Analgesia after c delivery - wound infusions, tap blocks and intrathecal opioids; what more can we offer our patients?
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1 Analgesia after c delivery - wound infusions, tap blocks and intrathecal opioids; what more can we offer our patients? Ashraf S Habib, MBBCh, MSc, MHSc, FRCA Associate Professor of Anesthesiology Interim Chief, Division of Women s Anesthesia OAA Three Day Course, November 2014
2 Outcome Rank Relative Value Pain During Caesarean 8.4 ± ± 18 Pain After Caesarean 8.3 ± ± 10 Vomiting 7.8 ± ± 7 Nausea 6.8 ± ± 7 Cramping 6.0 ± ± 8 Itching 5.6 ± ± 8 Shivering 4.6 ± ± 6 Anxiety 4.1 ± ± 4 Somnolence 2.9 ± ± 3 Carvalho B. Anesth Analg 2005; 101:
3 Does it matter? Better postoperative analgesia Faster ambulation Improved breast feeding success Higher patient satisfaction Reduced incidence of persistent pain and maternal depression
4 Persistent Pain after CD Author Number of CD Time of data collection after delivery Incidence of persistent pain Nikolajsen months 12.3 % Eisenach weeks 9.2 % Sng Months 9.2 % Kainu year 18 % Severity of acute pain was a significant predictor of persistent pain Nicolajsen L. Acta Anaesthesiol Scand 2004; 48: Eisenach JC. Pain 2008; 140: Sng BL. Anaesth Intensive Care 2009; 37: Kainu JP. Int J Obstet Anesth 2010; 19: 4-9
5 Modalities for Post-Caesarean Opioids Analgesia Systemic Adjuncts Local Anaesthetic Techniques Neuraxial Adjuncts
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7 Modalities for Post-Caesarean Opioids Analgesia Systemic Adjuncts Local Anaesthetic Techniques Neuraxial Adjuncts
8 Neuraxial vs. Parenteral Opioids Meta-analysis (10 studies): time to first analgesia pain scores pruritus (RR=2.7) and nausea (RR=2) sedation with parenteral opioids Bonnet MP. Eur J Pain 2010; 14: 894.e e9
9 Neuraxial vs. oral Opioids Intrathecal morphine vs. regular oral oxycodone need for analgesics/high pain scores patient satisfaction pruritus (87 % vs. 56 %, p=0.001) McDonnell NJ. Int J Obstet Anesth 2010; 19: 16-23
10 PCEA Morphine Use (mg) Dose Response of Neuraxial Morphine Epidural Morphine Intrathecal Morphine P<0.05 vs. 2.5, 3.75, 5 mg P<0.05 vs and 5 mg Epidural Morphine Dose (mg) Intrathecal Morphine Dose (μg) Palmer CM. Anesth Analg 2000; 90: Palmer C. Anesthesiology 1999; 90:
11 Husaini SW. Br J Anaesth 1998; 81: Kelly MC. Anaesthesia 1998; 53: Sibilla C. Int J Obstet Anesth 1997; 6: 43-8 Bloor GK. Int J Obstet Anesth 1999; 8: Neuraxial Diamorphine IT diamorphine as effective as epidural morphine IT: μg Epidural: 2-3 mg
12 Opioid Consumption Single Dose EREM vs. mg Morphine P=0.012 Carvalho B. Anesth Analg 2007;105:
13 CSE E Lidocaine % 70 P= P=0.02 P= Vomiting Need for Oxygen Hypotension Higher Cmax with E (P=0.038) Ralls LA. Anesth Analg 2011; 113: 251-8
14 Side Effects of Neuraxial Opioids Pruritus (40-90 %) PONV (30-50 %) Urinary Retention (22-58 %) Respiratory Depression (0-0.9 %)
15 Obesity Class III 17.6 % Obesity Class II 17.1 % Incidence of Respiratory Depression (95 % CI)= 0 (0, 0.07) % Obesity Class I 28.3 % Overweight 28.4 % Normal Weight 8.5 % % n=5036, mean BMI = 34 kg/m 2 Crowgey T. Anesth Analg 2013; 117:
16 Modalities for Post-Caesarean Opioids Analgesia Systemic Adjuncts Local Anaesthetic Techniques Neuraxial Adjuncts
17 NSAIDS Rectal, oral, IV, wound instillation Regular administration % opioid sparing 30 % reduction in relative risk of PONV, sedation RID= % Jakobi P. Isr Med Assoc J 2006; 8: Elia N. Anesthesiology 2005; 103: Marrett E. Anesthesiology 2005; 102:
18 Cox-2 inhibitors RID = % Celecoxib 400 mg? Analgesic Efficacy Valdecoxib: not effective Gardiner SJ. Br J Pharmacol 2006; 61: Fong WP. Br. J. Anaesth. (2008) 100 (6): Lee L. Anaesthesia 2004; 59: Carvalho B. Anesth Analg 2006; 103: Hale. Hum Lact 2004; 20:
19 Paracetamol Limited effect on uterine pain RID= 1-2 % IV paracetamol (1G Q 6 hrs) similar analgesia to ibuprofen 400 mg Q 6 hrs Proparacetamol did not provide better analgesia or enhance diclofenac analgesia Paracetamol/diclofenac 38% less morphine than paracetamol Alhashemi JA. Can J Anesth 2006; 53: Siddiq SM. Reg Anesth Pain Med 2001; 26: Munishankar B. Int J Obstet Anesth 2008; 17: 9-14 Hale. Hum Lact 2004; 20:
20 Combination > acetaminophen alone in 85 % of studies Combination > NSAIDs alone in 64 % of studies Pain scores reduced by 35 %/ 37 % over acetaminophen/ NSAIDs Analgesic needs reduced by 39 %/ 31 % over acetaminophen/ NSAIDs Ong CKS. Anesth Analg 2010; 10:
21 Gabapentin Pain scores on movement Pain scores at rest Umbilical V: Maternal V=0.86 RID=2.34 % Moore A. Anesth Analg 2010; 112: Short J. Anesth Analg 2012; 115:
22 Ketamine 10 mg IV following Delivery 0.5mg/kg IM followed by 2 μg/kg/min for 12 h Bauchat JR. Int J Obstet Anesth 2011; 20: 3-9 Suppa E. Minerva Anesthesiol 2012; 78:
23 Tramadol RID= 2.24 % More need for rescue and more side effects compared with naproxen Diclofenac/tramadol > Diclofenac/paracetamol with more side effects LLett KF. Br J Clin Pharmacol 2008; 65: Sammour RN. Int J Gynaecol Obstet 2011;113:144-7 Mitra S. Acta Anaesthesiol Scand 2012; 56:
24 Dexamethasone Early Pain (0-4 h) Late Pain (24 h) Need for rescue analgesics Allen TK. Anesth Analg 2012; 114:
25 Modalities for Post-Caesarean Opioids Analgesia Systemic Adjuncts Local Anaesthetic Techniques Neuraxial Adjuncts
26 Local Anesthetic infiltration Minimal benefit from single infiltration No benefit with long-acting neuraxial opioids? Extended release bupivacaine Trotter T. Anaesthesia 1991; 46: Pavy T. Int J Obstet Anesth 1994; 3: Niklasson B. Acta Obstet Gynecol Scand 2012; 91:
27 Continuous LA Wound Infiltration > Saline Infiltration Above the fascia (4 studies) % Opioid sparing Below the fascia (1 study) No opioid sparing < Epidural Levobupivacaine Below the fascia Fredman B. Anesth Analg 2000; 91: Givens VA. Am J Obstet Gynecol 2002; 186: Mecklem DW. Aust NZ J Obstet Gynecol 1995; 35: Kainu JP. Int J Obstet Anesth 2012; 21: Lavand homme P. Anesthesiology 2007; 106: Ranta P. Int J Obstet Anesth 2006; 15:
28 Continuous LA Wound Infiltration < Systemic NSAIDs Above the fascia? Neuraxial Opioids < Intrathecal Morphine Below the fascia > Epidural Morphine Below the fascia Zohar E. J Clin Anesth 2006; 18: Magnani E. Clin Exp Obstet Gynecol 2006;33:223 5 Kainu JP. Int J Obstet Anesth 2012; 21: O Neill P. Anesth Analg 2012; 114:
29 Rackelboom T. Obstet Gynecol 2010; 116:
30 Intraperitoneal LA Kahokehr A. ANZ J Surg 2011; 81: Shahin AY. Clin J Pain 2010; 26: 121-7
31 Local NSAIDs Infiltration Lavand homme P. Anesthesiology 2007; 106:
32 IL-6 (P=0.01) and IL-10 (0=0.005) with K vs. B Carvalho B. J Pain 2013; 14: 48-56
33 TAP Block
34 Opioid Consumption Pain on Movement No ITM ITM Vs. ITM Mishriky BM. Can J Anesth 2012;59:766-78
35 Mirza F. Can J Anesth 2013; 60:
36 Lidocaine Patch Habib AS. Anesth Analg 2009; 108:
37 Modalities for Post-Caesarean Opioids Analgesia Systemic Adjuncts Local Anaesthetic Techniques Neuraxial Adjuncts
38 Neuraxial Adjuncts Neostigmine, clonidine, ketamine, magnesium, etc.. Modest analgesic benefit Side effects Might reduce hyperalgesia and sensitization
39 Prediction of Post CS Pain QSTs Temporal summation DNIC Electrical pain Heat pain Scar Hyperalgesia pain scale (VAS) (0 = no pain, 10 = worst pain imaginable) at rest (R), while sitting (S) and for uterine cramping pain (U) at 12, 24 and 48 h following Caesarean delivery. With the exception of VAS-R24, pain scores were always higher in women with scar hyperalgesia. SHA = women with preoperative scar hyperalgesia (index > 0). No SHA = women with no preoperative scar hyperalgesia. *p < 0.05, **p < range ( ). The incidence and extent of postoperative WHA index were significantly higher in women with preoperative SHA compared with those with no preoperative SHA (Table 2). There was no Buhagiar LM. J Anaesthesiol Clin Pharmacol 2013; 29: Buhagiar LM. J Anaesthesiol Clin Pharmacol. 2011;27: Nielsen PR. Acta Anaesthesiol Scand. 2007;51:582-6 Ortner CM. Eur J Pain 2013; 17: Garnot M. Anesthesiology 2003; 98: Figure 2 Correlation between preoperative scar hyperalgesia (SHA) and post-operative pain while sitting at 48 h (VAS-S48). Solid line is the correlation between VAS-S48 and a cut-off for SHA index (p < 0.002, r = 0.247). Dashed and doted line is the correlation between VAS-S48 and SHA, if VA (p (p di m n 68 w re (T 3 W (A ce ce w 2. p [0 di sc be in su bo
40 Prediction of Post CS Pain Questionnaires STAI Three simple questions Anxiety level Anticipated pain Anticipated analgesic need Pan PH. Anesthesiology 2013;118: Pan PH. Anesthesiology 2006; 104:
41 Regimen at Duke Routine: Neuraxial Morphine Regular NSAIDs + Paracetamol PRN Oxycodone Rescue: TAP blocks Lidocaine patches Gabapentin
42 Regimen at Duke Opioid dependent parturients: PCEA TAP blocks Neuraxial Clonidine Gabapentin
43 Conclusions Optimal analgesia important short and long term Multimodal approach Targeted therapy for high risk patients
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