Anaesthetic agents and excretion in breast milk

Management of Accidental Succinylcholine Ingestion: Navigating Uncharted Waters

Accidental oral ingestion of intravenous drugs is rare and under-reported, which may lead to serious morbidity and worsen the outcome for the patient. Though oral ingestion of sedatives and opioid drugs is reported, literature regarding the ingestion of muscle relaxants and subsequent management is limited. We report an interesting case of oral intake of 10 ml (500 mg) of injection Succinylcholine, a depolarizing muscle relaxant, by a psychiatric patient awaiting electroconvulsive therapy (ECT) in the pre-procedure room. We hereby report the subsequent sequence of events along with the suggested recommendations to be followed in the case of such an eventuality. To the best of our knowledge, this is the first case report of oral ingestion of a depolarizing neuromuscular blocking drug and its subsequent consequences.

Should maternal anesthesia delay breastfeeding? A systematic review of the literature

Introduction

The importance and benefits of breastfeeding for the babies and mothers are well established and documented in the literature. However, it is frequent that lactating mothers need to undergo general or spinal anesthesia and, due to the lack of information, many of them interrupt breastfeeding after anesthesia. There are limited data available regarding anesthetics transfer to breast milk. This review aims to develop some considerations and recommendations based on available literature.

Methods

A systematic search of the literature was conducted by using the following health science databases: Embase, Lilacs, Pubmed, Scopus, and Web of Science. The latest literature search was performed on April 6^th, 2018. Additional literature search was made via the World Health Organization's website. We used the following terms for the search strategy: “Anesthesia” and “Breastfeeding”, and their derivatives.

Results

In this research, 599 registers were found, and 549 had been excluded by different reasons. Fifty manuscripts have been included, with different designs of studies: prospective trials, retrospective observational studies, reviews, case reports, randomized clinical trials, case–control, and website access. Small concentrations of the most anesthetic agents, are transferred to the breast milk; however, their administration seem to be safe for lactating mothers when administered as a single dose during anesthesia and this should not contraindicate the breastfeeding. On the other hand, high-doses, continuous or repeated administration of drugs increase the risk of adverse effects on neonates, and should be avoided. Few drugs, such as diazepam and meperidine, produce adverse effects on breastfed babies even in single doses. Dexmedetomidine seems to be safe if breastfeeding starts 24 h after discontinuation of the drug.

Conclusions

Most of the anesthetic drugs are safe for nursing mothers and offer low risk to the breastfed neonates when administered in single-dose. However, high-dose and repeated administration of drugs significantly increase the risk of adverse effects on neonates. Moreover, diazepam and meperidine should be avoided in nursing women. Finally, anesthesiologists and pediatricians should consider individual risk/benefit, with special attention to premature neonates or babies with concurrent diseases since they are more susceptible to adverse effects.

[Should maternal anesthesia delay breastfeeding? A systematic review of the literature]

INTRODUCTION

The importance and benefits of breastfeeding for the babies and mothers are well established and documented in the literature. However, it is frequent that lactating mothers need to undergo general or spinal anesthesia and, due to the lack of information, many of them interrupt breastfeeding after anesthesia. There are limited data available regarding anesthetics transfer to breast milk. This review aims to develop some considerations and recommendations based on available literature.

METHODS

A systematic search of the literature was conducted by using the following health science databases: Embase, Lilacs, Pubmed, Scopus, and Web of Science. The latest literature search was performed on April 6^th, 2018. Additional literature search was made via the World Health Organization's website. We used the following terms for the search strategy: "Anesthesia" and "Breastfeeding", and their derivatives.

RESULTS

In this research, 599 registers were found, and 549 had been excluded by different reasons. Fifty manuscripts have been included, with different designs of studies: prospective trials, retrospective observational studies, reviews, case reports, randomized clinical trials, case-control, and website access. Small concentrations of the most anesthetic agents, are transferred to the breast milk; however, their administration seem to be safe for lactating mothers when administered as a single dose during anesthesia and this should not contraindicate the breastfeeding. On the other hand, high-doses, continuous or repeated administration of drugs increase the risk of adverse effects on neonates, and should be avoided. Few drugs, such as diazepam and meperidine, produce adverse effects on breastfed babies even in single doses. Dexmedetomidine seems to be safe if breastfeeding starts 24h after discontinuation of the drug.

CONCLUSIONS

Most of the anesthetic drugs are safe for nursing mothers and offer low risk to the breastfed neonates when administered in single-dose. However, high-dose and repeated administration of drugs significantly increase the risk of adverse effects on neonates. Moreover, diazepam and meperidine should be avoided in nursing women. Finally, anesthesiologists and pediatricians should consider individual risk/benefit, with special attention to premature neonates or babies with concurrent diseases since they are more susceptible to adverse effects.

Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and other Healthcare Professionals Part I

Objective:

To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of common ambulatory care, analgesic, and anesthetic medications during breast-feeding.

Data Sources:

Primary texts used by the breast-feeding community were searched, as well as Micromedex, MEDLINE, PubMed, Embase, and Embase2 (1984–July 2003).

Study Selection and Data Extraction:

Multiple sources were utilized whenever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast feeding, lactation, nursing, and medications, as well as specific drug names.

Data Synthesis:

Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are medications that can be harmful to nursing infants, breast milk concentrations of most drugs are insufficient to cause any harm.

Conclusions:

Having objective and reliable information on medications enables pharmacists, pharmacy technicians, other healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.

Pharmacological treatment of unipolar depression during pregnancy and breast-feeding--a clinical overview

BACKGROUND

This overview is aimed at clinicians working with patients in the fertile age who suffer from depressive disorders. The study of adverse effects of antidepressants on the foetus is hampered by difficulty in distinguishing between the behavioural changes that are related to the disorder itself and changes that accompany its treatment with antidepressants. The current lack of solid scientific knowledge and the implications, mainly emotional, of treating pregnant or breast-feeding women often raise anxiety and cause concern among patients and clinicians.

METHODS

Currently available data are evaluated and clinical recommendations given.

RESULTS AND CONCLUSIONS

Citalopram and sertraline can be used during pregnancy, while some controversy remains over in utero exposure to paroxetine and fluoxetine, which might be associated with an increased risk of foetal cardiovascular malformation. Less data is available concerning fluvoxamine and escitalopram use but current data does not indicate a specific risk. Citalopram, paroxetine and sertraline can be used during breast-feeding, while fluoxetine probably should be avoided. Nortriptyline, amitriptyline and clomipramine can be used during pregnancy and lactation, although data are more abundant for SSRI treatment. Venlafaxine can be used during pregnancy, while caution is advised during breast-feeding. Other antidepressants should be avoided because of lack of data on their effect. A strongly indicated lithium therapy should be continued. Close monitoring of lithium levels throughout pregnancy is mandatory, as is detailed foetal echocardiography in weeks 18-22 of gestation. Lithium should not be used during breast-feeding. Electroconvulsive therapy (ECT) is a valid option if indicated, both during pregnancy and breast-feeding.

Buprenorphine and Norbuprenorphine Concentrations in Human Breast Milk Samples Determined by Liquid Chromatography-Tandem Mass Spectrometry

Buprenorphine (BUP) is considered to be safe during pregnancy. However, the extent of BUP transfer into breast milk has not been investigated thoroughly. Because the drug concentration in the milk is 1 of the determinants in the assessment of the exposure risk, a rapid and sensitive LC-MS/MS method has been developed and evaluated to measure BUP and norbuprenorphine (norBUP) concentrations in milk. A solid-phase and 2 liquid-liquid extraction procedures have been compared. The lower limits of detection and quantification were 0.05 ng/mL and 0.18 ng/mL for BUP and 0.05 ng/mL and 0.20 ng/mL for norBUP, respectively, using a sample volume of 0.5 mL milk. BUP and norBUP concentrations determined from 10 random breast milk samples collected over 4 successive days from a lactating woman during buprenorphine maintenance therapy ranged from 1.0 to 14.7 and 0.6 to 6.3 ng/mL, respectively. Drug exposure of the infant may be considered to be low. Further investigations may seek to extend these preliminary findings to evaluate an infant's level of BUP exposure through breast milk.

Effects on the fetus and newborn of maternal analgesia and anesthesia: a review

PURPOSE

To review the effects of maternal anesthesia and analgesia on the fetus and newborn.

METHODS

An on-line computerized search of Medline, Embase, and the Cochrane Collaboration via PubMed was conducted. English language articles were selected. The bibliographies of relevant articles and additional material from other published sources were retrieved and reviewed.

PRINCIPAL FINDINGS

No one test clearly separates the effects on the fetus/newborn, if any, of maternally administered medication during labour and delivery, or during surgery for non-obstetric indications. Supposition in this regard is limited in part by methodology previously used to study the transplacental passage of various drugs. This work needs to be repeated using a human model. Routine maternal supplemental oxygen administration is being questioned in light of research showing that free radical generation and oxidative stress are implicated as the underlying mechanisms in several neonatal conditions. Maternal hypotension is associated with neonatal acidemia and base excess correlates with neonatal outcome. Common postpartum analgesics transfer minimally into breast milk. Maternal or fetal surgery conducted during pregnancy necessitates modification of both anesthetic and surgical approaches. The key to resuscitation of the fetus is resuscitation of the mother: intra-uterine maneuvers, including perimortem Cesarean section, aim to reverse treatable causes of fetal asphyxia, restore fetal oxygenation, and correct fetal acidosis.

CONCLUSIONS

The well-being of the infant is a major criterion for evaluating the anesthetic management of pregnant women. Many tools exist to assist with this determination for the fetus, whereas few are available to evaluate the newborn.

High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia

Although the use of non-steroidal anti-inflammatory drugs (NSAIDs) is well established in the postoperative setting, their use after caesarean sections is still controversial. In a randomised, double-blinded, placebo controlled study we have estimated the opioid-sparing effect of diclofenac suppositories after elective caesarean sections in spinal anaesthesia. Eighty-two women ASA class I or II scheduled for caesarean section were randomised to receive either diclofenac suppositories 100 mg or placebo every 12 h after the operation. The diclofenac group (n = 40) consumed significantly less morphine in the postoperative period (14.0 +/- 1.5 mg in 32 h) compared with the placebo group (21.5 +/- 1.6 mg in 32 h, P < 0.05). The average level of postoperative pain as estimated by a visual analogue scale (VAS) and a verbal scale tended to be lower in the diclofenac group, but this was not significant. There were no differences in demographic data, perioperative bleeding, side-effects or discharge time between the groups. Diclofenac suppositories 100 mg given twice daily after caesarean section are opioid sparing.

Efficacy and safety of repeated postoperative administration of intramuscular diclofenac sodium in the treatment of post-cesarean section pain: a double-blind study

BACKGROUND

Analgesic drugs, either opioids or non-opioids, are required and useful for controlling postoperative pain after cesarean section.

METHODS

The analgesic and opioid-sparing effects of repeated intramuscular (i.m.) injections of 75 mg of diclofenac sodium given immediately after the experiencing of pain following cesarean section under general anesthesia were studied and compared with placebo in a double-blind trial. One hundred twenty patients 18-40 years of age undergoing elective lower segment cesarean section were treated with either 75 mg diclofenac sodium i.m. (60 patients) or identical placebo (60 patients), once patients awakened from anesthesia and experienced wound pain. Their initial responses to either treatment during the first hour after administration of medications were studied. The analgesic, sedative, and opioid-sparing effects of the medications were also studied during the next 48 h. Side effects including uterine relaxation and bleeding were compared between patients administered placebo and diclofenac.

RESULTS

Results showed that 55/60 patients showed significant pain relief within the first 1 h after administration of diclofenac sodium and their mean pain score decreased from 7.09 +/- 1.06 to 0.85 +/- 0.8 (p <0.05). Within the same period, 10/60 patients responded to placebo injections and mean pain score decreased from 6.6 +/- 0.96 to 0.8 +/- 0.78 (p <0.05). During the first postoperative 48 h, 45 patients showed complete pain relief with use of diclofenac alone while 15 patients required 2,800 mg of pethidine in addition to diclofenac treatment. All patients using placebo required pethidine injection; the total amount of pethidine used was 22,700 mg per 48 h. Verbal scores for sedation were lower in patients treated with diclofenac than in patients treated with placebo at 6 and 12 h postoperatively (p <0.05). There were no significant differences in the proportions of patients who required oxytocin infusion due to uterine relaxation in the diclofenac-treated and the placebo-treated groups (7/60 vs. 12/60, p >0.05).

CONCLUSIONS

It might be concluded that repeated i.m. injections of 75 mg diclofenac sodium (maximum two injections per day) could relieve postoperative pain after cesarean section and significantly reduce opioid analgesic requirements without significant effects on uterine relaxation or bleeding during the first postoperative 48 h.

Breastfeeding and maternal medication use

Drug therapy during lactation requires recognition of several elements, including drug properties, the status of the infant, the mother's milk production, and what is known about particular drugs. It is important to consider the various properties of a drug when evaluating its possible effects in the breastfeeding infant. In addition, the volume of milk the infant receives and its composition can influence exposure levels. Other factors of importance include the infant's age, frequency of feedings, recommended drug dosage, and whether the drug is short- or long-acting. Suggestions are offered for appropriate drug therapy when the mother is breastfeeding, including the safety of drugs commonly administered during lactation and questions to ask when a mother seeks assistance about suggested medication use.