Anesthesia and Breastfeeding

I get a lot of questions from my friends about receiving anesthesia while breastfeeding.  As more moms are breastfeeding, I think it’s an important question to tackle for the baby’s safety.  I’ve included references and summarized key points below.  If you have any questions, please do not hesitate to ask your anesthesiologist or physician who will be taking care of you.

 

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From Anesthesiology, October 2017.

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk.  Transl Perioper Pain Med. 2015; 1(2): 1–7.

ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017.  BREASTFEEDING MEDICINE Volume 12, Number 9, 2017.

KellyMom: breastfeeding and surgery resources

Key Points:

  • Intrathecal and epidural anesthesia and opioids are ok for breastfeeding mothers.
  • Acetaminophen, ibuprofen, and ketorolac are ok because they have relatively short half-lives.
  • Celecoxib: ok.
  • Naproxen: ok.
  • Propofol is ok.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Midazolam (sedation dose) is ok.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Fentanyl is short-acting enough.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Avoid meperidine in the post-operative unit – its metabolites have long half-lives.
  • Hydromorphone has a long half-life (10hours).  Best to avoid this medication or pump and dump.
  • Morphine: low dose is ok.  Caution if using morphine PCA.
  • Hydrocodone: dosage should be <30mg/day in breastfeeding moms.
  • Oxycodone: dosage should be <30mg/day in breastfeeding moms or not used at all.
  • Tramadol: ok. But FDA not recommend for breastfeeding moms (USA).

Things to Consider

  • Try to have your case booked as early in the morning to decrease the amount of time for fasting.
  • Pump a stash of breast milk ahead of surgery for 1 day of feeds just in case.  You can always use this expressed milk later.
  • Breastfeed or express milk just before the start of the procedure.
  • Have an adult supervise you post-operatively as well as the baby in case there are signs of medication transferred to the baby.
  • Consider anesthetic techniques (local anesthesia, regional anesthesia, non-narcotics, etc.) to minimize opioid consumption.

 

 

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Suprascapular Blocks

Trends are evolving in decreasing intraoperative and postoperative opioid use.  Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain.  For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks.  I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.

Nice paper from Anesthesiology, Dec 2017: Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 12 2017, Vol.127, 998-1013.

Nowadays, it seems that suprascapular blocks are gaining in popularity (I’d probably use it to supplement the supraclavicular block.

Supplies and Technique (from USRA):

Suprascapular Nerve

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How to position the ultrasound probe:

ssn5
From USRA

05_1_a_shoulder-suprascapular-artery-and-nerve_dsc_5085_copy

Ultrasound Image

ssn4
From USRA.  SSM = supraspinatus muscle
SSA = suprascapular artery
SSN = suprascapular nerve
TZM = trapezius muscle
STSL = superior transverse scapular ligament

05_1_c_shoulder-suprascapular-artery-and-nerve_labels

Useful Links


Update: June 19, 2018

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology 7 2018, Vol.129, 47-57.

PEEP Alone Atelectasis
From Anesthesiology, July 2018
  • Conclusions: The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.

Ketamine for intraoperative and postoperative analgesia

I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

ketamine_hydrochloride_050

Ketamine: (different doses I’ve seen in the literature below)

• Induction: 0.2-0.5 mg/kg

• Infusion: 0.1mg/kg/hr before incision

◦ 2mcg/kg/hr x 24hr (spine)

◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

◦ 2mcg/kg/min

◦ 2-8mcg/kg/min

What I’m using nowadays:

  • Oct 2017:
    • Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved.  Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol.  Patients are more comfortable and require less pain medication.
  • Dec 2018:
    • Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming; infusion 0.2 mg/kg/hr stopping when last dressing placed.

 

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Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia. J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

Ketamine for Perioperative Pain Management. Anesthesiology 2005; 102:211–20.

CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY. NHS Royal Cornwall Guidelines June 2015.

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial. HSS Journal: Volume 4, Number 1.

The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature. Pain Medicine Volume 16, Issue 2, pages 383–403, February 2015.

Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review. BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

Ketamine in Pain Management. CNS Neuroscience & Therapeutics 19 (2013) 396–402.

Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

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Acute and Chronic Post-Thoracotomy Pain, modes of treatment

Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.


***UPDATE July 8, 2018 ***

AnesthesiologyNews: July 2018: New Consensus Guidelines Issued for Use of IV Ketamine for Acute Pain.

  • Question 1: Which patients and acute pain conditions should be considered for ketamine treatment?
    Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use.
  • Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain?
    Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events.
  • Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia?
    Conclusion: There is moderate evidence to support using subanesthetic IV ketamine bolus doses up to 0.35 mg/kg and infusions up to 1 mg/kg per hour as adjuncts to opioids for perioperative analgesia.
  • Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings?
    Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure.
  • Question 5: What is the evidence to support nonparenteral ketamine for acute pain management?
    Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain.
  • Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain?
    Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.

New guidelines for the use of IV ketamine infusions for acute pain management have been published as a special article in Regional Anesthesia and Pain Medicine (2018;43[5]:456-466).

The guidelines were jointly developed by the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine and the American Society of Anesthesiologists.


Update Nov, 30, 2018

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 456–466

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.  Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 521–546

When the bark is louder than the bite

In residency, you learn to deal with many different personalities.  This ranges from super sweet and helpful to utterly cruel and egotistical.  At MGH, our CA-3 year was spent running the call schedule on night call (the first-call experience).  It’s a terrific experience in prioritizing as well as organizing your team to prepare for what rolls through the OR doors.  Fast forward 4 years and now I’m in private practice.

While running the schedule on call, I get a call from the trauma surgeon saying a patient with an epidural hematoma needs to come to the OR emergently and couldn’t wait for another anesthesiologist to be called in from home (home call gives an anesthesiologist 30 minutes to come into the hospital for an emergency).  So, I made the executive decision to pull the anesthesiologist from the elective suboccipital craniotomy case to do the emergency.  It was a crani to crani and neuro to neuro switch… meaning the neuro team and crani trays were already open and ready to go.  It made the most sense in my mind.  Of course, without missing a beat, the “elective” neurosurgeon showed complete disdain of my decision.  To add fuel to the fire, he proceeded to berate the OR nurses, myself, and staff to make sure his displeasure was known.  I stood by my decision because it was the best decision for the emergency craniotomy patient who could have potentially died.  Secondly, I chose not to call in my final anesthesiologist for an elective case as we would have gone on “trauma bypass”.  This means that no traumas or emergencies could come to our hospital.  The “elective” neurosurgeon became more livid by the minute.  2.5 hours after he was supposed to start his case, I finished my first case and was able to get his case started.

Now, who does an elective suboccipital craniotomy for tumor case on a Saturday?  Secondly, he decides to do this in a sitting position — this has it’s own sets of risks.  He needed a precordial doppler, which our hospital did not have, so we called for it from our neighboring sister hospital.  In the meantime, I had another plan…that was to put down a TEE probe to monitor for venous air embolism (VAE).  After speaking to the patient and family, I proceeded to explain the risks/benefits of arterial line, central venous line, transesophageal echo, mechanical ventilation, blood transfusion, and intensive care unit stay.  It’s always a lot for the family to comprehend, especially while meeting them for the first time.  However, it is our job as anesthesiologists to make them comfortable and calm their fears.

**This picture taken from a google search for “precordial doppler”.  It is not my own.**

IndianJAnaesth_2012_56_5_502_103979_u2

**This picture taken from a google search for “precordial doppler”.  It is not my own.**

We get to the room and proceed with vital signs monitoring.  Uneventful induction and intubation.  A right internal jugular vein central venous line is placed (mainly to use as a Bunegin-Albin catheter).   TEE probe placed to look for air in RV and possibly air lock and RV failure –> VAE.  Radial arterial line placed and transduced at the level of the head.  Pt was placed in Mayfield pins and positioned in steep sitting position with reverse Trendelenberg and flexing the legs up.  Neuromonitoring commenced looking for changes in sensory and motor signaling.

All throughout the case, the TEE showed various amounts of air coming through the right side of the heart:

IMG_6787.PNGWith greater amounts of air, there would be a detectable decrease in blood pressure as well as end-tidal CO2.  While the right ventricle was still capable of pushing blood forward, I simply increased the blood pressure pharmacologically and increased the patient’s volume with normal saline from the IV.  Rarely does one get to see this TEE view as most of these cases are monitored non-invasively via pre-cordial doppler or ETCO2 and BP.

Lastly, this patient had a great outcome.  A 2cm x 2 cm hemangioma was resected with minimal disruption or trauma to surrounding tissue.  2 hours after a lengthy 4 hour surgery, the patient was sitting with their family… communicating and interacting with them.  All motor and sensory intact.

Pearls from this case:

1) Always do what is best for the patient.  When a life-and-death situation presents itself, it gets priority.  Period.  It doesn’t matter what pressure or temper tantrums you get from outside parties.  Make the best clinical decision. Organize a plan.  Stick with it.

2) Find out the surgeon’s plan.  This case was not booked in sitting position.  Some of these cases are done in prone position, which makes the likelihood of VAE significantly lower than in sitting position.  Knowing the surgeon’s plan of attack is critical to an anesthetic plan.

3) Read. Read. And read more.  Although I’ve been out of residency and fellowship for 4 years, cases will always test your knowledge as well as make you learn new skills/techniques to better your plan.  Take the time to do your best.  Always review.  Medicine is a lifelong learning career.

4) Don’t sweat the small stuff.  The “elective” neurosurgeon who raised such hell at the beginning of the case was thanking me for my help and expertise by the end of the case.  Learn as much as you can from your residency.  Take the knowledge gained and let your clinical acumen do the talking.  There is no room for ego when taking care of a patient.  Your ability to be well-read, well-trained, and well-respected will dictate the tone.  No fluff is needed when you bring 100% to the table.  Don’t be intimidated by the loud bark.

TAVR Team: conscious sedation vs. general anesthesia

Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients.  More specifically, we are speaking of the transfemoral route.

Keypoints:

  • Patient selection is key (consider for COPD; bad for OSA)
  • Short surgical time for monitored anesthesia care (MAC)
  • Decrease invasive monitoring (no PA catheter,+/-CVP)
  • No difference in hospital LOS or 1 year mortality rate
  • Move from TEE to TTE if MAC
  • Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
  • MAC agents: dexmetetomidine, propofol, ofirimev
  • Decrease pressor use
  • Develop an algorithm for MAC vs. GA and patient selection

From goinggentleintothatgoodnight.com

For my own lit search:


***Update May 1, 2018***

We at Scripps Memorial Hospital in La Jolla do most of our transfemoral TAVRs via conscious sedation assuming appropriate patient selection.  These patients still tend to be the inoperable patients not cleared for open heart AVR (aortic valve replacement).  My techniques and choices for setup have changed over time as I’ve had a chance to fine-tune my plan based on prior experiences with TAVR.  Patients typically come to the hybrid room with a 20g PIV placed by the pre-op RN.

My Setup:

  • 4 channel Alaris pump:
    • dexmedetomidine @ 0.7 mcg/kg/hr until incision –> 0.4 mcg/kg/hr until valve deployment –> off
    • norepinephrine @ 2 mcg/min (titrating on/off, up/down as vitals suggest)
    • Isolyte (IV carrier fluid) @ 200ml/hr until valve deployment –> 50ml/hr
  • Cordis neck line
    • Initially, I would have the interventional cardiologist setup a femoral venous line since they’re getting access to the groin.  However, the cardiologist would use that femoral line for emergent ECMO cannulation and I would lose my venous access and have to depend on a measly 20g PIV.  Nowadays, I try for a short 14g or 16g PIV.  If I can’t get one, the patient gets an awake right IJ cordis for large venous access.
  • Hot line fluid warmer with blood-Y tubing: this is for hookup to a large PIV or cordis line
  • Right radial arterial line
    • I started only placing right radial arterial lines because there was a case of a dissection and I immediately lost my left radial arterial line and couldn’t do pressure monitoring.  I insist on only using the RIGHT radial for my arterial monitoring.  Do not let the cardiologist only give you arterial monitoring based on their femoral arterial access.  It will only give you intermittent monitoring and there are critical points leading up to the deployment where you need CONTINUOUS arterial monitoring.  Therefore, I’ve found the right RADIAL arterial line best for continuous monitoring.
  • Facemask for continuous oxygen at 10L/mim with ETCO2 monitoring
  • For trans-subclavian/axillary approach vs. transfemoral approach TAVR, I’ll put in a supraclavicular block right after Cordis/large-bore PIV venous access for patient comfort while still utilizing conscious sedation/MAC.

My Technique:

  • When the patient gets to the room, transfer patient to OR table.  Start IV fluids @ 200ml/hr.  Cases that go well are about 2 hours from start to end.
  • Facemask O2 at 10L/min.
  • Start sedation: precedex/dexmedetomidine @ 0.7 mcg/kg/hr.  Some patients may receive 1-2mg midazolam x 1 and 25-50mcg fentanyl for radial art line placement.
  • Place right radial art line with lidocaine for skin numbing.  Place PIV with lidocaine.  If unable to get access for PIV, prep neck –> sterile gown/glove/drapes for U/S guided Cordis placement with lidocaine.
  • OR staff preps patient.  Antibiotics prior to incision.
  • At incision –> precedex to 0.4 mcg/kg/hr.  25-50mcg fentanyl PRN discomfort. 10-20mg propofol push for discomfort if needed while large sheath placed for valve deployment.
  • Crossing valve –> BP changes.  Manage with volume or levophed.
  • Valvuloplasty
  • Don’t treat over-drive pacing too aggressively when the valve is deployed.  Typically, once the new valve is in, a little volume will help normalize the BP.
  • Once valve is deployed, turn precedex off.  No other sedation or BP meds needed.  Change IVF rate to 50ml/hr.
  • Patient heads to PACU awake, interactive, and comfortable.

What techniques do you like to do?  Any suggestions on a different approach?