Review of available options for post c-section pain relief. Reasonable pain management.
Dr I. Kozlov
Anesthesia Department, Wyckoff Heights Medical Center, Brooklyn NY, USA
Reasonable analysis of available options for post c-section pain relief brings us to conclusion that repeated doses of epidural opioids, supplemented by NSAIDS (Ketorolac) is a option of choice.
Keywords: neuroaxial opioids ,intrathecal , epidural morphine,iv opioids-,-pca morphine , po opioids ,percoset ,TAP blocks,pcea infusion of local anesthetics and opioids, NSAIDS .
Review of available options
Here we offer attempt on reasonable analysis , reflection , and concept itself of pain management of post c-section pain. From the very start we admit that in our institution we leave epidural catheter for 3 days and give epidural opioids twice a day (in am and in pm) for 3 day stay (Morphine 2mg BID or Dilaudid 0,5mg BID epidurally) , supplemented by Ketorolac 30mg IV BID. We ll explain why this regimen is reasonable, what advantages it allows, and that it offers results , unachievable by other methods.
So we will try analyze problem, solution, and available methods.
Problem: woman stays in our hospital for 3 days post c-section. Degree of pain during first 3 days requires opioids.(local anesthetics only could be used by PCEA continued for 3 days , but will prevent ambulation of patient). We need to find out what are optimal routs of administration of opioids and find optimal.We aim for perfection.Please see our patients testimonials at :
We chose ideal models–women who went for repeat c-section. Before they had PCA, IV or oral opioids. This time epidural opioids for 3 days. They know the difference.
What character of pain we are dealing with? Main source of pain is peritoneum , that was cut during surgery, not muscles or skin. Woman usually does not have pain at rest, but any effort create tension in abdominal wall —coughing, laughing, deep breathing, putting baby on the belly, moving bowels, farting,—-all what irritate damaged peritoneum will create sharp pain.
Optimal solution should be:
2)exclude sedation ,
3)allow ambulation of patient ,
4)easy to perform ,
5)less side effects,and if side effects–treated easily last for 3 days
Lets look in details for available options:
1) neuroaxial, hydrophilic opioids (intrathecal or epidural Morphine or Dilaudid)
–most effective, (but intrathecal last only from 12 to 24 h , does not cover 2 and 3 day,)
–no sedation (this is very important part—almost nowhere in Obstetric anesthesia literature made clear statement that hydrophilic epicure lopioids does not cause sedation, and distinction from lypophilic epidural opioids(like Fentanyl) that do cause sedation.
–early ambulation of patient , no motor block,
—easy to perform
–side effect –nausea,–
pruritis — easily treated with Nubane IV
respiratory depression—very rare, easy to treat, should be looked in context of absence of sedation, fear of this complication(respiratory depression) prevents to use this technique in many hospitals.
2) iv pca–
–not preventive(on demand –if i give you button to push i promise you pain),
—pt can not ambulate, nausea ,
–side effects–pruritis ,nausea
—possible pump malfunction
3) oral opioids–
—could be preventive (q4h percoset),
—-but heavy sedation
–can not be used if pt NPO, or vomiting
–side effects–pruritis, nausea
4) TAP blocks
– less effective than intrathecal morphine,
–difficult to perform, only for 1st day,
—side effects of penetrating abdominal wall , toxic dose of local anesthetics,
—ambulation of patients?
5) PCEA opioids and local anesthetics—
–for 1st day only,
– no ambulation–motor block(risk of fall),
— needs pump
—easy to perform
— not enough by themselves –only as a substitution
most effective route of administering opioids —-is neuroaxial opioids, but epidural catheter should be left for 3 days ,that dose could be repeated and given twice a day (effective reliably only for 12 h) morphine 2 mg bid and supplemented by Ketorolac 30 mg iv BID(minimize risk of respirator depression) and Ketorolac for breakthrugh pain.
Sedation–important distinction must be made: as a lipophilic (like fentanyl–onset of action and duration is almost the same iv or epidural) cause sedation —absorbed quickly
hydrophilic opioids (morphine—onset iv immediate , epidural in 60-90 min, duration iv 2 h , epidural 12-24 h)–no sedation , absorbed very slowly (old italian article).
In obstetric anesthesia literature and in discussion with my colleagues, i noticed that possibility of respiratory depression is never discussed together with absence of sedation . Most of obstetric anesthesiologist are not aware of absence of sedation during administration of neuroaxial opioids, effect that is known and discussed in pain management ( intrathecal morphine pumps).Cachectic patients with pancreatic cancer can use intrathecal pumps, but healthy post partum women can not get repeated epidural opioids? We need to look more in chronic pain management area to be more comfortable to use this technique. This absence of sedation makes this technique (repeated doses of epidural opioids) especially attractive and practical. The only known institution that uses post c-section epidural opioids , known to us, is Yale-New Heaven Hospital,(5) but they leave catheter for 36 h only, and give excessive amount of Morphine and Meperidine. The same results can be reached by much less amount of opioids. Neuroaxial opioids are used in abdominal or cardiac surgeries with great success. We believe this technique is option of choice for any abdominal surgery.
Proper monitoring of vital signs and respiratory rate. ASA recommend q1h . Lets see if this recommendation is reasonable.For comparison: patients on PCA are monitored q4h , PCA causes sedation and is more dangerous than neuroaxial opiods . We do not see any reason why patients on neuroaxial opioids should be monitored more often then PCA. ASA does not provide reasonable answer. Another example: cancer patients with intrathecal morphine pump are sent home without any monitoring. Why this could be done? We should not forget the fact that pregnant and postpartum woman have higher respiratory drive , than regular people. That diminishes risk of respiratory depression too. We thing that changing to less strict guidelines of monitoring can help to spread this technique. If we do not use our reason we will live in continuos fear of complication and law suits, and will not use what is best for the patient.
Epidural morphine(or dilaudid or any other hydrophilic opioid) continued BID for 3 days , supplemented by Ketorolac IV is only option with avoiding sedation, preventive,allows early ambulation, side effects are easily treatable .
Pruritis could be treated with nubane (effect in 60 sec)
nausea vomiting is not worse than other opioids, pregnant women are accustomed to nausea during pregnancy anyway.
In this little work we suggest on using reason and common sense more in dealing with post c-section pain. We cam make progress only if we start asking ourselves not what we do, but why we do it, what is the reason behind it. Our reflection is suggestive only.
Reflecting on available options, on our personal experience, we come to conclusion that epidural opioids twice a day , supplemented with Ketorolac IV is the most optimal option for pain relief post c-section.This is only method that has all desirable features:1) preventive,2)early ambulation, 3) absence of sedation 4)easy to perform 5) minimum of side effects. Important distinction between action of hydrophilic (Morphine, Dilaudid) and lypofilic opioids (Fentanyl) , thats is expressed in absence of sedation when using hydrophilic opioids ,should be emphasized more in obstetric anesthesia literature, to allow more anesthesiologist consider and use epidural opioids for post op pain relief. We truly believe that epidural opioids could be option of choice not only post c-section, but in any abdominal or thoracic surgery.
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