Article Notes
Although there remains much conflicting evidence, largely of a low-quality observational nature, the highest quality evidence to date refutes assertions that epidural fentanyl reduces breastfeeding rates.
Notably Lee et al.’s 2017 RCT of over 300 women showed no effect of epidural fentanyl up to 2 mcg/mL and successful maternal breastfeeding up to 6 weeks.
This paper is full of many important pearls, and should be read in full.
Regarding common practices in the conduct of BIS-guided anaesthesia:
It has been suggested that a BIS range of 60–75 is suitable for ‘the end of surgery’, but our results show that if neuromuscular block is used, this range is consistent with full awareness.
...and on the use of the Signal Quality Index:
Given that the major cause of patient-related artifact is movement, it is not surprising that the SQI will increase towards 100 when NMBDs are administered, as we found. Unfortunately, the high SQI will indicate that the BIS is at its most reliable exactly when it is performing most poorly in the aware but paralysed patient.
Brachial plexus block with sedation for shoulder surgery is not a technique I employ. It would be interesting to see a direct comparison between stroke rates between this technique and one using block plus GA. Though, it is comforting to know that stroke risk is incredibly low, in spite the considerable number of intraoperative hypotensive events.