American Society of Regional Anesthesia and Pain Medicine February 2015 - (Page 17)
Optimal Postcesarean Delivery Pain Management
O
ne-third of deliveries in the United States are by cesarean.
Anesthesiologists must consider the long-term consequences
of exposure to major surgery and postoperative pain in this
large group of patients. A survey of pregnant women showed that
the most pressing fear among parturients is pain during and after
cesarean delivery.1 Previous studies have shown that tissue trauma
from surgery is a common cause of chronic pain and disability,
particularly among women.2 In a multicenter trial, Eisenach et al
found the severity of acute postpartum pain was independently
associated with the risk of developing chronic postpartum pain
and depression, regardless of mode of delivery.3 These findings
underscore the importance of carefully addressing postcesarean
delivery pain. In 2006, the American Society of Anesthesiologists
Task Force on Obstetric Anesthesia recommended neuraxial opioids
(usually intrathecal or epidural morphine) as an important mainstay
for postcesarean analgesia;4 however, some parturients are not
candidates for neuraxial opioid and, in most patients, a multimodal
approach allows for lower opioid doses and fewer adverse effects.
In this article, we will highlight treatment strategies that may help
anesthesiologists provide patients with optimal postcesarean
analgesia.
TRANSVERSUS ABDOMINIS PLANE BLOCK
The transversus abdominis plane (TAP) block involves injection
of a large volume of local anesthetic into the plane between the
internal oblique and
transversus abdominis
muscles and can
provide postoperative
analgesia for abdominal
surgery. Techniques
include a landmarkassisted approach and
several ultrasound-guided approaches, including anterior obliquesubcostal, mid-axillary, and posterior approaches. The pattern of
spread of local anesthetic differs depending on the site of injection,
and this may have important implications for the efficacy of the
block.5 Compared to placebo, TAP blocks have been shown to
decrease postcesarean pain scores and morphine consumption for
up to 48 hours postoperatively in women receiving standard spinal
anesthesia without intrathecal opioids.
Samir Patel, MD
Instructor
Cynthia A. Wong, MD
Professor and Vice-Chair
Department of Anesthesiology
Northwestern University Feinberg School of Medicine
Chicago, Illinois
Section Editors: Brian Harrington, MD, and Steven Orebaugh, MD
contrast, the IT saline/TAP bupivacaine group had the highest
morphine consumption at 24 hours. These findings suggest that
TAP blocks do not offer analgesic benefit over IT morphine, nor
do they supplement analgesia from IT morphine in the setting of
multimodal analgesia.
A 2012 systematic
review and meta-analysis
analyzed five randomized
controlled trials (RCT)
comparing TAP blocks
with placebo in cesarean
deliveries.7 The trials
were stratified based on whether or not intrathecal morphine was
used as part of the analgesic regimen. The primary outcome was
IV morphine consumption during the first 24 hours; pain scores
and opioid-related adverse effects were secondary outcomes.
TAP block reduced the mean 24-hour morphine consumption if
IT morphine was not used. VAS pain scores (10-cm line) were
reduced by 0.8 cm, and the incidence of opioid-related adverse
effects was reduced as well. In contrast, there were no differences
in primary or secondary outcomes when the TAP block was used in
conjunction with IT morphine. Thus, TAP blocks provide analgesic
benefit to patients in the setting of a multimodal regimen that
does not include IT morphine. These blocks are best reserved for
patients who are not candidates for neuraxial morphine, including
women who receive general anesthesia and perhaps those who
have breakthrough pain following IT morphine.
"A multimodal analgesic approach is likely
the best approach for optimal postcesarean
pain management."
A 2011 trial addressed whether a TAP block augmented analgesia
in parturients who received intrathecal morphine analgesia.6
Subjects undergoing elective cesarean delivery were randomized
to receive intrathecal (IT) morphine or saline and a TAP block
with either 2 mg/kg bupivacaine or saline (four groups). All
patients received a standard multimodal postpartum analgesic
regimen. The primary outcome was pain with movement assessed
with a visual analogue scale (VAS). The groups that received
IT morphine had the lowest pain scores with movement and
the lowest morphine consumption at 6 hours after delivery. In
Of concern are studies that suggest the plasma concentrations of
local anesthetics injected during a TAP block may approach levels
consistent with local anesthetic systemic toxicity.8 Indeed, seizures
American Society of Regional Anesthesia and Pain Medicine
2015
17
3
Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine February 2015
In Memoriam : Alon Palm Winnie, M.D., ASRA Founding Father
President’s Message
Editorial
40th Annual Regional Anesthesiology and Acute Pain Medicine Meeting
Resident and Fellow Events at the 2015 Spring Meeting
How We Do It: Managing an Acute and Perioperative Pain Medicine (APPM) Service at the University of Florida
Ketamine—an Old Drug with New Tricks
Optimal Postcesarean Delivery Pain Management
Palliative Care and Pain Medicine—Beyond Intrathecal Pumps and Opioids
Scientist Spotlight—Dr. Guy Weinberg, Trailblazer in Patient Safety
American Society of Regional Anesthesia and Pain Medicine February 2015
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