Challenges faced in managing postoperative caesarean section pain.
Samina Ismail
Associate Professor
Aga Khan University
Karachi, Pakistan
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……..
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 & depression
de Brito Cancado 2012
Marcus 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
Pain models
Pain 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
(pressure, punctuate,
Thismechanical
review demonstrates
that QST vibratory, and light
touch), thermalassessments
(cold pain, cool,
maywarm,
predictand heat pain) or
electrical stimuli, was
in nearly
the studies
upused
to 54%
of the all
variance
in (5 CS/14 studies)
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 100
women 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)
Has become a gold standard for acute pain
management since it was introduced in June 1984.
The limitation of individual patient’s variability
and
fluctuating
blood level
of analgesic
is you
Works
on the Principal
of “WYNIWYG”:
what
overcome to some
extent
by the
need is
what you
get.use of PCA
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 metaanalysis, 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.
3-Multimodal analgesia
Multimodal analgesia
• 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.
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.
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.
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
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.
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 Medicine
Issue: 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 included
Conclusion 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 compared
with 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.
PERIPHERAL NPERIPHERAL
N-BLOCK
BLOCK(2014)
(2014)
JAN – JULY
(n=125)
AUG – OCT
(23)
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.%)
(N)
INTERSCALENE
Royal College of
Anaethetist (RCoA)
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”
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 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%
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??
Way Forward
The procedure-specific postoperative pain
management (PROSPECT) Working Group provides
procedure specific recommendations for
postoperative pain management
together 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