October 15, 2018
Patient-controlled epidural anesthesia after C-section may reduce oral opioid use
SAN FRANCISCO – Women who deliver their babies via cesarean section (C-section) are less likely to need opioids to manage post-delivery pain if they receive ongoing epidural analgesia (pain relief) that they can control, suggests first-of-its kind research presented at the ANESTHESIOLOGY® 2018 annual meeting.
Researchers found the longer patient-controlled epidural analgesia (PCEA) remained in place after C-section, the less likely the woman was to use oral opioids. PCEA helps the new mother manage the most severe pain, which occurs in the first two or three days after the procedure, typically spent in the hospital, they note.
“During the time the women studied used PCEA for their pain relief, they didn’t need oral opioids,” said Gilbert J. Grant, M.D., associate professor of anesthesiology at the New York University (NYU) School of Medicine and director of obstetric anesthesia at NYU Langone Health. “One in four used no oral opioids even after stopping the epidural.”
C-sections may be performed under a local anesthetic given via spinal or epidural techniques. Most U.S. hospitals use spinal anesthesia for planned C-sections. At the time the spinal is performed, the physician anesthesiologist injects a local anesthetic and a small dose of morphine into the spinal fluid. The morphine provides about 18 hours of pain relief after surgery, but women recovering from C-section may have significant surgical pain that lasts for several days. In most cases, after the spinal morphine effect wears off, women take oral opioids to manage their pain.
At the researchers’ institution, nearly all C-section patients have an epidural catheter (a tiny flexible tube) inserted into their lower back as part of their anesthesia. These patients do not receive spinal morphine. Instead, pain medication that numbs the abdomen is administered after surgery through the epidural catheter. The patient can “fine-tune” the amount of pain relief she desires by simply pushing a button. The PCEA can continue to relieve pain long after the commonly used spinal morphine wears off. Because the local anesthetic dose in PCEA is so low, muscle strength is not affected, so the mother is able to walk.
The study included 576 women who had planned C-sections and received PCEA during 2017. Researchers analyzed postoperative opioid use in the women and found that while PCEA was in place, the median quantity of oral opioids used was 0 mg. The researchers reported that overall, PCEA remained in place for a median of 43 hours after delivery. The longer the women were on PCEA, the fewer opioids they needed after it was stopped: each hour of PCEA resulted in a 0.33 mg decrease in the consumption of oxycodone, an oral opioid. The 25 percent of women who did not use any oral opioids, even after PCEA was stopped, used the epidural for a median of 44.9 hours.
Dr. Grant noted that while the routine U.S. practice is to use epidurals only for labor, PCEA after C-section has many advantages, including: ability to be maintained for as long as the patient is in the hospital; improved movement in the intestines (which reduces constipation); giving the mother a sense of control and; a reduced need for oral opioids, as seen in the study.
In addition to a risk for dependence, oral opioids have a number of side effects that can be particularly problematic for new mothers such as drowsiness, nausea, vomiting, itching and constipation.
THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 52,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves.
For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/WhenSecondsCount. Join the ANESTHESIOLOGY® 2018 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES18.