1
|
Azanu WK, Osarfo J, Larsen-Reindorf RE, Agbeno EK, Dassah E, Amanfo AO, Dah AK, Ampofo G. Assessment and determinants of acute post-caesarean section pain in a tertiary facility in Ghana. PLoS One 2022; 17:e0268947. [PMID: 35613148 PMCID: PMC9132330 DOI: 10.1371/journal.pone.0268947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 05/11/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction
Caesarean sections (CS) feature prominently in obstetric care and have impacted positively on maternal / neonatal outcomes globally including Ghana. However, in spite of documented increasing CS rates in the country, there are no studies assessing the adequacy of post-CS pain control. This study assessed the adequacy of post-CS pain management as well as factors influencing this outcome. Additionally, post-CS analgesia prescription and serving habits of doctors and nurses were also described to help fill existing knowledge gaps.
Methods
Pain scores of 400 randomly selected and consenting post-CS women at a tertiary facility in Ghana were assessed at 6–12 hours post-CS at rest and with movement and at 24–36 hours post-CS with movement using a validated visual analog scale (VAS) from February 1, 2015 to April 8, 2015. Participant characteristics including age, marital status and duration of CS were obtained using pretested questionnaires and patient records review. Descriptive statistics were presented as frequencies and proportions. Associations between background characteristics and the outcome variables of adequacy of pain control at 6–12 hours post-CS at rest and with movement and at 24–36 hours post-CS with movement were analysed using Chi-square and Fisher’s exact tests and logistic regression methods. Adequate pain control was defined as VAS scores ≤5.
Results
At 6–12 hours post-CS (at rest), equal proportions of participants had adequate and inadequate pain control (50.1% vrs 49.9%). Over the same time period but with movement, pain control was deemed inadequate in 93% of respondents (369/396). Women who had one previous surgery [OR 0.47 95%CI 0.27, 0.82; p = 0.008] and those whose CS lasted longer than 45 mins [OR 0.39 95% CI 0.24, 0.62; p<0.001] had lower odds of reporting adequate pain control. Women prescribed 12-hourly and 8-hourly doses of pethidine had only 23.5% (12/51) and 10.3% (3/29) served as prescribed respectively. At 24–36 hours post CS, adequate pain control was reported by 85.3% (326/382) of participants.
Conclusions
Pain management was deemed inadequate within the first 12 hours post-CS with potential implications for early mother-child interaction. Appreciable numbers of participants did not have their analgesics served as prescribed. Adjunct pain control measures should be explored and healthcare workers must be encouraged to pay more attention to patients’ pain relief needs.
Collapse
Affiliation(s)
- Wisdom Klutse Azanu
- Department of Obstetrics and Gynaecology, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Joseph Osarfo
- Department of Community Medicine, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
- * E-mail: ,
| | - Roderick Emil Larsen-Reindorf
- Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Evans Kofi Agbeno
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Edward Dassah
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Ofori Amanfo
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Anthony Kwame Dah
- Department of Obstetrics and Gynaecology, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Gifty Ampofo
- Department of Community Medicine, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| |
Collapse
|
2
|
Macias DA, Adhikari EH, Eddins M, Nelson DB, McIntire DD, Duryea EL. A comparison of acute pain management strategies after cesarean delivery. Am J Obstet Gynecol 2022; 226:407.e1-407.e7. [PMID: 34534504 DOI: 10.1016/j.ajog.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/01/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited. OBJECTIVE To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain. STUDY DESIGN This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant. RESULTS During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001). CONCLUSION Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.
Collapse
Affiliation(s)
- Devin A Macias
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX.
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Michelle Eddins
- Department of Anesthesiology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Nelson
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Don D McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Elaine L Duryea
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
3
|
Adhikari P, Subedi A, Sah BP, Pokharel K. Analgesic effects of intravenous ketamine after spinal anaesthesia for non-elective caesarean delivery: a randomised controlled trial. BMJ Open 2021; 11:e044168. [PMID: 34193480 PMCID: PMC8246353 DOI: 10.1136/bmjopen-2020-044168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This study aimed to determine if low dose intravenous ketamine is effective in reducing opioid use and pain after non-elective caesarean delivery. DESIGN Prospective, randomised, double-blind. SETTING Tertiary hospital, Bisheshwar Prasad Koirala Institute of Health Sciences, Dharan, Nepal PARTICIPANTS: 80 patients undergoing non-elective caesarean section with spinal anaesthesia. INTERVENTIONS Patients were allocated in 1:1 ratio to receive either intravenous ketamine 0.25 mg/kg or normal saline before the skin incision. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the total amount of morphine equivalents needed up to postoperative 24 hours. Secondary outcome measures were postoperative pain scores, time to the first perception of pain, maternal adverse effects (nausea, vomiting, hypotension, shivering, diplopia, nystagmus, hallucination) and neonatal Apgar score at 1 and 5 min, neonatal respiratory depression and neonatal intensive-care referral. RESULTS The median (range) cumulative morphine consumption during the first 24 hours of surgery was 0 (0-4.67) mg in ketamine group and 1 (0-6) mg in saline group (p=0.003). The median (range) time to the first perception of pain was 6 (1-12) hours and 2 (0.5-6) hours in ketamine and saline group, respectively (p<0.001). A significant reduction in postoperative pain scores was observed only at 2 hours and 6 hours in the ketamine group compared with placebo group (p<0.05). Maternal adverse effects and neonatal outcomes were comparable between the two groups. CONCLUSIONS Intravenous administration of low dose ketamine before surgical incision significantly reduced the opioid requirement in the first 24 hours in patients undergoing non-elective caesarean delivery. TRIAL REGISTRATION NUMBER NCT03450499.
Collapse
Affiliation(s)
| | - Asish Subedi
- Anesthesiology & Critical Care, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Birendra Prasad Sah
- Anesthesiology & Critical Care, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Krishna Pokharel
- Anesthesiology & Critical Care, BP Koirala Institute of Health Sciences, Dharan, Nepal
| |
Collapse
|
4
|
Bhiwal A, Sharma V, Sharma K, Tripathi A, Gupta S. Sub-anaesthetic bolus dose of intravenous ketamine for postoperative pain following caesarean section. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.4103/joacc.joacc_21_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
5
|
Imanieh MH, Mirahmadizadeh A, Imani B. Factors affecting public dissatisfaction with urban family physician plan: A general population based study in Fars Province. Electron Physician 2017; 9:5676-5681. [PMID: 29403604 PMCID: PMC5783113 DOI: 10.19082/5676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 06/16/2017] [Indexed: 11/20/2022] Open
Abstract
Background Understanding the level of public satisfaction with a family physician plan as well as the relevant factors in this respect, can be employed as valuable tools in identifying quality of services. Objective To determine the factors affecting public dissatisfaction with an urban family physician plan in Iran. Methods This cross-sectional study was conducted from January 2014 through June 2015 on Fars Province residents in Iran, selected based on cluster sampling method. The data collection instrument was comprised of a two-part checklist including demographic information and items related to dissatisfaction with the family physician plan, specialists, para-clinic services, pharmacy, physicians on shift work, emergency services, and family physician assistants. Data were described by SPSS 20. Results In this study, 1,020 individuals (524 males, 496 females) were investigated. Based on the results, the most frequent factor affecting dissatisfaction with physicians was their single work shifts and unavailability (53%). In terms of dissatisfaction with family physicians’ specialist colleagues and para-clinic services, the most common factors were related to difficulty in obtaining a referral form (41.5%) and making appointments (21.6%), respectively. Given the level of dissatisfaction with pharmacies, the significant factor was reported to be excessive delay in medication delivery (31.6%); and in terms of physicians on shift work and emergency services, the most important factor was lower work hours for family physicians (9.2%). Conclusion It seems that, the most common causes of dissatisfaction with the urban family physician plan are due to the short duration of services, obtaining a referral form and making appointments, and providing prescribed medications.
Collapse
Affiliation(s)
- Mohammad Hadi Imanieh
- M.D. Professor of Pediatrics, Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Mirahmadizadeh
- M.D. MPH, Ph.D. of Epidemiology, Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bahareh Imani
- M.D. Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
6
|
Analgesic Effects of Preincision Ketamine on Postspinal Caesarean Delivery in Uganda's Tertiary Hospital: A Randomized Clinical Trial. Anesthesiol Res Pract 2017; 2017:5627062. [PMID: 28321251 PMCID: PMC5339494 DOI: 10.1155/2017/5627062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/02/2016] [Accepted: 01/19/2017] [Indexed: 12/04/2022] Open
Abstract
Background. Good postoperative analgesic management improves maternal satisfaction and care of the neonate. Postoperative pain management is a challenge in Mulago Hospital, yet ketamine is accessible and has proven benefit. We determined ketamine's postoperative analgesic effects. Materials and Methods. We did an RCT among consenting parturients that were randomized to receive either intravenous ketamine (0.25 mg/kg) or placebo after spinal anesthetic. Pain was assessed every 30 mins up to 24 hours postoperatively using the numerical rating scale. The first complaint of pain requiring treatment was noted as “time to first breakthrough pain.” Results. We screened 100 patients and recruited 88 that were randomized into two arms of 44 patients that received either ketamine or placebo. Ketamine group had 30-minute longer time to first breakthrough pain and lower 24-hour pain scores. Postoperative diclofenac consumption was lesser in the ketamine group compared to placebo and Kaplan-Meier graphs showed a higher probability of experiencing breakthrough pain earlier in the placebo group. Conclusion. Preincision intravenous ketamine (0.25 mg/kg) offered 30-minute prolongation to postoperative analgesia requirement with reduced 24-hour pain scores. We recommend larger studies to explore this benefit. This trial is registered with Pan African Clinical Trial Registry number PACTR201404000807178.
Collapse
|
7
|
Haliloglu M, Ozdemir M, Uzture N, Cenksoy PO, Bakan N. Perioperative low-dose ketamine improves postoperative analgesia following Cesarean delivery with general anesthesia. J Matern Fetal Neonatal Med 2015; 29:962-6. [PMID: 25845277 DOI: 10.3109/14767058.2015.1027190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE In this study, the effect of perioperative uses of low dose ketamine on post-operative wound pain and analgesic consumption in patients undergoing elective Cesarean section was evaluated. METHODS In randomized, double blind clinical trial, 52 women with American Society of Anesthesiologists (ASA) class I-II identification undergoing elective Cesarean section in general anesthesia were enrolled. In the ketamine group (group K), a ketamine bolus of 0.5 mg kg(-1) IV was administered at the time of induction of general anesthesia. After induction, a ketamine infusion of 0.25 mg kg(-1) h(-1) was started and discontinued at the end of surgery. Patients allocated to the control group (group C) were given identical volumes of saline. The cumulative dose of morphine consumption after surgery was measured as the primary outcome of this study. Secondary outcomes were pain control assessed by numeric rating scale (NRS) and need for rescue analgesia and incidence of side effects. RESULTS The mean 24-h morphine consumption was lower in group K (p = 0,001). At 15 min postoperatively, NRS values were lower in group K than group C (p = 0,001). There was no difference among groups regarding the need for supplemental analgesia (rescue diclofenac doses) (p > 0.05). CONCLUSIONS Perioperative uses of low dose ketamine decreased post-operative opioid requirements, which was observed long after the normal expected duration of ketamine.
Collapse
Affiliation(s)
- Murat Haliloglu
- a Department of Anaesthesiology and Reanimation , Yeditepe University Faculty of Medicine , İstanbul , Turkey
| | - Mehtap Ozdemir
- b Department of Anaesthesiology and Reanimation , Umraniye education and Research Hospital , İstanbul , Turkey , and
| | - Neslihan Uzture
- a Department of Anaesthesiology and Reanimation , Yeditepe University Faculty of Medicine , İstanbul , Turkey
| | - Pinar Ozcan Cenksoy
- c Department of Obstetrics and Gynecology , Yeditepe University Faculty of Medicine , İstanbul , Turkey
| | - Nurten Bakan
- b Department of Anaesthesiology and Reanimation , Umraniye education and Research Hospital , İstanbul , Turkey , and
| |
Collapse
|
8
|
McNicol ED, Ferguson MC, Hudcova J. Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain. Cochrane Database Syst Rev 2015; 2015:CD003348. [PMID: 26035341 PMCID: PMC7387354 DOI: 10.1002/14651858.cd003348.pub3] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne et al found a strong patient preference for PCA over non-patient controlled analgesia, but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, a 2001 review by Walder et al did not find statistically significant differences in pain intensity or pain relief between PCA and groups treated with non-patient controlled analgesia. OBJECTIVES To evaluate the efficacy and safety of patient controlled intravenous opioid analgesia (termed PCA in this review) versus non-patient controlled opioid analgesia of as-needed opioid analgesia for postoperative pain relief. SEARCH METHODS We ran the search for the previous review in November 2004. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 12), MEDLINE (1966 to 28 January 2015), and EMBASE (1980 to 28 January 2015) for randomized controlled trials (RCTs) in any language, and reference lists of reviews and retrieved articles. SELECTION CRITERIA We selected RCTs that assessed pain intensity as a primary or secondary outcome. These studies compared PCA without a continuous background infusion with non-patient controlled opioid analgesic regimens. We excluded studies that explicitly stated they involved patients with chronic pain. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. We performed meta-analysis of outcomes that included pain intensity assessed by a 0 to 100 visual analog scale (VAS), opioid consumption, patient satisfaction, length of stay, and adverse events. MAIN RESULTS Forty-nine studies with 1725 participants receiving PCA and 1687 participants assigned to a control group met the inclusion criteria. The original review included 55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group. There were fewer included studies in our updated review due to the revised exclusion criteria. For the primary outcome, participants receiving PCA had lower VAS pain intensity scores versus non-patient controlled analgesia over most time intervals, e.g., scores over 0 to 24 hours were nine points lower (95% confidence interval (CI) -13 to -5, moderate quality evidence) and over 0 to 48 hours were 10 points lower (95% CI -12 to -7, low quality evidence). Among the secondary outcomes, participants were more satisfied with PCA (81% versus 61%, P value = 0.002) and consumed higher amounts of opioids than controls (0 to 24 hours, 7 mg more of intravenous morphine equivalents, 95% CI 1 mg to 13 mg). Those receiving PCA had a higher incidence of pruritus (15% versus 8%, P value = 0.01) but had a similar incidence of other adverse events. There was no difference in the length of hospital stay. AUTHORS' CONCLUSIONS Since the last version of this review, we have found new studies providing additional information. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides moderate to low quality evidence that PCA is an efficacious alternative to non-patient controlled systemic analgesia for postoperative pain control.
Collapse
Affiliation(s)
- Ewan D McNicol
- Departments of Anesthesiology and Pharmacy, Tufts Medical Center, Box #420, 800 Washington Street, Boston, Massachusetts, USA, 02111
| | | | | |
Collapse
|
9
|
Behdad S, Hajiesmaeili MR, Abbasi HR, Ayatollahi V, Khadiv Z, Sedaghat A. Analgesic Effects of Intravenous Ketamine during Spinal Anesthesia in Pregnant Women Undergone Caesarean Section; A Randomized Clinical Trial. Anesth Pain Med 2013; 3:230-3. [PMID: 24282773 PMCID: PMC3833040 DOI: 10.5812/aapm.7034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 10/11/2012] [Accepted: 06/20/2013] [Indexed: 12/04/2022] Open
Abstract
Background Suitable analgesia after cesarean section helps mothers to be more comfortable and increases their mobility and ability to take better care of their infants. Objectives Pain relief properties of ketamine prescription were assessed in women with elective cesarean section who underwent spinal anesthesia with low dose intravenous ketamine and midazolam and intravenous midazolam alone. Patients and Methods Sixty pregnant women scheduled for spinal anesthesia for cesarean section were randomized into two study groups. Ketamine (30 mg) + midazolam (1 mg = 2CC) or 1mg midazolam (2CC) alone, was given immediately after spinal anesthesia. Pain scores at first, second and third hours after CS operation, analgesic requirement and drug adverse effects were recorded in all patients. Results Ketamine group had significant pain relief properties in compare with control group in first hours after cesarean section (0.78 ± 1.09 vs. 1.72 ± 1.22, VAS score, P = 0.00). Total dose of meperidine consumption in women of ketamine group was significantly lower than women of control group (54.17 ± 12.86 vs. 74.44 ± 33.82 mg, P = 0.02). There were no significant drug side effects in participated patients. Conclusions Intravenous low-dose ketamine combined with midazolam for sedation during spinal anesthesia for elective Caesarean section provides more effective and long lasting pain relief than control group.
Collapse
Affiliation(s)
- Shekoufeh Behdad
- Department of Anesthesiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Mohammad Reza Hajiesmaeili
- Department of Anesthesiology and Critical Care Medicine, Rasoul Akram Medical Center, Iran University of medical sciences (IUMS), Tehran, Iran
- Corresponding author: Mohammad Reza Hajiesmaeili, Department of Anesthesiology and Critical Care Medicine, Rasoul Akram Medical Center, Iran University of Medical Sciences (IUMS), Tehran, Iran. Tel: +98-2166509059, Fax: +98-2166509059, E-mail:
| | - Hamid Reza Abbasi
- Department of Anesthesiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Vida Ayatollahi
- Department of Anesthesiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Zahra Khadiv
- Pain Research Center, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Alireza Sedaghat
- Department of Anesthesiology and Critical Care Medicine, Rasoul Akram Medical Center, Iran University of medical sciences (IUMS), Tehran, Iran
| |
Collapse
|
10
|
Bauchat JR, Higgins N, Wojciechowski KG, McCarthy RJ, Toledo P, Wong CA. Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial. Int J Obstet Anesth 2011; 20:3-9. [PMID: 21224020 DOI: 10.1016/j.ijoa.2010.10.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 10/06/2010] [Accepted: 10/07/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ketamine at subanesthetic doses has analgesic properties that have been shown to reduce postoperative pain and morphine consumption. We hypothesized that intravenous ketamine 10mg administered during spinal anesthesia for cesarean delivery, in addition to intrathecal morphine and intravenous ketorolac, would decrease the incidence of breakthrough pain and need for supplemental postoperative analgesia. METHODS Using a randomized double-blind placebo-controlled design, healthy women scheduled for cesarean delivery receiving hyperbaric spinal bupivacaine, fentanyl and morphine were randomized to intravenous ketamine 10mg or saline following delivery. Postoperative analgesia included scheduled ketorolac and acetaminophen/hydrocodone tablets as needed for breakthrough pain. The primary outcome was the incidence of breakthrough pain in the first 24h. Secondary outcomes included the number of acetaminophen/hydrocodone tablets administered and numeric rating scale for pain (0-10). RESULTS Group characteristics did not differ. There was no difference in the incidence of breakthrough pain (ketamine 75% VS. saline 74%, P=0.86). There was no difference in 24-h or 72-h use of supplemental acetaminophen/hydrocodone tablets between groups. Pain scores in the first 24h were similar, but lower in the ketamine compared to the saline group 2weeks postpartum (difference -0.6, 95% CI -1.1 to -0.9). CONCLUSIONS We found no additional postoperative analgesic benefit of low-dose ketamine during cesarean delivery in patients who received intrathecal morphine and intravenous ketorolac. Subjects who received ketamine reported lower pain scores 2weeks postpartum.
Collapse
Affiliation(s)
- J R Bauchat
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | | | | | | | | | | |
Collapse
|
11
|
Sekhavat L, Behdad S. Preoperative analgesia with local lidocaine for cesarean delivery pain relief. J Matern Fetal Neonatal Med 2011; 24:891-3. [DOI: 10.3109/14767058.2010.537410] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
12
|
Binder P, Gustafsson A, Uvnäs-Moberg K, Nissen E. Hi-TENS combined with PCA-morphine as post caesarean pain relief. Midwifery 2010; 27:547-52. [PMID: 20615594 DOI: 10.1016/j.midw.2010.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 03/31/2010] [Accepted: 05/02/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES to examine effectiveness and overall opiate consumption between high-sensory transcutaneous electrical nerve stimulation (Hi-TENS) combined with patient-controlled analgesia with morphine and patient-controlled analgesia with morphine alone following elective (e.g. scheduled) caesarean birth. DESIGN randomised, controlled study. SETTING a county hospital in south-west Sweden. PARTICIPANTS 42 multiparous women. MEASUREMENTS AND FINDINGS participants were randomly assigned and connected to patient-controlled analgesia with morphine alone or in combination with Hi-TENS apparatus. Levels of morphine consumed were calculated every third hour during the first 24 hours post partum. Pain and sedation were assessed by visual analogue scale at one, three, six, nine, 12 and 24 hours post partum. Total consumption of morphine differed significantly between the groups: morphine with TENS was 16.2 ± 12.6 mg and morphine alone was 33.1 ± 20.9 mg (p = 0.007). Assessment of pain relief showed no significant difference. Sedation differed significantly between the groups (p = 0.045), especially between three and 12 hours post partum (p = 0.011). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE pain relief from a combination of Hi-TENS and patient-controlled analgesia with morphine was as effective as patient-controlled analgesia with morphine alone, produced less sedation and reduced morphine use by approximately 50%. Women undergoing a caesarean section should be given the opportunity to make an informed choice about post operative pain relief before surgery. A presumed benefit of this treatment combination is that the mother is more alert and better able to interact with her newborn during the first hours after birth without drowsiness due to large doses of opiates.
Collapse
Affiliation(s)
- Pauline Binder
- Department of Women's and Children's Health, IMCH, Akademiska Hospital/Uppsala University, Drottninggatan 4, 4th Floor, SE-75185 Uppsala,
| | | | | | | |
Collapse
|
13
|
Bozkurt N, Kurdoglu M, Kurdoglu Z, Kutlusoy F, Biberoglu K. Postoperative pain control after cesarean section: Can diclofenac sodium be used instead of meperidine? J Matern Fetal Neonatal Med 2009; 22:1144-50. [DOI: 10.3109/14767050903019643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
14
|
Alhashemi JA, Alotaibi QA, Mashaat MS, Kaid TM, Mujallid RH, Kaki AM. Intravenous acetaminophenvs oral ibuprofen in combination with morphine PCIA after Cesarean delivery. Can J Anaesth 2006; 53:1200-6. [PMID: 17142654 DOI: 10.1007/bf03021581] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jamal A Alhashemi
- Department of Anesthesia & Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah 21418, Saudi Arabia.
| | | | | | | | | | | |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW The management of postoperative pain after cesarean section slightly differs from that of the general surgical population, specifically women need to recover quickly to take care of their newborn baby. Optimal pain management is imperative for the success of immediate-term and long-term rehabilitation and this principle applies to obstetric patients. There is growing evidence that perioperative pain management has consequences extending well beyond the immediate recovery period. Unrelieved postoperative pain is a striking risk factor for the development of residual pain. RECENT FINDINGS A recent study has highlighted that chronic pain may be a significant clinical problem after cesarean section. Among the risk factors, recalls of severe acute postoperative pain led to the reconsideration of postoperative pain management after cesarean delivery. Current published data agree that drug combinations, that is, multimodal or balanced analgesia, are mandatory to achieve satisfactory and effective pain relief with reduced side effects. SUMMARY The use of balanced analgesia has significantly improved acute pain management after cesarean section. Future studies should extend their investigations beyond the first 48 h and consider the long-term effects of different analgesic regimens, that is, those that alter the development of residual pain.
Collapse
|
16
|
Davis KM, Esposito MA, Meyer BA. Oral analgesia compared with intravenous patient-controlled analgesia for pain after cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol 2006; 194:967-71. [PMID: 16580284 DOI: 10.1016/j.ajog.2006.02.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Revised: 01/17/2006] [Accepted: 02/15/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether oral analgesia with oxycodone-acetaminophen or a patient-controlled analgesia device with morphine provides superior analgesia after cesarean delivery. STUDY DESIGN Ninety-three patients with scheduled cesarean delivery were assigned randomly to receive either oral analgesia with oxycodone-acetaminophen or a morphine patient-controlled analgesia device. At 6 and 24 hours after the procedure, pain was assessed on a visual analog pain scale of 0 to 10. Nausea, sedation, pruritus, ambulation, emesis, and oral fluid intake were also assessed. RESULTS Patients who used oral analgesia without a patient-controlled analgesia device experienced less pain at 6 and 24 hours after cesarean delivery. They also had less nausea and drowsiness at 6 hours but slightly more nausea at 24 hours. CONCLUSION Oral analgesia with oxycodone-acetaminophen may offer superior pain control after cesarean delivery with fewer side-effects as compared with morphine patient-controlled analgesia. Consideration should be given to expanding the use of oral analgesia in patients immediately after cesarean delivery.
Collapse
Affiliation(s)
- Kathryn M Davis
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, MA, USA
| | | | | |
Collapse
|
17
|
Feldman AM, Weitz H, Merli G, DeCaro M, Brechbill AL, Adams S, Bischoff L, Richardson R, Williams MJ, Wenneker M, Epstein A. The physician-hospital team: a successful approach to improving care in a large academic medical center. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2006; 81:35-41. [PMID: 16377816 DOI: 10.1097/00001888-200601000-00009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Initiatives to improve the quality and efficiency of care in academic medical centers (AMCs, teaching hospitals) can benefit the performance of academic departments as well as the hospital. However, the value of performance improvement programs in an AMC is often challenging. At Jefferson Medical College, clinical efficiency and bed availability are important priorities to the Department of Medicine. To this end, a multidisciplinary program was designed to (1) improve the quality and consistency of care by adapting and adopting national guidelines for patients with heart failure and acute coronary syndrome; (2) identify and improve hospital operational supports and maximize resource utilization; (3) increase hospital functional capacity to make way for increased volume; and (4) improve housestaff education and practice by using evidence-based approaches and by optimizing teaching relationships between housestaff and attending faculty. The eight-month project (November 2002 to July 2003) resulted in improvement in several quality measures including increased use of beta blockers and angiotensin converting enzyme inhibitors for heart failure patients, reduced length of stay for heart failure and acute coronary syndrome patients, and increased satisfaction of the clinicians involved in caring for these patients. However, the project was not without barriers including individual physician's unwillingness to embrace change and an inability to incentivize change. Development of faculty leadership skills and enhanced physician accountability helped in overcoming the challenges of change.
Collapse
Affiliation(s)
- Arthur M Feldman
- Jefferson Medical College, Department of Medicine, 1025 Walnut Street, Suite 822, Philadelphia, PA 19107, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
BACKGROUND In 1989 the World Health Organization and UNICEF introduced the "Ten Steps" for successful breastfeeding. One step suggests that a mother and her newborn baby should remain together day and night during the hospital stay. The purpose of this study was to investigate, first, whether or not mothers in our hospital roomed-in with their babies at night, second, the attitudes of mothers toward night rooming-in and their feelings of closeness to their babies, and third, how mothers perceived hospital staff attitudes toward night rooming-in. METHODS All mothers ( n = 132) of Nordic ancestry and with good knowledge of the Swedish language, who were admitted to the maternity wards during a 2-week period at Karolinska University Hospital, Stockholm, Sweden, answered a questionnaire on demographic background data and their current night rooming-in practices, including an attitude scale. RESULTS Most study mothers were positive toward night rooming-in, regardless of whether they had roomed in with their babies at night (93% positive) or not (73% positive). Mothers who had not roomed-in with their babies were more likely to perceive that the staff believed their babies should stay in the nursery compared with those mothers who practiced night rooming-in (z = -2.733, p = 0.006). Mothers not rooming-in with their babies scored closeness to their babies as less important than those mothers who roomed-in with their babies (z = -3.780, p = 0.0002); they also were more worried about their own and their babies' sleep (z = -2.321, p = 0.02) and disturbing noises (z = -3.487, p = 0.0005). CONCLUSIONS Mothers who left their babies in the nursery at night more often perceived that the staff believed their babies should stay in the nursery, rating closeness between mother and infant lower. Hence, negative staff attitudes toward night rooming-in may implicitly suggest to mothers that closeness between mothers and babies is not important.
Collapse
Affiliation(s)
- Kristin Svensson
- Department of Obstetrics and Gynaecology, Karolinska University Hospital, Solna, Sweden
| | | | | |
Collapse
|
19
|
Rohrer JE, Lund JD, Goldfarb S. Race and satisfaction in general OB/GYN clinics. BMC WOMENS HEALTH 2005; 5:6. [PMID: 15890078 PMCID: PMC1134665 DOI: 10.1186/1472-6874-5-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Accepted: 05/12/2005] [Indexed: 11/10/2022]
Abstract
BACKGROUND: The purpose of this study was to test the hypothesis that racial differences in satisfaction can be found among OB/GYN patients on a US naval base. METHODS: Cross-sectional surveys assessing satisfaction with services were obtained from 838 patients who were seen in one of the two general OB/GYN clinics (455 in the base hospital clinic and 391 in a satellite clinic). Multiple logistic regression analysis was used to identify subgroups of patients who were not very satisfied with care received. RESULTS: When the patients seen in the base hospital were analyzed separately, Asian respondents had significantly lower odds of being very satisfied relative to non-Hispanic white respondents (AOR = .33, p < .01). CONCLUSION: Asian patients may be less satisfied than others when treated at a larger facility. Patients treated at a satellite clinic tended to be more satisfied than patients seen at the base hospital.
Collapse
Affiliation(s)
- James E Rohrer
- Department of Family and Community Medicine, Texas Tech University Health Sciences Center, Amarillo TX, USA
| | - Jon D Lund
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Amarillo TX, USA
| | - Susan Goldfarb
- Department of OB-GYN, Naval Medical Center San Diego, San Diego CA, USA
| |
Collapse
|