International journal of obstetric anesthesia
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Int J Obstet Anesth · Aug 2019
ReviewMonitoring, prevention and treatment of side effects of long-acting neuraxial opioids for post-cesarean analgesia.
Long-acting neuraxial opioids such as morphine and diamorphine, administered via spinal or epidural routes, are staple components of a multimodal approach to postoperative analgesia following cesarean delivery. The widespread use of neuraxial opioids is due largely to their significant analgesic efficacy and favorable safety profile. The most common side effects of neuraxial opioids are pruritus, nausea and vomiting. ⋯ The most serious complication of neuraxial opioids is respiratory depression, which occurs in 0-0.9% of cases. Hypothermia has also been reported in association with neuraxial morphine use at cesarean delivery. This article will review recent advances in prophylaxis, treatment and monitoring of the side effects of long-acting neuraxial opioids.
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Int J Obstet Anesth · Aug 2019
ReviewPost-cesarean delivery pain. Management of the opioid-dependent patient before, during and after cesarean delivery.
The opioid crisis has reached an unprecedented magnitude in the United States and worldwide, and data on opioid use and misuse in the obstetric population are extremely concerning. Despite an abundant number of studies evaluating strategies to prevent neonatal opioid withdrawal syndrome in babies born to mothers who are chronic opioid users, in babies born to mothers using chronic opioids, numerous questions remain unanswered, including (1) how to optimally manage postpartum pain in opioid-dependent patients (2) how to reconcile buprenorphine and methadone use with intrapartum and post-partum analgesia, so as to avoid opioid withdrawal during and after delivery (3) how to safely and effectively provide a stepwise multimodal approach that incorporates systemic opioid-sparing approaches, such as neuraxial opioids, clonidine, ketamine, gabapentin, and regional anesthetic blocks, to ensure adequate pain relief while avoiding opioid withdrawal (4) how to optimally manage post-partum recovery and (5) how to avoid excessive opioid prescription and possibly leftover opioids that may promote persistent use, misuse and diversion. With the recognition that an increasing number of pregnant women are taking chronic opioids, the goals of this review article are to summarize the existing literature on post-cesarean pain management in the obstetric patient with an opioid-use disorder; and to provide clinicians with a stepwise approach for management before, as well as during and after, cesarean delivery of women who have been chronically using opioids during their pregnancy.