10/25/2013

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UCSF

October 23rd, 2013

Mark Rollins, MD, PhD

Anesthesia & Obstetrics

What’s New in Post-Cesarean

Analgesia?

2013 UCSFWhat 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 of 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 ImpactedVaginalDelivery

CesareanDelivery

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 PracticeFor 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 DosesFor Post-Cesarean Analgesia

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

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

Analgesia Pruritus

(mea

n ±

95%

CI)

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

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

Analgesia IT Morphine100µg

IT Morphine200µg 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 & 200µgFor Post-Cesarean Delivery Analgesia

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

Side Effects IT Morphine100µg

IT Morphine200µg 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 DosesFor 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 Diamonds12h - Solid Squares24h - 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 neuraxialanesthesia for cesarean delivery, neuraxialopioids 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 statementdo 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. 2013Flood & Aleshi. Chapter 27, Chestnut’s Obstetric Anesthesia. 5th Ed. 2013

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NSAIDsOn-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 con sumption

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. 2012Kulo A, et al. IJOA 21:125-8. 2012Lavoie, et al. Clin Perinatol 40:443-55. 2013Flood & 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. 2012Loane H, et al. IJOA 21:112-8. 2012Mishriky BM, et al. 59:766-78. 2012Onishi 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