Laparotomy – usually umbilicus to pubis, may be longer
Potential major blood loss
Xmatch 4 units/fluid warmer/cell salvage
Large bore IV
Awake epidural @ T10. Test does 3ml of mix (of 20ml 0.25% levobupivicaine + 100mcg/2ml fentanyl)
GA/ETT ( – 2mcg/ml fentanyl, less propofol)
Asleep art line/CVC +/- CO monitor
Just before KTS: Top-up epidural with 5ml mix/5ml H20/5ml mixRun epidural infusion 0.125% l-bupivicaine + 2mcg/ml fentanyl 4-8ml/hr.
At end bolus 5 ml of epidural infusion.
Run remi intra-op then epidural at end/extubation
Adv: can switch off if major haemorrhage to avoid hypotension
Dis: May be difficult to wean remi->epidural and establish post-op analgesia reliably
Spinal: 1.0ml of 0.5% heavy marcaine + 300mcg diamorphine
Epidural: Saline +/- LA top-up
Intra-thecal dose: 1ml of 0.25% levo-bupivicaine. no opioid. Beware fetal bradycardia.
After period of time ‘standard’ top-up of 15ml 0.1% levo-bupivicaine + 2mcg/ml fentanyl
Loading dose for analgesia. 15-20ml of 0.1% l-bupivicaine + 2mcg/ml fentanyl. Volume (not concentration/dose) is the key!
Top-up for C-section. 20ml made of 18ml 2% lignocaine, 2ml 8.4% NaHCO3, 0.1ml of 1:1000 adrenaline + 50-100mcg fentanyl.
3mg of diamorphine (in 8ml) towards the end.
If topping up epidural for c-section (cat 2 so time available) then…
– if it just does not work at all. Remove and do full dose spinal, with thoracic wedge to prevent rostral spread
– low height*/patchy. Remove and do CSE with 1-1.5ml in spinal
*try patient on left lateral with trendelenburg