10/25/2013 Anesthesia & Obstetrics What’s New in Post-Cesarean Analgesia? October 23rd, 2013 Mark Rollins, MD, PhD 2013 UCSF What Does The UC Evidence Tell Us? SF Post-Delivery Pain (Mean pain scores for first 24 hours after delivery) • 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 Eisenach JC, et al. Pain 140:87-94 2008 1
10/25/2013 Cesarean Delivery Pain (Impact on Daily Activities during first 24 hours) Two months after childbirth: “Women with severe acute postpartum Vaginal Cesarean Activity Impacted Delivery Delivery pain had a 2.5-fold increased risk of Walking 40% 72 % Mood 19% 40% persistent pain and a 3.0-fold increased Sleep 36% 57% risk of postpartum depression compared to Interactions with Others 8% 20% Ability to Concentrate 13% 31% those with mild postpartum pain.” Pain (8-weeks) 10% 9% Depression (8-weeks) 11% 11% Eisenach JC, et al. Pain 140:87-94 2008 Eisenach JC, et al. Pain 140:87-94 2008 Postoperative Analgesic Practice Patient Preferences for Outcomes Associated with Cesarean Delivery For Cesarean Delivery Survey of Institutional Practice: • 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% Aiono-Tagaloa, et al. Anesthesiology Research & Practice. 2009. PMID: 21217809 Carvahlo B, et al. Anesth Analg 101:1182–7. 2005 2
10/25/2013 Intrathecal Morphine Doses Intrathecal Opioids For Post-Cesarean Analgesia Analgesia Pruritus Opioid Dose Duration (mean ± 95% CI) Morphine 0.1 – 0.2 mg 18 – 24 hrs Fentanyl 5 – 10 mcg 3 – 4 hrs Sufentanil Up to 5 mcg 3 – 4 hrs • Nausea and Vomiting 10% to 50% • Respiratory Depression < 0.25% Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4):213-21. 2003 Palmer, CM, et al. Anesthesiology 90:437-44. 1999 Palmer, CM, Tech in Reg Anesth & Pain Mgmt 7(4):213-21. 2003 Intrathecal Morphine 100µg & 200µg Intrathecal Morphine 100µg & 200µg For Post-Cesarean Delivery Analgesia For Post-Cesarean Delivery Analgesia IT Morphine IT Morphine Analgesia P value IT Morphine IT Morphine 100µg 200µg Side Effects 100µg 200µg P value Opioid Use (0-24h) 54 ± 35mg 44 ± 35mg .04 Antiemetic Use 24% 52% <0.001 Opioid Use (24-48h) 54 ± 32mg 60 ± 31mg .18 Nausea Episodes (0-24h) 1.6 ± 1.3 1.9 ± 1.3 .04 IV morphine required 30% 18% .02 Nausea Episodes (24-48h) 0.02 ± 0.13 0.04 ± 0.46 .56 IV Morphine Use (0-24h) 2.5 ± 5.3mg 1.3 ± 3.5mg .054 Patients receiving NSAIDs 87% 87% .98 IV Morphine Use (24-48h) 0.02 ± 0.2mg 0 ± 0mg .32 Time of Surgery to Discharge 89 ± 20 hrs 89 ± 19 hrs .76 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 Wong JY , et al. IJOA 22:36-40 2013 Wong JY , et al. IJOA 22:36-40 2013 3
10/25/2013 Epidural Morphine Doses Epidural Opioids For Post-Cesarean Analgesia Analgesia Pruritus • Nausea and Vomiting < 10% • Respiratory Depression < 0.25% Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4):213-21. 2003 Palmer, CM, et al. Anesth Analg 90:887-91. 2000 Post-Cesarean Pain Post-Cesarean Pain (Efficacy of Two Epidural Morphine Doses) (Efficacy of Two Epidural Morphine Doses) Nausea & Vomiting Pruritus Singh SI, et al. Anesth Analg 117:677-85. 2013 Singh SI, et al. Anesth Analg 117:677-85. 2013 4
10/25/2013 European Journal of Pain 14:894e (2010) Anesthesiology 2007; 106:843-63 “…neuraxial opioids for postoperative analgesia improve analgesia and maternal 6h - Solid Diamonds satisfaction...” 12h - Solid Squares 24h - Open Squares Recommendation: “For postoperative analgesia after neuraxial anesthesia for cesarean delivery, neuraxial “A single bolus of epidural morphine provides better opioids are preferred over intermittent analgesia than parenteral opioids but with an effect limited injections of parenteral opioids.” to the first postoperative day after caesarean section” Oral vs. PCA Opioid Oral vs. PCA Opioid (Post-Cesarean Analgesia) (Post-Cesarean Analgesia) Dieterich MD, et al. Arch Gynecol Obstet 286:859-65. 2012 Dieterich MD, et al. Arch Gynecol Obstet 286:859-65. 2012 5
10/25/2013 Which PCA related statement do you use? PCA has been identified as #7 of the 10 TOP Health Technology Hazards for 2011 “Just press your pain button when . � ECRI Institute Report Nov, 2010 ever you need it” MEDMARX and U.S. Pharmacopeia (USP) “The use of PCA is a complex, high risk data show that when PCA pumps are treatment that is associated with involved, the chance for patient harm harmful events and death” increases more than 3.5 times (APSF). � Hicks et al m. J. Health Syst. Pharm. Mar 2008; 65 429-440 NSAIDs Multimodal Analgesia • All NSAIDs have opioid sparing activity - Effective in reducing post-cesarean delivery pain - Enhance opioid analgesia - Decrease opioid-related side effects • Optimize additive effects of various agents • Non-selectively inhibit cyclooxygenase-1 & -2 • Utilize different modes of analgesia - Undesirable side effects include platelet dysfunction, renal impairment, and GI irritation • Minimize maternal side effects • American Academy of Pediatrics regards NSAIDs safe for use in breast feeding women • Reduce transfer of medication to breast milk • Typical post-cesarean dosing in healthy women - Ibuprofen 600mg to 800mg orally every 8 hours Lavoie, et al. Clin Perinatol 40:443-55. 2013 Flood & Aleshi. Chapter 27, Chestnut’s Obstetric Anesthesia. 5 th Ed. 2013 6
10/25/2013 NSAIDs Acetaminophen On-Demand vs. Fixed-Interval • Less effective than NSAIDs in decreasing opioid consumption 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- Fixed-interval NSAID dosing provides more effective life of 116 minutes post-operative cesarean analgesia and results in better - No current analgesic outcome benefit compared to oral patient satisfaction compared to on-demand dosing. Rawlinswon A, et al. Evid Based Med 17:75-80. 2012 Kulo A, et al. IJOA 21:125-8. 2012 Lavoie, et al. Clin Perinatol 40:443-55. 2013 Jakobi P, et al. Am J Obstet Gynecol 187(4):1066-9. 2002 Flood & Aleshi. Chapter 27, Chestnut’s Obstetric Anesthesia. 5 th Ed. 2013 Landscape (set) Landscape (set) San Francisco Bay Brid San Francisco Bay Brid San Francisco (set) Alpha2 agonists San Francisco (set) Architecture (set) Architecture (set) NMDA antagonists Tags Tags architecture landscape architecture landscape Gabapentin San Francisco US San Francisco US Additional info Additional info Settings: 1/295 ƒ/2. Settings: 1/295 ƒ/2. Uploaded using Flickr Uploaded using Flickr License License Some rights res Some rights res Request to license eric Request to license eric Images Images Privacy Privacy This photo is visible to This photo is visible to unrise over the San Francisco Bay Bridge unrise over the San Francisco Bay Bridge omments and faves omments and faves 7
10/25/2013 TAP Block Technique Transversus Abdominis • Placed between subcostal margin and iliac crest Plane • Placed with either blind or U/S guidance techniques Block • 15–20mL of local anesthetic injected incrementally on Figure from Ultrasound For Regional Anesthesia, 2008 each side • Complications include (AKA - TAP Block) intravascular injection and bowel perforation McDonnell et al. Anesth Analg 106:186-9. 2008 TAP Block US Technique TAP Block US Technique www3.gehealthcare.com Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2 nd Edition. Elsevier-Saunders, 2013 Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2 nd Edition. Elsevier-Saunders, 2013 8
10/25/2013 TAP Block Efficacy TAP Block Efficacy Post-Cesarean Delivery Post-Cesarean Delivery • 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. Abdallah FW, et al. BJA 109(5):679-87. 2012 Loane H, et al. IJOA 21:112-8. 2012 Mishriky BM, et al. 59:766-78. 2012 McDonnell et al. Anesth Analg 106:186-9. 2008 Onishi Y , et al. J. Obstet. Gynaecol. Res 39(9):1397-1405. 2013 • 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 9
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