Study Of 80,000 Birthing Moms Suggests Epidurals Safer Than Thought

(archibald jude via Compfight)

(archibald jude via Compfight)

I subscribe to the dentistry school of birthing babies. That is, I wouldn’t want to get a tooth filled without Novocaine, and I wouldn’t want to have a baby without an epidural.

I know that opinions — strong ones — vary on this, but for those of my ilk who’d like yet another data point to support the pain-relief side, here it is: A national study, one of the biggest yet, of complications from epidurals has just been presented at the annual conference of the American Society of Anesthesiologists now under way in New Orleans. And it suggests that epidurals are even safer than previously thought, with rates of the most-feared complications well under 1 percent.

Dr. Samir Jani, a senior resident in anesthesiology at Beth Israel Deaconess Medical Center, presented the findings, gleaned from a giant national database of anesthesiology cases, the National Anesthesia Clinical Outcomes Registry.

He found that among more than 80,000 cases of anesthesia during labor and delivery, 2,223 involved complications, for an overall rate of 2.78 percent. But most of those concerned medication errors — over-dosing, under-dosing, or use of expired drugs.

The rate of the complications that many women fear most — nerve damage or an excruciating “spinal headache” — were even lower than previously estimated, Dr. Jani said: .2 percent — that’s 2/10 of one percent — for the headache; .002 percent for spinal nerve damage and .14 percent for damage to other nerves.

“So it’s well under 1 percent for the kinds of complications that I think a lot of women worry about,” he said, not the 1-2 percent that he’s been quoting his patients based on textbook teachings.

An awkward question: But don’t anesthesiologists tend to be pretty pro-anesthesia? Mightn’t that bias the results?

“Actually,” Dr. Jani said, “Whenever I talk to all my patients, I tell them, ‘I’m not here to sell you an epidural. it’s your ultimate decision.’ And I think that that’s the mentality that almost all of us have. We aren’t ever going to force on a patient what they don’t want. But in that informed consent process, it’s important we quote not only possible complications but the rates to the best of our knowledge. At the end of the day, it’s good to be able to tell your patient that this is a safe and efficient method to be able to control labor pain.”

And what about the common belief that getting an epidural can hinder the pushing process in labor? Continue reading

Surgery For Young Children May Pose Subtle Brain Risks

By Karen Weintraub
Guest Contributor

A parent’s nightmare just got worse. A new study from Columbia University suggests that children who have surgery before age 3 may be at increased risk for language and abstract reasoning problems at age 10.

Researchers don’t know yet whether the same medical problems that trigger the need for surgery cause the cognitive problems; or whether it’s the surgery itself; or the anesthesia.

Studies in animals, though, suggest that it may be the anesthesia. Young rats exposed to similar levels of anesthesia also lose the rat equivalent of a bit of brain power.

Dr. Caleb Ing, a pediatric anesthesiologist at Columbia University Medical Center and the first author on the new study, said he doesn’t want parents to hear about his finding and decide against surgery for their child. Postponing heart surgery, for instance, out of a concern for a small decline in language skills or abstract reasoning makes no sense, he said.

“These results do not mean children should not have surgery,” Ing said, emphatically.

But his research does suggest that surgeries among young children shouldn’t be taken lightly, and that local anesthesia – like the epidural mom may have had to ease the child’s delivery – is a better choice, when possible. Continue reading

What We Can All Learn From Michael Jackson’s Doctor

By Ken Farbstein
Guest blogger

Michael Jackson had what most of us think we want: Utterly personal attention from a dedicated doctor, on call all the time for him alone.

That doctor, Conrad Murray, is now on trial for manslaughter (see reports here and here) though no one thinks Michael’s death from an overdose of the anesthetic Propofol was deliberate. By all accounts, the treatment that Michael received was anything but normal or typical, but is there anything that typical patients can learn from what went wrong?

Hindsight is 20/20. Clearly, doctors shouldn’t administer Propofol on their own. This case is unique. But as a patient advocate, I try to learn from every medical error, and to extract useful guidance that patients can act on in the moment. The lessons of Michael’s death have little to do with Propofol. Much remains unclear about exactly what happened, but I see three key lessons:

•Don’t assume information about your medications has been communicated from one doctor to another.
•Keep an updated medication list.
•Get a family member or professional patient advocate to help oversee your care.

The story of Michael Jackson’s death is explored in my book, Getting Your Best Health Care:  Real-World Stories of Patient Empowerment, among case studies of other celebrities.  In particular, I examine more fully the role of his medical team. The conflicting accounts this week by the prosecutor, defense lawyer, and early witnesses make it hard to know the whole truth at this time, but useful lessons are already emerging.

‘For the doctor to proceed then without a professional assistant, a cogent patient, or a computer was like a groggy pilot flying at night with no co-pilot or flight instrument panel: flying blind.’


Poor communication among medical personnel

Michael’s primary care provider reportedly communicated some critical information poorly. When emergency medical technicians arrived to try to revive Michael, his primary care doctor did not inform them that he had given Propofol to Michael, according to the prosecutor.  That may have affected the way the EMTs tried to revive him.

Flumazenil was used to reverse the effects of benzodiazepines like the Lorazepam that Michael had been taking.  Miscommunication may have led the EMTs to administer the Flumazenil in a misdirected effort to counteract the effects of the Lorazepam.

The patient’s role Continue reading

Study: Use Ritalin To Wake Patients Up Sooner After Surgery?

Ritalin is famed as a drug for Attention Deficit Disorder, but a new study in rats suggests that its effects on the brain’s arousal circuits could also be used to wake patients up sooner after surgery.

Why bother? Several reasons, from saving health care money to possibly reducing post-operative delirium.

Dr. Emery Brown, a neuroscientist and anesthesia expert at MIT, Harvard and Massachusetts General Hospital, explains the new research, led by Mass. General’s Dr. Ken Solt, just out in the journal Anesthesiology. He is a co-author on the paper.

This is a major new result because it shows that we can wake the brain up from general anesthesia. Currently at the end of surgery, the anesthesiologist just lets the anesthetic drugs wear off and the patient regain consciousness.

We decided to study the possibility of devising a strategy to wake patients up from general anesthesia. In this paper we show that it is possible to administer to rats methylphenidate (Ritalin) -— the same drug that is used to treat attention deficit hyperactivity disorder (ADHD) in children. This drug actively induces emergence of the animals from general anesthesia.

‘This is an exciting experimental finding that has to be replicated in humans.’

It is not that the anesthesia is being reversed. Rather the arousal pathways, most likely the dopaminergic and noradrenergic pathways, are being activated to allow the brain to overcome the effects of the general anesthesia and the animal to awaken. It is known that Ritalin blocks the reuptake of dopamine to maintain the brain levels of this excitatory neurotransmitter.

This is an exciting experimental finding that has to be replicated in humans. If this pans out, it could change anesthesiology practice by initiating use of a drug that is already known to be safe to actively induce emergence from general anesthesia.

This would have important implications; possibly reducing cognitive dysfunction in the elderly and delirium in children after general anesthesia. Continue reading