OAA Survey 156: Current prescribing practices for post-operative analgesia following emergency and elective LSCS

Transcription

1 OAA Survey 56: Current prescribing practices for post-operative analgesia following emergency and elective LSCS Janis M Ferns, Jennifer Lambert, Dharshini Radhakrishnan 2. Specialty Trainee, Barts and London School of Anaesthesia 2. Whipps Cross Hospital, Barts Health Trust, London Keywords: Analgesia, breastfeeding, guidelines, LSCS Introduction: Current controversies exist regarding the safety of analgesic medication in postpartum women. It has recently been recommended by MHRA () and EMA (2) that codeine is no longer used as post operative analgesia in breast feeding mothers in light of ongoing concerns regarding transmission to neonates and subsequent neonatal respiratory depression. ( 3,4) The use of diclofenac is now contraindicated in patients with cardiovascular disease and is to be used with caution in patients with cardiovascular risk factors as it can increase arterial thrombotic risk. (5,6,7) This is of relevance to the changing demographic of pregnant women, where there are increasing rates of obesity, hypertension and older mothers. (8) This survey aimed to establish a national picture on how these recent recommendations have affected individual prescribing practices, to open a national dialogue on how to implement these recommendations in practice and to aid local and national guideline development for appropriate post-operative analgesia prescribing following emergency and elective LSCS. Methods: An Obstetric Anaesthetists Association (OAA) survey on current prescribing practices for post-operative analgesia following emergency and elective LSCS was produced and sent to all Consultant members of the OAA in Consultants responded giving a response rate of 46%. Results: Figure demonstrates the routine use of opiates used for central neuraxial blockade for LSCS with 88% of consultants using diamorphine. 3% 2% 6% Fentanyl Diamorph Morphine 88% Morph and Fent Figure Routine opiate used for central neuraxial blockade for caesarean sections (%)

2 Figure 2 demonstrates the number of consultants using rectus sheath blocks under direct vision and TAP blocks as part of their analgesic management for patients having undergone general anaesthesia (GA) for their LSCS. 44% Yes 56% No Figure 2 use of local anaesthetic blocks after GA LSCS Post operative prescribing Figure 3 shows the post-operative analgesia routinely prescribed by the consultants following LSCS under regional anaesthesia Regular % PRN % Figure 3 Post-operative analgesia routinely prescribed following LSCS under regional anaesthesia The most common (95%) regular post-operative analgesia prescription for LSCS under regional anaesthesia was paracetamol and an NSAIDs. Figure 4 shows the post-operative analgesia routinely prescribed by the consultants following LSCS under general anaesthesia.

3 Regular % PRN % Figure 4 Post-operative analgesia following LSCS under GA (%) Opiates Of those surveyed 72% prescribe opiate based medications post operatively for women who have had a LSCS under regional anaesthesia and 99% prescribe opiate based medications post operatively for women who have had a LSCS under general anaesthesia. 6% continue to prescribe codeine for LSCS under regional anaesthesia and 4% for LSCS under general anaesthesia. Alternatives to codeine included dihydrocodeine, tramadol and oral morphine in both groups with the addition of IM, IV and PCAS morphine in the general anaesthesia group PO IM/SC PCA No morphine Figure 5 Morphine route for post-operative analgesia following LSCS under GA (%) Comments surrounding this question had two main themes; firstly, that local midwives are not trained on PCA or IV morphine so IM/SC prescribed and secondly that PCA morphine was often given and PO morphine prescribed for once PCA was removed.

4 NSAIDS % of those surveyed prescribed NSAIDs with 9% giving PR diclofenac at the end of a case where NSAIDs are not contraindicated. Figure 6 shows which NSAIDs are being prescribed and figure 7 demonstrates what are considered to be contraindications to NSAID prescription. Figure 8 shows the drugs of choice when NSAIDS cannot be prescribed Ibuprofen Diclofenac Both 4 Figure 6 Choice of NSAID in percentage Contraindication to NSAIDs Never prescribe Asthma sensitive to NSAIDS Renal Disease Cardiovascular Disease Platelets < Massive Obstetric Haemorrhage Bleeding Disorder Peptic Ulcer Disease Morbid Obesity (BMI>) Gestational Diabetes Diabetes Mellitus Pre-eclampsia Hypertension Figure 7 Perceived contraindications to NSAIDs (% of those surveyed)

5 Paracetamol Codeine Co-codamol Dihydrocodeine Tramadol Oral Morphine Regular PRN Figure 8 Drug of choice when NSAIDs are contraindicated Breastfeeding Only 39% of respondents routinely asked if the mothers were breastfeeding prior to prescribing analgesia with 76% prescribing the same post operative medication irrespective of whether the patient was planning to breastfeed. Only 6% routinely counsel mothers on the potential side effects and complications for her baby from post-operative analgesia after LSCS. One centre had a mother information sheet on breast feeding with codeine. Themes in the free comments on these questions included the assumption that all women would breastfeed and therefore no longer prescribed codeine to any post-partum patients. Guidelines 88% of consultants were aware of hospital guidelines on post-operative analgesia with 42% believing these had been updated in that last year, 39% in the last -3 years, 7% over 3 years ago and 2% not knowing when they were last updated. 6% of responders were aware of current hospital guidance which specifically mention the avoidance of codeine in breastfeeding mothers and 4% of responders were aware of current hospital guidance which specifically mention the prescription of Diclofenac in postpartum women. Discussion: This data shows a very low codeine prescription rate suggesting that the MHRA and EMA recommendations have been followed. However, combine this with a minority asking if their patients are breastfeeding and a majority not altering their prescription habits despite this information and it suggests that an effective pain medication is not being utilised in the non breastfeeding population. NSAIDs are used without reservation by all respondents as long as they are not contraindicated. There is a slight increase in codeine use where NSAIDS are contraindicated. Opinion on what constitutes a contraindication to NSAID prescription varies considerably which likely leads to non-uniform practice.

6 Low post-operative analgesia counselling rates could be an area for improvement. In an anxious population group this lack of information could lead to a reluctance for the patient to take analgesia, worsening their birth experience, and potentially affecting their mental health (5,6). Suggestions for the future from this survey include a patient information leaflet on analgesia side effects and implications for breastfeeding mothers. This may be an effective way to open a discussion and educate new mothers regarding breastfeeding and post operative analgesia prescriptions. References:. MHRA. Codeine for analgesia: restricted use in children because of reports of morphine toxicity. Drug Safety Update July 3 Volume 6 issue 2: A 2. European Medicines Agency. Restrictions on use of codeine for pain relief in children CMDh endorses PRAC recommendation. Press Release. EMA/38576/3. 28 June Madadi P, Ross CJD, Hayden MR et al. Pharmacogenetics of neonatal opioid toxicity following maternal use of codeine during breastfeeding: A case-control study. Clin Pharmacol Ther 9;85: Koren G, Cairns J, Chitayat G Leeder SJ. Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine prescribed mother. Lancet 6;368:4 5. Astbury J, Brown S, et al. Birth events, birth experiences and social differences in postnatal depression. Australian Journal of Public Health 994;8: Garthus-Niegel S, et al. The Role of Labor Pain and Overall Birth Experience in the Development of Posttraumatic Stress Symptoms: A Longitudinal Cohort Study. Birth 4; 4: 8-5