Post CS analgesia A Mignon ASAO 1.3.2008

Post-CS analgesia
Is there a gold-standard ?
Dr Alexandre Mignon
DAR Cochin Port-Royal
Maternité Port-Royal
Paris, France
[email protected]
Plan
• Cesarean Section
– Epidemiology
– Indication, Anesthesia
• Rehabilitation
• How to do ?
• How to improve ?
• Our protocol in Port-Royal ?
C Section worldwide
• 160 000 cases
– > 20% deliveries
– Increasing +++
• Breech, multiple pregnancy, medical complex pregnancies, patient request …
– 2nd operation realized in France
• Despite important progress, still increased mortality & morbidity
– Bleeding, infection, DVT
• Anesthesia in less a problem
– Less GA
– Spinal or CSE gold standard for either elective or even urgent
– If epidural in place, top-up will solve > 90% of the problems
• Our New Challenges
– To much fear to GA : keep cool !
– Post op Rehabilitation
Rehabilitation
:
a
multimodal
intervention that may lead to a major
reduction in the undesirable sequelae
of surgical injury with improved
revovery
and
reduction
in
postoperative morbidity and averall
costs …
LOS
USA : C3
Suisse : ?
Reasonable : C5 ?
In my institution : C7 …
Pan et al. Anesthesiology 2006; 104(3): 417-425
Lavand’homme et al. Curr Opin Anaesthesiol 2006; 19(3):244-8
Lavand’homme et al. ASA 2007
H Kehlet, Lancet 2006
Risk factors for Chronic Pain after CS
Variables
Chronic Pain (n=27)
No (n=193)
p
Previous CS
41%
31%
ns
Previous abdominal Surgery
22%
16%
ns
Emergent CS
44%
51%
ns
Vertical incision
11%
7%
ns
Postop Infection
15%
9%
ns
BMI>25
51%
39%
ns
GA
37%
17%
<0,02
Previous pain for CS
63%
19%
<0,0001
Severe post-op pain
67%
44%
<0,04
Nikolajsen L et al., Acta Anaesthesiol Scand 2004
Postop Rehabilitation
• Surgical stress response
• Mobilisation
•Pain
• Nutrition (early feeding)
• PONV
• Ileus
• Hypoxemia
• Sleep disorders
• Fatigue
• Traditions
• Specific postop factors
– Urinary catheter
H Kehlet, BJA 1997
Pain and C-Section
Pain during and after CS is the greatest concern for
PG unlike in general surgical patients
Carvalho B et al., Anesth Analg 2001
Pain is severe and lasts at least 48-72H
Anesthetic technique has an impact on post-op pain
: Spinal > Epidural > GA
Balance Benefit/Risk favors multimodal approach
Opioids
Systemic
Epidural
Intrathecal
Early post-operative pain :
sufentanyl IT vs fentanyl IT
It allows to decrease IT Bupi
Less HypoTA
Duration of analgesia (min)
**
300
**
Time (min)
It improves intra-operative
confort and analgesia
n = 80 patients
4 groups
* p < 0.05 vs Placebo
** p < 0.05 vs Fenta
Pruritus > Gpe Suf 5
PONV, Sedation : NS
Dahlgren, Anesth Analg 1997
250
*
200
150
100
50
0
Placebo
Fenta
Suf 2,5
Suf 5
Intrathecal morphine : optimal dose
Palmer CM, Anesthesiology, 1999, 90:437-44
Cumulative PCA iv morphine use (mg)
75
*
50
0
0.1
0.2
25
0.3
0
0
4
8
12 16 20 24 Time (h)
n = 108
* p < 0.05
- pas de relation
entre la dose et
survenue de NV
- relation linéaire
entre la dose et
survenue de prurit
IT morphine : gold standard
Palmer CM et al., Anesthesiology 2001
sufentanil
IT morphine : gold standard
fentanyl
Mean Time
to rescue analgesia :
27h (11-29h)
morphine
Dahl JB et al., Anesthesiology 1999
● Ventilatory Response
to CO2 preserved
Abboud , Anesth Analg 1988
Abouleish , Reg Anesth 1991
Duration of analgesia (h)
IT Morphine : the gold standard
Prolonged analgesic efficacy (27H)
>sufentanil>fentanyl
Non dose dependent analgesia
Dose-dependent undesirable side effects
• Recommended : Morphine IT 100 µg
J Dahl, Anesthesiology 1999
Epidural Morphine : optimal dose
Palmer, Anesth Analg 2000, 90: 887-91
*
RCT dose ranging
n = 60
* p<0.05 Gpe 0 vs Gpe 2,5/3,75/5
** p<0.05 Gpe 1,25 vs Gpe 3,75/5
Undesirable side effects
→ No benefice for > 3,75 mg
70
60
**
PCA morphine
use (mg)
50
40
30
20
10
0
0
1,25 2,5
3,75
5
Epidural morphine for analgesia
after CS : a report of 4880 patients
Fuller JG et al, Can J Anaesth 1990; 37:636-40
Dose
N
Duration
(h)
Bradypnea (n)
Naloxone (n)
3 mg
225
19
0 (0)
3.5- 4 mg
373
23
1 (0)
4.5- 5 mg
4282
23
11 (3)
0.25% (0.6/1000)
Epidural
Epidural Morphine
Morphine :: Take
Take Care
Care
Ventilatory Response (L/min)
3 mg epidural Morphine
alters
ventilatory response to CO2
Obese patients
OSA
Unpredictability
3 mg epidural morphine
Yu PYH et al, Can J Anaesth 1993
dose de morphine péridurale
(mg)
Epidural Morphine
7,5
5
4
3
2
0
10
20
30
40
50
durée d'analgésie (h)
Epidural
Morphine
Prurit
Nausea
Vomiting
NNH
(IC 95%)
2 (2-3)
7 (4-55)
78 (ns)
Morphine : which route ?
Eisenach JC et al, Anesthesiology 1988,68:444
Patients (%)
*
100
*
75
*
50
Good
analgesia
Satisfaction
25
0
IM
PCA
Epidural
Undesirable side effects : sedation > PCA, itching > Epidural
Morphine : which route ?
Cohen SE et al: Regional Anesth 1991,16: 141-9
EVA (mm)
50
EM
40
30
SM
20
IM
10
0
PACU
PCA
0-8
8-16
16-24
24-48 (h)
PONV and neuraxial morphine
Nausea (%)
Vomiting (%)
IT Morphine
(100µg)
16 (8-29)
21 (13-31)
EPI Morphine
24 (0-67)
17 (0-78)
Gan TJ et al., Anesth Analg 2007
Dahl J et al. Anesthesiology 1999
NSAID are essential as a complement
“Many NSAIDs, particularly ibuprofen, are considered
usually compatible with breast-feeding
Ketorolac excretion in human breast milk is minimal
Ratio colostrum / plasma < 4%
Wischnik, Eur J Clin Pharmacol 89
Ketoprofene : non detected in colostrum before H48
Rorarius, BJA 93
NSAID required for < 48-72h
Improvement of pain scores, mainly at cough or movement
Pavy, Anesth Int Care 1995; 23: 555
-Bupivacaïne HB
NSAID
- Morphine 250 µg
- Fentanyl 15µg
-Indometacin vs placebo
Time to 1st analgesia (H)
Dennis, Anaesthesia 1995; 50: 297
- Bupivacaïne HB
50
*
40
- Morphine 200 µg
- Diclofenac vs placebo
30
Placebo
NSAID
*
20
10
0
Pavy
Dennis
Pain on movement
VAS (mm) on
movement
+ IT morphine
250 mcg
60
Placebo
40
Indomethacin
20 *
0
Day 1
Day 2
Day 3
Pavy, Anesth Int
Care, 1995, 23; 555
Pain management
• Our goals (48H)
• Neuraxial Morphine (Morphine IT)
• Systematically associated with
–
–
–
–
Paracetamol
NSAID
Nefopam
Oral morphine for rescue
• Multimodal + Undesirable Side Effects prevention
– PONV and itching
Could we do better ?
Long lasting epidural morphine
Continuous wound infiltration
Limitation of chronicisation
Carvalho Anesth Analg 2005;100:1150–8
• Depodur (morphine sulfate extended release liposome injection)
DepoFoam™ Encapsulation
DepoFoam™ Particle (diameter: 15 microns)
Drug-filled Chamber
DepoFoam™: Appearance of Formulation
Settled Particles
Resuspended Particles
Reference: SkyePharma Website. DepoFoam ™ overview.
Please see full Prescribing Information.
6
•
Vials of DepoDur™ should be gently inverted to resuspend
the particles immediately prior to withdrawal from the vial.
Aggressive agitation should be avoided.
•
Vials shown are for demonstration purposes only. Actual DepoDur™
vials are amber in color and the liquid inside is not easily visible.
Please see full Prescribing Information.
7
Continuous Wound Infiltrations
• Continuous administration of an analgesic
inflammatory drug in the surgical wound
±
anti-
– Several settings
– Several areas (sub cutaneous, pre peritoneal, intraperitoneal)
• Efficacy reported in several surgical settings
–
–
–
–
Decreased VAS scores
Less Morphine
Less Side Effects
Better Recovery
31
uJ
Am
S
l
l
Co
Li 6; 2
0
0
2
g
ur
:
3
0
4
1
9
2
3
-9
Auteur
Année
Groupes comparés
Mode / Site
Administration
Durée
d’étude
Consommation
d’opiacés
Scores de douleurs
NS au repos
• Ropivacaïne 0,2% (n=25)
• Eau Stérile (n=25)
PCIA
(10 mL/60 min)
Sus-aponévrotique
24 h
< si Ropivacaïne (H6)
< à toux/mobilisation si
Ropivacaïne
Givens
2002
• Bupivacaïne 0,25% (n=14)
• Sérum Physiologique (n=12)
Continu
(4 mL/h)
Sus-aponévrotique
48 h
< si Bupivacaïne
NS
Zohar
2002
• Bupivacaïne 0,125% (n=25)
• Bupivacaïne 0,125% + Kétamine (n=25)
PCIA
(9 mL/60 min)
Sus-aponévrotique
24 h
NS
NS
Ranta
2006
• Lévobupivacaïne 0,25% en infiltration
(n=20)
• Lévobupivacaïne 0,125% en péridural
(n=20)
Bolus
(10 mL)
Sous-aponévrotique
72 h
NS
NS
Zohar
2006
• Bupivacaïne 0,25% + Diclofénac IV (n=30)
• Bupivacaïne + Sérum Physiologique IV
(n=30)
• Sérum physiologique + Diclofénac IV
(n=30)
PCIA
(9 mL/60 min)
Sus-aponévrotique
<< si Bupivacaïne +
Diclofénac IV
< Bupi + Diclo
24 h
Magnani
2006
• Lévobupivacaïne 0,2% en infiltration
(n=10)
• Morphine 10 mg IV + Kétorolac IV 120mg
(n=10)
Continu
Sus-aponévrotique
24 h
< si Morphine IV +
Kétorolac IV
> si infiltration
• Sérum Physiologique (n=30)
• Ropivacaïne 0,2% (n=30)
• Diclofénac 300mg (n=30)
Continu
(5 mL/h)
Sus-aponévrotique
48 h
< si Diclofénac
< si Diclofénac
Fredman
2000
Lavand’homme
2007
< si Placebo +
Diclofénac IV
< Placebo + Diclofénac
Wound Infiltrations
Ropivacaine 0.2% 10mL/h
placebo
n=25/group
Fredman B et al., Anesth Analg 2000
• Patients et méthodes
– 3 groupes avec Cathéter sus-aponévrotique
• Sérum physiologique (n=30) [+ diclofenac IV]
• Ropivacaïne 0,2 % (n=30) [+ diclofenac IV]
• Diclofénac 300mg (n=30)
– Administration continue 5 mL/h pendant 48h
– Rescue PCA morphine
Groupe Diclofénac
Morphine totale
moindre
Scores de douleur
moindres
Pas de différence en
terme de douleur
chronique à 6 mois
Take home message for wound Infiltration
• Efficacy of continuous wound infiltration
rigorously confirmed by the Belgium study
is
only
• Costs are an important issue (multi-hole catheter +
elastomeric pump) : 150 Euros
It remains to establish
Which drug (for instance LA combined with NSAID)
Which site
Depending on the anesthetic technique used
Effects on chronic pain ?
Pharmaco-economic studies (micro-costing)
Rehabilitation program (including ↓LOS)
Intrathecal Clonidine and Hyperalgesia
Lavand’homme PM et al., ASA 2006 A997
• RCT
• Elective CS under spinal anesthesia
• 3 groups (n=20/group):
– Bupivacaine+sufentanil
– Bupivacaine+sufentanil+clonidine (75µg)
– Bupivacaine+clonidine (150µg)
• Questionnaire
Intrathecal Clonidine and Hyperalgesia
BS
n=20
BSC (75µg)
n=20
BC (150µg)
n=20
Hyperalgesia (H48)
(%)
53
27
16*
Residual Pain
1, 3 & 6 months (%)
35/13/6
35/22/11
11/0/0
VAS (1 à 5)
1, 3 & 6 months
2,5/2/2
2/1,5/1,5
1,5/0/0
Lavand’homme PM et al. ASA 2006 abstract A997
Analgesia for C Section
D0 post-operative :
• Variable
–
–
–
–
–
If IT : Sufentanil (2.5-5 µg) Morphine 100µg
If Epid : 3 mg morphine (I don’t do it)
Morphine SC 5-10 mg/6H
Oral morphine : sevredol 10mg/6H
Morphine iv-PCA: bolus 1 mg, lockout 5’, dose max/4H:25 mg, no
continuous perfusion
• Constant Multimodal
– Paracetamol 1gr IV en20’/ 6H
– Kétoprofene 50 mg IV /6H
– ± Nefopam IV 20 mg/6H
CS
CS Analgesia
Analgesia == Multimodal
Multimodal Analgesia
Analgesia
Opoids :
- AG : PCA / SC / PO
- Intratecal

Paracetamol
- CI : Liver disease
HELLP, SHAG
- Epidural

AINS
- CI : bleeding, ,
asthme, allergie
IHC, IR
(preeclampsia, PPT)

Nefopam
- CI : Epilepsy
Eclampsia
Glaucoma
Coronary Disease
Undesirable
Undesirable side
side effects
effects
prevention
prevention &
& treatment
treatment
To be included in our protocols
 PONV : “dose independent”
 Prevention : ondansetron or metoclopramide or dexamethasone
(5 à 8 mg)
• Treatment : Droperidol
 Pruritus : dose dependant, frequent
Which treatment ? ondansetron, anti-H1, nalbuphine 3 mg iv,
propofol 20 mg iv, naloxone 0,2 mg …
To conclude : the best scenario
• Operative period is optimized
Spinal or CSE preferred without hypoTA
• PACU :
Analgesia is initiated (morphine titration if necessary)
Oral intake (drinking Champagne ?)
Beast feeding is encouraged
Urinary catheter is removed before leaving PACU
• Light feeding in the first post op 6H
• No more IV line after 12H
• Early deambulation and baby care
• Decrease in LOS : 5 days, no more
Merci