# Labor anelgesia



## StCEMT (Mar 11, 2017)

So I actually asked this question to a medic in passing that was an adjunct for our class back when I was still in medic school and the response I got was akin to asking if I could poke the baby in the eye. However, I came across this article discussing exactly what I had asked about and it doesn't seem like my question was actually all that unreasonable.

The question was about the use of Ketamine to help try to dull some of the pain from birthing a tiny human; that is one pain I am very empathetic towards. I realize it is entirely dependent on the situation, but assuming there is an opportunity to start an IV and set up the Ketamine, why shouldn't we? In this sample at least, it was a safe and effective option. This would probably be walking a line and I'd be leaving it up to the receiving doc, but I have no problem calling for something like this. 

I ask because we actually get a fair amount of maternal calls where I work, whether they be hospital to hospital or scene calls and I have already very narrowly avoided walking in on a birth not too long ago. 

Obligatory link. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3950455/


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## EpiEMS (Mar 11, 2017)

Why not NO2? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594866/

I mean, sadly, not enough services have it. But, of course, it would be awfully helpful. 


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## StCEMT (Mar 11, 2017)

EpiEMS said:


> Why not NO2? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594866/
> 
> I mean, sadly, not enough services have it. But, of course, it would be awfully helpful.
> 
> ...


I'd be all for it. Like you said though, availability is an issue. I have ketamine and decently flexible use of it per protocol. I don't think I have even seen NO2.


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## TrueNorthMedic (Mar 11, 2017)

We use nitrous oxide all the time for patients in labour, and I find it to be very effective for most people. You really have to explain it well and get them to use it properly though. If they take full tidal volume breaths and hold each breath in for a couple of seconds then it works the best, from what I've seen.
Doesn't take the pain away completely but makes it tolerable. Another good thing is the short duration of action, stop using it for a few minutes, and it's pretty much gone from their system.


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## GMCmedic (Mar 11, 2017)

Im passing this on to my Medical director. I like it

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## Carlos Danger (Mar 12, 2017)

No doubt that ketamine is effective for labor pain, but it is a pretty dirty drug. In small doses like the ones used in this study the side effects won't be a problem, but in larger or repeated doses they may be.

In early stages of labor, when IV analgesics are safe to use fairly liberally, the pain of contractions is usually quite tolerable, and IV analgesia really shouldn't be required. In late stages when the pain gets worse, the conundrum is that small doses won't cut it, but now that you are getting closer to delivery you have to be very careful with IV analgesics.

Nalbuphine works pretty well for labor pain. Probably a better choice than ketamine.


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## EpiEMS (Mar 12, 2017)

@Remi, do you use nitrous/have you seen nitrous used?


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## StCEMT (Mar 12, 2017)

I know that article touched on some side effects, but are there any others you are thinking of in this case, specifically in the later stage? I'm really probably just going to give one dose anyway just due to circumstances.

 I know a lower dose is not likely to make the pain go away, but realistically my goal would just to be take some of the edge off. Kinda the same situation as NO2. Maybe not the best tool for the job, but the best that I have so long as it is a safe option.


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## Carlos Danger (Mar 12, 2017)

EpiEMS said:


> @Remi, do you use nitrous/have you seen nitrous used?


I use nitrous all the time in the OR, never even saw it prehospital though. It is a great drug and I think more EMS systems should use it.


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## Carlos Danger (Mar 12, 2017)

StCEMT said:


> I know that article touched on some side effects, but are there any others you are thinking of in this case, specifically in the later stage?



Primarily general dysphoria / confusion, as well as potential for amnesia of the birth, which some new moms find very distressing.

Really, if you do a lot of labor transports, you should try to get Nubain added to your protocols.


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## StCEMT (Mar 12, 2017)

Remi said:


> Primarily general dysphoria / confusion, as well as potential for amnesia of the birth, which some new moms find very distressing.
> 
> Really, if you do a lot of labor transports, you should try to get Nubain added to your protocols.



Ok, those make sense. 

I don't know how many we actually do. The code (06) just says maternal case. That could be just a few weeks to full term pregnancies and a transfer or a 911. Some days I don't hear any and some days I hear a few go out. I seem to get about one pregnant patient a month or so. 

Nitrous would be interesting to have and if I were to ask about anything, probably more likely. They are pretty tight with how much they give us, although we get generous use of what we have. Our clinical education guy had to fight just to get us nasal end tidal, Nubain would likely get shot down.


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## GMCmedic (Mar 12, 2017)

GMCmedic said:


> Im passing this on to my Medical director. I like it
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


I thought about this more last night and decided to take a deeper look at N2O. So far I like what I see and I can sell this to the medical director fairly easily. 

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## NomadicMedic (Mar 12, 2017)

You might have difficulty finding N2O equipment for EMS. 

I also think there is concern for abuse potential.


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## GMCmedic (Mar 12, 2017)

NomadicMedic said:


> You might have difficulty finding N2O equipment for EMS.
> 
> I also think there is concern for abuse potential.


Theyre anal about us checking tank pressure daily, though someone could always argue a leaky regulator. 

We are contracted by our employer to do L&D/NICU/PICU transports. I think I can get L&D to buy us the initial equipment. Just have to make them think the equipment is for them lol

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## VentMonkey (Mar 12, 2017)

NomadicMedic said:


> You might have difficulty finding N2O equipment for EMS.
> 
> I also think there is concern for abuse potential.


I thought it was much more prevalent in the prehospital setting in say, the 90's? (saw it used by "MEDIC" in NC on that old "paramedics" show), but was taken out of a lot of providers protocols for this very reason.

I remember learning about it as an NR drug during p school, and it being my favorite to learn because it was pretty basic to include max doses of: 

"When the patient can't stop laughing."


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## SandpitMedic (Mar 12, 2017)

Maybe after we increase some barriers to entry and get some more mature and professional folks around, we won't have the leading argument against NO2 being paramedics getting a quick high. 

Abuse happens... and always will. Humans are not perfect. That said, it's a sad argument for a medical profession. (That's what we are, correct?)

When I worked in the Emirates we had it from BLS to ALS levels of care. Like another said, the regulators and volume were checked and recorded daily. The drug was great for patients, and I never had the urge to try it.


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## EpiEMS (Mar 12, 2017)

They use similar things abroad without issue..."the green whistle", etc.


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## VentMonkey (Mar 12, 2017)

EpiEMS said:


> They use similar things abroad without issue..."the green whistle", etc.


Sandpit has a point about the fact that it should be a non-issue, and you're correct that Penthrox is very much common on ambulances in the UK. I don't know how, or why we're a different case.

I get increasing barriers, and educational standards, but is that literally all it takes? I wonder what the average age is for entry-level EMS providers across the pond?


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## Carlos Danger (Mar 12, 2017)

I don't know exactly why N2o fell out of favor in American EMS. I'm guessing it was a combination of the factors mentioned above, but mostly I imagine it's just logistics and possibly cost. It is probably cheaper to stock an EMS unit with vials of fentanyl than with the equipment to administer N2o, and it's definitely easier to store and account for the IV drugs. Plus, narcs have the obvious advantage of not wearing off immediately when you stop administering them.

Don't get me wrong - I think N2o would be great to have in the field, and anyone who thinks they might be able to get their agency to get it should try to do so.

But back to labor pain specifically.......really, nalbuphine is a good option, guys. That's what the OB nurses use until we get a chance to place an epidural. It generally works pretty well and it's safe (though perhaps not ideal) to use even in later stages of labor if you really need to give some analgesia. The only time we really use N2o in OB anesthesia is when they are having a cesarean and the spinal is starting to wear off or is just patchy. Though they do use it routinely in Europe, from what I understand.


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## GMCmedic (Mar 12, 2017)

We have a good group of medics at my current service. The youngest of us are in our early thirties, ranging up to 68 years old. On the tech side there are some in their early twenties but they have a good head on their shoulders. Almost all of us have been or are cops or firefighters also. Were all close as there are only about 36 of us field employees. 

Not that any of this matters, i just dont see any of our current employees abusing N2O but the risk is there. Like has been mentioned, i dont think we should let that fear hold us back. 

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## EpiEMS (Mar 12, 2017)

VentMonkey said:


> I get increasing barriers, and educational standards, but is that literally all it takes? I wonder what the average age is for entry-level EMS providers across the pond?



For what it's worth, providers at the EMT (or EMR) equivalent levels are permitted to administer nitrous and equivalents in many countries. we're talking about vocationally trained folks. 



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## VentMonkey (Mar 12, 2017)

EpiEMS said:


> For what it's worth, providers at the EMT (or EMR) equivalent levels are permitted to administer nitrous and equivalents in many countries. we're talking about vocationally trained folks.


Yep, my point exactly. Is it our culture on top of a limited educational barrier? I can't imagine other parts of the world don't have issues with substance abuse, providers with a less than professional approach, or both. 

A Penthrox whistle would be ideal for most BLS providers, along with basic meds such as ASA, and IN Narcan for_ respiratory depressed _opioid-suspected OD's_. _Again though, entry requirements, right?...


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## NomadicMedic (Mar 12, 2017)

EpiEMS said:


> For what it's worth, providers at the EMT (or EMR) equivalent levels are permitted to administer nitrous and equivalents in many countries. we're talking about vocationally trained folks.



 Eh, most paramedics is the US are vocationaly trained folks. 
Just sayin'. 

I think the big reason it went away in the US was lack of equipment. I had heard that the company that made the mixer went out of business and nobody picked up the slack (or FDA approval) for EMS.


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## VentMonkey (Mar 12, 2017)

NomadicMedic said:


> I think the big reason it went away in the US was lack of equipment. I had heard that the company that made the mixer went out of business and nobody picked up the slack (or FDA approval) for EMS.


Right, which then leads to the "so why not Penthrox whistles?" question. Is Penthrox even FDA regulated, let alone approved?


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## NomadicMedic (Mar 12, 2017)

VentMonkey said:


> Right, which then leads to the "so why not Penthrox whistles?" question. Is Penthrox even FDA regulated, let alone approved?



Withdrawn because of nephrotoxicity in larger doses. Apparently though, small doses have shown no ill effect. I also hear it's starting to fall out of favor down unda, being replaced with IN Fent.


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## SandpitMedic (Mar 12, 2017)

Penthrox is awesome. Used it on a MCI once (again, overseas).
 Works great and is also self limiting.
I think the topic has come up here before; it has gnarley side effects on the kidneys and liver in large quantities/doses... (like most medications).


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## VentMonkey (Mar 12, 2017)

NomadicMedic said:


> Withdrawn because of nephrotoxicity in larger doses. Apparently though, small doses have shown no ill effect. I also hear it's starting to fall out of favor down unda, being replaced with IN Fent.


Thanks, I learned something new here^^^.


SandpitMedic said:


> Penthrox has gnarley side effects on the kidneys and liver in large quantities/doses... (like most medications).


I'm unfamiliar with it, so what constitutes large or heavy doses for it?


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## NomadicMedic (Mar 12, 2017)

VentMonkey said:


> Thanks, I learned something new here^^^.
> 
> I'm unfamiliar with it, so what constitutes large or heavy doses for it?



https://www.fda.gov/ohrms/dockets/98fr/05-17559.htm

The dose for a Green Whisle is (I think) 3ml.
Very small.


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## NomadicMedic (Mar 12, 2017)




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## VentMonkey (Mar 12, 2017)

NomadicMedic said:


> https://www.fda.gov/ohrms/dockets/98fr/05-17559.htm
> 
> The dose for a Green Whisle is (I think) 3ml.
> Very small.


Well then...Fentanyl it is.


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## SandpitMedic (Mar 12, 2017)

VentMonkey said:


> I'm unfamiliar with it, so what constitutes large or heavy doses for it?



I'm not too sure on the current science on that, but our protocols over there was a 3mL/dose (one whistle), not to exceed more than 6mL in any 24 hour period or 15mL in a week. 

It is on a string you put around their wrist, they take puffs on the green whistle until they literally can't and they become flaccid (more or less). Then when they start to wake up you instruct them to take more puffs to desired effect. Self limiting, fast acting, great drug! 

One whistle will last about 10-20 minutes.


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## Handsome Robb (Mar 13, 2017)

My old agency used to carry nitrous then it became limited to ALS ski patrol and ILS special events teams. The reason it came off the truck was due to the inability to get parts for the regulators/mixing system. 

Whenever we'd pick people up from our ALS ski patrol we'd always use it to get people out of their ski clothes and especially ski boots while we established IV access and started giving opiates. 


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## usalsfyre (Mar 13, 2017)

Remi said:


> I don't know exactly why N2o fell out of favor in American EMS. I'm guessing it was a combination of the factors mentioned above, but mostly I imagine it's just logistics and possibly cost. It is probably cheaper to stock an EMS unit with vials of fentanyl than with the equipment to administer N2o, and it's definitely easier to store and account for the IV drugs. Plus, narcs have the obvious advantage of not wearing off immediately when you stop administering them.
> 
> Don't get me wrong - I think N2o would be great to have in the field, and anyone who thinks they might be able to get their agency to get it should try to do so.


The number one reason is (possibly) misplaced accountability fears. 

A very, very close number two is the FDA's stance on "adulterated gasses" makes the blenders a serious pain in the *** to obtain and carry around. 

Worked one place that had it, and it was great. Maybe one day we can get it pre-mixed.


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## GMCmedic (Mar 13, 2017)

Aside from the cost I dont think im going to have much issue getting the medical director to go for it. 

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## StCEMT (Mar 13, 2017)

Well look at that. No sooner than I start this, we get sent to IL to pick someone for a maternal transfer, early labor stages.....


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## Nova1300 (Mar 14, 2017)

VentMonkey said:


> Thanks, I learned something new here^^^.
> 
> I'm unfamiliar with it, so what constitutes large or heavy doses for it?



The nephrotoxicty reports come from its use as a general anesthetic agent. The concentration breathed to induce general anesthesia is far higher than the concentration needed for the analgesic effect.  

The "dose" would be measured in exposure hours (we call them MAC-hours) to the anesthetic gas, whereas the pen would deliver an exponentially smaller amount of exposure, both in terms of concentration and duration.  


I love the idea of penthrox.  It is rapid-onset, short-acting, probably highly predictable in its effects.  It's independent of renal or hepatic function, and is patient-administered in doses that are by design self-limiting.  Im also guessing you won't meet too many patients with a methoxyflurane allergy.  

And in a time of opiates run amok, it's nice to have an analgesic that still works on everyone, no matter their total daily oxycodone dose.  

I would love to see it here.


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## Handsome Robb (Mar 15, 2017)

Nova1300 said:


> And in a time of opiates run amok, it's nice to have an analgesic that still works on everyone, no matter their total daily oxycodone dose.



I gave a dude 400 mcg of fentanyl and 50 mg of ketamine the other day and it didn't touch him....

Made me 


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## E tank (Mar 15, 2017)

Nova1300 said:


> Im also guessing you won't meet too many patients with a methoxyflurane allergy.
> .



Not an allergy but a malignant hyperthermia trigger. It'd be pretty critical to flesh out a history before giving it.


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## VentMonkey (Mar 15, 2017)

Quick thread derail for the CRNA crowd:

How rare is MH? And is Dantrolene readily available in the pixxus in the event one is dealt this mysterious disorder?


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## Carlos Danger (Mar 15, 2017)

From mhaus.org:

_The exact incidence of MH is unknown. Epidemiologic studies reveal that MH complicates one in about 100,000 surgeries in adults and one in about 30,000 surgical procedures in children. The incidence varies depending on the concentration of MH families in a given geographic area. High incidence areas in the United States include Wisconsin, Nebraska, West Virginia and Michigan. However, the prevalence of genetic change that predisposes to MH is much higher. About one in 2,000 patients harbor a genetic change that makes them susceptible to MH._​
Most MH incidents occur in patients who have previous exposures to triggering agents. Events are also more common when the patient is exposed to more than one triggering agent. Also a large percentage of events are noted after the triggering agent has been discontinued (i.e. In PACU).

Every OR I've ever been in had a "MH cart" that had all the dantrolene, sterile water, bicarb, cold packs, etc in it.


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## EpiEMS (Mar 15, 2017)

Not a CRNA or anything fancy (), but PubMed had some useful write-ups. While incidence (# MH cases/# surgeries)seems low, susceptibility is pretty high. The review I skimmed cited incidence of 1:10,000 to 1:250,000 anesthetic administrations, but susceptibility between 1:400 and 1:3000 people.

That said, incidence of death (or cardiac arrest but not death) is in the single digits (small _n_ study though) for MH. Looks like temperature monitoring is the best method to prevent problems (unsurprisingly).

Pretty crazy stuff!


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## E tank (Mar 15, 2017)

EpiEMS said:


> .....incidence of 1:10,000 to 1:250,000 anesthetic administrations, but susceptibility between 1:400 and 1:3000 people.
> 
> That said, incidence of death (or cardiac arrest but not death) is in the single digits (small _n_ study though) for MH. Looks like temperature monitoring is the best method to prevent problems (unsurprisingly).
> 
> Pretty crazy stuff!



One to two cases a week in North America, 1 to 2 deaths per year. Low death rate because of quickly accessible curative drug (dantrolene) and awareness of everyone that works in the OR. BUT, there are rare cases of non anesthetic related triggered patients. Basically, anyone you treat for severe heat exhaustion/heat stroke should be assessed for an MH susceptible gene. BTW, succs is a triggering agent as well. Not sure how common that is in EMS these days. But if there was an MH concern with that, there should be with Penthrane as well. 

Tiny numbers we're talking about here, but devastating consequences.


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## VentMonkey (Mar 15, 2017)

E tank said:


> succs is a triggering agent as well. Not sure how common that is in EMS these days.


TMK, it's still fairly common with most prehospital-RSI formulary. It's our primary RSI paralytic. Roc is our back up, or second option. 

Aside from perhaps an intraocular injury coupled with the need to induce, I like Succs because of its shorter length of duration. It (IMO) allows the receiving docs a chance to better assess our patients neurological status sooner rather than later as our transport times to our ED's works with our push dose sedative/ analgesics combos, typically.

We have Vec as a post-RSI option as well. And yes, when learning about these drugs, MH was mentioned (mirroring what you and Remi have said thus far) with regards to Succs administrations; right down to its precursors. 

I just wondered how frequently you guys deal/ dealt with it, as I realize while very serious, is quite rare. 

The FP-C loves to throw a-"what's the reversal agent for a suspected MH patient."-question in almost without fail, why? I have no clue.


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## E tank (Mar 15, 2017)

VentMonkey said:


> TMK, it's still fairly common with most prehospital-RSI formulary. It's our primary RSI paralytic. Roc is our back up, or second option.
> 
> I just wondered how frequently you guys deal/ dealt with it, as I realize while very serious, is quite rare.
> 
> The FP-C loves to throw a-"what's the reversal agent for a suspected MH patient."-question in almost without fail, why? I have no clue.



Gotcha, thanks. There has been some controversy in succs being able to trigger on it's own (without being given with another trigger) but it absolutely can and has. As far as how often I deal with it, I've had one patient so far and the general incidence per anesthetist is roughly 1:15,000 performed anesthetics  and I'm way, way over due for my second.


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## Handsome Robb (Mar 15, 2017)

So knowing how dangerous MH is but also how uncommon it is does every patient who undergoes anesthesia with meds that are triggering agents receive continuous temperature monitoring? 


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## E tank (Mar 15, 2017)

Handsome Robb said:


> So knowing how dangerous MH is but also how uncommon it is does every patient who undergoes anesthesia with meds that are triggering agents receive continuous temperature monitoring?
> 
> 
> Sent from my iPhone using Tapatalk



For cases that last an hour or more, the very strong recommendation is continuous electronic core (not skin) temperature monitoring every single time.


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## Carlos Danger (Mar 17, 2017)

Handsome Robb said:


> So knowing how dangerous MH is but also how uncommon it is does every patient who undergoes anesthesia with meds that are triggering agents receive continuous temperature monitoring?



Yes.

Thought according to some, Etc02 monitoring provides earlier warning in most cases.


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## Nova1300 (Mar 18, 2017)

Interesting point.  For those outside the US using penthrox - do you screen for MH before use?


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## para40s (Mar 19, 2017)

Nova1300 said:


> Interesting point.  For those outside the US using penthrox - do you screen for MH before use?



Longtime lurker, regular penthrane administer-er

We ask prior to administration something along the lines of "have you had any prior problems with anaesthetic medications or have heard of something called MH..?" More specifically I'll also ask pt's if they've used the 'green whistle' before and if they've had any problems or side effects plus effects on their pain..the latter to decide if another analgesic might be more suitable.

In terms of analgesia for maternity pt's I've probably only given it maybe five times, maybe moderate effectiveness, even with good compliance. We did carry nitrous which was abandoned a few years ago mainly due to the cost from the supplier to supply and maintain the cylinders, regs, etc...I don't know how much was being spent, but when compared to pentrhane which costs $25-40 per dose and is given out like candy, I don't know if there was much to be saved. As good as penthrane is in terms of ease of use and low side-effects, I would love to have nitrous back for maternity pt's, extended transport times, and reduction of fractures especially. 

As for MH, I've only come across one pt who ?had a hx which we found noted in a hospital discharge summary. Treatment had already been commenced and was stopped with no adverse effects. Anyways, I've never heard of any cases of MH pre-hospitally and even after scanning a bunch of literature where penthrane was used in a number of clinical settings I haven't found any reports of MH occurring including published case studies


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## jwk (Apr 8, 2017)

Honestly much ado about nothing with the methoxyflurane discussions. MOF, Penthrane, Penthrox et al has been unavailable commercially in the US for probably 20 or more years.  About the only place penthrox inhalers have been used is down under.  It's clinical use in the US and most other first-world countries was abandoned because of nephrotoxicity, and because much safer and more reliable agents came along.  I doubt you ever see it because there won't be anyone in the US willing to sell it due to the potential risks involved.  I haven't checked, but I wouldn't be surprised if it is no longer FDA approved.

As far as ketamine for labor analgesia - if any hospital in the US is using it routinely for labor analgesia, I'm not aware of it.  I know some of you think ketamine is the greatest thing to come along in EMS in decades, but it does have it's downsides.  Trust me, you don't want to deal with a whacked out primip and there's no way to screen whether or not someone will have a hugely dysphoric reaction to it or not.  Most mommies either want to go natural or they want an epidural.  Our L&D unit gives IV fentanyl on occasion that's about it for IV pain meds.


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## E tank (Apr 8, 2017)

jwk said:


> As far as ketamine for labor analgesia - if any hospital in the US is using it routinely for labor analgesia, I'm not aware of it.  I know some of you think ketamine is the greatest thing to come along in EMS in decades, but it does have it's downsides.  Trust me, you don't want to deal with a whacked out primip and there's no way to screen whether or not someone will have a hugely dysphoric reaction to it or not.  Most mommies either want to go natural or they want an epidural.  Our L&D unit gives IV fentanyl on occasion that's about it for IV pain meds.



Not for labor analgesia per se, but ketamine works great for a spotty epidural for c section or even the occasional episiotomy or tear repair. 10-20 mg usually is plenty and moms do pretty well.


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