Dr. Gopika Hari and Dr. Lana Joudeh join the podcast to discuss the literature on the safety of peripartum opioid use and its implications for breastfeeding.

Dr. Hari is an anesthesia resident in the MGH Anesthesia Residency Program and a graduate of Washington University School of Medicine in St. Louis. Dr. Joudeh completed her anesthesia residency at Massachusetts General Hospital and is currently a faculty member. This episode was produced as part of the Depth of Anesthesia podcast elective.

Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.

—

Follow us on Instagram @DepthofAnesthesia for podcast and literature updates.

Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team.

Music by Stephen Campbell, MD.

—

References

​American Society of Anesthesiologists. Statement on Resuming Breastfeeding after Anesthesia. Amended October 23, 2024. Available at: https://www.asahq.org/standards-and-practice-parameters/statement-on-resuming-breastfeeding-after-anesthesia. Accessed April 6, 2025.

Mitchell J, Jones W, Winkley E, Kinsella SM. Guideline on anaesthesia and sedation in breastfeeding women 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2020 Nov;75(11):1482-1493. doi: 10.1111/anae.15179. Epub 2020 Aug 1. PMID: 32737881.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1. Obstet Gynecol. 2021 Sep 1;138(3):507-517. doi: 10.1097/AOG.0000000000004517. PMID: 34412076.

Robieux I, Koren G, Vandenbergh H, Schneiderman J. Morphine excretion in breast milk and resultant exposure of a nursing infant. J Toxicol Clin Toxicol. 1990;28(3):365-70. doi: 10.3109/15563659008994437. PMID: 2231835.

Baka, N.-E., Bayou Menu, F., Boutroy, M.-J., & Laxenaire, M.-C. (2002). Colostrum morphine concentrations during Postcesarean intravenous patient-controlled analgesia. Anesthesia & Analgesia, 94(1), 184–187. https://doi.org/10.1213/00000539-200201000-00035

Wittels B, Glosten B, Faure EA, et al. Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates. Anesth Analg. 1997;85(3):600-606.

Lam J, Kelly L, Ciszkowski C, et al. Central nervous system depression of neonates breastfed by mothers receiving oxycodone for postpartum analgesia. J Pediatr. 2012;160(1):33-37.e2.

Seaton, S., Reeves, M., & McLean, S. (2007). Oxycodone as a component of multimodal analgesia for lactating mothers after Cesarean section: relationships between maternal plasma, breast milk and neonatal plasma levels. The Australian & New Zealand journal of obstetrics & gynecology, 47(3), 181–185. https://doi.org/10.1111/j.1479-828X.2007.00715.x

Edwards, J. E., Rudy, A. C., Wermeling, D. P., Desai, N., & McNamara, P. J. (2003). Hydromorphone Transfer into Breast Milk After Intranasal Administration. Pharmacotherapy, 23(2), 153–158. https://doi.org/10.1592/phco.23.2.153.32081

Oommen, H., Oddbjørn Tveit, T., Eskedal, L. T., Myr, R., Swanson, D. M., & Vistad, I. (2021). The association between intrapartum opioid fentanyl and early breastfeeding: A prospective observational study. Acta obstetricia et gynecologica Scandinavica, 100(12), 2294–2302. https://doi.org/10.1111/aogs.14268

Goma, H. M., Said, R. N., & El-Ela, A. M. (2008). Study of the newborn feeding behaviors and fentanyl concentration in colostrum after an analgesic dose of epidural and intravenous fentanyl in cesarean section. Saudi medical journal, 29(5), 678–682.

Stocki D, Matot I, Einav S, Eventov-Friedman S, Ginosar Y, Weiniger CF. A randomized controlled trial of the efficacy and respiratory effects of patient-controlled intravenous remifentanil analgesia and patient-controlled epidural analgesia in laboring women. Anesthesia & Analgesia. 2014;118(3):589-597.

Dr. Jess Hawkins joins the show to discuss the literature pertaining to remifentanil and opioid-induced hyperalgesia. Dr. Hawkins is an anesthesia resident at the Massachusetts General Hospital.

This podcast was recorded as part of the Depth of Anesthesia podcast elective.

Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.

—

Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates.

Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team.

Music by Stephen Campbell, MD.

—

References

Peter Yi, MD, Peter Pryzbylkowski, MD, Opioid Induced Hyperalgesia, Pain Medicine, Volume 16, Issue suppl_1, October 2015, Pages S32–S36, https://doi.org/10.1111/pme.12914

Angst MS, Koppert W, Pahl I, Clark DJ, Schmelz M. Short-term infusion of the mu-opioid agonist remifentanil in humans causes hyperalgesia during withdrawal. Pain. 2003 Nov;106(1-2):49-57. doi: 10.1016/s0304-3959(03)00276-8. PMID: 14581110

Joly V, Richebe P, Guignard B, Fletcher D, Maurette P, Sessler DI, Chauvin M. Remifentanil-induced postoperative hyperalgesia and its prevention with small-dose ketamine. Anesthesiology. 2005 Jul;103(1):147-55. doi: 10.1097/00000542-200507000-00022. PMID: 15983467

Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a meta-analysis. Br J Anaesth. 2014 Jun;112(6):991-1004. doi: 10.1093/bja/aeu137. PMID: 24829420

Comelon M, Raeder J, Stuhaug A, et al. Gradual withdrawal of remifentanil infusion may prevent opioid-induced hyperalgesia. Br J Anaesth 2016; 116: 524–30

Dr. Caroline Andrew and Dr. David Nathan join the show to discuss the literature pertaining to intraoperative administration of dexamethasone.

Dr. Caroline Andrew is an anesthesia resident at the Massachusetts General Hospital. Dr. David Nathan is the Director of the Diabetes Center at Massachusetts General Hospital and Professor of Medicine at Harvard Medical School.

This podcast was recorded as part of the Depth of Anesthesia podcast elective.

Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.

—

Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates.

Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team.

Music by Stephen Campbell, MD.

—

References

Tien M, Gan TJ, Dhakal I, White WD, Olufolabi AJ, Fink R, Mishriky BM, Lacassie HJ, Habib AS. The effect of anti-emetic doses of dexamethasone on postoperative blood glucose levels in non-diabetic and diabetic patients: a prospective randomised controlled study. Anaesthesia. 2016 Sep;71(9):1037-43. doi: 10.1111/anae.13544. PMID: 27523051.

Polderman JA, Farhang-Razi V, Van Dieren S, Kranke P, DeVries JH, Hollmann MW, Preckel B, Hermanides J. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev. 2018 Nov 23;11(11):CD011940. doi: 10.1002/14651858.CD011940.pub3. PMID: 30480776; PMCID: PMC6426282.

Andrew J. Toner, Vyhunthan Ganeshanathan, Matthew T. Chan, Kwok M. Ho, Tomas B. Corcoran; Safety of Perioperative Glucocorticoids in Elective Noncardiac Surgery: A Systematic Review and Meta-analysis. Anesthesiology 2017; 126:234–248 doi: https://doi.org/10.1097/ALN.0000000000001466

Corcoran TB, O'Loughlin E, Chan MTV, Ho KM. Perioperative Administration of Dexamethasone And blood Glucose concentrations in patients undergoing elective non-cardiac surgery - the randomised controlled PADDAG trial. Eur J Anaesthesiol. 2021 Sep 1;38(9):932-942. doi: 10.1097/EJA.0000000000001294. PMID: 32833858.

Pang, QY., Wang, JY., Liang, XL. et al. The safety of perioperative dexamethasone with antiemetic dosage in surgical patients with diabetes mellitus: a systematic review and meta-analysis. Perioper Med 12, 4 (2023). https://doi.org/10.1186/s13741-023-00293-4

De Oliveira GS Jr, Castro-Alves LJ, Ahmad S, Kendall MC, McCarthy RJ. Dexamethasone to prevent postoperative nausea and vomiting: an updated meta-analysis of randomized controlled trials. Anesth Analg. 2013 Jan;116(1):58-74. doi: 10.1213/ANE.0b013e31826f0a0a. Epub 2012 Dec 7. PMID: 23223115.

Dr. Zach Cost and Dr. Tem Bendapudi join the show to discuss the literature pertaining to tranexamic acid and thromboembolic risk.

Dr. Zach Cost is an anesthesia resident at the Massachusetts General Hospital. Dr. Pavan (“Tem”) Bendapudi holds a joint faculty appointment in the Division of Hematology and Blood Transfusion Service and is assistant professor of medicine at Harvard Medical School.

This podcast was recorded as part of the Depth of Anesthesia podcast elective.

Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.

—

Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates.

Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team.

Music by Stephen Campbell, MD.

—

References

CRASH-2 trial collaborators; Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA, Mejía-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32. doi: 10.1016/S0140-6736(10)60835-5. Epub 2010 Jun 14. PMID: 20554319.

Henry DA, Carless PA, Moxey AJ, et al. Anti‐fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews. 2011;(1). doi:10.1002/14651858.CD001886.pub3

Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ. 2012;344:e3054. doi:10.1136/bmj.e3054

Myles PS, Smith JA, Forbes A, et al. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. New England Journal of Medicine. 2017;376(2):136-148. doi:10.1056/NEJMoa1606424

Devereaux PJ, Marcucci M, Painter TW, et al. Tranexamic Acid in Patients Undergoing Noncardiac Surgery. New England Journal of Medicine. 2022;386(21):1986-1997. doi:10.1056/NEJMoa2201171 POISE 3 PeriOperative ISchemic Evaluation-3 (POISE-3) study

Shakur H, Roberts I, Fawole B, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum hemorrhage (WOMAN): an international, randomized, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116. doi:10.1016/S0140-6736(17)30638-4

Roberts I, Shakur-Still H, Afolabi A, et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5

Taeuber I, Weibel S, Herrmann E, et al. Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surgery. 2021;156(6):e210884. doi:10.1001/jamasurg.2021.0884

Dr. Mark Neuman and Dr. Sam Falkson join the show to discuss the literature around risks of regional versus general anesthesia for postoperative delirium. Dr. Neuman is the founding Director of the Center for Perioperative Outcomes Research and Transformation and Professor of Anesthesiology at Penn Medicine. Dr. Sam Falkson is an anesthesia resident at the Massachusetts General Hospital.

This podcast was recorded as part of the Depth of Anesthesia podcast elective.

Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.

—

Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates.

Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team.

Music by Stephen Campbell, MD.

—

References

Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2016;2(2):CD000521.

Ravi B, Pincus D, Choi S, Jenkinson R, Wasserstein DN, Redelmeier DA. Association of duration of surgery with postoperative delirium among patients receiving hip fracture repair. JAMA Netw Open. 2019;2(2):e190111.

Patel V, Champaneria R, Dretzke J, Yeung J. Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review. BMJ Open. 2018;8(12):e020757.

Zheng X, Tan Y, Gao Y, Liu Z. Comparative efficacy of Neuraxial and general anesthesia for hip fracture surgery: a meta-analysis of randomized clinical trials. BMC Anesthesiol. 2020 Jun 30;20(1):162.

Neuman MD, Feng R, Carson JL, et al. Spinal anesthesia or general anesthesia for hip surgery in older adults. N Engl J Med. 2021;385(22):2025-2035.

Rathmell JP, Avidan MS. Patient-centered outcomes after general and spinal anesthesia. N Engl J Med. 2021 Nov 25;385(22):2088–9.

Stone AB, Poeran J, Memtsoudis SG. There remains a role for neuraxial anesthesia for hip fracture surgery in the post-REGAIN era. Reg Anesth Pain Med. 2023 Aug;48(8):430-432. doi: 10.1136/rapm-2022-104071. Epub 2023 Mar 28. PMID: 36977527.

Li T, Li J, Yuan L, et al. Effect of regional vs general anesthesia on incidence of postoperative delirium in older patients undergoing hip fracture surgery: the raga randomized trial. JAMA. 2022;327(1):50-58.

Dr. Nick Kumar and Dr. Andy Siemens from the Massachusetts General Hospital anesthesia residency join the show to discuss the literature comparing double lumen endotracheal tubes and bronchial blockers. Dr. Dan Saddawi-Konefka joins as our faculty expert - special thanks to Dan for supporting the ongoing Depth of Anesthesia podcast elective.

Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.

—

Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates.

Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team.

Music by Stephen Campbell, MD.

—

References

Clayton-Smith A, Bennett K, Alston RP, Adams G, Brown G, Hawthorne T, Hu M, Sinclair A, Tan J. A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth. 2015 Aug;29(4):955-66. doi: 10.1053/j.jvca.2014.11.017. Epub 2014 Dec 2. PMID: 25753765.

Uwe Klein, Waheedullah Karzai, Frank Bloos, Mathias Wohlfarth, Reiner Gottschall, Harald Fritz, Michael Gugel, Albrecht Seifert; Role of Fiberoptic Bronchoscopy in Conjunction with the Use of Double-lumen Tubes for Thoracic Anesthesia : A Prospective Study. Anesthesiology 1998; 88:346–350 doi: https://doi.org/10.1097/00000542-199802000-00012

Risse J, Szeder K, Schubert AK, Wiesmann T, Dinges HC, Feldmann C, Wulf H, Meggiolaro KM. Comparison of left double lumen tube and y-shaped and double-ended bronchial blocker for one lung ventilation in thoracic surgery-a randomised controlled clinical trial. BMC Anesthesiol. 2022 Apr 2;22(1):92. doi: 10.1186/s12871-022-01637-1. PMID: 35366801; PMCID: PMC8976407.

Morris BN, Fernando RJ, Garner CR, Johnson SD, Gardner JC, Marchant BE, Johnson KN, Harris HM, Russell GB, Wudel LJ Jr, Templeton TW. A Randomized Comparison of Positional Stability: The EZ-Blocker Versus Left-Sided Double-Lumen Endobronchial Tubes in Adult Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth. 2021 Aug;35(8):2319-2325. doi: 10.1053/j.jvca.2020.11.056. Epub 2020 Nov 28. PMID: 33419686.

Jo Mourisse, Jordi Liesveld, Ad Verhagen, Garance van Rooij, Stefan van der Heide, Olga Schuurbiers-Siebers, Erik Van der Heijden; Efficiency, Efficacy, and Safety of EZ-Blocker Compared with Left-sided Double-lumen Tube for One-lung Ventilation. Anesthesiology 2013; 118:550–561 doi: https://doi.org/10.1097/ALN.0b013e3182834f2d

It's our first solo episode! We review the evidence around perioperative use of gabapentinoids (gabapentin and pregabalin) and discuss interesting concepts including trial sequential analysis and minimally important difference.

If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues. 

—

Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates.

Email us at depthofanesthesia@gmail.com with episode ideas or if you’d like to join our team.

Music by Stephen Campbell, MD.

—

References

Dirks J, Fredensborg BB, Christensen D, Fomsgaard JS, Flyger H, Dahl JB. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mastectomy. Anesthesiology. 2002 Sep;97(3):560-4. doi: 10.1097/00000542-200209000-00007. PMID: 12218520.

Ian Gilron; Is Gabapentin a “Broad-spectrum” Analgesic?. Anesthesiology 2002; 97:537–539 doi: https://doi.org/10.1097/00000542-200209000-00004

Mishriky BM, Waldron NH, Habib AS. Impact of pregabalin on acute and persistent postoperative pain: a systematic review and meta-analysis. Br J Anaesth. 2015 Jan;114(1):10-31. doi: 10.1093/bja/aeu293. Epub 2014 Sep 10. PMID: 25209095.Fabritius ML, Geisler A, Petersen PL, Nikolajsen L, Hansen MS, Kontinen V, Hamunen K, Dahl JB, Wetterslev J, Mathiesen O. Gabapentin for post-operative pain management - a systematic review with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand. 2016 Oct;60(9):1188-208. doi: 10.1111/aas.12766. Epub 2016 Jul 18. Erratum in: Acta Anaesthesiol Scand. 2017 Mar;61(3):357-359. PMID: 27426431.

Chan JSK, Harky A. Trial sequential analysis in meta-analyses: A clinically oriented approach with real-world example. J Thorac Cardiovasc Surg. 2021 Jul;162(1):167-173. doi: 10.1016/j.jtcvs.2020.06.063. Epub 2020 Jun 27. PMID: 32868066.

Clephas PRD, Kranke P, Heesen M. How to perform and write a trial sequential analysis. Anaesthesia. 2022 Jul 13. doi: 10.1111/anae.15811. Epub ahead of print. PMID: 35831946.

Michael Verret, François Lauzier, Ryan Zarychanski, Caroline Perron, Xavier Savard, Anne-Marie Pinard, Guillaume Leblanc, Marie-Joëlle Cossi, Xavier Neveu, Alexis F. Turgeon, the Canadian Perioperative Anesthesia Clinical Trials (PACT) Group; Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology 2020; 133:265–279 doi: https://doi.org/10.1097/ALN.0000000000003428

Deljou A, Hedrick SJ, Portner ER, Schroeder DR, Hooten WM, Sprung J, Weingarten TN. Pattern of perioperative gabapentinoid use and risk for postoperative naloxone administration. Br J Anaesth. 2018 Apr;120(4):798-806. doi: 10.1016/j.bja.2017.11.113. Epub 2018 Feb 10. PMID: 29576120.

Kharasch ED, Clark JD, Kheterpal S. Perioperative Gabapentinoids: Deflating the Bubble. Anesthesiology. 2020 Aug;133(2):251-254. doi: 10.1097/ALN.0000000000003394. PMID: 32667153; PMCID: PMC7367437.