SMMC Combined Spinal-Epidural Protocol 10-09-98 (variations seen in practice).

1. LR 500 cc preload.

2. After opening the kit, draw-up 0.25cc of bupivacaine 0.5% (or 0.5 cc of bupivacaine 0.25%)

and 25 mcg (0.5 cc) of fentanyl in the TB syringe. (Don't use more than .25cc of bupivacaine 0.5%,

or you may see dramatic hypotension).

3. Place epidural needle as usual.

4. Place spinal needle after you are comfortable with epidural needle placement. Inject above mixture.

5. Place catheter as usual, bolus (or not) with 10cc of 1/8% bupivacaine with fentanyl 2 mcg/cc or

1-2 cc of 0.5% bupivacaine or saline, plus the remaining fentanyl. Then start infusion with

1/8% bupivacaine with fentanyl 2mcg/cc at 10 cc/hour.

6. If patient becomes uncomfortable you may use the "bolus function" on the new pumps,

(if desired), to bolus 10 cc of infusion mixture.

C/S Dosing

Spinal: bupivicaine 0.75%, 12mg (1.6cc) + fentanyl 25mcg (0.5cc) + spinal morphine 0.2mg (0.4cc)mg