Whats New in Post-Cesarean Analgesia? October 23rd, 2013 Mark - - PowerPoint PPT Presentation

10/25/2013 1

UC SF

October 23rd, 2013 Mark Rollins, MD, PhD

Anesthesia & Obstetrics

What’s New in Post-Cesarean Analgesia?

2013 UCSF What Does The Evidence Tell Us?

• Describe current impact of post-

cesarean 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
• f multimodal analgesia

Post-Delivery Pain

(Mean pain scores for first 24 hours after delivery)

Eisenach JC, et al. Pain 140:87-94 2008

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Cesarean Delivery Pain

(Impact on Daily Activities during first 24 hours)

Eisenach JC, et al. Pain 140:87-94 2008

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 140:87-94 2008

“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.”

Two months after childbirth:

Postoperative Analgesic Practice

For Cesarean Delivery

Aiono-Tagaloa, et al. Anesthesiology Research & Practice. 2009. PMID: 21217809

• 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%

Survey of Institutional Practice:

Patient Preferences for Outcomes Associated with Cesarean Delivery

Carvahlo B, et al. Anesth Analg 101:1182–7. 2005

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Intrathecal Opioids

Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4):213-21. 2003

Opioid Dose Duration

Morphine 0.1 – 0.2 mg 18 – 24 hrs Fentanyl 5 – 10 mcg 3 – 4 hrs Sufentanil Up to 5 mcg 3 – 4 hrs

Intrathecal Morphine Doses For Post-Cesarean Analgesia

Palmer, CM, et al. Anesthesiology 90:437-44. 1999 Palmer, CM, Tech in Reg Anesth & Pain Mgmt 7(4):213-21. 2003

• Nausea and Vomiting 10% to 50%
• Respiratory Depression < 0.25%

Analgesia Pruritus

(mean ± 95% CI)

Intrathecal Morphine 100µg & 200µg For Post-Cesarean Delivery Analgesia

Wong JY , et al. IJOA 22:36-40 2013

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 ± 1.1 1.6 ± 1.1 0.01 Mean VPS (24-48h) 2.5 ± 1.0 2.5 ± 1.0 0.92

Intrathecal Morphine 100µg & 200µg For Post-Cesarean Delivery Analgesia

Wong JY , et al. IJOA 22:36-40 2013

Side Effects IT Morphine 100µg IT Morphine 200µg Pvalue

Antiemetic Use 24% 52% <0.001 Nausea Episodes (0-24h) 1.6 ± 1.3 1.9 ± 1.3 .04 Nausea Episodes (24-48h) 0.02 ± 0.13 0.04 ± 0.46 .56 Patients receiving NSAIDs 87% 87% .98 Time of Surgery to Discharge 89 ± 20 hrs 89 ± 19 hrs .76

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Epidural Opioids

Palmer, CM, Techniques in Regional Anesthesia & Pain Management 7(4):213-21. 2003

Epidural Morphine Doses For Post-Cesarean Analgesia

Palmer, CM, et al. Anesth Analg 90:887-91. 2000

• Nausea and Vomiting < 10%
• Respiratory Depression < 0.25%

Analgesia Pruritus

Post-Cesarean Pain

(Efficacy of Two Epidural Morphine Doses)

Singh SI, et al. Anesth Analg 117:677-85. 2013

Post-Cesarean Pain

(Efficacy of Two Epidural Morphine Doses)

Singh SI, et al. Anesth Analg 117:677-85. 2013

Pruritus Nausea & Vomiting

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European Journal of Pain 14:894e (2010) 6h - Solid Diamonds 12h - Solid Squares 24h - Open Squares

“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”

Anesthesiology 2007; 106:843-63

“…neuraxial opioids for postoperative analgesia improve analgesia and maternal satisfaction...” Recommendation: “For postoperative analgesia after neuraxial anesthesia for cesarean delivery, neuraxial

• pioids are preferred over intermittent

injections of parenteral opioids.”

Oral vs. PCA Opioid

(Post-Cesarean Analgesia)

Dieterich MD, et al. Arch Gynecol Obstet 286:859-65. 2012

Oral vs. PCA Opioid

(Post-Cesarean Analgesia)

Dieterich MD, et al. Arch Gynecol Obstet 286:859-65. 2012

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“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; 65 429-440

Which PCA related statement do you use?

“Just press your pain button when ever you need it”

.

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 40:443-55. 2013 Flood & Aleshi. Chapter 27, Chestnut’s Obstetric Anesthesia. 5th Ed. 2013

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NSAIDs On-Demand vs. Fixed-Interval

Jakobi P, et al. Am J Obstet Gynecol 187(4):1066-9. 2002

Fixed-interval NSAID dosing provides more effective post-operative cesarean analgesia and results in better patient satisfaction compared to on-demand dosing.

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 half-

life of 116 minutes

• No current analgesic outcome benefit compared to oral

Rawlinswon A, et al. Evid Based Med 17:75-80. 2012 Kulo A, et al. IJOA 21:125-8. 2012 Lavoie, et al. Clin Perinatol 40:443-55. 2013 Flood & Aleshi. Chapter 27, Chestnut’s Obstetric Anesthesia. 5th Ed. 2013

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Alpha2 agonists Gabapentin NMDA antagonists

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Transversus Abdominis Plane Block (AKA - TAP Block)

Figure from Ultrasound For Regional Anesthesia, 2008

TAP Block Technique

McDonnell et al. Anesth Analg 106:186-9. 2008

• 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

• Complications include

intravascular injection and bowel perforation

TAP Block US Technique

Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2nd Edition. Elsevier-Saunders, 2013

TAP Block US Technique

Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2nd Edition. Elsevier-Saunders, 2013

www3.gehealthcare.com

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TAP Block Efficacy Post-Cesarean Delivery

McDonnell et al. Anesth Analg 106:186-9. 2008

TAP Block Efficacy Post-Cesarean Delivery

Abdallah FW, et al. BJA 109(5):679-87. 2012 Loane H, et al. IJOA 21:112-8. 2012 Mishriky BM, et al. 59:766-78. 2012 Onishi Y , et al. J. Obstet. Gynaecol. Res 39(9):1397-1405. 2013

• 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.

• 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