Does Multimodal Analgesia with Acetaminophen, Nonsteroidal Antiinflammatory Drugs, or Selective Cyclooxygenase-2 Inhibitors and Patient-controlled Analgesia Morphine Offer Advantages over Morphine Alone?

Purpose:To compare the effects of iv acetaminophen with those of oral ibuprofen with respect to postoperative pain control and morphine requirements in patients receiving morphine patient-controlled iv analgesia (PCIA) after Cesarean delivery.Methods: Forty-five term patients scheduled for Cesarean delivery were randomized to receive acetaminophen 1 g iv every six hours plus oral placebo (group A) or ibuprofen 400 mg po every six hours plus iv placebo (group I); the first dose of study drug was given 30 min preoperatively. Postoperatively, all patients received PCIA for 48 hr using morphine bolus dose 2 mg iv, lockout interval ten minutes, and no basal infusion. Visual analogue scale (VAS; 0 to 10) at rest and morphine requirements were recorded every hour for four hours then every four hours for a total of 48 hr postoperatively. Patient satisfaction was recorded on a ten-point scale (from 1 to 10) 48 hr postoperatively.Results: Visual analogue scale scores decreased similarly in both groups over time, however, there were no differences between groups at any time during the study period (estimated marginal means: 1.4 ± SEM 0.2 vs 1.9 ± SEM 0.2 for groups A and I, respectively, P = 0.124). Cumulative doses of postoperative morphine were 98 ± 37 vs 93 ± 33 mg for groups A and I, respectively (P = 0.628). Patient satisfaction with analgesia was high in both groups (9 ± 1 vs 9 ± 1, P = 0.93). Conclusion:Intravenous acetaminophen is a reasonable alternative to oral ibuprofen as an adjunct to morphine patient-controlled analgesia after Cesarean delivery. Objectif

Section: Study Limitationsmentioning

confidence: 99%

Intravenous acetaminophenvs oral ibuprofen in combination with morphine PCIA after Cesarean delivery

Alhashemi

Alotaibi

Mashaat

et al. 2006

“…At our institution, the obstetricians may withhold postoperative NSAIDs because of continued localized bleeding in the surgical field, uterine atony or inadequate uterine tone, and any medical condition in which NSAIDs are contraindicated. The type of analgesia provided by NSAIDs has been shown to be directed against the visceral cramping pain occurring after Cesarean delivery; 20,21 however, all three patients complained of predominantly somatic incisional pain (as opposed to visceral pain) for which TAP blocks are particularly indicated. [8][9][10] The analgesic efficacy of TAP blocks for these three women indicates that the pain was likely predominantly somatic incisional pain.…”

Section: Discussionmentioning

confidence: 99%

Transversus abdominis plane blocks for rescue analgesia following Cesarean delivery: a case series

Mirza

Carvalho

2012

Purpose The role of routine transversus abdominis plane (TAP) blocks at the time of surgery for Cesarean delivery analgesia is uncertain. Previous studies have shown no additional analgesic benefit in patients receiving intrathecal morphine. We present a series of three cases where TAP blocks were used for rescue analgesia in patients who had severe post-Cesarean delivery pain after a standard spinal anesthetic containing bupivacaine 12 mg, fentanyl 10 lg, and morphine 200 lg. Clinical features All three women experienced severe incisional pain in the postanesthetic care unit (PACU) after offset of spinal anesthesia. When the pain did not subside with intravenous opioids, the women were offered either additional intravenous opioids or a TAP block. They chose the latter. Bilateral TAP blocks were performed in a sterile posterior approach under ultrasound guidance with 0.375% ropivacaine 20 mL with epinephrine 1:400,000. All three patients experienced significant pain relief that lasted 10-19 hr and allowed for a timely discharge from the PACU. Conclusion These cases show that TAP blocks may play a valuable role as a rescue analgesic technique rather than as a routine preemptive block for all Cesarean delivery patients. Use of TAP blocks reduced the need for escalating intravenous opioid doses and potential maternal opioid-related side effects. Rescue TAP blocks should be considered after Cesarean delivery when intrathecal morphine does not provide adequate pain relief or for early breakthrough pain after offset of spinal anesthesia. RésuméObjectif Le rôle du bloc dans le plan du muscle transverse de l'abdomen (transversus abdominis plane block -TAP block) de routine pour l'analge´sie au moment de la chirurgie pour un accouchement par ce´sarienne est incertain. Les e´tudes pre´ce´dentes n'ont de´montre´aucun avantage analge´sique supple´mentaire chez les patientes recevant de la morphine intrathe´cale. Nous pre´sentons une se´rie de trois cas dans lesquels des TAP blocks ont e´te´utilise´s pour une analge´sie de secours chez des patientes qui souffraient de fortes douleurs apre`s un accouchement par ce´sarienne, pour lequel elles avaient reçu un anesthe´sique rachidien standard contenant de la bupivacaı¨ne 12 mg, du fentanyl 10 lg et de la morphine 200 lg. É léments cliniques Les trois femmes ont souffert de fortes douleurs au site d'incision en salle de re´veil, une fois l'effet de la rachianesthe´sie passe´. Lorsque la douleur ne s'est pas amenuise´e avec des opioı¨des intraveineux, on a propose´aux patientes des opioı¨des intraveineux supple´mentaires ou des TAP blocks, qu'elles ont choisi. Des TAP blocks bilate´raux ont e´te´re´alise´s par une approche poste´rieure ste´rile sous e´choguidage avec 20 mL de ropivacaı¨ne 0,375 % et 1:400 000 d'e´pine´phrine. Les trois patientes ont ressenti un soulagement important de la douleur d'une dure´e 10-19 h, ce qui a permis un conge´opportun de la salle de re´veil. Conclusion Ces cas de´montrent que les TAP blocks pourraient jouer un rôle pre´cieux en tant que te...

“…The concept relies on using multiple analgesic drugs with different modes of action (for example non-opioids combined with an opioid) There is now good evidence that this approach improves analgesia due to additive or synergistic effects, permitting the doses of the individual drugs to be reduced, thereby reducing the incidence and severity of adverse effects. 20 The administration of non-opioid oral agents for postoperative pain would avoid the respiratory depression and drowsiness associated with opioids, but the limited analgesia makes them useful only as adjuncts. Legeby et al 21 reported that after breast surgery the addition of non-steroidal anti-inflammatory drugs (NSAIDs) to paracetamol and opioid-PCA reduced opioid consumption and improved pain relief at rest, but not convincingly during mobilization.…”

Section: Discussionmentioning

confidence: 99%

Early oral analgesia after fast-track cardiac anesthesia

Kogan

Medalion

Raanani

et al. 2007

Purpose: Oral analgesia after "fast-track" cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens. Methods:One hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I) per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II) per os every 12 hr and placebo twice daily. Acetaminophen 500 mg per os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mg per os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.Results: Baseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea. Conclusion:Peroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.