At our hospital, fentanyl may only be given via IV in the ICU, PACU, or
intra-op.  All narcotics are respiratory depressants, and fentanyl's
respiratory effects actually persist beyond its analgesia.  It is considered
too risky (at least here) to give it to a patient who is not in a closely
monitored setting with continuous pulse oximetry -- I tend to be extremely
cautious when I give to awake patients (as I recently had to resuscitate
someone who became apneic and BLUE within 30 seconds of a second, albeit
large, dose).  I don't even know what our L/D department gives intravenously
for pain control, as patients seem to either opt for an epidural (VAST
majority), or non-pharmacological methods.

Fentanyl is a great intravenous analgesic, but I can provide much better
pain control with lower total doses if I give it epidurally.  I know that
fentanyl and bupivacaine have been much-maligned here recently for their
possible effects on infants, but when used in combination, they can provide
excellent analgesia and still preserve much motor function in moms:
narcotics block pain receptors while local anesthetics block all nerve
receptors, sensory preferentially (along with sympathetic pathways) and then
motor nerves, and to provide adequate analgesia (at least to patient
expectation) with LAs alone, patients would end up with a significant motor
blockade.  So combining the two allows lower doses to be used.  

Both narcotics and LAs cross the placenta, but of the LAs currently used in
labor, bupi likely has the least placental transfer owing to its high
protein binding.  As far as I know, there is not much difference between the
various narcotics used epidurally in terms of placental transfer, but since
less narcotic needs to be given epidurally than intravenously, the total
amount of drug reaching the infant is less when it is given via epidural
(and FAR less is given when dosed for a spinal injection such as for a
c-section).  

As a gross generality, anesthesiologists as a group do not tend to be quite
that concerned about long-term outcomes (such as breastfeeding -- of course
we're interested in directly attributable complications such as positional
nerve injury or airway catastrophes); if mom is safe and comfortable and
baby is healthy and breathing (we have this nagging focus on airways...) :)
then we have done our job.  I was happy to see the relatively recent study
(Dec 2005?) in "Anesthesiology" evaluating breastfeeding in relation to
total epidural fentanyl dose, just because it indicated that SOMEONE out
there was interested in investigating this.  

Anyway, enough rambling here, need to start reading about anesthesia for
bypass surgery and valve replacements for this week...  When I design a
fabulous study looking at epidural use and impact on breastfeeding, I'll
know where to come for help. :)

-Sarah Reece-Stremtan M.D.

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET email list is powered by LISTSERV (R).
There is only one LISTSERV. To learn more, visit:
http://www.lsoft.com/LISTSERV-powered.html