As Rachel pointed out, everything injected anywhere will eventually be
distributed and metabolized.

Intrathecal, or "spinal" injection involves puncturing the dura mater
and so our medications are injected right next to the desired nerves.
This requires a much smaller amount of medication to be given -- for a
cesarean delivery or any surgical procedure, I will usually give 12mg
bupivacaine and 15mcg fentanyl, often with a bit of long-acting
morphine (I'd have to look the dose up, sorry -- I haven't done a c/s
using a spinal in a long time) for post-op pain control.  It provides
a "denser" and slightly more reliable block for c/s than an epidural.
We would *never* do an intrathecal infusion for vag labor and delivery
unless we had an inadvertent dural puncture with our epidural needle
-- then by threading in the catheter into the intrathecal space we can
still provide continuous pain relief and significantly decrease the
risk of a "spinal headache" afterwards.

Contrast this with an epidural, where for a cesarean delivery, I will
give usually 16-20cc of 2% lidocaine, with 50-100mcg fentanyl
(depending on attending, we will sometimes wait until baby is out
before giving fentanyl).  For an initial bolus after epidural
placement for labor, I will give usually 10cc of .25% bupivacaine (so
25mg up front) + fentanyl 50mcg, then start and infusion of 0.1%
ropivacaine with 2mcg/cc of fentanyl, at 8-12cc/hr.

We will occasionally do a CSE (combined spinal-epidural -- we place
the epidural needle and then go through it to the intrathecal space
with a smaller needle and inject a very small dose there, then thread
our catheter into the epidural space and start our infusion) if a mom
is progressing rapidly in labor/screaming at us for drugs/etc because
the onset of a spinal block is much quicker than an epidural.

I have seen references showing that blood levels of fentanyl are
nearly equivalent after a certain time period if it is given
epidurally -- ie, 50mcg of fentanyl via epidural will give same the
same serum concentration as if it were given IV.  So yes, narcotics
DEFINITELY reach baby -- and it's quite apparent that moms like the
fentanyl, especially when bolused -- they tend to get very sleepy and
relaxed.  With my recent delivery I asked to not have fentanyl, and it
was amazing how weak our local anesthetic infusion was without it --
my attending just kept bolusing me with small amounts of lidocaine,
and I had very little on board at time of delivery, which was fine and
felt SO MUCH more empowering than with my first son, where I had a
profound sensory block and could feel absolutely nothing.

Anyway, so much more to discuss here, but it's about time to go over
and practice nursing the little guy again. :)  It is fantastic for me
to hear all the differing viewpoints and policies, though I may have
to refrain from even reading any more LN posts since it frustrates me
that I don't have the time to engage here enough...  Once he's home
and feeding well I may have to start re-opening my mouth online so I
can stick my foot in it more. :)

-Sarah

Oh yeah, and just to cause even more shock and horror over our "make
sure you see everyone on the L/D floor" polices, I am also supposed to
consent *everyone* for spinal/epidural/general anesthesia when I go
say hi.  Yeah, that freaks even me out, so I usually don't bother --
in a true emergency, consent is implied -- unless mom tells me she's
definitely going to want an epidural and then I go ahead and discuss
it with her then if she wants.  And the one small benefit about our
policy of seeing everybody ahead of time is that if there is some kind
of issue/emergency/heaven forbid crash section, at least they will
have met me up front.  And that's how I treat these little visits -- I
tell moms, "Hi, I'm supposed to go say hi to everyone here tonight,
just in case we have any problems..."  And then I do the "blame my
attending thing" and say that I know it sounds totally crazy but as an
anesthesiologist (resident who's being told what to do) the two things
I *have* to see are her IV and her mouth, and that in all likelihood,
she'll have a great night without me.

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome