scholarly journals The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

2021 ◽  
Vol 2021 ◽  
pp. 1-20
Author(s):  
L. Sangkum ◽  
T. Thamjamrassri ◽  
V. Arnuntasupakul ◽  
T. Chalacheewa
Keyword(s):  
Cesarean Delivery ◽  
Breakthrough Pain ◽  
Preoperative Evaluation ◽  
Multimodal Analgesia ◽  
Anesthetic Techniques ◽  
Treatment Protocols ◽  
Analgesic Regimen ◽  
Pain Outcomes ◽  
Patients At Risk ◽  
Long Acting

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

The role of multimodal analgesia in preventing the development of chronic postsurgical pain and reducing postoperative opioid use

2018 ◽  
Vol 14 (6) ◽  
pp. 453-461 ◽  
Author(s):  
Wenling Jian, MD ◽  
Damoon Rejaei, MD ◽  
Ahmed Shihab, MD ◽  
Theodore A. Alston, MD, PhD ◽  
Jingping Wang, MD, PhD
Keyword(s):  
Multimodal Analgesia ◽  
Anesthetic Techniques ◽  
Opioid Use ◽  
Postsurgical Pain ◽  
Chronic Postsurgical Pain ◽  
Patients At Risk ◽  
Chronic Opioid Use ◽  
The Relationship

Chronic postsurgical pain (CPSP) is a possible complication of various surgical procedures, which can impair patients' quality of life while also contributing to chronic opioid use. Multiple biopsychosocial factors put patients at risk for CPSP. Multimodal analgesia with the use of various pharmacologic and regional anesthetic techniques can help reduce the incidence and severity of CPSP. However, the relationship between various perioperative analgesic strategies and the development of CPSP is not fully understood. Although the use of multimodal analgesia will not automatically prevent CPSP and/or prolonged opioid consumption, there is potential to do so, especially by means of regional techniques.

scholarly journals Intrathecal Morphine versus Intrathecal Hydromorphone for Analgesia after Cesarean Delivery

2020 ◽  
Vol 132 (6) ◽  
pp. 1382-1391 ◽  
Author(s):  
Emily E. Sharpe ◽  
Rochelle J. Molitor ◽  
Katherine W. Arendt ◽  
Vanessa E. Torbenson ◽  
David A. Olsen ◽  
...  
Keyword(s):  
Cesarean Delivery ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Intrathecal Morphine ◽  
Oral Morphine ◽  
Multimodal Analgesia ◽  
Rank Test ◽  
Pain Scores ◽  
Analgesic Regimen ◽  
Significant Difference

Abstract Background Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. Methods In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. Results There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan–Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). Conclusions Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

scholarly journals Bilateral posterior Quadratus Lumborum block for pain relief after cesarean delivery: a randomized controlled trial

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Pawinee Pangthipampai ◽  
Sukanya Dejarkom ◽  
Suppachai Poolsuppasit ◽  
Choopong Luansritisakul ◽  
Suwida Tangchittam
Keyword(s):  
Side Effects ◽  
Cesarean Delivery ◽  
Pain Control ◽  
Spinal Block ◽  
Side Group ◽  
Link Type ◽  
Quadratus Lumborum Block ◽  
Analgesic Regimen ◽  
Quadratus Lumborum ◽  
Median Pain

Abstract Background Achieving optimal analgesia with few side effects is the goal of pain management after cesarean delivery. Intrathecal (IT) morphine is the current standard but ultrasound-guided quadratus lumborum block (QLB) may offer superior pain control with fewer side effects. This study compared the pain-free period after cesarean delivery among parturients who received spinal block with IT morphine, with IT morphine and bilateral QLB, or only bilateral QLB. Methods Parturients having elective cesarean delivery under spinal block were randomized and allocated into IT morphine 0.2 mg with sham QLB (Group IT), IT morphine 0.2 mg and bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group IT+QLB), or bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group QLB). A PCA pump was connected after completion of the QLB or sham block. The first time to PCA morphine requirement was recorded and compared. Results Eighty parturients were included. Analysis of Group QLB was terminated early because at the second interim analysis, median pain-free period was significantly shorter in Group QLB [hours (95%CI): 2.50 (1.04–3.96) in Group IT vs. 7.75 (5.67–9.83) in IT+QLB vs. 1.75 (0.75–2.75) in QLB (p < 0.001)]. The median (min, max) amount of morphine required during 24 h was 5.5 (0–25) in Group IT vs. 5.0 (0–36) in IT+QLB vs. 17.5 (1–40) mg in Group QLB (p < 0.001). In the final analysis the median pain-free period was 2.50 (1.23–3.77) hours (95%CI) in Group IT (n = 27) vs. 8.02 (5.96–10.07) in IT+QLB (n = 28). (p = 0.027). Conclusion US-QLB used in conjunction with IT morphine yielded a statistically significant longer median pain-free period compared with standard IT morphine alone. However, QLB alone provided inferior pain control compared with standard IT morphine. When combined with IT morphine, QLB could provide additional analgesic benefit as a part of multimodal analgesic regimen, especially during the early postoperative period. Trial registration ClinicalTrials.gov no. NCT03199170 Date registered on June 22, 2017. Prospectively registered.

scholarly journals Anesthetic management for cesarean delivery in a woman with congenital atlantoaxial dislocation and Chiari type I anomaly: a case report and literature review

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yuyan Nie ◽  
Weimin Zhou ◽  
Shaoqiang Huang
Keyword(s):  
Case Report ◽  
Cesarean Delivery ◽  
Anesthetic Management ◽  
Neurological Complications ◽  
Atlantoaxial Dislocation ◽  
Epidural Needle ◽  
Team Approach ◽  
Anesthetic Techniques ◽  
Type I ◽  
Combined Spinal Epidural Anesthesia

Abstract Background The preferable choice of anesthesia for the patients with congenital atlantoaxial dislocation (CAAD) and type I Arnold Chiari malformations (ACM-I) has been a very confusing issue in clinical practice. We describe the successful administration of combined spinal-epidural anesthesia for a woman with CAAD and ACM-1 accompanied by syringomyelia. Case presentation Our case report presents the successful management of a challenging obstetric patient with CAAD and ACM-1 accompanied by syringomyelia. She had high risks of difficult airway and aspiration. The injection of bolus drugs through the spinal or epidural needle may worsen the previous neurological complications. The patient was well evaluated with a multidisciplinary technique before surgery and the anesthesia was provided by a skilled anesthesiologist with slow spinal injection. Conclusions An interdisciplinary team approach is needed to weigh risks and benefits for patients with CAAD and ACM-1 undergoing cesarean delivery. Therefore, an individual anesthetic plan should be made basing on the available anesthetic equipments and physicians’ clinical experience on anesthetic techniques.

General principles of management

2019 ◽  
pp. 25-42
Author(s):  
Andrew Davies
Keyword(s):  
Bone Disease ◽  
Rescue Medication ◽  
Breakthrough Pain ◽  
Metastatic Bone Disease ◽  
Optimal Treatment ◽  
Common Phenomenon ◽  
Related Factors ◽  
Incident Type ◽  
Analgesic Regimen ◽  
Incident Pain

Breakthrough pain is not a single entity, but a spectrum of very different entities. In most cases, the underlying cause of the pain is a direct effect of the cancer. There is emerging evidence to suggest certain oncological treatments may be effective in managing certain types of breakthrough pain. Optimal treatment of breakthrough pain depends on a variety of pain-related factors. Optimal treatment of breakthrough pain depends on a variety of patient-related factors. Avoidance or treatment of precipitating factors should be considered in patients with incident-type breakthrough pain. Movement-related/incident pain, secondary to metastatic bone disease, is a common phenomenon. Modification of the background analgesic regimen has been shown to be a useful approach in managing breakthrough pain. Multimodal approaches are often required. The cornerstone of the management of breakthrough pain episodes is the use of so-called rescue medication. The management of end-of-dose failure involves modification of the background analgesic regimen. The use of rescue medication depends on the type of breakthrough pain and acceptance depends on factors such as the route of administration of medication.

scholarly journals Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial

Pain Medicine ◽  
2019 ◽  
Vol 21 (6) ◽  
pp. 1162-1167 ◽  
Author(s):  
Erin Koffel ◽  
Allyson M Kats ◽  
Kurt Kroenke ◽  
Matthew J Bair ◽  
Amy Gravely ◽  
...  
Keyword(s):  
Sleep Disturbance ◽  
Repeated Measures ◽  
Chronic Back Pain ◽  
Sleep Problems ◽  
Brief Pain Inventory ◽  
Opioid Therapy ◽  
Response To Treatment ◽  
Medication Therapy ◽  
Analgesic Regimen ◽  
Pain Outcomes

Abstract Objective Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy. Design Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120). Methods We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups. Results The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (β = 0.058, P = 0.0002) and BPI severity (β = 0.026, P = 0.0164). Conclusions Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.

scholarly journals Use of inhaled devices during a hospital exacerbation of COPD: a summary of an interdisciplinary audit held at ICS Maugeri Pavia, Italy (March-June 2019)

2020 ◽  
Vol 90 (1) ◽  
Author(s):  
Michele Vitacca ◽  
Cinzia Lastoria ◽  
Monica Delmastro ◽  
Domenico Fiorenza ◽  
Pasquale De Cata ◽  
...  
Keyword(s):  
Treatment Algorithm ◽  
Real Life ◽  
Inhalation Therapy ◽  
Chronic Obstructive ◽  
Patient Needs ◽  
Treatment Protocols ◽  
Obstructive Pulmonary Disease ◽  
Copd Patients ◽  
Long Acting ◽  
Exacerbation Of Copd

To date treatment protocols in Respiratory and or Internal departments across Italy for treatment of chronic obstructive pulmonary disease (COPD) patients at hospital admission with relapse due to exacerbation do not find adequate support in current guidelines. Here we describe the results of a recent clinical audit, including a systematic review of practices reported in literature and an open discussion comparing these to current real-life procedures. The process was dived into two 8-hour-audits 3 months apart in order to allow work on the field in between meeting and involved 13 participants (3 nurses, 1 physiotherapist, 2 internists and 7 pulmonologists). This document reports the opinions of the experts and their consensus, leading to a bundle of multidisciplinary statements on the use of inhaled drugs for hospitalized COPD patients. Recommendations and topics addressed include: i) monitoring and diagnosis during the first 24 h after admission; ii) treatment algorithm and options (i.e., short and long acting bronchodilators); iii) bronchodilator dosages when switching device or using spacer; iv) flow measurement systems for shifting to LABA+LAMA within 48 h; v) when nebulizers are recommended; vi) use of SMI to deliver LABA+LAMA when patient needs SABA <3 times/day independently from flow limitation; vii) use of DPI and pre-dosed MDI to deliver LABA+LAMA or TRIPLE when patient needs SABA <3 times/day, with inspiratory flow > 30 litres/min; viii) contraindication to use DPI; ix) continuation of LABA-LAMA when patient is already on therapy; x) possible LABA-LAMA dosage increase; xi) use of SABA and/or SAMA in addition to LABA+LABA; xii) use of SABA+SAMA restricted to real need; xiii) reconciliation of drugs in presence of comorbidities; xiv) check of knowledge and skills on inhalation therapy; xv) discharge bundle; xvi) use of MDI and SMI in tracheostomized patients in spontaneous and ventilated breathing.

Discharge prescribing of enteral opioids after initiation as a weaning strategy from continuous opioid infusions in the Intensive Care Unit

2018 ◽  
Vol 14 (1) ◽  
pp. 35 ◽  
Author(s):  
Bridgette Kram, PharmD, BCPS, BCCCP ◽  
Kylie M. Weigel, PharmD, BCPS ◽  
Michelle Kuhrt, PharmD ◽  
Daniel L. Gilstrap, MD
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Hospital Discharge ◽  
Physical Dependence ◽  
Total Duration ◽  
Opioid Therapy ◽  
Hospital Length ◽  
Patients At Risk ◽  
Long Acting ◽  
Discharge Prescription

Objective: To evaluate the proportion of patients receiving a hospital discharge prescription for a scheduled enteral opioid following initiation as a weaning strategy from a continuous opioid infusion in the Intensive Care Unit (ICU).Design: Retrospective, observational study.Setting: Five adult ICUs at a large, quaternary care academic medical center.Patients: Endotracheally intubated, opioid-naive adults receiving a continuous opioid infusion with a concomitant scheduled enteral opioid initiated. Exclusion criteria were receipt of fewer than two enteral opioid doses, documentation of a long-acting opioid as a home medication, the indication for the enteral opioid was not a weaning strategy, death during hospital admission or discharge to hospice. Interventions: None.Main outcome measures: The proportion of ICU and hospital survivors who received a discharge prescription for a scheduled enteral opioid, total duration of continuous opioid infusion, duration of continuous opioid infusion after initiation of an enteral opioid therapy, total duration of enteral therapy, ICU and hospital length of stay.Results: Of 62 included patients, 19 patients (30.6 percent) received a new prescription for a scheduled enteral opioid at hospital discharge. The median duration of enteral opioid therapy was longer for patients who received a discharge prescription compared to those who did not (20.09 vs 8.89 days, p = 0.02), though the remaining endpoints were not different.Conclusions: Utilizing scheduled enteral opioids as a weaning strategy from continuous opioid infusions may place patients at risk of ICU-acquired physical dependence on opioids.

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