What’s New in Post-Cesarean Analgesia? · PDF fileWhat’s New in Post-Cesarean Analgesia? 2013 UCSF ... CM, Techniques in Regional Anesthesia & Pain Management 7(4):213-21....
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10/25/2013
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UCSF
October 23rd, 2013
Mark Rollins, MD, PhD
Anesthesia & Obstetrics
What’s New in Post-Cesarean
Analgesia?
2013 UCSFWhat Does The
Evidence Tell Us?
• Describe current impact of post-cesarean pain
• Provide an overview of options for post-cesarean analgesia:• Neuraxial opioids
• Systemic opioids
• Non-opioid analgesics
• Transversus abdominis plane blocks
• Discuss the rational and benefits of multimodal analgesia
Post-Delivery Pain(Mean pain scores for first 24 hours after delivery )
Eisenach JC, et al. Pain 140:87-94 2008
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Cesarean Delivery Pain(Impact on Daily Activities during first 24 hours)
Eisenach JC, et al. Pain 140:87-94 2008
Activity ImpactedVaginalDelivery
CesareanDelivery
Walking 40% 72 %
Mood 19% 40%
Sleep 36% 57%
Interactions with Others 8% 20%
Ability to Concentrate 13% 31%
Pain (8-weeks) 10% 9%
Depression (8-weeks) 11% 11%Eisenach JC, et al. Pain 140:87-94 2008
“Women with severe acute postpartum
pain had a 2.5-fold increased risk of
persistent pain and a 3.0-fold increased
risk of postpartum depression compared to
those with mild postpartum pain.”
Two months after childbirth:
Postoperative Analgesic PracticeFor Cesarean Delivery
Aiono-Tagaloa, et al. Anesthesiology Research & Practice. 2009. PMID: 21217809
• Intrathecal Morphine (spinal) 77%• Use of Epidural following C/D 21%• Routine Use of PCA 12%• NSAIDS 81%
“Round The Clock” – 42%
PRN – 51%Other (often single dose) – 7%
• Acetaminophen 45%
Survey of Institutional Practice:
Patient Preferences for Outcomes Associated with Cesarean Delivery
Carvahlo B, et al. Anesth Analg 101:1182–7. 2005
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Intrathecal Opioids
Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4):213-21. 2003
Opioid Dose Duration
Morphine 0.1 – 0.2 mg 18 – 24 hrs
Fentanyl 5 – 10 mcg 3 – 4 hrs
Sufentanil Up to 5 mcg 3 – 4 hrs
Intrathecal Morphine DosesFor Post-Cesarean Analgesia
Palmer, CM, et al. Anesthesiology 90:437-44. 1999Palmer, CM, Tech in Reg Anesth & Pain Mgmt 7(4):213-21. 2003
• Nausea and Vomiting 10% to 50%• Respiratory Depression < 0.25%
Analgesia Pruritus
(mea
n ±
95%
CI)
Intrathecal Morphine 100µg & 200µgFor Post-Cesarean Delivery Analgesia
Wong JY, et al. IJOA 22:36-40 2013
Analgesia IT Morphine100µg
IT Morphine200µg Pvalue
Opioid Use (0-24h) 54 ± 35mg 44 ± 35mg .04
Opioid Use (24-48h) 54 ± 32mg 60 ± 31mg .18
IV morphine required 30% 18% .02
IV Morphine Use (0-24h) 2.5 ± 5.3mg 1.3 ± 3.5mg .054
IV Morphine Use (24-48h) 0.02 ± 0.2mg 0 ± 0mg .32
Mean VPS (0-24h) 2.0 ± 1.1 1.6 ± 1.1 0.01
Mean VPS (24-48h) 2.5 ± 1.0 2.5 ± 1.0 0.92
Intrathecal Morphine 100µg & 200µgFor Post-Cesarean Delivery Analgesia
Wong JY, et al. IJOA 22:36-40 2013
Side Effects IT Morphine100µg
IT Morphine200µg Pvalue
Antiemetic Use 24% 52% <0.001
Nausea Episodes (0-24h) 1.6 ± 1.3 1.9 ± 1.3 .04
Nausea Episodes (24-48h) 0.02 ± 0.13 0.04 ± 0.46 .56
Patients receiving NSAIDs 87% 87% .98
Time of Surgery to Discharge 89 ± 20 hrs 89 ± 19 hrs .76
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Epidural Opioids
Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4):213-21. 2003
Epidural Morphine DosesFor Post-Cesarean Analgesia
Palmer, CM, et al. Anesth Analg 90:887-91. 2000
• Nausea and Vomiting < 10%• Respiratory Depression < 0.25%
Analgesia Pruritus
Post-Cesarean Pain(Efficacy of Two Epidural Morphine Doses)
Singh SI, et al. Anesth Analg 117:677-85. 2013
Post-Cesarean Pain(Efficacy of Two Epidural Morphine Doses)
Singh SI, et al. Anesth Analg 117:677-85. 2013
Pruritus Nausea & Vomiting
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European Journal of Pain 14:894e (2010)
6h - Solid Diamonds12h - Solid Squares24h - Open Squares
“A single bolus of epidural morphine provides better analgesia than parenteral opioids but with an effect limited to the first postoperative day after caesarean section”
Anesthesiology 2007; 106:843-63
“…neuraxial opioids for postoperative analgesia improve analgesia and maternal satisfaction...”
Recommendation:“For postoperative analgesia after neuraxialanesthesia for cesarean delivery, neuraxialopioids are preferred over intermittent injections of parenteral opioids.”
Oral vs. PCA Opioid(Post-Cesarean Analgesia)
Dieterich MD, et al. Arch Gynecol Obstet 286:859-65. 2012
Oral vs. PCA Opioid(Post-Cesarean Analgesia)
Dieterich MD, et al. Arch Gynecol Obstet 286:859-65. 2012
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“The use of PCA is a complex, high risk treatment that is associated with harmful events and death”
� Hicks et al m. J. Health Syst. Pharm. Mar 2008; 65 429-440
Which PCA related statementdo you use?
“Just press your pain button when ever you need it”
.
PCA has been identified as #7 of the 10 TOP Health Technology Hazards for 2011
� ECRI Institute Report Nov, 2010
MEDMARX and U.S. Pharmacopeia (USP) data show that when PCA pumps are involved, the chance for patient harm increases more than 3.5 times (APSF).
Multimodal Analgesia
• Optimize additive effects of various agents
• Utilize different modes of analgesia
• Minimize maternal side effects
• Reduce transfer of medication to breast milk
NSAIDs• All NSAIDs have opioid sparing activity
- Effective in reducing post-cesarean delivery pain
- Enhance opioid analgesia
- Decrease opioid-related side effects
• Non-selectively inhibit cyclooxygenase-1 & -2- Undesirable side effects include platelet dysfunction, renal
impairment, and GI irritation
• American Academy of Pediatrics regards NSAIDs safe for use in breast feeding women
• Typical post-cesarean dosing in healthy women- Ibuprofen 600mg to 800mg orally every 8 hours
Lavoie, et al. Clin Perinatol 40:443-55. 2013Flood & Aleshi. Chapter 27, Chestnut’s Obstetric Anesthesia. 5th Ed. 2013
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NSAIDsOn-Demand vs. Fixed-Interval
Jakobi P, et al. Am J Obstet Gynecol 187(4):1066-9. 2002
Fixed-interval NSAID dosing provides more effective post-operative cesarean analgesia and results in better patient satisfaction compared to on-demand dosing.
Acetaminophen
• Less effective than NSAIDs in decreasing opioid con sumption
and post-op nausea & vomiting.- Effective in reducing post-cesarean delivery pain
- Enhance opioid analgesia
- Decrease opioid-related side effects
• Intravenous acetaminophen available- Higher peak plasma concentrations compared to oral- Dosing 650mg q4 hours or 1000mg q6 hours (4 g/day max)- In nursing mothers infant daily dose is 1% - 2% of maternal
- Pharmacokinetics recently determined post-cesarean elimination half-life of 116 minutes
- No current analgesic outcome benefit compared to oral
Rawlinswon A, et al. Evid Based Med 17:75-80. 2012Kulo A, et al. IJOA 21:125-8. 2012Lavoie, et al. Clin Perinatol 40:443-55. 2013Flood & Aleshi. Chapter 27, Chestnut’s Obstetric Anesthesia. 5th Ed. 2013
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Alpha2 agonists
Gabapentin
NMDA antagonists
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Transversus
Abdominis
Plane
Block
(AKA - TAP Block)
Figure from Ultrasound For Regional Anesthesia, 2008
TAP Block Technique
McDonnell et al. Anesth Analg 106:186-9. 2008
• Placed between subcostal margin and iliac crest
• Placed with either blind or U/S guidance techniques
• 15–20mL of local anesthetic injected incrementally on each side
• Complications include intravascular injection and bowel perforation
TAP Block US Technique
Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2nd Edition. Elsevier-Saunders, 2013
TAP Block US Technique
Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2nd Edition. Elsevier-Saunders, 2013
www3.gehealthcare.com
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TAP Block Efficacy Post-Cesarean Delivery
McDonnell et al. Anesth Analg 106:186-9. 2008
TAP Block Efficacy Post-Cesarean Delivery
Abdallah FW, et al. BJA 109(5):679-87. 2012Loane H, et al. IJOA 21:112-8. 2012Mishriky BM, et al. 59:766-78. 2012Onishi Y, et al. J. Obstet. Gynaecol. Res 39(9):1397-1405. 2013
• When spinal morphine is not used, the TAP block can reduce morphine consumption during the first 24-hours.
• When used in conjunction with spinal morphine there is minimal if any benefit.
• Rescue TAP blocks should be considered when spinal morphine with multimodal analgesic therapy does not provide adequate pain relief.
• Pain following cesarean delivery can significantly impact the new mother
• Use of neuraxial opioids is preferred to parenteral delivery
• TAP blocks should be considered when neuraxial morphine has not been administered
• Multimodal analgesic techniques provides superior pain relief
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