1. Analgesia Post Emergency Caesarean Section and Educational Intervention in The Developing World Dr Michelle Gerstman Anaesthesia Registrar Alfred Hospital Melbourne

2. Hospital Nacional Guido Valdares (HNGV)

3. Introduction Caesarean sections amongst the most common surgical procedures performed in the world Pain relief is a basic human right Acute pain often poorly managed in developing world High morbidity associated with pain Small improvements can potentially have a large positive impact Simple easy to follow education regarding obstetric postoperative analgesia has wide application WHO: Mother Baby Package: implementing safe motherhood in countries (practical guide). Bosenber, A, Paediatric anaesthesia in developing countries, Current opinion in Anaesthesiology, 2007, 20:204-120

4. Current Evidence Minimal in the developing world Extensive evidence regarding multimodal analgesia in the developed world Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3 rd Edition 2010

5. Hypothesis Simple education regarding postoperative multimodal analgesia can result in significantly improved pain scores after Emergency Surgery for Caesarean Section in a Developing World setting with limited resources.

6. Study Prospective audit Analgesia prescribing patterns and pain intensity after Emergency Cesarean Section for a 48 hour period in two groups. BEFORE and AFTER simple education regarding multimodal analgesia for prescribers.

7. Analgesic Prescribing Obstetricians prescribe post op analgesia in Timor Midwives transcribe and administer Analgesics available Any combination Opioid analgesia is not prescribed

8. Methods Emergency CS –Pre education - 16 October - 1 December 2009 –Education –Post education - 10 May 2010 - 21 June 2010 Anaesthesia Registrar/Consultant Nurse anaesthetists acted as an interpreters

9. Methods: Education Obstetricians and midwives Presentation and discussion of pre-education audit data Agreement that analgesia provision was inadequate A multimodal analgesia protocol of regular tramadol, paracetamol and ibuprofen was agreed upon

10. Audit data: Primary Measures Analgesia prescribed by the surgical team in surgical notes Actual analgesia transcribed by midwives to drug chart and given on day 1 and day 2 post operatively Pain scores at rest and with movement on day 1 and day 2 post surgery verbal description of pain (5 categories) from no pain to severe pain then converted to numerical value 1-5

11. Results 54 patients were included in the pre- education audit –54/54 on day 1 –52/54 on day 2 63 in the post- education audit –63/63 on day 1 –55/63 on day 2

12. Post op analgesia

13. Analgesia Pre EducationPost Education Day 1Day 2Day 1Day 2 Tramadol alone62%12%32%11% Paracetamol alone9%35%0% Ibuprofen alone2%31%5%0% Tramadol/Paracetamol19%6%0% Tramadol/ Ibuprofen4%0% Ibuprofen /Paracetamol0%4%3%74% Tramadol/ Ibuprofen / Paracetamol 0% 57%11% Nil4%12%0%2%

14. Mean Pain scores Pre EducationPost EducationP value Day 1 Rest 2.7 ± 0.92.0 ± 0.8 0.0003 Day 1 Movement 3.7 ± 0.83.3 ± 0.8 0.0036 Day 2 Rest 2.1 ± 0.81.8 ± 0.9 0.0908 Day 2 Movement3.0 ± 0.83.0 ± 0.7 0.8858

15. Conclusion Large increase in the use of multimodal analgesia after educational intervention Significant improvement of early postoperative pain relief Successful education and implementation of knowledge after one education session

16. Discussion Less marked improvement with late pain relief –Impact of tramadol? –Rapid mobilization of patients with less use of pre-emptive analgesia? –Loss to follow up? Language/cultural issues Challenges with staff changeover Stoic patients vs. developed world

17. Discussion Different Anaesthesia Registrar Audit, not RCT Small number of patients had midline incision rather than Pfannenstiel incision

18. Future Further education sessions Retention of information - repeat audit 1 year after post education audit Written pain protocol displayed in Obstetric ward and OR Potential application to other surgical specialties Potential for opioid?

19. Acknowledgements Dr Eric Vreede – Head Department of Anaesthesia HNGV, Team Leader RACS Dr Alex Konstantatos – Analysis Dr Jane Chia – Audit 1 HNGV Nurse Anaesthetists - Translation services