What s New in Post-Cesarean Analgesia?

Transcription

1 Anesthesia & Obstetrics What s New in Post-Cesarean Analgesia? October 23rd, UCSF What Does The Evidence Tell Us? Mark Rollins, MD, PhD UC SF Post-Delivery Pain (Mean pain scores for first 24 hours after delivery) Describe current impact of postcesarean 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:

2 Cesarean Delivery Pain (Impact on Daily Activities during first 24 hours) Two months after childbirth: Activity Impacted Vaginal Delivery Cesarean Delivery Walking 40% 72 % Mood 19% 40% Sleep 36% 57% Interactions with Others 8% 20% Ability to Concentrate 13% 31% Pain (8-weeks) 10% 9% Depression (8-weeks) 11% 11% Eisenach JC, et al. Pain 140: 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. Eisenach JC, et al. Pain 140: Postoperative Analgesic Practice For Cesarean Delivery Patient Preferences for Outcomes Associated with 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 PMID: Carvahlo B, et al. Anesth Analg 101:

3 Intrathecal Opioids Intrathecal Morphine Doses For Post-Cesarean Analgesia Opioid Dose Duration Analgesia Pruritus Morphine mg hrs Fentanyl 5 10 mcg 3 4 hrs (mean ± 95% CI) Sufentanil Up to 5 mcg 3 4 hrs Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4): Nausea and Vomiting 10% to 50% Respiratory Depression < 0.25% Palmer, CM, et al. Anesthesiology 90: Palmer, CM, Tech in Reg Anesth & Pain Mgmt 7(4): Intrathecal Morphine 100µg & 200µg For Post-Cesarean Delivery Analgesia Intrathecal Morphine 100µg & 200µg For Post-Cesarean Delivery Analgesia Analgesia IT Morphine 100µg IT Morphine 200µg Pvalue Opioid Use (0-24h) 54 ± 35mg 44 ± 35mg.04 Opioid Use (24-48h) 54 ± 32mg 60 ± 31mg.18 IV morphine required 30% 18%.02 IV Morphine Use (0-24h) 2.5 ± 5.3mg 1.3 ± 3.5mg.054 IV Morphine Use (24-48h) 0.02 ± 0.2mg 0 ± 0mg.32 Mean VPS (0-24h) 2.0 ± ± Mean VPS (24-48h) 2.5 ± ± Side Effects IT Morphine 100µg IT Morphine 200µg Pvalue Antiemetic Use 24% 52% <0.001 Nausea Episodes (0-24h) 1.6 ± ± Nausea Episodes (24-48h) 0.02 ± ± Patients receiving NSAIDs 87% 87%.98 Time of Surgery to Discharge 89 ± 20 hrs 89 ± 19 hrs.76 Wong JY, et al. IJOA 22: Wong JY, et al. IJOA 22:

4 Epidural Opioids Epidural Morphine Doses For Post-Cesarean Analgesia Analgesia Pruritus Nausea and Vomiting < 10% Respiratory Depression < 0.25% Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4): Palmer, CM, et al. Anesth Analg 90: Post-Cesarean Pain (Efficacy of Two Epidural Morphine Doses) Post-Cesarean Pain (Efficacy of Two Epidural Morphine Doses) Pruritus Nausea & Vomiting Singh SI, et al. Anesth Analg 117: Singh SI, et al. Anesth Analg 117:

5 European Journal of Pain 14:894e (2010) Anesthesiology 2007; 106: h - Solid Diamonds 12h - Solid Squares 24h - Open Squares neuraxial opioids for postoperative analgesia improve analgesia and maternal satisfaction... A single bolus of epidural morphine provides better analgesia than parenteral opioids but with an effect limited to the first postoperative day after caesarean section Recommendation: For postoperative analgesia after neuraxial anesthesia for cesarean delivery, neuraxial opioids are preferred over intermittent injections of parenteral opioids. Oral vs. PCA Opioid (Post-Cesarean Analgesia) Oral vs. PCA Opioid (Post-Cesarean Analgesia) Dieterich MD, et al. Arch Gynecol Obstet 286: Dieterich MD, et al. Arch Gynecol Obstet 286:

6 Which PCA related statement do you use? Just press your pain button when ever you need it The use of PCA is a complex, high risk treatment that is associated with harmful events and death Hicks et al m. J. Health Syst. Pharm. Mar 2008; PCA has been identified as #7 of the 10 TOP Health Technology Hazards for 2011 ECRI Institute Report Nov, 2010 MEDMARX and U.S. Pharmacopeia (USP) data show that when PCA pumps are involved, the chance for patient harm increases more than 3.5 times (APSF).. Multimodal Analgesia Optimize additive effects of various agents Utilize different modes of analgesia Minimize maternal side effects Reduce transfer of medication to breast milk NSAIDs All NSAIDs have opioid sparing activity - Effective in reducing post-cesarean delivery pain - Enhance opioid analgesia - Decrease opioid-related side effects Non-selectively inhibit cyclooxygenase-1 & -2 - Undesirable side effects include platelet dysfunction, renal impairment, and GI irritation American Academy of Pediatrics regards NSAIDs safe for use in breast feeding women Typical post-cesarean dosing in healthy women - Ibuprofen 600mg to 800mg orally every 8 hours Lavoie, et al. Clin Perinatol 40: Flood & Aleshi. Chapter 27, Chestnut s Obstetric Anesthesia. 5 th Ed

7 NSAIDs On-Demand vs. Fixed-Interval Fixed-interval NSAID dosing provides more effective post-operative cesarean analgesia and results in better patient satisfaction compared to on-demand dosing. Jakobi P, et al. Am J Obstet Gynecol 187(4): Acetaminophen 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 halflife of 116 minutes - No current analgesic outcome benefit compared to oral Rawlinswon A, et al. Evid Based Med 17: Kulo A, et al. IJOA 21: Lavoie, et al. Clin Perinatol 40: Flood & Aleshi. Chapter 27, Chestnut s Obstetric Anesthesia. 5 th Ed Landscape (set) Landscape (set) San Francisco Bay Brid San Francisco (set) Architecture (set) Alpha2 agonists San Francisco Bay Brid San Francisco (set) Architecture (set) Tags NMDA antagonists Tags architecture landscap San Francisco US architecture San Gabapentin Francisco landscap US Additional info Additional info Settings: 1/295 ƒ/2 Uploaded using Flickr Settings: 1/295 ƒ/2 Uploaded using Flickr License License Some rights res Request to license eri Images Some rights res Request to license eri Images Privacy Privacy nrise over the San Francisco Bay Bridge This photo is visible to nrise over the San Francisco Bay Bridge This photo is visible to mments and faves mments and faves 7

8 Figure from Ultrasound For Regional Anesthesia, 2008 Transversus Abdominis Plane Block TAP Block Technique Placed between subcostal margin and iliac crest Placed with either blind or U/S guidance techniques 15 20mL of local anesthetic injected incrementally on each side (AKA - TAP Block) Complications include intravascular injection and bowel perforation McDonnell et al. Anesth Analg 106: 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,

9 TAP Block Efficacy Post-Cesarean Delivery TAP Block Efficacy 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. McDonnell et al. Anesth Analg 106: Abdallah FW, et al. BJA 109(5): Loane H, et al. IJOA 21: Mishriky BM, et al. 59: Onishi Y, et al. J. Obstet. Gynaecol. Res 39(9): 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