Post Caesarean Analgesia An Update. Kim Ekelund MD, PhD, associate professor Rigshospitalet Copenhagen, Denmark

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1 Post Caesarean Analgesia An Update Kim Ekelund MD, PhD, associate professor Rigshospitalet Copenhagen, Denmark

2 Post caesarean analgesia No Conflicts of Interests Neuraxial opioids Multimodal therapy Plan B What do we do? How do we do? Take Home Messages Agenda

3 Post caesarean analgesia an update It is important! No magic bullet Increasing C-section rate Do good Mother-child Development of chronic pain (0.3% - 8%) 1. Nikolajsen L et al. Acta Anaesthesiol Scand. 2004; 48: Eisenach JC, et al. Anesthesiology 2013; 118: Liu et al. Anaesth Intensive Care 2013; 41: Woolhouse H et al. Birth. 2012;39: Jin et al. BMC Anesthesiology 2016; 16:99

4 Post caesarean analgesia Neuraxial Opioids Intrathecal Morphine effect 1. Palmer CM et al. Anesthesiology 1999;90: Carvalho FA et al. Braz J Anesthesiol 2013;63:492-9

5 Post caesarean analgesia Neuraxial Opioids Intrathecal Morphine side-effects Palmer CM et al. Anesthesiology 1999;90: J. Sarvela et al. Anesth Analg 2002;95:436-40

6 Post caesarean analgesia Neuraxial Opioids Intrathecal Sufentanil & Fentanyl 1. M. Wilwerth et al Acta Anaesth Scand. 2016;60: C. Hunt et al. Anaesth. 1989;71(4):535-40

7 Post caesarean analgesia Neuraxial Opioids Epidural Morphine effect 1.5 mg Epidural Morphine: Decreasing pruritus severity (at 6, 12, and 24 hrs) Less frequent incidence of nausea and vomiting (at 6 hrs) Singh SI et al. Anesth Analg. 2013;117:677-85

8 Post caesarean analgesia Multimodal Therapy Opioids IV, tablets or? IV vs. IT morphine - Easy, but not necessarily better Oral oxycodone = IV morphine - Or maybe even better Oral oxycodone = IT morphine - When part of multimodal analgesic package Oral analgesia - At fixed time interval + on-demand 1. Eisenach et al. Anesth. 1988;68: Egan et al. Can J Anesth. 1994;41: Davis et al. Am J Obstet Gynecol 2006;194: Niklasson et al. Scand J Pain. 2015;7: Dieterich et al. Arch Gynecol Obstet. 2012;286: McDonnell et al. IJOA. 2010;19: Jakobi et al. Am J Obestet Gynecol 2002;187:

9 Post caesarean analgesia Multimodal Therapy Non Steroidal Anti-Inflammatory Drugs 1 Effective against visceral pain from uterine incision Drug? Diclofenac, Ibuprofen, Naproxen, Ketorolac, Celecoxib or. Dose? X1, x2, x3. Fixed time interval or on-demand? Administration? IV, oral, rectal, subcutaneous?

10 Post caesarean analgesia Multimodal Therapy Non Steroidal Anti-Inflammatory Drugs 2 Drug and dose? Supp. Diclofenac 50mgx3, or 100mgx2 Diclofenac? Increased cardiovascular risk Ibuprofen is an alternative Side effects GI bleeding, atone uterus Administration? IV, oral, rectal, subcutaneous installation? Fixed time interval better than on demand 1. Olofsson et al Eur J Obstet Gynecol Reprod Biol Feb;88(2): Dahl et al. Int J Obstet Anesth Apr;11(2): Schmidt et al. Ugeskr Laeger Dec 26;178(52) 4. Yefet et al. BJOG 2017;124: Jakobi et al. Am J Obestet Gynecol 2002;187:1066-9

11 Post caesarean analgesia Multimodal Therapy Paracetamol PCM + NSAID - Better than PCM alone - Better than NSAID alone? PCM post CS no effect? PCM post CS no side effects Mean cumulative consumption of morphine by PCA in groups MDP, MD, MP, and M. Siddik et al. Reg Anesth and Pain Medicine 2001; 26(4):310-5

12 Post caesarean analgesia Multimodal Therapy Gabapentin Anesth Analg 2011;112: n = 44 n = 112 Anesth Analg 2012;115: Anesthesiology. 2015;123:320-6 n = 197

13 Post caesarean analgesia Multimodal Therapy Other Pregabalin Dexamethasone MgSo4 Ketamine El Kenany S et al. IJOA. 2016;26:24-31 Shalu PS et al. Anesth Essays Res Apr-Jun;11(2): Yousef AA et al IJOA Oct;19(4): Heesen et al. Acta Anaesthesiol Scand Apr;59(4):414-26

14 Post caesarean analgesia Multimodal Therapy Clonidine & Dexmedetomidine Clonidine & Dexmedetomidine, IV or intrathecal Effects Prolonged time to first analgesic requirement Reduce postoperative morphine consumption Side effects Sedation (hypotension or bradycardia) Caution TAP block. 1µg/kg. Prolong effect 10hrs Tradition Paech et al. Anesth Analg. 2004;98(5): van Tuijl et al. Br J Anaesth Sep;97(3): Nie et al. Eur J Analgesia. 2014;31(4): Future? Crespo et al. IJOA 2017, article in press Singh et al. J Anaesth Clin Pharm ;32(4):501-4

15 Post caesarean analgesia Plan B Transversus Abdominis Plane (TAP) block TAP bupi > TAP placebo ITM + TAP bupi = ITM + TAP placebo TAP bupi < ITM R. Champaneria et al. IJOA. 2016;28:45-60 Mishriky et al. J Can Anesth. 2012;59: Opioid consumption at 24 hr.

16 Post caesarean analgesia Plan B TAP or Wound Infiltration? Fig. 3. Graphs of mean cumulative morphine consumption in the two groups, in continuous time. A. Telnes, et al. Acta Anaesth Scand 2015;59: Fig. 2. Kaplan-Meier graph of the proportion of patients in each group who did not require fentanyl over time after cesarean delivery. MM Tawfik et al. Anesth Analg 2017;124:1291-7

17 Post caesarean analgesia Plan B Wound infiltration with NSAID Infiltration with Diclofenac & Ketorolac Provides improved analgesia compared with Systemic NSAIDs or Local infiltration with local anaesthetic alone Reduces inflammatory mediators in wound exudate More studies are needed... P. Lavand homme et al. Anesthesiology 2007; 106: B. Carvalho et al. The Journal of Pain, 2013;14(1):48-56

18 Post caesarean analgesia Plan B Quadratus Lumborum Block QL bupi > QL placebo - Pain - Opioid consumption R. Blanco et al. Eur J Anaesthesiol 2015; 32: QL bupi > TAP bupi - Visceral pain hrs K: kidney, lv: liver, ql: quadratus lumborum, p:psoas major, lift: lumbar interfascial triangel R. Blanco et al. Reg Anesth Pain Med. 2016;41(6); ClinicalTrial.gov - 6 trials. Multimodal approach - QL vs ITM or TAP

19 Post caesarean analgesia an update Delivery system: multiple microscopic, liposomal particles EREM Extended release of epidural morphine. DepoFoam EXPAREL Bupivacaine liposome injectable suspension ClinicalTrial.gov - 4 trials - TAP/wound infiltration Tranversus Abdominus Plane Block Performed with EXPAREL for Post Cesarean Section Analgesia: A Case Report A. Grab et al. ASA Annual Meeting 2014, A1298

20 Post caesarean analgesia an update After CS in spinal What do we actually do? Colleagues from 14 sites were asked. Iceland 1 site Finland 2 sites Norway 4 sites Sweden 3 sites Denmark TAP - (1)/ QL - - (1)/4 - - Wound infiltraion After CS in GA 1/1-1/4 2/3 1/4 Iceland 1 site Finland 2 sites Norway 4 sites Sweden 3 sites Denmark 4 sites TAP - 2/2-2/3 - QL - - 1/4 - - Wound infiltraion 1/1-2/4 1/3 1/4

21 Post caesarean analgesia an update Evaluation! How do we do? Do better Instead of What do we do? Pain After Delivery group Recovery Unit? Maternity ward? At home?

22 Post caesarean analgesia Take Home Message Take Home Messages 1. Intrathecal opioids 2. Multimodal therapy Tbl NSAID + Tbl PCM and Tbl Opioid 3. Plan B? 3. Re-evaluate Thanks to previous and present colleagues at the faculty of SSAI Obstetric Anaesthesia for providing me with information about their local post caesarean section analgesia

23 Thank you

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