Episode 240 — Inadequate Analgesia During C-Section With Mike Hofkamp and Emily Sharpe
Highlights
- Adjuvants in General Anesthesia
Summary:
General anesthesia for C-section is more dangerous than regional anesthesia. Another study showed that 17% of patients had adjuvants, IV, Aztecs, or nitrous oxide with a 7% drawn-on-ast-ease rate. Dr. Sharp: Not only just risk and patient safety, but just long term harm to the patient psychologically.
Transcript:
Speaker 2
And then let me ask you. So it seems like, you know, maybe and tell me if I'm wrong here, but it seems like if this story were simple, it would be, OK, joys, group finds that general anesthesia for C-section is more dangerous than regional anesthesia. So everybody just does regional and end of story. We're better off because we're you have this lower mortality rate. But what you're saying is it's not that simple because if you have to use a ton of adjuvants to prevent general anesthesia to supplement your regional, then maybe there's risk associated with that that we need to take into account. Is that right?
Speaker 3
Absolutely. Not only just risk and patient safety, but just long term harm to the patient psychologically. And I'll let Dr. Sharp go into that a little bit more later. But another study showed that Davis and Vescares looked at all scissoring deliveries in a year and 17% of patients had adjuvants, IV, Aztecs, or nitrous oxide with a 7% drawn-on-ast-ease rate. (Time 0:07:52)
- Do You Do Prophylactic Treatment for Bradycardia?
Summary:
Emily, what dose are you using for those patients? So typically, it kind of depends on the indication. For a patient who's having pain due to inadequate anesthesia for their C-section,. I do use a larger dose for that. The average patient will start with about 15 to 20 mics.
Transcript:
Speaker 2
And Emily, let me ask you, what dose are you using for those patients? Yeah.
Speaker 1
So typically, it kind of depends on the indication. So I did mention shivering. So I should mention the dose that I use for a patient who does encounter shivering for C-section. Typically, we have a four mic per mil vial, and so we have that. And so I used to use five to 10 mics when I was deleting out myself. Now I usually use four to eight mics. And that usually is enough to abate the shivering.
Speaker 2
As a bowl.
Speaker 1
As a bowl, yes. And not given slowly. So most patients tolerate that quite well. For a patient who's having pain due to inadequate anesthesia for their C-section, I do use a larger dose for that. And typically, depending on the size of the patient, but I would say our average patient, I usually will start with about 15 to 20 mics. And then I can adjust my pain or my dose there. Ideally, it would be to maybe use a dexmeditomine infusion. But the time that it takes to order that from pharmacy, we're discouraged from making our own drips. (Time 0:10:35)
- Do You Do Prophylactic Treatment for Bradycardia?
Summary:
The dose that I use for a patient who does encounter shivering for C-section. typically, it kind of depends on the indication. Most patients tolerate that quite well. But sometimes you really just need a little bit to take the edge off. And hypotension was no different between the groups.
Transcript:
Speaker 1
So typically, it kind of depends on the indication. So I did mention shivering. So I should mention the dose that I use for a patient who does encounter shivering for C-section. Typically, we have a four mic per mil vial, and so we have that. And so I used to use five to 10 mics when I was deleting out myself. Now I usually use four to eight mics. And that usually is enough to abate the shivering.
Speaker 2
As a bowl.
Speaker 1
As a bowl, yes. And not given slowly. So most patients tolerate that quite well. For a patient who's having pain due to inadequate anesthesia for their C-section, I do use a larger dose for that. And typically, depending on the size of the patient, but I would say our average patient, I usually will start with about 15 to 20 mics. And then I can adjust my pain or my dose there. Ideally, it would be to maybe use a dexmeditomine infusion. But the time that it takes to order that from pharmacy, we're discouraged from making our own drips. So I just kind of do a poor man's infusion. And if it's working well for the patient, then you know, I'll maybe rebalance 10 mics at a time as needed. But sometimes you really just need a little bit to take the edge off. Yeah.
Speaker 2
Okay. That's great. And do you do any prophylactic treatment for potential bradycardia? Or no, you just treat it if it happens.
Speaker 1
We treat it as we as it happens. So we actually did look at the hemodynamic effects in our study. And hypotension was no different between the groups. (Time 0:10:40)
- Do We Know What Was Happening?
Summary:
11.9% of C-section patients had intraoperative pain, according to a study out of Israel. The physicians were not able to accurately identify the pain as it was happening,. So definitely worrisome. What else do we know that's going on here?
Transcript:
Speaker 2
Yeah, that's striking. And so let me ask you, do we know what was happening? Was it that the spinal was wearing off? So the pain was coming toward the end? Or was it never working that well? And the first place in the pain was throughout? Or do we not know the answer to that?
Speaker 1
Looks like they just asked them overall, you know, like on a zero no pain to 10 greatest pain imaginable scale, whether they had intraoperative pain.
Speaker 2
Okay, so sounds like it was not not specific to when just did you have it? Yeah. Okay, that's a weird kind of presumed. All right. So, all right. So that's that's study. As you said, mostly out of Israel found 11.9% had had at some point during their C section some pain. And as you said, pretty concerning was that the physicians, both anesthesiologists and obstetricians were not able to accurately identify the pain as it was happening. So definitely worrisome. What else do we know that's going on here?
Speaker 1
So Mike and I recently published a study together where we looked at a predictors of intraoperative pain during C section. So the primary aim of this study was to determine what demographics clinical variables about patients predict patients who are going to have intraoperative pain during their C section under Norexial amisia. (Time 0:16:57)
- Is Clonidine a Black Box Warning?
Summary:
The dose thing that I use off of my epinephrine is based up on a study by Dan Katz where he did a randomized controlled trial of adding epinephrine. He looked at basically the duration of anesthesia and found that that 200 mics epinephrine group definitely prolonged the duration of the sensory blockade much more than that low dose or that 100 mics group. However, I do have colleagues here that I work with that use a routine dose of 100 mics and they have a lot of great success with that. It's more so in like nuraxial for epidural use, not so much for intrathecal use if I'm remembering correctly.
Transcript:
Speaker 1
So I do epinephrine a whole lot more often than I use clonidine. So I have a lot more familiarity with that. And I actually, the dose thing that I use off of my epinephrine is based up on a study by Dan Katz where he did a randomized controlled trial of adding epinephrine and he randomized to three different groups. He did a low-dose epinephrine group which he defined as 100 mics of epinephrine and then a 200 mics epinephrine group. And then he looked at basically the duration of anesthesia and found that that 200 mics epinephrine group definitely prolonged the duration of the sensory blockade much more than that low dose or that 100 mics group where statistically speaking there wasn't much difference between the no-epi and the low-epi group. However, I do have colleagues here that I work with that use a routine dose of 100 mics and they have a lot of great success with that. So based off of the CAT study though, I typically use 200 mics but I know many people who will use 50 or 100 mics.
Speaker 2
Okay. Now I thought that, and of course it doesn't mean it's not able to be used. But I was in the impression that clonidine had a black box warning for this use. Is that true? And so you're saying that despite that, like other things like droparadol, it probably still can be used just carefully.
Speaker 1
Is that the deal? So the black box warning, I am terrible when it comes to history of anesthesia. So Mike, if you know better, please speak up. But I think it's more so in like nuraxial for epidural use, not so much for intrathecal use if I'm remembering correctly. And so I was talking about it more with the intrathecal use to prolong the sensory block and motor block, which is been (Time 0:30:18)