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
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• 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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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• 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.
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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
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• 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
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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
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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
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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
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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
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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
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Thank you