Analgesia Post Emergency CaesareanSection and Educational Intervention in

The Developing World

Dr Michelle GerstmanAnaesthesia Registrar

Alfred Hospital Melbourne

Hospital Nacional Guido Valdares (HNGV)

Introduction

• Caesarean sections amongst the most common surgical procedures performed in the world

• Pain relief is a basic human right• Acute pain often poorly managed in developing

world• High morbidity associated with pain• Small improvements can potentially have a large

positive impact• Simple easy to follow education regarding obstetric

postoperative analgesia has wide application

WHO: Mother Baby Package: implementing safe motherhood in countries (practical guide).

Bosenber, A, Paediatric anaesthesia in developing countries, Current opinion in Anaesthesiology, 2007, 20:204-120

Current Evidence

• Minimal in the developing world

• Extensive evidence regarding multimodal analgesia in the developed world

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3rd Edition 2010

Hypothesis

• Simple education regarding postoperative multimodal analgesia can result in significantly improved pain scores after Emergency Surgery for Caesarean Section in a Developing World setting with limited resources.

Study

• Prospective audit

• Analgesia prescribing patterns and pain intensity after Emergency Cesarean Section for a 48 hour period in two groups.

• BEFORE and AFTER simple education regarding multimodal analgesia for prescribers.

Analgesic Prescribing

• Obstetricians prescribe post op analgesia in Timor

• Midwives transcribe and administer• Analgesics available• Any combination• Opioid analgesia is not prescribed

Methods• Emergency CS

– Pre education - 16 October - 1 December 2009– Education – Post education - 10 May 2010 - 21 June 2010

• Anaesthesia Registrar/Consultant

• Nurse anaesthetists acted as an interpreters

Methods: Education

• Obstetricians and midwives

• Presentation and discussion of pre-education audit data

• Agreement that analgesia provision was inadequate

• A multimodal analgesia protocol of regular tramadol, paracetamol and ibuprofen was agreed upon

Audit data: Primary Measures

• Analgesia prescribed by the surgical team in surgical notes

• Actual analgesia transcribed by midwives to drug chart and given on day 1 and day 2 post operatively

• Pain scores at rest and with movement on day 1 and day 2 post surgery

• verbal description of pain (5 categories) from no pain to severe pain then converted to numerical value 1-5

Results• 54 patients were

included in the pre-education audit– 54/54 on day 1– 52/54 on day 2

• 63 in the post-education audit– 63/63 on day 1– 55/63 on day 2

Post op analgesia

AnalgesiaPre Education Post Education

Day 1 Day 2 Day 1 Day 2

Tramadol alone 62% 12% 32% 11%

Paracetamol alone 9% 35% 0% 0%

Ibuprofen alone 2% 31% 5% 0%

Tramadol/Paracetamol 19% 6% 0% 0%

Tramadol/ Ibuprofen 4% 0% 0% 0%

Ibuprofen /Paracetamol 0% 4% 3% 74%

Tramadol/ Ibuprofen /Paracetamol

0% 0% 57% 11%

Nil 4% 12% 0% 2%

Mean Pain scores

Pre Education Post Education P value

Day 1 Rest 2.7 ± 0.9 2.0 ± 0.8 0.0003

Day 1 Movement 3.7 ± 0.8 3.3 ± 0.8 0.0036

Day 2 Rest 2.1 ± 0.8 1.8 ± 0.9 0.0908

Day 2 Movement 3.0 ± 0.8 3.0 ± 0.7 0.8858

Conclusion

• Large increase in the use of multimodal analgesia after educational intervention

• Significant improvement of early postoperative pain relief

• Successful education and implementation of knowledge after one education session

Discussion

• Less marked improvement with late pain relief – Impact of tramadol? – Rapid mobilization of patients with less use of

pre-emptive analgesia?– Loss to follow up?

• Language/cultural issues• Challenges with staff changeover• Stoic patients vs. developed world

Discussion

• Different Anaesthesia Registrar

• Audit, not RCT

• Small number of patients had midline incision rather than Pfannenstiel incision

Future

• Further education sessions

• Retention of information - repeat audit 1 year after post education audit

• Written pain protocol displayed in Obstetric ward and OR

• Potential application to other surgical specialties

• Potential for opioid?

Acknowledgements

• Dr Eric Vreede – Head Department of Anaesthesia HNGV, Team Leader RACS

• Dr Alex Konstantatos – Analysis

• Dr Jane Chia – Audit 1

• HNGV Nurse Anaesthetists - Translation services