The American Academy of Pediatrics places emphasis on increasing breastfeeding in the United States. A common reason for the cessation of breastfeeding is the use of medication by the nursing mother and advice by her physician to stop nursing. Such advice may not be warranted. This statement is intended to supply the pediatrician, obstetrician, and family physician with data, if known, concerning the excretion of drugs into human milk. Most drugs likely to be prescribed to the nursing mother should have no effect on milk supply or on infant well-being. This information is important not only to protect nursing infants from untoward effects of maternal medication but also to allow effective pharmacologic treatment of breastfeeding mothers. Nicotine, psychotropic drugs, and silicone implants are 3 important topics reviewed in this statement.

Transfer of drugs and other chemicals into human milk

To the Editor.— I read with interest the Committee on Drugs second report about transfer of drugs and other chemicals into human milk.1 Although the objective to categorize those drugs with reported harmful, or not, effects on children has been achieved with admirable brevity, the report fails to cite two useful areas of information. The WHO Task Force on Drugs in Human Milk reviewed the world literature and compiled a recently published book entitled Drugs and Human Lactation.2

Transfer of Drugs and Other Chemicals into Human Milk

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the "Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care". Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade "A" (strong recommendation), Grade "B" (recommendation) and Grade "0" (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) – short version

Postoperative thrombotic complications increase hospital length of stay and health care costs. Given the potential for thrombotic complications to result from hypercoagulable states, we sought to determine whether postoperative blood analysis using thromboelastography could predict the occurrence of thrombotic complications, including myocardial infarction (MI). We prospectively enrolled 240 patients undergoing a wide variety of surgical procedures. A cardiac risk score was assigned to each patient using the established revised Goldman risk index. Thromboelastography was performed immediately after surgery and maximum amplitude (MA), representing clot strength, was determined. Postoperative thrombotic complications requiring confirmation by a diagnostic test were assessed by a blinded observer. Ten patients (4.2%) suffered a total of 12 postoperative thrombotic complications. The incidence of thrombotic complications with increased MA (8 of 95 = 8.4%) was significantly (P = 0.0157) more frequent than that of patients with MA < or =68 (2 of 145 = 1.4%). Furthermore, the percentage suffering postoperative MI in the increased MA group (6 of 95 = 6.3%) was significantly larger than that in the MA < or =68 group (0 of 145 = 0%) (P = 0.0035). In a multivariate analysis, increased MA (P = 0.013; odds ratio, 1.16; 95% confidence interval, 1.03-1.20) and Goldman risk score (P = 0.046; odds ratio, 2.39; 95% confidence interval, 1.02-5.61) both independently predicted postoperative MI. A postoperative hypercoagulable state as determined by thromboelastography is associated with postoperative thrombotic complications, including MI, in a diverse group of surgical patients.

Thromboelastography maximum amplitude predicts postoperative thrombotic complications including myocardial infarction.

Rapid thrombelastography (r-TEG) identifies hypercoagulability and predicts thromboembolic events in surgical patients.

Thromboelastography and sonoclot analysis in the healthy parturient

Remifentanil versus alfentanil in a balanced anesthetic technique for total abdominal hysterectomy

/pdf/anaesthetic-management-of-a-parturient-with-thrombocytopenia-4mxy03mn18.pdf

Anaesthetic management of a parturient with thrombocytopenia using thrombelastography and sonoclot analysis

/pdf/a-nontraumatic-induction-technique-for-paediatric-patients-1vyv6lbjak.pdf

A nontraumatic induction technique for paediatric patients

The purpose of this study was to measure the concentration of fentanyl in human colostrum after intravenous administration of an analgesic dose. Thirteen healthy women were given fentanyl 2 micrograms.kg-1 for analgesic supplementation during either Caesarean section or postpartum tubal ligation. Serum and colostrum were collected for 45 min, two, four, six, eight, and ten hours following administration of the drug. Radioimmunoassay showed that colostrum fentanyl concentrations were greatest at 45 min, the initial sampling time, reaching 0.40 +/- 0.059 ng.ml-1, but were virtually undetectable ten hours later. Fentanyl concentrations were always higher in colostrum than in serum. This concluded that with these small concentrations and fentanyl's low oral bioavailability, intravenous fentanyl analgesia may be used safely in breast-feeding women.

http://e-lactancia.org/media/papers/FentaniloBF-CanJAnest1992.pdf

Concentration of fentanyl in colostrum after an analgesic dose.

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