Episode 318: Pain During C-Section Revisited with Drs. Hofkamp and Sharpe

0:13 [SPEAKER_01]: Hello and welcome back to Accraq. [SPEAKER_01]: I'm Jed Wolpa and I'm really excited for a great show today. [SPEAKER_01]: Many of you have probably listened to the podcast, The Retrievals, the first season was about the pain that people were having during their REI procedures and the second season, which just recently came out, is about pain during cesarean section.

0:34 [SPEAKER_01]: And when I heard it, I thought, wait a minute, we've talked about this on Accraq. [SPEAKER_01]: and it would be great to revisit in light of these stories and of course there's been new and upcoming research and more information that has been learned about this just such an important topic.

0:48 [SPEAKER_01]: And so I thought let's have Dr. Hofkamp and Dr. Sharp back on the show to discuss. [SPEAKER_01]: So listeners will know they both been on ACRAC before. [SPEAKER_01]: Dr. Mike Hofkamp is an associate professor of anesthesiology and obstetrics and gynecology at Baylor College of Medicine Temple.

1:01 [SPEAKER_01]: He's also the director of obstetrics anesthesia at Baylor Scott and White Medical Center Temple. [SPEAKER_01]: And Dr. Emily Sharp is an associate professor of anesthesiology at the Mayo Clinic Rochester and the obstetric anesthesia fellowship program director. [SPEAKER_01]: She recently gave the Ostheimer Lecture at the 2025 Society for Obstetric Anastasia and Perinatology Annual Meeting, which is an invited lecture that covers the obstetric and obstetric anesthesia literature for the preceding year.

1:23 [SPEAKER_01]: So both obviously super qualified to talk about this and I'm excited to cover it with them, Mike and Emily, welcome back to the show. [SPEAKER_00]: Thank you for having us. [SPEAKER_02]: Thanks for the invitation. [SPEAKER_01]: So, let's start by just talk a little bit about how you got interested in this topic.

1:38 [SPEAKER_01]: I know you both have been interested in this from before the retrievals happen, so it wasn't the podcast that got you into it, but was it just from practicing as an OBNC'sologist or, you know, did you have some specific instance or something that made you think, you know, we got to think hard about what we're doing here.

1:52 [SPEAKER_01]: Mike, do you want to start? [SPEAKER_00]: Sure, so in my experience as a resident and as a young attending, I noticed that we had this really ambivalence towards starting Gerai Esthesia for pregnant patients during Cesare and Delivery. [SPEAKER_00]: We would let them go through tremendous suffering.

2:14 [SPEAKER_00]: And many times, Gerlion Seasho would never be initiated, and the stated purpose of this practice was to avoid morbidity mortality. [SPEAKER_00]: And I think we were kind of siloed in that, you know, there was very little upside personally for the anesthesologist to initiate Gerlion Seasho and lots of downside and risk and liability.

2:38 [SPEAKER_00]: and we really kind of glossed over the patient experience and that those observations led me to want to investigate this further. [SPEAKER_01]: How about you, Emily? [SPEAKER_02]: Yeah, I actually, as a, when I was trying to work on art department's center of excellence, one of the requirements was that our journal [SPEAKER_02]: percent and so I was paying really close attention to the general anesthetic that we were doing in our department and noticing you know like how can we reduce our general anesthetic seizure rate what can we be doing to meet this metric and as I reviewed every single case I didn't feel like we were doing a lot of inappropriate general anesthetics and I realized that to kind of meet this metric we were we may be have to.

3:30 [SPEAKER_02]: not be treating our patients with pain. [SPEAKER_02]: And so I actually got interested because I was trying to, you know, I was trying to get rid of general anesthesia, but then I realized how actually we're probably doing the right thing. [SPEAKER_02]: And so I first worked somewhere where we didn't kind of force women to continue through these situations.

3:49 [SPEAKER_02]: But I kind of got interested in it. [SPEAKER_02]: I feel like almost the backwards way in that I was trying to reduce general anesthesia. [SPEAKER_02]: And then realizing, I don't want to do that. [SPEAKER_02]: We should really be actually doing general anesthesia when it's appropriate for our patients having pain.

4:06 [SPEAKER_02]: And then of course, I've had some really interesting kind of cases that have also really brought the story home to me in dealing with patients who have had pain and talking to them about that situation. [SPEAKER_01]: Yeah, well, that's really compelling. [SPEAKER_01]: And so let's start there.

4:22 [SPEAKER_01]: You know, it definitely feels like we've gotten to a point where people will avoid, and by people, I mean, we, right? [SPEAKER_01]: Anacisial just will avoid using general anesthesia for C sections, almost no matter what. [SPEAKER_01]: And why is that? [SPEAKER_01]: How did we get here?

4:37 [SPEAKER_01]: You mentioned one thing, Emily, that there's actual guidelines that require you to be below a certain percentage in order to be to meet a certain metrics. [SPEAKER_01]: Talk about that and anything else that has led us [SPEAKER_00]: So, I think that when you look at where we're at, I think you have to look at the history of this topic, and it starts in the late 90s.

5:00 [SPEAKER_00]: A very distinguished and accomplished Nancy Geologist by the name of Joy Hawkins, she published a paper in 1997, and she looked at close claims data from the 1980s. [SPEAKER_00]: and she reported the case of a tally ratio for general anesthesia, compared to regional anesthesia, was about 17 fold, and so every time I put a patient to sleep first, it's around delivery, it was believed that you were increasing that patient's risk of mortality by 17 times.

5:30 [SPEAKER_00]: And so people took notice of this, and there was soon a race to the bottom. [SPEAKER_00]: We're trying to get that general anesthesia [SPEAKER_00]: published in 2011, the retrospectively looked at data from 2000 to 2005 at Brigham Hospital. [SPEAKER_00]: And what it found was, or what reported was, a journal asked easier rates for a sezary delivery of less than 1%.

6:01 [SPEAKER_00]: And this is a strikingly low rate because it takes into account all comeers. [SPEAKER_00]: Both failure of regional anesthesia, maternal core abilities, like thromocyopinion, intercarino pathology, and emergency cesarean deliveries. [SPEAKER_00]: It's just amazing that they had this low of a trial anesthesia rate.

6:22 [SPEAKER_00]: What's missing from this study is how they got there. [SPEAKER_00]: What kind of adjuven agents did they use? [SPEAKER_00]: Did they use how much prepaffold they use, how much ketamine do they use? [SPEAKER_00]: And so the picture is a little bit incomplete. [SPEAKER_00]: But clearly, this hospital program was responding to incentives by having a low rate.

6:42 [SPEAKER_00]: And to touch on Dr. Sharp's experience with the Sub-Series of Excellence, they want to journal anesthesia rate of less than 5% as a marker of quality, and they have realized that there are institutions there are going to have a higher journal anesthesia rate, so you can have a higher than 5% journal anesthesia rate, but you have to show that you're continually auditing your journal anestetics, [SPEAKER_00]: And I think it's a great example that Dr. Sharps said that she was in the process of auditing all her journal aspects and said, you know, most of these are completely appropriate, even though we have a rate higher than 5%.

7:22 [SPEAKER_00]: And what happened is that, uh, [SPEAKER_00]: There's other studies that reported that reported liability. [SPEAKER_00]: There's a good study published in 2009 in anesthesia and about the NHS in England from cases that were done from 1997 to 2007. [SPEAKER_00]: They had about 1100 claims and 50 of these claims were related to [SPEAKER_00]: OB anesthesia, particularly inadequate regional anesthesia.

7:56 [SPEAKER_00]: So this was starting to be recognized as a problem in the 2000s. [SPEAKER_01]: Yeah, and it is clearly, there's a lot of fear around this, right? [SPEAKER_01]: People are worried about litigation. [SPEAKER_01]: I mean, the difficult airway aspect of this is huge. [SPEAKER_01]: This came up in the retrievals, right?

8:17 [SPEAKER_01]: The people are, they think, look, the airway is going to be super difficult. [SPEAKER_01]: And if I try and fail, then I'm toast, right? [SPEAKER_01]: I'm going to get the patient's going to die and pain is better than death. [SPEAKER_01]: And by all of these things are on people's minds.

8:33 [SPEAKER_01]: Emily anything to add to kind of how we got where we are? [SPEAKER_02]: Well, I mean, I agree with you that that is, you know, the fear of the obstetric airway. [SPEAKER_02]: It was a legitimate concern. [SPEAKER_02]: We probably all can think of a really pad OB airway that we've been involved in that really is some of some of the scariest moments that I've had to do with as an anesthesiologist.

8:58 [SPEAKER_02]: But fortunately, [SPEAKER_02]: In 2025, we have a lot of different airway adjuncts that we can utilize to make this safer. [SPEAKER_02]: And so I think that we're not in the same situation that we were in the 80s and 90s. [SPEAKER_02]: And I don't think that we should continue to practice in the way that we did back then.

9:17 [SPEAKER_01]: Yeah, that's a great point, right? [SPEAKER_01]: So when Joy published her paper, that was at a time when, certainly, VL was not ubiquitous. [SPEAKER_01]: And that's a huge difference. [SPEAKER_01]: I mean, there's a lot of things that have changed and so we really wanna think about that.

9:34 [SPEAKER_01]: Now, what's interesting is, [SPEAKER_01]: There's the reality, which is probably it's not as dangerous as we maybe once thought to convert to GA. [SPEAKER_01]: And then there's the fear of litigation, right? [SPEAKER_01]: So how do we address the fact that people are afraid they're going to get sued if they try it and it doesn't go well.

9:55 [SPEAKER_01]: Because they're going to be told you weren't supposed to do this. [SPEAKER_01]: You approached you, you tried to intubate a pregnant woman and that's dangerous. [SPEAKER_02]: Yeah, and I think that's what we're trying to do here. [SPEAKER_02]: We're trying to change that [SPEAKER_02]: And there has been data showing safety and showing that we can utilize video of the ringoscopes.

10:14 [SPEAKER_02]: And when we talk about litigation, it really should be based off of our standard practice. [SPEAKER_02]: And so when you are approaching the obstetric airway, are you following the difficult airway algorithm? [SPEAKER_02]: Are you using your airway adjuncts such as video of the ringoscopes?

10:29 [SPEAKER_02]: Are you using an LMA or a superglotic airway as a backup device? [SPEAKER_02]: And so I think that's what we need to think about going forward. [SPEAKER_02]: And just as Mike had said, you're going to have actually a whole lot more problems with litigation with a patient who has inadequately controlled pain than with a lost airway.

10:50 [SPEAKER_02]: But you need to do make sure what, you know, you do need to understand what your resources are. [SPEAKER_02]: So, you know, in my hospital in every single OB operating room, I have a video the ring scope mounted on the IV poll. [SPEAKER_02]: I don't have to find it. [SPEAKER_02]: Whereas if you're in a low resource setting, you may not have that.

11:07 [SPEAKER_02]: And so maybe some of the things that we discussed in a little bit about. [SPEAKER_02]: management and mitigation of a pain may actually be what they have to do, but I would say most of us are practicing in hospitals here in the U.S. [SPEAKER_02]: that have the ability to safely secure the airway.

11:25 [SPEAKER_02]: There are sometimes, though, you know, where patients have a really difficult airway, and we know about that, and, you know, so there are things that maybe we can do before the sea section to prevent pain as well. [SPEAKER_02]: Again, we'll discuss those. [SPEAKER_01]: Yeah. [SPEAKER_01]: Well, let's talk about pain.

11:38 [SPEAKER_01]: So how common is intra-opane during a C-section? [SPEAKER_01]: You know, let's give people an idea of how common this is. [SPEAKER_01]: And then also, you know, is some pain okay? [SPEAKER_01]: How do we know when it's too much? [SPEAKER_01]: How common is some pain versus bad intolerable pain?

11:54 [SPEAKER_01]: And how can we tell, you know, or can we tell who will have, are there predictors? [SPEAKER_01]: We can say, you know, what you're more likely to have pain during C-section or you're not. [SPEAKER_01]: How do we, what do we know about pain? [SPEAKER_02]: Well, I think it's important to go back to 2016 when Susanna Stanford, a patient who experienced intra-operative pain, published her experience.

12:18 [SPEAKER_02]: So she published her personal experience with pain during the Serial Delivery, and she in this report that was published in the International Journal of Obstetric and Assigea. [SPEAKER_02]: describes how at the beginning of the see section, she had difficulty distinguishing if her distinguishing if her block is working and then when she gave them permission to go forward, she immediately felt pain upon his decision.

12:43 [SPEAKER_02]: She was given nitrous oxide, alphetnel, but this was not enough to treat the way she describes as uncontrollable and indescribable pain. [SPEAKER_02]: She finally requested a general anesthetic after the birth of her son. [SPEAKER_02]: And then she goes on to discuss how she suffered from PTSD, and really could almost loss the first year of her son's life.

13:04 [SPEAKER_02]: Just, it doesn't remember a lot of that. [SPEAKER_02]: And really had a lot of trauma and flashback events to that experience. [SPEAKER_02]: Her, her, her, her, her, her, her, her, [SPEAKER_02]: And she is interviewed in the retrieval. [SPEAKER_02]: So people don't necessarily have to read this sheet as a nice job of describing what happened to this.

13:22 [SPEAKER_02]: But through her brave account of this harrowing experience, I really think this is probably one of the first reported in a journal, you know, K-Share reported experiences of pain. [SPEAKER_02]: And I think that her bravery really brought this important issue to light in our specialty. [SPEAKER_02]: I actually can still remember the first time [SPEAKER_02]: on an interview that she did with the OAA.

13:49 [SPEAKER_02]: And that was when I really feel like the first time I became aware of the patient perspective as well as the long-term impact that this can have. [SPEAKER_02]: on our patients. [SPEAKER_02]: And so I think that that is, you know, kind of one of the initial things that really got our, our, especially going on this.

14:06 [SPEAKER_01]: Yeah. [SPEAKER_01]: That was such a, one of the, I thought the most compelling parts of that series of the retrieval was hearing her talk about her experience and about how, not just how bad the pain was. [SPEAKER_01]: but also how hard it was to feel empowered to talk about it. [SPEAKER_01]: You know, that that was really interesting and I think a wake-up call.

14:29 [SPEAKER_02]: Yeah, and I, and to tell you, listen to the reach people, I actually didn't know about that backstory about how long it'd taken for her to speak up. [SPEAKER_02]: Because I just, I just knew the Suzanne that was speaking up, but so I didn't realize what she had gone through. [SPEAKER_02]: Um, it is pretty, I mean, she's incredible.

14:46 [SPEAKER_02]: I've always thought she's incredible, but it was really cool to kind of hear a little bit more of her backstory. [SPEAKER_01]: Yeah. [SPEAKER_02]: So you asked about, um, how, like, what's the incidence or how often in property pain occurs? [SPEAKER_02]: And, um, this is not an easy question that you asked because, uh, there really are two distinct ways.

15:12 [SPEAKER_02]: And so when we look at our incidents, rates, they really can vary anywhere from like 2%. [SPEAKER_02]: All the way up to 36%. [SPEAKER_02]: So initially early retrospective studies use data for medical records. [SPEAKER_02]: And they relied on surrogate markers, such as analgesia use, anzyolidic use, sedatives, repeat niraxial procedures, or conversion to general anesthesia.

15:34 [SPEAKER_02]: And that's what they utilized to identify inadequate niraxial anesthesia. [SPEAKER_02]: Also another common study that was used is this large systematic review of 54 random highest controlled trials that gave an incidence of 15% [SPEAKER_02]: supplemental analogies or anesthesia in those cases.

15:58 [SPEAKER_02]: And so a lot of times, you'll hear people say that there's an incidence of pain of about 15%. [SPEAKER_02]: And that comes from that study. [SPEAKER_02]: But more recently, fortunately, the studies are now focusing more on anesthetic interventions and are rather focusing on patient-reported pain.

16:19 [SPEAKER_02]: And so I think a lot of these studies were probably underestimating the true incidents of pain during the serene delivery. [SPEAKER_02]: So one study that was done by Kelts and colleagues looked specifically at the incidents, risk factors, and physician perception of pain. [SPEAKER_02]: So they surveyed 193 patients in the recovery room after their c-section and 12% of patients reported pain.

16:45 [SPEAKER_02]: Now, what is interesting in the city is that they also ask the anesthesiologist and the obstetrician about their perception of whether the patient had pain or not, and both groups of physicians underestimated the incidence of interoperative pain. [SPEAKER_02]: with the false negative rate.

17:03 [SPEAKER_02]: So meaning the doctor assumed the patient didn't have pain and the patient actually had pain of 52% in the anesthesiologist group. [SPEAKER_02]: And 83% in the obstetricic group. [SPEAKER_02]: So this study kind of gave us patient-reported pain incidents but then also let us know that we as physicians even the anesthesiologist on the side of the current with the patient, we oftentimes don't even realize [SPEAKER_02]: Another important study that was published last year by Sanchez and colleagues was a prospective observational study that approached patients after cesarean under NORACTIAL anesthesia to assess their experience with anesthesia care and management of pain.

17:47 [SPEAKER_02]: Again, they had a very similar incidence of 12 percent of women who reported pain during their C-section. [SPEAKER_02]: But what is interesting about this study is that not all women who reported pain [SPEAKER_02]: and all women who receive the analgesia medications reported pain. [SPEAKER_02]: So we have a mismatch or some sort of gap and intraoperative communication between the patient and the anesthesiologist.

18:16 [SPEAKER_02]: Now the question is, is this the patient not reporting pain because they were treated with analgesia? [SPEAKER_02]: We, we, we, the city isn't set up to determine that, but nevertheless, the inadequate management of introoperative pain can lead to traumatic birth experiences. [SPEAKER_02]: And so we definitely need to do a better job of, you know, better understanding the six periods of pain during the sea section.

18:48 [SPEAKER_02]: that evaluated predictors of intraoperative pain. [SPEAKER_02]: And we gave patients a survey after they're cesarean, crying about pain during their delivery. [SPEAKER_02]: And we found an incidence of pain of 23%. [SPEAKER_02]: And when we tried to determine different predictors, the only predictor that we really found was pain, a predictor of pain was the length of surgery.

19:13 [SPEAKER_02]: Now, if we look at other studies, a lot of other studies have also now looked at predictors of pain, and they find risk factors associated with pain are usually patient related factors, so anxiety substance use disorder, some anesthesia specific factors, you know, use seven in dwelling epidural labor.

19:33 [SPEAKER_02]: catheter, care by a non-achesiologist, and an obstetric and surgical factor, such as urgencesary and delivery, have all been associated with intraoperative pain. [SPEAKER_01]: Interesting. [SPEAKER_01]: So let me ask you a couple of things. [SPEAKER_01]: Obviously, pain is a broad spectrum.

19:52 [SPEAKER_01]: And if you do these studies differentiate between, I mean, if you ask a patient, did you have any pain? [SPEAKER_01]: And they say yes. [SPEAKER_01]: you are then including both people who had some pain but were fine with it right it wasn't traumatic it wasn't overwhelming it was you know like a little pain but you're also including people who had intolerable pain so do these studies try to differentiate between pain that was intolerable versus pain that was completely tolerable because the other question is is what is our goal is our goal to have zero pain or is our goal to have zero [SPEAKER_00]: Yeah, so that's a great question.

20:32 [SPEAKER_00]: We did Emily and I, we did another study with Jessica Littman as the first author, and we surveyed 110 patients. [SPEAKER_00]: And what we did is we used a new methodology to measure pain instead of asking patients and up-down did you have pain yesterday? [SPEAKER_00]: No, we used a 100-millimeter BAS scale.

20:58 [SPEAKER_00]: And we said, mark your pain with an X. When one side of the scale was no pain, and the other side of the scale was excruciane pain, or the worst pain in their lives. [SPEAKER_00]: And we defined a priority that 30 millimeters would constitute pain. [SPEAKER_00]: And what we found was that 40 patients, [SPEAKER_00]: and what we found, we found four things that were independently associated with pain during the necessary delivery.

21:32 [SPEAKER_00]: One was surgical duration. [SPEAKER_00]: We weren't surprised by that given that other studies have found this, it could in our own history of anxiety was associated with pain. [SPEAKER_00]: Interestingly enough, we did a validated catastrophizing questionnaire, and that was not associated with pain during cesarean delivery.

21:56 [SPEAKER_00]: As Emily was saying, activation of an angelian labor epidural catheter, and this is versus spinal or combined spinal epidural, and the adjusted odds ratio for that was 6.13, so very high risk of having pain if you're having an epidural catheter activated. [SPEAKER_00]: And we found that black race was also associated with pain during the Zaryn delivery at my hospital with the white race as the reference race and this finding was highlighted in the retrieval's podcast during the last episode.

22:32 [SPEAKER_00]: Now to answer your question about severe pain, we did ask a supper question about pain during the Caesarine Delivery as it was related to patient expectations. [SPEAKER_00]: We asked them was the pain worst, was it no pain, was it better than expected, was it as [SPEAKER_00]: was it a little worse than expected or was it a lot worse than expected?

23:04 [SPEAKER_00]: And what we found was that we found that seven patients or six percent reported pain that was much more than expected. [SPEAKER_00]: And another seven patients reported pain that was more than expected during [SPEAKER_00]: And so to answer your previous question, about 6% of patients are going to report that released in our study, 6% of patients reported severe pain and another 6% of patients reported pain that was worse than expected but not severe.

23:39 [SPEAKER_00]: And I think I'll let Emily talk about prevention and how we can prevent this kind of pain. [SPEAKER_01]: Yeah, I want it. [SPEAKER_02]: I do want to hear from you guys about that Emily about how we can prevent it and that I think takes us to the question of adjuvant meds, but I want to I want to say something else about like just the measure of which I think because I think I think one of the problems that we have an OB and a seizure right now is we haven't [SPEAKER_02]: agreed upon the best way to ask pain and so every study that you look at is asking about it a little bit differently and also within our practices were asking about a little bit differently so we heard on the retrievals how.

24:21 [SPEAKER_02]: Heather Nixon's group is like has a pop up in Epic where they're asking interoperatively and and I think you know that probably you know asking about it while it's while the surgery is happening is probably the best way to assess this. [SPEAKER_02]: But you know like is the best way to ask you know on as you know is zero to hundreds zero to 10 scale what your pain score is or did you have pain or so no.

24:48 [SPEAKER_02]: And currently right now, I think that we, number one, we don't have a valid validated outcome measure. [SPEAKER_02]: And two, there's definitely not a great upon way to ask this. [SPEAKER_02]: And so I think that really needs to be the next step in that we need to get together and figure out what is the right way to ask this.

25:03 [SPEAKER_02]: So then we can, I think, do a better job of defining the problem. [SPEAKER_02]: And that always helps, if you can define the problem, helps with answering the, how to solve it. [SPEAKER_01]: So it's been a while, but I think the way that we do anesthesia for vaginal deliveries is that we have a conversation with a patient, right?

25:30 [SPEAKER_01]: And we say, hey, do you want a funeral? [SPEAKER_01]: Do you want it now? [SPEAKER_01]: Do you want it later? [SPEAKER_01]: And the patient at some point will say, okay, you know, the pain is now at a point where I want the epidural. [SPEAKER_01]: right? [SPEAKER_01]: Do you imagine us getting to a point where that's how we do c-sections where you try it under niraxial and at some point if the patient says you know the pain is at a point now where I no longer want this I want to go to general just like a laboring patient who's having a vaginal delivery would at some point opt for the epidural the c-section patient would at some point have the option to opt for general.

26:04 [SPEAKER_01]: Like do you think is that where we're going does that make sense or not? [SPEAKER_02]: I hope that's where we're going. [SPEAKER_02]: I think some of those are actually practicing that way now. [SPEAKER_02]: So I think this actually goes really well along with prevention, but we kind of keep trying to take you there.

26:21 [SPEAKER_01]: Let's do it. [SPEAKER_01]: And so I've been mad. [SPEAKER_01]: Yeah. [SPEAKER_02]: So I think prevention begins with our consent of the patient. [SPEAKER_02]: So Ruthie Landau and I recently wrote a review article. [SPEAKER_02]: And in it, she established her framework for the informed consent process before cissary delivery.

26:38 [SPEAKER_02]: So important points that we need to discuss is that no no-neoraxial anesthetic will make women feel nothing. [SPEAKER_02]: We need to let them know that they're not going to go to the C-section and not feel anything if they're having the center interaction anesthesia. [SPEAKER_02]: And so I have a, like a spiel and residents that work with me know.

26:56 [SPEAKER_02]: I say the same thing every time and I might have, I don't, maybe I said this on the accurate before. [SPEAKER_02]: So I apologize that this is a repeat, but before it's necessary to live right, typically tell patient, it is normal to feel pressure pulling tugging. [SPEAKER_02]: You shouldn't feel anything sharp or cutting.

27:11 [SPEAKER_02]: There's a few times during your C-section, you're going to feel a little bit more pull, a little bit more tug and we'll try to warn you about those. [SPEAKER_02]: And then what I have added more recently is then I say now every once in a while a patient's going to have more than just discomfort or pulling during surgery and you're going to have pain.

27:29 [SPEAKER_02]: If that happens to you, I want you to speak up and I want you to tell me because our things that I can do to treat that. [SPEAKER_02]: And then it's actually sometimes I'll actually point to their epidural like put medicine in your epidural. [SPEAKER_02]: I can give you medicine, IV, or we can give you numbing medicine down with a certain [SPEAKER_02]: But I like I prompt them like if we're having pain tell me because you know the studies are showing that anesthesiologists are bad at telling that.

27:51 [SPEAKER_02]: And then I say and you know sometimes the pain we we can't treat your pain well enough. [SPEAKER_02]: We have to go off to sleep with the general anesthetic. [SPEAKER_02]: It's you know I that's not what I'm planning for you today but if we need to we can do that. [SPEAKER_02]: And I can do that safely for you some.

28:08 [SPEAKER_02]: I think it's important to have some sort of discussion with the patient about what to expect and then also moving beyond that we need to let the patient know that the anesthesiologist is going to check the quality of anesthesia that the surgeon will check the quality of anesthesia before proceeding.

28:34 [SPEAKER_02]: to speak up that we will acknowledge her pain and then we will treat her pain. [SPEAKER_01]: And checking is a really important question. [SPEAKER_01]: This came up in the retrievals of how do you test to see how adequate your block is? [SPEAKER_01]: And they mentioned that they think maybe putting a clamp on the skin is maybe not adequate or doing, I can't remember, the other things that they did, maybe a some sort of wetness or something.

28:59 [SPEAKER_01]: But so how should we be checking to see if the block is working? [SPEAKER_02]: Yeah. [SPEAKER_02]: I mean, if we go back to Susanna's story, part of it is that she really struggled to differentiate the difference between the cold fluid that they were spraying on her and she can tell that she was just going wet or cold and she describes a little bit that she was a little embarrassed that she had a hard time distinguishing that.

29:21 [SPEAKER_02]: So I think it's important that we we give the patient. [SPEAKER_02]: adequate time without pressure to allow them to assess their level of the block, both the ASA statement on pain-dressing-sacering delivery, as well as the OAA statement, recommend testing the block to light-touch. [SPEAKER_02]: And then also confirming the block with a straight leg raise and a clamp by the surgeon, [SPEAKER_02]: But even all of those as you a loop to may not be adequate, I think, you know, there's really no optimal method that has been determined for testing in our actual block that is going to predict a hundred percent full perfect surgical anesthesia.

30:05 [SPEAKER_02]: And, but I, you know, I think if we're going to be doing something sharp, and then we need to be testing with sharp. [SPEAKER_02]: So we have we, you know, in our hospital we use like a little plastic. [SPEAKER_02]: uh, bile, like, uh, one of those, I have gosh, I'm struggling with that, but the little introduces that we use to drop meds as kind of, uh, plastic sharp tip, I know some people use, uh, broken, tongue depressor, um, I've seen, you know, all, all different things that are used, but you do need to have something that's a little pokey, a little sharp if you are going to make sure that they're not going to fill the sharp knife of the incision for the cesarean.

30:41 [SPEAKER_01]: Yeah, that makes sense. [SPEAKER_01]: So, all right, so we, you said we start with consent. [SPEAKER_01]: We talk about the fact that there is going to be some discomfort, some pressure, although the retrieval's made the word pressure seem like it was a bad word and we should not be using it.

30:52 [SPEAKER_01]: Yeah. [SPEAKER_01]: And I think what I took from that is we can't little allow providers to just say, listen, [SPEAKER_01]: Pressure's normal. [SPEAKER_01]: That's probably just pressure. [SPEAKER_01]: Yeah, I know it's okay. [SPEAKER_01]: It's pressure. [SPEAKER_01]: Right. [SPEAKER_01]: It's one thing to say you may have some pressure, but tell me if it's if it's too much for you.

31:10 [SPEAKER_01]: It's another thing to just blame everything on pressure and not pay attention to the patient. [SPEAKER_01]: So that's kind of what I took from that. [SPEAKER_01]: But we so you said we got to make sure we're consenting correctly, explaining correctly what is going to happen and what and then we want them to speak up.

31:23 [SPEAKER_01]: We want to test well to see to best we can, how well the block is working. [SPEAKER_01]: And then [SPEAKER_01]: What else can we do to prevent and then treat pain if it happens to try to prevent GA again, not wanting GA to be a never event, but what do we do between deciding there is some pain here and GA?

31:43 [SPEAKER_01]: What's the approach to try to mitigate the need for GA? [SPEAKER_02]: So prevention is is so important and there's two different ways that we typically will provide anesthesia versus serendent liver and it's either with interethical medications or epidural medications. [SPEAKER_02]: So starting with interethical medications, which is, you know, typical we're using for our schedule C sections or Michael talk a little bit more about his approach in a minute.

32:10 [SPEAKER_02]: But we think that the combined use of local anesthetics and opioids is really important for achieving that effective Naraxia, I'm Azizha. [SPEAKER_02]: as not, you know, having that, you know, we use fentanyl in our hospital, some people who use soup fentanyl or alpha and all in other places, but it really helps prevent those bisterals and sensations that patients often will describe as pulling or tugging and has been shown to reduce pain or incestary delivery.

32:36 [SPEAKER_02]: When we're talking about injury-thecopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiopiop [SPEAKER_02]: has been determined to be 11.2 milligrams. [SPEAKER_02]: And you'll see in the US, the ASA statement recommends 12 milligrams.

32:53 [SPEAKER_02]: And I think most hospitals use 12 milligrams, or 1.6 ml of 3.4% bupivocaine as the common dose. [SPEAKER_02]: In our practice, we sometimes will increase our dose to 13.5 milligrams if we're concerned the surgery may be of longer duration, or, and or, we'll add up an effort [SPEAKER_02]: help with that additional duration as, you know, we've discussed that longer duration of surgery can definitely increase the problems with pain.

33:23 [SPEAKER_02]: So in addition to the interethical bupivicane dose, utilizing hidrethical fentanyl is another important component. [SPEAKER_02]: As I've already mentioned, but I wanted to discuss an important meta-analysis of 17 randomized [SPEAKER_02]: where he determined that Fendell added to Intereth Eagle but you could have can reduce interoperative analogies as supplementation by 82%.

33:51 [SPEAKER_02]: And so, when I hear about hospitals that aren't utilizing Intereth Eagle Fendell for the Shesaring deliveries, I just think that there's really no evidence to support the practice of not including it, and there really isn't any risk for the patient. [SPEAKER_02]: It's shown to have a great safety.

34:10 [SPEAKER_02]: Mike and I performed a study together evaluating different doses of interethical fentanyl and specifically compared 10 mics and 15 mics of interethical fentanyl. [SPEAKER_02]: And found that there was a 33% reduction in needing rescue analgesia intervention with a 15 mic dose compared to 10 mics.

34:32 [SPEAKER_02]: So, you know, my typical spinal, you know, for a C-section is 1.6 ml, a 3.4% B-pivicame, 15 mics, a fentanyl, and then 150 mics of interethical morphine. [SPEAKER_02]: But that's more so for post-operative pain, of course, that is not going to help us smudge for the topic at hand. [SPEAKER_02]: Now, in patients with labor epidural amalghesia, I think it's incredibly important to have active management of this catheter for successful conversion to surgical anesthesia.

35:04 [SPEAKER_02]: If an epidural is not providing adequate analgesia, it is not going to provide adequate surgical anesthesia. [SPEAKER_02]: And multiple studies have demonstrated that the occurrence of breakthrough pain, prior to see section, as well as the need, [SPEAKER_02]: for physician and ministered epidural topop boluses are correlated with the increased risk of pain during cistering delivery and need for supplemental medications.

35:30 [SPEAKER_02]: If you have a patient that is complaining of a unilateral analgesia, there are evidence that pulling back that catheter 1 to 2 centimeters may potentially help your block go both, you know, bilateral. [SPEAKER_02]: However, if analgesia remains insufficient catheter replacement, again, should occur.

35:51 [SPEAKER_02]: Now, depending on whether this is a serene delivery is urgent or emergent, then we typically will give, you know, light a cane 2% with app and nephrine for our non-emergent or a chloroporecane 3% with the addition of bi-carb to expedite onset for both of those. [SPEAKER_02]: in our emergence, see sections.

36:13 [SPEAKER_02]: And just like for Spimals, the addition of epidural fentanyl can improve the naraxial blockade and help with this role, sensations that the patients can experience. [SPEAKER_01]: And how much fentanyl do you give epidurally? [SPEAKER_01]: Stay with us, we'll be right back. [SPEAKER_01]: All right, and we're back.

36:33 [SPEAKER_02]: I give a hundred mics, and I think most studies will typically describe [SPEAKER_01]: Yep. [SPEAKER_01]: Okay. [SPEAKER_01]: Great. [SPEAKER_01]: So you've laid out techniques to try to maximize the effectiveness of your intersequal or epidural medications. [SPEAKER_01]: Let's say that you do that.

36:51 [SPEAKER_01]: You think you're in good shape, you start, but now some point during the procedure they're clearly having pain. [SPEAKER_01]: So now what do we do? [SPEAKER_01]: Obviously the end point here is convert to GA, but what do we do to try to avoid that? [SPEAKER_00]: I'm going to back up just to hear and discuss what we do in the instance of a patient who's got an indwelling labor epidural catheter.

37:18 [SPEAKER_00]: Just like Emily said, we should be actively managing these catheters and making sure they work correctly and the question becomes, what do you do if you have and [SPEAKER_00]: Yes, a patient who has an enjoying labor epidural catheter that's not working, and now they need a C-section. [SPEAKER_00]: If you dose up that epidural catheter, it's got a high chance of either not working at all or not working well enough to provide a pleasant experience.

37:46 [SPEAKER_00]: And so I am a big believer that we should be removing these labor epidural catheters in the operating room and performing a new, [SPEAKER_00]: then compasses a spinal anesthetic, and so if you look at three recent studies, one by Sanchez and colleagues and we talked about the Whitman and colleagues tell you that both of them were united together, and another study of systematic review of men analysis by Charles and colleagues, all three of these studies shared an association between [SPEAKER_00]: inadequate analgesia during cesarean delivery.

38:32 [SPEAKER_00]: And we, Emily and I, we did a study where we did a propensity match, retrospective review on patients who had activation, versus removal of a labor epidural catheter. [SPEAKER_00]: And what we did for the propensity match, is we did the indication for cesarean delivery like why they're having the cesarean delivery.

38:54 [SPEAKER_00]: And we looked at how many physician administered rescue boluses, the patients received during labor. [SPEAKER_00]: And that was a proxy or surrogum marker for how well the epidural catheter was working. [SPEAKER_00]: And so we came up with 124 patients in each cohort. [SPEAKER_00]: Then what we found was that patients who had removal of a labor epidural catheter filed by a new interaction technique had an odds ratio of 4.3 [SPEAKER_00]: of having a regional only anesthetic, that mean no additional anesthetic medications.

39:28 [SPEAKER_00]: And so this is, to me, this is pretty compelling evidence. [SPEAKER_00]: My current practice is that I have a very, very low threshold. [SPEAKER_00]: to remove labor-of-adural catheters and put in low-dose combined spinal epidural anesthetics. [SPEAKER_00]: This is not the constituent medical advice, but what my usual recipe is is I will do 1.2 milliliters of three-quarter percent having to be pivicane and I'll use the usual opioids in my hospital, which are 15 mics of fentanyl and 150 mics of morphing.

40:02 [SPEAKER_00]: And I'd like to do this in a combined spiral epidural technique because if the block is too low, the epidural catheter gives me an opportunity to move the block higher. [SPEAKER_00]: And our practice is such that about 40, 45% of our enjoying labor epidural catheters are removed and a new net and our actual technique is performed.

40:24 [SPEAKER_00]: Now this technique is not without its [SPEAKER_00]: and our cohort of hard 24 patients that had their catheters removed, three of them did not have completion of a new neural actual technique. [SPEAKER_00]: I think a lot of this had to do with urgency of the procedure, but they went to sleep anyway.

40:42 [SPEAKER_00]: And one patient of the 124 had to be intubated for what was a high spinal block with destiny. [SPEAKER_00]: And so this technique isn't foolproof, but I think it should be considered particularly for patients. [SPEAKER_00]: It's got risk factors for inadequate and ill-Jewsinesses during delivery.

41:02 [SPEAKER_01]: So Mike, that's great. [SPEAKER_01]: Let me give you a scenario and tell me what you would do here. [SPEAKER_01]: So you have a woman who's in labor. [SPEAKER_01]: She has an epidural in place. [SPEAKER_01]: Your resident gets called because she's having pain and goes and [SPEAKER_01]: Bollis is the epidural with 10 mls of, you know, whatever it is you're running, 8th percent view of the game.

41:23 [SPEAKER_01]: And then 30 seconds later, the OB's decide they have to do a C-section. [SPEAKER_01]: And by the way, the Bollis didn't help at all. [SPEAKER_01]: So you know, this is not a working epidural, but you also know they just got 10 mls in there. [SPEAKER_01]: Do you do the spinal with the dose, the 1.2 mls, or do you do something different?

41:42 [SPEAKER_00]: That's an amazingly good question. [SPEAKER_00]: And so this varies from patient to patient. [SPEAKER_00]: One of my considerations would be, or one of my things I would do would be to chest the block level as to see what that 10 ml's did for the patient. [SPEAKER_00]: If the block level is low, like if it's T10 or lower, then I'm probably going to remove the epidural and do a load of spinal.

42:08 [SPEAKER_00]: If the block level is high, [SPEAKER_00]: like if it's up to T4 on any level or any side of the patient, I'm going to be a lot more hesitant to do a spinal because I fear of hyneraxial block, but every patient is different and a lot of it has to do with [SPEAKER_00]: how the patient's airway looks, too, that this is a patient you could easily intubate, you might be a little bit more aggressive and removing that epidural and put in a spinal or a combined spinal epidural.

42:41 [SPEAKER_00]: If the patient is difficult appearing, you want to manage that airway under your own terms and not be in a reaction to a high spinal block. [SPEAKER_00]: And so, but I still have a strong preference and a low threshold to remove these enjoying labor epidural catheters and do low dose CSEs, particularly when the epidural is not working while for labor.

43:05 [SPEAKER_01]: Emily, how about you? [SPEAKER_02]: Yeah. [SPEAKER_02]: Well, and I think when you're managing this, you really have to consider the two different scenarios, right? [SPEAKER_02]: Because you have, you know, the epidural's just has been not very great. [SPEAKER_02]: for analgesia. [SPEAKER_02]: And so I, you definitely managed that differently than someone you've already started voicing.

43:23 [SPEAKER_02]: And I actually had a call, not recently. [SPEAKER_02]: It's been long enough that I've recovered, but I didn't have a call switch once, but I had two patients coming to the OR very similar times who had labor analgesia catheters that were not adequate. [SPEAKER_02]: And so I pulled both of them, [SPEAKER_02]: and one of them had unfortunately been bolus for a forseps delivery and so I you know she had already gotten a good amount of local anesthetic for that forseps had failed forseps and now we had a move to see section baby was doing fine so we had time to do a combined spinal epidural and I did a low dose spinal [SPEAKER_02]: But I did actually end up with a high spinal with her.

44:09 [SPEAKER_02]: So I did not do a low enough low dose. [SPEAKER_02]: Whereas the other patients hadn't had any bolus of her epidural, but she was starting to have pain. [SPEAKER_02]: And so we were able just to pull it, did a CSE for her and things worked out well. [SPEAKER_02]: So it's really the, I think you need to have a whole lot more caution when you're going to be pulling an epidural [SPEAKER_02]: If you've already started to bullise that epidural, that's, I think when we really get in trouble is when you've already given 15 or 20 ml of light a canicle or a protein and the epidural is not set up and now you're like, oh no, now I need to do something else and I could be really tricky.

44:54 [SPEAKER_02]: And Mike had a lot of great advice about considering the patient in the airway and such of whether you're willing to take that risk of putting a block that could potentially go high. [SPEAKER_02]: So. [SPEAKER_01]: Yeah. [SPEAKER_01]: Great points. [SPEAKER_01]: All right. [SPEAKER_01]: So let's then get back to this question of we've done everything we can to optimize the in our axial approach.

45:13 [SPEAKER_01]: It's not working. [SPEAKER_01]: The patient's having pain. [SPEAKER_01]: How do we handle that? [SPEAKER_01]: And this scenario is we're in the middle of the sees section. [SPEAKER_02]: Well, you're not supposed to have already put me in the middle of the C-section. [SPEAKER_02]: No, I think we've done a good job of talking about, you know, if your patients, if the cathode doesn't seem to be working beforehand, what we could do.

45:32 [SPEAKER_02]: And so, if the patient is experiencing pain during the C-section, then I think what we need, the first thing that we need to do is ask the surgeon to pause. [SPEAKER_02]: And, um, [SPEAKER_02]: If they're planning for, or if they've already done uterine ex-seriesation, or they're planning for that, you can ask them to close inside too, as studies have shown that there is less interoperative pain, as well as less nausea and vomiting, both interoperative and postoperatively in patients who have insight to repair of their uterus.

46:10 [SPEAKER_02]: And so a lot of times I'll work with my surgeons to be like, hey, could we close this, this one inside too. [SPEAKER_02]: And then reassure our patients. [SPEAKER_02]: We need to tell the patient and also the support person that's with them that you understand that they're uncomfortable.

46:25 [SPEAKER_02]: And then ask if they would like medications. [SPEAKER_02]: And if we're stopping surgery, we typically think that they would, you know, this all needs to be a shared decision-making process. [SPEAKER_02]: And, you know, [SPEAKER_02]: does the patient having pain or are they having anxiety?

46:41 [SPEAKER_02]: And discuss, you know, what's going on with them? [SPEAKER_02]: And then we need a minister of medication. [SPEAKER_02]: So tell the patient what you're what you're going to give them. [SPEAKER_02]: And then assess the effect of the intervention and then offer more if they need it. [SPEAKER_02]: So good practice is to offer general anesthesia.

46:57 [SPEAKER_02]: If it's effective, analgesias not achieved. [SPEAKER_02]: And, you know, there's a lot of different [SPEAKER_02]: adjuvant medications that we can give to treat this pain. [SPEAKER_02]: And I don't know if Mike wants to kind of take over and discuss these. [SPEAKER_01]: Mike, you want to talk about your approach here?

47:18 [SPEAKER_00]: Sure, so I was an honor for me to lead the working group on the recent ASA statement on the Juven Agents, the Ministry of Drain's is airing delivery, and we talked about all the different kinds of adjuven agents we can give, which includes medications given through the epidural catheter, that you can give epidural fatinal, like we talked about before, that's [SPEAKER_00]: intravenous medication, I think that either intravenous fattenal or intravenous dexmatdominine is a great personaline agent.

47:58 [SPEAKER_00]: And there is considerable difference amongst practitioners as to how to proceed. [SPEAKER_00]: after that. [SPEAKER_00]: There are some practitioners who think that ketamine is a perfectly good and aesthetic or analgesic medication that can be given. [SPEAKER_00]: It really does provide some good analgesia, but and it will make patients without pre-administered anxiety and leg agents.

48:24 [SPEAKER_00]: I think you run the risk of having some potential psychosis afterwards. [SPEAKER_00]: I'm not a big fan of ketamine, so other people are, I can't fault people for being enthusiasts of ketamine, but if my fentanyl and ordexmantobinine are not working, I will consider and held nitrous oxide.

48:44 [SPEAKER_00]: I think that's a potent anesthetic. [SPEAKER_00]: It doesn't have many [SPEAKER_00]: and held nitrous oxide aren't working. [SPEAKER_00]: Depending on the circumstance, sometimes you get into a scenario where the surgeon just has to throw in one or two last special stitches and I will occasionally give ketamine or [SPEAKER_00]: The surgeon just needs literally one or two minutes to throw in a couple of stitches and you think about it.

49:23 [SPEAKER_00]: If you were to do induction of anesthesia, you would give a lot higher doses that would last a longer period of time. [SPEAKER_00]: But I'm not a fan of giving perpetual serial big doses of ketamine profile just because I don't want to bite the bullet and do a journal aesthetic. [SPEAKER_00]: And obviously, we talked about before with shared decision-making, Dr. Alastasia is sometimes the best decision for the patient.

49:53 [SPEAKER_01]: Yeah, that makes a lot of sense. [SPEAKER_01]: Emily, anything to add there? [SPEAKER_02]: Yeah, I think each of us approach the medications that we give to patients differently. [SPEAKER_02]: Because if you do look at the guidelines, a lot of times they will, you know, recommend nitrous and ketamine.

50:10 [SPEAKER_02]: And those medications, and I agree with Mike, I'm not a can be a fan, but I actually don't typically use nitrous either. [SPEAKER_02]: And so my first approach after I've talked to the patient and told them the plan, if they do have an epidural catheter, I will administer additional local anesthetic through the catheter.

50:27 [SPEAKER_02]: And then for a pain medication, I'll usually reach for IV fentanyl and I often will combine that with IV dexment is homidine. [SPEAKER_02]: A pink continues, I often have actually had some pretty great success with inter-parachneal chloroproquin. [SPEAKER_02]: It's not widely used, but has been recently studied specifically by like Brennan, Tagioca and Portland, and basically, before his study, I would always do like 20 of chloroproquin and 20 of saline and mix them together, but he doesn't [SPEAKER_02]: Some studies to look at drug levels after administration of 40 MLs of chloroprocane and looked at patient drug levels and found that those were still within safe flowments.

51:17 [SPEAKER_02]: And so since the study was published, I now will do two vials of 20 MLs of chloroprocane. [SPEAKER_02]: I dumped it onto the kidney basin on the surgical field with and tell the surgeons [SPEAKER_02]: Um, tell them to not suction it up and actually I'll have them kind of, uh, swish it around a little bit.

51:42 [SPEAKER_02]: And, um, I've actually had some, some really great success. [SPEAKER_02]: If the, if the pain is happening later on and the patients, you know, we're, have a spite of that swearing off because, um, the surgery went a little bit longer and they're literally closing skin. [SPEAKER_02]: Sometimes we'll just do local anesthesia right there on the skin and that can, that can work as well.

52:05 [SPEAKER_02]: with, you know, with IV fentanyl, interparationial chloroprocane, then I'm talking to the patient. [SPEAKER_02]: And again, I also said I really like IV dexmenatomini. [SPEAKER_02]: And so usually, you know, I'll start a little bit at the fentanyl, but then go a little bit more heavy hand up with my dexmenatomini.

52:24 [SPEAKER_02]: But if I can't get the patient comfortable then, then it's time to move on to the discussion of general anesthesia. [SPEAKER_01]: So let me ask you this, let's say that you have a patient and they start to see section and after shortly after the start, they're saying, I'm having pain and you say, okay, I'm gonna give you, maybe you try some epidural or stuff that doesn't work and then you say, okay, let me give you some IV fentanyl or IV dexmeditomidine.

52:49 [SPEAKER_01]: And they say, no, no, I don't do that. [SPEAKER_01]: I don't want that. [SPEAKER_01]: I'm worried about it getting to the baby. [SPEAKER_01]: I just wanna go to sleep. [SPEAKER_01]: Are you going to do, is that okay? [SPEAKER_01]: You say, okay, no problem. [SPEAKER_01]: Let's just do GA, or do you say, well, I'd really like to try these other medications first.

53:01 [SPEAKER_01]: You know, what's your algorithm there? [SPEAKER_02]: Well, a lot of times, I mean, I often I was doing almost everything at once. [SPEAKER_02]: I often don't do like a separate, why is it approach? [SPEAKER_02]: But I mean, if at any point, the patients were requesting general anesthesia, then I'll let them have it.

53:19 [SPEAKER_02]: I'm not going to deny that from them. [SPEAKER_02]: And I do, in my discussion, when [SPEAKER_02]: When I'm talking with the patient, she's having pain and say, okay, so my plan is I'm going to give you some medicine in there, but they're all going to give you some medicine, IV. [SPEAKER_02]: And, you know, these are the steps we're going to XYZ.

53:33 [SPEAKER_02]: And if at any point, you know, you feel like this isn't working, then we'll go off to sleep. [SPEAKER_02]: But I have to, you know, you do need to be careful with that, because you don't want the patient to feel like, oh, she can, she can handle it, kind of like, with Susanna described.

53:48 [SPEAKER_02]: And so, you know, I, [SPEAKER_02]: If I see the patient having pain, I say, this doesn't look like it's working. [SPEAKER_02]: I think we need to go to sleep. [SPEAKER_02]: But at any point, a patient requests it. [SPEAKER_02]: I'm not going to deny them that. [SPEAKER_01]: And what if the patient gets into the subtleties of the consent process?

54:07 [SPEAKER_01]: But let's say the patient says, I want to go to sleep, but only if it's not going to put me or the baby at risk. [SPEAKER_01]: Do you say, I'm confident it won't. [SPEAKER_01]: Do you say, well, look, there's always risk. [SPEAKER_01]: Because again, this is like, if you say there's risk, then some number of people, because I say, well, listen, I'd rather take the pain.

54:27 [SPEAKER_01]: I don't want to put my baby at risk. [SPEAKER_01]: I'd rather take the pain. [SPEAKER_01]: Others. [SPEAKER_01]: might feel differently. [SPEAKER_01]: But so, you know, where is our responsibility in terms of being honest, but not discouraging of GA? [SPEAKER_01]: This is where it gets really subtle.

54:39 [SPEAKER_02]: It's very subtle. [SPEAKER_02]: It's very tricky. [SPEAKER_02]: And so, I think this is where, I mean, and hopefully you're at a point in the surgery where you can have the surgeons' posse, you have a little bit of time for discussion. [SPEAKER_02]: And that's when we have a discussion about the risks of general because there is no such thing as no risks.

54:57 [SPEAKER_02]: And, you know, you can say, you know, your airway looks fine. [SPEAKER_02]: I think it would be a good but pregnant women are increased risk for, for, for a difficult intubation. [SPEAKER_02]: But so that, so that, you know, and if they're requesting general anesthesia prior to delivery, then 100% chance that, you know, the meds will cross over to baby as well.

55:16 [SPEAKER_02]: And so, I definitely think it's important to talk to the patient about that. [SPEAKER_02]: And then, [SPEAKER_02]: Like you said, then they maybe would be like, no, actually, at least me, you know, let me decide. [SPEAKER_02]: And I mean, I had a terrible case of where a woman had a lot of pain during her see section.

55:34 [SPEAKER_02]: And I said recommended that she go off to sleep and she was like, no, no, I don't want to go off to sleep. [SPEAKER_02]: And [SPEAKER_02]: So I did a couple other things and the surgeon started again as she was having a lot of pain. [SPEAKER_02]: And I was just, I said, I feel really uncomfortable.

55:49 [SPEAKER_02]: I feel like we need to have you drift off to sleep and the patient refused to go off to sleep with general anesthesia. [SPEAKER_02]: And fortunately, for that case, things were emergent. [SPEAKER_02]: And so that's why everything was kind of happening quickly. [SPEAKER_02]: And once her epidural actually set up, [SPEAKER_02]: We were able to go.

56:09 [SPEAKER_02]: But the first few minutes of the case, the patient had a lot of pain and was screaming. [SPEAKER_02]: And, you know, myself and the amazing CRNA era was working with really wanted to have her go to sleep. [SPEAKER_02]: And, but the patient refused. [SPEAKER_02]: And so, I'm not going to assault her with my general anesthetic.

56:28 [SPEAKER_02]: And I had to abide by her desires. [SPEAKER_02]: And, um, [SPEAKER_02]: And, you know, I, of course, you know, went and followed up with her afterwards about it, because I said, you had a lot of pain beginning of your C section. [SPEAKER_02]: Let's talk about it. [SPEAKER_02]: But she ultimately actually is really pleased with how things went because she was able to be awake and that's what she wanted.

56:50 [SPEAKER_02]: And that's really, I think those are the hardest cases as anesthesiologists because like our goal is to just like, [SPEAKER_02]: take care of our patients and provide them safe and comfortable experience and when we aren't able to do that in a patient has pain yet they aren't listening to whatever recommendations are I mean that's that's you know patient autonomy is really hard sometimes yep totally alright so let's talk about the conversion to GA let's say it's the patient says this is not tolerable I want to go to sleep we want to be open to that um [SPEAKER_01]: how are we going to do it, or what is there other certain techniques do we go straight to the VL is that kind of standard of care these days or not?

57:31 [SPEAKER_01]: What medications are we using? [SPEAKER_01]: Is it purple false socks? [SPEAKER_01]: Is it something else? [SPEAKER_01]: How are we approaching it? [SPEAKER_00]: Yeah, so I think this is what strikes fear in the hearts of people and converting to trial and asthesia. [SPEAKER_00]: What do you do?

57:47 [SPEAKER_00]: How do you do it? [SPEAKER_00]: And so, one of the older studies from the mid-2010s quoted a field area risk for obstetric patients of about one in 500, [SPEAKER_00]: And that figure has been updated with a more recent published in 2022 using MPHG data. [SPEAKER_00]: And what they found was that the risk of field intubation was now 1 and 800.

58:16 [SPEAKER_00]: This includes the use of video learningoscopy. [SPEAKER_00]: And so I think that as you said before, our tools for managing the airway are much different today than they were in the 80s. [SPEAKER_00]: And so that being said, I think it's 2025, I think that every single obstetric operating room should have at least the availability of video there in Goscopy.

58:45 [SPEAKER_00]: And I think we're going towards [SPEAKER_00]: using video-arengoscopy as the first line, as the first line technique, and with the hyper-angulated blade, like a d-blade on the C-max system, for instance, you're obligated to look at the screen. [SPEAKER_00]: and not do direct learningoscopy.

59:08 [SPEAKER_00]: It is possible to use a Mac, Macintosh style video learnedoscopy blade and the operator can still do direct learningoscopy and then switch to video learningoscopy if they so wish. [SPEAKER_00]: My personal practice and this may vary from others is I will typically just use a hyper-angly blade because we've gotten so good at it.

59:33 [SPEAKER_00]: and it's the file having pathway. [SPEAKER_00]: If we, everything else fails, we go to the hyper-ingulate blade. [SPEAKER_00]: So my, my thing is just to go the hyper-ingulate blade anyway. [SPEAKER_00]: And I think that's, in these circumstances, [SPEAKER_00]: You have to take, for particularly in training institutions, you have to take a critical look at the patient and the trainee.

59:56 [SPEAKER_00]: It should be the most experienced operator who's doing this intubation. [SPEAKER_00]: It doesn't necessarily have to be the attending, but if I've got a CA1 who's only done less than 100 intubations, they're probably not going to do [SPEAKER_00]: the perturing and airway for a C-sections, probably going to be either a senior resident if they're available or just myself.

1:00:20 [SPEAKER_00]: And so I think we have to really kind of wave the interest of the patients against the our goals of train or resonance. [SPEAKER_00]: And for managing the airway, I think one thing to keep in mind, if you remember anything else from this talk, is that [SPEAKER_00]: An LMA is permissible and acceptable for managing the airway particularly when you are unable to intubates with video learning, learning tooscopy, or any other technique, and the OAA, and the difficult airway society guidelines, state that you can use, [SPEAKER_00]: a laryngeal mask airway to not only rescue yourself in the other way, but to do the rest of the case, particularly when you have a fetus that's in trouble and you don't want to take extra time imagine the airway.

1:01:14 [SPEAKER_00]: And I had a case like this once where I just couldn't anticipate the patient. [SPEAKER_00]: We put an LMA in, we got the baby out and with my most nicest tone, I asked the obese if they could just [SPEAKER_00]: go as quickly as they could, and they did, and that case ended up really well.

1:01:30 [SPEAKER_00]: I've heard of Actal reports and the scene case studies where anesthesologists were per severates on trying to secure the airway while the fetus is dying, and by the time they secure the airway, there has already been some bad neonatal outcome. [SPEAKER_00]: Now, for the induction of anesthesia, we're typically using purple fall and succinal calling, the use of opioids is plus minus.

1:02:03 [SPEAKER_00]: If you give fentanyl, you have the chance of causing some neonatal depression. [SPEAKER_00]: There's a study by white and colleagues that showed that compared to placebo, fentanyl reduced [SPEAKER_00]: some other induction agents did not, like remedy fentanyl, alpha and all, did not. [SPEAKER_00]: There are some people, myself included, who will use as well as an induction and use it for the effects of mitigating the sympathetic response to Leningoscopy.

1:02:39 [SPEAKER_00]: As far as what we do with volatile anesthetics, you want to limit the volatile anesthetics prior to delivery, but you also want to be able to deliver 100% FIO2 to the patients so that the fetus has a good oxygen, so the fetus is receiving enough oxygen. [SPEAKER_00]: So if the patient's oxygen saturation is below 97%, I'm reluctant to give nitrous oxide prior to delivery.

1:03:08 [SPEAKER_00]: After delivery, we know that volatile anesthetics will decrease uterine tone and it could increase blood loss. [SPEAKER_00]: And so we will try to decrease volatile anesthetics by the mystery nitrous in place of some of the volatile. [SPEAKER_00]: And one of our colleagues from across the pond.

1:03:30 [SPEAKER_00]: advocates for Tiva, total intravenous anesthesia with purple fall, that that could provide a better profile for blood loss. [SPEAKER_00]: And that's a great idea. [SPEAKER_00]: The problem is is implementing it in the middle of the night when you have a stat section. [SPEAKER_00]: It's hard to do.

1:03:49 [SPEAKER_01]: Great Emily anything to add? [SPEAKER_02]: Yeah, on that Tiva, so yeah, I use a lot of this of similar medications, but we actually do a Tiva for every see section that we do under general in a seizure. [SPEAKER_02]: We typically don't start with a Tiva just as you say when it's a merger.

1:04:04 [SPEAKER_02]: You don't have time to set up the proposal on fusion because this is typically a merger. [SPEAKER_02]: We don't have the time and so we will start with volatile agents, but once we've gone through all of our required checklist of the things that we need to do and we're settling things [SPEAKER_02]: Um, for the patient, um, the first elective thing that we do is we pull out our profile of fusion and move the patient to, um, complete, uh, um, IV anaesthetic because I do think that, um, it can help with that uterine tone profile.

1:04:35 [SPEAKER_02]: These are young healthy women who have a high risk of post-up nausea and vomiting. [SPEAKER_02]: And so that's going to help that as well. [SPEAKER_02]: And so, um, we do that. [SPEAKER_02]: And we do have, um, um, [SPEAKER_02]: like RemiFat and I'll available in our pick and all of our OB and a seizure pixis machines, so that if the patient has specific cardiac disease or poorly controlled hypertension with their pre-clampsia, things like that, and they do feel like they need something more than just propsucks too.

1:05:06 [SPEAKER_02]: We do have RemiFat and I'll available to administer for those unique cases, but for the most part, we do [SPEAKER_01]: Great. [SPEAKER_01]: All right. [SPEAKER_01]: This has been fabulous. [SPEAKER_01]: Anything that we didn't cover that you want to add before we move on. [SPEAKER_01]: Either of you.

1:05:21 [SPEAKER_00]: Again, I think that take our message here is the tile that's hot, just poem to sleep. [SPEAKER_00]: I think if a patient is experiencing an adequate analgesia and you've tried to treat it with adjunct of medication and the patient still wishes to go off to sleep, I think we need to just put them off to sleep.

1:05:40 [SPEAKER_01]: Yeah, I mean, that's I think that's the paradigm shift and it's it's so important, right? [SPEAKER_01]: Is that practitioners have to feel supported in that decision? [SPEAKER_01]: They can't feel like that's a violation of the standard of care and that is how it is felt. [SPEAKER_01]: I had no question when I was a resident.

1:05:57 [SPEAKER_01]: I felt like the message we were getting was avoided at all costs. [SPEAKER_01]: Um, and so that's that's what has to change and this is great that we're doing this because this message is going to get out there as long as the bit might you give and talks the retrievals what others doing Emily what you're doing this is all going to Eventually move that needle so that's why this is fabulous and I really appreciate you guys share in the message Let's move on to the part of our show where we make random recommendations Emily what would you recommend the audience check out for fun.

1:06:28 [SPEAKER_02]: Okay, so I just finished this book on Monday. [SPEAKER_02]: And the author is Frederick Bachman, who is actually one of my favorite authors. [SPEAKER_02]: So if you are familiar with either his bare town series, man called Uva, or anxious people, then I think you'll really like this book.

1:06:48 [SPEAKER_02]: His most recent book is called My Friends. [SPEAKER_02]: That was just translated into English this year. [SPEAKER_02]: But it's a story of 14agers. [SPEAKER_02]: um, and a powerful summer, um, where they find connection. [SPEAKER_02]: And then many years later, their story, um, hasn't unexpected impact on a, uh, another young stranger's life.

1:07:10 [SPEAKER_02]: Um, but it is just typical, um, Bachman, um, writing with, um, a lot of humor and, um, there's, there's moments of, of tears and moments of joy and, um, I know, it was really fun and I'd highly recommend [SPEAKER_02]: Um, reckon in the book. [SPEAKER_01]: That's awesome. [SPEAKER_01]: I just started it.

1:07:29 [SPEAKER_01]: So I'm excited to, uh, I'm excited to keep reading. [SPEAKER_01]: Yeah. [SPEAKER_01]: Absolutely. [SPEAKER_01]: That's awesome. [SPEAKER_01]: Mike, how about you? [SPEAKER_00]: I am far less cultured than the two of you. [SPEAKER_00]: My recommendations a little more low brow. [SPEAKER_00]: I recommend you go see the newest Jurassic World movie.

1:07:47 [SPEAKER_00]: I've been a fan of the Jurassic World franchise since I was a high school student in the 90s. [SPEAKER_00]: They made a part of our science class to discuss DNA and the theoretical concepts of Jurassic Park. [SPEAKER_00]: And the current Jurassic World [SPEAKER_00]: Not to give too much away, but the promise is that these big dinosaurs did not have cardiovascular disease and some drug company is interested in getting biosamples from these dinosaurs so that they can develop the next blockbuster cardiovascular drug.

1:08:24 [SPEAKER_00]: And at this point in time, the dinosaurs have become kind of extinct again, because the whole human race is sick of dealing with them. [SPEAKER_00]: And there's one prohibited island that no one's supposed to visit, and they go visit it and try to get these samples. [SPEAKER_00]: And I'll leave it at that.

1:08:42 [SPEAKER_00]: I don't want to spoil the movie. [SPEAKER_00]: But it's a really fun movie. [SPEAKER_00]: Obviously, better to see it the movie theater, if you can, because of the sound and the effects. [SPEAKER_00]: But I think it's still enjoyable if you can watch them in your home. [SPEAKER_01]: fabulous.

1:08:55 [SPEAKER_01]: I am going to recommend two things my wife and I'm my wife and I saw the new Superman movie and thought it was it was actually quite good. [SPEAKER_01]: I don't it's it I grew up with the Christopher Reeve superman's and I can't I don't think everything anything is as good as those but despite that it was [SPEAKER_01]: pretty entertaining and I think worth seeing.

1:09:15 [SPEAKER_01]: And then a book called The Door Man by Chris Pavone, which is quite good. [SPEAKER_01]: It's not super deep, but entertaining, read, set in New York City. [SPEAKER_01]: The main character is a door man in a very wealthy apartment building right on Central Park and there's a lot of things that happen.

1:09:33 [SPEAKER_01]: I won't give away, but it's entertaining, easy, read, nice summer read. [SPEAKER_01]: So I recommend that. [SPEAKER_01]: All right, Emily and Mike, thank you so much for [SPEAKER_00]: Thank you for having us. [SPEAKER_02]: Yeah, thank you for giving us a platform to be able to talk about this important topic in anesthesia.

1:09:51 [SPEAKER_01]: All right, hopefully you got as much out of that as I did. [SPEAKER_01]: That was really fantastic. [SPEAKER_01]: Let us know what you thought. [SPEAKER_01]: Go to the website,acrack.com where you can leave a comment. [SPEAKER_01]: Others can learn from what you have to say. [SPEAKER_01]: If you are a fan of the show, you can follow us.

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1:11:09 [SPEAKER_01]: Our original ACRAG music is by Dr. Dennis Quow. [SPEAKER_01]: You can check out his website at studymusicproject.com. [SPEAKER_01]: All right, that is it for today. [SPEAKER_01]: For the ACRAG podcast, I'm Jed Wolpa. [SPEAKER_01]: Thanks for listening. [SPEAKER_01]: Remember what you're doing out there every day is really important and valued.