Hello, and welcome back to AckRack. I'm Jed Wolplot, and we've got a great show for you today. I'm excited to have back a very famous long standing visitor to the show, but who hasn't been on in a while. And it's a double.

We also have for you a brand new first time or both of them working together to put on a fantastic show today. So we've got Dr. Mike Hofcamp, who as frequent listeners will know is the director of a stector of anesthesia at Scott and White Medical Center temple and a clinical associate professor of anesthesiology at Texas A&M Health Science Center College of Medicine. Mike's been on a bunch of shows done some really great work and I'm glad he's finally back. I've been trying to get him back for a while now. And then we have joining us for the first time. Someone I'm really excited to have with us Emily Sharp, who is the program director for the OB anesthesia fellow.

And an assistant professor of anesthesiology at the Mayo Clinic in Rochester, Minnesota. So both of you, welcome to the show. Thank you. So really interesting topic that you two have been working on. And we are going to talk about today, which is inadequate and outgisia for cesarean delivery. And this is something I bet a lot of listeners just it hadn't even occurred to them. This was an issue. Certainly people who don't do a lot of OB like me, not something I would have ever have even thought was an issue, but really interested to hear from you about

this. So why don't we start Mike with you and just tell us a little bit about why are we talking about this? How do we even know it's an issue? And what are we talking about? Thank you, Jed. Thanks for having us on the show. When I was a resident at Hopkins from 2005 to 2008, I started to learn how to do obstetric anesthesia. And it astonished me about how we were taught to never put people to sleep for sea sections. And so the message

I received was you put this patient to sleep. You are really risking their lives. And as a resident, when you got a million things coming at you at once, you just kind of take what you're saying says and you go with it. And it was very, there's very unpleasant to see some of these women. Extremely uncomfortable during cesarean deliveries. And there was really kind of a binary outcome. It's either there was journal anesthesia or you avoid journal anesthesia. I didn't really matter how

you avoid journal anesthesia, just as long as you avoided it. And so as I became attending, I had a little bit more time and space to think about why I was taught to do things this way. And we're really to give you kind of historical account. Joy Hawkins, who actually was the valedictorian of the Texas A&M Charter Medical School class 40 years ago, she was a younger faculty member in the 90s and looked at data.

She was from the 80s and found that from 1985 to 1990, the relative risk of dying in a sea section was about 17 times for journal anesthesia versus regional anesthesia. And this sent shockwaves through the anesthesia community overnight.

And they said, you know what, we can't do journal anesthesia versus zaryn delivery anymore. And so if you see there would be a race to the bottom, as far as who can have the lowest journal anesthesia rate, Brigham and women's reported a journal anesthesia rate versus zaryn delivery of less than 1% from 2000 to 2005.

Estonishing that you can go to a tertiary academic medical center and have a sea section rate or journal anesthesia of less than 1%. What wasn't reported was the use of anesthetic adjuncts that got them there, like how much ketamine are using, how much peripheral are using this stuff matters.

And so there were follow-up studies like the score study, which was done by Danielo using soap data. There was over 200,000 zaryn deliveries and they reported a journal anesthesia rate of about 5.6%.

Similarly, Rick Dutton used his NAICOR data and from the ASA is again, it was about 200,000 zaryn deliveries and reported a zaryn delivery rate for journal anesthesia about 5.8%.

And then interestingly enough, at the University of Pennsylvania, which is also an academic medical center, they reported that obstetric anesthesiologists had a lower rate of journal anesthesia compared to generalists.

So it was about 7% for obstetric anesthesiologists. So that means people are fellowship trained or have specific work expertise in obstetric anesthesia versus 12% for the generalists.

But interestingly enough in this study, that difference went away when you looked at just weekend and after hour cases. So when you say, all right, this is the weekends, after hours you're doing urgent, emerging cases, there's really no difference between specializations, it's just these cases are tougher and you're going to have a higher rate of journal anesthesia.

And so what happened is that I figured, you know what, someone should be reporting data on the use of anesthetic adjunct. So I had a summer student in 2019 and we looked at data from a community hospital in our system from 2014 to 2018.

And this approximate, I think, more of the everyday obstetric anesthesia practice. And we found that in this community center, community or community hospital, there was a 5.6% rate for general anesthesia and a 17.8% rate for using anesthetic adjuncts.

So this means that, you know, it used to be a binary outcome. It's either it's general anesthesia or it's not, but there's this kind of middle outcome of, you know, general anesthesia wasn't performed, but anesthetic adjuncts were necessary.

And so we reported for about 1800 patients that 17.8% of them needed some kind of anesthetic adjuncts such as intravenous fentanyl, intravenous ketamine, hell nitrous oxide.

And let me ask you, so it seems like, you know, maybe and tell me if I'm wrong here, but it seems like if the story were simple, it would be, okay, joys, group finds that general anesthesia for C section is more dangerous than that.

It's more dangerous than regional anesthesia. So everybody just does regional and end of story. We're better off because we're, we're have this lower mortality rate.

But what you're saying is it's not that simple, because if you have to use a ton of adjuvants to prevent general anesthesia to supplement your regional, then maybe there's risk associated with that that we need to take into account. Is that right?

Absolutely, not only just risk and patient safety, but just long term harm to the patient psychologically and I'll let, I'll let Dr. Sharp go into that a little bit more later, but another study showed that the Davis and Vescares looked at all cesarean deliveries in a year and 17% of patients had adjuvants.

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