IntraThecal
Analgesia:
Duramorph 150 mcg &
Fentanyl 25 mcg diluted to 2cc with NS
onset: 3-5 minutes
duration: 1-3 hours
ambulation allowed
ALTERNATIVE:
Marcaine 0.25% 1 cc diluted to 3cc with NS
No ambulation allowed
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Combined
Spinal-Epidural
(CSE):
-Indications: primip <4cm
or multip >7cm
-Ambulation not allowed.
-INTRATHECAL: 1-1.5cc
0.25% bupivacaine + 25mcg fentanyl
-EPIDURAL: Bupivacaine 0.1% + fentanyl 3 mcg/cc; run infusion @
12- 15 cc/hr
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Analgesia
for Cephalic Version
8/31/98:
Ascanio
If version successful,
obstetrician will induce labor or send patient home, to return
when labor commences. If the version attempt fails, they will
schedule a C-Section.
1. CSE with 25 mcg Fentanyl/ 0.8cc
0.25% bupivacaine
- IT dose alone should
give excellent analgesia for the procedure
- epidural is there if C/S needs to be done,or for labor analgesia
if labor is induced.
2. Epidural with 10cc
0.25% bupivacaine titrated to T10 level. Adding 50-100 mcg fentanyl (EPIDURAL) will
enhance analgesia.
-again, epidural is available
if the block needs to be extended for C/S or for labor analgesia.
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C/Section
Spinals
(11/97)
Suggested recipe:
-1.6 cc bupivacaine 0.75% w /dextrose
-200 mcg duramorph (Not at Mercy Hospital)
-20 mcg fentanyl
Be sure to note IT narcotics
on billing slip
For Post-op Breakthrough Pain: Ketorolac 15
mg IV q 6 hr prn. Breastfeeding is not an issue.
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Using Labor
Epidural for C/S
Sutherland 5/07
Suggested Guidelines
1. Selection of appropriate candidates
a. Quality of epidural: few boluses required
b. Duration of epidural:
- < 6 hours usually work well, >18 hours much less effective.
There is no literature on this, although discussions with some OB
anesthesiologists at the BI raise the possibilities of expansion of the
epidural space due to large volume infused over long time or
desensitization to effects of local anesthetics as causes of a
recognized problem. I use approx 12 hours as my cutoff, although this
is clearly not based on any hard evidence.
c. Personality of patient if very sensitive to discomfort, may be uncomfortable
with sensations experienced with epidural (consider spinal instead)
d. Quality of labor/fetal factors---if very dysfunctional labor/very large
fetus, may have greater discomfort with epidural than with spinal.
2. Dosing
a. Emergent/STAT 3% chloroprocaine , 20cc with 2cc NaHCO3
Rebolus as below after 20 minutes
b. Non-emergent 2% Lidocaine 20-30cc with NaHCO3 plus 100 mcg Fentanyl
Rebolus after ~ 30 minutes
1. More 2% lido if expect case to be completed within 30-45 minutes
2. Bupiv 0.5% if expect case to be longer
c. Morphine 3 mg after delivery of infant
3. IV Supplementation (after delivery if at all possible to avoid transfer to
fetus)
a. Midazolam: 2-4 mg
b. Fentanyl: Average 100-200 mcg
c. Alfenta: 500-1000 mcg boluses very effective for acute discomfort
d. Propofol: Usually 30-40 mg boluses for sedation
e. Ketamine: 20-30 mg/dose very effective (give Versed prior)
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Anesthesia for PUBS
(percutan,
umbilical blood sampling):
(9/2000)
Indications: therapeutic & diagnostic purposes in:
-fetal hydrops,
-twin-twin transfusion, or
-other congenital defects.
Anesthetic Management:
either MAC-sedation or GA.
A. Fetal movement ideally should be minimized. (narcotics helpful)
B. Nitrous
Oxide: ?Avoid?
-methionine
synthetase inhibition, esp. w/ multiple procedures.
-air bubbles introduced by surgeon (potential)
C. Risk
of fetal distress, and potential for emergent C-Section
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Twins/Double Setup
August 2001- Ascanio
Indications: Multiple births /
vaginal delivery
Rationale: potential for sudden profound fetal bradycardia
secondary to umbilical cord prolapse. May require urgent intervention
/C-Section.
Management:
- OB will notify Anesthesia Team (AT) when
mother begins labor; patient "pink-sheeted" and anesthetic plan
developed.
- when delivery is imminent, OB notifies AT of status, requesting OR
presence.
- proceed as with MAC:
*Continuous presence
*NIBP, EKG, SpO2
*Anesthesia Record & Charge Data
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OB Consults
August 2001-Sutherland/Ascanio
-Use only the special triplicate form. Complete and
return to Ann Taylor. She will forward copies to:
a. requesting obstetrician
b. billing
c. OB Consult Binder
Location: above printer shelf on
Labor/Delivery Nurse's Station.
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Spinals for Tension Vaginal Tape
(TVT) Procedures
Two Recipes:
1) Ascanio/ D.Dean March 2008
Over
the past several weeks we have been trialing various spinal marcaine
mixtures here at SSC for Mary Brandes' TVT cases. The goal is to
provide safe and adequate surgical anesthesia as well as maintaining
efficiency and timely discharge from PACU to home. Given the above we
have settled on the following recommendation:
Isobaric marcaine, 0.25%, 2cc (5mg total dose) + 20 mcg fentanyl.
Given the low dose of local anesthetic most patients will be moving
their legs on arrival to PACU. The fentanyl is essential as it not only
will complement the spinal with its narcotic effect it actually has a
mild local anesthetic effect as well.
Obviously there will be a patient now and then who does not achieve an
adequate surgical anesthesia level. In these cases I would encourage
supplementing with IV alfenta or remifentanil (once we are comfortable
using it.)
If you have a case of inadequate anesthesia
using this recipe, make sure you document such on the QA form; tracking
this will allow objective assessment and appropriate adjustment.
2) Charles Higgins January
09
I have used the following with great results for Mary's TVTs at MMC:
2% (not 3%) Chloroprocaine (Nesacaine) 3cc with fentanyl 20ug.
The kinetics are the same as lidocaine. The incidence of TNS is 0% in studies.
Patients are generally fully recovered from the spinal in about 90 min.
This dose has been well studied and published and is the drug of choice at the Mason Clinic.
I haven't found a clear statement of it's baricity, but I've used it sitting and supine with, usually around a T10 level.
Charlie
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Epidural
Continuous Infusions (rev. 3/2002)
Premixed from Pharmacy:
Use Preprinted Drug Order Sheet on Epidural Cart
Bupivicaine 0.125% + fentanyl 2 mcg/cc
-Suggested initial bolus 10cc
-Start infusion at 10-15cc/hr
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Non-Obstetrical Surgery on a
Pregnant Patient
NEW
statement
from ASA and ACOG, October,
2009
in pdf format
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Emergency C-Section
Protocol After-Hours
4 PM- 7AM weekdays (8AM on Thursdays), and weekends
Blackstone, Tarraza, Sweatt, Sutherland
11/2005
1. Attending Obstetrician to page 0610 when decision is made for emergency C/S
a. Communication is to be between attending obstetrician
and attending anesthesiologist, not involving residents
2. Information conveyed should include
a. Degree of emergency (need to start in 2 minutes vs 15 minutes)
b. Brief OB synopsis (i.e. 28 wk GA with bleeding previa)
c. Medical hx (i.e. asthma, etc)
d. Allergies
e. Medications
3. Upon receiving notification of emergency C/S, anesthesiologist
should send an available person to assess the patient and prepare the OR
4. Staff in OR should be kept to a minimum to lessen confusion
a. Anesthesia team
b. Obstetric team
c. Scrub tech or nurse
d. Circulating nurses—maximum of 2
e. Neonatology team
5. Communication between all staff in OR should remain clear, direct and respectful at all times
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