Post Caesarean Analgesia An Update - sfai.se · Post caesarean analgesia –an update DepoFoam®...
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Post Caesarean Analgesia – An Update Kim Ekelund MD, PhD, associate professor Rigshospitalet Copenhagen, Denmark
Transcript of Post Caesarean Analgesia An Update - sfai.se · Post caesarean analgesia –an update DepoFoam®...
Post Caesarean Analgesia –An Update
Kim Ekelund
MD, PhD, associate professor
Rigshospitalet Copenhagen, Denmark
• Neuraxial opioids
• Multimodal therapy
• Plan B
• What do we do?
• How do we do?
• Take Home Messages
Post caesarean analgesia – No Conflicts of Interests
Agenda
Post caesarean analgesia – an update
• No magic bullet
• Increasing C-section rate
• Do good
• Mother-child
• Development of chronic pain (0.3% - 8%)
It is important!
1. Nikolajsen L et al. Acta Anaesthesiol Scand. 2004; 48:111–116. 2. Eisenach JC, et al. Anesthesiology 2013; 118:143–1513. Liu et al. Anaesth Intensive Care 2013; 41: 496-5004. Woolhouse H et al. Birth. 2012;39:221-95. Jin et al. BMC Anesthesiology 2016; 16:99
Post caesarean analgesia – Neuraxial Opioids
Intrathecal Morphine – effect
1. Palmer CM et al. Anesthesiology 1999;90:437-442. Carvalho FA et al. Braz J Anesthesiol 2013;63:492-9
Intrathecal Morphine– side-effects
Palmer CM et al. Anesthesiology 1999;90:437-44 J. Sarvela et al. Anesth Analg 2002;95:436-40
Post caesarean analgesia – Neuraxial Opioids
Intrathecal Sufentanil & Fentanyl
1. M. Wilwerth et al Acta Anaesth Scand. 2016;60:1306-132. C. Hunt et al. Anaesth. 1989;71(4):535-40
Post caesarean analgesia – Neuraxial Opioids
Epidural Morphine– effect
Singh SI et al. Anesth Analg. 2013;117:677-85
1.5 mg Epidural Morphine:• Decreasing pruritus severity (at 6, 12, and 24 hrs)• Less frequent incidence of nausea and vomiting (at 6 hrs)
Post caesarean analgesia – Neuraxial Opioids
Opioids – IV, tablets or?
Post caesarean analgesia – Multimodal Therapy
• IV vs. IT morphine- Easy, but not necessarily better…
• Oral oxycodone = IV morphine- Or maybe even better
• Oral oxycodone = IT morphine - When part of multimodal analgesic package
• Oral analgesia - At fixed time interval + on-demand
1. Eisenach et al. Anesth. 1988;68:444-82. Egan et al. Can J Anesth. 1994;41:66-113. Davis et al. Am J Obstet Gynecol 2006;194:967–714. Niklasson et al. Scand J Pain. 2015;7:17-245. Dieterich et al. Arch Gynecol Obstet. 2012;286:859–8656. McDonnell et al. IJOA. 2010;19:16–237. Jakobi et al. Am J Obestet Gynecol 2002;187:1066-9.
Non Steroidal Anti-Inflammatory Drugs 1
• Effective against visceral pain from uterine incision
• Drug?– Diclofenac, Ibuprofen, Naproxen, Ketorolac,
Celecoxib or ….
• Dose? – X1, x2, x3. Fixed time interval or on-demand?
• Administration?– IV, oral, rectal, subcutaneous?
Post caesarean analgesia – Multimodal Therapy
Non Steroidal Anti-Inflammatory Drugs 2
• Drug and dose?– Supp. Diclofenac 50mgx3, or 100mgx2
• Diclofenac?– Increased cardiovascular risk– Ibuprofen is an alternative
• Side effects– GI bleeding, atone uterus
• Administration?– IV, oral, rectal, subcutaneous installation?– Fixed time interval better than on demand
1. Olofsson et al Eur J Obstet Gynecol Reprod Biol. 2000 Feb;88(2):143-62. Dahl et al. Int J Obstet Anesth. 2002 Apr;11(2):91-43. Schmidt et al. Ugeskr Laeger. 2016 Dec 26;178(52)4. Yefet et al. BJOG 2017;124:1063–10705. Jakobi et al. Am J Obestet Gynecol 2002;187:1066-9
Post caesarean analgesia – Multimodal Therapy
Paracetamol
Siddik et al. Reg Anesth and Pain Medicine 2001; 26(4):310-5
Mean cumulative consumption of morphine by PCA in groups
MDP, MD, MP, and M.
• PCM + NSAID- Better than PCM alone- Better than NSAID alone?
• PCM post CS – no effect?• PCM post CS – no side effects
Post caesarean analgesia – Multimodal Therapy
n = 112
n = 44
n = 197
Anesthesiology. 2015;123:320-6
Anesth Analg2012;115:1336-42.
Anesth Analg2011;112:167-73.
Gabapentin
Post caesarean analgesia – Multimodal Therapy
Other
• Pregabalin
• Dexamethasone
• MgSo4
• Ketamine
El Kenany S et al. IJOA. 2016;26:24-31Shalu PS et al. Anesth Essays Res. 2017 Apr-Jun;11(2):321-325.Yousef AA et al IJOA. 2010 Oct;19(4):401-4.Heesen et al. Acta Anaesthesiol Scand. 2015 Apr;59(4):414-26
Post caesarean analgesia – Multimodal Therapy
Clonidine & Dexmedetomidine
• Clonidine & Dexmedetomidine, IV or intrathecal
– Effects
• Prolonged time to first analgesic requirement
• Reduce postoperative morphine consumption
– Side effects
• Sedation (hypotension or bradycardia)
• Caution…
• TAP block. 1µg/kg. Prolong effect 10hrs
Crespo et al. IJOA 2017, article in pressSingh et al. J Anaesth Clin Pharm. 2016 ;32(4):501-4
Paech et al. Anesth Analg. 2004;98(5):1460-6van Tuijl et al. Br J Anaesth. 2006 Sep;97(3):365-70. Nie et al. Eur J Analgesia. 2014;31(4):197-203
Tradition Future?
Post caesarean analgesia – Multimodal Therapy
• TAPbupi > TAPplacebo
• ITM + TAPbupi = ITM + TAPplacebo
• TAPbupi < ITM
Post caesarean analgesia – Plan B
Transversus Abdominis Plane (TAP) block
R. Champaneria et al. IJOA. 2016;28:45-60Mishriky et al. J Can Anesth. 2012;59:766–778
Opioid consumption at 24 hr.
TAP or Wound Infiltration?
MM Tawfik et al. Anesth Analg 2017;124:1291-7
A. Telnes, et al. Acta Anaesth Scand 2015;59:496-504
Fig. 3. Graphs of mean cumulative morphine consumptionin the two groups, in continuous time.
Fig. 2. Kaplan-Meier graph of the proportion of patients in each group who did not require fentanyl over time aftercesarean delivery.
Post caesarean analgesia – Plan B
• Infiltration with Diclofenac & Ketorolac
– Provides improved analgesia compared with
• Systemic NSAIDs or
• Local infiltration with local anaesthetic alone
– Reduces inflammatory mediators in wound exudate
– More studies are needed ...
Wound infiltration with NSAID
P. Lavand’homme et al. Anesthesiology 2007; 106:1220–5B. Carvalho et al. The Journal of Pain, 2013;14(1):48-56
Post caesarean analgesia – Plan B
Quadratus Lumborum Block
• QLbupi > TAPbupi
- Visceral pain- 12-48 hrs
R. Blanco et al. Reg Anesth Pain Med. 2016;41(6);757-62
• QLbupi > QLplacebo
- Pain- Opioid consumption
R. Blanco et al. Eur J Anaesthesiol 2015; 32:812–818K: kidney, lv: liver, ql: quadratus lumborum, p:psoas major,
lift: lumbar interfascial triangel
Post caesarean analgesia – Plan B
• ClinicalTrial.gov- 6 trials. Multimodal approach- QL vs ITM or TAP
Post caesarean analgesia – an update
DepoFoam®
• Delivery system: multiple microscopic, liposomal particles
• EREM – Extended release of epidural morphine.
• EXPAREL – Bupivacaine liposome injectable suspension
• ClinicalTrial.gov- 4 trials- TAP/wound infiltration
Tranversus Abdominus Plane Block Performed with EXPAREL for Post Cesarean Section Analgesia:
A Case ReportA. Grab et al. ASA Annual Meeting 2014, A1298
Post caesarean analgesia – an update
What do we actually do?
After CS in spinal
Iceland1 site
Finland2 sites
Norway4 sites
Sweden3 sites
Denmark
TAP - (1)/2 - - -
QL - - (1)/4 - -
Woundinfiltraion
1/1 - 1/4 2/3 1/4
Colleagues from 14 sites were asked.
After CS in GA
Iceland1 site
Finland2 sites
Norway4 sites
Sweden3 sites
Denmark4 sites
TAP - 2/2 - 2/3 -
QL - - 1/4 - -
Woundinfiltraion
1/1 - 2/4 1/3 1/4
Post caesarean analgesia – an update
• Evaluation!
– How do we do?
• Instead of ”What do we do?”
• Pain After Delivery – group• Recovery Unit?
• Maternity ward?
• At home?
Do better
Post caesarean analgesia – Take Home Message
1. Intrathecal opioids
2. Multimodal therapy Tbl NSAID + Tbl PCM and Tbl Opioid
3. Plan B?
3. Re-evaluate
Take Home Messages
Thanks to previous and present colleagues at the faculty of SSAI Obstetric Anaesthesia for providing me with information about their local post caesarean section analgesia
Thank you
