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  • C-section under local -- suggestions for supplementation?



    Due to a couple or recent cases where the family practice docs thought they were going to have to do a section under local, they've asked me for suggestions as to how they might safely supplement local anesthesia. Having never done this, I thought I'd poll the OB wizards here and see whether they had any thoughts beyond ketamine, and if anyone has any clinical experiences they'd like to share.
    This article was originally published in forum thread: C-section under local -- suggestions for supplementation? started by pdsr View original post
    Comments 38 Comments
    1. wtbcrna's Avatar
      wtbcrna -
      Show them how to place the circuit mask on the patient and give nitrous oxide, and there is at least one good article out about doing surgeon administered TAP blocks through direct visualization of the musculature.
    1. gaspass3's Avatar
      gaspass3 -
      Can they be trained to place TAP blocks? Obviously they would still need other adjuncts, but it may be a place to start.

      Sent from my SAMSUNG-SGH-I747 using Tapatalk 2
    1. Burnt2's Avatar
      Burnt2 -
      I agree with Mike. I've used ketamine in 3rd world countries in all kinds of completely unsafe environments with almost no monitoring equipment because I feel it's the least likely to cause respiratory depression or cardiac issues.

      .2 of Robinul then 10mg at a time until they're taking soil samples from one of Jupiter's moons.

      A couple versed after baby comes out *if* mom is getting weird, but it's not necessary...especially if anesthesia isn't around.

      We were investigating US guided TAP blocks at our facility; IDK how well they would work as primary anesthetic but that's definitely an option.
    1. pdsr's Avatar
      pdsr -
      Quote Originally Posted by wtbcrna View Post
      Show them how to place the circuit mask on the patient and give nitrous oxide, and there is at least one good article out about doing surgeon administered TAP blocks through direct visualization of the musculature.
      Had not thought of TAP block... I'll have to research that.
    1. MmacFN's Avatar
      MmacFN -
      The nitrous is a great idea

      As for the TAP block, well ive had a hard time teaching anesthesia ppl to get that right let alone surgeons.

      Its easy to identify the layers in u/s but what isnt easy is getting the local inthe correct plane and people make that mistake ALL the time. If placed in the internal oblique or trans-abdomins muscles it simply does not work.

      Id skip that option.

      Quote Originally Posted by pdsr View Post
      Had not thought of TAP block... I'll have to research that.
    1. wtbcrna's Avatar
      wtbcrna -
      Quote Originally Posted by pdsr View Post
      Had not thought of TAP block... I'll have to research that.
      http://www.ncbi.nlm.nih.gov/pubmed/21083866. Here is the article that describes it.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by pdsr View Post
      Had not thought of TAP block... I'll have to research that.
      Are we talking about 3rd world LA sections, or here? In my experience here, a section under local is a desperate, unplanned flail to rescue a baby that involves a lot of hand holding and straps. If there's time for an FP doc to do a TAP I wonder where the anesthetist can be, unless he's disabled/unavailable somewhere else. I really like the nitrous/ketamine way of thinking because of the simplicity of keeping it to just those two. Introducing levels of complexity to non-anesthesia providers (especially L and D non-anesthesia providers) in what could be a crash situation seems kinda dicey.
    1. wtbcrna's Avatar
      wtbcrna -
      Quote Originally Posted by MmacFN View Post
      The nitrous is a great idea

      As for the TAP block, well ive had a hard time teaching anesthesia ppl to get that right let alone surgeons.

      Its easy to identify the layers in u/s but what isnt easy is getting the local inthe correct plane and people make that mistake ALL the time. If placed in the internal oblique or trans-abdomins muscles it simply does not work.

      Id skip that option.
      You are not teaching them anything. This is a surgical TAP block done on an open abdomen through direct visualization of the abdominal muscles. I posted the link above. It would be done during the case to either augment pain relief during the case or just for post op pain control.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by wtbcrna View Post
      http://www.ncbi.nlm.nih.gov/pubmed/21083866. Here is the article that describes it.
      This makes more sense.
    1. wtbcrna's Avatar
      wtbcrna -
      Quote Originally Posted by Teillard View Post
      This makes more sense.
      There is also a case studies presentation where the C-sections were done using TAP blocks and ketamine as needed, but I couldn't find that one. By the way Obstetricians should be able to do TAP blocks with little to no training. Most obstetricians should already be proficient in US-guided needle techniques.
    1. pdsr's Avatar
      pdsr -
      Quote Originally Posted by Teillard View Post
      Are we talking about 3rd world LA sections, or here? In my experience here, a section under local is a desperate, unplanned flail to rescue a baby that involves a lot of hand holding and straps. If there's time for an FP doc to do a TAP I wonder where the anesthetist can be, unless he's disabled/unavailable somewhere else. I really like the nitrous/ketamine way of thinking because of the simplicity of keeping it to just those two. Introducing levels of complexity to non-anesthesia providers (especially L and D non-anesthesia providers) in what could be a crash situation seems kinda dicey.
      The situation is solo anesthesia provider that is tied up in a GA case. Not 3rd world, although many might consider my corner of WY very close. I like the possibility of the surgical TAP block to supplement things after the baby is out. Doubt that it would be a viable option up-front due to time and technical difficulty.

      Another question I have is would 1% lido with epi give a sufficiently dense block (as the primary local for the field block), or would it require 2%? I'd rather they be able to add local more freely without worrying about toxicity, but need a dense block as well.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by wtbcrna View Post
      Most obstetricians should already be proficient in US-guided needle techniques.
      Most? I don't know a single one.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by pdsr View Post
      The situation is solo anesthesia provider that is tied up in a GA case. Not 3rd world, although many might consider my corner of WY very close. I like the possibility of the surgical TAP block to supplement things after the baby is out. Doubt that it would be a viable option up-front due to time and technical difficulty.

      Another question I have is would 1% lido with epi give a sufficiently dense block (as the primary local for the field block), or would it require 2%? I'd rather they be able to add local more freely without worrying about toxicity, but need a dense block as well.

      No matter what you did, it'd be awful....but... I might suggest 50/50 2% with epi and chloroprocaine.
    1. wtbcrna's Avatar
      wtbcrna -
      Quote Originally Posted by pdsr View Post
      The situation is solo anesthesia provider that is tied up in a GA case. Not 3rd world, although many might consider my corner of WY very close. I like the possibility of the surgical TAP block to supplement things after the baby is out. Doubt that it would be a viable option up-front due to time and technical difficulty.

      Another question I have is would 1% lido with epi give a sufficiently dense block (as the primary local for the field block), or would it require 2%? I'd rather they be able to add local more freely without worrying about toxicity, but need a dense block as well.
      1 or 2% lido with epi should be fine. That gives the surgeon between 35-70mls to use on a 100 kilo pregnant lady, if I did the math right. Lidocaine is very forgiving. I trained with one anesthesiologist that routinely gave over gram of IV lidocaine during surgical cases. He would do the cases without narcotics and just give blouses of lidocaine instead. Usually, starting with 400-600 mg bolus at the beginning of the case. I am not advocating it, but it does give you a different perspective after seeing it done a few times with good results.
    1. wtbcrna's Avatar
      wtbcrna -
      Quote Originally Posted by Teillard View Post
      Most? I don't know a single one.
      Don't your OBs do their own amniocentesis and their own ultrasounds? Ours do, but maybe it is different at other places. The TAP block is one the easiest US-guided blocks IMO. My students and coworkers that I have taught to do them seem to pick it up right away.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by wtbcrna View Post
      Don't your OBs do their own amniocentesis and their own ultrasounds? Ours do, but maybe it is different at other places. The TAP block is one the easiest US-guided blocks IMO. My students and coworkers that I have taught to do them seem to pick it up right away.
      Proficiency with u/s guided amnio is not proficiency with a nerve block, and there's way more to peripheral nerve blocks than identifying a structure on u/s and injecting medicine. Knowing one block isn't proficient.
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by wtbcrna View Post
      1 or 2% lido with epi should be fine. That gives the surgeon between 35-70mls to use on a 100 kilo pregnant lady, if I did the math right. Lidocaine is very forgiving. I trained with one anesthesiologist that routinely gave over gram of IV lidocaine during surgical cases. He would do the cases without narcotics and just give blouses of lidocaine instead. Usually, starting with 400-600 mg bolus at the beginning of the case. I am not advocating it, but it does give you a different perspective after seeing it done a few times with good results.
      what kind of cases was the anesthesiologist doing this for? any untoward effects, to your knowledge?
    1. wtbcrna's Avatar
      wtbcrna -
      Quote Originally Posted by Teillard View Post
      Proficiency with u/s guided amnio is not proficiency with a nerve block, and there's way more to peripheral nerve blocks than identifying a structure on u/s and injecting medicine. Knowing one block isn't proficient.
      Yes, that is true but you are not training them to do identify anything new or doing something radically different than what they already do routinely. It would be rather simple adaptation of what they already know and do. The TAP block is a US-guided field block and not a true PNB. It is just a matter of perspective.
    1. wtbcrna's Avatar
      wtbcrna -
      Quote Originally Posted by ethernaut View Post
      what kind of cases was the anesthesiologist doing this for? any untoward effects, to your knowledge?
      He would do it in all sorts of cases, but this guy is in his mid-70's at least by now. To my knowledge while I was there he never had any adverse outcomes. This apparently was something that used to be fairly routine at one time just as closed circuit anesthesia anesthesia where you inject Iso (or another IA) directly into the expiratory limb of the breathing circuit used to be fairly common. It is one of those neat techniques to learn, but one of those you just put into your toolbox for extreme cases only.
    1. squeege's Avatar
      squeege -
      No clinical experience Paul, but we have a piece of paper in the top drawer of the anesthesia machines that say something like:
      1) Apply oxygen mask
      2) open a 10cc syringe with needle
      3) draw up 2cc Ketamine (100mg) into the 10cc syringe.
      4) dilute with 8cc LR or NS for a 10mg/cc mixture.
      5) Give 2cc first, then titrate 1cc at a time

      Squeege
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