Thread by @OBsleepmerchant

Dr Eva Roofthooft (from @gzaziekenhuizen) talks on new drugs in #OBAnes at #OAA3dc2022

What are we really talking about? As @MarcVandeVelde6 pointed out for LEA mix is pretty standard, spinal less so? Adjuvants are #OBAnes aspiring to cocktail perfection, to address problems and achieve desires #OAA3dc2022

Dr Eva Roofthooft (@gzaziekenhuizen) summarizes advantage of opioids, but as these are surely standard practice (not experience of @HofkampMichael & @emilysharpe), moves on to clonidine & dexmedetomidine. Dexmedetomidine 7 x more selective than clonidine. #OAA3dc2022

Neither clonidine or dexmedetomidine are new to anesthesia practice. Clonidine epidural has a black box warning in North America (not intrathecal use though). Low dose clonidine added to epidural has advantages, although maternal BP lower. #OAA3dc2022

Clonidine bolus in epidural May have advantages for treating breakthrough pain. Adding neostigmine counteracts the hypotension. Check institutional policies before introducing to your practice? #OAA3dc2022

Intrathecal clonidine? Potentially advantageous - but more sedation and hypotension. Then again we actively manage hypotension from neuraxial anyway? Dr Roofthooft’s clondinine perspective: epidural YES, intrathecal NO.

Dexmedetomidine good adjuvant for epidurals.
#OAA3dc2022

Dexmedetomidine benefit maxes out at 0.4mcg/mL. Efficacy and safety may depend on what you compare it to. Lots of studies demonstrate multiple advantages with tolerable side effects. Synergistic effects on sedation and analgesia a positive. #OAA3dc2022

Only possible question arises that vast majority of studies smaller and only in one population, however, addition of dexmedetomidine may improve effectiveness of intrathecal ropivacaine & give same analgesia as sufentanil, with less shivering & pruritis. #OAA3dc2022

With exception of 1min Apgar (which has no relevance?) & Ua PCO2 - dexmedetomidine has no adverse fetal effects used intrathecally for cesarean. Animal studies raise potential for neurotoxicity at epidural -further study needed. Summary slide = positive. Need studies
#OAA3dc2022

Chloroprocaine is not a new drug with clear potential advantages. #OAA3dc2022

Norway has been using 3% Chloroprocaine for extension of epidural for emergency cesarean. Not common in UK and Belgium though. #OAA3dc2022

Epidural mixtures (as seen @ArviPalanisamy’s lecture) fastest only 8 minutes faster (when/where start activating may impact). Adding HCO3 to 2% lidocaine beats 3% Chloroprocaine, but MUST be preservative free. Fastest options require mixing = #patientsafety risk? #OAA3dc2022

Do mixing time & potential 4 errors cancel speed of onset of mixtures? Could 3% Chloroprocaine be fastest, safest (IF available)? May be best 4 breakthrough if prophylactic top-up given (ropivacaine 0.75% otherwise) CAUTION: plasma cholinesterase deficiency = seizures
#OAA3dc2022

What of dexmedetomidine IV? Has pro’s & con’s. Adjuvant to both spinal & GA cesarean sections. Definitely beneficial in reducing shivering postop after spinal. Dexmedetomidine IV unlikely to affect infant/breastfeeding. Beneficial to parturients under epidural as well
#OAA3dc2022

While placental transfer ranges 0.68 - 0.76, no neonatal adverse events noted. Compared with remifentanil, dexmedetomidine has better 1 min Apgar (relevance?) Ultimately, 15-30mcg relieves shivering, but more studies needed for any other conclusions.
#OAA3dc2022

Dr Roofthooft highlights this important work in @Anaes_Journal from @noolslucas @MarcVandeVelde6 @DevroeSarah @rex_steffen. No evidence in general population for association between prenatal anesthesia exposure and impaired neurodevelopmental outcomes. #OAA3dc2022

“New” drugs after cesarean section: dexamethasone. Link back to PROSPECT trial in #OAA3dc2019 (was “gold” standard then) - still a good choice now (5-8mg). #OAA3dc2022

In terms of analgesic effects of dexamethasone, doses closer to 0.1mg/kg (most 8-10mg) associated with improved analgesia in meta-analysis in @EJA_Journal
#OAA3dc2022

Conclusions from Dr Eva Roofthooft regarding new (and old) drugs in #OBAnes. #OAA3dc2022

@threadreaderapp unroll please