Samina IsmailAssociate Professor

Aga Khan University Karachi, Pakistan

Challenges faced in managing post-operative caesarean section pain.

Road Map

• Challenges faced in managing post-operative caesarean section pain.

• The National Institute for Health and Clinical Excellence (NICE) Guidelines-2011:

Intrathecal opioids PCA Multimodal analgesia

• Reaching the standards• Way forward

Managing post-operative caesarean section pain

Striking a balance!!

Providing effective analgesia/ anesthesia

Prevention of side effects.

Harmful effects on the fetus.

If inadequately controlled……..If inadequately controlled……..

Subjective discomfort Neuro-endocrine response

Delayed restoration of function

Increasing the risk of

Thromboembolism

Inability to take care & breast feed the newborn

Risk of persistent pain & depressionde Brito Cancado 2012Marcus HE et al 2011

Eisenach JC et at ,Pain 2008;140:87-94

Further challenges

Unavailability of drugs & expertise.

Inter-individual variability in pain response to same noxious stimuli.

Inter-individual variability in “Pain Perception”

Predicting the Pain• Pain models• Genetic testing

Predicting the Pain• Pain models• Genetic testing

Pain modelsPain models are valuable since they generate a painful stimulus under controlled and standardized conditions. Allows for an essentially unbiased assessment of an exceptionally subjective experience. Clinical application of the pressure pain model

has been validated for evaluating pain sensitivity.

Hsu Y, Somma et al .Predicting postoperative pain by preoperative pressure pain assessment. Anesthesiology 2005;103:613-8.

Kinser AM et al.Reliability and validity of a pressure algometer. J Strength Cond Res 2009;23:312-4.

Quantitative sensory testing (QST),

defined as quantifiable mechanical (pressure, punctuate, vibratory, and lighttouch), thermal (cold pain, cool, warm, and heat pain) or

electrical stimuli, was used in nearly all the studies (5 CS/14 studies)

This review demonstrates that QST assessments may predict

up to 54% of the variance in postoperative pain experience,

particularly after cesarean section, and in development of

persistent postsurgical pain

Genetic test to predict to individualize postoperative Pain therapy-2010

Landau et al tried to individualize anaesthetic care during caesarean section by identifying some genetic polymorphisms.

It was concluded that genetic test may become useful bedside screening test in predicting individual postoperative pain

therapy & development of chronic pain

Recommended Guidelines

The National Institute for Health and Clinical Excellence (NICE) Guidelines-2011

Section 9.2 of The National Institute for Health and Clinical Excellence (NICE) Guidelines

1.Intrathecal/epidural opioids: Morphine/diamorphine

2.PCA with morphine

3.Multimodal analgesia: NSAIDS Wound infilteration

(NICE) Guideline:1. Intrathecal/epidural opioids

Spinal cord selectivity of neuraxial opioid in the treatment of acute postoperative pain

Morphine & Diamorphine commonly used intrathecal opioids

for caesarean section

Monitoring after intrathecal opioids

NICE guidelines on caesarean section, suggested minimum hourly observations of: Respiratory rate , sedation & pain scores for at least

12 h for diamorphine 24 h for morphine

Conclusion

•There is evidence that intrathecal morphine produced a clinically relevant reduction in postoperative pain and analgesic consumption •They recommended 0.1 mg morphine as the drug and dose of choice.

However, for every 100women receiving 0.1 mg intrathecal morphine added to a spinal anesthetic:

43 patients will experience pruritus,10 will experience nausea 12 will experience vomiting

Significant decrease in vomiting but no effect

on nausea

2. Patient controlled Analgesia (PCA)

Patient controlled analgesia (PCA)

The limitation of individual patient’s variability and fluctuating blood level of analgesic is overcome to some extent by the use of PCA

The limitation of individual patient’s variability and fluctuating blood level of analgesic is overcome to some extent by the use of PCA

Has become a gold standard for acute pain management since it was introduced in June 1984.

Works on the Principal of “WYNIWYG”: what you need is what you get.

More recent development in PCA includes intranasal &regional techniques.

Despite being less efficacious than neuraxial administration, patient satisfaction scores are

highest with IV-PCA

B.M. Block, S.S. Liu, A.J. Rowlingson, A.R. Cowan, J.A. Cowan and C.L. Wu, Efficacy of postoperative epidural analgesia: a meta-

analysis, JAMA 290 (2003): 2455–63.

G.E. Larijani, I. Sharaf, D.P. Warshal, A. Marr, I. Gratz and M.E. Goldberg, Pain evaluation in patients receiving intravenous

patient-controlled analgesia after surgery, Pharmacotherapy 25 (2005) :1168–73.

S Ismail et al

Postoperative Analgesia Following Caesarean Section: Comparison of Intravenous Patient Controlled Analgesia with Conventional Continuous Infusion.

We found better pain score at 6, 12 and 24 hours postoperatively , less need for rescue analgesia and better pain satisfaction.

We found better pain score at 6, 12 and 24 hours postoperatively , less need for rescue analgesia and better pain satisfaction.

3-Multimodal analgesia

Multimodal analgesia

• Co-analgesic/ adjuvant drugs.• Nerve block and wound infilteration

• Co-analgesic/ adjuvant drugs.• Nerve block and wound infilteration

“Goals” of multimodal analgesia

obtain synergistic or additive analgesia with each drug with different mechanisms of action

fewer side effects by combining lesser

amounts of each drug.

obtain synergistic or additive analgesia with each drug with different mechanisms of action

fewer side effects by combining lesser

amounts of each drug.

Co-analgesic/ adjuvant drugs

Non-steroidal anti-inflammatory drugs (NSAIDs)

“Anti-inflammatory and antipyretic properties”

Reduce visceral pain originating from the uterus, complementing the somatic wound pain relief from the opioid.

“Anti-inflammatory and antipyretic properties”

Reduce visceral pain originating from the uterus, complementing the somatic wound pain relief from the opioid.

NSAIDs

potentiate opioid effect

decrease opioid consumption and reduce side effects

C.H. Wilder-Smith, L. Hill, R.A. Dyer, G. Torr and E. Coetzee, Postoperative sensitization and pain after Cesarean delivery and the effects of single im doses of tramadol and

diclofenac alone and in combination, Anesth Analg 97 (2003) : 526–33.

J.L. Lowder, D.P. Shackelford, D. Holbert and T.M. Beste, A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain

and narcotic usage, Am J Obstet Gynecol 189 (2003) : 1559–1562.

potentiate opioid effect

decrease opioid consumption and reduce side effects

C.H. Wilder-Smith, L. Hill, R.A. Dyer, G. Torr and E. Coetzee, Postoperative sensitization and pain after Cesarean delivery and the effects of single im doses of tramadol and

diclofenac alone and in combination, Anesth Analg 97 (2003) : 526–33.

J.L. Lowder, D.P. Shackelford, D. Holbert and T.M. Beste, A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain

and narcotic usage, Am J Obstet Gynecol 189 (2003) : 1559–1562.

Acetaminophen - useful alternative

CONCLUSION: Both diclofenac-tramadol and diclofenac-acetaminophen combinations can achieve satisfactory post-operative pain control in women undergoing caesarean section. The diclofenac-tramadol combination was overall more efficacious but associated with higher incidence of post-operative nausea

A newer COX-2 inhibitor, (parecoxib) was compared with Ketorolac combined with morphine on IV-PCA in post CS pain management.It was found to have efficacy equating Ketorolac with PCA morphine for an opioid sparing effect

.

Anesth Analg 2011

Preoperative gabapentin 600mg in the setting of multimodal analgesia reduces post CS pain and increase maternal satisfaction 19% of the patient had severe sedation as compared to 0% in the controlled group no difference in the APGAR score or umbilical artery pH

Anesth Analg 2011

Preoperative gabapentin 600mg in the setting of multimodal analgesia reduces post CS pain and increase maternal satisfaction 19% of the patient had severe sedation as compared to 0% in the controlled group no difference in the APGAR score or umbilical artery pH

Low-dose S-ketamine, administered by i.m. bolus and continuous i.v. infusion, reduced

morphine consumption and prolonged postoperative analgesia after cesarean

section with spinal anesthesia. Only minor side effects were detected

Nerve block and wound infiltration

The Cochrane database of 2009 indicates that local analgesia infiltration and abdominal nerve block as adjunct to regional analgesia and general anaesthesia are of benefit in caesarean section by reducing opioid consumption.

The Cochrane database of 2009 indicates that local analgesia infiltration and abdominal nerve block as adjunct to regional analgesia and general anaesthesia are of benefit in caesarean section by reducing opioid consumption.

Wound infiltration and/or ilioinguinal nerve block

Ranta et al. report the subfascial catheter administration of levobupivacaine following caesarean delivery to be a useful and safe component of multimodal pain management and a viable alternative to epidural analgesia

Regional Anesthesia and Pain MedicineIssue: Volume 34(6), November/December 2009, pp 586-589

Patient-controlled i.v. morphine without long-acting intrathecal opioids was used for postoperative pain management.

Conclusions The US-guided TAP block reduces morphine requirements after Caesarean delivery when used as a

component of a multimodal analgesic regimen.

Nine studies were includedConclusion Transversus abdominis plane block significantly improved postoperative analgesia in women undergoing CD who did not receive ITM but showed no improvement in those who received ITM. Intrathecal morphine was associated with improved analgesia comparedwith TAP block alone at the expense of an increased incidence of side effects.

Therefore TAP block can be a better option for patients not receiving long acting neuraxial

opioids.

Therefore TAP block can be a better option for patients not receiving long acting neuraxial

opioids.

PERIPHERAL N- BLOCK (2014)

(N) JAN – JULY (n=125)

AUG – OCT(23)

INTERSCALENE 11 (8.8%) -

FEMORAL 10 (8%) 3 (13%)

BRACHEAL PLEXUS 2 (1.6%) -

SUPRA CLAVICULAR 1 (0.8%) 6 (26%)

AXILLARY N 1(0.8%) 1(4.3%)

TAP BLOCK 100 (80%) 13 (56.%)

PERIPHERAL N- BLOCK (2014)

Royal College of Anaethetist (RCoA)

The standard suggests that > 90% of women should score their worst pain as < 3 on VAS of 0-10.

The standard suggests that > 90% of women should score their worst pain as < 3 on VAS of 0-10.

Every health care facility should have a goal to generate uniformly low pain scores of

“< 3 out of 10 both at rest & movement”

Every health care facility should have a goal to generate uniformly low pain scores of

“< 3 out of 10 both at rest & movement”

Have we reached the standard?

S Ismail et al-Observational study to assess the effectiveness of postoperative pain management of patients undergoing

elective caesarean section

Percentage of patients having mild, moderate and severe pain scores at rest and movementPercentage of patients having mild, moderate and severe pain scores at rest and movement

The analysis of pain at rest:• VAS of 4-6 in 9.5% • VAS of7-10 in 0.8%

The analysis of pain at movement:

• VAS 4-6 in 33.1% • VAS 7-10 in 6.8% of

patients.Patient satisfaction>90%

The analysis of pain at rest:• VAS of 4-6 in 9.5% • VAS of7-10 in 0.8%

The analysis of pain at movement:

• VAS 4-6 in 33.1% • VAS 7-10 in 6.8% of

patients.Patient satisfaction>90%

A literature search revealed that we are not the only one failing this target .

• Noblet J, Plaat F. Raising the standard…to unachievable heights? Anaesthesia 2010; 65: 87–8.

• Halpern S, Yee J, Oliver C, Angle P. Pain relief after Cesarean

Section: a prospective cohort study. Canadian Journal of Anesthesia 2007; 1: 44214.

• Wrench IJ, Sanghera S, Pinder A, Power L, Adams MG. Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard. International Journal of Obstetric Anesthesia 2007; 16: 17–21.

A literature search revealed that we are not the only one failing this target .

• Noblet J, Plaat F. Raising the standard…to unachievable heights? Anaesthesia 2010; 65: 87–8.

• Halpern S, Yee J, Oliver C, Angle P. Pain relief after Cesarean

Section: a prospective cohort study. Canadian Journal of Anesthesia 2007; 1: 44214.

• Wrench IJ, Sanghera S, Pinder A, Power L, Adams MG. Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard. International Journal of Obstetric Anesthesia 2007; 16: 17–21.

The result of these studies and our results showed a patient satisfaction of >90%.

This raises the question of the need to reconsider pain relief and its assessment in CS patient??

The result of these studies and our results showed a patient satisfaction of >90%.

This raises the question of the need to reconsider pain relief and its assessment in CS patient??

Way Forward

The procedure-specific postoperative pain management (PROSPECT) Working Group provides procedure specific recommendations for postoperative pain managementtogether with supporting evidence from systematic literature reviews and related procedures at:

http://www.postoppain.org

Effect of Anaesthesia technique on postoperative pain

Effect of surgical technique on postoperative pain

Conclusion: Exteriorization of the uterus for repair of the uterine incision increases the first- and second-night postoperative pain significantly in women undergoing cesarean section.

Conclusion

• Need to have guidelines according to availability of resources at each center.

• The future vision is for prediction of pain by genetic testing and pain models

• Way forward is for procedure-specific postoperative pain management

“The position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged by the care given to her at the birth of her child”

Haggard HW. Devils, drugs and doctors: The theory of

the science of healing from medicine man to doctor. 1929; New York

Thanks