Doctoring and Mothering Today

Now that my oldest is almost 4 years old and my youngest is almost 3… it’s a good time to reflect back on my time during pregnancy, post-partum, breastfeeding, maternal/family leave, full-time work, and raising 2 toddlers.


Pregnancy really was a wonderful time. Aside from the GERD, waddles, having to pee all the time and drinking a ton of water… it was wonderful feeling the little kicks and getting the attention of people to always help me (open a door, lift things, walk with me, etc.). I worked up until I went into labor… literally.

Hours worked baby #1
Hours Worked Baby #2

The most difficult things to do during MY pregnancy: make appointments, drink enough water, peeing every 2 hours (even during the night), eating (I could only take 4-5 bites before getting full), sleep.


No one tells you what to expect post-partum. It’s a rude awakening when it’s really difficult to have a BM, wipe, breastfeed, wake up, and think clearly. For me, the SI joint pain from pregnancy lingered on even until today. Bonding with baby is unique and special. It was a wonderful time to watch my babies explore their senses. Sleep and breastfeeding: It’s really tough to get in enough sleep and breastfeed constantly. But after 2 weeks, breastfeeding got better for me. Maybe I was lucky. Sleep got better for me after 2 months After the 2nd kiddo, I think I had a bit of postpartum depression. Coupling the lack of sleep while also trying to be present for a 13-month old really wore me down. I was in a really dark place: the thoughts, the lack of care of harm to myself, the total loss of happiness for things I previously enjoyed. It was all very real, very memorable, and something that I look back on with sadness bc I wasn’t my best for the kids, my hubs, or myself. I’m thankful to have moved beyond that. The Peloton saved me on this one. I told NO ONE.


Rent a hospital-grade breast pump prior to leaving the hospital. Visit with the lactation consultant while at the hospital to really learn how everything works. I was lucky to have a great LC for both deliveries. The first one really encouraged me and taught me good technique. The second was fabulous as she supported me and encouraged my efforts while also allowing me to opt for normalcy and not beat myself up if my milk production wasn’t 100%. Both excellent teachers and perspectives. Breastfeeding is new and it’s hard. Get help early and often! When you come back to work, do what you can. I oftentimes pumped in the OR and immediately put my stash in the freezer during breaks. This became really tough for me as breaks are uncertain and you don’t want to burden people who also need breaks. My milk supply went down fast, but I did what I could and that was my best. Don’t beat yourself up.

Maternal/Family Leave:

I was really lucky to be able to have 3 months off work. My anesthesia group was absolutely wonderful in allowing bonding time. I took the full 3 months. My husband then took his 1 month and we were able to do a solid bond with the kiddos for 4 months and then put them into daycare when they were 5 months old. Would it be great if we had full pay for 1 year of maternal/family leave? Yes. But, in the US, this is the best I could get and I’m grateful for it!

Full-time Work:

This was my own decision to continue working full-time. You can see in the charts above. After my second baby, I came back and still worked full-time. This was a personal choice. Kids are innocently demanding…. so is my job. I don’t really know how to find that right balance just yet. I miss out on my babies, and I miss out on work. In the end, you have to be ok with not being the best at everything. You will make sacrifices and you will feel awful. It was be a gut punch that you readied yourself for, but still feel every ounce of hurt when you miss things. The first tuck-in, the first goodnight kiss, the many goodbyes, the bathtime shenanigans, the sweet baby smells…. you will miss them. It gets easier. But, it still hurts when you miss these things. It’s almost like life moves on without you. That is…. until you get back and see the smiles and feel the hugs and kisses from them.

Raising 2 toddlers 13 months apart:

This is something! We brought home our second baby just after our 1st baby turned a year old. I don’t think the concept of a sibling coming to the house was even a concept that a one year old can grasp. Having two kids so close in age, but at different stages of development was REALLY HARD. They are just now starting to play together and sharing appropriately. It is still hard for us despite both kiddos being potty-trained (nighttime diapers only for my sanity). Everyone says 5 years old is the magical age where things get easier. We’re almost there!

During the delivery of our 2nd kiddos, I had a moment of weakness and thought a third child would be great. The second delivery was significantly easier than the first. Perhaps my body and mind were playing tricks on me. We feel complete. We have two beautiful and healthy kids. We couldn’t ask for more.

Mothers in Medicine: Making Residency Safer in Pregnancy

Maternal wellbeing and pregnancy outcomes in anaesthetic trainees. Anaesthesia and Intensive Care. Volume: 47 issue: 4, page(s): 326-333.

Pregnancy and Motherhood for Trainees in Anesthesiology: A Survey of the American Society of Anesthesiologists. J Educ Perioper Med. 2021 Jan-Mar; 23(1): E656.

A Penned Point: Give yourself a break–Don’t have a baby during residency. March 2012.

Aprepitant (Emend)

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies. Ther Clin Risk Manag. 2020; 16: 1305–1317.

Patient risk factors (including female gender, non-smoker, history of PONV, or motion sickness) could be quantified using risk scores such as the Apfel score and the Koivuranta score, while surgical procedures such as laparotomy and cholecystectomy confer additional PONV risk. Other perioperative risk factors of PONV includes the length of surgery, the use of volatile anesthesia, including nitrous oxide, as well as perioperative opioid administration. Perioperative risk reduction interventions include multimodal, opioid sparing anesthesia, avoidance of volatile anesthetic, as well as nitrous oxide exposure. Gan et al2 have extensively reviewed various options for PONV prophylaxis and rescue treatment, which includes pharmacological and non-pharmacological interventions. The authors acknowledged that currently the biggest challenge in PONV management is often low compliance to the guidelines.

Fig 1. Summary of the expert consensus guidelines on postoperative nausea and vomiting (PONV) management.

Palonosetron monotherapy for PONV prophylaxis is more effective than other 5-HT3 antagonists, including ondansetron, granisetron, ramosetron; it is also more effective than dexamethasone. Palonosetron has comparable efficacy to aprepitant.

Aprepitant is a competitive Neurokinin (NK)-1 receptor antagonist which was also initially approved for the treatment of chemotherapy-induced nausea and vomiting. It is administered orally, although an intravenous equivalent is also available, in the form of a pro-drug Fosaprepitant. It has a half-life of 9–13 hours, and it has been suggested that its duration of action may be as long as 40 hours.  Fosaprepitant is approved only for chemotherapy-induced nausea and vomiting. As a single agent prophylaxis, 40 mg aprepitant has similar efficacy as 0.075 mg palonosetron. Clinical trials and meta-analyses have reported that aprepitant is more effective in preventing PONV when compared to ondansetron. Similar to palonosetron, the aprepitant is also shown to be beneficial in ambulatory surgery due to its long duration of action and lower risk of postdischarge nausea and vomiting. Vallejo et al59 conducted a clinical trial of 150 patients with moderate-to-high risk undergoing ambulatory plastic surgery, and found that aprepitant plus ondansetron was associated with significantly lower incidence of postdischarge nausea and vomiting than ondansetron alone.

Amisulpride is a dopamine receptors antagonist. While initially licensed as an antipsychotic, in February 2020 the FDA approved its IV formulation for prophylactic and rescue therapy of PONV. The anti-emetic dose for prophylaxis is 5 mg IV, 10 mg IV for rescue treatment, whereas its antipsychotic dose is 50–1,200 mg/day orally.

Comparing the efficacy of aprepitant and ondansetron for the prevention of postoperative nausea and vomiting (PONV): A double blinded, randomised control trial in patients undergoing breast and thyroid surgeries. Indian J Anaesth. 2019 Apr; 63(4): 289–294.

This study found that the antiemetic efficacy of ondansetron and aprepitant was comparable in preventing PONV in patients undergoing thyroidectomy and mastectomy. We found both ondansetron and aprepitant were equally efficacious in preventing emetic episodes, reducing the incidence of nausea and delaying the time to request of a rescue antiemetic. Although not statistically significant, the aprepitant group had a higher incidence of vomiting in the 12-24 h period. However, this group took longer to develop the first episode of vomiting and also to receive the first dose of rescue antiemetic, when compared with ondansetron group. Although the ondansetron group had less vomiting after 12 h, there was a higher incidence of nausea (both being statistically insignificant). So, overall there was no statistically significant difference in the incidence of PONV in both the groups.

Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: a randomized, double-blind Phase III trial in patients undergoing open abdominal surgery. BJA: AUGUST 01, 2007; VOLUME 99, ISSUE 2, P202-211.

BJA:Aug2007, Vol99;Issue2,P202-211. Fig4. Kaplan–Meier curves for the time to first vomiting during the 48 h after surgery.
BJA. Fig 3 Proportions of patients with no vomiting 0–24 and 0–48 h after surgery, by treatment group (modified intent-to-treat population). For each group, the error bar represents the value of the upper bound of the 95% CI for the percentage of patients achieving the endpoint. For 0–24 h, n = 293 for aprepitant 40 mg, n = 293 for aprepitant 125 mg, and n = 280 for ondansetron 4 mg. For 0–48 h, n = 292 for aprepitant 40 mg, n = 290 for aprepitant 125 mg, and n = 279 for ondansetron 4 mg.


Aprepitant at both doses was non-inferior to ondansetron for complete response 0–24 h after surgery (64% for aprepitant 40 mg, 63% for aprepitant 125 mg, and 55% for ondansetron, lower bound of 1-sided 95% CI > 0.65), superior to ondansetron for no vomiting 0–24 h after surgery (84% for aprepitant 40 mg, 86% for aprepitant 125 mg, and 71% for ondansetron; P < 0.001), and superior for no vomiting 0–48 h after surgery (82% for aprepitant, 40 mg, 85% for aprepitant, 125 mg, and 66% for ondansetron; P < 0.001). The distribution of peak nausea scores was lower in both aprepitant groups vs ondansetron (P < 0.05).


Aprepitant was non-inferior to ondansetron in achieving complete response for 24 h after surgery. Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 h after surgery, and in reducing nausea severity in the first 48 h after surgery. Aprepitant was generally well tolerated.

Neurokinin-1 Receptor Antagonists in Preventing Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2015 May; 94(19): e762.

Fourteen RCTs were included. Meta-analysis found that 80 mg of aprepitant could reduce the incidences of nausea (3 RCTs with 224 patients, pooled risk ratio (RR) = 0.60, 95% confidence interval (CI) = 0.47 to 0.75), and vomiting (3 RCTs with 224 patients, pooled RR = 0.13, 95% CI = 0.04 to 0.37) compared with placebo. Neither 40 mg (3 RCTs with 1171 patients, RR = 0.47, 95% CI = 0.37 to 0.60) nor 125 mg (2 RCTs with 1058 patients, RR = 0.32, 95% CI = 0.13 to 0.78) of aprepitant showed superiority over 4 mg of ondansetron in preventing postoperative vomiting. NMA did not find a dose-dependent effect of aprepitant on preventing postoperative vomiting.

Limited data suggested that NK-1R antagonists, especially aprepitant were effective in preventing PONV compared with placebo. More large-sampled high-quality RCTs are needed.

In conclusion, our study found that NK-1R antagonists, especially aprepitant, helped preventing PONV in patients undergoing surgery with general anesthesia by decreasing the incidence of nausea and vomiting, and delaying the time to first vomiting. However, more data from high-quality RCTs and a comprehensive evaluation of related adverse events were needed before a recommendation of using NK-1R antagonists to prevent PONV could be made.

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia: January 2014 – Volume 118 – Issue 1 – p 85-113.

Postoperative nausea and vomiting (PONV) are common and distressing to patients. The general incidence of vomiting is about 30%, the incidence of nausea is about 50%, and in a subset of high-risk patients, the PONV rate can be as high as 80%. Unresolved PONV may result in prolonged postanesthesia care unit (PACU) stay and unanticipated hospital admission that result in a significant increase in overall health care costs. The goal of PONV prophylaxis is therefore to decrease the incidence of PONV and thus patient-related distress and reduce health care costs.

Figure 1: Risk score for PONV in adults. Simplified risk score from Apfel et al.9 to predict the patient’s risk for PONV. When 0, 1, 2, 3, and 4 of the risk factors are present, the corresponding risk for PONV is about 10%, 20%, 40%, 60%, and 80%, respectively. PONV = postoperative nausea and vomiting.
Figure 2
Simplified risk score for PDNV in adults. Simplified risk score from Apfel et al.19 to predict the risk for PDNV in adults. When 0, 1, 2, 3, 4, and 5 risk factors are present, the corresponding risk for PDNV is approximately 10%, 20%, 30%, 50%, 60%, and 80%, respectively. PDNV = postdischarge nausea and vomiting; PONV = postoperative nausea and vomiting; PACU = postanesthesia care unit.
Table 2: Strategies to Reduce Baseline Risk. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.
Table 3. Antiemetic Doses and Timing for Prevention of PONV in Adults. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.
Figure 4. Algorithm for management of postoperative nausea and vomiting. PONV = postoperative nausea and vomiting. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting
Anesthesia & Analgesia118(1):85-113, January 2014.
Table 4. Pharmacologic Combination Therapy for Adults and Children. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.

Ondansetron is also as effective as dexamethasone and haloperidol 1 mg IV, with no difference in effect on the QTc interval. However, it is less effective than aprepitant for reducing emesis and palonosetron for the incidence of PONV.

Compared with palonosetron 0.075 mg, granisetron 2.5 mg is as effective at 3 hours and 3 to 24 hours but less effective at 24 to 48 hours. Palonosetron 0.075 mg is more effective than granisetron 1 mg and ondansetron 4 mg in preventing PONV.

Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 hours after surgery and in reducing nausea severity in the first 48 hours after surgery. It also has a greater antiemetic effect compared with ondansetron. When used in combination, aprepitant 40 mg per os, plus dexamethasone, is more effective than ondansetron plus dexamethasone in preventing POV in patients undergoing craniotomy. A dose-ranging study for gynecologic laparotomy patients found a 80 mg per os dose of aprepitant is the most appropriate dose and is more effective than a 40 mg dose.

Preoperative dexamethasone 8 mg enhances the postdischarge quality of recovery in addition to reducing nausea, pain, and fatigue. Dexamethasone also has dose-dependent effects on quality of recovery. At 24 hours, patients receiving dexamethasone 0.1 vs 0.05 mg/kg required less opioid and reported less nausea, sore throat, muscle pain, and difficulty falling asleep. A meta-analysis evaluating the dose-dependent analgesic effects of perioperative dexamethasone found that doses >0.1 mg/kg are an effective adjunct in multimodal strategies to reduce postoperative pain and opioid consumption.

A recent meta-analysis suggests that with prophylactic low-dose droperidol (<1 mg or 15 µg/kg IV) in adults, there is still significant antiemetic efficacy with a low risk of adverse effects.

When haloperidol 1 mg was compared with ondansetron 4 mg and placebo, there was no difference in QTc effect among the 3 groups. There was no difference in PONV incidence between haloperidol and ondansetron given before the end of surgery, but both were not significantly better than placebo at 24 hours. There was no difference in early antiemetic efficacy between haloperidol 1 mg and ondansetron 4 mg and no difference in the risk of QT prolongation. Comparing haloperidol 2 mg IV vs ondansetron 4 mg IV given before the end of surgery, there was no difference in effect on early versus late PONV or QTc prolongation. However, Meyer-Massetti et al. recently reviewed the literature and all FDA Med Watch reports of haloperidol-associated adverse events and recommended doses of haloperidol <2 mg to reduce the risk of side effects and QT prolongation. 

Meclizine 50 mg per os plus ondansetron 4 mg IV is more effective than either ondansetron or meclizine alone.

Scopolamine patch can be applied the evening before surgery or 2 to 4 hours before the start of anesthesia due to its 2- to 4-hour onset of effect. Adverse events associated with TDS are generally mild, the most common being visual disturbances, dry mouth, and dizziness.

Perphenazine is a phenothiazine derivative that has been used for the prevention of PONV at doses between 2.5 mg to 5 mg IV or IM.

Metoclopramide is a weak antiemetic and at a dose of 10 mg is not effective in reducing the incidence of nausea and vomiting. Metoclopramide in 25 and 50 mg doses had an effect similar to ondansetron 4 mg for early PONV but a smaller effect than ondansetron for late PONV. Dyskinesia or extrapyramidal symptoms were 0.6%, and 0.6%, respectively, and can increase with increasing metoclopramide doses.

Mirtazapine 30 mg per os plus dexamethasone 8 mg reduces the incidence of late PONV by >50% compared with dexamethasone 8 mg alone. Less rescue medication is needed with the combination of antiemetics.

Gabapentin doses of 600 mg per os given 2 hours before surgery effectively decreases PONV. Given 1 hours before surgery, gabapentin 800 mg per os is as effective as dexamethasone 8 mg IV, and the combination is better than either drug alone.

Midazolam 2 mg when administered 30 minutes before the end of surgery was as effective against PONV as ondansetron 4 mg.

The following strategies are not effective for PONV prophylaxis: music therapy, isopropyl alcohol inhalation, intraoperative gastric decompression, the proton pump inhibitor esomeprazole, and administration of nicotine patch 7 mg to nonsmokers. The latter modality may actually increase the incidence and severity of PONV. Although isopropyl alcohol inhalation is not effective for the prophylaxis of PONV, aromatherapy with isopropyl alcohol was effective in achieving a quicker reduction in nausea severity compared with promethazine or ondansetron when used for the treatment of PONV (Evidence A2).

A meta-analysis of 40 articles including 4858 subjects concluded that P6 stimulation with 10 different acupuncture modalities reduces nausea, vomiting, and the need for rescue antiemetics compared with sham stimulation (Evidence A1). The efficacy of P6 stimulation is similar to that of prophylactic antiemetics such as ondansetron, droperidol, metoclopramide, cyclizine, and prochlorperazine. In subgroup analysis, there was no difference in effectiveness in adults compared with children or invasive versus noninvasive modalities for P6 stimulation. The timing of transcutaneous acupoint electrical stimulation does not impact PONV, with similar reductions being achieved with stimulation initiated before or after induction of anesthesia. Neuromuscular stimulation over the median nerve also reduces the incidence of PONV in the early postoperative period, particularly when tetanic stimulation is used.

The additional costs associated with PONV in placebo patients are up to 100 times higher compared with prophylaxis with a generic antiemetic, and the cost of treating vomiting is 3 times higher than the cost of treating nausea. When using a willingness to pay rate of $100 per case avoided, PONV prophylaxis proved cost-effective in groups with a 40% risk of PONV. Lower drug acquisition costs would generally support PONV prophylaxis in patient groups at a lower risk for PONV. The decision about whether or not to use PONV prophylaxis, or to treat patients with established symptoms, not only depends on the efficacy of the drug but also on the baseline risk for PONV, adverse effects of the antiemetics, and drug acquisition costs, which will vary from 1 setting to another.

When nausea and vomiting occur postoperatively, treatment should be administered with an antiemetic from a pharmacologic class that is different from the prophylactic drug initially given, or if no prophylaxis was given, the recommended treatment is a low-dose 5-HT3 antagonist. During the first 4 postoperative hours, patients who failed PONV prophylaxis with ondansetron 4 mg did not respond either to a second administration of ondansetron 4 mg or to crossover with granisetron 0.1 or 1 mg.

The results show that mixing IV and per os antiemetics at various perioperative times decreases PDNV. For instance, 1 study found that dexamethasone 8 mg IV at induction plus ondansetron 4 mg IV at the end of surgery plus ondansetron 8 mg per os postoperatively had a greater effect on decreasing PDNV than ondansetron 4 mg IV alone at the end of surgery.

Table 7. PONV-Prevention Algorithm in All Patients Including Low-Risk Patients Plus Additional Interventions for High-Risk Patients. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.

When developing a management strategy for each individual patient, the choice should be based on patient preference, C/E, and level of PONV risk. Among the interventions considered, a reduction in baseline risk factors and use of nonpharmacologic therapy are least likely to cause adverse events. PONV prophylaxis should be considered for patients at moderate to high risk for PONV. Depending on the level of risk, prophylaxis should be initiated with monotherapy or combination therapy using interventions that reduce baseline risk, nonpharmacologic approaches, and antiemetics. Antiemetic combinations are recommended for patients at moderate and high risk for PONV. When rescue therapy is required, the antiemetic should be chosen from a different therapeutic class than the drugs used for prophylaxis, and potentially one with a different mode of administration. If PONV occurs within 6 hours postoperatively, patients should not receive a repeat dose of the prophylactic antiemetic. An emetic episode more than 6 hours postoperatively can be treated with any of the drugs used for prophylaxis except dexamethasone, TDS, aprepitant, and palonosetron.

Category A: Supportive Literature

Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.

Level 1: The literature contains multiple randomized controlled trials, and aggregated findings are supported by meta-analysis.

Level 2: The literature contains multiple randomized controlled trials, but the number of studies is insufficient to conduct a viable meta-analysis for the purpose of these guidelines.

Level 3: The literature contains a single randomized controlled trial.


Depths of Anesthesia podcast: Should buprenorphine be discontinued preoperatively?

From the articles below (updated Feb 2021):

  • Consider continuing current or decreased buprenorphine dose
  • Consider non-opioid therapies: ketamine, gabapentin, acetaminophen, regional, lidocaine infusions, etc.
  • Team management with pain physician, surgeon, anesthesiologist, nurses, and patient
  • When mild to moderate acute pain is anticipated for a short period of time (e.g. dental extraction), consider treating the pain with buprenorphine and nonopioid analgesics such as NSAIDs.  The total daily dose of buprenorphine can be increased (to a maximum of 32 mg sublingual/day); it should be given in divided doses every 6-8 hours.  
  • When opioid analgesic therapy is expected to be required for a short period of time for moderate to severe pain, federal guidelines recommend holding the buprenorphine and starting short acting opioid agonists.  While the buprenorphine’s effects diminish (20-60 hours), the patient should be monitored carefully for the first several days as higher opioid doses may be needed to compete with the presence of buprenorphine on mu-opioid receptors.  Before restarting buprenorphine, the patient should be opioid-free for 12-24 hours, otherwise the reinitiation of buprenorphine could precipitate withdrawal.  This process should be overseen by an approved buprenorphine provider. 
  • Another option is to continue buprenorphine and use short-acting opioid agonists at high enough doses to overcome buprenorphine’s partial agonism.  One retrospective chart review found decreased opioid requirements in patients who were continued on buprenorphine during and after surgery.  Opioids that have a higher intrinsic activity at the mu-opioid receptor, including morphine, fentanyl, or hydromorphone, are all options, while opioids with less efficacy such as hydrocodone or codeine should be avoided.  
  • If a patient is expected to have an ongoing, long-term need for opioid analgesia (e.g. cancer progression), consider replacing buprenorphine with methadone.  Then, other as needed ‘full’ mu-opioid receptor agonists can be added for breakthrough pain without problems related to use of a partial opioid agonist.

Treatment of Acute Pain in Patients Receiving Buprenorphine/Naloxone – 2014

CA Bridge Program Acute Pain and Buprenorphine – ED and Crit Care – Nov 2019

A Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery. June 2020.

From Mayo Clinic Proceedings. 2020.

Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction. Jan 2018

To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. June 2017.


Nov 2021: (includes Oct ASA annual mtg recommendations)

Buprenorphine is a good analgesic.  Some patients prefer it to other opioids, even post-op. It is not recommended to stop buprenorphine, which can lead to relapse in 50% of patients.  There is a significant increase in mortality in patients in the first month after buprenorphine is stopped.

Regional Anesthesia & Pain Medicine journal recommends no weaning.

Mass General considers high dose to be more than 16 mg daily.  

Different approach suggested in Anesthesiology 2016 paper.

If patient is on 32 mg, only 5% of mu receptors are left for anesthesiologist to work with. If patient is on 16 mg, 20% of mu receptors are available. If patient is on 8-10-12 mg, 50% of mu receptors are available, which is why this is considered optimal by some. Need to overcome receptors with opioids that are high potency, high affinity and titratable, fentanyl and hydromorphone.

Cardiac Arrest in the OR

Cardiac Arrest in the Operating Room:  Resuscitation and Management for the Anesthesiologist Part 1

Moitra, Vivek K.; Einav, Sharon; Thies, Karl-Christian; Nunnally, Mark E.; Gabrielli, Andrea; Maccioli, Gerald A.; Weinberg, Guy; Banerjee, Arna; Ruetzler, Kurt; Dobson, Gregory; McEvoy, Matthew D.; O’Connor, Michael F.

Anesthesia & Analgesia126(3):876-888, March 2018.

Cardiac anesthesiologists and LVAD patients: Pro vs Cons

There’s been a big debate re: who should care for LVAD patients… a general anesthesiologist or a cardiac anesthesiologist?  See below for pros and cons of each.  Ultimately, I think all anesthesiologists should be comfortable caring for these patients as we’ll see more and more LVAD patients undergoing procedures.

Troubleshooting the Left Ventricular Assist Device.  Emergency Medicine. 2016 February;48(2):58-63.

From Emergency Medicine, Feb 2016.

LVAD Parameter Abnormalities:
  • High power, low-pulsatility index and fluctuating pump speed: Consider pump thrombosis or hypotension, vasodilation, initial response to exercise.
  • High power with high pulsatility index: Consider fluid overload, normal physiological response to increased demand; myocardial recovery.
  • Low power, low pulsatility index, and unchanging speed: Consider hypertension or inflow/outflow obstruction, LV failure, dysrhythmia.
  • Low power with normal or high pulsatility index: Consider suction event.

Pro: Cardiothoracic Anesthesiologists Should Provide Anesthetic Care for Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 378–381

Con: Cardiothoracic Anesthesiologists Are Not Necessary for the Management of Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 382–387.


Ventricular assist devices and non-cardiac surgery.  BMC Anesthesiology201515:185

  • Goals of care for LVAD patients undergoing non-cardiac surgery should be directed at maintaining forward flow and adequate perfusion. Three main factors that affect LVAD flow are preload, RV function, and afterload.
  • The right ventricle is the primary means of LVAD filling; therefore, maintaining RV function is imperative.
  • Marked increases in systemic vascular resistance should be avoided.
  • Generally, decreases in pump flow should first be treated with a fluid challenge. Hypovolemia should be avoided and intraoperative losses should be replaced aggressively. Second line treatment should include inotropic support for the right ventricle.
  • Low-dose vasopressin (<2.4 U/h) may be the vasopressor of choice due to its minimal effect on pulmonary vascular resistance.
  • Standard Advanced Cardiovascular Life Support Guidelines should be followed; however, external chest compressions should be avoided during cardiac arrest.
  • Steep Trendelenburg may increase venous return, risking RV strain. Peritoneal insufflation for laparoscopic surgery also increases afterload and has detrimental effects on preload.  Insufflation should utilize minimum pressures and be increased in a gradual, step-wise fashion.
  • TEE can be extremely valuable in diagnosing the cause of obstruction.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery. Annals of cardiac anaesthesia 2016. Vol 19, Issue 4: 676-686.

LVAD: What Should I report? Feb 2017 ASE conference. **ECHO**

  • Higher the RPMs (pump speed)
    • More LV compression, smaller LV size
    • Less functional MR
    • More AI, less AV opening
    • Less LVED diameter
  • De Novo Aortic Regurgitation Post LVAD
    • Proposed mechanisms
      • Aortic valve remains closed during systole
      • Commissural fusion of the aortic valve from disuse
      • Subsequent degeneration of valve
      • Turbulent blood backflow from small outflow cannula onto a closed valve
      • Persistent elevation of aortic root pressure –> aortic root dilation and valve incompetence
    • Treatment
      • Lower LVAD speed (but that may worsen mitral regurgitation)
      • Aortic valve surgery or percutaneous intervention
      • Heart transplant
  • RV Fractional Area Change (RV FAC)
    • RVFAC is a rough measure of RV systolic function (4 chamber view)
    • Normal RVFAC = 35 – 63%

Ventricular Assist Device (VAD). .

Care of the LVAD patient PPT. Summit 2014.

  • Pulsatility Index:
    • —normally decrease as pump speed is increased

LVAD: Understanding equipment and Alarms. Duke Heart Center PPT.

LVAD Management in the ICU. Crit Care Med 2014; 42:158–168. 

Screen Shot 2018-11-26 at 11.20.26 AM
From Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review

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Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review


Anesthesia for Left Ventricular Assist Device Insertion: A Case Series and Review. Ochsner J. 2011 Spring; 11(1): 70–77.

Medical Management of Patients With Continuous-Flow Left Ventricular Assist Devices. Curr Treat Options Cardiovasc Med. 2014 Feb; 16(2): 283.


My blog posts:

HeartWare vs. HeartMate LVAD

Ventricular Assist Devices: Impella

Neuraxial anesthesia and External Cephalic Version

ACOG: If Your Baby is Breech

What is an external cephalic version?


Wikipedia: external cephalic version

Randomized trial of anaesthetic interventions in external cephalic version for breech presentation. British Journal of Anaesthesia 114 (6): 944–50 (2015)

  • Conclusions: Spinal Anesthesia (SA: hyperbaric bupivacaine 9mg + fentanyl 15mcg) increased the success rate and reduced pain for both primary and re-attempts of External Cephalic Version (ECV), whereas IV Anesthesia (IVA) using remifentanil infusion (0.1mcg/kg/min) only reduced the pain. There was no significant increase in the incidence of fetal bradycardia or emergency CS, with ECV performed under anaesthetic interventions. Relaxation of the abdominal muscles from SA appears to underlie the improved outcomes for ECV.
  • Editor’s key points: There is no consensus on best anaesthetic technique for external cephalic version (ECV).  In this study, success at ECV was higher using spinal anaesthesia compared with remifentanil infusion or no intervention.  Pain was also reduced in the remifentanil group but success at ECV was no different to the no intervention group.  The effect of spinal anaesthesia in ECV may relate to relaxation of the abdominal musculature.

Neuraxial blockade for external cephalic version: Cost analysis. J Obstet Gynaecol Res. 2015 Jul; 41(7): 1023–1031.

  • Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

External cephalic version with or without spinal anesthesia: a cost-effectiveness analysis.  American Journal of Obstetrics and Gynecology, January 2016Volume 214, Issue 1, Supplement, Pages S206–S207.  

  • It is both effective and cost-effective to utilize spinal anesthesia to perform ECV in term, nulliparous women with breech fetuses. Translation of this potentially impactful approach into broad obstetric practice should be undertaken.

Effect of Regional Anesthesia on the Success Rate of External Cephalic Version: A Systematic Review and Meta-Analysis. Obstet Gynecol. 2011 Nov; 118(5): 1137–1144.

  • Six RCTs met criteria for study inclusion. Regional anesthesia was associated with a higher external cephalic version success rate compared to intravenous or no analgesia (59.7% vs. 37.6%; pooled RR 1.58, 95% confidence interval [CI] 1.29-1.93). This significant association persisted when the data was stratified by type of regional anesthesia (spinal vs. epidural). The number needed to treat with regional anesthesia to achieve one additional successful ECV was 5. There was no evidence of statistical heterogeneity (p=0.32, I2=14.9%) or publication bias (Harbord test p=0.78). There was no statistically significant difference in the risk of cesarean delivery comparing regional anesthesia to intravenous or no analgesia (48.4% vs. 59.3%; pooled RR 0.80, 95% CI 0.55-1.17). Adverse events were rare and not significantly different between the two groups.

Does Regional Anesthesia for External Cephalic Version Increase the Risk of Emergent Cesarean Delivery? Obstetrics & Gynecology: May 2016

  • Neuraxial Anesthesia (NA) for External Cephalic Version (ECV) increased the risk of emergent cesarean delivery (CD) without impacting ECV success. These findings differ from previous randomized controlled trials (RCTs). The increased risk and decreased success of our ECVs compared to ECVs performed in the context of RCTs could be explained by patient selection, variation in operator experience or technique, or variation in anesthetic management.  Future studies should further evaluate the risk of NA for ECV in true practice scenarios outside of RCTs.

Clinical outcomes after external cephalic version with spinal anesthesia after failure of a first attempt without anesthesia.  International Journal of Obstetrics & Gynecology. Volume139, Issue3. December 2017: 324-328.

  • Repeat ECV with spinal anesthesia after a failed first attempt without spinal anesthesia increased vertex presentation at birth and decreased the rate of cesarean delivery.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial. Anesthesiology 10 2017, Vol.127, 625-632.

  • Results: A total of 240 subjects were enrolled, and 239 received the intervention. External cephalic version was successful in 123 (51.5%) of 239 patients. Compared with bupivacaine 2.5 mg, the odds (99% CI) for a successful version were 1.0 (0.4 to 2.6), 1.0 (0.4 to 2.7), and 0.9 (0.4 to 2.4) for bupivacaine 5.0, 7.5, and 10.0 mg, respectively (P = 0.99). There were no differences in the cesarean delivery rate (P = 0.76) or indication for cesarean delivery (P = 0.82). Time to discharge was increased 60 min (16 to 116 min) with bupivacaine 7.5 mg or higher as compared with 2.5 mg (P = 0.004).
  • Conclusions: A dose of intrathecal bupivacaine greater than 2.5 mg does not lead to an additional increase in external cephalic procedural success or a reduction in cesarean delivery.