Samina Ismail

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Challenges faced in managing post-operative
caesarean section pain.
Samina Ismail Associate Professor Aga Khan
University Karachi, Pakistan
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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

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Managing post-operative caesarean section pain
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Striking a balance!!
Prevention of side effects. Harmful effects
on the fetus.
Providing effective analgesia/ anesthesia
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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 200814087-94
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Further challenges

• Unavailability of drugs expertise.
• Inter-individual variability in pain response to
  same noxious stimuli.

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Inter-individual variability in Pain Perception

• Predicting the Pain
• Pain models
• Genetic testing

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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 2005103613-8.
Kinser AM et al.Reliability and validity of a
pressure algometer. J Strength Cond Res
200923312-4.         
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Quantitative sensory testing (QST), defined as
quantifiable mechanical (pressure, punctuate,
vibratory, and light touch), 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
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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
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Recommended Guidelines
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The National Institute for Health and Clinical
Excellence (NICE) Guidelines-2011
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Section 9.2 of The National Institute for Health
and Clinical Excellence (NICE) Guidelines

• Intrathecal/epidural opioids Morphine/diamorphine
  
• PCA with morphine
• Multimodal analgesia
• NSAIDS
• Wound infilteration

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• (NICE) Guideline
• Intrathecal/epidural opioids

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Spinal cord selectivity of neuraxial opioid in
the treatment of acute postoperative pain
Morphine Diamorphine commonly used intrathecal
opioids for caesarean section
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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

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• 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

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Significant decrease in vomiting but no effect on
nausea
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• 2. Patient controlled Analgesia (PCA)

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Patient controlled analgesia (PCA)

• The limitation of individual patients
  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.
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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) 245563.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) 116873.
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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.

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• 3-Multimodal analgesia

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Multimodal analgesia

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

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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.

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Co-analgesic/ adjuvant drugs
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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.

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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)
  52633.
• 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)
  15591562.

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Acetaminophen - useful alternative
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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
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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

• .

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• 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

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 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
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• Nerve block and wound infiltration

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• 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.

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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

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Regional Anesthesia and Pain MedicineIssue
Volume 34(6), November/December 2009, pp 586-589
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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.
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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.
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• Therefore TAP block can be a better option for
  patients not receiving long acting neuraxial
  opioids.

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PERIPHERAL N- BLOCK (2014)
PERIPHERAL N- BLOCK (2014)
(N) JAN JULY (n125) 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.)
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Royal College of Anaethetist (RCoA)

• The standard suggests that gt 90 of women should
  score their worst pain as lt 3 on VAS of 0-10.

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• Every health care facility should have a goal to
  generate uniformly low pain scores of
• lt 3 out of 10 both at rest movement

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Have we reached the standard?
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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 satisfactiongt90

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• A literature search revealed that we are not the
  only one failing this target .
• Noblet J, Plaat F. Raising the standardto
  unachievable heights? Anaesthesia 2010 65 878.
• 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 1721.

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• The result of these studies and our results
  showed a patient satisfaction of gt90.
• This raises the question of the need to
  reconsider pain relief and its assessment in CS
  patient??

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Way Forward
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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.pos
toppain.org
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Effect of Anaesthesia technique on postoperative
pain
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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.
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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

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• 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
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• Haggard HW. Devils, drugs and doctors The theory
  of the science of healing from medicine man to
  doctor. 1929 New York

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• Thanks