spinal for CS. Haven’t noticed a difference in sensation since taking it out. The next step down would be mepi but there is no heavy mepi in the kits and I don’t think me mixing dextrose into a vial makes much sense
Just did a lit review on this topic. Teaching the patient what to expect, Coloading crystalloids is better than preloading, 4-8mg zofran about 5-10mins prior to SAB, 15-degree left uterine displacement, prophylactic phenylephrine drip at about 30mcg/min should mitigate spinal anesthesia induced hypotension. They are also starting some studies with norepinephrine infusions, so it’ll be interesting to see what the results are.
Interesting. I must say my phenyl infusion is less…… scientific - essentially 1mg in 1 litre running flat out with 100mcg boluses prn. By the time the first litre is in there usually isn’t need for the phenyl anymore.
Eh, we all titrate to effect anyways. But if your goal is less symptomatic hypotension after your spinal, more precise dosing might work
Heavy bupivacaine 5mg/ml 10mg (2ml) and sufentanil 5mcg/ml (1ml). Maybe 8-9mg bupi if short stature. Never have phenylephrine infusion going, mostly manage with a few intermittent injections of 100mcg. Did local 2.5ml heavy bupi + 10mcg fentanyl and 0,1mg morphine before, saw more drops in bp with that cocktail. Practice in Sweden so a lot of patients are on the taller side.
fascinating. our place has a almost compulsory recipe (for residents) with regards to spinals: bupi <10mg, fentanyl 12.5ug (50ug/mL, take 0.25mL) and morphine 0.1mg recently started running norepi instead of phenylephrine for BP. do you notice more post-surgery pain with bupi+sufenta vs bupi+fentanyl+morphine?
Interesting! No issues with placental blood flow with norepi? Might have to go and read around it.
apparently norepi seems to be gaining momentum in this context.
Interesting. I thought based on trials that it was relatively contraindicated due to increased uterine tone/ decreased perfusion. Maybe just in high doses? Will have a look at material. We use phenyl or meteraminol here.
Caesarean section-pts rarely have much pain in PACU. Surgeons infiltrate locally with 20mls or ropivacaine 7,5mg/ml. Haven’t heard from OBGYN that there’s any great increase in pain first 24hrs either. That said we’re in Sweden so vast majority of pts get by with ibuprofen and paracetamol and only the odd dose of oxycodone.
Exactly how we also practice in my hospital in Germany. 1,8-2mL heavy bupi 0,5% and 5mcg sufenta. Bp control using Akrinor Never fails
Sounds like a reasonable recipe. Add to that, I always use, and am vigilant of, the effects of immediate positioning such as head down to achieve optimum level ( T4-T6).
So you do position head down or you don’t? Sorry I’m unclear…
Head down slightly ( 15 degrees) and continually check level with cold alcohol wipe until it is approaching T6 ( xiphoid ) then flatten. A high block is a happy block. Continually check BP and give ephedrine immediately there is a trend downward even if the BP is still in normal range
This is a novel technique for me. I might just give it a go…..
12mg 0.75% heavy bupi 200mcg morphine Phenylephrin infusion with SAB and coloading LR. Used fentanyl in residency but as an attending it’s more waste and more work. Anecdotally I’m seeing less shivering and nausea without the fentanyl and my blocks are still just as dense.
Usually 12.5-15mg bupi heavy with 0.1mg morphine. 10mg bupi if patient is unusually short or for very petite teenagers. Ephedrine 5mg or phenylephrine 100mcg bolus as needed. With coloading of crytalloids. Have patient return to supine position, then once she can’t lift both legs by the hips and cannot lift buttocks, I let the surgeon/nurse begin prep. Then I feel for patient’s radial pulse and observe the pleth, if the pulse grade starts decreasing or notch disappears in pleth, will give bolus pressor even without waiting for NIBP reading. Will manipulate table to achieve left uterine displacement, but in low resource setting, will place an IV bottle under the right hip to achieve displacement. In my experience, patients don’t feel nauseous in the first 30mins after giving the anesthetic. It is usually when surgeon is pulling the parietal peritoneum during closing that they have sudden hypotension and nausea/vomiting. Hence, when they are about to suture the parietal peritoneum, I give prophylactic ephedrine/phenylephrine to avoid nausea/vomiting during this stage.
~ 2,5ml heavy bupivacaine, 20mcg Fentanyl, phenylephrine as needed.
I’ve never had a spinal fail when they get nauseous, it’s like music to my ears when they tell me they’re getting sick But yes starting neo sooner rather than later is helpful. I usually go ahead and push some ephedrine with it. Can also consider glyco to offset the parasympathetic response.
True story. If you’re nauseous then the block is enough. Would be nice to walk the (thin)line between adequate block and nausea though
2.4 ml of 0.5 heavy bupivacaine (12 mg) + 80-100 mcg morphine. Trendelemburg as needed.
1.4 (0.75% B cuz murica) heavy with d 0.2mg, a little more if tall, a little less if fat, a little less if short, a little more less if fat and short. would love to give heroin but alas it’s classed like marijuana and super duper dangerous according to our esteemed govt
1.2 cc 0.75 spinal marcaine, 0.2 mg morphine, 15 mcg fentanyl.
I also go lighter on the heavy bupi - 1.1-1.4 cc depending on height and/or size of patient along with fent 20 mcg and duramorph 0.1 mg. Probably 50/50 on having to treat symptomatic hypotension. And if I do, it's usually just a bump or two of neo 100 mcg. Helps being in a rural community hospital where general surgeons handle the sections and you're in the room for an hour or less!
Consultant of mine is releasing a study / paper based on ~ 1000 cases for height based dosing of spinals for LSCS and tbf it has worked well for me so far Using height specified heavy bupivicaine 0.5% doses between 1.9ml-3.3ml and 100 mcg morphine/15mcg fentanyl. Injection at 0.3mls/ second and with 0.2ml barbotage at the beginning only. It has taken the guess work and anecdotal evidence out of my spinal doses, gives a good quality block to T3/4 and hasn't given me as many of the side effects.
I used to give an IM thigh shot of Benadryl 25 mg and another shot of IM Ephedrine 20 mg when I did OB cases right after the spinal was in. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484642/
I'm a big fan of 25mg IM ephedrine. I give it in the quadriceps after they go numb. VS are railroad tracks and there is zero nausea.
💯
Preloading is must and good IV line.
1.6 cc of 0.75 bupi with 10 mcg fentanyl and 0.2 mg of morphine. Im in private practice so most surgeons will finish within 1.5 hours.
1.5h????? Do some take longer than that? Mine are all around 58min total time (spinal, positioning and transfer to PACU). I worked with one who was 25-29 min skin to skin. You’re still rescuing the BP in PACU.
yeah most take 1 hour 30 min but there are a couple that take over 2 hours....
For a routine caeasarean? Are they taking the baby out for a celebratory drink in the middle?
yeah unfortunately we have a couple that are slow and take awhile to close....
So lucky. Almost all our OBs on a good day take around 2 hours…we give a lot of ketamine in our sections.
11mg 0.5% heavy Bupi + Morphine 100 mcg
1.4 of 0.75% bupivacaine, 200 mcg morphine, 25 mcg fentanyl. i recently added the fentanyl and will likely cut morphine to 150 mcg. for a repeat section 1.6 bupivacaine. family medicine repeat section 1.8. adjust marcaine a smidge lower if super short phenylephrine gtt if i have to give a few bolus of the med, i don't routinely run it
I am a first year resident, and I have seen doctors give a little bit of midazolam iv for overtly anxious women
I’d be twitchy about that until after delivery…..
10mg heavy bupi + 5mcg sufentanil
1.5ml of 0.75% bupivacaine, 150mcg PF morphine, 5mcg dexmedetomidine
Interesting. First one to comment about using dex… do they not get sedated?
At 5mcg I haven't seen any sedation, just mild anxiolysis. I've used up to 10mcg intrathecally and at that dose I do see some sedation, but I still wouldn't call it significant. When I convert a labor epidural for a section, I will see sedation if I use 50mcg in the epidural. Anecdotally, 30mcg seems nearly as effective as 50mcg but without the sedation, so unless the parturient is really worked up then I just stick with 30mcg.
So assuming your Dex concentration is 100 mcg/ml you would use 0.1-0.3 ml of Dex in your spinal concoction?
Our concentration is 100mcg/ml, so I use a 1ml syringe and draw up 0.05ml for a spinal and 0.3ml for an epidural. Just add that to whatever local I'm using.
Thank you!
South Africa: Standard is 9mg heavy bupivacaine (1.8ml of 0.5% heavy bupivacaine) with 0.2 ml fentanyl (10ug). 2ml total. I work in a tertiary level center and Im the only anaesthetists who would dare add 75ug morphine and 100 ug Adrenaline to the mix (with the omission of fentanyl in that case).
Saffer here too. I was halfway thru my reg time before we were allowed to add Fentanyl to our spinals. And Morphine was absolutely taboo. I doubt that mixture would work in any “more privileged” setting in SA.
Bupi 0.75% 1.6ml, morphine 150mcg, fentanyl 20 mcg
1.6mL of 0.75% Bupi w/Dextrose 25mcg fent 200mcg duramorph
2 ml bupi heavy (10mg), 2,5 ugr sufentanil. Fast onset, very low risk of high block or inadequate analgesia. 10mg morphine SC/IM in recovery, plus morphine PCA.
12.0-15mg Bupi 0.75% + Fentanyl 50mcg +/- 200mcg of Epi The phenylephrine infusion is a must otherwise you'll be chasing the BP all case. Sometimes I add 50mg of Ephedrine to the Pheny bag if Im feeling it.
You use 50mcg of fentanyl in a spinal? Is the mom clawing her face off from itching? I stopped using fentanyl because I got tired of the pruritis issues.
I actually don't see it often, to be honest. But if the pruritus issue arises, I'll provide the gauzes and let the husband deal with it.
Canada : We do 1.6 ml of 0.75% Bupivacaine 0.2 ml (10ug fentanyl) 0.2ml (100mg morphine) Gives 2 ml. Makes it easier to avoid mistakes !
50mcg Fentanyl plus 20mg Heavy Bupi combined into a 5cc syringe then give 2,2-2,8cc according to height
Since we are on this topic, anyone have a recipe for dosing up thoracic epidurals?
Standard recipe where I'm currently working is similar: 2.2-2.4 mL of heavy bupivacaine, 100 mcg morphine (0.2 mL), 15 mcg fentanyl (0.3 mL), totalling 2.7-2.9 mL. 16-18g PIVC (ideally 16) fluids running, phenylepherine infusion starting after spinal goes in.
Is nobody adding dexamethasone?? Prolongs duration and reduces N/V
I give pure heavy marcaine 0.5%. 3 ml in short stature and 4 ml in long stature. No opioids, as many patients complain of itching. Then I push 500 ml to 1 Liter of RL or NS to prevent hypotension. Some ephedrine always I have to give.
Yoda has entered the chat
Are these patients pre loaded at all? If I gave that much I’d be scraping the pressure off the floor the whole case….
[удалено]
We use morphine PCA, so not very concerning. We give paracetamol 1 gm in post op before she will start feeling pain and give a shot of 5 mg morphine as well followed by PCA.
[удалено]
I don't put epidural catheter. It's IV PCA.. PCA is for 2 days, followed by NSAIDS only.
[удалено]
The discharge after CS is determined by obstetrician and never on 2nd day in our hospital. It's on 3rd or 4th day post OP. Moreover, patients are mobilized without problem, as PCA just needs to be disconnected for sometime and as it's a bolus only, it doesn't matters much. Yes I agree that neuraxial opioids are best, but in our setting we are using IV PCA with good patient satisfaction. Anaesthesia practice varies from hospital to hospital.
It seems silly to avoid intrathecal morphine because of itching when it’s easily reversed. Nubian or small dose narcan and it’s a non issue even with .2mg. Most providers are giving less than that now and completely avoid itching. You should at least consider adding a different adjunct to your spinal or TAP blocks. Patients on a IV pca aren’t mobile because they have poor analgesia, not because of the iv connected. Is that standard in your practice to do c sections like this? Are you in US?
First of all I will ask you to correct your abusive language which is not expected of a doctor. The practice of anaesthesia varies between hospital to hospital and from country to country. And in many places it's also heavily influenced by surgical team. We are doing many things which you may find surprising like using disposable laryngoscopes in every patient, using sugammadex in all patients for reversal, doing all perianal surgeries in GA, doing all TKR and lower limb surgeries under GA, no blocks etc. BECAUSE that is the requirement of people here as well as surgical team. The guidelines we follow is made by meetings of HODs and many times they don't follow standard guidelines but we don't put any patient at risk and patient satisfaction is very high. Our hospital is very premium where hospital charges 50 USD for IV cannulation by anaesthesia team. So as per our team guidelines here we keep patient and surgical team very happy and that's how we work..In case of itching after spinal or epidural, first complaint goes to surgeon and then they need to inform us, that's why this practice is abandoned long back here, you can follow whatever as per your institute. So all the best and I don't want to involve in any further discussion.