by David Hao, MD
Depth of Anesthesia is a podcast that critically explores dogmatic practices (we call them claims) in anesthesiology. Join us as we explore the literature around the latest clinical controversies!
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4/27/2019
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April 9, 2025
<p class="p1">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.</p> <p class="p1">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.</p> <p class="p1">Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.</p> <p class="p1">—</p> <p class="p1">Follow us on Instagram @DepthofAnesthesia for podcast and literature updates.</p> <p class="p1">Email us at [email protected] with episode ideas or if you'd like to join our team.</p> <p class="p1">Music by Stephen Campbell, MD.</p> <p class="p1">—</p> <p class="p1">References</p> <p class="p1">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.</p> <p class="p1">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.</p> <p class="p1">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.</p> <p class="p1">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.</p> <p class="p1">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. <a href= "https://doi.org/10.1213/00000539-200201000-00035">https://doi.org/10.1213/00000539-200201000-00035</a></p> <p class="p1">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.</p> <p class="p1">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.</p> <p class="p1">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. <a href= "https://doi.org/10.1111/j.1479-828X.2007.00715.x">https://doi.org/10.1111/j.1479-828X.2007.00715.x</a></p> <p class="p1">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. <a href= "https://doi.org/10.1592/phco.23.2.153.32081">https://doi.org/10.1592/phco.23.2.153.32081</a></p> <p class="p1">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. <a href= "https://doi.org/10.1111/aogs.14268">https://doi.org/10.1111/aogs.14268</a></p> <p class="p1">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.</p> <p class="p1">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.</p>
January 10, 2025
<p class="p2">Dr. Mary Daniels and Dr. Scott Cao join the show to discuss the literature surrounding opioid-free versus opioid-based anesthesia and analgesia techniques.</p> <p class="p2">Dr. Scott Cao is currently serving as a chief resident of the MGH anesthesia residency program. He is a graduate of the University of Colorado School of Medicine. Dr. Mary Daniels is a graduate of Harvard Medical School and she is a resident in the anesthesia program. </p> <p class="p2">Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.</p> <p class="p2">—</p> <p class="p2">Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates.</p> <p class="p2">Email us at [email protected] with episode ideas or if you'd like to join our team.</p> <p class="p2">Music by Stephen Campbell, MD.</p> <p class="p2">—</p> <p class="p2">References</p> <p class="p2">Shanthanna H, Beloeil H, Joshi GP. Opioid-free anesthesia in research and practice: so near yet so far! Can J Anaesth. 2024 Nov 5. English. doi: 10.1007/s12630-024-02830-1. Epub ahead of print. PMID: 39500839.</p> <p class="p2">Brandal D, Keller MS, Lee C, Grogan T, Fujimoto Y, Gricourt Y, Yamada T, Rahman S, Hofer I, Kazanjian K, Sack J, Mahajan A, Lin A, Cannesson M. Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. Anesth Analg. 2017 Nov;125(5):1784-1792. doi: 10.1213/ANE.0000000000002510. PMID: 29049123; PMCID: PMC7402216.</p> <p class="p2">Olausson A, Svensson CJ, Andréll P, Jildenstål P, Thörn SE, Wolf A. Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis. Acta Anaesthesiol Scand. 2022 Feb;66(2):170-185. doi: 10.1111/aas.13994. Epub 2021 Nov 11. PMID: 34724195.</p> <p class="p2">Zhang Y, Ma D, Lang B, Zang C, Sun Z, Ren S, Chen H. Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies. Medicine (Baltimore). 2023 Sep 22;102(38):e35126. doi: 10.1097/MD.0000000000035126. PMID: 37746991; PMCID: PMC10519493.</p> <p class="p2">Parra-Sanchez I, Abdallah R, You J, Fu AZ, Grady M, Cummings K 3rd, Apfel C, Sessler DI. A time-motion economic analysis of postoperative nausea and vomiting in ambulatory surgery. Can J Anaesth. 2012 Apr;59(4):366-75. doi: 10.1007/s12630-011-9660-x. Epub 2012 Jan 6. PMID: 22223185.</p> <p class="p2">Apfel, CC, Laara, E, Koivuranta, M, Greim, CA, Roewer, N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693-700</p> <p class="p2">Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017 Sep;15(9):1338-1349. doi: 10.1016/j.cgh.2017.05.014. Epub 2017 May 19. PMID: 28529168; PMCID: PMC5565678.</p> <p class="p2">Jin S, Liang DD, Chen C, Zhang M, Wang J. Dexmedetomidine prevent postoperative nausea and vomiting on patients during general anesthesia: A PRISMA-compliant meta analysis of randomized controlled trials. Medicine (Baltimore). 2017 Jan;96(1):e5770. doi: 10.1097/MD.0000000000005770. PMID: 28072722; PMCID: PMC5228682.</p> <p class="p2">Qi Y, Zhou M, Zheng W, Dong Y, Li W, Wang L, Xu H, Zhang M, Yang D, Wang L, Zhou H. Effect of S-Ketamine on Postoperative Nausea and Vomiting in Patients Undergoing Video-Assisted Thoracic Surgery: A Randomized Controlled Trial. Drug Des Devel Ther. 2024 Apr 16;18:1189-1198. doi: 10.2147/DDDT.S449705. PMID: 38645990; PMCID: PMC11032156.</p> <p class="p2">Wang Q, Ding X, Huai D, Zhao W, Wang J, Xie C. Effect of Intravenous Lidocaine Infusion on Postoperative Early Recovery Quality in Upper Airway Surgery. Laryngoscope. 2021 Jan;131(1):E63-E69. doi: 10.1002/lary.28594. Epub 2020 Mar 2. PMID: 32119135.</p> <p class="p2">Bakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H, Salihoglu Z. Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study. Braz J Anesthesiol. 2015 May-Jun;65(3):191-9. doi: 10.1016/j.bjane.2014.05.001. Epub 2014 Jun 3. PMID: 25925031.</p> <p class="p2">Beloeil H, Garot M, Lebuffe G, Gerbaud A, Bila J, Cuvillon P, Dubout E, Oger S, Nadaud J, Becret A, Coullier N, Lecoeur S, Fayon J, Godet T, Mazerolles M, Atallah F, Sigaut S, Choinier PM, Asehnoune K, Roquilly A, Chanques G, Esvan M, Futier E, Laviolle B; POFA Study Group; SFAR Research Network. Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery. Anesthesiology. 2021 Apr 1;134(4):541-551. doi: 10.1097/ALN.0000000000003725. PMID: 33630043.</p> <p class="p2">Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, Jin Z, Kovac AL, Meyer TA, Urman RD, Apfel CC, Ayad S, Beagley L, Candiotti K, Englesakis M, Hedrick TL, Kranke P, Lee S, Lipman D, Minkowitz HS, Morton J, Philip BK. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020 Aug;131(2):411-448. doi: 10.1213/ANE.0000000000004833. Erratum in: Anesth Analg. 2020 Nov;131(5):e241. doi: 10.1213/ANE.0000000000005245. PMID: 32467512.</p> <p class="p2">Egan TD. Are opioids indispensable for general anaesthesia? Br J Anaesth. 2019 Jun;122(6):e127-e135. doi: 10.1016/j.bja.2019.02.018. Epub 2019 Mar 28. PMID: 31104756.</p> <p class="p2">Shanthanna H, Ladha KS, Kehlet H, Joshi GP. Perioperative Opioid Administration. Anesthesiology. 2021 Apr 1;134(4):645-659. doi: 10.1097/ALN.0000000000003572. PMID: 32991672.</p> <p class="p2">Myles PS, Wengritzky R. Simplified postoperative nausea and vomiting impact scale for audit and post-discharge review. Br J Anaesth. 2012 Mar;108(3):423-9. doi: 10.1093/bja/aer505. Epub 2012 Jan 29. PMID: 22290456.</p> <p class="p2">Dinges HC, Otto S, Stay DK, Bäumlein S, Waldmann S, Kranke P, Wulf HF, Eberhart LH. Side Effect Rates of Opioids in Equianalgesic Doses via Intravenous Patient-Controlled Analgesia: A Systematic Review and Network Meta-analysis. Anesth Analg. 2019 Oct;129(4):1153-1162. doi: 10.1213/ANE.0000000000003887. PMID: 30418234.</p> <p class="p2">Feng CD, Xu Y, Chen S, Song N, Meng XW, Liu H, Ji FH, Peng K. Opioid-free anaesthesia reduces postoperative nausea and vomiting after thoracoscopic lung resection: a randomised controlled trial. Br J Anaesth. 2024 Feb;132(2):267-276. doi: 10.1016/j.bja.2023.11.008. Epub 2023 Dec 1. PMID: 38042725.</p> <p class="p2">Zhang Y, Ma D, Lang B, Zang C, Sun Z, Ren S, Chen H. Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies. Medicine (Baltimore). 2023 Sep 22;102(38):e35126. doi: 10.1097/MD.0000000000035126. PMID: 37746991; PMCID: PMC10519493.</p> <p class="p2">Zhou F, Cui Y, Cao L; Opioid-Free Anesthesia Working Group. The effect of opioid-free anaesthesia on the quality of recovery after endoscopic sinus surgery: A multicentre randomised controlled trial. Eur J Anaesthesiol. 2023 Aug 1;40(8):542-551. doi: 10.1097/EJA.0000000000001784. Epub 2023 Jun 29. PMID: 37377372.</p>
September 23, 2024
<p class="p1">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.</p> <p class="p1">This podcast was recorded as part of the Depth of Anesthesia podcast elective.</p> <p class="p1">Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues.</p> <p class="p1">—</p> <p class="p1">Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates.</p> <p class="p1">Email us at [email protected] with episode ideas or if you'd like to join our team.</p> <p class="p1">Music by Stephen Campbell, MD.</p> <p class="p1">—</p> <p class="p1">References</p> <p class="p1">Peter Yi, MD, Peter Pryzbylkowski, MD, Opioid Induced Hyperalgesia, Pain Medicine, Volume 16, Issue suppl_1, October 2015, Pages S32–S36, <a href= "https://doi.org/10.1111/pme.12914">https://doi.org/10.1111/pme.12914</a></p> <p class="p1">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</p> <p class="p1">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</p> <p class="p1">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</p> <p class="p1">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</p>
Jed Wolpaw
Tanner and Cole
Scott D. Weingart, MD FCCM
Anesthesiology, the journal of the American Society of Anesthesiologists
University of Kentucky Department of Anesthesiology
Anesthesia Patient Safety Foundation
Dr. Jim Dahle of the White Coat Investor
OpenAnesthesia, sponsored by the IARS
JAMA Network
Jeff Gadsden & Amit Pawa
Mike MacKinnon and Joe Rodriguez
NPR
audiochuck
Benjamin Felix, Cameron Passmore, Mark McGrath, and Dan Bortolotti
NPR
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