International journal of obstetric anesthesia
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The incidence of persistent pain after cesarean deliveries (CD) varies but is much lower than after comparable surgeries. However, with over four million deliveries annually and a rising CD rate, even a low prevalence of persistent pain after CD impacts many otherwise healthy young women. Consideration of the pathophysiology of persistent pain after surgery and the risk factors predisposing women to persistent and chronic pain after CD provides insights into the prevention and treatment of persistent pain; and improves the quality of care and recovery after CD. ⋯ Persistent pain has been linked to the severity of acute postoperative pain and opioid exposure. Modified surgical techniques, neuraxial anesthesia and opioid-sparing analgesia may help limit the development of persistent and chronic pain. The goal of this narrative review is to examine the incidence of persistent pain after CD; review briefly the underlying pathophysiology of persistent pain and the transition from acute to chronic pain (with particular emphasis on the uniqueness after CD); and to review modifiable risk factors and prevention strategies that identify at-risk patients and allow tailored treatment.
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Int J Obstet Anesth · Nov 2019
Randomized Controlled Trial Comparative StudyA triple-blinded randomized trial comparing spinal morphine with posterior quadratus lumborum block after cesarean section.
What did they do?
Tamura and team randomised 176 elective CS patients to spinal anaesthesia with or without morphine, in addition to placebo or ultrasound-guided quadratus lumborum block (QLB).
And they found
Only intrathecal morphine significantly improved analgesia, not QLB whether performed with or without spinal morphine. Thus QLB probably does not improve analgesia further beyond current best practices.
Not so fast...
While this modest-sized RCT concluded that QLB did not improve pain after caesarean section, the conclusion is i) somewhat inconsistent with earlier studies that did show benefit, and ii) the adjuvant analgesic regime1 used may not be applicable to practice outside Japan.
summary
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The researchers administered the remaining 90 mcg fentanyl IV, along with droperidol 1.25 mg and acetaminophen/paracetamol 15mg/kg after baby delivery. An NSAID (diclofenac 50mg) was only provided when breakthrough pain was requested. ↩
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Int J Obstet Anesth · Nov 2019
Review Meta AnalysisInduction opioids for caesarean section under general anaesthesia: a systematic review and meta-analysis of randomised controlled trials.
Remifentanil and alfentanil effectively reduce the pressor response to intubation for general anaesthesia cesarean section, without depressing neonatal Apgar scores.
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Int J Obstet Anesth · Nov 2019
Review Meta AnalysisDifficult epidural placement in obese and non-obese pregnant women - A systematic review and meta-analysis.
Maternal obesity increases the risk of epidural failure (OR 1.8) and difficult insertion requiring multiple attempts (OR 2.2).
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Int J Obstet Anesth · Nov 2019
ReviewDural puncture epidural versus conventional epidural block for labor analgesia: a systematic review of randomized controlled trials.
Dural puncture epidural (DPE) analgesia is a modification of conventional epidural analgesia that involves the intentional puncture of the dura with a spinal needle through the needle placed in the epidural space, without a medication being injected intrathecally. There have been contradictory findings regarding better analgesia and better block quality. ⋯ There is a lack of clear evidence on either the benefits or therisks of the DPE technique, such that a recommendation for or against its routine use is premature. Two of the three studies showing a beneficial effect of DPE came from the same institution and replication of the findings by other groups is warranted.