In this episode, episode 53, I welcome back Dr. Mike Hofkamp to discuss analgesia for cesarean delivery. We discuss indications for C-section, urgent and emergent sections, anesthetic techniques and associated complications, how to approach the difficult airway in a pregnant patient, and aspiration prophylaxis.
Additional information:
- Outline by Brian Park
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Discussion references
Urgent cesarean section
Maternal indications (1:52)
Fetal indications (7:35)
Urgent (11:59) vs emergent (17:10)Labor analgesia
Goals (18:19)
Options (19:52)Spinals
Why do they fail? (22:59)
How to dose? (24:49)
Additives? (27:50)
If lots of subcutaneous tissue.. (30:25)Epidurals
If bolus not adequate? (32:42)
How to dose for C-section? (35:48)
When preferred over spinal? (37:50)
What predicts success? (40:01)
General Anesthesia
Evidence (46:10)
Technique (50:07)How would you approach..
Difficult Airway? (52:28)
High spinal? (54:45)
Aspiration prophylaxis? (58:08)
Hi,
Do you have the reference for the spinal doses based on height and weight, please? I believe the author was Halpern?
Thank you.
Hi Ericka,
Should have been Harten. Here’s the reference.
Harten JM, Boyne I, Hannah P et al. Effects of a height and weight adjusted dose of local anaesthetic for spinal anaesthesia for elective Cesarean section. Anaesthesia. 2005;60(4):348-53
Thanks for the Harten reference!
I was taught various regimes but 2.3ml of 0.5 isobar bupivacain with 0,2ml sufenta epi has in my experience produced an adequate block to slightly under xyphoid in a wide variety of patients (obese/ short/tall).
I regularly use 2.5 to 5 ml of Akrinor (cafedrine/theodrenaline, it’s the German go to for all vasopressor needs), (in c section diluted 10:1 to reduce burning sensation at injection site) just prior to commencing the spinal, this greatly reduces the blood pressure drop.
Interesting tactic to use a Tuohy as an introducer in obese patients never thought about that. In those cases we usually use 150 mm 22g Quincke needle which is pretty stiff and can be used without an introducer.
For some odd reason Propofol is still not officially allowed for c section in Germany, hence we have to use Thiopental/sux with some Esketamin. Once the clamp is on the cord I generally switch to low dose Sevo with remifentanyl or propofol with remifentanyl. Nitrous has been removed from most hospitals here altogether.
Cheers
Thanks for sharing your practice!