Enhanced Cesarean Analgesia

1. 2019 CSA Fall Anesthesia Conference Enhanced Cesarean Analgesia Ronald B. George, MD FRCPC Professor, Anesthesia & Perioperative Care Chief, Obstetric Anesthesia Betty Irene Moore Women’s Hospital at Mission Bay University of California San Francisco (C) Ronald George, MD FRCPC

2. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 ๏Briefly discuss the consequences of inadequately managed postcesarean analgesia ๏Discuss the evidence to support neuraxial morphine as the primary analgesic postcesarean. ๏Describe the evidence in support of multimodal postcesarean analgesia. ๏Describe an approach to postcesarean analgesia for all women Learning Objectives (C) Ronald George, MD FRCPC

3. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Incidence of chronic pain after surgery Type of Operation Incidence of Chronic Pain (%) Incidence of Chronic Severe Pain (%) Amputation 30–85 5–10 Thoracotomy 5–65 10 Mastectomy 11–57 5–10 Inguinal hernia 5–63 2–4 Coronary bypass 30–50 5–10 Cesarean delivery 6–55 4 Cholecystectomy 3–50 Not estimated Vasectomy 0–37 Not estimated PAIN Clinical Updates 2011; Vol XIX, Issue 1: iasp-pain.org (C) Ronald George, MD FRCPC

4. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 (C) Ronald George, MD FRCPC

7. @Ron_George #CSAHSFall2019Anesthesiology 2014; 121:1056-67 (C) Ronald George, MD FRCPC

8. @Ron_George #CSAHSFall2019 (C) Ronald George, MD FRCPC

9. @Ron_George #CSAHSFall201911.2 %(C) Ronald George, MD FRCPC

10. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 J Obstet Gynaecol Can 2017;39(9):734(C) Ronald George, MD FRCPC

11. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 NumberofParticipants (%) 0 25 50 75 100 Cesarean Delivery Yes No Pain No Pain NumberofParticipants (%) 0 25 50 75 100 Cesarean Delivery Yes No 2 Weeks 3 Months (C) Ronald George, MD FRCPC

15. S E T T H E B A R(C) Ronald George, MD FRCPC

17. @Ron_George #CSAHSFall2019 • > 95% women should be satisfied with analgesia on day 1 post-cesarean delivery. • 100% women should receive subarachnoid or epidural morphine if cesarean performed with regional anesthesia. • Unless contraindicated, 100% women should be prescribed regular NSAIDs (C) Ronald George, MD FRCPC

18. Obstet Gyne 2017;130:29 (C) Ronald George, MD FRCPC

19. Obstet Gyne 2017;130:29 (C) Ronald George, MD FRCPC

20. (C) Ronald George, MD FRCPC

25. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 A&A 2002;95:741 (C) Ronald George, MD FRCPC

26. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 AJOG 2003;189:1559 (C) Ronald George, MD FRCPC

35. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Anesth Analg 2019;129:458–74 (C) Ronald George, MD FRCPC

36. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 ๏Neuraxial morphine provides superior analgesia ๏Neuraxial opioids do not increase the risk of respiratory depression compared to systemic opioids after cesarean delivery ๏Monitoring should be appropriately adjusted for high-risk patients SOAP Task Force Summary Points Anesth Analg 2019;129:458–74 (C) Ronald George, MD FRCPC

42. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 ๏Dexmedetomidine ๏Gabapentin ๏Ketamine Alternatives / Adjuncts (C) Ronald George, MD FRCPC

44. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 24 h morphine consumption MD: 7.2 mg; 95%CI: [11.4 to 3.0 mg](C) Ronald George, MD FRCPC

45. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Intraop Hypotension OR: 2.8 95%CI: [1.4 to 6.0 mg](C) Ronald George, MD FRCPC

50. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Anesthesiology 2013; 118:1170-9 (C) Ronald George, MD FRCPC

51. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 1. How anxious are you about your upcoming surgery? 2. How much pain do you anticipate experiencing after your upcoming surgery? 3. How much pain medication do you anticipate needing after your upcoming surgery? (C) Ronald George, MD FRCPC

52. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Anesthesiology 2013; 118:1170-9 (C) Ronald George, MD FRCPC

53. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Are women having a cesarean delivery interested and engaged in shared decision- making regarding postoperative analgesia? George RB, Eaghn E, MacCormick H, Carvalho B; Unpublished, Manuscript in preparation •55% were passive in the decisions regarding pain management •68% wish to play a collaborative or active role in decisions related to pain medication (C) Ronald George, MD FRCPC

62. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 •Response to the ACOG, SMFM, and Academy of Breastfeeding Medicine….oxycodone may also result in increased risks in infants breastfed by women •Long history of safe use of oxycodone •Limited provider experience with alternative opioids •Oral or intravenous opioids should be used for rescue analgesia only, at the lowest effective dose, and for the shortest duration possible. •Awareness should be raised about the risk of maternal and neonatal adverse effects in all breastfeeding mothers taking opioids.(C) Ronald George, MD FRCPC

63. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 TAP Blocks (C) Ronald George, MD FRCPC

64. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Mishriky BM, George RB, Habib AS. CJA 2012 59:766-78 (C) Ronald George, MD FRCPC

65. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 Habib AS, et al. SOAP 2019 - RCT (C) Ronald George, MD FRCPC

66. @Ron_George #CSAHSFall2019 Group 1 - M+ QLB+ Group 2 - M+ QLB- Group 3 - M- QLB+ Group 4 - M- QLB- (C) Ronald George, MD FRCPC

68. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 ๏Discuss post-cesarean pain and analgesia with patients - manage expectations - SDM ๏Neuraxial Morphine (<= 150 mcg) ๏Phenylephrine & antiemetics ๏Maximize Non-opioid PO adjuncts • Scheduled Acetaminophen & NSAIDs ๏PRN PO Opioids ๏Encourage a discussion with discharge physician Elective CD - Spinal (C) Ronald George, MD FRCPC

69. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 ๏ Neuraxial Morphine ๏ Consider IV ketorolac & PR Tylenol Labour CD - Epidural (C) Ronald George, MD FRCPC

72. #IARS2019 2019 CSA FALL ANESTHESIA CONFERENCE Nov 4-8, 2019, Kauai, Hawaii #CSAHSFall2019 ๏ Minimize GA ๏ QLB / TAP GA Cesarean (C) Ronald George, MD FRCPC

73. Questions? ronald.george@ucsf.edu @Ron_George (C) Ronald George, MD FRCPC

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