Pain Management: Updating the Outdated
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This document discusses pain management options for labor and cesarean sections. It provides an overview of common medications and techniques used such as epidurals for labor analgesia and spinal anesthesia for c-sections. It also discusses managing common side effects like itching and risks of certain medications. Recent studies investigating links between labor pain management and risk of postpartum depression are summarized as well.
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Pain Management: Updating the Outdated
- 2. Why this?
- 10. Pain management options for labor Pain management options for C/S “Best” management of side effects, i.e. pruritis Common special populations
- 13. To the woman He said, I will greatly multiply your pain in childbirth; In pain you will give birth to children... -Genesis 3:16 AMP
- 20. What we know…
- 21. Shnider, S. M., et al (1983). Maternal catecholamines decrease during labor after lumbar epidural anesthesia. American journal of obstetrics and gynecology, 147(1), 13-15.
- 23. What we are also starting to learn…
- 24. List articles about PPdepression
- 25. Thangavelautham Suhitharan, T., et al (2016). Investigating analgesic and psychological factors associated with risk of postpartum depression development: a case–control study. Neuropsychiatric Disease and Treatment, 12, 1333.
- 26. Ding, T. et al (2014): Epidural labor analgesia is associated with a decreased risk of postpartum depression: a prospective cohort study. Anesthesia & Analgesia, 119(2), 383-392.
- 27. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression Eisenach, J.C., et al. 2008 Nov 15;140(1):87-94. doi: 10.1016/j.pain.2008.07.011. Epub 2008 Sep 24
- 28. doi: 10.1213/01.ane.0000492595.98883.93 E Poster discussion: Obstetric Du, W., et al.
- 29. October 26, 2016: ASA Annual Meeting: Intrapartum Pain Improvement Is a Predictor for Postpartum Depression: Labor Pain Matters. Lim, G., et al. University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
- 30. Photo of blame for anesthesia.
- 32. Davies, J. M., et al. (2009). Liability Associated with Obstetric Anesthesia. A Closed Claims Analysis. The Journal of the American Society of Anesthesiologists, 110(1), 131-139.
- 34. Carvalho, B., et al. (2005). Patient preferences for anesthesia outcomes associated with cesarean delivery. Anesthesia & Analgesia, 101(4), 1182-1187. 1. PAIN during C/S 2. PAIN after C/S 3. Vomiting 4. Nausea 5. Cramping 6. Itching 7. Shivering 8. Anxiety 9. Somnolence 10.Normal
- 36. Aiono-Le Tagaloa, L., et al. (2010). A survey of perioperative and postoperative anesthetic practices for cesarean delivery. Anesthesiology research and practice, 2009.
- 37. Csection
- 39. Sng, BL, et al. “Hyperbaric versus isobaric bupivacaine for spinal anaesthesia for caesarean section." The Cochrane Library Sept (2016). C/S
- 40. Rev Bras Anestesiol. 2009 Nov-Dec;59(6):674- 83. Dose requirement of intrathecal bupivacaine for cesarean delivery is similar in obese and normal weight women. [Article in English, Portuguese] Lee Y1, Balki M, Parkes R, Carvalho JC.
- 41. C/S
- 43. Anesth Analg. 2005 Nov;101(5 Suppl):S30-43. The role of intrathecal drugs in the treatment of acute pain. Rathmell JP1, Lair TR, Nauman B
- 44. Sibilla., et al. Int Jnl Obstetric Anesthesia. 1997 Jan;6(1):43-8.
- 47. Sibilla., et al. Int Jnl Obstetric Anesthesia. 1997 Jan;6(1):43-8.
- 49. Anesthesiology. 1999 Feb;90(2):437-44. Dose-response relationship of intrathecal morphine for postcesarean analgesia. Palmer CM, et al
- 55. Intrathecal Hydromorphone and Morphine for Postcesarean Delivery Analgesia: Determination of the ED90 Using a Sequential Allocation Biased-Coin Method Sviggum, et al. Anesthesia & Analgesia Vol 123(3), September 2016, p 690–697
- 57. NSAIDs Acetaminophen Side effect treatment and prevention +/- TAP Block
- 58. Michael T Wiisanen, MD Assistant Professor of Anesthesiology, Loyola University, Chicago Stritch School of Medicine; Attending Anesthesiologist, Program Director, Loyola University Medical Centerhttp://emedicine.medscape.com/article/2000944-overview
- 59. Anesth Analg. 2010 Aug;111(2):475-81. doi: 10.1213/ANE.0b013e3181e30b9f. Epub 2010 May 20. The analgesic efficacy of subarachnoid morphine in comparison with ultrasound-guided transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Kanazi GE1, Aouad MT, Abdallah FW, Khatib MI, Adham AM, Harfoush DW, Siddik-Sayyid SM.
- 60. See comment in PubMed Commons belowAnaesth Crit Care Pain Med. 2016 Apr 11. pii: S2352-5568(16)30019-4. doi: 10.1016/j.accpm.2015.10.012. [Epub ahead of print] Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery: A randomized controlled trial. Jarraya A1, Zghal J2, Abidi S2, Smaoui M2, Kolsi K2.
- 61. Anaesthesia Critical Care & Pain Medicine Available online 23 June 2016 Postoperative analgesia after caesarean section with transversus abdominis plane block or continuous infiltration wound catheter: A randomized clinical trial. TAP vs. infiltration after caesarean section •Fanny Klasena, b, et al
- 67. BMC Anesthesiol. 2015 Feb 17;15:18. doi: 10.1186/1471-2253-15-18. Prophylactic administration of ondansetron in prevention of intrathecalmorphine-induced pruritus and post- operative nausea and vomiting in patients undergoing caesarean section. Koju RB1,2, Gurung BS3, Dongol Y4.
- 68. Am J Health Syst Pharm. 2011 Aug 1;68(15):1419-25. doi: 10.2146/ajhp100475. Use of pure opioid antagonists for management of opioid- induced pruritus Kumar K, Singh SI. Neuraxial opioid-induced pruritus: An update. J Anaesthesiol Clin Pharmacol 2013;29:303-7.
- 71. Anesth Analg. 2013 Dec;117(6):1368-70. doi: 10.1213/ANE.0b013e3182a9b042. A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia. Crowgey TR1, Dominguez JE, Peterson-Layne C, Allen TK, Muir HA, Habib AS
- 74. IV boluses PCAs (fent/remi)
- 77. More dilute Addition of opioids
- 78. Hogan, RAPM 2002;27;150-6; Carvalho 2016, Labor Analgesia Modern Technology. Sol Schneider Conference SF, CA.
- 79. Manual Bolus CEI PCEA CEI + PCEA PIEB + PCEA
Editor's Notes
- Thank you sooo much for sharing your precious time with me in this beautiful city. My primary goal is to make the best use of this valuable time together by presenting you with information that you will find useful and interesting… and maybe a little entertaining as well.
- With such a wide range of anesthesia topics to choose from, you may be wondering why I specifically chose OB analgesia to speak about. (Pause)… I would have to say that the topic kind of chose me. Let me explain…
- First, a little background….Before I started working for Duke, I worked at a small, rural 100-bed community hospital in North Central NC. Even though it was less than an hour from both Duke and UNC hospitals…in many ways it seemed worlds apart…. Our resources were limited…The community that we served had the friendliest, most good-hearted people that you would ever want to meet!.... They were also some of the poorest in the state. Half of ALL the children (49.8% to be exact) living in the community, lives BELOW the poverty line. Every year we top the list for highest teen pregnancy rates in the state. As you might have already guessed, teenagers make up a large percentage of our OB populaton. It was here that I have done C-sections and labor epidurals for 12 & 13 year olds. When I first started at that job, I was 1 of only 3 CRNAs. There was only 1 MDA and I was the only female on staff. The combined anesthesia experience of my colleagues equalled approximately 85 years…I had barely 22 months! CLICK NEW GIRL PICTURE
- I vividly remember the 1st day that there was a scheduled c/s for my room. I searched everywhere for duramorph. When I finally asked one of my colleagues for help in finding it, he told me that we didn’t have any…. I was so confused. What was I suppose to do??! I had never done a c/s without adding morphine to the spinal. He explained how it was normally done with either plain bupivacaine or if I wanted to be fancy, I could also add a little fentanyl. The Obstetricians would then handle post-op pain management by writing for IV morphine PCA. He went on to explain that the former medical director was opposed to duramorph as he didn’t want to be responsible for pain management and be called in the middle of the night….Plus, it would require a change in policy in procedure for the L&D nurses r/t new monitoring requirements and the like. I accepted his answer. I was NOT going to rock the boat…at least for a very long while. Fast forward 5 years. I had earned the respect of my colleagues and had even had a child of my own by then. The time had finally come time to address the issue of post-op pain management for c/s’s. Even so, it was not going to be easy! (next slide)
- When I mentioned to my new Director that my new year’s resolution was going to be FINALLY create the protocol for c/s post-op pain management…His response was: Why do u want to do that for?! The primary concern from my CRNA colleagues was that the itching would be worse than the pain. And don’t forget, I also had to get the OB’s on board! That was not going to be easy either! Two of the three OB’s had absolutely no experience with it. The new OB that did, had a personal experience with duramorph. She recently had a c/s (at another facility) and told me that she wanted to scratch the skin off of her face. I knew I had my work cut out for me...
- I would have to come up with a solid game plan! I actually started my project by doing an extensive literature review on opioid-induced pruritis... I knew... that my plan would instantly fail if I didn’t have a way to deal with it. Once I realized, I would be able to manage the pruritis, I went forward with the rest of the literature review on post-op pain management. Long story short, I was able to present convincing evidence (to most) of the parties involved. And... after much collaboration, the orderset was launched in January of 2015 with much success. What a relief!
- So, That is the long story as to how I got involved with this topic. So then, when I was invited to speak at this conference.. it seemed like a good idea ...AT THE TIME! I was so honored by the invitation that I immediately accepted!
- So let’s get started!! I am going to break down this lecture into the following 3 major topics: Labor analgesia options Post-op pain management for c-sections And how to best manage the side effects from our interventions. I will also briefly touch upon a couple of the special populations that we see in all of of our practices, whether big of small: Wheth they are the opioid dependent and morbidly obese moms.
- I am NOT going to talk about non-pharm topics. Although nonpharm techniques have been beneficial to some moms, the evidence is limited. Some non-pharm techniques are better than placebo, some are not. This mom looks very happy & satisfied with her experience. (Click) I am not so sure about the little boy.... Obviously, we are here today to review pharmacologic options, so that will be our focus.
- Queen Victoria
- Virginia Apgar
- Physiology of labor pain: Increased catecholaminesincreased vasoconstriction to uterus Hyperventilation causes left shift of oxyhemoglobin curve
- Lumbar epidural anesthesia during labor reduces maternal epinephrine levels, probably by eliminating the psychological and physical stress associated with painful uterine contractions or by denervating the adrenal medulla. Whatever the mechanism, reducing pain and activity of the sympathetic nervous system should increase uterine blood flow.
- Hyperventilationrespiratory alkalosisshifts the oxyhemoglobin curve to Lthereby increasing the affinity of oxygen for maternal hgbthereby ↓ing off-loading of o2 to fetus. Hyperventilation also decreases uterine bloodflow 2nd utero-placental vasoconstriction. Stats 61% of all women get epidurals.
- The aim of this study was to investigate the role of peripartum analgesic and psychological factors that may be related to postpartum depression (PPD). METHODS: This case-control study was conducted in pregnant females who delivered at KK Women's and Children's Hospital from November 2010 to October 2013 and had postpartum psychological assessment. Demographic, medical, and postpartum psychological status assessments, intrapartum data including method of induction of labor, mode of labor analgesia, duration of first and second stages of labor, mode of delivery, and pain intensity on hospital admission and after delivery were collected. PPD was assessed using the Edinburgh Postnatal Depression Scale and clinical assessment by the psychiatrist. RESULTS: There were 62 cases of PPD and 417 controls after childbirth within 4-8 weeks. The odds of PPD was significantly lower (33 of 329 [10.0%]) in females who received epidural analgesia for labor compared with those who chose nonepidural analgesia (29 of 150 [19.3%]) ([odds ratio] 0.47 (0.27-0.8), P=0.0078). The multivariate analysis showed that absence of labor epidural analgesia, increasing age, family history of depression, history of depression, and previous history of PPD were independent risk factors for development of PPD. CONCLUSION: The absence of labor epidural analgesia remained as an independent risk factor for development of PPD when adjusted for psychiatric predictors of PPD such as history of depression or PPD and family history of depression.
- Cesarean delivery rates continue to increase, and surgery is associated with chronic pain, often co-existing with depression. Also, acute pain in the days after surgery is a strong predictor of chronic pain. Here we tested if mode of delivery or acute pain played a role in persistent pain and depression after childbirth. In this multicenter, prospective, longitudinal cohort study, 1288 women hospitalized for cesarean or vaginal delivery were enrolled. Data were obtained from patient interviews and medical record review within 36 h postpartum, then via telephone interviews 8 weeks later to assess persistent pain and postpartum depressive symptoms. The impact of delivery mode on acute postpartum pain, persistent pain and depressive symptoms and their interrelationships was assessed using regression analysis with propensity adjustment. The prevalence of severe acute pain within 36 h postpartum was 10.9%, while persistent pain and depression at 8 weeks postpartum were 9.8% and 11.2%, respectively. Severity of acute postpartum pain, but not mode of delivery, was independently related to the risk of persistent postpartum pain and depression. 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. In summary, cesarean delivery does not increase the risk of persistent pain and postpartum depression. In contrast, the severity of the acute pain response to childbirth predicts persistent morbidity, suggesting the need to more carefully address pain treatment in the days following childbirth.
- Poster presentation from 3rd year Duke Medical Student (Singapore Campus) at the World Federation of Societies of Anesthesiologists Annual meeting in Hong Kong Materials & Methods: We conducted a cohort study involving 200 healthy nulliparous term women who received epidural analgesia. Psychological vulnerability was assessed using the Perceived Stress Scale (PSS) and the Pain Catastrophizing Scale (PCS). A postnatal phone survey was conducted at 6 to 8 weeks to assess the presence of persistent childbirth pain and anxiety status, using pain questionnaire and Spielberger State Trait Anxiety Inventory (STAI) respectively. Postnatal depressive scores were measured using the Edinburgh Postnatal Depression Scale (EPDS). Generalized linear model for normal distribution was used to identify possible associations between pain, anxiety and stress with EPDS. Results: 138 women (69%) were included in the analysis. The incidence of PND (defined as EPDS score≥12) after 4 weeks postpartum, was 5.8%. Patients with persistent pain (>4 weeks postpartum) had significantly higher EPDS scores as compared to patients who had pain resolved by 4 weeks by a difference of 2.86 mean score (p=0.0145; 95% CI=0.59-5.34), and compared to patients who never had pain postpartum by a difference of 3.32 mean score (p=0.0207; 95% CI=0.51-6.13). Other factors that were positively associated with higher EDPS score include higher stress level (PSS) (p<0.05), higher anxiety level (STAI) at 6-8 weeks postpartum (p<0.001) and greater pain vulnerability (PCS) (p<0.001). Conclusion: We concluded that greater pain vulnerability and stress during intrapartum period, and presence of persistent pain or higher anxiety during postpartum period are positively associated with higher EPDS score. This supports the need to address pain comprehensively to lessen the risk of developing PND.
- C/S is the most common major surgery in the us and the world. About 1 in 3 babies born in US are delivered by C/S.
- This information should already be familiar to you. We know that there are many advantages for regional anesthesia for moms and babies. Decreased mortality for both, babies born with higher APGARs thus breastfeeding better. This graph by Davies, et al. represents OB anesthetic-related complications Pre and post 1990 from closed-claims analysis. The majority of the pre-1990 claims occurred during the mid 70’s and 80’s when GA was used more often c/s. Decreases in respiratory events in the 1990 or later obstetric claims are probably associated with the use of respiratory system monitors in modern anesthesia practice,8 the decrease in the use of general anesthesia in obstetric practice, and the enhanced awareness of the risk of aspiration of gastric contents in the obstetric patient. Background: Obstetrics carries high medical liability risk. Maternal death and newborn death/brain damage were the most common complications in obstetric anesthesia malpractice claims before 1990. As the liability profile may have changed over the past two decades, the authors reviewed recent obstetric claims in the American Society of Anesthesiologists Closed Claims database. Methods: Obstetric anesthesia claims for injuries from 1990 to 2003 (1990 or later claims; n = 426) were compared to obstetric claims for injuries before 1990 (n = 190). Chi-square and z tests compared categorical variables; payment amounts were compared using the Kolmogorov-Smirnov test. Results: Compared to pre-1990 obstetric claims, the proportion of maternal death (P = 0.002) and newborn death/brain damage (P = 0.048) decreased, whereas maternal nerve injury (P < 0.001) and maternal back pain (P = 0.012) increased in 1990 or later claims. In 1990 or later claims, payment was made on behalf of the anesthesiologist in only 21% of newborn death/brain damage claims compared to 60% of maternal death/brain damage claims (P < 0.001). These payments in both groups were associated with an anesthesia contribution to the injury (P < 0.001) and substandard anesthesia care (P < 0.001). Anesthesia-related newborn death/brain damage claims had an increased proportion of delays in anesthetic care (P = 0.001) and poor communication (P = 0.007) compared to claims unrelated to anesthesia. Conclusion: Newborn death/brain damage has decreased, yet it remains a leading cause of obstetric anesthesia malpractice claims over time. Potentially preventable anesthetic causes of newborn injury included delays in anesthesia care and poor communication between the obstetrician and anesthesiologist. We avoid GA when we can, but in a true OB emergency, when there is no time to place a spinal or if you should have a failed epidural, you must proceed to GA to avoid delay. Compared to the 1970’s and 80’s, our monitoring equipment and airway devices have improved dramatically over the last 30 years. Although, there still is a potential risk for a difficult airway, we are better prepared to handle it now than we have ever been.
- You will remember that the general surgery population when surveyed feared nausea more than pain. This study specifically looks at the obstetric population. Note pain management during and after c/s most important factor that patients wanted to avoid. The results of this study might not necessarily reflect the national population as the study population from this single-center study had, older, more-educated, caucasian and married parturients than the national average. What currently is being studied are individual preferences and including them in the plan of care to be published next year.
- What TECHNIQUE are you going to use? What Local Anesthetic are you going to use? What dose? Any adjuvants?
- Reasons why spinal is generally superior: (If time allows, show additional studies to validate statements). Respondents in this study were anesthesiologists that were members of the SOAP. Quicker Better analgesia 3. Decreased failure rates and decreased need for supplementation
- Benefits over single-shot SAB in select cases: Allows you to use lower doses of local anesthetic, thereby reducing degree of hypotension and associated side effects, you can dose the epidural catheter before surgery to push the dermatome level up. (This is called Epidural volume extension). Potential to be more beneficial in certain populations, i.e. extremes in height (super short or tall) where you are not sure of the response you might get from a standard dose. Also, in the morbidly obese, it may be technically easier as the epidural needle serves as a better introducer for the spinal needle. Catheter available to use for prolonged surgery.
- intrathecal hyperbaric bupivacaine had a more rapid onset of sensory blockade at the 4th thoracic vertebra (T4) level than isobaric bupivacaine. Hower, despite incorporating more data in the analysis, we found little evidence that the need for conversion to general anaesthesia and supplemental analgesia differed between the hyperbaric or isobaric bupivacaine groups. This is mainly due to the rarity of these outcomes, variability in the dose, use of adjuvant drugs and differences in the technique used for regional anaesthesia. There were no differences in the adverse effects studied. Any possible advantage of hyperbaric bupivacaine needs to be confirmed in larger randomized trials. In future research, criteria for conversion to general anaesthesia need to be defined objectively and applied uniformly.
- Nice visual representation of the lipophilic vs lipophobic drugs
- Notice the extended pain relief that you get from morphine. If that is the case, do you still want to give fentanyl? Yes. Because it helps with INTRAop analgesia. It actually can decrease n/v because of better analgesia and decrease dose of bupivacaine needed, therefore less hypotension.
- traction on the uterus often causes n/v and pain. Fentanyl Decreases N/V and improves comfort with exteriorization of uterus for repair. bupivacaine -fentanyl combination leads to abolishment of the visceral pain, reduction in nausea incidence increased hemodynamic stability and increases the duration of post-operative analgesia; however no effect can be seen on bradycardia, nausea, vomiting, shivering, maternal or neonatal respiration. Thus, overall the combined effect of fentanyl-bupivacaine is superior over just bupivacaine alone as fentanyl apart from positive effects, retards the negativity as well as reduces the doses of bupivacine too.
- Most of the studies and meta-analyses that I have reviewed recommend a dose between 10-20 mcg. There was only one old study from 1989 by Hunt that reported nothing > 6.25 mcg was effective, however the study used very small sample sizes (<10 in each group), so the results must be viewed with caution.
- Notice the extended pain relief that you get from morphine. If that is the case, do you still want to give fentanyl? Yes. Because it helps with INTRAop analgesia. It actually can decrease n/v because of better analgesia and decrease dose of bupivacaine needed, therefore less hypotension.
- POLL THE AUDIENCE
- dose-response relationship of intrathecal morphine for post-cesarean analgesia was investigated. Doses of 0.1 mg or less were found to produce analgesia comparable with doses as high as 0.5 mg. BACKGROUND: This series investigated the quality of analgesia and the incidence and severity of side effects of intrathecal morphine for post-cesarean analgesia administered over a dose range of 0.0-0.5 mg. METHODS: ONE hundred eight term parturients undergoing cesarean delivery at term and given spinal anesthesia were randomized to receive a single dose of intrathecal morphine (0.0, 0.025, 0.05, 0.075, 0.1, 0.2, 0.3, 0.4, or 0.5 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. PCA morphine use, incidence and severity of side effects, and need for treatment interventions were recorded for 24 h. Data were analyzed with analysis of variance and linear regression analysis for trends among groups. RESULTS: Patient-controlled analgesia use differed significantly between groups; PCA use was higher in the control group than in groups receiving 0.075, 0.1, 0.3, 0.4, or 0.5 mg. Twenty-four-hour PCA morphine use was 45.7 mg lower (95% CI, 4.8-86.6 mg lower) in the 0.075-mg group than the control group. There was no difference in PCA morphine use between the 0.075- and 0.5-mg groups (95% CI, 36.8 mg lower to 45.0 mg higher); despite a fivefold increase in intrathecal morphine dose, PCA morphine use remained constant. There was no difference between control and treatment groups or among treatment groups with respect to nausea and vomiting. Pruritus and the need for treatment interventions increased in direct proportion to the dose of intrathecal morphine (linear regression, P = 0.001 and P = 0.0002, respectively). CONCLUSIONS: These data indicate there is little justification for use of more than 0.1 mg for post-cesarean analgesia. For optimal analgesia, augmentation [corrected] of intrathecal morphine with systemic opioids may be necessary.
- First saw this in the OB literature as a case report by a CRNA about 5 years ago. Since then more studies have been done to try to determine an effective dose and evaluate the presence and severity of side effects. The initial reports described a dose of 100 mcg but since then lower doses have been reported. The recent study above reports an ED90 of 75 mcg for hydromorphone. It reports a 2:1 ration with morphine, i.e. 150 mcg morphine equal to 75 mcg hydromorphone
- Also would consider a CSE for morbid obesity or extemes in height
- NSAIDs decrease opioid requirements by 40%. Helps with visceral pain. Acetaminophen has an additive effect. Both meds should be scheduled ATC (NOT PRN). Side effects: will discuss in the next section shortly What about TAP blocks?
- The transverse abdominis plane (TAP) block is a peripheral nerve block designed to anesthetize the nerves supplying the anterior abdominal wall (T6 to L1). It was first described in 2001 by Rafi as a traditional blind landmark technique using the lumbar triangle of Petit (see the image below).[1]
- BACKGROUND: Ultrasound-guided transversus abdominis plane block is an effective method of providing pain relief after cesarean delivery. Neuraxial morphine is currently the "gold standard" treatment for pain after cesarean delivery. In this study we tested the hypothesis that subarachnoid morphine would provide more prolonged and superior analgesia than would transversus abdominis plane block in patients undergoing elective cesarean delivery. METHODS: In this prospective, double-blind study, 57 patients were randomly assigned to receive either subarachnoid morphine (group SAM; n = 28) or transversus abdominis plane block (group TAP; n = 29). Patients received bupivacaine spinal anesthesia combined with morphine 0.2 mg in group SAM and received saline in group TAP. At the end of surgery, bilateral transversus abdominis plane block was performed using saline in group SAM or using bupivacaine 0.375% plus epinephrine 5 microg/mL in group TAP with 20 mL on each side. Postoperative analgesia for the first 24 hours consisted of scheduled rectal diclofenac and IV paracetamol; breakthrough pain was treated with IV tramadol. For the next 24 hours, scheduled rectal diclofenac was given; oral paracetamol and IV tramadol were administered upon patient request. Patients were assessed postoperatively in the postanesthesia care unit (time 0 hours) and at 2, 4, 6, 12, 24, 36, and 48 hours. The primary outcome measure was the time to first analgesic request. RESULTS: Median (range) time to first analgesic request was longer in group SAM than in group TAP [8 (2-36) hours versus 4 (0.5 to 29) hours (P = 0.005)]. Median (range) number of tramadol doses received between 0 and 12 hours was 0 (0-1) in group SAM versus 0 (0-2) in group TAP (P = 0.03). Postoperative visceral pain scores at rest and on movement during first the 4 hours were lower in group SAM than in group TAP, but were not different at any other time points. The incidence of moderate to severe nausea was higher in group SAM than in group TAP [13/28 (46%) versus 5/29 (17%) (P = 0.02)]. More patients developed pruritus requiring treatment in group SAM than in group TAP [(11/28 (39%) versus none (0%) (P < 0.001)]. CONCLUSION: As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.
- Abstract INTRODUCTION: Subarachnoid morphine is widely used for pain relief in enhanced recovery program after cesarean section in spite of its side effects. However, the role of TAP block is still controversial. The aim of our study was to compare the impact of these analgesic techniques (subarachnoid morphine and TAP block) on enhanced recovery after cesarean section. MATERIALS AND METHODS: In this randomized controlled trial, we included patients scheduled for cesarean delivery under spinal anesthesia. Patients were randomized in two groups. Group I: received spinal anesthesia with 100μg of subarachnoid morphine. Group II: received spinal anesthesia without subarachnoid morphine followed by an ultrasound-guided TAP block. We assessed the time required for mobilization, for re-establishment of gastrointestinal transit and for breast-feeding. RESULTS: TAP block allowed earlier postoperative mobilization. Time required for getting up was significantly lower in group II (9.4h versus 6.9h; P=0.024) as well as time required for walking (12.4h versus 7.4h; P=0.001). TAP block allowed earlier re-establishment of gastrointestinal transit (11.2h in group I versus 8.1h in group II; P<0.001). CONCLUSIONS: TAP block seems to be suitable with enhanced recovery programs.
- Abstract Objective Single shot transversus abdominis plane (TAP) block and continuous local anesthetic infiltration wound catheter (CLAIWC) decreased the morphine consumption after caesarean section. The aim of this study was to compare the analgesic efficacy of CLAIWC and ultrasound-guided TAP block. Method Sixty patients undergoing caesarean section were prospectively randomized. After the caesarean section, the postoperative analgesia was randomized to either a CLAIWC localized below the fascia with an elastomeric pump for 48 hours or a bilateral ultrasound-guided TAP block with injection of ropivacaine. Every patient had a morphine pump patient-controlled analgesia. The primary outcome was the morphine consumption during the first 48 hours. Secondary outcomes were pain score levels, adverse effects of opioids, and patient satisfaction. Variables were collected during 48 hours after the caesarean section. Results Median cumulative 48-hour morphine consumption was 17 [8–51] mg in the TAP group versus 21 [7–34] mg in the CLAIWC group (P = 0.3). We did not find a difference between the groups regarding pain, side effects and satisfaction scores. Conclusion As part of a multimodal analgesic regimen, there is no significant difference between the TAP block and CLAIWC for postoperative analgesia after a caesarean section.
- SPINAL NUCLEUS OF THE TRIGEMINAL NERVE IS RICH IN OPIOID RECEPTORS. THE OPTHALMIC DIVISION IS MOST INFERIOR OF THE TRIGEM NERVE NEXT SLIDE
- BMC Anesthesiol. 2015 Feb 17;15:18. doi: 10.1186/1471-2253-15-18. Prophylactic administration of ondansetron in prevention of intratheca morphine-induced pruritus and post-operative nausea and vomiting in patients undergoing caesarean section. Koju RB1,2, Gurung BS3, Dongol Y4. Ondansetron which is antiemetic, non-sedative and has no antianalgesic effect is an antagonist to 5-HT3 receptor, the receptor with which opioids interacts and imparts its effects. Ondansetron, thus, would be an attractive treatment strategy for both opioid-induced pruritus and post-operative nausea and vomiting. METHODS: After the approval from institutional review committee and written consent received from the patient, 50 healthy parturients of ASA I and II physical status undergoing caesarean section under spinal anaesthesia were enrolled for the study. They were randomly categorized into placebo group (2 ml normal saline) and treatment group (2 ml of 4 mg ondansetron), each group containing 25 patients. Pruritus and post-operative nausea and vomiting scores were recorded up to 24 hours after the administration of intrathecal morphine. Statistical analysis was performed using chi-square test. RESULTS: The incidence, severity and necessity of treatment for pruritus in the treatment group was significantly reduced compared to the placebo group (16% vs 88%). Similarly, the risk of post-operative nausea and vomiting in the treatment group was less compared to the placebo group (8% vs 56%). CONCLUSION: Prophylactic administration of ondansetron to parturients receiving intrathecal morphinefor post-operative analgesia provides a significant reduction of intrathecal morphine-induced pruritusand nausea and vomiting.
- 0.25- 1 mcg/kg/h is most effective without affecting analgesia Doses above 2mcg/kg/hr NOT recommended.
- Small dose is very effective in prevention and tx of OIP. Potential to be complicated by drowsiness.
- Need to be monitored for 24 hours
- Just over 61% of American women elect to have a labor epidural
- More dilute than they used to be (more volume and better spread). They addition of lipophilic opioids allow us to significantly decrease our dose of anesthetic which can decrease incidence of motor block, assisted vaginal delivery.
- Just like a CSE without injecting any medicine in the spinal needle. These have improved analgesia, a significant decrease in failure rate for epidural catheter placement. Some decreased incidence one-sided epidural. If there is a patient where there is a question about LOR, just do a spinal puncture and double check!
- Better accurately identifies space better, increases satisfaction and improves function
- Continue Methadone throughout perioperative period Consult with specialist regarding continuing buprenorphine Rescue tap blocks Maintenance of epidural for extra day Consider neuraxial adjuvants that you would normally not use 2nd to black box (clonidine)
- Multi-disciplinary resource that provide evidence based tool-kits for everyone for common OB problems: hemorrhage, VTE, HTN in pregnancy, etc.
- Computer-Integrated Epidural Smart pump Hand held ultrasound device Ultrasound transducer that fits inside a touhy needle.
- ASA Practice Guidelines for OB Anesthesia Updated 2016