OPIOID SPARING STRATEGIES FOR OBSTETRIC SURGERY: BRINGING ERAS INTO THE CESAREAN SECTION SUITE Gregory Collins, DNP, CRNA

FINANCIAL DISCLOSURES: NONE OFF-LABEL DRUG USAGE: ONDANSETRON DEXAMETHASONE

REVIEW IDENTIFY PROPOSE Review the origins of ERAS and the history of ERAS strategies in OB surgery. Identify strategies shown to reduce opioid consumption after CS. Propose means of evaluation and methods for implementing ERAS strategies.

1997 2013

2014 2015 2017

2017

CESAREAN SECTION POST-OP COMPLICATIONS MATERNAL EXPERIENCE PAIN MANAGEMENT

http://www.newschannel10.com/clip/14178403/amarillo-ranks-in-top-25-cities-with-opioid-abuse

https://www.hhs.gov/sites/default/files/opioid%20phe%20declaration-no-sig.pdf

https://www.cdc.gov/drugoverdose/data/analysis.html

CESAREAN SECTION MATERNAL EXPERIENCE PAIN MANAGEMENT POST-OP COMPLICATIONS

PREOPERATION INTRAOPERATION POSTOPERATION

PREOPERATION ALLOW LIGHT MEAL UP TO 6 HOURS BEFORE SURGERY

PREOPERATION ALLOW LIGHT MEAL UP TO 6 HOURS BEFORE SURGERY ENCOURAGE CARB-RICH CL UP TO 2 HOURS BEFORE SURGERY

PREOPERATION ALLOW LIGHT MEAL UP TO 6 HOURS BEFORE SURGERY ENCOURAGE CARB-RICH CL UP TO 2 HOURS BEFORE SURGERY INITIATE PHARMACOLOGICAL ASPIRATION PROPHYLAXIS

PREOPERATION ALLOW LIGHT MEAL UP TO 6 HOURS BEFORE SURGERY ENCOURAGE CARB-RICH CL UP TO 2 HOURS BEFORE SURGERY INITIATE PHARMACOLOGICAL ASPIRATION PROPHYLAXIS PREGABALIN 100 mg PO 1 HOUR BEFORE SURGERY

INTRAOPERATION ACETAMINOPHEN 1000 mg IV BEFORE INCISION

INTRAOPERATION ACETAMINOPHEN 1000 mg IV BEFORE INCISION ONDANSETRON 4-8 mg IV JUST PRIOR TO SAB PLACEMENT

INTRAOPERATION ACETAMINOPHEN 1000 mg IV BEFORE INCISION ONDANSETRON 4-8 mg IV JUST PRIOR TO SAB PLACEMENT PF MORPHINE 100 mcg INTRATHECAL WITH SAB

INTRAOPERATION ACTIVE, FORCED-AIR PATIENT WARMING

INTRAOPERATION ACTIVE, FORCED-AIR PATIENT WARMING DEXAMETHASONE 8 mg IV AFTER CORD CLAMP

INTRAOPERATION ACTIVE, FORCED-AIR PATIENT WARMING DEXAMETHASONE 8 mg IV AFTER CORD CLAMP CONSIDER TRANSVERSUS ABDOMINUS PLANE BLOCK

INTRAOPERATION

Reprinted from Block Buddy application. www.myblockbuddy.com

SQ EOM IOM TAM VENTRAL DORSAL VENTRAL DORSAL

VENTRAL DORSAL

VENTRAL DORSAL VENTRAL DORSAL

INTRAOPERATION

POSTOPERATION ENCOURAGE EARLY ORAL INTAKE

POSTOPERATION ENCOURAGE EARLY ORAL INTAKE ENCOURAGE EARLY REMOVAL OF URINARY CATHETER

POSTOPERATION ENCOURAGE EARLY ORAL INTAKE ENCOURAGE EARLY REMOVAL OF URINARY CATHETER ACETAMINOPHEN 1000 mg IV/PO EVERY 6 HOURS

POSTOPERATION ENCOURAGE EARLY ORAL INTAKE ENCOURAGE EARLY REMOVAL OF URINARY CATHETER ACETAMINOPHEN 1000 mg IV/PO EVERY 6 HOURS KETOROLAC 30 mg IV EVERY 6 HOURS

EDUCATION

https://en.wikipedia.org/wiki/everett_rogers

Stolen from Tom Baribeault s FaceBook post

OUTCOMES?

QUESTIONS? g.collins@txana.org

REFERENCES Hebbard P. Transversalis fascia plane block, a novel ultrasound-guided abdominal wall nerve block. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2009;56(8):618-620. doi:10.1007/s12630-009-9110-1 Hutchins J, Renfro L, Orza F, Honl C, Navare S, Berg A. The addition of intrathecal morphine to a transversus abdominis plane block with liposome bupivacaine provides more effective analgesia than transversus abdominis plane block with liposome bupivacaine alone: a retrospective study. Local Reg Anesth. 2019;12:7-13. Tulgar S, Serifsoy T. Transversalis fascia plane block provides effective postoperative analgesia for cesarean section: New indication for known block. J Clin Anesth. 2018;48:13-14. doi:10.1016/j.jclinane.2018.04.006 www.myblockbuddy.com