剖宫产后疼痛管理Flood

Post Cesarean Pain Management,Pamela Flood Professor of Anesthesiology, Perioperative and Pain MedicineStanford University,The basic recipe for Patients who have Regional Anesthesia,Neuraxial Opioid 150 mcg spinal morphine or 2 mg epidural morphine Must be preservative freeScheduled oral non-steroidal anti-inflammatory drugs if not contraindicated by bleeding or allergyIbuprophen every 6 hoursNaproxen every 12 hoursKetorolac every 6 hoursScheduled oral acetaminophen 650-1000 mg given between non-steroidal doses every 6 hoursAlternating non-steroidal and acetaminophen assures steady state level of analgesic,The basic recipe for Patients who have General Anesthesia,IV Patient Controlled Analgesia Morphine (1mg, available every 6 minutes with a maximum of 10mg/hour)Fentanyl (25mcg, available every 6 minutes for a maximum of 250 mcg/hour)Scheduled oral non-steroidal anti-inflammatory drugs if not contraindicated by bleeding or allergyIbuprophen every 6 hoursNaproxen every 12 hoursKetorolac every 6 hoursScheduled oral acetaminophen 650-1000 mg given between non-steroidal doses every 6 hoursAlternating non-steroidal and acetaminophen assures steady state level of analgesic,Analgesia for Home,Oral non-steroidal anti-inflammatory drugs if not contraindicated by bleeding or allergyIbuprophen every 6 hoursNaproxen every 12 hoursKetorolac every 6 hoursOral acetaminophen 650-1000 mg given between non-steroidal doses every 6 hoursAlternating non-steroidal and acetaminophen assures steady state level of analgesicOxycodone or hydrocodone 10mg every 4 hours as needed30 pills are given but almost certainly not that many will be needed,Variability in Acute Pain and Analgesic Use,The next slides are derived from our ongoing study designed to provide a granular picture of the resolution of pain in individual women after cesarean delivery. Each parturient was contacted daily after surgery until they reported no pain, no need for medication and recovery to previous state of wellness.JACHO (Joint Commission of Hospital Organizations in United States) recommends as a goal that all patients have pain scores less than 3 after delivery.,Post Cesarean Pain With Standard Analgesic Regimen:Non-steroidal anti-inflammatory drugsAcetaminophenOpioids (Neuraxial Oral),Komotsu R, Carvalho B and Flood P. SOAP 2015,Parturients who have severe pain on POD1Require opioids for longer than those with less pain.It is not clear whether the severe pain reflects greater sensitivity to pain in general or an adverse effect of the experience.Either way, this is a red flag identifying patients who need further attention.,Why are some women in the red box?,Are they at risk for chronic pain because of their experience of acute pain after cesarean section?Is their experience of severe pain after cesarean section, despite multimodal pain treatment that works for most mothers due to previous sensitization.,0 1 2 3 4 5 6 7 Days,NRS,Sensitization: Amplification of intensity of a pain signal,Can occur in peripheral nervesAt the spinal levelOr in the Brain,Identification of Women at Risk for Severe Pain Before Birth,Questionnaire designed to identify capacity to catastrophizeLevel of anxiety Level of anticipated painHyperalgesia around old cesarean section scar (Sensitization),Strulov L, Zimmer EZ, Granot M, Tamir A, Jakobi P, Lowenstein L. Pain catastrophizing, response to experimental heat stimuli, and post-cesarean section pain. The journal of pain : official journal of the American Pain Society 2007;8:273-9Booth JL, Harris LC, Eisenach JC, Pan PH. A Randomized Controlled Trial Comparing Two Multimodal Analgesic Techniques in Patients Predicted to Have Severe Pain After Cesarean Delivery. Anesth Analg 2015.Ortner CM, Granot M, Richebe P, Cardoso M, Bollag L, Landau R. Preoperative scar hyperalgesia is associated with post-operative pain in women undergoing a repeat Caesarean delivery. Eur J Pain 2013;17:111-23.,When they are identified either pre-delivery or post-delivery, how do you treat them differently?,Several approachesHigher doses of drugs currently used?Should we be adding another modality for patients at risk?Continuous local anesthetic infusion Only during hospitalizationMay limit mobility May delay removal of urinary catheter and increase risk of infectionAdd another adjuvantGabapentinKetamineClonidine,Higher Dose of Neuraxial Opioid?,For most women, 100-200 mcg intrathecal morphine is near the top of the dose response curve. Sarvela reported equal analgesia but more rescue drug use in the 100 mcg group. The 200 mcg group reported more itching.In our study reported at 2015 SOAP, we found that patients who requested the higher dose of analgesic but were then randomly assigned a dose had more pain.Among patients who requested the higher dose, the was no difference in analgesia or rescue medication by dose received. (may have been underpowered to detect a difference).,Sarvela J, Halonen P, Soikkeli A, Korttila K. A double-blinded, randomized comparison of intrathecal and epidural morphine for elective cesarean delivery. Anesth Analg. 2002 Aug;95(2):436-40Flood P, Mirza F and Carvahlo B. Patient Preoperative Choice of Intrathecal Morphine Dose Anticipates Post-CesareanDelivery Pain and Opioid Requirement Independent of Actual Dose Received. SOAP 2015,More Intrathecal Morphine in High Risk Patients,High risk patients randomized to 300 mcg IT morphine + acetaminophen or 150 mcg ITM. Pain with movement was less in the group treated with the higher dose and acetaminophen.46 25 mm in control group versus 31 17 mm in intervention group, P = 0.009; 95% CI for the difference between means: 4 - 26 mm)Was it the acetaminophen or the increased dose of IT morphine?,Booth JL, Harris LC, Eisenach JC, Pan PH. A Randomized Controlled Trial Comparing Two Multimodal Analgesic Techniques in Patients Predicted to Have Severe Pain After Cesarean Delivery. Anesth Analg. 2015 Mar 24.,Additional Analgesic Adjuvants,IV Ketamine 10 mg intraoperative (very low dose)In parturients with no risk factors, no difference in acute pain scores or opioid utilization, but patients treated with ketamine had lower scores at 2 weeks.Unclear if there would be efficacy at in high risk patients, with a higher dose or with repeated dosing.IV Ketamine 0.25 mg/kg intraoperative without neuraxial morphineLess pain at 2, 6 and 12 hours20% had hallucinations,Bauchat JR, Higgins N, Wojciechowski KG, McCarthy RJ, Toledo P, Wong CA. Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial. Int J Obstet Anesth. 2011 Jan;20(1):3-9. Rahmanian M, Leysi M, Hemmati AA, Mirmohammadkhani M The effect of low-dose intravenous ketamine on postoperative pain following cesarean section with spinal anesthesia: a randomized clinical trial. Oman Med J. 2015 Jan;30(1):11-6. Behaeen K, Soltanzadeh M, Nesioonpour S, Ebadi A, Olapour A, Aslani SM. Analgesic effect of low dose subcutaneous ketamine administration before and after cesarean section. Iran Red Crescent Med J. 2014 Mar;16(3):e15506,Additional Analgesic Adjuvants,Intrathecal Clonidine (60-150 mcg : Thats a lot!)There was no difference in analgesia between patients who were treated with 60, 90, 150 mcg clonidine. Patients treated with 100 mcg IT morphine + 60 mcg IT clonidine had lower pain scores, used less rescue medication.Patients treated with any dose of clonidine had more sedation.Patients treated with any dose of morphine had more itching.My Conclusion- might be considered in a high risk patient but would prefer epidural use due to case reports of difficult to treat hypotension with spinal use.,Paech MJ, Pavy TJ, Orlikowski CE, Yeo ST, Banks SL, Evans SF, Henderson J. Postcesarean analgesia with spinal morphine, clonidine, or their combination. Anesth Analg. 2004 May;98(5):1460-6.,Additional Analgesic Adjuvants,Oral Gabapentin (300- 600 mg) two studies by the same group2011-In a cohort of women who were not identified as high risk for severe pain, women given gabapentin had less pain, more satisfaction and more sedationgabapentin 21 mm (CI = 13-28) and placebo 41 mm (CI = 31-50; P = 0.001). 2012-In a cohort of women who were not identified as high risk for severe pain, there was no significant difference between either dose of gabapentin or placebo.My Conclusion- The benefit of gabapentin is in high risk women and should be studied in that group.,Moore A1, Costello J, Wieczorek P, Shah V, Taddio A, Carvalho JC.Gabapentin improves postcesarean delivery pain management: a randomized, placebo-controlled trial. Anesth Analg. 2011 Jan;112(1):167-73. Short J1, Downey K, Bernstein P, Shah V, Carvalho JC. A single preoperative dose of gabapentin does not improve postcesarean delivery pain management: a randomized, double-blind, placebo-controlled dose-finding trial. Anesth Analg. 2012 Dec;115(6):1336-42.,Conversion from Acute to Chronic Pain:Why is this worth talking about?,Conversion to chronic pain occurs at high incidence in a number of surgeries including herniorrhaphy, mastectomy and thoracotomy. Lots of women have cesarean sections making even a small incidence a potential public health issue.,What is the incidence?,First trials were retrospective and used non-validated questionnaires by mail without adjustment for preexisting chronic pain.Nikolajsen L, Srensen HC, Jensen TS, Kehlet H. Chronic pain following caesarean section. Acta Anaesthesiol Scand. 2004;48:111116 (6% at 10 mo.)Sng BL, Sia AT, Quek K, Woo D, Lim Y. Incidence and risk factors for chronic pain after caesarean section under spinal anaesthesia. AnaesthIntensive Care. 2009;37:748752 (10% at 3 mo.)Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. The pfannenstiel incision as a source of chronic pain. Obstet Gynecol. 2008;111:839846 (Mod.-severe 7%, 2 yrs.)Kainu JP, Sarvela J, Tiippana E, Halmesmaki E,Korttila KT. Persistent pain after caesarean section and vaginal birth: a cohort study. Int J Obstet Anesth. 2010;19:49 (Persistent pain 18% at 1 year, Mod.-severe 8%),6-10%, That seems like a lot!,Observational trials with telephone follow-up,Eisenach JC, Pan P, Smiley RM, Lavandhomme P, Landau R, Houle TT. Resolution of pain after childbirth. Anesthesiology. 2013;118:143151 (Mixed VD and CS, 2% at 6 mo and 0.3% at 12 months)Liu TT, Raju A, Boesel T, CynaAM, Tan SG. Chronic pain after caesareandelivery: an Australian cohort. Anaesth Intensive Care. 2013;41: 496500 (12 months 4%, 1% requiring analgesia)Ortner CM, Turk DC, Theodore BR, Siaulys MM, Bollag LA, Landau R. The Short-Form McGill Pain Questionnaire-Revised to evaluate persistent pain and surgery-related symptoms in healthy women undergoing a planned cesarean delivery. Reg Anesth Pain Med. 2014 Nov-Dec;39(6):478-86 2013;118:143151 (All CS, 3% at 6 mo and 0.6% at 12 months)These numbers are quite different, why?Recall bias- you are more likely to fill out a questionnaire and mail it back if you think you had a problem.Question of severity- more able to evaluate with telephone interview,Incidence of conversion from acute to chronic pain after cesarean section - conclusion,The incidence of pain tha