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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.