Oral analgesia in the treatment of post-cesarean pain

Analgesic effects of a 5% lidocaine patch after cesarean section: A randomized placebo-controlled double-blind clinical trial

STUDY OBJECTIVE

This study aimed to evaluate the analgesic effects of a 5% lidocaine patch in acute postoperative pain after cesarean section.

DESIGN

This is a prospective, randomized, double-blind study.

SETTING

After surgery, active and placebo patches were applied in the operating room, and patients were evaluated during their stay at the postoperative recovery room and at the hospital ward.

PATIENTS

Seventy-two women (18 years of age or older and American Society of Anesthesiologists status II) scheduled for cesarean section under spinal anesthesia were enrolled in the study.

INTERVENTIONS

Patients were randomly assigned to an intervention or placebo group. According to the assigned group, a 5% lidocaine patch or a placebo patch was applied 1 cm above and below the Pfannenstiel incision after the surgery.

MEASUREMENTS

The primary outcome was the pain score, evaluated using an 11-point numerical verbal scale in the first 36 h postoperatively. Secondary outcomes were the quality of recovery 24 h after surgery, consumption of rescue opioids, and the presence of adverse effects.

MAIN RESULTS

Sixty-five women completed the study. The pain score was lower in the lidocaine group at 6 h (lidocaine group: 2.16 ± 1.71, placebo group: 3.21 ± 2.25; p = 0.031), 12 h (lidocaine: 1.58 ± 0.81, placebo: 2.24 ± 0.74; p = 0.001), 24 h (lidocaine: 0.74 ± 0.89, placebo: 1.94 ± 1.39; p < 0.0001), and 36 h (lidocaine: 0.48 ± 1.03, placebo: 1.68 ± 0.94; p = 0.001) after surgery. There were no differences in secondary outcomes during the follow-up period.

CONCLUSION

The lidocaine patch reduced pain scores compared to placebo in the first 36 h after the surgery, despite no influence over opioid consumption, quality of recovery, or incidence of side effects.

Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery

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.

Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain: a randomised controlled trial

OBJECTIVES

To compare the efficacy, safety and satisfaction from two modes of oral analgesia administration for the treatment of post-caesarean pain in the first 48 h following surgery: on-demand versus fixed time interval administration.

DESIGN

Open label parallel-group, randomised-controlled trial from February to December 2013.

SETTING

University-affiliated hospital in Israel.

POPULATION

Two-hundred women who underwent caesarean delivery with regional anaesthesia.

METHODS

Patients were randomly assigned to receive predetermined combinations of tramadol, paracetamol and diclofenac either following patient demand or at predetermined 6-h intervals for the first 48 h. If the patient requested additional analgesia, Percocet (oxycodone and paracetamol) was given as a rescue treatment.

MAIN OUTCOME MEASURES

Pain intensity and satisfaction were self-evaluated with visual analogue scale of 0 (no pain/least satisfaction) to 10 (worst pain/highest satisfaction). Breastfeeding, need for supplemental formula, and maternal and neonatal adverse effects were also evaluated.

RESULTS

The 'fixed time interval' group, compared with the 'on-demand' group, had lower mean pain score (2.8 ± 0.84 versus 4.1 ± 0.48, respectively; P < 0.0001), higher satisfaction rate (9.1 ± 1.2 versus 8.3 ± 1.5, respectively; P < 0.0001), more breastfeeds (23.7 ± 6.5 versus 19.2 ± 6.2, respectively; P < 0.0001) and less use of supplemental formulas (8.2 ± 5.2 versus 11.9 ± 6.5, respectively; P < 0.0001). The number of times that drugs were given was slightly higher in the 'fixed time interval' group without an increase in maternal adverse effects, which were mild. No adverse effects were reported for the neonates.

CONCLUSION

Administration of oral analgesia in fixed time intervals is superior to drug administration following patient demand without increasing maternal or neonatal adverse outcomes.

TWEETABLE ABSTRACT

Oral analgesia in fixed time intervals is superior to analgesia following demand.

Comparison of Efficacy and Safety of Intramuscular Piroxicam and Tramadol for Post-operative Pain in Patients Undergoing Caesarean Delivery

INTRODUCTION

Post-caesarean section pain can be both stressful and unfavourable. Effective and rapid reduction of pain facilitates early ambulation and care of the new born. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and opioids are used for pain relief but they are associated with adverse effects both in the mother and the child.

AIM

To evaluate efficacy and safety of piroxicam and tramadol in post-caesarean section pain.

MATERIALS AND METHODS

Primigravidae who underwent elective caesarean section received either piroxicam 20mg or tramadol 100mg intra-muscularly, following recovery from anaesthesia. Severity of pain was assessed using Visual Analogue Scale (VAS) and side-effects to study drugs were noted. Rescue analgesic butorphanol 2mg was administered if VAS score was more than four. Patient's satisfaction score was assessed at 12 hours post-operatively.

RESULTS

Mean age in piroxicam and tramadol groups were 23.32±3.43 and 22.03±2.0 years respectively. Significant reduction in pain was observed at 2, 4, 8, 12 and 24 hours in both groups (p<0.001). Pain relief was significant at 2, 4 and 8 hours in piroxicam group compared to tramadol. Twenty-one and 12 patients in tramadol and piroxicam groups received rescue analgesic respectively. Sedation and nausea was significantly higher in tramadol group (p<0.001), 46.66% of patients graded their satisfaction score as good and 15% as excellent in piroxicam group.

CONCLUSION

Intra-muscular piroxicam was effective in reducing post-caesarean section pain for 24 hours with minimal side-effects compared to tramadol.

Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomised controlled trial

We assessed the effectiveness of early patient-controlled oral analgesia compared with parenteral analgesia in a randomised controlled non-inferiority trial of women undergoing elective caesarean section under regional anaesthesia. Seventy-seven women received multimodal paracetamol, ketoprofen and morphine analgesia. The woman having patient-controlled oral analgesia were administered four pillboxes on the postnatal ward containing tablets and instructions for self-medication, the first at 7 h after the spinal injection and then three more at 12-hourly intervals. Pain at rest and on movement was evaluated using an 11-point verbal rating scale at 2 h and then at 6-hourly intervals for 48 h. The pre-defined non-inferiority limit for the difference in mean pain scores (patient-controlled oral analgesia minus parenteral) was one. The one-sided 95% CI of the difference in mean pain scores was significantly lower than one at all time-points at rest and on movement, demonstrating non-inferiority of patient-controlled oral analgesia. More women used morphine in the patient-controlled oral analgesia group (22 (58%)) than in the parenteral group (9 (23%); p = 0.002). The median (IQR [range]) number of morphine doses in the patient-controlled oral analgesia group was 2 (1-3 [1-7]) compared with 1 (1-1 [1-2]); p = 0.006) in the parenteral group. Minor drug errors or omissions were identified in five (13%) women receiving patient-controlled oral analgesia. Pruritus was more frequent in the patient-controlled oral analgesia group (14 (37%) vs 6 (15%) respectively; p = 0.03), but no differences were noted for other adverse events and maternal satisfaction. After elective caesarean section, early patient-controlled oral analgesia is non-inferior to standard parenteral analgesia for pain management, and can be one of the steps of an enhanced recovery process.

The effect of post-surgical neuroplasticity on the stability of systemic pain perception: a psychophysical study

BACKGROUND

Surgery-induced neuroplasticity at spinal and supra-spinal levels is assumed to evoke a clinical acute post-operative pain (cAPOP) experience, which is expressed by allodynia and/or hyperalgesia. It remains unclear whether the systemic pain perception measured outside the incision area remains unchanged and whether it is affected by the presence of cAPOP.

AIMS

This study explored whether the systemic perception of experimental pain would be altered towards hypersensitivity following elective gynecological surgery unmasked by opioids.

METHODS

A perioperative psychophysical evaluation of heat pain thresholds (HPT) and pain estimations were obtained in a remote bodily area before and after surgery among 35 women.

RESULTS

The ratings for both pain dimensions of intensity and unpleasantness remained stable following surgery. However, there was a reduction found in HPT the day after surgery (43.6 ± 2.2 °C to 42.2 ± 3.1 °C, p = 0.002). This reduction was associated with lower HPT measured before surgery (r = .56, p < 0.000) and with higher cAPOP intensity obtained at rest (r = -.44, p = 0.008).

CONCLUSIONS

This post-surgical allodynia, as reflected by the systemic enhancement of pain perception, may represent plasticity in the central pain pathways at the supra-spinal level. Pre-surgical assessment of a patient's pain perception profile may predict certain pain dimensions of post-surgical pain plasticity. The evaluation of individual pain profiles may contribute to a mechanism-based approach aimed to attenuate the cAPOP.

Pain management after cesarean: a randomized controlled trial of oxycodone versus intravenous piritramide

PURPOSE

Primary objective was to assess whether oral analgesia with oxycodone offers superior pain relief after cesareans than patient controlled analgesia (PCA). Secondary outcomes were additional pain medication, time to first mobilization, therapeutic side effects, postoperative restrictions, overall satisfaction and costs.

MATERIALS AND METHODS

Randomized controlled trial at a University Hospital conduct between July 2009 and November 2009. Of the 1,112 patients, 257 met the inclusion criteria and 239 agreed to participate. Patients were randomly assigned to either receive intravenous piritramide PCA (2 mg piritramide/ml 0.9 % saline) or oral oxycodone (20 mg). Pain was assessed on a visual analog pain scale (VAS) at 2, 12, 24, 32, 40, 48 and 72 h after cesarean.

RESULTS

No differences in VAS scores were observed within the general study population. Pain scores of oxycodone versus PCA were comparable at 24 h. Patients randomized to PCA demonstrated increased demand for rescue medication 48 h after cesarean (p = 0.057). In the PCA group, patients with previous cesarean had increased operative times, a trend towards increased VAS scores after 48 h (p = 0.081) and increased VAS scores in comparison to patients who did not have cesarean before (p = 0.044). For this subgroup, no difference was seen in the oxycodone patients (p = 0.883).

CONCLUSION

General satisfaction with both treatment regimes was high. The results support the potential use of oral pain regimes and emphasis the importance of a multimodal approach to treat post-cesarean pain. Oral oxycodone is a not expensive, convenient and comparable analgesic to PCA devices with opioids after cesarean. Trial registration at clinicaltrials.gov identifier: NCT 01115101.

Analgesia after caesarean delivery

As the number of women giving birth by caesarean increases throughout most of the developed world, so too is research into postoperative pain relief for these women. Like most other post-surgical populations, the new mother needs effective pain relief so that she can mobilise early but she also has the added responsibility of needing to care for her newborn baby. There is no 'gold standard' for post-caesarean pain management; the number of options is large and the choice of method is at least partly determined by drug availability, regional and individual preferences, resource limitations and financial considerations. Most methods rely on opioids, supplemented with anti-inflammatory analgesics, nerve blocks or other adjunctive techniques. The aim of this review is to detail commonly used opioid-based methods and to review the evidence supporting non-opioid methods, when incorporated into a multimodal approach to post-caesarean pain management. Areas of promising research are also discussed.

Postoperative Pain After Cesarean Birth Affects Breastfeeding and Infant Care

OBJECTIVE

To study women's experience of postoperative pain and pain relief after cesarean birth and factors associated with pain assessment and the birth experience.

DESIGN

Descriptive patient survey. Data were collected through a questionnaire. The outcome variables were assessments of pain using a Visual Analog Scale and women's birth experience measured on a seven-point Likert scale.

SETTING

Central Swedish county hospital, maternity unit.

PATIENTS/PARTICIPANTS

The sample consisted of 60 women undergoing cesarean birth.

RESULTS

Women reported high levels of experienced pain during the first 24 hours. Seventy-eight percent of the women scored greater than or equal to 4 on the Visual Analog Scale, which can be seen as inadequately treated pain. There was no difference between elective and emergency cesarean births in the levels of pain. In spite of high levels of pain, women were pleased with the pain relief. The risk of a negative birth experience was 80% higher for women undergoing an emergency cesarean birth compared with elective cesarean birth. Postoperative pain negatively affected breastfeeding and infant care.

CONCLUSIONS

There is a need for individual and adequate pain treatment for women undergoing cesarean birth, as high levels of pain interfere with early infant care and breastfeeding.

Pain Catastrophizing, Response to Experimental Heat Stimuli, and Post–Cesarean Section Pain

This prospective study assessed the relation between pain catastrophizing, response to experimental pain stimuli, and pain perceived by women after elective cesarean sections. Forty-seven women who were scheduled for elective cesarean section were enrolled in the study. Magnitude estimation to suprathreshold phasic and tonic heat pain stimuli was assessed 1 or 2 days before surgery. Women completed the Pain Catastrophizing Scale after the heat stimuli and again on the first postoperative day. During the first and second postoperative days, perception of pain intensity was assessed by visual analog scale at each analgesia request. A multiple regression analysis revealed that pain on the first postoperative day was predicted by patient response to preoperative tonic heat stimuli (r(2) = .167, P = .008). Pain on the second postoperative day was predicted by preoperative pain catastrophizing (r(2) = .139, P = .021). No significant association was observed between preoperative response to heat stimuli or pain catastrophizing and the patient's analgesic consumption in the obstetrical ward. It is concluded that pain catastrophizing and response to experimental tonic heat pain correlate with post-cesarean section pain.

PERSPECTIVE

This article presents psychological and psychophysical measures that may be of help in the prediction of post-cesarean section pain. It may therefore contribute to the treatment of the sequelae of the most common major surgical procedure performed in women in their reproductive years.

Evaluation of the pharmacokinetic profile and analgesic efficacy of oral morphine after total hip arthroplasty

BACKGROUND AND OBJECTIVE

Oral morphine may be useful for postoperative pain relief, but few studies have tested its use after in-hospital surgery.

METHODS

We evaluated clinical efficacy and the pharmacokinetic parameters of oral morphine after total hip arthroplasty. We recruited 60 patients who had total hip arthroplasty under general anaesthesia. The patients were randomized to receive placebo, 10 mg morphine sulphate or 20 mg morphine sulphate orally every 4 h for 24 h. The oral administration was started 3 h after the morphine-loading dose in the Post Anaesthesia Care Unit and then patients used intravenous morphine patient-controlled analgesia for 24 h. Pain score at rest (scored by patients on a visual analogue scale), sedation, nausea, vomiting and urinary retention were monitored. In 11 additional total hip arthroplasty patients, we determined the pharmacokinetics of morphine and its metabolites after oral administration of 20 mg morphine sulphate every 4 h for 16 h.

RESULTS

The amount of morphine administered via patient-controlled analgesia over 24 h was reduced in the 20-mg group compared with that in the placebo group (19.0 +/- 2.7 mg vs. 33.0 +/- 5.5 mg; P = 0.03). No significant morphine-sparing effect was observed in the 10-mg group. Pain scores and side-effects were similar in all groups. The pharmacokinetic study revealed a limited and slow absorption of morphine.

CONCLUSION

Despite a limited absorption of oral morphine postoperatively, high doses of oral morphine have a significant analgesic effect after total hip arthroplasty.

Oral analgesia compared with intravenous patient-controlled analgesia for pain after cesarean delivery: a randomized controlled trial

OBJECTIVE

The purpose of this study was to determine whether oral analgesia with oxycodone-acetaminophen or a patient-controlled analgesia device with morphine provides superior analgesia after cesarean delivery.

STUDY DESIGN

Ninety-three patients with scheduled cesarean delivery were assigned randomly to receive either oral analgesia with oxycodone-acetaminophen or a morphine patient-controlled analgesia device. At 6 and 24 hours after the procedure, pain was assessed on a visual analog pain scale of 0 to 10. Nausea, sedation, pruritus, ambulation, emesis, and oral fluid intake were also assessed.

RESULTS

Patients who used oral analgesia without a patient-controlled analgesia device experienced less pain at 6 and 24 hours after cesarean delivery. They also had less nausea and drowsiness at 6 hours but slightly more nausea at 24 hours.

CONCLUSION

Oral analgesia with oxycodone-acetaminophen may offer superior pain control after cesarean delivery with fewer side-effects as compared with morphine patient-controlled analgesia. Consideration should be given to expanding the use of oral analgesia in patients immediately after cesarean delivery.

Over-the-counter oral analgesia for postcesarean pain

OBJECTIVE

The purpose of this study was to evaluate patient satisfaction for oral analgesia for postcesarean pain management.

STUDY DESIGN

A prospective study was conducted on women who underwent cesarean section with regional analgesia. Women were treated with ibuprofen 400 mg in liquid-filled capsules on the first postoperative day by two modes of drug administration: on patient demand (n = 60) and at predetermined regular intervals (n = 54). Pain intensity and satisfaction were self-evaluated by the patients with use of a visual analog scale.

RESULTS

Patients in the fixed time interval group had lower pain scores (by 38%-54%, P <.001) compared with the on-demand group. Satisfaction scores in both groups were high but superior in the fixed time interval group (87.5 +/- 18.8, median 94.5, vs 78.6 +/- 21, median 85, P <.001).

CONCLUSIONS

Oral, nonnarcotic, postcesarean analgesia provides satisfactory pain relief. Patient satisfaction can be further enhanced by providing the medications in fixed time intervals rather than leaving it to patient request.