Analgesia after c delivery -

wound infusions, tap blocks

and intrathecal opioids; what

more can we offer our patients?

Ashraf S Habib, MBBCh, MSc, MHSc, FRCA

Associate Professor of Anesthesiology

Interim Chief, Division of Women’s Anesthesia

OAA Three Day Course, November 2014

Outcome Rank Relative Value

Pain During Caesarean 8.4 ± 2.2 27 ± 18

Pain After Caesarean 8.3 ± 1.8 18 ± 10

Vomiting 7.8 ± 1.5 12 ± 7

Nausea 6.8 ± 1.7 11± 7

Cramping 6.0 ± 1.9 10 ± 8

Itching 5.6 ± 2.1 9 ± 8

Shivering 4.6 ± 1.7 6 ± 6

Anxiety 4.1 ± 1.9 5 ± 4

Somnolence 2.9 ± 1.4 3 ± 3

Carvalho B. Anesth Analg 2005; 101: 1182-7

Does it matter?

• Better postoperative analgesia

– Faster ambulation

– Improved breast feeding success

– Higher patient satisfaction

• Reduced incidence of persistent pain

and maternal depression

Persistent Pain after CD

Author Number of CD Time of data

collection after

delivery

Incidence of

persistent pain

Nikolajsen 2004 224 6-18 months 12.3 %

Eisenach 2008 391 8 weeks 9.2 %

Sng 2009 857 3 Months 9.2 %

Kainu 2010 229 1 year 18 %

Severity of acute pain was a significant predictor of persistent pain

Nicolajsen L. Acta Anaesthesiol Scand 2004; 48: 111-16

Eisenach JC. Pain 2008; 140: 87-94

Sng BL. Anaesth Intensive Care 2009; 37: 748-52

Kainu JP. Int J Obstet Anesth 2010; 19: 4-9

Modalities for Post-Caesarean

Analgesia

• Opioids

• Systemic Adjuncts

• Local Anaesthetic Techniques

• Neuraxial Adjuncts

Modalities for Post-Caesarean

Analgesia

• Opioids

• Systemic Adjuncts

• Local Anaesthetic Techniques

• Neuraxial Adjuncts

Neuraxial vs. Parenteral

Opioids

• Meta-analysis (10 studies):

time to first analgesia

pain scores

– pruritus (RR=2.7) and nausea (RR=2)

sedation with parenteral opioidsBonnet MP. Eur J Pain 2010; 14: 894.e1-894. e9

Neuraxial vs. oral Opioids

• Intrathecal morphine vs. regular

oral oxycodone

need for analgesics/high pain scores

patient satisfaction

pruritus (87 % vs. 56 %, p=0.001)

McDonnell NJ. Int J Obstet Anesth 2010; 19: 16-23

Dose Response of Neuraxial

Morphine

Epidural Morphine

0

10

20

30

40

50

60

70

0 1.25 2.5 3.75 5

P<0.05 vs. 3.75 and 5 mg

Intrathecal Morphine

P<0.05 vs. 2.5, 3.75, 5 mg

Epidural Morphine Dose (mg)

PC

EA

Morp

hin

e U

se (

mg)

Intrathecal Morphine Dose (μg)

Palmer CM. Anesth Analg 2000; 90: 887-91 Palmer C. Anesthesiology 1999; 90: 437-44

Neuraxial Diamorphine

• IT diamorphine as effective as

epidural morphine

• IT: 250-375 μg

• Epidural: 2-3 mg

Husaini SW. Br J Anaesth 1998; 81: 135-9

Kelly MC. Anaesthesia 1998; 53: 231-7

Sibilla C. Int J Obstet Anesth 1997; 6: 43-8

Bloor GK. Int J Obstet Anesth 1999; 8: 11-16

Single Dose EREM vs.

Morphinemg

P=0.012

Carvalho B. Anesth Analg 2007;105:176-183

Opio

id C

onsum

ption

0

10

20

30

40

50

60

70

Vomiting Need for Oxygen Hypotension

CSE E Lidocaine

P=0.02 P=0.04

P=0.01

%

Ralls LA. Anesth Analg 2011; 113: 251-8

Higher Cmax with E (P=0.038)

Side Effects of Neuraxial

Opioids

• Pruritus (40-90 %)

• PONV (30-50 %)

• Urinary Retention

(22-58 %)

• Respiratory Depression (0-0.9 %)

8.5 %

28.4 %

28.3 %

17.1 %

17.6 %

0 5 10 15 20 25 30

Normal Weight

Overweight

Obesity Class I

Obesity Class II

Obesity Class III

n=5036, mean BMI = 34 kg/m2

Crowgey T. Anesth Analg 2013; 117: 1368-70

%

Incidence of Respiratory Depression (95 % CI)= 0 (0, 0.07) %

Modalities for Post-Caesarean

Analgesia

• Opioids

• Systemic Adjuncts

• Local Anaesthetic Techniques

• Neuraxial Adjuncts

NSAIDS

• Rectal, oral, IV, wound instillation

• Regular administration

• 30-50 % opioid sparing

• 30 % reduction in relative risk of PONV,

sedation

• RID=0.2-0.6 %Jakobi P. Isr Med Assoc J 2006; 8: 722-3

Elia N. Anesthesiology 2005; 103: 1296-1304

Marrett E. Anesthesiology 2005; 102: 1249-60

Cox-2 inhibitors

• RID = 0.23-0.3 %

• Celecoxib

– 400 mg

– ? Analgesic Efficacy

• Valdecoxib: not effectiveGardiner SJ. Br J Pharmacol 2006; 61: 101-4

Fong WP. Br. J. Anaesth. (2008) 100 (6): 861-862

Lee L. Anaesthesia 2004; 59: 876-80

Carvalho B. Anesth Analg 2006; 103: 664-70

Hale. Hum Lact 2004; 20: 397-403

Paracetamol

• Limited effect on uterine pain

• RID= 1-2 %

• IV paracetamol (1G Q 6 hrs) similar analgesia to ibuprofen 400

mg Q 6 hrs

• Proparacetamol did not provide better analgesia or enhance

diclofenac analgesia

• Paracetamol/diclofenac 38% less morphine than paracetamol

Alhashemi JA. Can J Anesth 2006; 53: 1200-6

Siddiq SM. Reg Anesth Pain Med 2001; 26: 310-5

Munishankar B. Int J Obstet Anesth 2008; 17: 9-14

Hale. Hum Lact 2004; 20: 397-403

• Combination > acetaminophen alone in 85 % of

studies

• Combination > NSAIDs alone in 64 % of studies

• Pain scores reduced by 35 %/ 37 % over

acetaminophen/ NSAIDs

• Analgesic needs reduced by 39 %/ 31 % over

acetaminophen/ NSAIDs

Ong CKS. Anesth Analg 2010; 10: 1170-9

Gabapentin

Moore A. Anesth Analg 2010; 112: 167-73

Short J. Anesth Analg 2012; 115: 1336-42

Umbilical V: Maternal V=0.86

RID=2.34 %

Pain scores on movement Pain scores at rest

Ketamine10 mg IV following

Delivery

0.5mg/kg IM followed by

2 μg/kg/min for 12 h

Bauchat JR. Int J Obstet Anesth 2011; 20: 3-9

Suppa E. Minerva Anesthesiol 2012; 78: 774-81

Tramadol

• RID= 2.24 %

• More need for rescue and more side

effects compared with naproxen

• Diclofenac/tramadol >

Diclofenac/paracetamol with more

side effectsLLett KF. Br J Clin Pharmacol 2008; 65: 661–666

Sammour RN. Int J Gynaecol Obstet 2011;113:144-7

Mitra S. Acta Anaesthesiol Scand 2012; 56: 706-11

Dexamethasone

Early Pain

(0-4 h)

Late Pain

(24 h)

Need for

rescue

analgesics

Allen TK. Anesth Analg 2012; 114: 813-22

Modalities for Post-Caesarean

Analgesia

• Opioids

• Systemic Adjuncts

• Local Anaesthetic Techniques

• Neuraxial Adjuncts

Local Anesthetic infiltration

• Minimal benefit from single infiltration

• No benefit with long-acting neuraxial

opioids

• ? Extended release bupivacaine

Trotter T. Anaesthesia 1991; 46: 404-7

Pavy T. Int J Obstet Anesth 1994; 3: 199-202

Niklasson B. Acta Obstet Gynecol Scand 2012; 91: 1433-9

Continuous LA Wound

Infiltration

• > Saline Infiltration

– Above the fascia (4 studies)

• 25-75 % Opioid sparing

– Below the fascia (1 study)

• No opioid sparing

• < Epidural Levobupivacaine

– Below the fascia Fredman B. Anesth Analg 2000; 91: 1436-40

Givens VA. Am J Obstet Gynecol 2002; 186: 1188-91

Mecklem DW. Aust NZ J Obstet Gynecol 1995; 35: 416-21

Kainu JP. Int J Obstet Anesth 2012; 21:119–124

Lavand’homme P. Anesthesiology 2007; 106: 1220-5

Ranta P. Int J Obstet Anesth 2006; 15: 189-94

Continuous LA Wound

Infiltration

• < Systemic NSAIDs

– Above the fascia

• ? Neuraxial Opioids

– < Intrathecal Morphine

• Below the fascia

– > Epidural Morphine

• Below the fasciaZohar E. J Clin Anesth 2006; 18: 415-21

Magnani E. Clin Exp Obstet Gynecol 2006;33:223–5

Kainu JP. Int J Obstet Anesth 2012; 21:119–124

O’Neill P. Anesth Analg 2012; 114: 179-85

Rackelboom T. Obstet Gynecol 2010; 116: 893-900

Intraperitoneal LA

Kahokehr A. ANZ J Surg 2011; 81: 237–245

Shahin AY. Clin J Pain 2010; 26: 121-7

Local NSAIDs Infiltration

Lavand’homme P. Anesthesiology 2007; 106: 1220-5

Carvalho B. J Pain 2013; 14: 48-56

IL-6 (P=0.01) and IL-10 (0=0.005) with K vs. B

TAP Block

No ITM

ITM

Vs. ITM

Opioid Consumption Pain on Movement

Mishriky BM. Can J Anesth 2012;59:766-78

Mirza F. Can J Anesth 2013; 60: 299-303

Lidocaine Patch

Habib AS. Anesth Analg 2009; 108: 1950-3

Modalities for Post-Caesarean

Analgesia

• Opioids

• Systemic Adjuncts

• Local Anaesthetic Techniques

• Neuraxial Adjuncts

Neuraxial Adjuncts

• Neostigmine, clonidine, ketamine,

magnesium, etc..

• Modest analgesic benefit

• Side effects

• Might reduce hyperalgesia and

sensitization

Prediction of Post CS Pain

• QSTs

– Temporal summation

– DNIC

– Electrical pain

– Heat pain

• Scar HyperalgesiaBuhagiar LM. J Anaesthesiol Clin Pharmacol 2013; 29: 465-71

Buhagiar LM. J Anaesthesiol Clin Pharmacol. 2011;27:185-91

Nielsen PR. Acta Anaesthesiol Scand. 2007;51:582-6

Ortner CM. Eur J Pain 2013; 17: 111–123

Garnot M. Anesthesiology 2003; 98: 1422-6

range (0.068–5.12). The incidence and extent of post-

operative WHA index were significantly higher in

women with preoperative SHA compared with those

with no preoperative SHA (Table 2). There was no

difference in post-operative analgesic requirements

between groups.

3.7 SHA to predict post-operative pain upon

mobilization at 48 h

Pain upon mobilization was evaluated by asking

women to report their pain while moving into the

sitting position. Preoperative SHA index was corre-

lated with VAS-S48 [(p < 0.002, r = 0.247), Fig. 2] ,

VAS-S24 (p < 0.01, r = 0.203), preoperative mTS

(p < 0.04, r = 0.164) and post-operative WHA

(p < 0.001, r = 0.608).

The presence of preoperative SHA (index > 0) pre-

dicted moderate or severe post-operative pain while

moving into the sitting position at 48 h (VAS-S48 3,

n = 78) with a sensitivity of 51%, and a specificity of

68%. PPV and NPV were both 60%.

Severe pain (VAS-S48 7, n = 20) was predicted

with a sensitivity and specificity of 60% and 62%,

respectively. PPV was 18% and NPV was 92%

(Table 3).

3.8 Study centre effect

Women at UWMC had lower preoperative mTS scores

(Appendix 4). As mTS scores were different between

centres, inferential analysis was repeated for each

centre separately and found to be higher in women

with preoperative SHA in both centres[ (HSJM: 1 [0.10;

2.0] in SHA group vs. 0 [0; 1.0] in no SHA group,

p < 0.001); (UWMC: 0.15 [0; 1.40] in SHA group vs. 0

[0; 0.10] in no SHA group, p < 0.034)] . There was no

difference in any of the recorded post-operative pain

scores (VAS-R, VAS-S, VAS-U at 12, 24 and 48 h)

between the two study centres. Therewasno difference

in post-operative opioid and non-opioid analgesic con-

sumption between women with and without SHA in

both study centres. However, overall higher rescue

analgesic use was recorded in the UWMC cohort com-

pared with the HSJM cohort (Appendix 4).

Figure 2 Correlation between preoperative scar hyperalgesia (SHA) and

post-operative pain while sitting at 48 h (VAS-S48). Solid line is the corre-

lation between VAS-S48 and a cut-off for SHA index (p < 0.002, r = 0.247).

Dashed and doted line is the correlation between VAS-S48 and SHA, if

SHA isdefined with an index > 0.75 [(n = 23 women), p < 0.05, r = 0.173].

Defining SHA with a SHA index of 1 (presented as dashed line), the corre-

lation r-value increases to 0.323 [(n = 18 women), p < 0.05].

Figure 1 Post-operative pain was tested on a 10-point visual analogue

pain scale (VAS) (0 = no pain, 10 = worst pain imaginable) at rest (R), while

sitting (S) and for uterine cramping pain (U) at 12, 24 and 48 h following

Caesarean delivery. With the exception of VAS-R24, pain scores were

always higher in women with scar hyperalgesia. SHA = women with pre-

operative scar hyperalgesia (index > 0). No SHA = women with no preop-

erative scar hyperalgesia. *p < 0.05, **p < 0.01.

Table 3 Preoperative scar hyperalgesia as pain prediction test.

n = 163 Pain upon mobilization at 48 h (VAS-S48)

SHA VAS< 3 (n = 85) VAS 3 (n = 78) VAS< 7 (n = 143) VAS 7 (n = 20)

Yes (n = 67) a16%(n = 27) b25%(n = 40) a34%(n = 55) b7%(n = 12)

No (n = 96) c36%(n = 58) d23%(n = 38) c54%(n = 88) d5%(n = 8)

Percentages express ratios of total n = 163. Sensitivity (b/(b + d)) of SHA as pain predictor: 51%for VAS-S48 3, 60%for VAS-S48 7. Specificity

(c/(a + c)): 68%for VAS-S48 3, 62%for VAS-S48 7. Positive predictive value (b/(b + a)) = 60%VAS-S48 3, 18%for VAS-S48 7. Negative predictive

value (c/(c + d)) = 60%VAS-S48 3, 92%for VAS-S48 7. SHA, preoperative scar hyperalgesia.

Scar hyperalgesia and pain in repeat Caesarean delivery C.M. Ortner et al.

116 Eur J Pain 17 (2013) 111–123 © 2012 European Federation of International Association for the Study of Pain Chapters

Prediction of Post CS Pain

• Questionnaires

– STAI

– Three simple questions

• Anxiety level

• Anticipated pain

• Anticipated analgesic need

Pan PH. Anesthesiology 2013;118: 1170-9

Pan PH. Anesthesiology 2006; 104: 417-25

Regimen at Duke

• Routine:

– Neuraxial Morphine

– Regular NSAIDs + Paracetamol

– PRN Oxycodone

• Rescue:

– TAP blocks

– Lidocaine patches

– Gabapentin

Regimen at Duke

• Opioid dependent parturients:

– PCEA

– TAP blocks

– Neuraxial Clonidine

– Gabapentin

Conclusions

• Optimal analgesia important short and

long term

• Multimodal approach

• Targeted therapy for high risk patients