CAESAREAN SECTION Brian Fredman

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1 CHAPTER 3 GYNAECOLOGICAL SURGERY CAESAREAN SECTION Brian Fredman Review of evidence: surgical site infusion Of the seven studies on surgical site local anaesthetic infusion after Caesarean section performed through a Pfannenstiel incision, five were randomized, double-blind, placebo-controlled trials (Fredman et al. 2000, Givens et al. 2002, Lavand homme et al. 2007, Mecklem et al. 1995, Zohar et al. 2006) and two were randomized and double-blind, but not placebo-controlled (Rackelboom et al. 2010, Zohar et al. 2002).

2 In three studies, intermittent local anaesthetic surgical site infusion following Caesarean section performed through a Pfannenstiel incision decreased postoperative opioid requirements and improved patient comfort, compared with placebo (Fredman et al. 2000, Givens et al. 2002, Mecklem et al. 1995). One study of continuous ropivacaine infusion below the fascia decreased pain scores and opioid requirements compared with infusion above the fascia (Rackelboom et al. 2010). Bupivacaine (0.25%) infusion was associated with postoperative results similar to those for adjuvant intravenous diclofenac (75 mg/8 h) (Zohar et al. 2006). Local administration of ketamine (1 mg/ml) together with bupivacaine (0.125%) was not associated with improved postoperative analgesia, compared with bupivacaine alone (Zohar et al. 2002). Diclofenac (300 mg/240 ml saline, 5 ml/h) infusion via a multiholed (rather than single-holed epidural) catheter was associated with greater opioid sparing and improved analgesia, compared with intermittent intravenous diclofenac (75 mg/12 h) (Lavand homme et al. 2007). Overall, surgical site infusion was not associated with clinically significant complications or side effects. There was no evidence of systemic infection (Fredman et al. 2000, Zohar et al. 2002, Zohar et al. 2006) or toxicity (Fredman et al. 2000). Wound cellulitis has been reported (Fredman et al. 2000, Givens et al. 2002), but there were no cases of surgical wound breakdown or delay in healing (Givens et al. 2002, Lavand homme et al. 2007). Surgical site infusion does not increase the incidence of postoperative nausea (Fredman et al. 2000, Givens et al. 2002, Zohar et al. 2002)

3 Publication Fredman et al. Anesth Analg 2000 Givens et al. Am J Obstet Gynecol 2002 Lavand homme et al. Anesthesiology 2007 Mecklem et al. Aust N Z J Obstet Gynaecol 1995 Grade* (1 13) Number of patients Catheter type and location 5 50 Epidural 5 36 Multiholed 9 92 Multiholed 4 70 Multiholed Beneath rectus sheath Preclosure bolus Bupivacaine 0.25%, 25 ml Postoperative administration PCSSA ropivacaine 0.2% Bupivacaine 0.25% continuous infusion Ropivacaine 0.2% continuous infusion; diclofenac (300 mg/240 ml saline) Intermittent bolus administration bupivacaine 0.25% Outcomes Pain after coughing / leg raise VAS pain scores VAS Nausea Table 17. Summary of literature for Caesarean section.

4 Publication Grade* (1 13) Number of patients Catheter type and location Preclosure bolus Postoperative administration Outcomes Rackelboom et al. Obstet Gynecol Multiholed Above vs below the fascia Ropivacaine 450 mg + ketoprofene 200 mg continuous infusion, 5 ml/h for 48 h Below fascia: Pain scores Satisfaction Zohar et al. J Clin Anesth Epidural PCSSA bupivacaine 0.25% + diclofenac 75 mg/100 ml saline VAS pain scores Zohar et al. J Clin Anesth Epidural PCSSA bupivacaine 0.125% ± ketamine 1 mg/ml No difference between the groups Table 17 cont. Summary of literature for Caesarean section. *see page 15 for grading of publications

5 Review of evidence for surgical site local anaesthetic infusion vs epidural morphine Two randomized, double-blind studies compared surgical site local anaesthetic infusion after Caesarean section performed through a Pfannenstiel incision with epidural morphine (O'Neill et al. 2012, Ranta et al. 2006). In one study, epidural analgesia was superior to surgical site infusion, but only during the first 4 h after the operation. After that time, pain scores, patient satisfaction and opioid consumption were similar in both groups (Ranta et al. 2006). In one study, continuous ropivacaine infusion below the fascia decreased pain score and opioid requirements compared with epidural morphine (O'Neill et al. 2012). Surgical site infusion did not increase the incidence of postoperative nausea (O'Neill et al. 2012, Ranta et al. 2006).

6 Publication Grade* (1 13) Number of patients Catheter type and location Preclosure bolus Postoperative administration Outcomes O'Neill et al. Anesth Analg Multiholed Below the fascia Ropivacaine 10 mg/ml, 10 ml Ropivacaine 2 mg/ml continuous infusion, 5 ml/h for 48 h vs intermittent epidural morphine 2 mg (every 12 h for 48 h) Opioid requirement Pain scores Nausea Ranta et al. Int J Obstetric Anesthesia Multiholed Subfascial Intermittent 10 ml bolus levobupivacaine 0.25% via subfascial catheter vs intermittent epidural levobupivacaine 0.125%, 10 ml Pain scores at 4 h (epidural levobupivacaine) = Pain relief at 24 h = Opioid consumption = Patient satisfaction Table 18. Summary of literature comparing surgical site infusion with epidural analgesia after Caesarean section. *see page 15 for grading of publications

7 Practical details for Caesarean section Catheter type Three studies used a standard epidural catheter (Fredman et al. 2000, Zohar et al. 2002, Zohar et al. 2006). Six used a multiholed catheter (Givens et al. 2002, Lavand homme et al. 2007, Mecklem et al. 1995, O'Neill et al. 2012, Rackelboom et al. 2010, Ranta et al. 2006). A multiholed catheter placed along the entire length of the wound is suggested, because intuitively this seems likely to produce better results than a standard epidural catheter. However, there are no double-blind, randomized studies comparing the efficacy of different catheter types. Catheter placement The catheter was placed above the fascia in five studies (Fredman et al. 2000, Givens et al. 2002, Lavand homme et al. 2007, Zohar et al. 2002, Zohar et al. 2006), below the fascia in two studies (Ranta et al. 2006, O'Neill et al. 2012), and beneath the rectus sheath in another (Mecklem et al. 1995). One study compared the effectiveness of continuous infusion of local anaesthetic via catheters placed above and below the fascia (Rackelboom et al. 2010). Catheters placed above the fascia (Fredman et al. 2000, Givens et al. 2002, Ranta et al. 2006), below the fascia (Ranta et al. 2006, O'Neill et al. 2012), or beneath the rectus sheath (Mecklem et al. 1995) were associated with decreased postoperative pain scores, reduced opioid requirements and improved patient comfort. In the study comparing catheter placement, catheters placed below the fascia were associated with reduced postoperative pain, decreased opioid requirement, and increased patient satisfaction compared with catheters placed above the fascia (Rackelboom et al. 2010). For Caesarean section, the ideal catheter placement (above or below the fascia) is unknown, although one study comparing catheter placement suggests that below the

8 fascia is more effective for continuous local anaesthetic infusion. Data suggest that a multiholed catheter placed above or below the fascia for the continuous administration of local anaesthetic is effective. Preclosure bolus administration The majority of studies did not use preclosure bolus infiltration. The surgical site was infiltrated with 25 ml bupivacaine (0.25%) or placebo prior to closure in one study (Given et al. 2002), and 10 ml ropivacaine (10 mg/ml) in another (O'Neill et al. 2012). It is not possible to determine the relative contribution of infiltration vs continuous infusion. Preclosure bolus administration is suggested using bupivacaine %, ropivacaine 0.2%, or levobupivacaine 0.125%. Transferable evidence supports the concept that a single local anaesthetic infiltration into the wound decreases postoperative opioid requirements and increases patient comfort. Drug and dosing regimen There are no comparative studies designed to determine the ideal drug, drug concentration or dosing regimen. Ropivacaine 0.2% (Fredman et al. 2000, Lavand homme et al. 2007, O'Neill et al. 2012), ropivacaine 450 mg (Rackelboom et al. 2010), bupivacaine 0.25% (Givens et al. 2002, Mecklem et al. 1995), bupivacaine 0.25% + adjuvant intravenous diclofenac (Zohar et al. 2006), diclofenac (300 mg/240 ml saline) (Lavand homme et al. 2007), bupivacaine 0.125% + adjuvant ketamine, (Zohar et al. 2002) and levobupivacaine 0.125% (Ranta et al. 2006) have all been used as infusion regimens. Five studies used an intermittent infusion technique (Fredman et al. 2000, Mecklem et al. 1995, Ranta et al. 2006, Zohar et al. 2002, Zohar et al. 2006), whereas four used a continuous infusion technique (Givens et al

9 2002, Lavand homme et al. 2007, O'Neill et al. 2012, Rackelboom et al. 2010). Bupivacaine %, ropivacaine 0.2%, or levobupivacaine 0.125% is suggested. Local administration of diclofenac appears effective, but is not recommended until further data are generated. Duration of infusion Postoperative surgical site infusion of 24 h (Fredman et al. 2000, Zohar et al. 2002, Zohar et al. 2006), 48 h (Givens et al. 2002, Lavand homme et al. 2007, Mecklem et al. 1995, O'Neill et al. 2012, Rackelboom et al. 2010) or 72 h (Ranta et al. 2006) have all been used. Infusion duration of up to 72 h is suggested, but duration should be tailored to the patient s needs. The optimum duration of infusion has not been investigated. Post- Caesarean-section pain is usually limited, and patients usually prefer to be mobile as soon as possible. Compact, elastomeric technology and lack of neuro-axial or central nervous effects mean that wound catheter analgesia is ideally suited to this patient group. Key messages for Caesarean section Surgical site infusion for post-caesarean-section analgesia is simple, safe and effective. Surgical site infusion has been shown to be superior to epidural analgesia Since surgical site infusion facilitates early mobility, this technique is ideally suited to the treatment of post-caesarean-section pain.