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Nov 8, 2022 20 tweets 23 min read Read on X
Dr Eva Roofthooft (from @gzaziekenhuizen) talks on new drugs in #OBAnes at #OAA3dc2022 ImageImageImage
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 ImageImageImageImage
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 ImageImageImageImage
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 ImageImageImageImage
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 ImageImageImage
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 ImageImageImageImage
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 ImageImageImageImage
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 ImageImageImageImage
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 ImageImageImage
Chloroprocaine is not a new drug with clear potential advantages. #OAA3dc2022 ImageImageImageImage
Norway has been using 3% Chloroprocaine for extension of epidural for emergency cesarean. Not common in UK and Belgium though. #OAA3dc2022 ImageImageImage
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 ImageImageImageImage
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 ImageImageImageImage
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 ImageImageImageImage
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 ImageImageImage
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 ImageImageImage
“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 ImageImageImageImage
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 ImageImageImage
Conclusions from Dr Eva Roofthooft regarding new (and old) drugs in #OBAnes. #OAA3dc2022 ImageImage
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More from @OBsleepmerchant

May 9
@SQuashie presents an update on anesthesia for operative delivery. Declarations. Methodology and themes. #OAA24ASM #OBAnes

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Gastric USS. Oral rehydration has benefits over NPO wrt vasopressor use. #siptilsend safe, noting some patients have increased gastric volumes irrespective of starvation status. #OAA24ASM #OBAnes
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@SQuashie continues at a rapid pace. To DPE or not to DPE remains a question - 16min vs 19 min, is that 3 min clinically relevant? Esketamine for supplemental analgesia - >95% had psych effects, read @rjharrison79 editorial. #OAA24ASM #OBAnes
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Read 16 tweets
May 9
@Jamesocarroll presents an Update on Labour and Delivery. Disclosures #OAA24ASM #OBAnes

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How the lecture was put together. Screening. Themes. How to interpret the slides. Very Ostheimer-esque @Jamesocarroll #OAA24ASM #OBAnes


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@Jamesocarroll Clinical practice theme: intrathecal catheters & ADP. Intrathecal catheters: No decrease in PDPH, but reduction in EBP. 10mL intrathecal saline decreased PDPH & need for EBP. Of note, the percentage of epidurals requiring multiple attempts. #OAA24ASM #OBAnes

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Read 17 tweets
May 5
8am-ish in Denver and time for a much anticipated session: PDPH beyond the guidelines. Moderated by Dr Lisa Leffert, featuring @Ropivacaine, @euklaas, @sharonOzynger and @WouterSchievink at #SOAPAM2024 #OBAnes

(HT: @Ropivacaine, bless his heart, he knows I hate missing out)

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Hot off the Press? August 2023! @JAMANetworkOpen with quite an illustrious team including @Ropivacaine @robin_russell1 @KalagaraHari @LimGrapes @claralexlobo @noolslucas @NarouzeMD (please tag others if you have their handles?) #SOAPAM2024 #OBAnes

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Introduction, Methods and the 10 questions. #SOAPAM2024 #OBAnes

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Read 11 tweets
Jun 12, 2023
Next up at #CASAM2023 - fittingly keeping the most important academic session to last: #OBAnes
@ValZaph moderating the Maternal Experience and Outcomes: Improving the care we provide. @DrWesleyEdwards

Bookends the 1st #OBAnes session, on intrapartum pain at cesarean section… twitter.com/i/web/status/1… Image
Dr Christina Lamontagne kicks off the session with: Use of Dexmedetomidine in improving maternal experience and outcomes. Nothing to disclose. Then an important disclosure: All indications discussed are OFF LABEL in Canada. Objectives.
#OBAnes #CASAM2023 ImageImageImageImage
Why does Dr Lamontagne use a lot of dexmedetomidine (not only in #OBAnes mind)? Clinical pharmacology of dexmedetomidine (1): highly selective alpha-2 agonist; sedation WITHOUT amnesia at locus coeruleus. #CASAM2023 ImageImageImage
Read 9 tweets
Jun 11, 2023
Dr Ning Nan Wang introduces @harshamd5 to open the chronic pain session: Perioperative use of opioid in the context of Opioid Epidemic. #CASAM2023 ImageImageImage
The opioid crisis isn’t new - China probably remembers the Opium wars that helped establish a British foothold on the continent. Opioids and OUR crisis. Is what we fear the real crisis? Are opioid-related deaths due to surgical prescriptions? No, mostly due to street fentanyl.… twitter.com/i/web/status/1… ImageImageImage
Opioid use around the time of surgery. Understanding nociception vs pain. Does eliminating opioids during surgery make a difference - no definitive conclusions. #CASAM2023 ImageImageImage
Read 11 tweets
Jun 10, 2023
@DrLucieFilteau introduces @CMA_Docs president @AlikaMD for his keynote address at #CASAM2023 Image
@AlikaMD starts with the state of the 🇨🇦 health system, including a little history. #CASAM2023 ImageImage
The 🇨🇦 health system approach to problems, creating new problems as a result with a dangerous lack of interoperability. #CASAM2023 ImageImageImage
Read 12 tweets

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