The effect of a single intraoperative dose of intravenous dexamethasone 8 mg on post-cesarean delivery analgesia: a randomized controlled trial.

BACKGROUND: A single perioperative dose of dexamethasone has been shown to improve postoperative analgesia and reduce opioid consumption. However, this analgesic and opioid sparing effect has not been well assessed as part of a multimodal analgesic regimen in women post-cesarean delivery. METHODS: Healthy women having cesarean delivery under spinal anesthesia were randomly assigned to receive intravenous dexamethasone 8 mg or placebo after delivery and clamping of the umbilical cord. The primary outcome variable was total opioid consumption in the 24 hours following cesarean delivery. We hypothesized that a single dose of intravenous dexamethasone, administered as part of a multimodal analgesia regimen after spinal anesthesia for cesarean delivery, would significantly reduce postoperative opioid consumption. RESULTS: Fifty-two women were enrolled and randomized to two groups of 26 patients. The median (IQR) opioid consumption in the first 24 hours after cesarean delivery was 12 mg (5-20 mg) in the dexamethasone group compared to 15 mg (5-22 mg) in the placebo group. The median difference in opioid consumption at 24 hours (95% CI) was -3 mg (-12.2 to 5.7) and was not significantly different between groups (P=0.32). CONCLUSIONS: The addition of intravenous dexamethasone 8 mg to a multimodal postoperative analgesic regimen that included intrathecal morphine, in women who had a cesarean delivery under spinal anesthesia, did not reduce 24 hour postoperative opioid consumption.

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with life-threatening anemia following postpartum hemorrhage.

We present a case of a Jehovah's Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.