Ob Anesthesia

President of SOAP grand rounds 10/14/24.

15% of CS patients require rescue analgesia. 11-20% of patients report pain, our false negative rate is 62%, we are bad at assessing who is in pain. CS pain has long term consequences for mothers. Talk to patient about their prior experiences with birth. What are their expectations? What kind of baggage are they bringing in? How can you best partner with them? Tell them when it's going to be uncomfortable (delivery, gutters). 11.0 +/- 0.95 mg is ED95 for hyperbaric bupivicaine, this is with fentanyl and duramorph (source: Ginosar, 2004 anesthesiology). Things associated with epidural failure: hx of, multiparity, opioid tolerance, air for LOR, deeper catheters, radicular pain during placement, DPE, non-obstetric provider, requirement for multiple boluses. SCOW registry from 2013 (before advent of videoscopes) is best data for GA safety and shows 1:533 rate of failed airway, compared to old data which said 1:8 failed airway. Don't discount what the patient is saying by blowing them off with "it's ok". Need T4 level for peritoneal innervation. Motor block is 2 levels below pin prick, which is 2 levels below cold sensation. Pin prick to T4 is what she does. Stop normalizing pressure, don't say "just pressure". You need to STOP the surgery if patient is having pain >=5. Usually the visceral block is the one that is inadequate. Redose epidural fentanyl or clonidine. Intraperitoneal chloroprocaine if they can close the peritoneum quickly (insist that it is the more senior providers closing at this point because it only lasts 20 minutes).