C-section under epidural top-up

There is debate here about top-up solutions- do you use the fast acting mix that takes time to prepare, or the slower one that can be drawn up more quickly? Research suggests the lidocaine based mix is faster at achieving surgical anaesthesia, even accounting for the extra time taken to prepare it.

Pre-op

• Antacid prophylaxis
• Explain that they should feel no sharp pain, but that they will feel pushing, pulling etc (like having the washing up done inside you)

Intra-op

• 18ml of 2% lidocaine + 2ml 8.4% bicarbonate + 1ml of 1:10,000 adrenaline (or 0.1ml of 1:1000)
• Can start top up in room
  • Give 3ml, wait for 30 secs. Check ankle dorsiflexion – this is looking for a spinal catheter
  • Give another 3ml, wait 1 minute. This is checking for IV placement. Patient may report tinnitus etc if so
  • Then give remainder. 15ml total frequently sufficient
• Left tilt on table
• 5 units of oxytocin given slowly after cord clamped
• Dexamethasone 6.6mg
• Diamorphine/morphine 3mg down the epidural at the end, followed by 2ml flush of 0.9% saline
• Diclofenac 100mg PR by surgeon if blood loss acceptable etc

Documentation

Always document (if true!):

• Sensory block
  • Before start: Cold to T4, light touch to T6
  • By delivery: Light touch S5 to T4
• Motor block- unable to straight leg raise
• Sympathetic block- warm feet
• Mother comfortable throughout
• If there was pain, that you offered analgesia and GA
• Documenting timings is critical here

Post-op

• Paracetamol 1g QDS
• Ibuprofen 400mg QDS (to start after diclofenac worn off)
• Dihydrocodeine 30mg QDS
• Naloxone 100-400 mcg PRN
• Oramorph 20mg 2 hourly PRN
• Lactulose 10-20ml BD
• Ondansetron 4mg PRN

Out of favour

• 20ml 0.5% bupivicaine

Alternatives

• Carbetocin instead of oxytocin