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In this 318th episode I welcome Dr. Mike Hofkamp and Dr. Emily Sharpe back to the show to discuss the problem of inadequate analgesia during c-sections. We discuss the issues that came up in The Retrievals Podcast, how to prevent pain, how to treat it if it happens, and how and when to convert to GA.
CME: Link
Random Recs:
I do not hesitate to convert to a GA for the common reason stated in this podcast which is the usual teaching. I don’t question at all the safety of offering a GA for a c-section patient. In 25yrs of practice, I have not encountered a challenging airway on OB. Direct laryngoscopy is adequate for all intubations on OB that I’ve had to perform. (We do have easy access to videolaryngoscope as well).
One big concern that has not really been touched on in avoiding a GA is taking away the opportunity for the mother to see their child being born. That first sight of their child or that first cry. If they are unconscious with a GA, they miss out on that. This is what makes me hesitate to offer/convert to a GA during a c-section. Not legal liabilities or airway issues… No one seems to address this in all the discussions I hear, including the “Retrievals” podcast.
All great points!
Great episode. May be a scenario I encounter on boards this spring. I was actually thinking how amazing it would be if you did simulated oral board stems and answers on the show!
We’ve done three of them so feel free to check out episodes 34, 75 and 221.
Wonderful review of this important topic!
A couple questions ( I thought of these while commuting, so apologies if you addressed these in the episode):
1. If you decide to remove an existing labor epidural in order to perform a new neuraxial technique, what is your usual dose for the spinal? Assuming this is a patchy labor epidural that has not been bolused recently.
2. Many of us are trained to avoid administering IV adjuncts until the baby is delivered to avoid neonatal respiratory depression, etc. If prior to delivery, and you have no neuraxial catheter to optimize, but via shared decision making you and the patient are not yet ready to move to general anesthesia, what is your strategy/choice for adjuvant medications.
Thanks for all that you do!
Great questions. Here are the answers from Drs. Sharpe and Hofkamp:
1: My usual practice is to administer 1.2 ml 0.75% bupivacaine (9 mg), 15 mcg fentanyl, and 0.15 mg morphine to patients 5’3” (160 cm) and taller. For shorter patients, I’ll use 1.0 ml 0.75% bupivacaine (7.5 mg) and same opioids. I use a CSE technique that allows me to extend the block if necessary.
2: I agree that we do try to avoid administering medications prior to cord clamp. If the pain occurs right at incision, should you consider sitting the patient up and redoing the spinal? I’ve done it a handful of times but it requires a special patient and surgeon. As you mention, if a patient is having pain, a discussion with the patient is important and it is reasonable to administer IV adjuncts. If baby isn’t delivered, my first choice is IV Dexmedetomidine but knowing that may not be adequate or work fast enough then I may reach for IV fentanyl and let the neo team know that mom has received fentanyl. Once baby is delivered, consider using intraperitoneal chloroprocaine (https://pubmed.ncbi.nlm.nih.gov/35544759/) in addition to IV fentanyl and IV dexmedetomidine. I am not a big fan of IV ketamine and avoid it in my patients experiencing intraoperative pain. If IV pain meds and intraperitoneal chloroprocaine are not adequate and the patient continues to endorse pain, it’s time to discuss conversion to general anesthesia.
When a c-section is urgent or emergent, when and how do you consent for anxiolysis, and the treatment of pain?
Here is the response from Drs. Hofkamp and Sharpe: Ideally, every patient admitted to labor and delivery should have a preoperative evaluation that includes consent for labor epidural analgesia and cesarean delivery anesthesia including anxiolysis and general anesthesia. Occasionally, patients will arrive to the hospital in extremis and will need urgent or emergent cesarean deliveries. For the patient who requires an urgent cesarean delivery where there is time for a brief preoperative evaluation and consent, I quickly explain the risks and benefits of anesthesia for cesarean delivery. If there is inadequate analgesia for cesarean delivery, I will give analgesic medications such as fentanyl or dexmedetomidine. If there is patient anxiety, I will use shared decision making during the procedure to determine the next best course of action. Such shared decision making includes the patient being informed that they could have amnesia for the birth of their baby. I think it is important to emphasize that anxiolytic medications such as midazolam or propofol should not be given for inadequate analgesia. For inadequate analgesia, we need to give medications such as intravenous fentanyl or dexmedetomidine and possibly consider conversion to general anesthesia. And finally, for the patient who presents for a truly emergent/stat cesarean delivery and there is no time to obtain written consent for anesthesia, we will use general anesthesia and consent the patient for a peripheral nerve block after they emerge from general anesthesia.