4Road MapChallenges faced in managing post-operative caesarean section pain.The National Institute for Health and Clinical Excellence (NICE) Guidelines-2011:Intrathecal opioidsPCAMultimodal analgesiaReaching the standardsWay forward
6Striking a balance!! Prevention of side effects. Harmful effects on the fetus.Providing effective analgesia/ anesthesia
7If inadequately controlled…….. Subjective discomfortNeuro-endocrine responseDelayed restoration of functionIncreasing the risk of ThromboembolismInability to take care & breast feed the newbornRisk of persistent pain & depressionde Brito Cancado 2012Marcus HE et al 2011Eisenach JC et at ,Pain 2008;140:87-94
8Further challenges Unavailability of drugs & expertise. Inter-individual variability in pain response to same noxious stimuli.
9Inter-individual variability in “Pain Perception” Predicting the PainPain modelsGenetic testingpost-caesarean section pain and analgesic consumption
10Pain modelsPain 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:
11Quantitative sensory testing (QST), defined as quantifiable mechanical (pressure, punctuate, vibratory, and lighttouch), thermal (cold pain, cool, warm, and heat pain) orelectrical stimuli, was used in nearly all the studies (5 CS/14 studies)This review demonstrates that QST assessments may predictup to 54% of the variance in postoperative pain experience,particularly after cesarean section, and in development ofpersistent postsurgical pain
12Genetic 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
14The National Institute for Health and Clinical Excellence (NICE) Guidelines-2011
15Intrathecal/epidural opioids: Morphine/diamorphine Section 9.2 of The National Institute for Health and Clinical Excellence (NICE) GuidelinesIntrathecal/epidural opioids: Morphine/diamorphinePCA with morphineMultimodal analgesia:NSAIDSWound infilteration
17Spinal cord selectivity of neuraxial opioid in the treatment of acute postoperative pain Morphine & Diamorphine commonly used intrathecal opioids for caesarean section
18Monitoring after intrathecal opioids NICE guidelines on caesarean section, suggested minimum hourly observations of:Respiratory rate , sedation & pain scores for at least12 h for diamorphine24 h for morphine
19They recommended 0.1 mg morphine as the drug and dose of choice. ConclusionThere is evidence that intrathecal morphine produced a clinically relevant reduction in postoperative pain and analgesic consumptionThey recommended 0.1 mg morphine as the drug and dose of choice.However, for every 100women receiving 0.1 mg intrathecal morphine added to a spinal anesthetic:43 patients will experience pruritus,10 will experience nausea12 will experience vomiting
20Significant decrease in vomiting but no effect on nausea
22Patient controlled analgesia (PCA) The limitation of individual patient’s variability and fluctuating blood level of analgesic is overcome to some extent by the use of PCAHas 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 ®ional techniques.
23Despite 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): 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.
24S 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.
29Non-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.
30NSAIDs potentiate opioid effect decrease opioid consumption and reduce side effectsC.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.
32CONCLUSION: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
33A 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.
34Anesth Analg 2011Preoperative gabapentin 600mg in the setting of multimodal analgesia reduces post CS pain and increase maternal satisfaction19% of the patient had severe sedation as compared to 0% in the controlled groupno difference in the APGAR score or umbilical artery pH
35Low-dose S-ketamine, administered by i. m. bolus and continuous i. v 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
38The 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.
39Wound 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
40Regional Anesthesia and Pain Medicine Issue: Volume 34(6), November/December 2009, pp 586-589
41Patient-controlled i. v 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.
42Nine 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 comparedwith TAP block alone at the expense of an increased incidence of side effects.
43Therefore TAP block can be a better option for patients not receiving long acting neuraxial opioids.
44PERIPHERAL N- BLOCK (2014) (N) JAN – JULY (n=125) AUG – OCT (23) INTERSCALENE11 (8.8%)-FEMORAL10 (8%)3 (13%)BRACHEAL PLEXUS2 (1.6%)SUPRA CLAVICULAR1 (0.8%)6 (26%)AXILLARY N1(0.8%)1(4.3%)TAP BLOCK100 (80%)13 (56.%)
50The analysis of pain at rest: VAS of 4-6 in 9.5% VAS of7-10 in 0.8% S Ismail et al-Observational study to assess the effectiveness of postoperative pain management of patients undergoing elective caesarean sectionPercentage of patients having mild, moderate and severe pain scores at rest and movementThe 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 in 6.8% of patients.Patient satisfaction>90%
51A 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: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.
52The 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??
54The procedure-specific postoperative pain management (PROSPECT) Working Group provides procedure specific recommendations for postoperative pain managementtogether with supporting evidence from systematic literature reviews and related procedures at:
59Effect 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.
61ConclusionNeed to have guidelines according to availability of resources at each center.The future vision is for prediction of pain by genetic testing and pain modelsWay forward is for procedure-specific postoperative pain management
62“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