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Masaracchia MM, Zaretsky MV, Pan Z, Zhou W, Chow FS, Wood CL. Evolution of postoperative care: marked reduction of opioid consumption when ERAC pathway added to wound soaker therapy for cesarean delivery. J Matern Fetal Neonatal Med 2023; 36:2130241. [PMID: 36191923 DOI: 10.1080/14767058.2022.2130241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Achieving functional recovery after cesarean delivery is critical to a parturient's ability to care for herself and her newborn. Adequate pain control is vital, and without it, many other aspects of the recovery process may be delayed. Reducing opioid consumption without compromising analgesia is of paramount importance, and enhanced recovery pathways have generated considerable interest given their ability to facilitate this. Our group's process for reducing opioid consumption for cesarean delivery patients evolved over time. We first demonstrated that providing additional incisional pain control with continuous bupivacaine infusions through wound catheters, with the concurrent use of neuraxial morphine, reduced postoperative opioid use. Iterations of an enhanced recovery after cesarean (ERAC) delivery pathway were then implemented after the Society for Obstetric Anesthesia and Perinatology's consensus statement for ERAC was issued to eliminate variability in both hospital course and in the treatment of postoperative pain. In this retrospective cohort analysis, we sought to identify whether adding ERAC protocols to our existing combination of neuraxial morphine and wound soaker catheters further reduced opioid consumption after cesarean delivery. METHODS A retrospective cohort analysis of cesarean deliveries from 2015 through 2020 was performed. Deliveries were divided by analgesic pathway into four time-periods - time-point 1 [January 2015-April 2016, previous standard of care (control, N = 61)]: neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 2 [May 2016-May 2019, introduction of wound soaker (wound-soaker, N = 40)]: continuous wound catheter infusions of local anesthetic, neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 3 [May 2019-December 2019, wound soaker + early ERAC pathway (early ERAC, N = 78)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine, in addition to scheduled non-opioid analgesics (acetaminophen and ibuprofen) every 6 h, alternating in relation to one another so that one is given every 3 h; time-point 4 [January 2020-July 2020, wound soaker + late ERAC pathway (late ERAC, N = 57)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine in addition to non-opioid analgesics scheduled together every 6 h (to facilitate periods of uninterrupted rest). Cumulative and average daily opioid use for postoperative days (POD) 1-4 were analyzed using ANOVA and a mixed effect model, respectively. RESULTS Average daily opioid consumption and total cumulative opioid consumption POD 1-4 (morphine milligram equivalents) for both early and late ERAC groups (23.9 ± 31.1 and 29.4 ± 35.1) were significantly reduced compared to control and wound soaker groups (185.1 ± 93.7 and 134.8 ± 77.1) (p < .001). CONCLUSION The addition of ERAC protocols to our standardized multimodal analgesic regimen (local anesthetic wound infusion catheters and neuraxial morphine) for cesarean delivery significantly reduced postoperative opioid consumption.
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Affiliation(s)
- Melissa M Masaracchia
- Division of Pediatric Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA.,Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael V Zaretsky
- Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Zhaoxing Pan
- School of Public Health, University of Colorado, Aurora, CO, USA
| | - Wenru Zhou
- School of Public Health, University of Colorado, Aurora, CO, USA
| | - Franklin S Chow
- Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Cristina L Wood
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
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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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Wood CL, Zuk J, Rollins MD, Silveira LJ, Feiner JR, Zaretsky M, Chatterjee D. Anesthesia for Maternal-Fetal Interventions: A Survey of Fetal Therapy Centers in the North American Fetal Therapy Network. Fetal Diagn Ther 2021; 48:361-371. [PMID: 33827094 DOI: 10.1159/000514897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/31/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A wide range of fetal interventions are performed across fetal therapy centers (FTCs). We hypothesized that there is significant variability in anesthesia staffing and anesthetic techniques. METHODS We conducted an online survey of anesthesiology directors at every FTC within the North American Fetal Therapy Network (NAFTNet). The survey included details of fetal interventions performed in 2018, anesthesia staffing models, anesthetic techniques, fetal monitoring, and postoperative management. RESULTS There was a 92% response rate. Most FTCs are located within an adult hospital and employ a small team of anesthesiologists. There is heterogeneity when evaluating anesthesiology fellowship training and staffing, indicating there is a multidisciplinary specialty team-based approach even within anesthesiology. Minimally invasive fetal interventions were the most commonly performed. The majority of FTCs also performed ex utero intrapartum treatment (EXIT) and open mid-gestation procedures under general anesthesia (GA). Compared to FTCs only performing minimally invasive procedures, FTCs performing open fetal procedures were more likely to have a pediatric surgeon as director and performed more minimally invasive procedures. CONCLUSIONS There is considerable variability in anesthesia staffing, caseload, and anesthetic techniques among FTCs in NAFTNet. Most FTCs used maternal sedation for minimally invasive procedures and GA for EXIT and open fetal surgeries.
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Affiliation(s)
- Cristina L Wood
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeannie Zuk
- Department of Surgery, Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mark D Rollins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lori J Silveira
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John R Feiner
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Michael Zaretsky
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Colorado Fetal Care Center, Aurora, Colorado, USA
| | - Debnath Chatterjee
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Wang H, Yang X, Chen X, Xie H, Wang J, Zhang Y. Identify the role of Human Wharton's Jelly Mesenchymal Stem Cells in repairing injured uterine of rat. J Obstet Gynaecol Res 2021; 47:320-328. [PMID: 33393183 DOI: 10.1111/jog.14526] [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: 03/05/2020] [Revised: 08/18/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022]
Abstract
AIM Maternal complications caused by the cesarean delivery inhibit the capability of preserving the uterus and subsequent fertility. However, successful restoration of the incisional scar continuously still remains a challenge. This work was to evaluate the repairing effect of Human Wharton's Jelly Mesenchymal Stem Cells (hWJ-MSC) on incisional scar of the uterine. METHODS Eighteen rats were randomly assigned into two groups and nine for each: one group injected with hWJ-MSC in phosphate buffer saline (PBS) and the other injected with PBS for comparison. RESULTS With hWJ-MSC in PBS injected, the uterine endometrium and myometrium with full-thickness injury were restored and the functionality was greatly improved in comparison with the group only with PBS injected. CONCLUSION The hWJ-MSC can repair the injured uterine effectively by promoting the uterine endometrium and myometrium cells proliferation and according to the chi-square analysis the pregnancy is improved.
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Affiliation(s)
- Hezhu Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Jiangsu, China.,Jiangsu Taizhou Peoples' Hospital, Jiangsu, China
| | - Xiaoqing Yang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Xiaojing Chen
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Huihui Xie
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Junxia Wang
- Center for Stem Cell Engineering and Technology, Jiangsu, China
| | - Yuquan Zhang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Nantong University, Jiangsu, China
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Porter AC, Behrendt NJ, Zaretsky MV, Liechty KW, Wood C, Chow F, Galan HL. Continuous local bupivacaine wound infusion reduces oral opioid use for acute postoperative pain control following myelomeningocele repair. Am J Obstet Gynecol MFM 2020; 3:100296. [PMID: 33485023 DOI: 10.1016/j.ajogmf.2020.100296] [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: 10/19/2020] [Revised: 12/05/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For pregnancies complicated by fetal myelomeningocele who meet the established criteria, prenatal closure is a viable management option. Prenatal closure is an open procedure, with some techniques requiring greater dissection of maternal tissue than cesarean delivery; pain control is an important postoperative goal. Given the rising rates of opioid dependence and concerns regarding the fetal and neonatal effects of opioid use, our practice has turned to nonopioid pain management techniques. OBJECTIVE This study aimed to compare postoperative opioid use and pain scores in women undergoing open fetal myelomeningocele repair with and without continuous local bupivacaine wound infusion. STUDY DESIGN This was a retrospective, single-center chart review of all consecutive patients who underwent open myelomeningocele repair from March 2013 to December 2019. Women were enrolled at the time of referral and locally followed for 2 weeks postoperatively. The control group received patient-controlled epidural analgesia for 48 hours with acetaminophen and oral and intravenous opioids as needed. The treatment group received patient-controlled epidural analgesia for 24 hours with acetaminophen, oral and intravenous opioids, and continuous local bupivacaine infusion. Pain scores, medication use, and postoperative milestones and complications through discharge were abstracted from the chart and compared. RESULTS Of 72 subjects, 51 were in the control group and 21 in the treatment group. Total opioid use, including intravenous doses (165 vs 52.5 mg; P=.001) and daily average oral opioid use (30 vs 10.5 mg; P=.002) were lower in the treatment group. In addition, 24% of women in the treatment group used no opioid postoperatively, compared with 4% in the control group. There was no difference in postoperative day 1 to 4 pain scores, antiemetic use, or bowel function; the treatment group was discharged significantly earlier. CONCLUSION Postoperative opioid use was reduced in women who received continuous local wound infusion of bupivacaine for incisional pain control after prenatal myelomeningocele repair. Pain control is paramount following open myelomeningocele repair; local bupivacaine wound infusion is an important adjunct to reduce opioid use postoperatively.
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Affiliation(s)
- Anne C Porter
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO.
| | - Nicholas J Behrendt
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Michael V Zaretsky
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Division of Pediatric Surgery; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Cristina Wood
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Franklin Chow
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Henry L Galan
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
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Paladini G, Di Carlo S, Musella G, Petrucci E, Scimia P, Ambrosoli A, Cofini V, Fusco P. Continuous Wound Infiltration of Local Anesthetics in Postoperative Pain Management: Safety, Efficacy and Current Perspectives. J Pain Res 2020; 13:285-294. [PMID: 32099452 PMCID: PMC6999584 DOI: 10.2147/jpr.s211234] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/14/2020] [Indexed: 12/18/2022] Open
Abstract
Local infiltration and continuous infusion of surgical wound with anesthetics are parts of multimodal analgesia for postoperative pain control. The techniques, given the simplicity of execution that does not increase the timing of the intervention and does not require additional technical skills, are applied in several kinds of surgeries. The continuous wound infiltration can be used for days and a variety of continuous delivery methods can be chosen, including patient-controlled analgesia, continuous infusion or intermittent bolus. The purpose of this narrative review is to analyze the literature, in particular by researching the safety, efficacy and current perspectives of continuous wound infiltration for postoperative pain management in different surgical settings. We have identified 203 articles and 95 of these have been taken into consideration: 17 for the lower limb surgery; 7 for the upper limb surgery, 51 for the laparotomy/laparoscopic surgery of the abdominopelvic area, 13 studies regarding breast surgery and 7 for cardiothoracic surgery. The analysis of these studies reveals that the technique has a variable effectiveness based on the type of structure involved: it is better in structures rich in subcutaneous and connective tissue, while the effectiveness is limited in anatomic districts with a greater variability of innervation. However, regardless the heterogeneity of results, a general reduction in pain intensity and in opioid consumption has been observed with continuous wound infiltration: it is an excellent analgesic technique that can be included in the multimodal treatment of postoperative pain or represents a valid alternative when other options are contraindicated.
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Affiliation(s)
- Giuseppe Paladini
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Stefano Di Carlo
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti, Chieti, Italy
| | - Giuseppe Musella
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Emiliano Petrucci
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
| | - Paolo Scimia
- Department of Anesthesia and Intensive Care, ASUR Marche AV5, San Benedetto Del Tronto, Italy
| | - Andrea Ambrosoli
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Vincenza Cofini
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Pierfrancesco Fusco
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
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