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Giral T, Delvaux BV, Huynh D, Morel B, Zanoun N, Ehooman F, Garnier T, Maupain O. Posterior quadratus lumborum block versus intrathecal morphine analgesia after scheduled cesarean section: a prospective, randomized, controlled study. Reg Anesth Pain Med 2024:rapm-2024-105454. [PMID: 39237149 DOI: 10.1136/rapm-2024-105454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 08/24/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND During the postoperative period of elective cesarean section, intrathecal morphine is effective in the multimodal analgesic regimen, but can cause significant adverse effects. Bilateral posterior quadratus lumborum block could be alternatively used. The aim of this study was to compare efficacy and safety of both strategies as part of a multimodal analgesic regimen. METHODS This was a prospective, randomized, blinded, controlled study. 104 parturients were randomly selected to receive intrathecal morphine or posterior quadratus lumborum block during cesarean section under spinal anesthesia. The primary endpoint was patient-controlled 24-hour cumulative intravenous morphine use. Secondary endpoints were 48-hour cumulative morphine use, static/dynamic pain scores, functional recovery (ObsQoR-11 questionnaire) and adverse effects. RESULTS There was no statistical difference in the mean cumulative morphine dose at 24-hour between groups (posterior quadratus lumborum block group, 13.7 (97.5% CI 10.4 to 16.9) mg; intrathecal morphine group, 11.1 (97.5% CI 8.4 to 13.8) mg, p=0.111). Pain scores did not show any difference between groups, excepted at 6 hours for the pain at cough/movement in favor of the posterior quadratus lumborum block group (p=0.013). A better recovery quality was observed at 24 hours in the posterior quadratus lumborum block group (p=0.009). Pruritus was more frequent in intrathecal morphine group parturients (35% vs 2%) CONCLUSIONS: No difference in cumulative morphine dose at 24 hours was observed in posterior quadratus lumborum block group compared with intrathecal morphine group. Posterior quadratus lumborum block can be considered an alternative to intrathecal morphine in cesarean postoperative analgesia, especially in cases of intolerance to morphine. TRIAL REGISTRATION NUMBER NCT04755712.
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Affiliation(s)
- Thomas Giral
- Anaesthesia, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | | | - Davy Huynh
- Anaesthesia, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | - Bertrand Morel
- Anaesthesia, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | - Nabil Zanoun
- Anaesthesia, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | - Franck Ehooman
- Anaesthesia, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | - Thierry Garnier
- Anaesthesia, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | - Olivier Maupain
- Anaesthesia, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
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Zhang J, Sun D, Wang J, Chen J, Chen Y, Shu B, Huang H, Duan G. Exploring the Analgesic Efficacy and mechanisms of low-dose esketamine in pregnant women undergoing cesarean section: A randomized controlled trial. Heliyon 2024; 10:e35434. [PMID: 39170110 PMCID: PMC11336589 DOI: 10.1016/j.heliyon.2024.e35434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/28/2024] [Accepted: 07/29/2024] [Indexed: 08/23/2024] Open
Abstract
Background Postoperative pain is a prevalent concern following a cesarean section. This study aimed to investigate the effect and mechanism of low-dose (0.1 mg/kg) esketamine on postoperative pain management in pregnant women undergoing cesarean sections, specifically in cases where both patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) were employed. Methods Pregnant women intending to undergo elective cesarean section were divided into four subgroups based on the intravenous administration of esketamine and the specific analgesia methods employed: E1 (0.1 mg/kg esketamine + PCEA), E2 (0.1 mg/kg esketamine + PCIA), C1 (saline + PCEA), and C2 (saline + PCIA). The primary outcome was the maximum pain score within 24 h postoperatively. Secondary outcomes included the pressure pain threshold and tolerance at 30 min and 24 h postoperatively, along with the inflammation and adverse event index scores. Results A total of 118 pregnant women were assigned to the four groups: E1 (n = 29), E2 (n = 29), C1 (n = 30), and C2 (n = 30). Compared with those in the control groups (C1 + C2), the maximum postoperative pain scores within 24 h in the esketamine groups (E1 + E2) were significantly lower (4 [2-5] vs. 4 [4-6], P = 0.002), and the E1 group exhibited superior analgesic effects compared with other groups. No significant differences were observed in postoperative hyperalgesia or inflammation across the four groups. Notably, esketamine combined with PCIA increased the incidence of postoperative nausea and vomiting (7 [25 %] vs. 0 [0 %]; P = 0.005). Conclusion The administration of low-dose (0.1 mg/kg) esketamine effectively alleviates pain following cesarean section, and the analgesic effect is notably enhanced in combination with PCEA. Importantly, these effects do not appear to be mediated through anti-inflammatory mechanisms or the inhibition of hyperalgesia. Clinical trial registration number NCT05414006.
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Affiliation(s)
- Junhua Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Dina Sun
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jing Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jie Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yuanjing Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Bin Shu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - He Huang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Cheng J, Wan M, Yu X, Yan R, Lin Z, Liu H, Chen L. Pharmacologic Analgesia for Cesarean Section: An Update in 2024. Curr Pain Headache Rep 2024:10.1007/s11916-024-01278-8. [PMID: 38951467 DOI: 10.1007/s11916-024-01278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE OF THE REVIEW With the increasing prevalence of cesarean section globally, the importance of perioperative analgesia for cesarean section is becoming increasingly evident. This article provides an overview and update on the current status of cesarean section worldwide and associated analgesic regimens. RECENT FINDINGS Some recent studies unveiled potential association of neuraxial analgesia might be associated with children's autism, pharmacologic analgesia in obstetric will potentially gain some more attention. Various commonly used techniques and medications for analgesia in cesarean section are highlighted. While neuraxial administration of opioid remains the most classic method, the use of multimodal analgesia, particularly integration of nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks has provided additional and better options for patients who are not suitable for intrathecal and neuraxial techniques and those experiencing severe pain postoperatively. Optimal pain management is crucial for achieving better clinical outcomes and optimal recovery, and with the continuous development of medications, more and better pharmacologic regimen will be available in the future.
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Affiliation(s)
- Jing Cheng
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, NO.745 Wuluo Road, Hongshan District, Wuhan, Hubei, China, 430070
| | - Mengjiao Wan
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, NO.745 Wuluo Road, Hongshan District, Wuhan, Hubei, China, 430070
| | - Xiaoyan Yu
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, NO.745 Wuluo Road, Hongshan District, Wuhan, Hubei, China, 430070
| | - Rongrong Yan
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, NO.745 Wuluo Road, Hongshan District, Wuhan, Hubei, China, 430070
| | - Zirui Lin
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, NO.745 Wuluo Road, Hongshan District, Wuhan, Hubei, China, 430070
| | - Henry Liu
- Department of Anesthesiology & Critical Care, The University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Lin Chen
- Department of Anesthesiology, Maternal and Child Health Hospital of Hubei Province, NO.745 Wuluo Road, Hongshan District, Wuhan, Hubei, China, 430070.
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Boshoff J, Fourtounas M, Pegu K, McInerney P. Effectiveness of intrathecal dexmedetomidine vs fentanyl as additives to hyperbaric bupivacaine for postoperative analgesia in women undergoing cesarean section: a systematic review protocol. JBI Evid Synth 2024; 22:933-939. [PMID: 38126265 DOI: 10.11124/jbies-23-00215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE The aim of this review is to compare the effectiveness of intrathecal dexmedetomidine vs fentanyl as additives to hyperbaric bupivacaine in providing postoperative analgesia in patients undergoing cesarean section. INTRODUCTION Pain following cesarean section remains a challenge, with limited treatment options due to potential undesirable parturient and neonatal side effects. Intrathecal dexmedetomidine has emerged as a favorable alternative to opioid additives to hyperbaric bupivacaine in prolonging postoperative analgesia, but its effectiveness requires further investigation. INCLUSION CRITERIA The review will evaluate studies of patients who underwent cesarean section under spinal anesthesia where dexmedetomidine and fentanyl were compared as intrathecal additives to hyperbaric bupivacaine for postoperative analgesia. This review will consider randomized controlled trials, non-randomized controlled trials, and prospective cohort studies for inclusion. No limits regarding publication date or language will be applied. METHODS A preliminary search of PubMed and Cochrane Central Register of Controlled Trials has been conducted to identify relevant index terms and keywords, which will be applied in a second search across PubMed, Cochrane CENTRAL, Scopus, and Embase. Google Scholar, National Library of Medicine (Clinicaltrials.gov), and the World Health Organization International Clinical Trial Registry Platform will be searched to identify unpublished literature. Full-text studies will be subjected to an assessment of methodological quality, and data extraction will be performed independently by 2 reviewers. The results will be presented in both tabular and narrative format and, where possible, pooled into a meta-analysis. A Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings will be created to grade the certainty of evidence of the reported outcomes. REVIEW REGISTRATION PROSPERO CRD42022364815.
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MESH Headings
- Humans
- Dexmedetomidine/administration & dosage
- Dexmedetomidine/therapeutic use
- Cesarean Section
- Female
- Fentanyl/administration & dosage
- Fentanyl/therapeutic use
- Fentanyl/adverse effects
- Pain, Postoperative/drug therapy
- Pain, Postoperative/prevention & control
- Systematic Reviews as Topic
- Pregnancy
- Bupivacaine/administration & dosage
- Injections, Spinal
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/therapeutic use
- Anesthesia, Spinal/methods
- Anesthesia, Spinal/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Analgesics, Opioid/adverse effects
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Affiliation(s)
- Jorica Boshoff
- Department of Anesthesiology, Faculty of Health Sciences, The University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Maria Fourtounas
- Department of Anesthesiology, Faculty of Health Sciences, The University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Kylesh Pegu
- Department of Anesthesiology, Faculty of Health Sciences, The University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Patricia McInerney
- The Wits-JBI Centre for Evidence-Based Practice: A JBI Centre of Excellence, The University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Heresco L, Schonman R, Weitzner O, Cohen G, Schreiber H, Daykan Y, Klein Z, Kovo M, Yagur Y. Pain perception and analgesic use after cesarean delivery among women with endometriosis. Eur J Obstet Gynecol Reprod Biol 2024; 294:71-75. [PMID: 38218161 DOI: 10.1016/j.ejogrb.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/09/2023] [Accepted: 12/25/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Patients with endometriosis are known to have altered pain perceptions. Cesarean delivery (CD) is one of the most prevalent surgeries performed worldwide. Appropriate pain control following CD is clinically important to the recovery and relief of patients. This study assessed pain perception and analgesic use after CD among women with or without endometriosis. METHODS This retrospective case control study included women diagnosed with endometriosis, based on clinical or surgical findings, who underwent CD from 2014 to 2022. Controls were matched to the study group by maternal age, BMI (kg/m2), parity, number of previous CDs and by CD indication, in a 2:1 ratio. Post-operative visual analogue scale (VAS) pain scores, on each post-operative day (POD) were compared between groups. Pain intensity was measured and compared using the VAS, range 0 (no pain) to 10 (worst pain). The standard pain relief analgesia protocol in our department includes fixed oral treatment with paracetamol and diclofenac, with the addition of morphine sulphate on POD 0. Analgesic dosages used and the percentage of patients not using the full standard analgesic protocol were compared between groups. RESULTS As compared to controls (n = 142), the endometriosis group (n = 71) was characterized by higher rates of in-vitro fertilization (IVF) pregnancies and previous abdominal surgeries other than CD (p < .001 for both). Other maternal characteristics between groups did not differ. On POD 0, mean morphine dosage was significantly higher in the endometriosis group compared to the control group (24 mg vs. 22.8 mg, respectively; p = .044). More patients in the endometriosis group used the full standard analgesia protocol or more, as compared to controls. VAS scores were not significantly different between groups. CONCLUSIONS Increased use of analgesics after CD was more common among women with endometriosis. These findings imply that pain relief protocols should be personalized for women with endometriosis.
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Affiliation(s)
- Lior Heresco
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ron Schonman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omer Weitzner
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Cohen
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanoch Schreiber
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Daykan
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Klein
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Yagur
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Fowler C, Stockert E, Hoang D, Guo N, Riley E, Sultan P, Carvalho B. Continuous wound infusion catheter as part of a multimodal analgesia regimen for post-Caesarean delivery pain: a quality improvement impact study. BJA OPEN 2024; 9:100242. [PMID: 38179106 PMCID: PMC10761342 DOI: 10.1016/j.bjao.2023.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/08/2023] [Indexed: 01/06/2024]
Abstract
Background The role of continuous wound infusion catheters as part of a multimodal analgesia strategy after Caesarean delivery is unclear. We introduced continuous wound infusion catheters to our multimodal analgesia regimen to evaluate the impact on analgesic outcomes after Caesarean delivery. Methods After institutional review board (IRB) approval, a 4-month practice change was instituted as a quality improvement initiative. In addition to multimodal analgesia, continuous wound infusion catheters for up to 3 days were offered on alternate weeks for all women undergoing Caesarean deliveries. The primary outcome was postoperative in-hospital opioid consumption. Secondary outcomes were static and dynamic pain scores at 24 and 72 h, time until first analgesic request, opioid-related side-effects, length of stay, satisfaction (0-100%), and continuous wound infusion catheter-related complications. Results All women scheduled for Caesarean delivery (n=139) in the 4-month period were included in the analysis, with 70 women receiving continuous wound infusion catheters, and 69 in the control group. Opioid consumption (continuous wound infusion catheter group 11.3 [7.5-61.9] mg morphine equivalents vs control group 30.0 [11.3-48.8] mg morphine equivalents), pain scores (except 24 h resting pain scores which were higher in the control group 2 [1-3] vs 1.5 [0-3] in the continous wound infusion catheters group; P=0.05), side-effects, length of stay, and complications were similar between groups. Satisfaction scores at 24 h were higher with continuous wound infusion catheters (100% [91-100%] vs 90% [86-100%]; P=0.003) with no differences at 72 h. One patient demonstrated symptoms of systemic local anaesthetic toxicity which resolved without significant harm. Conclusions The addition of continuous wound infusion catheters to a multimodal analgesia regimen for post-Caesarean delivery pain management demonstrated minimal clinically significant analgesic benefits. Future studies are needed to explore the use of continuous wound infusion catheters in populations that may benefit most from this intervention.
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Affiliation(s)
- Cedar Fowler
- Division of Obstetric Anesthesiology and Maternal Health, Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Emily Stockert
- Division of Obstetric Anesthesiology and Maternal Health, Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Dan Hoang
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Nan Guo
- Division of Obstetric Anesthesiology and Maternal Health, Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward Riley
- Division of Obstetric Anesthesiology and Maternal Health, Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Pervez Sultan
- Division of Obstetric Anesthesiology and Maternal Health, Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Brendan Carvalho
- Division of Obstetric Anesthesiology and Maternal Health, Department of Anesthesiology Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Silverman M, Zwolinski N, Wang E, Lockwood N, Ancuta M, Jin E, Li J. Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients. J Pain Res 2023; 16:3807-3835. [PMID: 38026463 PMCID: PMC10644837 DOI: 10.2147/jpr.s428332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction With the current surge on peripheral nerve blocks in post-cesarean pain management and the historical lack of unequivocal evidence supporting its universal use, this review intended to re-examine the extended scope of literature on regional anesthesia and postoperative analgesia in low-transverse cesarean section. Methods A literature search was conducted up to April 2023 using PubMed to identify articles relevant to our search words "cesarean section", "neuraxial morphine", "post-cesarean analgesia", as well as the name of each individual nerve block. The literature search was ultimately narrowed to systematic reviews and randomized controlled trials published between 2012 and 2023. We define, describe, and discuss the evidence surrounding each individual regional anesthetic technique in the presence and absence of intrathecal morphine, which is used as the gold standard when appropriate. Results In the absence of neuraxial morphine, all regional anesthetic techniques have some level of analgesic benefit in the post-cesarean analgesia. Transversus Abdominis Plane blocks continue to have the most studies in their use. Newer fascia plane blocks including the anterior Quadratus Lumborum, and Erector Spinae Plane blocks provide significant analgesia. In addition, direct comparison among peripheral nerve blocks consistently favors the more proximal, centralized techniques. Conversely, in the presence of neuraxial morphine, no peripheral anesthetic technique has reliably and reproducibly demonstrated an added analgesic benefit regardless of the peripheral nerve block technique or location of local anesthetic injection in the post-cesarean population. Conclusion Neuraxial morphine continues to be the gold standard for post-cesarean section analgesia, the benefit of additional single injection regional anesthetic is currently not evidence supported. In cases where neuraxial opioids have not or cannot be given, there is overwhelming evidence that regional anesthetic techniques improve post-cesarean section analgesia and decrease post-operative opioid consumption. Even though there is no consensus on the optimal peripheral nerve block, emerging evidence suggests more centralized abdominal fascia plane block trends towards better analgesia.
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Affiliation(s)
- Matthew Silverman
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Nicholas Zwolinski
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Ethan Wang
- Yale University School of Medicine, New Haven, CT, USA
| | - Nishita Lockwood
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael Ancuta
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Evan Jin
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Jinlei Li
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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Bishop D, van Dyk D, Dyer R. Safe obstetric anaesthesia in low- and middle-income countries-a perspective from Africa. BJA Educ 2023; 23:432-439. [PMID: 37876763 PMCID: PMC10591126 DOI: 10.1016/j.bjae.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 10/26/2023] Open
Affiliation(s)
- D. Bishop
- University of Kwazulu-Natal, Durban, South Africa
| | - D. van Dyk
- University of Cape Town, Cape Town, South Africa
| | - R.A. Dyer
- University of Cape Town, Cape Town, South Africa
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Grasch JL, Costantine MM, Mast DDD, Klopfenstein B, Russo JR, Summerfield TL, Rood KM. Noninvasive Bioelectronic Treatment of Postcesarean Pain: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2338188. [PMID: 37862016 PMCID: PMC10589807 DOI: 10.1001/jamanetworkopen.2023.38188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/05/2023] [Indexed: 10/21/2023] Open
Abstract
Importance Improved strategies are needed to decrease opioid use after cesarean delivery but still adequately control postoperative pain. Although transcutaneous electrical stimulation devices have proven effective for pain control after other surgical procedures, they have not been tested as part of a multimodal analgesic protocol after cesarean delivery, the most common surgical procedure in the United States. Objective To determine whether treatment with a noninvasive high-frequency electrical stimulation device decreases opioid use and pain after cesarean delivery. Design, Setting, and Participants This triple-blind, sham-controlled randomized clinical trial was conducted from April 18, 2022, to January 31, 2023, in the labor and delivery unit at a single tertiary academic medical center in Ohio. Individuals were eligible for the study if they had a singleton or twin gestation and underwent a cesarean delivery. Of 267 people eligible for the study, 134 (50%) were included. Intervention Participants were randomly assigned in a 1:1 ratio to a high-frequency (20 000 Hz) electrical stimulation device group or to an identical-appearing sham device group and received 3 applications at the incision site in the first 20 to 30 hours postoperatively. Main Outcomes and Measures The primary outcome was inpatient postoperative opioid use, measured in morphine milligram equivalents (MME). Secondary outcomes included pain scores, measured with the Brief Pain Inventory questionnaire (scale, 0-10, with 0 representing no pain), MME prescribed at discharge, and receipt of additional opioid prescriptions in the postpartum period. Normally distributed data were assessed using t tests; otherwise via Mann-Whitney or χ2 tests as appropriate. Analyses were completed following intention-to-treat principles. Results Of 134 postpartum individuals who underwent a cesarean delivery (mean [SD] age, 30.5 [4.6] years; mean [SD] gestational age at delivery, 38 weeks 6 days [8 days]), 67 were randomly assigned to the functional device group and 67 to the sham device group. Most were multiparous, had prepregnancy body mass index (calculated as weight in kilograms divided by height in meters squared) higher than 30, were privately insured, and received spinal anesthesia. One participant in the sham device group withdrew consent prior to treatment. Individuals assigned to the functional device used significantly less opioid medication prior to discharge (median [IQR], 19.75 [0-52.50] MME) than patients in the sham device group (median [IQR], 37.50 [7.50-67.50] MME; P = .046) and reported similar rates of moderate to severe pain (85% vs 91%; relative risk [RR], 0.77 [95% CI, 0.55-1.29]; P = .43) and mean pain scores (3.59 [95% CI, 3.21-3.98] vs 4.46 [95% CI, 4.01-4.92]; P = .004). Participants in the functional device group were prescribed fewer MME at discharge (median [IQR], 82.50 [0-90.00] MME vs 90.00 [75.00-90.00] MME; P < .001). They were also more likely to be discharged without an opioid prescription (25% vs 10%; RR, 1.58 [95% CI, 1.08-2.13]; P = .03) compared with the sham device group. No treatment-related adverse events occurred in either group. Conclusions and Relevance In this randomized clinical trial of postoperative patients following cesarean delivery, use of a high-frequency electrical stimulation device as part of a multimodal analgesia protocol decreased opioid use in the immediate postoperative period and opioids prescribed at discharge. These findings suggest that the use of this device may be a helpful adjunct to decrease opioid use without compromising pain control after cesarean delivery.
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Affiliation(s)
- Jennifer L. Grasch
- Division of Maternal-Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Maged M. Costantine
- Division of Maternal-Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Devra D. Doan Mast
- Division of Maternal-Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Baylee Klopfenstein
- Division of Maternal-Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jessica R. Russo
- Division of Maternal-Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Taryn L. Summerfield
- Division of Maternal-Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kara M. Rood
- Division of Maternal-Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Bakİ Erİn K, Erİn R, Sahal SO, Kartal S, Kulaksiz D. The evaluation of the efficacy of etofenamate spray in postoperative cesarean pain: Randomized, double-blind, placebo-controlled trial. Taiwan J Obstet Gynecol 2023; 62:697-701. [PMID: 37678997 DOI: 10.1016/j.tjog.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVE It was aimed to investigate the effect of etofenamate spray to be applied around the postoperative incision on pain control in cesarean section in this trial. MATERIAL AND METHODS This was a prospective, randomized, double-blind, and placebo-controlled trial. 187 patients (93 cases and 94 controls) were recruited for the study. In the trial group, we applied the etofenamate spray (Doline® 50 ml) after closing the cesarean skin incision and go on four times a day on the skin incision for 24 h. In the control group, we applied a placebo. All patients received paracetamol IV (Paracerol®) as standard analgesic doses. If analgesia was insufficient, tramadol (Contramal®) 50 mg IV doses were added and recorded. A visually analog pain scale (VAS) was performed on both groups at 6-12-18-24th hours. Independent t-tests were performed for data showing normal distributions. RESULTS There were no significant differences in the mean of differences VAS scores between the two groups at 6-12, and 6-18 h. However, a significant difference was obtained in the mean of differences VAS score at the 6-24th hour (p < 0.05). When the groups were compared in terms of additional paracetamol need, a significant difference was found again (p < 0.05). There was no significant difference between the groups in terms of tramadol need. CONCLUSION Postoperative administration of etofenamate spray provided an analgesic effect at 24 h and additional analgesic usage decreased. Postoperative analgesia can also be used by administering NSAIDs around the cesarean section incision. In this way, the side effects of other systemic analgesics are avoided. CLINICAL TRIAL ID PACTR201811864509898. CLINICAL TRIAL WEB LINK: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5745.
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Affiliation(s)
- Kübra Bakİ Erİn
- University of Health Sciences, Trabzon Kanuni Health Practice and Research Center, Department of Obstetrics and Gynecology, Trabzon, Turkey.
| | - Recep Erİn
- University of Health Sciences, Trabzon Kanuni Health Practice and Research Center, Department of Obstetrics and Gynecology, Trabzon, Turkey; University of Health Sciences, Somalia Mogadishu Recep Tayyip Erdogan Health Practice and Research Center, Department of Obstetrics and Gynecology, Mogadishu, Somalia
| | - Safia Omar Sahal
- University of Health Sciences, Somalia Mogadishu Recep Tayyip Erdogan Health Practice and Research Center, Department of Obstetrics and Gynecology, Mogadishu, Somalia
| | - Seyfi Kartal
- University of Health Sciences, Trabzon Kanuni Health Practice and Research Center, Department of Anesthesiology and Reanimation, Trabzon, Turkey
| | - Deniz Kulaksiz
- University of Health Sciences, Trabzon Kanuni Health Practice and Research Center, Department of Obstetrics and Gynecology, Trabzon, Turkey; University of Health Sciences, Somalia Mogadishu Recep Tayyip Erdogan Health Practice and Research Center, Department of Obstetrics and Gynecology, Mogadishu, Somalia
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Zanolli NC, Fuller ME, Krishnamoorthy V, Ohnuma T, Raghunathan K, Habib AS. Opioid-Sparing Multimodal Analgesia Use After Cesarean Delivery Under General Anesthesia: A Retrospective Cohort Study in 729 US Hospitals. Anesth Analg 2023; 137:256-266. [PMID: 36947464 DOI: 10.1213/ane.0000000000006428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Optimizing analgesia after cesarean delivery is essential to quality of patient recovery. The American Society of Anesthesiologists and the Society for Obstetric Anesthesia and Perinatology recommend multimodal analgesia (MMA). However, little is known about clinical implementation of these guidelines after cesarean delivery under general anesthesia (GA). We performed this study to describe the use of MMA after cesarean delivery under GA in the United States and determine factors associated with use of MMA, variation in analgesia practice across hospitals, and trends in MMA use over time. METHODS A retrospective cohort study of women over 18 years who had a cesarean delivery under GA between 2008 and 2018 was conducted using the Premier Healthcare database (Premier Inc). The primary outcome was utilization of opioid-sparing MMA (osMMA), defined as receipt of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen with or without opioids and without the use of an opioid-combination drug. Any use of either agent within a combination preparation was not considered osMMA. The secondary outcome was use of optimal opioid-sparing MMA (OosMMA), defined as use of a local anesthetic technique such as truncal block or local anesthetic infiltration in addition to osMMA. Mixed-effects logistic regression models were used to examine factors associated with use of osMMA, as well as variation across hospitals. RESULTS A total of 130,946 patients were included in analysis. osMMA regimens were used in 11,133 patients (8.5%). Use of osMMA increased from 2.0% in 2008 to 18.8% in 2018. Black race (7.9% vs 9.3%; odds ratio [OR] [95% confidence interval {CI}] 0.87 [0.81-0.94]) and Hispanic ethnicity (8.6% vs 10.0%; OR, 0.86 [0.79-0.950]) were associated with less receipt of osMMA compared to White and non-Hispanic counterparts. Medical comorbidities were generally not associated with receipt of osMMA, although patients with preeclampsia were less likely to receive osMMA (9.0%; OR, 0.91 [0.85-0.98]), while those with a history of drug abuse (12.5%; OR, 1.42 [1.27-1.58]) were more likely to receive osMMA. There was moderate interhospital variability in the use of osMMA (intraclass correlation coefficient = 38%). OosMMA was used in 2122 (1.6%) patients, and utilization increased from 0.8% in 2008 to 4.1% in 2018. CONCLUSIONS Variation in osMMA utilization was observed after cesarean delivery under GA in this cohort of US hospitals. While increasing trends in utilization of osMMA and OosMMA are encouraging, there is need for increased attention to postoperative analgesia practices after GA for cesarean delivery given low percentage of patients receiving osMMA and OosMMA.
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Affiliation(s)
- Nicole C Zanolli
- From the Duke University School of Medicine, Durham, North Carolina
| | - Matthew E Fuller
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Tetsu Ohnuma
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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Swisher MW, Dolendo IM, Sztain JF, Alexander BS, Tsuda PS, Anger JT, Said ET. Intrathecal Morphine Injection for Postoperative Analgesia Following Gender-Affirming Pelvic Surgery: A Retrospective Case-Control Study. Cureus 2023; 15:e36748. [PMID: 37123779 PMCID: PMC10139671 DOI: 10.7759/cureus.36748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
Background Gender-affirming pelvic surgery (GAPS) can be associated with significant postoperative pelvic pain. Given the lack of available peripheral nerve blocks to the perineum, intrathecal morphine (ITM) injection could offer a potent analgesic modality for this patient population. No prior studies to date have been performed examining the analgesic effects of intrathecal morphine for these patients. Methods This retrospective case-control study aims to understand the postoperative analgesic effects of intrathecal morphine for these patients with a historical comparison group of patients who did not receive intrathecal morphine. Results Fourteen patients presented for gender-affirming pelvic surgery over an eight-month period at a single institution and were offered intrathecal morphine for postoperative analgesia. Their analgesic results were compared to a similar historical group of 13 patients who were not offered or declined intrathecal morphine. Conclusions Intrathecal morphine injection is a potent analgesic modality for patients presenting for gender-affirming pelvic surgery.
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13
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A Multimodal Protocol to Limit Opioid Exposure and Effectively Manage Postoperative Cesarean Birth Pain. MCN Am J Matern Child Nurs 2023; 48:69-75. [PMID: 36823724 DOI: 10.1097/nmc.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
PURPOSE To evaluate the impact of implementing a multimodal plan of care in treating the pain of the postoperative cesarean birth patient that limited opioid exposure. STUDY DESIGN AND METHODS A retrospective medical record review was conducted to evaluate a pain management protocol implemented for postoperative cesarean patients before and after a practice change. Sample included term postoperative cesarean patients ≥ 37 weeks of gestation, who had spinal or epidural, were 18 years or older, gave birth to a singleton newborn, admitted to the maternal child health department, and were prescribed opioids as a postoperative pain management treatment plan. Participants (N = 150) were evaluated based on two groups: n = 75 in the preimplementation group and n = 75 in the postimplementation group. RESULTS There was a significant difference in the total oral opioid milligrams administered between the pregroup (M = 27.13) and postgroup (M = 8.43), after the practice change (p < .001). There was an increase of nonopioids administered to treat and manage postoperative cesarean pain, Motrin PO (p = < .001) and Tylenol PO (p = .002). CLINICAL IMPLICATIONS Fewer milligram equivalents of morphine were administered when postoperative cesarean patients were placed on scheduled nonopioids to treat pain.
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14
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Wang HM, Worly BL. Inequities in Inpatient Obstetrics Pain Management and Evaluation: Age, Race, Mental Health, and Obesity. Matern Child Health J 2023; 27:538-547. [PMID: 36719539 DOI: 10.1007/s10995-023-03602-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate disparities of pain management among patients giving birth in inpatient Obstetrics units based on age, race, BMI, and mental health diagnoses. METHODS A retrospective cohort study was performed and included all individuals giving birth at a tertiary-care institution in 2019. Patient-reported pain scores, and inpatient narcotic administration and dosing for pain control were collected. Models were adjusted for race, age, BMI, and diagnoses of anxiety, depression, opioid use disorder, and/or schizophrenia. RESULTS 4788 Individuals met the inclusion criteria. A higher proportion of African American patients reported severe pain (n = 233/607, 38.4%) and received narcotics (n = 653/1141, 57.2%) compared to patients of other races. Despite controlling for several possible confounders, African American patients (OR 1.55, 95% CI 1.08-2.22), patients with increased BMI (OR 1.02, 95% CI 1.01-1.03), and patients with a mental health diagnosis (OR 2.33, 95% CI 1.32-4.12) were more likely to have worse pain at rest. Older patients were more likely to be administered narcotics (n = 447/757, 59.0%) compared to younger patients (patients aged 18-26: n = 577/1257, 52.3%; patients aged 27-35: n = 1451/2774, 52.3%; p < 0.001), despite younger patients being more likely to have severe pain (OR 1.50; 95% CI 1.20-1.86; p = 0.001). CONCLUSIONS Patients who are Non-Hispanic African American and patients with obesity and mental health diagnoses experience inequities in postpartum pain management. Pain is complex and multifactorial and can be impacted by cultural, social, environmental factors and more. Further studies on factors that influence pain perception and management in inpatient obstetrics units are needed.
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Affiliation(s)
- Heather M Wang
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 W. 12th Avenue, Office 500, Columbus, OH, 43210, USA
| | - Brett L Worly
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, 395 W. 12th Avenue, Office 500, Columbus, OH, 43210, USA.
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15
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Priya TK, Singla D, Talawar P, Sharma RS, Goyal S, Purohit G. Comparative efficacy of quadratus lumborum type-II and erector spinae plane block in patients undergoing caesarean section under spinal anaesthesia: a randomised controlled trial. Int J Obstet Anesth 2023; 53:103614. [PMID: 36535864 DOI: 10.1016/j.ijoa.2022.103614] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/03/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Quadratus lumborum and erector spinae plane blocks have been used to provide analgesia in patients undergoing thoracic or abdominal surgeries. Our study compared the analgesic efficacy of the quadratus lumborum type-II block (QLB-II) and the erector spinae plane block (ESPB) in parturients who underwent caesarean section under spinal anaesthesia. METHODS Fifty-two patients with comparable demographic profiles were randomised into two groups, QLB-II (n = 26) and ESPB (n = 26). After the surgery, patients received either ultrasound-guided QLB-II or ESPB using 0.25% bupivacaine 0.3 mL/kg. Comparison of analgesic efficacy was in terms of fentanyl consumption (primary outcome), pain scores, incidence of complications in the 24-h postoperative period, and quality of recovery (QoR-15) on postoperative days one and two, and day of discharge. RESULTS There was no significant difference in cumulative number of fentanyl doses (W = 349.000, P = 0.840), numerical rating score at rest (P = 0.648) or with movement (P = 0.520), QoR-15 scores on postoperative day one (P = 0.549), day two (P = 0.927) or day of discharge (P = 0.676). CONCLUSION We concluded that patients who underwent QLB-II or ESPB reported similar analgesic efficacy, complications, and quality of recovery in the postoperative period.
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Affiliation(s)
- T K Priya
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
| | - D Singla
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India.
| | - P Talawar
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
| | - R S Sharma
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
| | - S Goyal
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
| | - G Purohit
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
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Associations between postpartum pain type, pain intensity and opioid use in patients with and without opioid use disorder: a cross-sectional study. Br J Anaesth 2023; 130:94-102. [PMID: 36371258 PMCID: PMC9900726 DOI: 10.1016/j.bja.2022.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 09/25/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Pain is a multidimensional construct. The purpose of this cross-sectional, single-centre study was to evaluate the relationship between postpartum pain type with pain intensity and opioid use in people with and without opioid use disorder (OUD). METHODS Postpartum pain type was coded from McGill Pain Questionnaire and Patient-Reported Outcome Measurement Information System (PROMIS) inventories in people with or without OUD after childbirth in a 4-month period. The co-primary outcomes were pain intensity (0-10 scale) and total inpatient oxycodone (mg). Multivariable linear mixed-effects models assessed between- and within-person relationships for pain type (primary predictor) and outcomes. RESULTS There were 44 522 unique pain scores and types from 2610 people. Pain types were associated with pain intensity (P<0.001). Between-person comparisons showed affective pain was associated with a small but higher total oxycodone dose (difference 1.04 mg compared with no affective pain, P<0.001). Among people with OUD, within-person comparisons showed that the presence of affective pain resulted in pain scores 1 point higher than when affective pain was not present (P=0.002); between-person comparisons showed that people with affective pain had pain scores 6 points higher (P=0.048). Within-person and between-person comparisons among OUD showed that nociceptive/neuropathic pain was associated with a higher total oxycodone dose (1.6 and 11.4 mg, respectively). CONCLUSIONS Postpartum pain type was associated with pain intensity and opioid use. Further research is required to address the multiple dimensions of postpartum pain in people with and without OUD to improve treatment of postpartum pain.
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Comparison of Post-Cesarean Pain Perception of General Versus Regional Anesthesia, a Single-Center Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:medicina59010044. [PMID: 36676668 PMCID: PMC9866267 DOI: 10.3390/medicina59010044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/17/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
Background and Objectives: Pain during and after the procedure remains the leading concern among women undergoing cesarean section. Numerous studies have concluded that the type of anesthesia used during a cesarean section undoubtedly affects the intensity and experience of pain after the operation. Materials and Methods: This prospective cohort study was conducted at the Clinic for Gynecology and Obstetrics, Clinical Center "Dragisa Misovic-Dedinje", Belgrade, Serbia. Patients at term pregnancy (37-42 weeks of gestation) with an ASA I score who delivered under general (GEA) or regional anesthesia (RA) by cesarean section were included in the study. Following the procedure, we assessed pain using the Serbian McGill questionnaire (SF-MPQ), Visual Analogue Scale (VAS) and the pain attributes questionnaire at pre-established time intervals of 2, 12, and 24 h after the procedure. Additionally, time to patient's functional recovery was noted. We also recorded the time to the first independent mobilization, first oral intake, and lactation establishment. Results: GEA was performed for 284 deliveries while RA was performed for 249. GEA had significantly higher postoperative sensory and affective pain levels within intervals of 2, 12, and 24 h after cesarean section. GEA had significantly higher postoperative VAS pain levels. On pain attribute scale intensity, GEA had significantly higher postoperative pain levels within all intervals. Patients who received RA had a shorter time to first oral food intake, first independent mobilization, and faster lactation onset in contrast to GEA. Conclusions: The application of RA presented superior postoperative pain relief, resulting in earlier mobilization, shorter time to first oral food intake, and faster lactation onset in contrast to GEA.
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18
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Cesarean delivery using an ERAS-CD process for nonopioid anesthesia and analgesia drug/medication management. Best Pract Res Clin Obstet Gynaecol 2022; 85:35-52. [PMID: 35995654 DOI: 10.1016/j.bpobgyn.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022]
Abstract
Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.
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Punchuklang W, Nivatpumin P, Jintadawong T. Total failure of spinal anesthesia for cesarean delivery, associated factors, and outcomes: A retrospective case-control study. Medicine (Baltimore) 2022; 101:e29813. [PMID: 35801788 PMCID: PMC9259130 DOI: 10.1097/md.0000000000029813] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Spinal anesthesia is the anesthetic technique of choice for patients undergoing cesarean delivery. In the present study, total spinal anesthesia failure was defined as a case when an absent blockade or inadequate surgery required general anesthesia administration with an endotracheal tube. This study aimed to investigate factors related to this condition and report its maternal and neonatal outcomes. This retrospective matched case-control study was conducted by recruiting 110 patients with failed spinal anesthesia and 330 control patients from September 1, 2016, to April 30, 2020, in the largest university hospital, Thailand. Of 12,914 cesarean deliveries, 12,001 patients received single-shot spinal anesthesia (92.9%) during the study period. Total spinal anesthesia failure was experienced by 110/12,001 patients, giving an incidence of 0.9%. Factors related to the failures were a patient body mass index (BMI) ≤29.5 kg/m2 (adjusted odds ratio 1.9; 95% confidence interval 1.2-3.1; P = .010) and a third-year resident (the most senior trainee) performing the spinal block (adjusted odds ratio 2.4; 95% confidence interval 1.5-3.7; P < .001). In the group with failed spinal anesthesia, neonatal Apgar scores at 1 and 5 minutes were lower than those of the control group (both P < .001). Two patients in the failed spinal anesthesia group (2/110; 1.8%) had difficult airways and desaturation. Independent factors associated with total spinal anesthesia failure were a BMI of ≤29.5 kg/m2 and a third-year resident performing the spinal block. Although the incidence of total failure was infrequent, there were negative consequences for the mothers and neonates. Adjusting the dose of bupivacaine according to the weight and height of a patient is recommended, with a higher dose appropriate for patients with a lower BMI.
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Affiliation(s)
- Wiruntri Punchuklang
- Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patchareya Nivatpumin
- Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Patchareya Nivatpumin, Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University2 Wanglang Road, Bangkok Noi, Bangkok 10700, Thailand (e-mail: )
| | - Thatchanan Jintadawong
- Division of Obstetric Anesthesia, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Anterior Quadratus Lumborum Block at the Lateral Supra-Arcuate Ligament versus Transmuscular Quadratus Lumborum Block for Analgesia after Elective Cesarean Section: A Randomized Controlled Trial. J Clin Med 2022; 11:jcm11133827. [PMID: 35807110 PMCID: PMC9267333 DOI: 10.3390/jcm11133827] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 02/05/2023] Open
Abstract
Several studies have shown the effectiveness of trans-muscular quadratus lumborum block (TQLB) in analgesia after cesarean delivery. However, the influence of anterior QLB at the lateral supra-arcuate ligament (QLB-LSAL) in this surgery is unclear. This study aimed to compare the analgesic efficacy of bilateral TQLBs with bilateral QLBs-LSAL following cesarean delivery. Ninety-four parturients scheduled for cesarean delivery under spinal anesthesia were enrolled and randomly allocated to undergo either bilateral TQLBs or bilateral QLBs-LSAL with 0.375% of ropivacaine (20 mL each side) following cesarean delivery. Intravenous sufentanil was administered for patient-controlled analgesia (PCA). The primary outcome was postoperative sufentanil consumption during the initial 24 h post-surgery. Secondary endpoints included pain scores, time to the first PCA request, postoperative rescue analgesia, satisfaction scores, and nausea/vomiting events. Sufentanil consumption was significantly reduced in the QLB-LSAL group in the first 24 h compared with the TQLB group after surgery (29.4 ± 5.7 μg vs. 39.4 ± 9.6 μg, p < 0.001). In comparison with TQLB, the time to the first PCA request in the QLB-LSAL group was significantly longer (10.9 ± 4.1 h vs. 6.7 ± 1.8 h, p < 0.001). No differences were observed between two groups regarding pain scores, rescue analgesia after surgery, satisfaction scores, or nausea/vomiting incidence. The significant reduction in opioid consumption in the first 24 h and prolongation in time to first opioid demand in parturients receiving QLB-LSAL compared with TQLB suggest that the QLB-LSAL is a superior choice for multimodal analgesia after cesarean delivery.
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21
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Veef E, Van de Velde M. Post-cesarean section analgesia. Best Pract Res Clin Anaesthesiol 2022; 36:83-88. [PMID: 35659962 DOI: 10.1016/j.bpa.2022.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.
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Affiliation(s)
- Ellen Veef
- Department of Cardiovascular Sciences, KULeuven and Department of Anaesthesiology, UZLeuven, Herestraat 49, 3000 Leuven, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, KULeuven and Department of Anaesthesiology, UZLeuven, Herestraat 49, 3000 Leuven, Belgium.
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22
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23
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Loomis BR, Yee LM, Hayes L, Badreldin N. Nurses' Perspectives on Postpartum Pain Management. WOMEN'S HEALTH REPORTS 2022; 3:318-325. [PMID: 35415715 PMCID: PMC8994431 DOI: 10.1089/whr.2021.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 11/13/2022]
Abstract
Introduction: There is variation in postpartum opioid use by prescriber characteristics that cannot be explained by patient or birth factors. Thus, our objective was to evaluate nursing training, clinical practices, and perspectives on opioid use for postpartum pain management. Materials and Methods: In this survey study, postpartum bedside nurses at a single, large academic center were asked about training, factors influencing clinical decisions, and viewpoints regarding pain management and opioid use. Findings were summarized using descriptive analyses. Results: A total of 92 nurses completed the survey. A majority (77%) reported having received some formal training on opioid use for pain management. About a quarter (25.7%) felt their training was not adequate. Regarding clinical practices, the majority (71% and 70%, respectively) reported that “routine habit” and “patient preference” most influenced the type and amount of pain medication they administered. Finally, nurses' perspectives on pain management demonstrated a wide range of beliefs. Most nurses strongly agreed with the importance of maximizing nonopioid pain medication before opioid administration. The majority agreed that patient-reported pain score is important to consider when deciding to administer opioids. Conversely, most nurses disagreed that patients should be encouraged to endure as much pain as possible before using an opioid. Similarly, beliefs about the reliability of use of vital signs in assessing pain intensity varied widely. Conclusions: Bedside nurses rely on routine habits, patient preference, and patient-reported pain score when administering opioids for postpartum pain management. Increased training opportunities to improve consistency and standardization of opioid administration may be beneficial.
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Affiliation(s)
- Benjamin R. Loomis
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Hayes
- Department of Obstetrics and Gynecology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Persistent pain after childbirth. BJA Educ 2022; 22:33-37. [PMID: 34992799 PMCID: PMC8703132 DOI: 10.1016/j.bjae.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 01/03/2023] Open
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Mukarram S, Ali S, Zulqurnain M, Alkadi IM, Alhatlan A, Abbasi MH, Mushtaq M, AbuHammad A, Shahid K, Waqas A, Shafqat A. Validation of translated Obstetric Quality of Recovery (ObsQoR-10A) score after nonelective cesarean delivery (CD) in an Arabic-speaking population. Saudi J Anaesth 2022; 16:390-400. [PMID: 36337390 PMCID: PMC9630706 DOI: 10.4103/sja.sja_52_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The ObsQoR-11 is a validated scale that assesses recovery after cesarean delivery (CD). This observational study aimed to evaluate the psychometric properties of its Arabic version. Methods: The original ObsQoR-11 was translated into an Arabic version (ObsQoR-10A). All participants completed the ObsQoR-10A at 24 h and 48 h postoperatively after CD. Validity, reliability, responsiveness, and feasibility were assessed. Results: The ObsQoR-10A correlated with Global Health Numerical Rating Scale (NRS) at 24 h (R = 0.68, 95% CI: 0.56–0.80, P < 0.001) and at 48 h (R = 0.66, 95% CI: 0.54–0.78, P < 0.001) and differentiated between good and poor recovery (median scores at 24 h 88 vs. 71, P < 0.001; at 48 h 95.5 vs. 70, P < 0.001). ObsQoR-10A correlated with hospital length of stay at 24 h (R = −0.21, 95% CI: −0.40 to −0.02, P = 0.03) and at 48 h (R = −0.21, 95% CI: −0.40 to −0.03, P = 0.02); gestational age at 24 h (R = 0.22, 95% CI: 0.03–0.40, P = 0.02); change in hemoglobin at 24 h (R = −0.30, 95% CI: 0.51 to −0.10, P < 0.01); and total opioids at 48 h (R = −0.45, 95% CI: −0.62 to −0.27, P < 0.001). There was a significant difference between 24 h and 48 h postoperative ObsQoR-10A scores (median difference: −18; P < 0.001 which shows responsiveness). Other key measures included a Cronbach's alpha of 0.87, split-half 0.75, and intra-class correlation >0.62 with no floor or ceiling effects. Median (IQR) completion time was 3 (3-5) and 3 (2.5-3.5) minutes at 24 h and 48 h. Conclusions: ObsQoR-10A is a valid, reliable, responsive, and a clinically feasible tool in an Arabic-speaking obstetric population.
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Huang JY, Wang LZ, Chang XY, Xia F. Impact of Transversus Abdominis Plane Block With Bupivacaine or Ropivacaine Versus Intrathecal Morphine on Opioid-related Side Effects After Cesarean Delivery: A Meta-analysis of Randomized Controlled Trials. Clin J Pain 2021; 38:231-239. [PMID: 34928872 DOI: 10.1097/ajp.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Intrathecal morphine (ITM) is frequently associated with side effects such as postoperative nausea and vomiting (PONV) and pruritus. The aim of this meta-analysis was to compare the impact of transversus abdominis plane (TAP) block versus ITM on side effects following cesarean delivery. MATERIALS AND METHODS PubMed, Embase, Web of Science, and CENTRAL were searched for randomized controlled trials that compared TAP with ITM for cesarean delivery. The primary outcomes were opioid-related side effects. The secondary outcomes included pain scores, opioid consumption, patient satisfaction, and time to the first analgesia request. RESULTS Seven studies involving 660 patients were included. TAP blocks were performed with bupivacaine or ropivacaine. There was less PONV with TAP versus ITM (risk ratio [RR]=0.45, 95% confidence interval [CI]: 0.33-0.63, P<0.001; I2=0%), but no significant difference in pruritus (RR=0.76, 95% CI: 0.49-1.18, P=0.22; I2=78%) and sedation (RR=0.44, 95% CI: 0.19-1.00, P=0.05; I2=0%). TAP had a greater morphine consumption in 24 hours (mean difference: 5.80 mg; 95% CI: 1.38-10.22 mg, P=0.01; I2=89%) and higher pain score at rest at 6 hours (mean difference: 0.70, 95% CI: 0.39-1.02, P<0.001; I2=56%), but similar pain at rest at 24 hours and on movement compared with ITM. No differences were found in time to first analgesia and patient satisfaction. DISCUSSION Compared with ITM, TAP block is associated with less PONV but inferior early analgesia after cesarean delivery. However, the heterogeneity among the studies highlights the need for more well-designed studies to obtain more robust conclusions.
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Affiliation(s)
- Jia-Yu Huang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital, Jiaxing University, Jiaxing, Zhejiang Province, China
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Koksal E, Aygun H, Genç C, Kaya C, Dost B. Comparison of the analgesic effects of two quadratus lumborum blocks (QLBs), QLB type II vs QLB type III, in caesarean delivery: A randomised study. Int J Clin Pract 2021; 75:e14513. [PMID: 34117829 DOI: 10.1111/ijcp.14513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/31/2021] [Accepted: 06/06/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Quadratus lumborum blocks (QLBs) are relatively novel regional anaesthesia techniques, and the efficacy of all three types of QLB for postoperative analgesia in caesarean delivery (CD) has been demonstrated in separate studies. The aim of the present study is to compare the analgesic efficacy of the QLB-II and QLB-III blocks performed at the end of surgery in patients undergoing spinal anaesthesia for CD. METHODS We conducted a comparative, blinded, prospective, randomised and efficiency study. A total of 80 patients scheduled for elective CD under spinal anaesthesia were randomly allocated to receive either bilateral ultrasound-guided QLB-II or QLB-III block in a 1:1 ratio. The primary outcome was opioid consumption administered by a patient-controlled analgesia in the first 24 hours postoperatively. The secondary outcome of the study was pain intensity. Also, the time of first opioid requirement and the presence of nausea and vomiting were recorded. RESULTS Morphine consumption was statistically significantly lower in the QLB-III group when compared with the QLB-II group at the 3rd, 6th, 12th and 24th hours (P < .001, P < .001, P = .004, and P = .015, respectively). The QLB-III group showed significantly lower pain scores at rest at the 1st, 3rd, 6th, 9th and 24th hours after surgery (P < .001, P < .001, P < .001, P = .007 and P < .001, respectively). The QLB-III group also showed significantly lower pain score on movement at all measurement times (P < .001). CONCLUSIONS The analgesic efficacy of QLB-III was superior to QLB-II in patients who had undergone CD under spinal anaesthesia without use of intrathecal opioids and nonsteroidal anti-inflammatory drugs.
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Affiliation(s)
- Ersin Koksal
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hakan Aygun
- Department of Anesthesiology, Cigli Regional Training Hospital, Izmir, Turkey
| | - Caner Genç
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Cengiz Kaya
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Burhan Dost
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review. Anesthesiol Res Pract 2021; 2021:2156918. [PMID: 34589125 PMCID: PMC8476264 DOI: 10.1155/2021/2156918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.
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Munsaka EF, Van Dyk D, Parker R. A retrospective audit of pain assessment and management post-caesarean section at New Somerset Hospital in Cape Town, South Africa. S Afr Fam Pract (2004) 2021; 63:e1-e6. [PMID: 34636591 PMCID: PMC8517764 DOI: 10.4102/safp.v63i1.5320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/03/2022] Open
Abstract
Background The most common major surgical procedure performed worldwide is the caesarean section (CS). Effective pain management is a priority for women undergoing this procedure, to reduce the incidence of persistent pain (a risk factor for postpartum depression), as well as optimise maternal-neonatal bonding and the successful establishment of breastfeeding. Multimodal analgesia is the gold standard for post-CS analgesia. At present, no perioperative pain management protocols could be identified for the management of patients presenting for CS at regional hospitals in South Africa. This audit aimed to review the folders of patients who underwent CS, with particular reference to perioperative pain management guidelines for CS. Methods A descriptive, retrospective, cross-sectional audit was conducted. Three hundred folders (10% of the annual number of caesarean procedures performed) from New Somerset Hospital, a regional hospital in Cape Town, South Africa were reviewed. Results The women were a mean age of 30 years (standard deviation [s.d.]: 6.2). Median gravidity was 3 (interquartile range [IQR]: 2–3) and parity was 1 (IQR: 1–2); 52% had previously undergone a CS. In 93.3% cases, spinal anaesthesia was employed for CS. Pain assessment was poor, with only 55 (18%) patients having their pain assessed on the day of the operation. Analgesia was prescribed in over 98% of the patients, however, medication was only administered as prescribed in 32.6%. Non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed in < 5% of cases. None of the patients received a patient-controlled analgesia (PCA), transversus abdominis plane (TAP) block, or wound infusion catheter as supplementary strategies. Conclusion Pain management for post-CS patient at this hospital is lacking. There is the need for the implementation of a structured assessment tool to improve administration of analgesics in these patients. In addition, the reasons for the omission of NSAIDs from the analgesia regimen requires investigation. Hospital requires post-CS pain protocols to guide management especially in resource-limited settings.
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Affiliation(s)
- Effraim F Munsaka
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town.
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Predicting pain after Cesarean delivery: pressure algometry, temporal summation, three-item questionnaire. Can J Anaesth 2021; 68:1802-1810. [PMID: 34585366 DOI: 10.1007/s12630-021-02105-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 07/22/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Approximately one in five women will experience severe postoperative pain after Cesarean delivery (CD). Previously, a bedside three-item questionnaire (3-IQ) has shown to predict women experiencing higher evoked pain intensity after CD, with an area under the receiver operator characteristics (ROC) curve of 0.72. We hypothesized that the addition of psychophysical pain tests to the existing 3-IQ would improve the ability to predict severe pain in women undergoing elective CD under spinal anesthesia METHODS: This was a prospective cohort study on women undergoing elective CD under spinal anesthesia. Women were assessed preoperatively using the 3-IQ, pressure algometry (PA) and mechanical temporal summation (TS) response. All women received standard perioperative care, including a multimodal analgesia regimen that included intrathecal fentanyl and morphine. A 0-100 mm visual analogue scale (VAS) was used to assess the severity of pain at rest (VASr) and on movement (VASm) at 24 and 48 hr after surgery. Patient satisfaction and opioid consumption were also recorded. We performed ROC curve analyses to assess whether we could improve the ability to predict our primary outcome of severe pain on movement at 24 hr (VASm24 ≥ 70). RESULTS We studied 195 women. Median [interquartile range] VASm24 was 53 [32-72] and 28% of patients experienced a VASm24 ≥ 70. The ability to predict a VASm24 ≥ 70 assessed by the area under the ROC curve was 0.64 using the 3-IQ and 0.67 using the 3-IQ combined with TS and PA. CONCLUSION The addition of PA and TS to the 3-IQ model resulted in a predictive model that performed similarly to the 3-IQ model alone. Further research is warranted in this area to better predict women at risk of severe pain post CD.
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Meloxicam administration in the management of postoperative pain and inflammation associated with caesarean section in beef heifers: Evaluation of reproductive parameters. Theriogenology 2021; 175:148-154. [PMID: 34547630 DOI: 10.1016/j.theriogenology.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 11/21/2022]
Abstract
Post-operative pain and inflammation are normal physiological reactions to caesarean section. Their management in cattle have rarely been investigated. This surgical procedure negatively affects reproductive function with, for example, a reduction in fertility resulting in an increase in calving interval. In this multicenter clinical trial, the objective was to evaluate the impact on reproductive performance of meloxicam injected before caesarean section to manage post-operative pain and inflammation. Meloxicam is a non-steroidal anti-inflammatory drug. One hundred and twenty-seven Charolais heifers (n = 127) were recruited from 47 farms in six French veterinary practices in the Burgundy region. The heifers underwent a non-elective standardized caesarean section operation. Heifers were randomly assigned to one of two groups: meloxicam (n = 66), intravenous meloxicam injection before surgery, or control (n = 61). Reproductive performance and health information were recorded from the time of the caesarean section to the next calving or to culling. In our study, meloxicam administration before caesarean section had no effect on the incidence of retained placenta (18.2% of treated vs 25.0% of control cows, p = 0.35). The pregnancy rate was higher in treated than in control cows (83.1% vs 67.8%, p = 0.04 after multivariate analysis) and a survival analysis showed that the median calving interval was 35 days shorter in the meloxicam (t50% = 417 days) compared to the control group (t50% = 452 days, p = 0.05). A trend was also observed for culling rate to be lower in treated (4.7%) compared to control cows (13.3%, p = 0.09). In conclusion, this study suggests that there is a beneficial effect of meloxicam administration before caesarean section on reproductive performance in Charolais heifers.
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Panjeton GD, Reynolds PS, Saleem D, Mehkri Y, Samra R, Wendling A. Neuraxial anesthesia and postoperative opioid administration for cesarean delivery in patients with placenta accreta spectrum disorder: a retrospective cohort study. Int J Obstet Anesth 2021; 49:103220. [PMID: 34598859 DOI: 10.1016/j.ijoa.2021.103220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/17/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is no consensus on optimal anesthetic and analgesic management of patients presenting for cesarean delivery with suspected placenta accreta spectrum disorder. Neuraxial anesthesia is preferred for uncomplicated procedures, but general anesthesia may be indicated for those at risk of hemorrhage and hysterectomy. We compared the effect of anesthesia techniques on postoperative maternal opioid administration and neonatal respiratory distress. METHODS A single-center retrospective study from 2016 to 2019 using electronic records to identify singleton pregnancies with a high index of suspicion of placenta accreta spectrum disorder. Patients were categorized by the anesthetic technique they received: general, neuraxial, or neuraxial with conversion to general anesthesia following delivery. Postoperative maternal opioid administration (oral morphine in mg equivalents) and risk of neonatal respiratory distress were compared using linear mixed models. RESULTS Thirty-nine records were analyzed. Mean-adjusted oral morphine mg equivalents were 192 for patients receiving general anesthesia vs. 90 for neuraxial anesthesia only (P=0.009) and 104 for neuraxial with conversion to general anesthesia (P=0.052). Neonates delivered under general anesthesia had a 3.5 times relative risk (95% CI 1.3 to 9.8, P=0.017) of respiratory distress compared with those exposed to neuraxial anesthesia alone. CONCLUSION Patients receiving general anesthesia alone were administered more opioids than those undergoing neuraxial anesthesia or neuraxial with conversion to general anesthesia. This finding was maintained when accounting for whether or not the patient underwent hysterectomy. Deciding on anesthetic management requires consideration of patient comorbidities, severity of placenta accreta spectrum pathology, and surgical requirements.
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Affiliation(s)
- G D Panjeton
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
| | - P S Reynolds
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA; Statistics in Anesthesiology Research (STAR) Core, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - D Saleem
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Y Mehkri
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - R Samra
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - A Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
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Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1. Obstet Gynecol 2021; 138:507-517. [PMID: 34412076 DOI: 10.1097/aog.0000000000004517] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.
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Meng X, Chen K, Yang C, Li H, Wang X. The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. Front Med (Lausanne) 2021; 8:694385. [PMID: 34409050 PMCID: PMC8365302 DOI: 10.3389/fmed.2021.694385] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS. Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software. Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD -7.47 h, 95% CI: -8.36 to -6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: -1.23, 95% CI: -1.32 to -1.15, p < 0.00001), opioid use (SMD: -0.46, 95% CI: -0.58 to -0.34, p < 0.00001), and hospital cost (SMD:-0.54, 95% CI: -0.63 to -0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62). Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.
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Affiliation(s)
| | | | | | | | - Xiaohong Wang
- Department of Obstetrics and Gynecology, Jinan City People's Hospital, Jinan People's Hospital Affiliated to Shandong First Medical University, Shandong, China
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Kahn KM, Demarco K, Pavsic J, Sangillo J. A Quality Improvement Project to Reduce Postcesarean Opioid Consumption. MCN Am J Matern Child Nurs 2021; 46:190-197. [PMID: 34016836 DOI: 10.1097/nmc.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The opioid epidemic is a public health emergency in the United States, stemming in part from widespread misuse and overprescribing of opioids following surgery. Approximately 1 in 300 women with no prior exposure to opioids develops an opioid use disorder following cesarean birth. Effective management of postcesarean pain requires individualized treatment and a balance of the woman's goals for optimal recovery and ability to safely care for her newborn. The American College of Obstetricians and Gynecologists recommends a multimodal approach to pain management after cesarean birth. METHODS In April 2019, a multidisciplinary team was formed at New York University Langone Health to study opioid use postcesarean. The team used the Plan, Do, Study, Act process model for continuous quality improvement to launch a postcesarean pathway called "Your Plan After Cesarean," a standardized visual tool with quantifiable milestones. It facilitates integration of women's preferences in their postcesarean care, and emphasizes providers' routine use of nonpharmacological interventions to manage pain. RESULTS During the pilot period of the project, postcesarean high consumption of 55 to 120 mg of opioids was reduced from 25% to 8%. By January 2020, 75% of women postoperative cesarean took little-to-no opioids during their hospital stay. By February 2021, the total number of opioids consumed by women after cesarean birth in-hospital was reduced by 79%. Satisfaction among women with pain management after cesarean continued to be high. CLINICAL IMPLICATIONS Reduction in postcesarean opioid administration and the number of opioids prescribed at hospital discharge can be accomplished without having a negative effect on women's perceptions of post-op pain relief. These changes can potentially be a factor in helping to avoid an opioid-naive woman who has a cesarean birth from developing an opioid use disorder.
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Wang J, Zhao G, Song G, Liu J. The Efficacy and Safety of Local Anesthetic Techniques for Postoperative Analgesia After Cesarean Section: A Bayesian Network Meta-Analysis of Randomized Controlled Trials. J Pain Res 2021; 14:1559-1572. [PMID: 34103981 PMCID: PMC8180269 DOI: 10.2147/jpr.s313972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022] Open
Abstract
Objective Cesarean section (CS) is one of the most frequently performed major surgical interventions. Local anesthetic techniques, a universal component of perioperative multimodal analgesia, are reportedly effective in reducing pain scores and opioid requirements. However, the optimal local anesthetic technique for postoperative CS pain remains unclear. Methods Six databases were searched, and a Bayesian network meta-analysis was performed. The outcomes included cumulative morphine consumption and pain scores at four time points, time to first analgesic request, postoperative nausea and vomiting, pruritus, and sedation. Results Sixty-eight studies with 5039 pregnant women were included. Six local anesthetic techniques were involved, including transversus abdominis plane block (TAPB), ilioinguinal and iliohypogastric nerve block, quadratus lumborum blocks, transversalis fascia plane block, erector spinae block, and wound infiltration. Compared to inactive controls, TAPB reduced cumulative morphine consumption at 6, 12, 24, and 48 h, pain scores at 6, 12, and 24 h (with the exception of 24 h at rest), the risk of postoperative nausea and vomiting, and sedation. Compared with inactive controls, ilioinguinal and iliohypogastric nerve block reduced cumulative morphine consumption at 6 and 24 h and pain scores at 6, 12, and 24 h during movement. Compared with inactive controls, quadratus lumborum blocks reduced cumulative morphine consumption at 24 and 48 h and pain scores at 6 and 12 h and lengthened the time to first analgesic request. Compared with inactive controls, wound infiltration reduced cumulative morphine consumption at 12 and 24 h, pain scores at 12 and 24 h during movement, and risk of sedation. Compared with inactive controls, erector spinae block reduced pain scores at 6 and 12 h. Transversalis fascia plane block was found to have similar outcomes to inactive controls. Conclusion TAPB is the most comprehensive local anesthetic technique for postoperative CS analgesia in the absence of intrathecal morphine.
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Affiliation(s)
- Jian Wang
- Department of Anesthesiology, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Ge Zhao
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Jing Liu
- Department of Obstetrics, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
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Analgesia After Cesarean Delivery in the United States 2008-2018: A Retrospective Cohort Study. Anesth Analg 2021; 133:1550-1558. [PMID: 34014182 DOI: 10.1213/ane.0000000000005587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Optimizing analgesia after cesarean delivery is a priority and requires balancing adequate pain relief with the risk of analgesics-associated adverse effects. Current recommendations are for use of a multimodal, opioid-sparing analgesic regimen that includes neuraxial morphine combined with scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) and scheduled acetaminophen. Furthermore, recent studies recommend scheduled acetaminophen with as-needed opioids in lieu of acetaminophen-opioid combination drugs to reduce opioid consumption and optimize analgesia. However, the extent of utilization of this recommended regimen in the United States is unclear. We therefore performed this retrospective study to evaluate postoperative analgesic regimens utilized after cesarean delivery under neuraxial anesthesia, examine variability across institutions, evaluate changes over time in postoperative analgesic practice, and examine factors associated with the use of neuraxial morphine and of multimodal analgesia. METHODS This retrospective cohort study was approved by the Duke University Institutional Review Board. Parturients who underwent cesarean delivery under neuraxial anesthesia from 2008 to 2018 were included. Data were extracted from a nationwide inpatient administrative-financial database (Premier Inc, Charlotte, NC) and included parturient characteristics, comorbidities, hospital characteristics, and charges for administered medications. The primary outcome was the postoperative analgesic regimen utilized during hospitalization, including utilization of neuraxial morphine and of multimodal analgesia for postoperative pain control. We also examined the factors associated with the use of neuraxial morphine and of the multimodal regimen incorporating neuraxial morphine, NSAIDs, and acetaminophen. RESULTS Data from 804,752 parturients were analyzed. Of this cohort, 75.8% received neuraxial morphine, 93.2% received NSAIDs, 28.4% received acetaminophen, and 81.3% received acetaminophen-opioid combination drugs. Only 6.1% received the currently recommended regimen of neuraxial morphine with NSAIDs and acetaminophen, with this percentage increasing from 1.3% in 2008 to 15.0% in 2018. On the other hand, 58.9% received neuraxial morphine, NSAIDs, and an acetaminophen-opioid combination drug, with this regimen being utilized in 57.0% of cases in 2008 and 58.1% in 2018. The hospital in which the patient was treated accounted for 54.7% of the variation in receipt of neuraxial morphine and 41.2% in the variation in receipt of multimodal analgesia with neuraxial morphine, NSAIDs, and acetaminophen, with this variability in receipt of neuraxial morphine and of multimodal analgesia being largely independent of patient characteristics. CONCLUSIONS Relatively few parturients received the currently recommended multimodal analgesic regimen of neuraxial morphine with NSAIDs and acetaminophen after cesarean delivery. Additionally, the majority received acetaminophen-opioid combination drugs rather than plain acetaminophen. Further studies should investigate the implications for patient outcomes.
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Bollag L, Lim G, Sultan P, Habib AS, Landau R, Zakowski M, Tiouririne M, Bhambhani S, Carvalho B. Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean. Anesth Analg 2021; 132:1362-1377. [PMID: 33177330 DOI: 10.1213/ane.0000000000005257] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.
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Affiliation(s)
- Laurent Bollag
- From the Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania
| | - Pervez Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Ruth Landau
- Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York
| | - Mark Zakowski
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - Sumita Bhambhani
- Department of Anesthesiology, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
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Zanfini BA, Biancone M, Famele M, Catarci S, Lavalle R, Frassanito L, Piersanti A, Olivieri C, Lanzone A, Draisci R, Draisci G. Comparison of ropivacaine plasma concentration after posterior Quadratus Lumborum Block in Cesarean Section with ropivacaine with epinephrine vs plane. Minerva Anestesiol 2021; 87:979-986. [PMID: 33938678 DOI: 10.23736/s0375-9393.21.15354-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The posterior Quadratus Lumborum Block (pQLB) has been used in postoperative pain management after Cesarean Section (CS). However, clinicians have no data about pQLB safety in pregnants, at increased risk of local anesthetic systemic toxicity (LAST). The purpose of the present study was to explore the efficacy and the safety of adding epinephrine to ropivacaine for bilateral pQLB vs. bilateral pQLB performed with ropivacaine alone in CS. METHODS in this prospective trial 52 pregnants, ASA 2 physiological status, were consecutively allocated to one of 2 groups, e-pQLB and pQLB; e-pQLB group received 0.375% ropivacaine+100 mcg epinephrine, 20 ml each side; pQLB received 0.375% ropivacaine alone, 20 ml each side. The primary and secondary outcomes were to evaluate if the adjunct of epinephrine to ropivacaine increases efficacy and safety of pQLB, respectively. RESULTS Authors found in e-pQLB group vs. p-QLB group: a total mean morphine consumption statistically lower during the first 24 postoperative hours (5.08±3.12, vs 9.11±4.67 SD mg, p=0.0002); NRS values statistically lower at 6 hours from block, both at rest (1,73±1,88 SD vs. 2,88±2,53, p=0.03) and with movement (3,03±1,98 SD vs. 4,23±2,87, p=0.04); a longer time between block and the first opioid request (5.92±2.48 vs 3.78±2.68 SD hrs, p< 0.003); venous ropivacaine concentrations significantly lower at any time of samples but at 120 minutes. CONCLUSIONS Adding epinephrine to ropivacaine increases efficacy and duration of pQLB. Moreover it increases block safety, reducing peak and mean venous ropivacaine concentration.
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Affiliation(s)
- Bruno A Zanfini
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
| | - Matteo Biancone
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Famele
- National Institute of Health, National Center for Chemicals, Cosmetic Products and Consumer Health Protection, Rome, Italy
| | - Stefano Catarci
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberta Lavalle
- National Institute of Health, National Center for Chemicals, Cosmetic Products and Consumer Health Protection, Rome, Italy
| | - Luciano Frassanito
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandra Piersanti
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cristina Olivieri
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Lanzone
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Catholic University of Sacred Heart, Rome, Italy
| | - Rosa Draisci
- National Institute of Health, National Center for Chemicals, Cosmetic Products and Consumer Health Protection, Rome, Italy
| | - Gaetano Draisci
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Catholic University of Sacred Heart, Rome, Italy
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Sultan P, Carvalho B. Pain after vaginal delivery and during breastfeeding: underexplored and underappreciated. Int J Obstet Anesth 2021; 46:102969. [PMID: 33794439 DOI: 10.1016/j.ijoa.2021.102969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/09/2021] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- P Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine. Stanford University School of Medicine, Stanford, CA, USA.
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Aaronson J, White R. The Role of Truncal Blocks in Obstetric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00436-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Miao F, Feng K, Feng X, Fan L, Lang Y, Duan Q, Hou R, Jin D, Wang T. The Analgesic Effect of Different Concentrations of Epidural Ropivacaine Alone or Combined With Sufentanil in Patients After Cesarean Section. Front Pharmacol 2021; 12:631897. [PMID: 33692693 PMCID: PMC7937801 DOI: 10.3389/fphar.2021.631897] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 01/14/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Patients experience moderate-high intensity postoperative pain after cesarean section (CS). The aim of this study was to investigate the optimal concentrations of ropivacaine and sufentanil for use in controlling pain after CS. Methods: One hundred and seventy-four women undergoing elective CS were randomly allocated to four groups. Epidural analgesia was administered with 0.1% ropivacaine in the R1 group, 0.15% ropivacaine in the R2 group, a combination of 0.1% ropivacaine and 0.5 μg/ml of sufentanil in the R1S group, and a combination of 0.15% ropivacaine and 0.5 μg/ml of sufentanil in the R2S group (at a basal rate of 4 ml/h, bolus dose of 4 ml/20 min as needed). Pain scores (numerical rating scale [NRS]: 0-10 cm) at rest (NRS-R), during movement (NRS-M), and when massaging the uterus (NRS-U) were documented at 6 and 24 h. We also recorded patient satisfaction scores, time to first flatus, motor deficits, and adverse drug reactions. Results: NRS (NRS-R, NRS-M, NRS-U) scores in the R2S group (2 [1-3], 4 [3-5], 6 [5-6], respectively) were lower than in the R1 group (3 [3-4], 5 [4-6], 7 [6-8], respectively) (p < 0.001, p < 0.05, p < 0.01, respectively) at 6 h; and patient satisfaction (9 [8-10]) was improved compared to the R1 group (8 [6-8]) (p < 0.01). The time to first flatus (18.7 ± 11.8 h) was reduced relative to the R1 group (25.9 ± 12.0 h) (p < 0.05). The time to first ambulation was not delayed (p > 0.05). However, the incidence of pruritus (4 [9.3%]) was increased compared to the R2 group (0 [0]) (p < 0.05) at 6 h, and the incidence of numbness (23 [53.5%], 23 [53.5%]) was increased compared to the R1 group (10 [23.3%], 10 [23.3%]) (all p < 0.01) at both 6 and 24 h. Conclusions: Although we observed a higher incidence of pruritus and numbness, co-administration of 0.15% ropivacaine and 0.5 μg/ml of sufentanil administered epidurally optimized pain relief after CS, with treated subjects exhibiting lower NRS scores, shorter time to first flatus, and higher patient-satisfaction scores.
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Affiliation(s)
- Fangfang Miao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kunpeng Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuexin Feng
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Long Fan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu Lang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingfang Duan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ruixue Hou
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Jin
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Al-Husban N, Elmuhtaseb MS, Al-Husban H, Nabhan M, Abuhalaweh H, Alkhatib YM, Yousef M, Aloran B, Elyyan Y, Alghazo A. Anesthesia for Cesarean Section: Retrospective Comparative Study. Int J Womens Health 2021; 13:141-152. [PMID: 33564269 PMCID: PMC7866905 DOI: 10.2147/ijwh.s292434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/29/2020] [Indexed: 01/01/2023] Open
Abstract
Background Cesarean section is a widely performed surgery. Objective To compare anesthetic types regarding feto-maternal outcomes. Materials and Methods Retrospective comparative study of 3599 cesarean sections (emergency and elective categories). Results Mean APGAR score was statistically higher in the spinal than general anesthesia among the emergency category, P = 0.000 and 0.026, respectively, with no significant difference in the elective category. Estimated blood loss among the elective category was statistically significantly higher in the spinal than general anesthesia, P = 0.001. However, among the emergency category, it was significantly higher in the general than in spinal or epidural anesthesia, P = 0.000. Diclofenac sodium was used more after spinal than general anesthesia (P = 0.000), with no significant difference between epidural and general or between epidural and spinal anesthesia. Pethidine hydrochloride (HCL) was used more after general than after spinal anesthesia (P = 0.000). However, pethidine HCL use was not statistically significantly different between spinal and epidural anesthesia. In the elective category, paracetamol was requested more after spinal than epidural or general anesthesia, P = 0.000. No significant difference was seen between epidural and general anesthesia, P = 1.000. No statistically significant difference was found among the anesthetic types in both categories regarding tramadol HCL. Length of hospital stay, operative time and neonatal intensive care unit admission were not statistically different between anesthetic modes. In the emergency category, significantly higher percentage of patients were satisfied with and would recommend epidural anesthesia. Conclusion There was no statistically significant difference among the three types of anesthesia regarding neonatal intensive care admission and length of hospital stay for emergency and elective categories. APGAR score was higher with spinal than with general anesthesia in the emergency category with no significant difference in the elective category. More diclofenac sodium and paracetamol and less opioids were used after regional than after general anesthesia. Satisfaction was higher with epidural anesthesia. Limitations Retrospective and single centered.
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Affiliation(s)
- Naser Al-Husban
- Faculty of Medicine, The University of Jordan, Amman, Jordan
| | | | | | - Mohammed Nabhan
- Obstetrics and Gynecology Department, Jordan University Hospital, Amman, Jordan
| | - Hamza Abuhalaweh
- Obstetrics and Gynecology Department, Jordan University Hospital, Amman, Jordan
| | | | - Maysa Yousef
- Obstetrics and Gynecology Department, Jordan University Hospital, Amman, Jordan
| | - Bayan Aloran
- Obstetrics and Gynecology Department, Jordan University Hospital, Amman, Jordan
| | - Yousef Elyyan
- Obstetrics and Gynecology Department, Jordan University Hospital, Amman, Jordan
| | - Asma Alghazo
- Obstetrics and Gynecology Department, Jordan University Hospital, Amman, Jordan
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An optimal epidural catheter placement site for post-cesarean section analgesia with double-space technique combined spinal-epidural anesthesia: a retrospective study. JA Clin Rep 2021; 7:3. [PMID: 33398592 PMCID: PMC7782655 DOI: 10.1186/s40981-020-00405-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/11/2022] Open
Abstract
Background Epidural anesthesia affects lower extremities, which often prevents early mobilization postoperatively. The incidence of numbness and motor weakness in the lower extremities with respect to epidural catheter placement site in cesarean section (CS) is uncertain. We aimed to investigate the effect of catheter placement site on postoperative lower extremities numbness and motor weakness in patients who received combined spinal–epidural anesthesia (CSEA) for CS including analgesic effects and optimal epidural placement site in CS. Methods We retrospectively included 205 patients who underwent CS with CSEA at the University of Tsukuba Hospital between April 2018 and March 2020, and assessed numbness and motor weakness in the lower extremities. We also examined whether differences in the intervertebral space of epidural catheter placement and epidural effect on the lower extremities are related to analgesic effects. ANOVA and Mann–Whitney U test were used for statistical analysis. Results The incidence of numbness and motor weakness were 67 (33%) and 28 (14%), respectively. All patients with motor weakness had numbness. A more caudal placement was associated with increased incidence of affected lower extremities. There was no significant difference in the analgesic effect depending on the catheter placement site. When the lower extremities were affected, the number of additional analgesics increased (p < 0.001). Patient-controlled epidural analgesia was used for fewer days in patients with motor weakness (p = 0.046). Conclusion In CS, epidural catheter placement at T10–11 or T11–12 interspace is expected to reduce effect on the lower extremities and improve quality of postoperative analgesia.
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Roofthooft E, Joshi GP, Rawal N, Van de Velde M. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 76:665-680. [PMID: 33370462 PMCID: PMC8048441 DOI: 10.1111/anae.15339] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/15/2022]
Abstract
Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.
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Affiliation(s)
- E Roofthooft
- Department of Anesthesiology, GZA Sint-Augustinus Hospital, Antwerp, Belgium.,Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven, Belgium
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - N Rawal
- Department of Anesthesiology, Orebro University, Orebro, Sweden
| | - M Van de Velde
- Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven, Belgium
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Mehraban SS, Suddle R, Mehraban S, Petrucci S, Moretti M, Cabbad M, Lakhi N. Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery. J Obstet Gynaecol Res 2020; 47:873-881. [PMID: 33354810 DOI: 10.1111/jog.14582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/19/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022]
Abstract
AIM To evaluate an opioid-free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre-MAP). METHODS The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5-6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3. RESULTS Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P-value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD. CONCLUSION MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre-MAP results while maintaining high patients' satisfaction with pain control.
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Affiliation(s)
- Shadan S Mehraban
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, New York, USA
| | - Rahat Suddle
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, New York, USA
| | - Shadi Mehraban
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, New York, USA
| | - Samantha Petrucci
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, New York, USA
| | - Michael Moretti
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, New York, USA
| | - Michael Cabbad
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, New York, USA
| | - Nisha Lakhi
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, New York, USA.,Department of Obstetrics and Gynecology, New York Medical College, Valhalla, New York, USA
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Tan HS, Taylor C, Weikel D, Barton K, Habib AS. Quadratus lumborum block for postoperative analgesia after cesarean delivery: A systematic review with meta-analysis and trial-sequential analysis. J Clin Anesth 2020; 67:110003. [DOI: 10.1016/j.jclinane.2020.110003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/01/2020] [Accepted: 07/17/2020] [Indexed: 02/06/2023]
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Abstract
The rate of pregnant women with an opioid use disorder has risen drastically in the past 20 years, paralleling that in the general population. Pregnancies associated with opioid use, abuse, or dependence have significantly higher rates of complications, such as neonatal opioid withdrawal syndrome, intrauterine growth restriction, neural tube defects, stillbirth, increased maternal mortality, greater postpartum pain, and longer inpatient stays. Patient education about the risks and benefits of multimodal analgesia and empowering shared decision making may help curb the opioid epidemic. Tailoring pain management to individual needs might be the solution to the problem.
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Affiliation(s)
- Ben Shatil
- Department of Anesthesiology, Emory University Hospital Midtown, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Irving Medical Center, CHONY North CHN-1123, 3959 Broadway, New York, NY 10032, USA.
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Management of pain after Cesarean delivery without intrathecal morphine: networking for the best answer. Can J Anaesth 2020; 67:1704-1709. [PMID: 33021726 DOI: 10.1007/s12630-020-01819-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 08/21/2020] [Indexed: 10/23/2022] Open
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