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October 15, 2018
10/15/2018 1:00:00 PM - 10/15/2018 3:00:00 PM
Room North, Hall D, Area D
General Anesthesia for Elective Caesarean Delivery Can Be Opioid Free
Enrico M. Camporesi, M.D., Garrett Enten, B.S., Mina Shenouda, M.D., Naomi Crosen, M.S.N., Devanand Mangar, M.D., David J. Samuels, M.D.
TEAMHealth, Tampa, Florida, United States
Disclosures: E.M. Camporesi: None. G. Enten: None. M. Shenouda: None. N. Crosen: None. D. Mangar: None. D.J. Samuels: None.

Opioid use for labor analgesia has been linked with neonatal respiratory depression and changes in fetal outcome [1]. In the past few decades, the use of general anesthesia for cesarean delivery (CD) has decreased dramatically. A survey from 2005 estimates that only 0.6% of CDs performed in tertiary care facilities utilize general anesthesia [2]. However, general anesthetic still may be required in non-emergent CD. In these cases, current methods of decreasing fetal opioid exposure include: early clamping the umbilical cord, minimizing opioids prior to delivery, and delivering the baby in a timely fashion. Complete removal of opioids from the general anesthetic could be the next step in eliminating potential fetal opioid exposure. This study evaluates the efficacy of Opioid Free Anesthesia (OFA) for elective CD. The patients evaluated in this series were not candidates for neuraxial anesthesia because they specifically requested general anesthesia or had contraindications such as spinal instrumentation or thrombocytopenia.

Materials & Methods:

After obtaining approval from the local IRB, a retrospective chart review was performed. The review comprised 17 patients who underwent general anesthesia for elective CD using the same nursing staff and surgeon over 9 months during the same period (3/17 to 12/17): 8 patients received opioid free anesthesia (OFA), and 9 patients received standard opioid anesthesia (OA).

Both patient groups received standard pre-op treatment with famotidine 20 mg PO and induction with propofol, succinylcholine, and rapid sequence intubation with sevoflurane up to 1.5 MAC. In all cases, the umbilical cord was clamped and the baby delivered before any other anesthetic drug was given. Prior to delivery but after the umbilical clamp was in place, OFA patients received ketamine 0.5 mg/kg followed by magnesium 60mg /kg over 20-30 mins and lidocaine 1.5-2 mg /kg/hr. OA patients received fentanyl 200-500 mcg. Both groups received esmolol 10 mg intraoperatively. Post-delivery, all patients received Zofran 30mg and ketorolac 15-30 mg. Magnesium sulfate was not continued post-op for fear of intra-uterine bleeding. Opioids were administered to both groups during the PACU stay and the next 24 hr, as pain was managed by the obstetric team.

Demographics, outcome metrics, and length of stay were collected. Postoperative Narcotic requirement in milligram morphine equivalents (MME) were calculated for the procedure, recovery in the post-anesthesia care unit(PACU), Post-PACU 24 hr, and Post PACU 24-48 hr All endpoints were analyzed using unpaired two tailed t-tests; statistical significance was determined with a p-value < 0.05.


No significant differences were found between groups in patient characteristics, surgical characteristics, APGAR scores, pain scores, postoperative narcotics requirement in MME, length of post-anesthesia recovery, and hospital length of stay (Table). While not significant, persistent nausea only occurred within the OA group with an incidence of 22.22%.


Our study is limited by opioid use during post-anesthesia recovery. Nevertheless, this brief series demonstrates that opioid free anesthesia for elective CD produces equivalent results to opioid anesthesia in regards to procedure duration, blood loss, APGAR scores, and perioperative analgesia.

1. Obstetric drugs and infant behavior: a reevaluation. 1985 Sep; 10(3):345-53.

2. General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005. 2011;20(1):10-6.
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