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Qin PP, Zou BY, Liu D, Li MX, Liu XN, Wei K. Lateral quadratus lumborum block vs acupuncture for postcesarean analgesia: a randomized clinical trial. Am J Obstet Gynecol MFM 2024; 6:101433. [PMID: 39019211 DOI: 10.1016/j.ajogmf.2024.101433] [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: 03/15/2024] [Revised: 06/27/2024] [Accepted: 07/04/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Improved pain control after cesarean section remains a challenging objective. Although both the lateral quadratus lumborum block (L-QLB) and acupuncture have been reported to provide superior postoperative analgesia after cesarean section when compared to placebo, the efficacy of these techniques has never been compared head-to-head. OBJECTIVE This study was conducted to investigate the comparative analgesic efficacy of L-QLB and acupuncture following elective cesarean section. STUDY DESIGN In this prospective, randomized, controlled clinical trial, a total of 190 patients with singleton-term pregnancies scheduled for cesarean section under spinal-epidural anesthesia were enrolled. Patients were randomized 1:1 to acupuncture group or L-QLB group. L-QLB group received bilateral L-QLB with 0.33% ropivacaine and sham acupuncture, acupuncture group received transcutaneous electrical acupoint stimulation and press needle therapy, and sham L-QLB. All patients received the standard postoperative pain treatment. The primary outcome was pain scores on movement at 24 hours. Secondary endpoints included pain scores in the first 48 hours postoperatively, patient-controlled intravenous analgesia (PCIA) demands, analgesia-related adverse effects, postoperative complications, QoR-15, the time to mobilization, and gastrointestinal function. RESULTS Median (interquartile range [range]) pain scores at 24 hours on movement were similar in patients receiving acupuncture or L-QLB (3 [2-4] vs 3 [2-4], respectively; P=.40). PCIA consumption and pain scores within 48 hours postoperatively also showed no difference between the two groups. The acupuncture improved QoR-15 scores at 24 and 48 hours postoperatively (P<.001), as well as shortened the time to first flatus (P=.03) and first drinking (P<.001) compared to L-QLB. In addition, the median time to mobilization in the L-QLB group was markedly prolonged compare with acupuncture group (17.0 [15.0-19.0] hours vs 15.3 [13.3-17.0] hours, estimated median difference, 1.5; 95% CI, 1-2; P<.001). CONCLUSION As a component of multimodal analgesia regimen after cesarean section, acupuncture did not lower postoperative pain scores or reduce analgesic medication consumption compared to L-QLB.
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Affiliation(s)
- Pei-Pei Qin
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bing-Yu Zou
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Liu
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ming-Xi Li
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Nan Liu
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ke Wei
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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White TD, Matthew SK, Tubog TD. Postoperative Cesarean Section Pain Management Using Transversus Abdominis Plane Block Versus Intrathecal Morphine: A Systematic Review and Meta-analysis. J Perianesth Nurs 2024:S1089-9472(24)00123-0. [PMID: 39001740 DOI: 10.1016/j.jopan.2024.03.027] [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: 12/20/2023] [Revised: 03/22/2024] [Accepted: 03/29/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE Compare and evaluate the effectiveness of transversus abdominis plane (TAP) block versus intrathecal morphine (ITM) on elective postcesarean section pain, opioid consumption, and related side effects. DESIGN Systematic review and meta-analysis. METHODS A search for evidence was conducted in PubMed, Google Scholar, CINAHL, Cochrane Collaboration Database, UpToDate, Health Source, and gray literature. Only randomized controlled trials (RCTs) were included in the study. The methodological quality of evidence assessment was conducted using the Risk of Bias and Grades of Recommendation, Assessment, Development, and Evaluation system. The meta-analysis used Review Manager (RevMan 5.4, The Cochrane Collaboration). FINDINGS A total of 11 RCTs involving 1,129 patients were analyzed. Compared to ITM, TAP has a similar effect on static (mean difference [MD]; 0.37; 95% confidence interval [CI], -0.04 to 0.79; P = .08) and dynamic pain scores (MD, 0.43; 95% CI, -0.06 to 0.92; P = .09) within the first 48 hours after surgery. Additionally, the TAP block had a lower incidence of postoperative nausea and vomiting (risk ratio, 0.45; 95% CI, 0.31 to 0.66; P < .0001) and increased opioid consumption (MD, 6.78; 95% CI, 3.79 to 9.77; P < .00001). Overall, TAP block and ITM did not differ in the time to first to rescue analgesia, incidence of sedation, and pruritus. CONCLUSIONS Evidence suggests that TAP blocks are equivalent to ITM in pain scores and more effective at lowering the incidence of postoperative nausea and vomiting, yet ITM has been shown to be more effective in reducing postoperative opioid consumption.
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Affiliation(s)
- Tyler D White
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Shilpa K Matthew
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Tito D Tubog
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX.
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Ferguson JE, Tubog TD, Johnson W, Evans H, Furstein J. Quadratus Lumborum Block and Transversus Abdominis Plane Block in Non-emergency Cesarean Delivery: A Systematic Review and Meta-analysis. J Perianesth Nurs 2024; 39:226-234. [PMID: 37865903 DOI: 10.1016/j.jopan.2023.07.017] [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: 12/07/2022] [Revised: 07/22/2023] [Accepted: 07/23/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE Investigate the analgesic efficacy of quadratus lumborum (QL) block versus transversus abdominis plane (TAP) block in postoperative pain management in nonemergent cesarean section. DESIGN Systematic review with meta-analysis. METHODS PubMed, Cochrane, CINAHL, Google Scholar, and gray literature were searched for evidence. Only randomized controlled trials examining the effects of QL and TAP block for nonemergent cesarean delivery were included. Mean difference (MD) was used to estimate continuous outcomes with appropriate effect models. The quality of evidence was rated using the Risk of Bias and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. FINDINGS Six studies involving 543 parturients were included. Compared to the TAP block, the cumulative 24-hour pain score at rest (MD, -0.60; 95% CI, -1.03 to -0.17; P = .007) and during activity (MD, -1.05; 95% CI, -1.54 to -0.56; P < .0001) were significantly lower in QL block. Time to the first analgesic rescue (MD, 21.67; 95% CI, -18.58 to 61.91; P = .29) and opioid consumption (MD, -1.96; 95% CI, -4.59 to 0.66; P = .14) were similar in both groups. No difference was found in the incidence of postoperative nausea and vomiting and sedation. However, patients treated with QL block reported higher patient satisfaction scores. CONCLUSIONS There is limited evidence to suggest that QL block is superior to TAP block for postoperative pain management in nonemergent cesarean delivery. The study limitations must be considered when extrapolating the review's findings to clinical practice.
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Affiliation(s)
- Jeffery E Ferguson
- Graduate Programs of Nurse Anesthesia, Middle Tennessee School of Anesthesia, Madison, TN.
| | - Tito D Tubog
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - William Johnson
- Graduate Programs of Nurse Anesthesia, Middle Tennessee School of Anesthesia, Madison, TN
| | - Hallie Evans
- Graduate Programs of Nurse Anesthesia, Middle Tennessee School of Anesthesia, Madison, TN
| | - James Furstein
- Graduate Programs of Nurse Anesthesia, Middle Tennessee School of Anesthesia, Madison, TN
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Jun MR, Lee MO, Shim HS, Park JW, Kim JY, Shim S, Lee J. Intravenous patient-controlled analgesia regimen in postoperative pain management following elective cesarean section: A single-center retrospective evaluation. Medicine (Baltimore) 2023; 102:e33474. [PMID: 37058066 PMCID: PMC10101246 DOI: 10.1097/md.0000000000033474] [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] [Indexed: 04/15/2023] Open
Abstract
Intravenous patient-controlled analgesia (IV PCA; IVA) is the most widely used method for postoperative pain management. An appropriate IVA regimen is required, depending on the expected intensity of pain after surgery. This study expected that a decrease in the second prescription rate of IVA after elective cesarean section (CS) would help establish an appropriate regimen for the initial IVA. We retrospectively reviewed the records of 632 patients who were prescribed IVA after CS. We classified patients into phase 1 (basal rate 15.00 mcg/hours, bolus dose 15.00 mcg, total volume 100 mL) and phase 2 (basal rate 31.25 mcg/hours, bolus dose 31.25 mcg, nefopam 60 mg, paracetamol 3 g, total volume 160 mL) according to the IVA regimen, and patients in phase 2 were classified into the basal 15 group and basal 30 group according to the basal rate of IVA. We compared the rates of second prescription, drug removal, and side effects of IVA between the 2 phases and the 1 group. We analyzed the data of 631 eligible patients. The second prescription rate of IVA in phase 2 was 3.77%, a significant decrease compared to that in phase 1 (27.48%); however, the incidence of complications in phase 2 was 6.92%, a significant increase compared to that in phase 1 (0.96%). Within phase 2, in the basal 30 group, the basal rate was almost double that in the basal 15 group. However, there were no significant differences in the rate of second prescription, removed drug IVA, or adverse events between the basal 15, and 30 groups. In the case of CS, which has a high degree of postoperative pain, it is beneficial to control acute pain by properly setting the regimen of the initial IVA with a basal rate infusion to nullify a second prescription.
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Affiliation(s)
- Mi Roung Jun
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Moon Ok Lee
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Haeng Seon Shim
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jeong Won Park
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jeong Yeon Kim
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Sungbo Shim
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jihoon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Mackeen AD, Vigh RS, Davis LB, Satti M, Cumbo N, Pauley AM, Leonard KS, Stephens M, Corr TE, Roeser RW, Deimling T, Legro RS, Pauli JM, Downs DS. Obstetricians' prescribing practices for pain management after delivery. Pain Manag 2022; 12:645-652. [PMID: 35289656 PMCID: PMC10015511 DOI: 10.2217/pmt-2021-0101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To examine postpartum opioid prescribing practices. Materials & methods: Obstetricians were interviewed about opioids: choice of opioid, clinical factors considered when prescribing, thoughts/beliefs about prescribing, and typical counseling provided. Inductive thematic analyses were used to identify themes. Results: A total of 38 interviews were analyzed. Several key points emerged. The choice of opioid, dosing and number of pills prescribed varied widely. The mode of delivery is the primary consideration for prescribing opioids. All providers would prescribe opioids to breastfeeding women. Some providers offered counseling on nonopioid treatment of pain. Discussion: At two large tertiary centers in Pennsylvania, the 38 physicians interviewed wrote 38 unique opioid prescriptions. Patient counseling addressed short-term pain management, but not the chronic overuse of opioids.
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Affiliation(s)
- A Dhanya Mackeen
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Geisinger, Danville, PA 17822, USA
| | - Richard S Vigh
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Geisinger, Danville, PA 17822, USA
| | - Lisa Bailey Davis
- Department of Population Health Sciences, Geisinger, Danville, PA 17822, USA
| | - Mohamed Satti
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Geisinger, Danville, PA 17822, USA
| | - Nicole Cumbo
- Department of Obstetrics & Gynecology, Penn State Health, Milton S Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Abigail M Pauley
- Exercise Psychology Laboratory, Department of Kinesiology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Krista S Leonard
- Exercise Psychology Laboratory, Department of Kinesiology, The Pennsylvania State University, University Park, PA 16802, USA
| | - Mark Stephens
- Department of Family & Community Medicine, Penn State College of Medicine, University Park, PA 16802, USA
| | - Tammy E Corr
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA
| | - R W Roeser
- Department of Human Development and Family Studies, College of Health and Human Development, Pennsylvania State University, University Park, PA 16802, USA
| | - Timothy Deimling
- Department of Obstetrics & Gynecology, Penn State Health, Milton S Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Richard S Legro
- Department of Obstetrics & Gynecology, Penn State Health, Milton S Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Jaimey M Pauli
- Department of Obstetrics & Gynecology, Penn State Health, Milton S Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Danielle Symons Downs
- Departments of Kinesiology, College of Health & Human Development, & Obstetrics & Gynecology, Penn State College of Medicine, The Pennsylvania State University, University Park, PA 16802, USA
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Usichenko TI, Henkel BJ, Klausenitz C, Hesse T, Pierdant G, Cummings M, Hahnenkamp K. Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e220517. [PMID: 35226080 PMCID: PMC8886541 DOI: 10.1001/jamanetworkopen.2022.0517] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements. OBJECTIVE To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone. DESIGN, SETTING, AND PARTICIPANTS This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019. INTERVENTIONS In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles. MAIN OUTCOMES AND MEASURES The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain. RESULTS A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups. CONCLUSIONS AND RELEVANCE Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02364167.
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Affiliation(s)
- Taras I. Usichenko
- Department of Anesthesiology, University Medicine of Greifswald, Greifswald, Germany
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Thomas Hesse
- Department of Anesthesiology, University Medicine of Greifswald, Greifswald, Germany
| | - Guillermo Pierdant
- Department of Gynecology and Obstetrics, University Medicine of Greifswald, Greifswald, Germany
| | - Mike Cummings
- British Medical Acupuncture Society, London, United Kingdom
| | - Klaus Hahnenkamp
- Department of Anesthesiology, University Medicine of Greifswald, Greifswald, Germany
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Affiliation(s)
- Elizabeth M S Lange
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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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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Downs DS, Pauley AM, Leonard KS, Satti M, Cumbo N, Teti I, Stephens M, Corr T, Roeser R, Deimling T, Legro RS, Pauli JM, Mackeen AD, Bailey-Davis L. Obstetric Physicians' Beliefs and Knowledge on Guidelines and Screening Tools to Reduce Opioid Use After Childbirth. Obstet Gynecol 2021; 137:325-333. [PMID: 33416288 PMCID: PMC10846479 DOI: 10.1097/aog.0000000000004232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/05/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine obstetric physicians' beliefs about using professional or regulatory guidelines, opioid risk-screening tools, and preferences for recommending nonanalgesic therapies for postpartum pain management. METHODS A qualitative study design was used to conduct semi-structured interviews with obstetric and maternal-fetal medicine physicians (N=38) from two large academic health care institutions in central Pennsylvania. An interview guide was used to direct the discussion about each physicians' beliefs in response to questions about pain management after childbirth. RESULTS Three trends in the data emerged from physicians' responses: 1) 71% of physicians relied on their clinical insight rather than professional or regulatory guidelines to inform decisions about pain management after childbirth; 2) although many reported that a standard opioid patient screening tool would be useful to inform clinical decisions about pain management, nearly all (92%) physician respondents reported not currently using one; and 3) 63% thought that nonpharmacologic pain management therapies should be used whenever possible to manage pain after childbirth. Key physician barriers (eg, lack time and evidence, being unaware of how to implement) and patient barriers (eg, take away from other responsibilities, no time or patience) to implementation were also identified. CONCLUSION These findings suggest that obstetric physicians' individual beliefs and clinical insight play a key role in pain management decisions for women after childbirth. Practical and scalable strategies are needed to: 1) encourage obstetric physicians to use professional or regulatory guidelines and standard opioid risk-screening tools to inform clinical decisions about pain management after childbirth, and 2) educate physicians and patients about nonopioid and nonpharmacologic pain management options to reduce exposure to prescription opioids after childbirth.
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Affiliation(s)
- Danielle Symons Downs
- Department of Kinesiology, College of Health and Human Development, and the Department of Obstetrics and Gynecology, Penn State College of Medicine, the Exercise Psychology Laboratory, Department of Kinesiology, the Pennsylvania State University, University Park, the Division of Maternal-Fetal Medicine, Women's Health Service Line, Geisinger, Danville, the Department of Obstetrics and Gynecology, Penn State Health, Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, the Department of Family and Community Medicine, Penn State College of Medicine, University Park, the Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, the Department of Health and Human Development, Pennsylvania State University, University Park, and the Department of Epidemiology and Health Services Research, Geisinger, Danville, Pennsylvania
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Toledo P, Banayan JM. Conflict Is in the Eye of the Beholder. Anesth Analg 2020; 131:1827-1829. [PMID: 33186168 DOI: 10.1213/ane.0000000000005222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Paloma Toledo
- From the Department of Anesthesiology
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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12
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Hawkins NN, Lamon AM, Li YJ, Grotegut C, Habib AS. Analgesic use after vaginal delivery in women with perineal lacerations: a retrospective cohort study. Curr Med Res Opin 2020; 36:1009-1013. [PMID: 32268793 DOI: 10.1080/03007995.2020.1754185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: To evaluate opioid consumption among parturients with varying degrees of perineal lacerations.Methods: This was a retrospective analysis of women who delivered vaginally at our institution from 1 January 2014 to 12 April 2015. We collected information regarding the degree of perineal lacerations (no lacerations, first-/second-degree, third-/fourth-degree), analgesic consumption, and postpartum pain scores. The primary outcome was opioid use from 0-48 h postpartum. Univariate and multivariable regression analyses were performed to test for the association of laceration severity with opioid use.Results: We included 5598 women in the analysis; 1948 had no lacerations, 3434 had first-/second-degree lacerations, and 216 had third-/fourth-degree lacerations. In univariate analysis, parturients with third-/fourth-degree lacerations had significantly higher use of opioids within 48 h postpartum (53.2%) compared to women with no lacerations (30.03%) or first-/second-degree lacerations (28.6%) (p < .001). In the multivariable analysis, women with third-/fourth-degree lacerations had higher odds of opioid use than those without laceration [OR (95% CI) = 2.61 (1.75-3.85), p < .001]. In pairwise comparisons, those with third-/fourth-degree lacerations had higher odds of opioid use than those without lacerations [OR (95% CI) = 3.55 (2.20-5.74)], and those with first-/second-degree lacerations [OR (95% CI) = 2.15 (1.49-3.10)] (p < .001). Oxycodone equivalent consumption was significantly different among groups with a median (IQR) of 5.00 mg (0.00-27.50), 0.00 mg (0.00-5.00) and 0.00 mg (0.00-5.00) in women with third-/fourth-degree, first-/second-degree, and no lacerations, respectively, during the 0-48 h postpartum (p < .001).Conclusion: The use of opioids and opioid doses are higher in women with third-/fourth-degree perineal lacerations compared to those with first-/second-degree or no lacerations.
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Affiliation(s)
| | - Agnes M Lamon
- Department of Anesthesiology, Penn Medicine Princeton Health, Plainsboro, NJ, USA
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Chad Grotegut
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Aditianingsih D, Pryambodho, Anasy N, Tantri AR, Mochtar CA. A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy. BMC Anesthesiol 2019; 19:221. [PMID: 31805855 PMCID: PMC6894195 DOI: 10.1186/s12871-019-0891-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 11/25/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy. METHODS Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB (n = 31) or continuous epidural (n = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed. RESULT The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group (p = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter (p < 0.001) in the QLB group. CONCLUSION The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia, and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy. TRIAL REGISTRATION ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.
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Affiliation(s)
- Dita Aditianingsih
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Pryambodho
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Naufal Anasy
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Aida Rosita Tantri
- Department of Anesthesiology and Intensive Care, Cipto Mangunkusumo General Hospital, Universitas Indonesia, 6th Salemba Raya, DKI Jakarta, 10430 Indonesia
| | - Chaidir Arif Mochtar
- Department of Urology, Cipto Mangunkusumo General Hospital, Universitas Indonesia, DKI Jakarta, Indonesia
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Patel S, Sharawi N, Sultan P. Local anaesthetic techniques for post-caesarean delivery analgesia. Int J Obstet Anesth 2019; 40:62-77. [DOI: 10.1016/j.ijoa.2019.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 05/21/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022]
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A Quality Improvement Initiative to Reduce Opioid Consumption after Cesarean Birth. MCN Am J Matern Child Nurs 2019; 44:250-259. [DOI: 10.1097/nmc.0000000000000549] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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A call for multidisciplinary cesarean delivery analgesia care. Am J Obstet Gynecol MFM 2019; 1:100033. [PMID: 33345797 DOI: 10.1016/j.ajogmf.2019.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/14/2019] [Indexed: 11/22/2022]
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Sun KW, Pan PH. Persistent pain after cesarean delivery. Int J Obstet Anesth 2019; 40:78-90. [PMID: 31281032 DOI: 10.1016/j.ijoa.2019.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 05/01/2019] [Accepted: 06/03/2019] [Indexed: 01/22/2023]
Abstract
The incidence of persistent pain after cesarean deliveries (CD) varies but is much lower than after comparable surgeries. However, with over four million deliveries annually and a rising CD rate, even a low prevalence of persistent pain after CD impacts many otherwise healthy young women. Consideration of the pathophysiology of persistent pain after surgery and the risk factors predisposing women to persistent and chronic pain after CD provides insights into the prevention and treatment of persistent pain; and improves the quality of care and recovery after CD. The findings that the peripartum state and oxytocin confer protection against persistent pain may provide new and interesting perspectives for the prevention and treatment of chronic pain caused by trauma or surgery. Predictive tools available to identify and target patients at high risk of acute and chronic pain have mostly weak to modest predictive correlations and many are either not clinically feasible or too time-consuming to apply. Persistent pain has been linked to the severity of acute postoperative pain and opioid exposure. Modified surgical techniques, neuraxial anesthesia and opioid-sparing analgesia may help limit the development of persistent and chronic pain. The goal of this narrative review is to examine the incidence of persistent pain after CD; review briefly the underlying pathophysiology of persistent pain and the transition from acute to chronic pain (with particular emphasis on the uniqueness after CD); and to review modifiable risk factors and prevention strategies that identify at-risk patients and allow tailored treatment.
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Affiliation(s)
- K W Sun
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - P H Pan
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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Multimodal Stepwise Approach to Reducing In-Hospital Opioid Use After Cesarean Delivery. Obstet Gynecol 2019; 133:700-706. [DOI: 10.1097/aog.0000000000003156] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Sharawi N, Carvalho B, Habib AS, Blake L, Mhyre JM, Sultan P. A Systematic Review Evaluating Neuraxial Morphine and Diamorphine-Associated Respiratory Depression After Cesarean Delivery. Anesth Analg 2018; 127:1385-1395. [DOI: 10.1213/ane.0000000000003636] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Imani F, Rahimzadeh P, Faiz HR, Nowruzina S, Shakeri A, Ghahremani M. Comparison of the Post-Caesarean Analgesic Effect of Adding Dexmedetomidine to Paracetamol and Ketorolac: A Randomized Clinical Trial. Anesth Pain Med 2018; 8:e85311. [PMID: 30538943 PMCID: PMC6252045 DOI: 10.5812/aapm.85311] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 12/15/2022] Open
Abstract
Background Paracetamol and non-steroidal anti-inflammatory drugs (e.g. ketorolac) can be considered for mild to moderate post-caesarean pain. As a selective α-2 agonist adrenergic receptor, dexmedetomidine has analgesic and sedative effects without causing respiratory depression. Objectives This study aimed to evaluate the effects of adding dexmedetomidine to paracetamol or ketorolac on post-caesarean pain and the associated complications thereof. Methods Sixty pregnant women, who were candidates for caesarean section with spinal anesthesia, were randomly assigned to either of two groups of 30 patients. For post-operative pain management, an intravenous patient-controlled analgesia (PCA) device was used for 24 hours. Dexmedetomidine (3 µg kg-1) was added to paracetamol (35 mg kg-1) in the group DP and to ketorolac (1 mg kg-1) in the group DK. Visual analog scale (VAS), Ramsay sedation scale, hemodynamic changes, rescue analgesic (meperidine) consumption, patient satisfaction, and possible complications were recorded at 6, 12, and 24, hours after surgery, and compared afterward. Results The pain score was significantly lower in the DK group than in the DP group (P < 0.05). The hemodynamics and sedation scale were similar in both groups. The total meperidine consumption was higher in the DP group, but it was not significantly different. Maternal satisfaction was greater in the DK group (P < 0.05). Concerning complications, the two groups did not show statistically significant differences (P = 0.4). Conclusions The addition of dexmedetomidine to ketorolac, compared with its addition to paracetamol, causes further reduction in the post-operative pain score and provides more satisfaction.
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Affiliation(s)
- Farnad Imani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Professor, MD, FIPP, Pain Research Center, Iran University of Medical Sciences, Tehran, Iran. Eamil:
| | - Poupak Rahimzadeh
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid-Reza Faiz
- Rasoul Akram Hospital, Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shiva Nowruzina
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Fellowship, Pain Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Asadolla Shakeri
- Department of Anesthesiology and Pain Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
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The effect of a single intraoperative dose of intravenous dexamethasone 8 mg on post-cesarean delivery analgesia: a randomized controlled trial. Int J Obstet Anesth 2018; 35:57-63. [DOI: 10.1016/j.ijoa.2018.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/09/2018] [Accepted: 03/21/2018] [Indexed: 12/15/2022]
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Disparity between High Satisfaction and Severe Pain in Patients after Caesarean Section: A Prospective Observational-Controlled Investigation. Anesthesiol Res Pract 2018; 2018:2634768. [PMID: 29849609 PMCID: PMC5925022 DOI: 10.1155/2018/2634768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/10/2018] [Indexed: 12/16/2022] Open
Abstract
Objectives Recent advances in the treatment of postoperative pain (POP) have increased the quality of life in surgical patients. The aim of this study was to examine the quality of POP management in patients after CS in comparison with patients after comparable surgical procedures. Methods This was a prospective observational analysis in patients after CS in comparison with the patients of the same age, who underwent comparable abdominal gynaecological surgeries (GS group) at the university hospital. A standardised questionnaire including pain intensity on the Verbal Rating Scale (VRS-11), incidence of analgesia-related side effects, and incidence of pain interference with the items of quality of life and patients' satisfaction with the treatment of POP was used. Results Sixty-four patients after CS reported more pain on movement than the patients after GS (N=63): mean 6.1 versus 3.6 (VRS-11; P < 0.001). The patients after CS reported less nausea (8 versus 41%) and vomiting (3 versus 21%; P < 0.001) and demonstrated better satisfaction with POP treatment than the patients after GS: 1.4 (0.7) versus 1.7 (0.7) (mean (SD); VRS-5; P=0.02). Conclusion The disparity between the high level of pain and excellent satisfaction with POP treatment raises the ethical and biomedical considerations of restrictive pharmacological therapy of post-CS pain.
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Parikh P, Sunesara I, Singh Multani S, Patterson B, Lutz E, Martin JN. Intra-incisional liposomal bupivacaine and its impact on postcesarean analgesia: a retrospective study. J Matern Fetal Neonatal Med 2017; 32:966-970. [PMID: 29065741 DOI: 10.1080/14767058.2017.1397118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The efficacy of long-acting intraincisional bupivacaine in reducing postoperative opioid use among women who have undergone a cesarean is currently unknown. MATERIALS AND METHODS This was a retrospective case-control study with a 1:1 allocation. We identified 40 patients in each group, for a total of 80. The treatment group was administered 266 mg of liposomal bupivacaine after completion of the cesarean and was compared to historical controls. Data regarding anesthesia administered, opioid consumption, nonsteroidal anti-inflammatory use, acetaminophen use, type of cesarean, reason for cesarean, and length of postoperative stay were recorded. RESULTS The treatment group used 41.51 mg of morphine equivalents, while the control group consumed 69.90 mg (p < .001); multivariate analysis demonstrated a mean difference of 26.52 mg (95%CI 12.76-40.28). Univariate analysis demonstrated mean difference in intravenous (IV) ketorolac (40.77 mg, p < .001) and IV acetaminophen (1333.33 mg, p < .001) was different and greater in the treatment group; this was controlled for in the multivariate model. There was no difference in oral and IV ibuprofen or oral acetaminophen use between groups. There were no differences between the type of anesthesia, length of stay, reason for cesarean, and classical sections between groups. CONCLUSIONS Incisional administration of liposomal bupivacaine may be an effective adjunct in reducing opioid use postoperatively and may be a useful adjunct within an enhanced recovery program.
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Affiliation(s)
- Pavan Parikh
- a Department of Obstetrics and Gynecology , the University of Mississippi Medical Center , Jackson , MS , USA
| | - Imran Sunesara
- a Department of Obstetrics and Gynecology , the University of Mississippi Medical Center , Jackson , MS , USA
| | - Sukhpreet Singh Multani
- a Department of Obstetrics and Gynecology , the University of Mississippi Medical Center , Jackson , MS , USA
| | - Brandy Patterson
- a Department of Obstetrics and Gynecology , the University of Mississippi Medical Center , Jackson , MS , USA.,b North Mississippi Medical Center , Tupelo , MS , USA
| | - Elizabeth Lutz
- a Department of Obstetrics and Gynecology , the University of Mississippi Medical Center , Jackson , MS , USA
| | - James N Martin
- a Department of Obstetrics and Gynecology , the University of Mississippi Medical Center , Jackson , MS , USA
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Abstract
Racial and ethnic disparities are prevalent within healthcare and have persisted despite advances in medicine and public health. Disparities have been described in the use of neuraxial labor analgesia, with minority women being less likely to use neuraxial labor analgesia than non-minority white women. Minority women are also more likely to have a general anesthetic for cesarean delivery than non-minority women. The origins of these disparities are likely multi-factorial, with patient-, provider-, and systems-level contributors. The purpose of this article is to give an overview of disparities in obstetric anesthesia.
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Affiliation(s)
- Elizabeth M S Lange
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E, Huron St, F5-704, Chicago, IL 60611
| | - Suman Rao
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E, Huron St, F5-704, Chicago, IL 60611
| | - Paloma Toledo
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E, Huron St, F5-704, Chicago, IL 60611; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL 60611.
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Wang SC, Pan PT, Chiu HY, Huang CJ. Neuraxial magnesium sulfate improves postoperative analgesia in Cesarean section delivery women: A meta-analysis of randomized controlled trials. Asian J Anesthesiol 2017; 55:56-67. [PMID: 28797894 DOI: 10.1016/j.aja.2017.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/10/2017] [Accepted: 06/26/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND We conducted this meta-analysis to elucidate whether additional neuraxial magnesium sulfate (MgSO4) can improve postoperative analgesia in women undergoing Cesarean section (CS) delivery. METHOD We searched Pubmed, Embase and ClinicalTrial.gov. We included only randomized controlled trials that have compared the quality of postoperative analgesia with and without additional neuraxial MgSO4 in women undergoing CS delivery with neuraxial anesthesia regimens. The primary outcomes included analgesic duration of neuraxial anesthesia, postoperative pain scores and postoperative consumption of analgesics. The secondary outcomes included patients' satisfaction and adverse effects related to postoperative analgesia. RESULTS Nine relevant studies comprising a total of 827 women undergoing CS delivery were included. Analyses revealed that CS women receiving additional neuraxial MgSO4 (the MgSO4 group) had longer duration of neuraxial anesthesia (effect size [ES] = 1.920, 95% confidence interval [CI] = 0.999 to 2.842, P < 0.001), longer duration of sensory block (ES = 1.020, 95% CI = 0.463 to 1.577, P < 0.001), lower postoperative pain scores at rest (ES = -1.206, 95% CI = -2.084 to -0.329, P = 0.007), pain scores with motion (ES = -1.435, 95% CI = -2.631 to -0.240, P = 0.019) and consumption of analgesics (ES = -1.620, 95% CI = -2.434 to -0.806, P < 0.001) than CS women without receiving additional neuraxial MgSO4 (the control group). Of note, the MgSO4 group tended to have higher rate on rating satisfaction as "excellent" than the control group did (odds ratio = 3.748, 95% CI = 2.218 to 6.332, P < 0.001). However, the incidences of adverse effects (i.e., nausea and vomiting, pruritus and hypotension) were not significantly different between these two groups. CONCLUSION Neuraxial MgSO4 improves postoperative analgesia in CS women.
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Affiliation(s)
- Shih-Ching Wang
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Po-Ting Pan
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Chun-Jen Huang
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Taipei, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Bateman BT, Franklin JM, Bykov K, Avorn J, Shrank WH, Brennan TA, Landon JE, Rathmell JP, Huybrechts KF, Fischer MA, Choudhry NK. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women. Am J Obstet Gynecol 2016; 215:353.e1-353.e18. [PMID: 26996986 PMCID: PMC5003640 DOI: 10.1016/j.ajog.2016.03.016] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/23/2016] [Accepted: 03/10/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND The incidence of opioid-related death in women has increased 5-fold over the past decade. For many women, their initial opioid exposure will occur in the setting of routine medical care. Approximately 1 in 3 deliveries in the United States is by cesarean, and opioids are commonly prescribed for postsurgical pain management. OBJECTIVE The objective of this study was to determine the risk that opioid-naïve women prescribed opioids after cesarean delivery will subsequently become consistent prescription opioid users in the year following delivery and to identify predictors for this behavior. STUDY DESIGN We identified women in a database of commercial insurance beneficiaries who underwent cesarean delivery and who were opioid naïve in the year prior to delivery. To identify persistent users of opioids, we used trajectory models, which group together patients with similar patterns of medication filling during follow-up, based on patterns of opioid dispensing in the year following cesarean delivery. We then constructed a multivariable logistic regression model to identify independent risk factors for membership in the persistent user group. RESULTS A total of 285 of 80,127 (0.36%, 95% confidence interval, 0.32-0.40), opioid-naïve women became persistent opioid users (identified using trajectory models based on monthly patterns of opioid dispensing) following cesarean delivery. Demographics and baseline comorbidity predicted such use with moderate discrimination (c statistic = 0.73). Significant predictors included a history of cocaine abuse (risk, 7.41%; adjusted odds ratio, 6.11, 95% confidence interval, 1.03-36.31) and other illicit substance abuse (2.36%; adjusted odds ratio, 2.78, 95% confidence interval, 1.12-6.91), tobacco use (1.45%; adjusted odds ratio, 3.04, 95% confidence interval, 2.03-4.55), back pain (0.69%; adjusted odds ratio, 1.74, 95% confidence interval, 1.33-2.29), migraines (0.91%; adjusted odds ratio, 2.14, 95% confidence interval, 1.58-2.90), antidepressant use (1.34%; adjusted odds ratio, 3.19, 95% confidence interval, 2.41-4.23), and benzodiazepine use (1.99%; adjusted odds ratio, 3.72, 95% confidence interval, 2.64-5.26) in the year prior to the cesarean delivery. CONCLUSION A very small proportion of opioid-naïve women (approximately 1 in 300) become persistent prescription opioid users following cesarean delivery. Preexisting psychiatric comorbidity, certain pain conditions, and substance use/abuse conditions identifiable at the time of initial opioid prescribing were predictors of persistent use.
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Affiliation(s)
- Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Obstetric Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard Medical School, Boston, MA.
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | - Joan E Landon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James P Rathmell
- Departments of Anesthesia and Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Sultan P, Halpern SH, Pushpanathan E, Patel S, Carvalho B. The Effect of Intrathecal Morphine Dose on Outcomes After Elective Cesarean Delivery. Anesth Analg 2016; 123:154-64. [DOI: 10.1213/ane.0000000000001255] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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A randomized controlled trial of abdominal binders for the management of postoperative pain and distress after cesarean delivery. Int J Gynaecol Obstet 2016; 133:188-91. [DOI: 10.1016/j.ijgo.2015.08.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 08/14/2015] [Accepted: 01/05/2016] [Indexed: 11/20/2022]
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Hesse T, Henkel B, Zygmunt M, Mustea A, Usichenko TI. Acupuncture for pain control after Caesarean section: a prospective observational pilot study. Acupunct Med 2015; 34:14-9. [PMID: 26307554 DOI: 10.1136/acupmed-2015-010852] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Options for pharmacological analgesia in patients who have undergone Caesarean section (CS) are often restricted. Acupuncture is a promising tool for treating postoperative pain. We aimed to study the feasibility and acceptability of acupuncture as an additional method of analgesia in CS patients in a prospective observational pilot investigation. METHODS Twenty-two patients scheduled for elective CS under spinal anaesthesia were enrolled according to set inclusion criteria. Each patient received auricular and body acupuncture with 20 indwelling fixed needles according to previously validated protocols of acupuncture for postoperative analgesia. Pain intensity on an 11-point verbal rating scale (VRS-11, where 0=no pain and 10=maximal pain), analgesia-related side effects, time to mobilisation and Foley catheter removal after CS, and patients' compliance and satisfaction with treatment of pain on a 5-point VRS (VRS-5, where 1=excellent; 5=bad) were recorded. RESULTS Twenty patients were included in the final analysis. One patient was disturbed by paraesthesia at the site of needling. All other patients tolerated acupuncture well. Pain intensity on movement on the first postoperative day was 4.3±2.4 (mean±SD; VRS-11) and decreased to 2.2±1.2 on the day of discharge. Patient satisfaction was 1.9±0.8 (mean±SD; VRS-5) and compliance (rated by their nurses) was 1.5±0.5 (mean±SD; VRS-5). CONCLUSIONS Acupuncture for additional analgesia after CS was well accepted. The primary outcome measurement was feasible and allowed the sample size to be calculated for a future randomised controlled trial.
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Affiliation(s)
- Thomas Hesse
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, University Medicine of Greifswald, Greifswald, Germany
| | - Berthold Henkel
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, University Medicine of Greifswald, Greifswald, Germany
| | - Marek Zygmunt
- Department of Gynaecology and Obstetrics, University Medicine of Greifswald, Greifswald, Germany
| | - Alexander Mustea
- Department of Gynaecology and Obstetrics, University Medicine of Greifswald, Greifswald, Germany
| | - Taras I Usichenko
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, University Medicine of Greifswald, Greifswald, Germany
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Niklasson B, Arnelo C, Öhman SG, Segerdahl M, Blanck A. Oral oxycodone for pain after caesarean section: A randomized comparison with nurse-administered IV morphine in a pragmatic study. Scand J Pain 2015; 7:17-24. [PMID: 29911601 DOI: 10.1016/j.sjpain.2015.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 01/09/2015] [Indexed: 11/18/2022]
Abstract
Background and aims The present randomized open label parallel group study was conducted to evaluate if an oral oxycodone (OXY) regimen can be at least equally effective and as safe for postoperative analgesia after caesarean section (CS) as a standard of care program using nurse-administered intravenous morphine (IVM), followed by oral codeine. Methods Eighty women (40 + 40) were scheduled for elective CS under spinal anaesthesia. All patients received postoperative multimodal analgesic therapy, including ibuprofen and paracetamol. The OXY group got standardized extended release and short acting oral treatment (and in a few cases intravenous OXY) as needed and the other group received current standard of care, IVM as needed for 24 h, followed by codeine. Opioid treatment lasted maximum five days. Outcome measures were pain intensity (numerical rating scale, NRS), opioid requirements, duration of administering opioids and safety for mother and newborn. All opioids in the study were expressed in OXY equivalents, using a conversion table. As the bioavailability of each opioid has a certain extent of interindividual bioavailability this conversion represents an approximation. The possible influence of opioids on the newborns was evaluated by the Neurological Adaptive Capacity Score at birth and at 24 and 48 h. Results During the first 24 h, there were no differences between treatments in opioid requirements or mean pain intensity at rest but pain intensity when asking for rescue medication was lower in the OXY than in the IVM group (mean ± SD; 5.41 ± 6.42 vs. 6.42 ± 1.61; p = 0.027). Provoked pain (uterus palpation) during the first 6h was also less in the OXY group (3.26 ± 2.13 vs. 4.60 ± 2.10; p = 0.007). During the 25-48 h period postoperatively, patients on OXY reported significantly lower pain intensity at rest (2.9 ± 1.9 vs. 3.8 ± 1.8; p = 0.039) and consumed less opioids (OXY equivalents; mg) (31.5 ± 9.6 vs. 38.2 ± 38.2; p = 0.001) than those on IVM/codeine. The total amount of opioids 0-5 days postoperatively was significantly lower in the OXY than in the IVM/codeine group (108.7 ± 37.6 vs. 138.2 ± 45.1; p = 0.002). Duration of administering opioids was significantly shorter in the OXY group. Time to first spontaneous bowel movement was shorter in the OXY group compared with the IVM/codeine group. No serious adverse events were recorded in the mothers but the total number of common opioid adverse effects was higher among women on IVM/codeine than among those receiving OXY (15 vs. 3; p = 0.007). No adverse outcomes in the newborns related to treatment were observed in either group. Conclusions In a multimodal protocol for postoperative analgesia after CS better pain control and lower opioid intake was observed in patients receiving oral OXY as compared to those on IVM/codeine. No safety risks for mother and child were identified with either protocol. Implications Our findings support the view that use of oral OXY is a simple, effective and time saving treatment for postoperative pain after CS.
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Affiliation(s)
- Boel Niklasson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Obstetrics and Gynecology, Karolinska Institute at the Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
- Sophiahemmet University, Box 5605, 114 86 Stockholm, Sweden
| | - Catarina Arnelo
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Obstetrics and Gynecology, Karolinska Institute at the Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
| | - Susanne Georgsson Öhman
- Sophiahemmet University, Box 5605, 114 86 Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Solna, 171 77 Stockholm, Sweden
| | - Märta Segerdahl
- Department of Physiology and Pharmacology, Karolinska Institute, 171 77 Stockholm, Sweden
| | - Agneta Blanck
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Obstetrics and Gynecology, Karolinska Institute at the Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
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Affiliation(s)
- T I Usichenko
- Dr Taras Usichenko, Anaesthesiology and Intensive Care Medicine, University Medicine of Greifswald, Fleischmannstr. 42-44, Greifswald 17475, Germany
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Bauchat J. Editorial Comment: Possible Neonatal Herpes Simplex Virus (HSV) Acquired Postpartum from Maternal Oral HSV Reactivation after Neuraxial Morphine. A & A CASE REPORTS 2014; 2:106-107. [PMID: 25611873 DOI: 10.1213/xaa.0000000000000014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Jeanette Bauchat
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, ,
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