The administration of diclofenac 100 mg rectally every 8 h and propacetamol 2 g IV every 6 h (group MDP) and diclofenac 100 mg rectally every 8 h and placebo injection (group MD) were superior to placebo injection and suppository (group M) in pain scores at rest and on coughing at 2 h, but not at 6 h. Pain scores at rest at 24 h were significantly lower in patients receiving diclofenac 100 mg rectally every 8 h and propacetamol 2 g IV every 6 h (group MDP) compared with patients receiving propacetamol 2 g IV every 6 h and placebo rectally (group MP) and patients receiving placebo (group M). The incidence of pruritus and PONV were similar between the groups (Siddik 2001, N=79, LoE 1)
Efficacy and safety of repeated postoperative administration of intramuscular diclofenac sodium in the treatment of post-cesarean section pain: a double-blind study.
Archives of Medical Research, 2001. 32(2): p. 148-54.
not reported
exclusion criteria
– allergy to NSAIDs
– bronchial asthma
– bleeding disturbances
– diabetes mellitus
– pregnancy-induced hypertension or preeclampsia
– liver or kidney diseases
demographic data:
no significant differences in baseline characteristics
maternal age [yr.]: mean ± SD
group D: 31.2 ± 6.65
group P: 29.7 ± 7.17
maternal weight [kg]: mean ± SD
group D: 64.2 ± 5.75
group P: 63.4 ± 5.58
gestation [week]: mean ± SD
group D: 37.8 ± 0.65
group P: 37.6 ± 0.68
indication for surgery: group D/ group P
placenta previa: 13/ 12
previous caesarean: 14/ 16
cephalopelvic disproportion: 26/ 24
malpresentation: 7/ 8
patient flow and follow up:
total patient number included:
120
randomised in:
group D: 60
group P: 60
excluded:
0
analysed:
all patients
follow-up:
48 hours
no premedication
mode of anaesthesia
GA: using atropine, sodium thiopental, suxamethonium, pancuronium hydrochloride and neostigmine (not specified)
maintained with 50% nitrous oxide and 0.5% halothane in oxygen
surgical approach
lower segment caesarean section (not specified)
postoperative pain management
given at immediate recovery with pain experience
group D:
75 mg diclofenac sodium IM
group P:
placebo
similar doses of the same medication were administered in case of pain relapse after 12 h
(</=2 injections of tested drug were allowed per day)
supplemental analgeisa
100 mg pethidine IM
rescue analgesia (after 1 h)
pethidine IM
response within 1 h after first dose: pain relief/ no pain relief
group D: 55/ 5
group P: 10/ 50
p<0.05
supplemental and rescue analgesia [mg] during two days
group D: 2,800
group P: 22,700
sedation
only significantly lower in group D at 6 and 12 h, but not at 1, 3 and 24 h
– generation of allocation sequence not reported
– allocation concealment not reported
– selective outcome reporting
– no sample size calculation
level of evidence: 1
caveat:
The authors did not analyse the data according to the group assignment. Thus, no conclusion on postoperative pain is possible.
A randomized controlled trial examining the effect of naproxen on analgesia during the second day after cesarean delivery.
Anesthesia and Analgesia, 2002. 95(3): p. 741-745.
– ASA physical status I/II
– spinal anaesthesia
– contraindication to spinal anaesthesia
– known hypersensitivity or intolerance to study drugs
– diabetes
– severe preeclampsia
– active peptic ulcer disease within the past year
group N: 34.0 ± 4.7
group P: 32.0 ± 4.9
BMI: mean ± SD
group N: 28.8 ± 4.2
group P: 29.6 ± 5.4
parity >0 [n]:
group N: 27
group P: 24
gestational age [week]: mean ± SD
group N: 38.4 ± 1.0
group P: 38.5 ± 1.0
previous caesarean deliveries >0 [N]
group N: 24
group P: 23
additional procedures [N]
group N: 1
group P: 3
80
group N: 40
group P: 40
72 hours
1000-1500 crystalloid
SpA: 0.75% bupivacaine in 8.25% dextrose (1.2–1.8mL), fentanyl 10–20 µg, preservative-free morphine 0.2 mg IT
low transverse abdominal (Pfannenstiel) incision (not specified)
group N:
naproxen as a 500 mg suppository followed by oral naproxen sodium 550 mg every 12 h for six doses
placebo suppository per rectum followed by oral lactose capsules every 12 h for six doses
rescue suppositories as substitute for oral application in patients with vomiting in both study arms
conventional therapy as needed:
– paracetamol 300 mg, caffeine 15 mg and codeine 30 mg, one or two tablets every 3–4 h as needed
rescue medication
morphine or meperidine IM
incision pain on sitting
only significantly reduced in group N at 36 h, but not on other measurements
(p=0.05)
incision pain at rest
(p=0.049)
uterine cramping pain at rest
significantly reduced in group N at 36 h (p=0.0004)
gas pain
significantly reduced in group N at 36 h (p=0.026)
interval worst pain
from 25 to 36 h clinically modest reduction in group N (p=0.012)
overall pain relief
significantly lower only in group N on POD 1 (p=0.0006), but not on POD 2 (p=0.057) and POD 3 (p=0.4)
time to first analgesic request [h]: median (range)
group N: 22 (1–50)
group P: 9 (1–49)
(p=0.003)
significantly less in group N over time compared with group P
(p<0.01)
adverse effects/ events
no significant differences in pruritus, PONV, maternal sedation or respiratory rates, vaginal blood loss, use of additional uterotonic drugs
three neonates with jaundice in group N (p=0.02)
– no methodological shortcomings according to the evaluation sheet
authors’ conclusion
“Adding regular doses of naproxen to spinal morphine and conventional on request oral analgesia leads to improved analgesia on day 1 and has added benefits of a lesser degree on day 2. These benefits are most evident as reductions in VAS pain scores at 36 hours, when pain levels peak in women receiving placebo. Although the use of naproxen was associated with a statistically significant improvement in overall pain relief and a reduction in the number of women with inadequate analgesia in day 1, these differences did not persist for the naproxen group as a whole on day 2.”
Small doses of intrathecal morphine combined with systemic diclofenac for postoperative pain control after cesarean delivery.
Anesthesia and Analgesia, 1998. 86(3): p. 538-541.
– ASA physical status I
no significant differences in age, weight and height (data not shown)
group 1: 20
group 2: 20
group 3: 20
group 4: 20
group 5: 20
group 6: 20
24 hours
10 mL/kg of lactated Ringer’s solution
SpA: 0.5% hyperbaric bupivacaine 15 mg combined with varying doses of morphine
group 1:
morphine 0.1 mg plus diclofenac 75 mg IM every 8 h
group 2:
morphine 0.1 mg plus diclofenac 75 mg IM on request
group 3:
morphine 0.05 mg plus diclofenac 75 mg IM every 8 h
group 4:
morphine 0.05 mg plus diclofenac 75 mg IM on request
group 5:
morphine 0.025 mg plus diclofenac 75 mg IM every 8 h
group 6:
morphine 0.025 mg plus diclofenac 75 mg IM on request
after cord clamping
groups 1, 2 and 3 received first dose of diclofenac IM
see above
supplemental analgesia
initially diclofenac 75 mg IM, additionally meperidine 50 mg IM if no pain relief after 30 min
group 1 (M 0.1 + D 8/8 h): 0.22 ± 0.40*†
group 2 (M 0.1): 0.26 ± 0.29*
group 3 (M 0.05 + D 8/8 h): 0.35 ± 0.29†
group 4 (M 0.05): 0.54 ± 0.40
group 5 (M 0.025 + D 8/8 h): 0.23 ± 0.30†
group 6 (M 0.025): 0.66 ± 0.62
* p<0.05, groups 1 and 2 < groups 3 and 4 = groups 5 and 6
† p<0.05, groups 1, 3, and 5 < groups 2, 4, and 6, respectively
pain scores of groups 1 and 2 (0.1 mg of morphine) were lower than the pain scores of groups 3 and 4 and groups 5 and 6 (0.05 and 0.025 mg of morphine, respectively)
pain scores of groups 1, 3, and 5 (subarachnoid morphine plus IM diclofenac every 8 h) were significantly lower compared with the pain scores of groups 2, 4, and 6, respectively (subarachnoid morphine and additional analgesics only on request)
supplemental analgesics: n/N
group 1 (M 0.1 + D 8/8 h): 0/20
group 2 (M 0.1): 9/20
group 3 (M 0.05 + D 8/8 h): 0/20
group 4 (M 0.05): 12/20
group 5 (M 0.025 + D 8/8 h): 0/20
group 6 (M 0.025): 15/20
(p-value not stated)
no patient required systemic opioids
treated vomiting n/N
groups 1 and 2 (morphine 0.1 mg): 10/40
groups 3 and 4 (morphine 0.05 mg): 6/40
groups 5 and 6 (morphine 0.025 mg): 4/40
treated pruritus n/N
groups 1 and 2 (morphine 0.1 mg): 23/40*
groups 3 and 4 (morphine 0.05 mg): 13/40
groups 5 and 6 (morphine 0.025 mg): 13/40
* p<0.05, groups 1 and 2 > groups 3 and 4 = groups 5 and 6
significantly greater incidence of severe pruritus was observed in the groups receiving 0.1 mg of subarachnoid morphine
no patient experienced respiratory depression
– no blinding of personnel and patients
level of evidence: 2
“… small doses of subarachnoid morphine combined with IM diclofenac every eight hours provide excellent postoperative pain control after caesarean delivery and that there are no advantages in using doses larger than 0.025 mg of subarachnoid morphine, if such a combination is used. Further studies are warranted to evaluate the efficacy of even smaller doses of morphine.”
Ketorolac and spinal morphine for postcesarean analgesia. International
Journal of Obstetric Anesthesia, 1996. 5(1): p. 14-18.
– positive or suspicious history of bleeding tendencies
– sleep apnoea
– morbid obesity
-renal disease
– peptic ulcer symptoms
– asthma
– nasal polyps
– allergy to aspirin, NSAIDs or opioids
group SM2: 30 ± 2
group SM1: 32 ± 2
group SMK: 34 ± 1
group K: 34 ± 2
maternal height [cm]: mean ± SD
group SM2: 150 ± 15
group SM1: 158 ± 3
group SMK: 160 ± 3
group K: 160 ± 3
group SM2: 86 ± 4
group SM1: 85 ± 7
group SMK: 80 ± 5
group K: 75 ± 4
48
group SM2: 11
group SM1: 12
group SMK: 13
group K:12
1500–2000 mL of lactated Ringer’s solution
SpA: 0.75% hyperbaric bupivacaine 12 mg (1.6 mL) and one of four treatments:
group SM2:
spinal morphine 0.2 mg (0.4 mL)
group SM1:
spinal morphine 0.1 mg (0.2 mL) plus 0.2 mL saline
group SMK:
spinal morphine 0.1 mg (0.2 mL) plus 0.2 mL saline,
ketorolac 60 mg IV 1 h after spinal injection and 30 mg IV every 6 h for three doses
group K:
spinal saline 0.4 mL and
ketorolac 60 mg IV 1 h after spinal injection and 30 mg IV every 6 h for three doses.
intraoperative pain management
fentanyl 50–100 µg IV
meperidine 12.5–25 mg IV, <50 mg/h
no significant differences between the four groups
(p-value not reported)
postoperative pain [VAS]:
no significant differences between the four groups during the first 20 h
time to first analgesic request [min]: mean ± SD
group SM2: 828 ± 169
group SM1: 603 ± 182
group SMK: 697 ± 143
group K: 693 ± 165
(p=NS)
supplemental analgesics:
patients given meperidine: %
group SM2: 72
group SM1: 75
group SMK: 77
group K: 67
total meperidine dosage (mg): mean ± SD
group SM2: 46 ± 21
group SM1: 72 ± 22
group SMK: 39 ± 11
group K: 49 ± 15
pruritus: %
group SM2: 100
group SM1: 83
group SMK: 85
group K:17*
* p=0.0001 compared with all other groups
two patients aborted study due to severe pruritus
nausea: %
group SM2: 45
group SM1: 50
group SMK: 31
group K: 33
vomiting: %
group SM2: 36
group SM1: 17
group SMK: 15
group K: 0
similar between the four groups
“… we found no better pain relief with a combination of intravenous ketorolac and spinal morphine than with either drug given alone. Although patients receiving spinal morphine had a high incidence of pruritus, overall satisfaction was high and similar in all groups.”
High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia.
International Journal of Obstetric Anesthesia, 2002. 11(2): p. 91-94.
– single fetus in cephalad position
– BMI >30 kg/m²
– contraindication to NSAIDs
no significant differences in age, weight and height
group D: 32.2 ± 4.4
group P: 32.9 ± 4.4
ASA I (n)/ ASA II (n)
group D: 39/1
group P: 39/3
84
group D: 42
group P: 42
group D: 0
group P: extensive bleeding: 2
32 hours
SpA: hyperbaric bupivacaine 5 mg/mL, 2.2–2.4 mL
after surgery
500 mL dextran-70
all women
rectal paracetamol 1000 mg every 6 h for 32 h
rectal diclofenac 100 mg after surgery, 12 h and 24 h
rectal placebo suppository given in same time intervals
rescue analgesia
if VAS >30 mm
morphine 2.5 mg IV as needed
no significant differences between the groups
cumulative morphine consumption
significantly reduced in group D from 5 h – 32 h, but not before
(p=0.048)
nausea (needed treatment): n
group P: 4
“…diclofenac suppositories, 100 mg twice daily after caesarean section in regional anaesthesia, was opioid-sparing. The use of diclofenac 200 mg daily did not seem to have any significant side-effects in this group of healthy parturients.”
Single dose diclofenac suppository reduces post-Cesarean PCEA requirements.
Canadian Journal of Anesthesia, 2001. 48(4): p. 383-386.
– patients who declined regional anaesthetic
– history of allergy to NSAIDs
– bleeding tendency
– peptic ulcer disease
– liver disease
– kidney disease
– unable to perform PCEA
group D: 30 (22–39)
group P: 32 (26–39)
group D: 156 ± 6
group P: 155 ± 6
group D: 66 ± 14
group P: 67 ± 11
group D: 24
excluded: 9
group D: 5
– PCA malfunction: 2
– epidural catheter dislodged: 1
– data collection incomplete: 1
– request for the removal of pump: 1
– data collection incomplete: 2
– administration of meperidine IM: 1
analysed: unclear
data from these patients were included up to the assessment time before premature exclusion from the study
– 30 mL 0.3 molar concentration sodium citrate
– 500 mL Hartmann`s solution IV
-infiltration of 1% lidocaine
SpA: 0.5% hyperbaric bupivacaine 1.5 mL (7.5 mg) IT,
no additional epidural anaesthetics needed
diclofenac suppository 100 mg
no suppository
PCEA: bolus dose of 4 mL of 0.2% ropivacaine with fentanyl 2 µg/mL (lockout 10 min, </=12 mL/h, no basal infusion)
cumulative PCEA consumption [mL]: mean ± SD
0–6 h
group D: 13.1 ± 7.7
group P: 18.1 ± 11.9
6–12 h
group D: 10.0 ± 3.1
group P: 18.7 ± 6.1
(p<0.005)
12–18 h
group D: 11.1 ± 5.2
group P: 20.0 ± 7.8
18–24 h
group D: 16.4 ± 6.3
group P: 17.7 ± 12.5
motor blockade: n
at 6 and 12 h: [modified Bromage 2]
group D: 1
group P: 1
at 24 h: [modified Bromage 0]/ [modified Bromage 1]
group D: 18/ 1
group P: 0/ unclear
none of the patients experienced:
– nausea
– vomiting
– pruritus
– excessive sedation
– allocation concealment unclear
– method of blinding unclear
“A single administration of 100 mg diclofenac suppository is effective in reducing post-caesarean epidural local anaesthetic/ opioid requirements by 33% for the first 24 h postoperatively”
A randomized controlled study comparing subcutaneous pethidine with oral diclofenac for pain relief after caesarean section.
Journal of the University of Malaya Medical Centre, 2009. 12(2): p. 63-69.
– single fetus
– <18 yr.
– known contraindication to NSAIDs:
– hypersensitivity
– renal impairment
– bleeding disorders
– gastric problems
– asthmatics
group P: 30.4 ± 4.4
group D: 31.4 ± 5.6
parity [n]: mean IQR
group P: 2.0 (1.00; 2.75)
group D: 2.5 (1.25; 3.75)
40
group P: 20
group D: 20
analysed: 40
one patient discharged before last evaluation was included in analysis
ranitidine 150 mg PO night and the morning of surgery, respectively;
sodium citrate 30 mL
SpA: 0.5% hyperbaric bupivacaine 2–2.5 mL IT,
no additional analgesia was given
0.5% plain bupivacaine 20 mL,
rectal diclofenac suppository 50 mg
subcutaneous pethidine 1 mg/kg before discharged from recovery room,
continued with subcutaneous pethidine 1 mg/kg with metoclopramide 10 mg IM every 8 h for three days
diclofenac sodium 75 mg PO twice daily, first dose given on the evening of surgery
pethidine 1 mg/kg subcutaneously 3 hourly as needed
need for supplemental analgesia on day 1: n
group P: 0
group D: 12
satisfaction score
similar between groups on day 1, significantly higher in group D on day 2 and day 3
sedation scores: median (IQR) day 1 group P: 2 (2, 2) group D: 0 (0, 2)
(p<0.001)
day 2 group P: 1 (1, 2) group D: 0 (0, 0)
day 3 group P: 0 (0, 1) group D: 0 (0, 0)
(p=0.024)
no significant differences in:
– PONV (only two women in group P)
– no blinding of patients and physicians
“…the use of regular oral diclofenac 75 mg twice daily may not provide comparable pain relief on the first postoperative day, but it provided superior patient satisfaction as compared to the traditional method of subcutaneous pethidine 1 mg/kg. Although offering less than perfect analgesia, oral diclofenac provided comfort to the patients with few side effects and can be monitored on the ward. The use of oral diclofenac 150 mg daily did not seem to have any significant side effects in this group of healthy parturient. Therefore, it is still acceptable to use diclofenac alone as an alternative pain relief following caesarean section, in view of the other benefits of a non-opioid analgesics and especially in places where newer techniques are neither possible nor practical. However this is only a pilot study, a bigger sample size would be needed to confirm the findings.”
A double-blind randomised controlled trial of paracetamol, diclofenac or the combination for pain relief after caesarean section.
International Journal of Obstetric Anesthesia, 2008. 17(1): p. 9-14.
– >/=37 gestational weeks
– between 18 and 45 yr.
– any significant history of maternal medical or obstetric illness
– any evidence of fetal compromise within the current pregnancy
group P: 31.9 ± 6.2
group D: 29.7 ± 6.4
group PD: 28.8 ± 5.8
group P: 160.5 ± 6.4
group D: 159.4 ± 6.6
group PD: 163.2 ± 6.0
group P: 73.0 ± 13.1
group D: 73.3 ± 13.3
group PD: 76.0 ± 14.3
gestation (wk.): mean ± SD
group P: 39.0 ± 0.8
group D: 38.7 ± 0.5
group PD:39.1 ± 0.9
78
group P: 26
group D: 26
group PD: 26
excluded: 4
request for rescue analgesia: 2
due to excessive vomiting: 1
group PD:
analysed: 74
group D: 25
infusion of Ringers Lactate IV
SpA: bupivacaine 5 mg/mL with dextrose 80 mg/mL in 2.25–2.5 mL, mixed with fentanyl 12.5 µg (total volume 2.5–2.75 mL)
– if systolic blood pressure <100 mmHG increments of IV ephedrine 3–6 mg
suppositories given at the end of surgery
paracetamol 1 g
diclofenac 100 mg
paracetamol 1 g and diclofenac 100 mg
6 h after surgery
oral paracetamol 1 g 6-hourly and placebo 8-hourly
placebo 6-hourly and oral diclofenac 50 mg 8-hourly
oral paracetamol 1 g 6-hourly and and oral diclofenac 50 mg 8-hourly
morphine via iPCA (bolus 1 mg, lockout 5 min.)
rescue analgesia:
morphine IV (not specified)
at rest and on movement
morphine consumption via iPCA
in consecutive 4 h periods up to 24 h
differences were significant between all time periods except 8–11.9 h and 12–15.9 h.
consumption after 24 h: mean ± SD
group P: 54.5 ± 28.5*
group D: 44.1 ± 24.4
group PD:33.8 ± 23.8*
(p=0.02, difference between groups)
iPCA attempts: mean ± SD
group P: 68.7 ± 35.6*
group D: 63.7 ± 31.8
group PD: 40.3 ± 30.3*
(p=0.04, difference between groups))
significantly higher in group D and group PD compared with group P
recovery
time to first independent mobilisation (h): mean ± SD
group P: 22.8 ± 2.8
group D: 24.6 ± 14.4
group PD:19.4 ± 6.7
(p=0.39)
– heart rate
– systolic and diastolic blood pressure
“…patients given a combination of paracetamol and diclofenac for pain relief after caesarean section use significantly less morphine compared to patients given paracetamol alone. Almost one third of patients in the paracetamol group were dissatisfied with pain management after surgery. Larger studies are required to investigate the differences between diclofenac alone and the combination of paracetamol and diclofenac, particularly when long-acting intrathecal opioids are used.”
Diclofenac in the treatment of pain after caesarean delivery: An opioid-saving strategy.
European Journal of Obstetrics Gynecology and Reproductive Biology, 2000. 88(2): p. 143-146.
– >/=38 gestational weeks
– uncomplicated pregnancy
– indication for operation were cephalo-pelvic disproportions, breech position or repeated sections
– not reported
group D: 31.2 ± 1.25
group P: 32 ± 0.82
primiparous (n)/ multiparous (n)
group D: 8/ 17
group P: 14/ 11
breech (n)
group D: 8
group P: 11
repeat c-section (n)
group D: 4
cephalo-pelvic disproportions (n)
group D: 13
50
group P: 25
unclear
2.5% Ringer-Dextrane solution 1000–1500 mL preceded by 3 g Dextrane haptene
SpA: 0.5% bupivacaine 12.5 mg (2.5 mL hyperbaric solution with 8% glucose)
intraoperative rescue analgesia
fentanyl 0.1 mg or dixyrazin 10 mg
first suppository given at the end of surgery
3x diclofenac 50 g during first 24 h
placebo suppositories during the same period
ketobemidone via iPCA (dose of 1 mg, lockout 6 min., </=10 mg/h),
ketobemidone 5–10 mg IV
group D: 2/4
group P: 2/4
postoperative rescue analgesia [n]
group P: 7
ketobemidone consumption during first 20 h
total dose [mg]: mean ± SD
group D: 30.9 ± 3.3
group P: 47.6 ± 3.08
demands from iPCA: mean ± SD
group D: 43.6 ± 5.8
group P: 72.6 ± 7.55
(p<0.004)
delivery refused: mean ± SD
group D: 12.6 ± 3.72
group P: 25 ± 5.48
(p<0.03)
significantly reduced in group D compared with group P during the first 3 h, but not afterwards
(p=0.025)
none of the patients had any bleeding complications
– incomplete outcome data
“This study demonstrates that adding 150 mg diclofenac administered rectally after surgery in addition to PCA systemic opioids increases the quality of pain relief and reduces the need for opioids after Caesarean section performed under spinal anaesthesia.”
Rectal indomethacin potentiates spinal morphine analgesia after caesarean delivery.
Anaesthesia and Intensive Care, 1995. 23(5): p. 555-559.
– history of asthma
– intolerance to NSAIDs
group I: 32.8 ± 4.98
group P: 29.6 ± 5.2
weight [kg]: mean ±SD
group I: 84.6 ± 17
group P: 76.6 ± 17.7
height [cm]; mean ± SD
group I: 161 ± 11
group P: 162.3 ± 7.4
primiparous [n]
group I: 4
30
group I: 15
group P: 15
all patients included
preloading with 1000–2000 mL of warmed crystalloid
SpA: 0.75% hyperbaric bupivacaine 1.2–1.4 mL, morphine 250–300 µg, fentanyl 10–15 µg
Pfannenstiel incision
(not specified)
group I:
indomethacin 100 mg suppositories (200 mg immediately, 100 mg twice-daily thereafter)
suppository: haemorrhoidal preparation containing zinc oxide, balsam and benzyl benzoate
oral codeine 30 mg and paracetamol 325 mg, three-hourly as needed,
parenteral opioids if requested
group I: 39.6 (7–82)
group P: 9 (2–76)
(p<0.003)
total additional analgesic requests [n]: median (range)
group I: 4 (0–11)
group P:11 (1–20)
(p<0.0009)
no requests for parenteral opioids
POD 1 on movement
group I: 1.4 ± 1.2
group P: 5.1 ± 2.1
(p<0.00001)
POD 2 on movement
group I: 3.3 ± 2
group P: 5.5 ± 2.9
POD 3 on movement
group I: 2.8 ±1.7
group P: 4.5 ±2.7
mean pain on movement at all times [VAS] group P higher score than group I (p=0.0003)
incisional pain
no difference between groups on POD 1, POD 2 and POD 3
visceral pain
no differences in:
– vaginal blood loss
– uterine cramps
– itching
no episodes of
– respiratory depression
– urinary retention
“Rectal indomethacin use following caesarean delivery leads to significantly improved pain relief compared with placebo. The combination of spinal morphine and rectal indomethacin leads to high-quality postoperative analgesia.”
The effect of intravenous ketorolac on opioid requirement and pain after cesarean delivery.
Anesthesia and Analgesia, 2001. 92(4): p. 1010-1014.
– contraindications to NSAID
– opioid use
– unwillingness to use PCEA
group K: 29.3 ± 5.1
group P: 30.8 ± 3.1
weight [kg]: mean ± SD
group K: 79.9 ± 11.9
group P: 77.4 ± 10.6
group K: 26
excluded: 6
– failure to obtain data: 6
group K: 24
CSEA: 0.5% hyperbaric bupivacaine 10–12.5 mL and fentanyl 12.5 µg IT
product information was altered
first six cases:
after delivery: initial dose of ketorolac 30 mg
PACU: IV infusion of ketorolac 120 mg over 24 h
following cases
after delivery: initial dose of ketorolac 15 mg
PACU: IV infusion of ketorolac 105 mg over 24 h (total 120 mg)
after delivery: initial dose of saline
PACU: IV infusion of normal saline 500 mL over 24 h
epidural meperidine via PCA (6 mg/mL, 4 mL incremental dose, 15 min lockout)
infusion stopped after 24 h and continued with meperidine and oral paracetamol 500 mg/ codeine 30 mg (1–2 capsules 6-hourly as needed)
group K: 155 (78, 200)
group P: 90 (63, 125)
(p=0.06)
consumption of meperidine: median (IQR)
group K group P
0–12 h 114 (60, 183) 193 (129, 249)
(p=0.013)
12–24 h 105 (57, 150) 150 (108, 226)
(p=0.012)
24–48 h 183 (69, 300) 216 (177, 357)
0–72 h 546 (413, 786) 792 (672, 963)
postoperative pain [VAS] on movement:
no significant differences between groups
satisfaction with analgesia
no significant difference in time to
– first ambulation
– first ingestion of fluid
– first ingestion of solid
– first passage of flatus
– removal of urinary catheter
free of pruritus (%):
at 24 h
group K: 58
group P: 35
at 48 h
group K: 4
(p=0.006)
no significant difference in:
– sedation
“…IV ketorolac used for 24 h as an adjunct to PCEA meperidine produced a dose-sparing effect of approximately 30%, but did not significantly improve pain relief, reduce opioid-related side effects or change patient outcomes.”
Diclofenac and/or propacetamol for postoperative pain management after caesarean delivery in patients receiving patient controlled analgesia morphine
Regional Anesthesia and Pain Medicine 2001. 26 (4):p. 310-315
– atopia
– abuse of drugs or alcohol
group MDP: 31.5 ± 4.4
group MD: 31.4 ± 6
group MP: 31.0 ± 4.6
group M: 30.6 ± 5.1
group MDP: 81.3 ± 11.2
group MD: 78.4 ± 9.6
group MP: 72.9 ± 10.1
group M: 80.9 ± 13.3
parity: primiparus [%]/ multiparus [%]
group MDP: 26.3/ 73.7
group MD: 25/ 75
group MP: 26.3/ 73.7
group M: 31.6/ 68.4
gestational age [wk.]: mean ± SD
group MDP: 37.4 ± 2.7
group MD: 38.2 ± 2.1
group MP: 37.6 ± 2.2
group M: 37.4 ± 2.1
group MDP: 20
group MD: 20
group MP: 20
group M: 20
excluded: 1
– technical problems with PCA: 1
group MDP: 19
polygeline 500 mL IV
SpA: 12 mg of hyperbaric bupivacaine (7.5 mg/mL) in 8.25% dextrose with fentanyl 12.5 µg
group M:
placebo (injection and suppository)
group MD:
diclofenac 100 mg rectally every 8 h and placebo injection
group MP:
propacetamol 2 g IV every 6 h and placebo rectally
group MDP:
diclofenac 100 mg rectally every 8 h and propacetamol 2 g IV every 6 h
morphine PCA
bolus of 1 mg , lockout 6 min, </=25 mg/4 h for 24h
if analgesia was inadequate
additional boluses given by anaesthesiologist until VAS <3, then reduced the lockout time to 5 min and increase the maximum dose
2 h
group MDP: 3.1 ± 4.1 (0–15)
group MD: 2.5 ± 3 (0–12)
group MP: 6.2 ± 5 (0–17)
group M: 6.3 ± 5.3 (0–17)
(p<0.05 in group MDP versus groups MP and M;
p<0.05 in group MD versus groups MP and M)
6 h
group MDP: 13.6 ± 8.4 (2–35)
group MD: 15.2 ± 7.2 (5–30)
group MP: 24 ± 9.3 (8–41)
group M: 28.7 ± 13.1 (1–52)
24 h
group MDP: 28.3 ± 15.8 (3–68)
group MD: 36 ± 18 (12–63)
group MP: 61.1 ± 23 (28–107)
group M: 66.7 ± 20 (33–100)
need for additional boluses: n
group MDP: 0
group MD: 0
group MP: 5
group M: 8
(p<0.05)
postoperative pain [VAS]: mean ± SD (range)
at rest 2 h
group MDP: 2.7 ± 2 (0–7)
group MD: 2.9 ± 2.6 (0–9)
group MP: 4.3 ± 2.5 (0–8)
group M: 6 ± 3 (0–10)
(p<0.05 in groups MDP and MD versus group M)
at rest 6 h
group MDP: 3.7 ± 1.9 (1–9)
group MD: 3.4 ± 1.8 (0–7)
group MP: 3.9 ± 2 (1–9)
group M: 3.8 ± 1.7 (0–7)
at rest 24 h
group MDP: 1.5 ± 1.3 (0–5)
group MD: 2.3 ± 2 (0–7)
group MP: 3.5 ± 2 (0–8)
group M: 3.2 ± 2.7 (0–10)
(p<0.05 in group MDP versus groups MP and M)
on coughing 2 h
group MDP: 3.6 ± 3.1 (0–10)
group MD: 4 ± 3.1 (0–8)
group MP: 5.3 ± 3.2 (0–10)
group M: 6.9 ± 3.1 (0–10)
on coughing 6 h
group MDP: 5.5 ± 2.2 (3–10)
group MD: 5.1 ± 2.9 (0–10)
group MP: 5.6 ± 2 (3–9)
group M: 6.1 ± 1.7 (2–9)
on coughing 24 h
group MDP: 3.5 ± 1.6 (1–6)
group MD: 4.8 ± 2.2 (1–9)
group MP: 5.3 ± 2 (2–9)
group M: 5.3 ± 2.2 (0–9)
satisfaction
good outcome [n]/ bad outcome [n]
group MDP: 19/ 0
group MD: 20/ 0
group MP: 17/ 3
group M: 17/ 3
pruritus: n
group MDP: 6
group MD: 5
group MP: 4
nausea and/ or vomiting: n
group MDP: 3
group MD: 2
group MP: 3
group M: 4
sedation: n
group MD: 1
group MP: 1
group M: 3
“…the concurrent administration of diclofenac in parturients receiving PCA morphine after caesarean delivery improves analgesia and has a significant morphine-sparing effect compared with propacetamol and placebo alone. We were unable to show a significant morphine-sparing effect of propacetamol or additive effect of propacetamol and diclofenac in this group of patients.”
The comparison between suppository diclofenac and pethidine in post-cesarean section pain relief: A randomized controlled clinical trial.
Journal of Research in Medical Sciences, 2006. 11(5): p. 292-296.
– gestational age >28 wk.
– no history of convulsion, drug sensitivity, opioid addiction, epigastric pain and gastrointestinal bleeding
– operation time >90 min
– any complication during surgery that needed another operation
– postoperative ileus
– any other state which required administration of other analgesics
group D: 27.2 ± 6.5
group P: 26.4 ± 5.6
group D: 38.8 ± 1.7
group P: 39.1 ± 1.4
parity: single parity [% (n)]/ multiparous [% (n)]
group D: 99 (82.5)/ 21 (17.5)
group P: 109 (90.8)/ 11 (9.2)
previous abortion: 0 [n (%)]/ >/=1 [n (%)]
group D: 105 (87.5)/ 15 (12.5)
group P: 104 (86.7)/ 16 (13.3)
previous c-section: yes [n (%)]/ no [n (%)]
group D: 29 (24.2)/ 91 (75.8)
group P: 25 (20.8)/ 95 (79.2)
240
group D: 120
group P: 120
26 hours
SpA: hyperbaric lidocaine 60–100 mg (adjusted for height)
diclofenac suppository 100 mg after surgery followed by 3 other identical doses at 8 h intervals
pethidine 1 mg/kg IM after surgery followed by other three doses at 8 h intervals
pethidine 1 mg/kg as needed
at 2 h
group D: 6.8 ± 2.3
group P: 7.3 ± 2.4
at 10 h
group D: 2.05 ± 2.07
group P: 2.6 ± 2.2
at 18 h
group D: 1.4 ± 1.6
group P: 2.3 ± 2.2
at 26 h
group D: 0.5 ± 1.1
group P: 1.3 ± 1.9
satisfaction for pain relief
good: n (%)
group D: 85 (70.8)
group P: 73 (60)
moderate: n (%)
group D: 31 (25.8)
group P: 36 (30)
poor: n (%)
group D: 4 (3.3)
group P: 11 (9.2)
headache: n (%)
group D: 1 (0.8)
group P: 2 (1.6)
dizziness: n (%)
group D: 0 (0)
group P: 11 (9.1)
PONV
similar between groups (not specified)
– no blinding
“Pethidine is one of the most effective opioids for pain relief after caesarean section, but general concerns have been raised for its wide side effects, high cost, and legal issues. It seems that diclofenac suppository is a suitable replacement for this drug because it has shown better analgesic effects on postoperative pain.”
Diclofenac sodium and low dose epidural morphine for postcesarean analgesia.
Anaesthesiologica Sinica, 1990. 28(3): p. 295-301.
– allergy history to NSAIDs
– abnormal bleeding tendency
– history of peptic ulceration
– multiple pregnancy
maternal age [yr.]: mean ± SEM
group D: 29.52 ± 0.73
group P: 31.32 ± 0.78
maternal weight [kg]: mean ± SEM
group D: 68.30 ± 4.57
group P: 65.71 ± 1.42
maternal height [kg]: mean ± SEM
group D: 156.50 ± 1.27
group P: 157.77 ± 1.18
parity: primiparas n/ multiparas n
group D: 10/ 15
group P: 7/ 18
all included patients analysed
lactated Ringer’s solution 750 mL
EA: 2% lidocaine added 1:200 000 epinephrine, gradual lidocaine topping-up
30 min after last supplemental lidocaine, morphine HCl 2 mg in saline 10 mL given epidurally
diclofenac sodium 75 mg deep gluteal muscle injection
normal saline 3 mL
meperidine 25 mg IV at the recovery room and
group D group P
baseline 3.08 ± 0.31 2.96 ± 0.28
2 h 2.08 ± 0.44 2.80 ± 0.47
4 h 1.84 ± 0.35 3.02 ± 0.45*
8 h 0.40 ± 0.16 1.80 ± 0.29**
12 h 0.40 ± 0.16 2.24 ± 0.33**
18 h 0.80 ± 0.27 2.82 ± 0.45**
24 h 1.92 ± 0.45 4.30 ± 0.60**
(*p=0.064; p**<0.005)
nausea/vomiting 13 9
itching 25 25
respiratory depression 0 0
hematoma/ bleeding 0 0
rescue analgesia 1 2
“… with the addition of diclofenac, a potent NSAID, to low dose epidural morphine, the post-caesarean analgesic quality and duration can be greatly improved”
Combination of low-dose epidural morphine and intramuscular diclofenac sodium in postcesarean analgesia.
Anesthesia and Analgesia, 1992. 75(1): p. 64-68.
– severe liver or kidney diseases
– peptic ulcer
. abnormal bleeding tendency
– known history of allergy to NSAIDs
group A: 31 ± 1
group B: 30 ± 1
group C: 31 ± 1
group D: 30 ± 1
group A: 67.4 ± 1.1
group B: 69.1 ± 2.0
group C: 65.9 ± 1.5
group D: 66.5 ± 1.3
group A: 157.3 ± 1.0
group B: 157.4 ± 1.0
group C: 157.2 ± 0.9
group D: 157.2 ± 0.9
group A: 10/ 19
group B: 11/ 18
group C: 10/ 19
group D: 13/ 17
group A: 30
group B: 30
group C: 30
group D: 30
excluded: 3
owing to severe uterine contraction pain:
group A: 1
group B: 1
group C: 1
group A: 29
group B: 29
group C: 29
EA: 2% lidocaine with freshly added epinephrine 1:200 000
after delivering
oxytocin 10 U and ergonovine 0.2 mg IV
group A:
epidural saline (10 mL)
and saline solution (3 mL) IM
group B:
and diclofenac 75 mg (3 mL) IM
group C:
epidural morphine 2 mg (10 mL)
meperidine 50 mg IV every 4 h at request
group C versus group D
significantly reduced in group D only at 12 h
group B versus group D
significantly reduced in group D at 4, 8, 12 and 18 h
group B versus group C
significantly reduced in group B at 4, 8 and 12 h
group A versus group B
significantly reduced in group B at 12 and 18 h
postoperative uterine contraction pain:
significantly reduced in group D only at 4, 8, 12 and 18 h
significantly reduced in group C only at 4, 8, 12 and 18 h
significantly reduced in group B only at 4, 8, 12 and 18 h
patient satisfaction
significantly superior in group D compared with group A, group B and group C
no significant differences among the latter three groups
meperidine consumption [mg]
group A: 3650
group B: 2450
group C: 400
groups A and B required significantly more rescue analgesia than groups C and D
group A: 3
group B: 6
group C: 10
pruritus
group A: 0
group C: 27
bleeding
bradypnea
group B: 0
group C: 0
“… diclofenac sodium alone is not adequate for post-caesarean analgesia. Although effective in relieving most wound pain, 2 mg of epidural morphine is not fully effective in relieving uterine contraction pain. The combination of low-dose (2 mg) epidural morphine and 75 mg of IM diclofenac sodium enhances the analgesic effect in the treatment of both wound pain and uterine cramps after caesarean section.”
Intramuscular diclofenac for analgesia after cesarean delivery: A randomized controlled trial.
Journal of the Medical Association of Thailand, 2009. 92(6): p. 733-737.
– single viable fetus in cephalic presentation
– no history of NSAIDs allergy or contraindication
– operative time >2 h
– intraoperative blood loss >1000 mL
– injury to bowel or bladder
group D: 29.6 ± 5.19
group P: 30.8 ± 4.82
parity: nulliparas n (%)/ multiparas n (%)
group D: 12 (30)/ 28 (70)
group P: 6 (15)/ 34 (85)
repeat caesarean section: n (%)
group D: 26 (65)
group P: 34 (85)
group D: 40
SpA: hyperbaric bupivacaine 10–12 mg with morphine 0.2 mg
low transverse caesarean section with low midline incision
diclofenac sodium 75 mg IM postoperatively within 2 h and then at 12 h (altogether 2 doses)
no intervention
tramadol 50 mg IM
at 6 h
group D: 1 (0–6)
group P: 4 (0–6)
(p=0.002)
at 12 h
group D: 2 (0–5)
group P: 3 (0–7)
(p=0.031)
group D: 1.5 (0–4)
group P: 3 (1–8)
group D: 3 (0–4)
(p=0.136)
rescue analgesia: n (%)
group P: 8 (20)
(0.003)
patient satisfaction: mean ± SD
group D: 4.33 ± 0.52
group P: 4.05 ± 0.59
(p=0.073)
group D: 4.00 ± 0.50
group P: 4.25 ± 0.54
(p=0.12)
no occurrence of
– gastrointestinal bleeding
– uterine atony
– injection site irritation
– anaphylaxis
– selective outcome reporting unclear
“… diclofenac can be prescribed in postoperative caesarean pain control with effectiveness and safety when wishing to avoid opioids and its derivatives because of side effects.”
Analgesia after caesarean section with intramuscular ketorolac or pethidine.
Anaesthesia and Intensive Care, 1993. 21(4): p. 420-423.
– ASA physical status I/II Asian women
– general anaesthesia
– uncomplicated term pregnancies
– will bottle-feed their babies
– moderate or severe pain and requesting analgesia
– mild, or very severe pain
group K: 31.5 ± 4.4
group P: 31.4 ± 3.9
height [cm]: mean ± SEM
group K: 153 ± 5.8
group P: 154 ± 6.0
weight [kg]: mean ± SEM
group K: 62.6 ± 7.6
group P: 64.8 ± 8.0
100
group K: 49
group P: 51
GA: induced with thiopentone 4–5 mg/kg, suxamethonium 1.5 mg/kg,
maintained with atracurium, nitous oxide and isoflurane
at the end of surgery
fentanyl 100 µg and oxytocin 10 mg, neuromuscular block was antagonised with neostigmine, atropine
in recovery room:
ketorolac 30 mg IM
pethidine 75 mg IM
pethidine 75 mg IM as needed
VAS
no difference between the groups
assessment of overall pain: group K n/ group P n
no analgesia: 6/ 6
some: 21/ 23
marked: 21/ 22
complete: 1/ 0
supplemental analgesia: n
time to first request
similar in both groups
(p=0.27)
not necessary in:
group P: 6
overall opinion of study drug: group K n/ group P n
poor: 8/ 5
fair: 12/ 18
good: 25/ 23
very good: 4/ 4
group K
one patient with dizziness, nausea and vomiting
group P
nine patients (6 nausea, 2 dizziness, 1 nausea, vomiting and dizziness)
– unclear blinding of participants and personnel
– method of blinding not described
“…ketorolac 30 mg and pethidine 75 mg have similar, short but variable efficacy after caesarean section. We consider the administration of either drug by the intramuscular route as generally unsatisfactory and unsuitable for the initial treatment of patients with severe pain when the intravenous route is available. Analgesic regimens should be individualised, and provided that effective e analgesia is achieved immediately after surgery, we expect intramuscular ketorolac to be an alternative to intramuscular pethidine for further routine analgesia on the ward. Ketorolac should have fewer logistic problems associated with its administration because it is not subject to the strict regulations governing opioid drugs. Ketorolac also has a lower incidence of side-effects compared with pethidine but studies are still required to determine whether ketorolac is cost-effective.”
Intravenous acetaminophen vs oral ibuprofen in combination with morphine PCIA after Cesarean delivery
Canadian Journal of Anesthesia, 2006. 53(12): p. 1200-1206.
– >/=37 weeks pregnant
– caesarean section under spinal anaesthesia
– abnormally lying placenta
– prenatally diagnosed fetal abnormalities
– intra-uterine fetal death
– hypertensive diseases of pregnancy
– any contraindication to spinal anaesthesia
– language barrier or mental disorder
– any allergy and/or contraindication to any of the study medications
group A: 33 ± 5
group I: 32 ± 5
group A: 81 ± 16
group I: 78 ± 15
ASA status: [n I]/ [n II]
group A: 12/ 10
group I: 12/ 11
gestational age [weeks]: mean ± SD
group A: 38 ± 1
group I: 38 ± 1
parity
group A: 3 ± 2
group I: 3 ± 2
gravidity
group A: 4 ± 2
group I: 4 ± 2
45
group A: 22
group I: 23
– SpA using 2.5 mL of 0.5% hyperbaric bupivacaine mixed with fentanyl 10 µg
horizontal lower segment uterine incision
intraoperative pain
fentanyl 50 µg IV as needed
intra- and postoperative PONV
metoclopramide 10 mg IV every 6 h as needed
group A
– paracetamol 1 g (100 mL) IV over 15 min and one placebo tablet PO, each given every 6 h for 48 h
group I
– ibuprofen 400 mg PO and saline 100 mL IV over 15 min, each given every 6 h for 48 h
first administration in both groups 30 min before surgery
PACU
– morphine 0.05 mg/kg IV bolus
– iPCA: morphine bolus dose 2 mg IV, lockout 10 min, no basal infusion
– if VAS >/= 5:
morphine 5 mg IV bolus every 4 h as needed
– 48 h after surgery: tramadol 1 mg/kg IM every 4 hours
no significant differences
(p=0.143)
iPCA morphine consumption [mg]: mean ± SD
(p=0.562)
rescue morphine [n]
group I: 2
(p=1.0)
APGAR-Score
patient satisfaction with analgesia: mean ± SD
group A: 9 ± 1
group I: 9 ± 1
(p=0.93)
no significant differences between the groups in:
– PONV
– oxygen desaturation
group A: 10
group I: 19
“Intravenous paracetamol is a reasonable alternative to oral ibuprofen as an adjunct to morphine patient-controlled analgesia after cesarean delivery”
Valdecoxib for postoperative pain management after cesarean delivery: A randomized, double-blind, placebo-controlled study.
Anesthesia and Analgesia, 2006. 103(3): p. 664-670.
– 18–45 yr
– singleton pregnancy
– gestation >37 wk
– no postpartum tubal ligation
– pregnancy-induced hypertension
– renal disorders
– coagulation disorder
– significant cardiovascular disease
– use of narcotic analgesics
– anticonvulsants
– corticosteroids
– antidepressants
– anxiolytics
– NSAIDS <24
– BMI >40
– prior myomectomy or vertical uterine scar
– history of alcohol, analgesic, or narcotic abuse
– any significant antepartum, intrapartum, or postpartum haemorrhage
– inadequate intraoperative neuraxial anaesthesia requiring conversion
– previous breast surgery or other breast problems resulting in inability to breast-feed
– allergies to sulfa, opioid or NSAID medications
– NSAID-sensitive asthmatics
group V: 34 ± 6
group P: 34 ± 5
height [cm]: mean ± SD
group V: 157 ± 6
group P: 160 ± 6
group V: 74 ± 8
group P: 79 ± 12
nullipara: n (%)
group V: 5 (20)
group P: 5 (22)
previous caesarean deliveries: n (%)
group V: 18 (72)
group P: 17 (74)
group V: 25
withdrawn:
group V: 1 for administering NSAIDs
excluded
SpA: hyperbaric bupivacaine 12 mg fentanyl 10 µg, morphine 100 µg IT
group V:
valdecoxib PO 20 mg twice daily for 72 h, first dose 90 min after spinal block
placebo at the same point in time as valdecoxib was given
mild pain: VPS<3
1 tablet (hydrocodone 5 mg or oxycodone 5 mg) every 4 h as needed
moderate pain: VPS 3–7
2 tablets (hydrocodone 10 mg or oxycodone 10 mg) every 4 h as needed
severe pain: VPS >7 or moderate pain not responsive to oral analgesics
morphine 2–4 mg IV every 10 min as necessary until comfortable (<10 mg/h)
max. doses allowed were oxycodone 60 mg or hydrocodone 60 mg or 4 g paracetamol (in combination with the oral opioid) in a 24 h period
pain at rest during 72 h
no significant differences between the two groups
(p=0.37)
pain on movement during 72 h
(p=0.42)
group V: 335 ± 204
group P: 364 ± 189
(p=0.68)
total IV morphine [mg]: mean ± SD
group V: 3 ± 4
group P: 2 ± 3
total analgesic use (morphine-equivalent) [mg]: mean SD
group V: 121 ± 70
group P: 143 ± 77
(p=0.26)
no significant differences between groups in:
– vaginal bleeding
– hypertension
no methodological shortcomings according to the evaluation sheet.
“However, because of concerns about the safety of COX-2 inhibitors that became apparent from published reports during this study, a decision was made to terminate the study early until the safety concerns were better understood”
“… were unable to demonstrate significant analgesic efficacy of valdecoxib compared with placebo. Patients did not experience any adverse events related to short-term postoperative administration of valdecoxib. In light of the lack of significant analgesic efficacy observed and the potential thrombotic cardiovascular risks associated with valdecoxib, its routine use in the management of pain after caesarean delivery is not supported at this time..”
Low-dose ketamine with multimodal postcesarean delivery analgesia: A randomized controlled trial.
International Journal of Obstetric Anesthesia, 2011. 20(1): p. 3-9.
– >/=37 weeks of gestation
– ASA physical status I–II
– BMI >/=40 kg/m²
– allergies to any of the study medications
– history of hallucinations
– substance abuse
– chronic opioid therapy or chronic pain
maternal age [yr.]: median [IQR]
group K: 34 [31–37]
group P: 34 [31–37]
weight [kg]: median [IQR]
group K: 77 [71–87]
group P: 77 [70–85]
BMI: median [IQR]
group K: 29 [27–31]
group P: 29 [26–32]
gestational age [week]: median [IQR]
group K: 39 [39–39]
group P: 39 [39–39]
prior caesarean deliveries: n (%)
group K: 59 (69)
group P: 59 (66)
188
group K: 94
group P: 94
group K: 5
loss to follow up:
group K: 1 group P: 1
excluded from analyses: group K: 3 group P: 1
group K: 85
group P: 89
2 weeks
SpA: hyperbaric bupivacaine 12 mg (1.6 mL 0.75% bupivacaine in 5% dextrose), fentanyl 15 µg and morphine 150 µg as single injection
five minutes after delivery
ketamine 10 mg IV diluted to 20 mL with 0.9% saline
20 mL of 0.9% saline
administered over 10 min via infusion pump (2 mL/min)
in PACU
ketorolac 30 mg IV every 6 h for 24 h, but patients could refuse this analgesic intervention
the first 24 h
1 tablet of paracetamol 325 mg/hydrocodone 10 mg every 4 h as needed
due to insufficient pain relief
an additional tablet could be provided after 1 h
between 24 and 72 h
ibuprofen 600 mg every 6 h and 1–2 tablets of paracetamol 325 mg/hydrocodone 10 mg every 4 h
pain scores in the first 24 h were similar between the groups, but patients in the ketamine group had significantly lower pain scores at 2 weeks compared to the placebo group
(p=0.02)
incidence of breakthrough pain <24 h: n (%)
group K: 64 (75)
group P: 66 (74)
(p=0.86)
NRS for pain at first analgesic request: median (IQR)
group K: 3 (2–4)
group P: 4 (2–5)
time to first analgesic request [min]: median (95%-CI)
group K: 684 (337,1031)
group P: 760 (346,1174)
(p=0.65)
cumulative paracetamol/ hydrocodone tablets: median (IQR)
group K: 2 (1–4)
group P: 1 (0–3)
(p=0.22)
48 h
group K: 6 (4–9)
group P: 5 (3–8)
(p=0.11)
72 h
group K: 10 (6–14)
group P: 9 (5–12)
(p=0.24)
cumulative ibuprofen dose [mg]: median (IQR)
group K: 3600 (1200–4200)
group P: 3600 (2400–4200)
(p=0.28)
satisfaction with analgesia: median (IQR)
group K: 9 (8–10)
group P: 9 (8–10)
nausea: n (%)
group K: 27 (32)
group P: 30 (23)
(p=0.87)
vomiting: n (%)
group K: 13 (15)
group P: 13 (15)
(p=0.90)
pruritus: n (%)
group K: 12 (14)
group P: 19 (21)
“… no additional postoperative analgesic benefit of low-dose ketamine during caesarean delivery in patients who received intrathecal morphine and intravenous ketorolac. Subjects who received ketamine reported lower pain scores 2 weeks postpartum.
Effect of three different doses of ketamine prior to general anaesthesia on postoperative pain following Caesarean delivery: a prospective randomized study.
Minerva Anestesiol, 2012. 78(4): p. 442-9.
– ASA physical status I/ II
– nulliparous women
– caesarean section indicated
– pre-eclampsia
– cardiovascular problems
– allergy to any of the study medications
– chronic preoperative pain
– regular analgesic use
group KL: 30 ± 3
group KM: 31 ± 4
group KH: 32 ± 4
group P: 32 ± 4
group KL: 78 ± 9
group KM: 77 ± 9
group KH: 77 ± 10
group P: 82 ± 15
140
group KL: 35
group KM: 35
group KH: 35
all randomised patients analysed
48 hours/ 1 year
IV administration of study drugs:
group KL:
ketamine 0.25 mg/kg
group KM:
ketamine 0.5 mg/kg
group KH:
ketamine 1 mg/kg
placebo (0.9% saline)
GA:
induced with:
propofol 2–2.5 mg/kg
maintained with:
50% oxygen in N2O and
sevoflurane
after delivery
IV infusion of 20 IU oxytocin,
IV morphine chloride 0.1 mg/kg,
IV lornoxicam 8 mg
if NRS>4 in PACU:
IV morphine </=0.05 mg/kg
IV morphine chloride via PCA (0.5 mg/mL),
(1 mg bolus, 10 min lock-out time, without basal infusion)
IM diclofenac sodium 75 mg every 12 h as needed
up to 48 h
prolonged postoperative pain
no significant differences at 2 weeks, 1 month, 6 month and 12 months
morphine consumption via PCA
similar between the groups during 48 h
need for rescue analgesia: n
group KL: 8
group KM: 11
group KH: 7
group P: 14
Apgar score
at 1 min
group KL: 8.3 ± 1
group KM: 8.2 ± 1
group KH: 8.0 ± 1
group P: 8.0 ± 1
at 5 min
group KL: 9.6 ± 0.5
group KM: 9.5 ± 0.7
group KH: 9.5 ± 0.6
group P: 9.5 ± 0.7
– nystagmus
– hallucination
– diplopia
“No benefit was observed when ketamine was used as an analgesic drug in doses of 1 mg/kg or lower, with respect to postoperative pain reduction, as well the quality of our anaesthesia was not improved. We had comparable hemodynamic parameters in all groups. Therefore this topic needs further evaluation with studies assessing the plasma concentrations of ketamine.”
Low-dose intravenous ketamine improves postoperative analgesia after caesarean delivery with spinal bupivacaine in African parturients.
Int J Obstet Anesth, 2012. 21(3): p. 217-21.
– pre-existing neurological disease
– evidence of fetal compromise
– patient refusal
– coagulopathy
– thrombocytopenia
– infection at the puncture site
– previous history of reaction to local anaesthetic agents
group B: 29.8 ± 3.1
group BK: 30.3 ± 4.0
group B: 161 ± 12
group BK: 164 ± 3
group B: 72.2 ± 5.0
group BK: 73.7 ± 6.2
parity: median [range]
group B: 0 [0–4]
group BK: 0 [0–4]
gestational age [wk.]: mean SD
group B: 38.3 ± 1.0
group BK: 38.3 ± 0.9
60
group BK: 30
group B: 2
– failed block (1)
– conversion to GA (1)
group BK: 2
– severe intraoperative shivering (2)
analysed: 56
group B: 28
group BK: 28
IV 0.9% saline 20 mL/kg
SpA: 0.5% hyperbaric bupivacaine 15 mg
after institution of SpA
IV 0.9% saline
group BK:
IV ketamine 0.15 mg/kg
rescue analgesia: VAS score >3
IM diclofenac 75 mg and pentazocine 30 mg
thereafter:
IM pentazocine 30 mg/4 h and diclofenac 75 mg/8 h if requested
higher in group B at 60, 90 and 120 min, but not at 30 min
Apgar score: median [range]
group B: 9 [7–10]
group BK: 9 [8–9]
group B: 10 [8–9]
group BK: 10 [9–10]
group B: 164 ± 14.1
group BK: 209 ± 14.7
analgesic requirements
total diclofenac dose
group B group BK p-value
day 1 212 ± 29.2 147 ± 24.9 <0.001
day 2 137 ± 41.1 126 ± 35.7 0.3
total pentazocine dose
day 1 150 ± 20.0 109 ± 18.6 <0.001
day 2 102 ± 18.9 99 ± 16.4 0.092
– hypotension
– shivering
– headache
– blurred vision
“… administration of 0.15 mg/kg intravenous ketamine as an adjuvant to intrathecal bupivacaine for cesarean delivery improved postoperative analgesia and reduced cumulative analgesic administration on the first day after cesarean delivery. There were no significant side effects, and neonatal outcome was not affected.”
Preemptive analgesic effect of ketamine in patients undergoing elective cesarean section.
Clin J Pain, 2010. 26(3): p. 223-6.
– allergy to ketamine, thiopental, or morphine
– history of substance abuse
– transverse or breach positions
group K: 26.96 ± 5.1
group P: 27.33 ± 4.54
group K: 71.54 ± 12.3
group P: 73.34 ± 13.4
group K: 30
group P: 30
all randomised patient analysed
Ringer solution 500 mL
IV ketamine 0.5 mg/kg (diluted to 10 mL with normal saline)
saline 10 mL
thiopental 4 mg/kg followed by succinylcholine 1.5 mg/kg
nitrous oxide (50%) and halothane in oxygen
10 IU of oxytocin, IV fentanyl 2 µg/kg, IV morphine 0.15 mg/kg
rectal diclofenac 200 mg
if VAS </=3:
no morphine
if VAS 4-6:
IV morphine 3 mg
if VAS >/=7:
IV morphine 5 mg
in the ward
rectal diclofenac 100 mg every 4 h
if VAS >/=4:
IM morphine 0.15 mg/kg
no significant differences between groups at 2, 6, 12 and 24 h
morphine consumption
0–2 h
lower in group K
2–24 h
no significant difference
Apgar score: mean ± SD
group K: 8.64 ± 0.75
group P: 8.57 ± 1.02
group K: 9.96 ± 0.2
group P: 9.93 ± 0.24
– delirium
– recall intraoperative events
– unpleasant dreams
“…small doses of ketamine reduced by 40% the use of morphine during the first 2 hours after surgery, but no difference was found over 24 hours. Side effects were similar in the 2 groups, and pain scores were identical. Therefore, we believe that any preemptive effect of ketamine is likely to depend on the intensity of the noxious stimulus, the dose of ketamine used, and the types of adjuvant drugs administered. This remains to be worked out in further research.”
The persisting analgesic effect of low-dose intravenous ketamine after spinal anaesthesia for caesarean section.
Eur J Anaesthesiol, 2005. 22(7): p. 518-23.
– coexisting diseases (pregnancy-induced hypertension and gestational diabetes)
– fetal compromise
group F: 28.5 ± 5.1
group K: 26.3 ± 5.3
group P: 27.1 ± 4.6
group F: 158.3 ± 7.6
group K: 162.0 ± 6.1
group P: 160.0 ± 5.2
group F: 76.7 ± 8.5
group K: 78.1 ± 7.8
group P: 73.2 ± 9.4
group F: 39.3 ± 1.9
group K: 39.1 ± 1.6
group P: 38.2 ± 1.8
90
group F: 30
SpA: bupivacaine 15 mg combined with:
group F:
IT fentanyl 10 µg
saline
if VAS >3
IM diclofenac sodium 75 mg
diclofenac
group F: 165.2 ± 17.1*
group K: 198.6 ± 18.9**
group P: 144.8 ± 15.2
* p=0.034 group F versus group P
** p=0.001 group K versus group P
pain [VAS]
group F group K group P:
30 min 0 0 0
60 min 0 0 0
90 min 1.2 ± 0.7 0* 2.4 ± 0.8
120 min 2.3 ± 0.8 1.4 ± 0.8 3.1 ± 1.0
150 min 3.0 ± 0.9 2.2 ± 1.0 5.6 ± 1.5**
180 min 5.4 ± 1.7 3.5 ± 1.2* 6.0 ± 1.8
* (p<0.05) for group K versus group P and group F
** (p<0.05) for group P versus group K and group F
diclofenac consumption [mg]: mean ± SD
0–24 h
group F: 185.6 ± 30
group K: 117.5 ± 27*
group P: 225.4 ± 28
* p<0.05 for group K versus group F and group P
24–48 h
group F: 128.3 ± 22
group K: 124.5 ± 25
group P: 137.2 ± 24
Apgar score: mean
group F: 10 (9–10)
group K: 10 (9–10)
group P: 10 (9–10)
– postdural puncture headache
– total complicaton
“… the combination of IV low-dose ketamine and intathecal bupivacaine results in lower postoperative analgesic consumption and lower VAS scores compared to bupivacaine alone or the combination of bupivacaine and intrathecal fentanyl after caesarean section suggesting a pre-emptive analgesic effect.”
Effects of preemptive ketamine on post-cesarean analgesic requirement
Acta Medica Iranica, Vol 40, No 2 (2002)
– allergy to either of thiopental, ketamine, morphine
– gestational age <36 weeks
– fetal distress
– candidate for classical caesarean incision
group K: 28.66 ± 5.25
group P: 27.07 ± 3.28
(p=0.195)
group K: 74.48 ± 12.49
group P: 67.16 ± 10.31
(p=0.026)
gestational age [wk.]: mean
group K: 39.92
group P: 39.72
53
group K: 27
IV ketamine 0.2 mg/kg
distilled water
GA
thiopental 5%,
succinylcholine 1.5 mg/kg
halothan 0.5%, 50% nitrous oxide in oxygen
5 IU oxytocin, morphine 0.1 mg/kg and midazolam 1 mg (as bolus IV),
in addition 10 IU oxytocin
intravenously
postoperative analgesia
if NRS </=3
if NRS between 4 and 6:
morphine 3 mg
if NRS >/=7
morphine 5 mg
higher in group P
time to first analgesic request [h]: mean ± SD
group K: 10.22 ± 8
group P: 1.65 ± 1.01
total morphine consumption [mg]: mean ± SD
group K: 6.25 ± 3.42
group P: 17.73 ± 4.08
no significant differences between the groups at 1 and 5 min
“…ketamine in analgesic dose (0.2 mg/kg), given before induction of general anesthesia in cesarean patients, has a preemptive analgesia effect that prevents central sensitization. It may also reverse the established central sensitization in patients who have had experienced labour pain. These altogether, cause much reduction in postoperative analgesic requirements.”
The effect of low-dose ketamine on post-caesarean delivery analgesia after spinal anesthesia
Korean J Pain 26(3): 270-276.
– between 37–42 wk.
– psychological diseases
– difficulties communicating
– allergies to local anaesthesia
– inflammation in the spinal puncture area
– administered analgesics
– emergency operation
group K: 32.7 ± 3.7
group P: 32.5 ± 3.6
group K: 159.1 ± 6.8
group P: 159.0 ± 4.3
group K: 68.4 ± 11.7
group P: 69.1 ± 11.4
group K: 38.5 ± 1.9
group P: 39.2 ± 1.8
group K: 20
failed spinal puncture (n=4)
group K: 19
group P: 17
SpA: 0.5% bupivacaine 10 mg
before incision:
IV ketamine 0.5 mg/kg followed by continuous infusion of 0.25 mg/kg/h until the end of surgery
IV saline followed by continuous infusion of saline
patient’s request or decision of anaesthesiologist:
fentanyl 50 µg (</=2 times)
IV fentanyl via PCA:
25 µg/mL, dose 1 mL, lockout 15 min, without continuous dose)
VAS >/=5 or patient requested:
IM ketorolac 30 mg
group K: 48.5 ± 10.4
group P:49.7 ± 9.2
intraoperative administration of fentanyl: n
group K: 3
postoperative pain [VAS]
at rest
no significant differences between the groups at 2, 6, 24 and 48 h
coughing
fentanyl consumption
significantly lower in group K at 2 h (p=0.033), but not at 6, 24 and 48 h
need for ketorolac: n
– blinding of outcome assessor not reported
“…0.5 mg/kg ketamine was injected IV before the skin incision and infused continually at 0.25 mg/kg/h until the end of the operation in pregnant mothers receiving cesarean section under spinal anesthesia, but this treatment did not reduce the fentanyl requirement or postoperative VAS score. Further research is needed regarding the postoperative pain relief effect and complications according to administration time, period, and dosage of ketamine in pregnant mothers receiving cesarean section under spinal anesthesia”
A study of low-dose S-ketamine infusion as “preventive” pain treatment for cesarean section with spinal anesthesia: benefits and side effects.
Minerva Anestesiol 78(7): 774-781.
– elective repeat caesarean section
– age <18 years or >40 years
– ASA physical status status III–IV
– preexisting neurological or psychiatric illnesses
– pathologic pregnancy
-gestational age <37 weeks
-difficulties in cooperation between physician and patient
– history of chronic pain
– assuming NSAIDs or opioids or opioids addicted
maternal age [yr.]: mean
group K: 34.00
group P: 33.54
maternal weight [kg]: mean
group K: 73.22
group P: 75.04
group K: 38.44
group P: 38.05
(p=0.004)
parity: n: mean
group K: 2.33
group P: 2.46
56
group K: 28
group P: 28
after 24 h
after 3 months
group K: 13
group P: 13
24 h and 3 months
SpA: 0.5% hyperbaric bupivacaine 8–10 mg and sufentanil 5 µg
IM S-Ketamine bolus 0.5 mg/kg 10 min after birth followed by 2 µg/kg/min IV continuous infusion for 12 h via infusional pump
placebo in the same manner
IV morphine via PCA </=24 h:
bolus 1 mg, 8 min lock out, </=30 mg/4 h, without continuous infusion
>24 h
oral paracetamol 4 g/day and ketorolac 30–90 mg/day as needed
significantly reduced in group K at 4–8, 8–12, and 12–24 h, but not before
cumulative morphine consumption [mg]: mean ± SD
group K: 25.33 ± 11.76
group P: 37.00 ± 11.57
need for paracetamol and ketorolac
group K: 268 ± 158
group P: 190 ± 81.48
significantly more frequent in group K:
– drowsiness
– dizziness
– light-headness
– positive dysphoria
– dreaming
– negative dysphoria
– hallucinations
follow-up after 3 months (telephone survey)
– residual wound pain
– wound dysesthesia
– pain in other sites
– analgesic drugs for pain in other sites
– improved experience
– breastfeeding duration
“Preventive S-ketamine, administered by i.m. bolus and continuous i.v. infusion, enhanced the analgesic effect of morphine even after ketamine effect had ceased, suggesting anti-hyperalgesic action of the drug. S-ketamine administration in obstetric patients after cesarean section was safe and did not affect breastfeeding. A benefit of S-ketamine on prevention of postoperative hyperalgesia remains to be demonstrated, probably through studies on larger populations with objective methods of pain and hyperalgesia assessment.”
A randomised comparison of regular oral oxycodone and intrathecal morphine for post-caesarean analgesia.
International Journal of Obstetric Anesthesia, 2010. 19(1): p. 16-23.
– >/=18 yr.
– consented to combined spinal-epidural anaesthesia
– concurrent opioid therapy
– contraindications to combined spinal-epidural anaesthesia
– contraindication to any of the study medications
– history of preoperative pruritus or nausea
– failure to identify subarachnoid space during surgery
– inadvertent dural puncture with epidural needle
-conversion of spinal to general anaesthesia
maternal age [yr.]: median (IQR; range)
group M: 32 (28–37; 20–44)
group O: 31 (26–36; 20–42)
height [cm]: median (IQR; range)
group M: 165 (162–170; 152–183)
group O: 165 (158–169; 152–183)
weight [kg]: median (IQR; range)
group M: 86 (73–107; 58–153)
group O: 87 (76–107; 51–157)
group M: 2 (1–2; 0–4)
group O: 1 (1–2; 0–4)
ASA physical status II: n (%)
group M: 21 (38)
group O: 24 (43)
previous caesarean section: median (IQR; range)
group M: 1 (1–2; 0–4)
group O: 1 (0–1; 0–3)
group M: 60
group O: 60
– withdrew consent intraoperative: 1
– uncontrolled early postoperative pain: 3
group O: 5
– uncontrolled early postoperative pain: 2
– withdrew consent: 2
– conversion to general anaesthesia: 1
group M: 56
group O: 55
oral ranitidine 300 mg on the morning of surgery
CSEA: hyperbaric bupivacaine 11–12.5 mg combined with fentanyl 15 µg plus 0.2 mL of IT study solution:
IT morphine 100 µg
group O:
IT placebo
epidural lidocaine with adrenaline 1:200,000 if surgery was delayed or intraoperative pain experienced,
dexamethasone 4 mg IV after delivery
parecoxib 40 mg IV at the end of surgery and 8-hourly oral diclofenac 50 mg starting 12 h postoperatively
morphine IT 100 µg at the same time as spinal anaesthesia and placebo (0.2 mL) medication orally
saline placebo 0.2 mL IT and oral oxycodone 20 mg in recovery room, followed by oral oxycodone 10 mg every 6 h plus oral paracetamol 1 g
oral oxycodone 10–15 mg 2-hourly as needed,
additionally, oral tramadol 100 mg for insufficient pain relief (NRS>6)
group M: 160 (92–230; 23–1419)
group O: 144 (64–218; 20–1440)
(p=0.597)
additional analgesia requested: n (%)
group M: 35 (63)
group O: 46 (82)
(p=0.034)
additional oxycodone [mg]: median (IQR, range)
group M: 23 (10–35; 5–70)
group O: 25 (10–44; 5–85)
(p=0.953)
additional tramadol [mg]: median (IQR, range)
group M: 100 (100–100; 50–300)
group O: 100 (100–200; 50–500)
(p=0.299)
postoperative pain [NRS]: median (IQR, range)
at rest 6 h/ on movement 6 h
group M: 2 (0–3; 0–7) 4 (3–6; 0–10)
group O: 2 (1–3; 0–10) 5 (3–7; 1–10)
(p=0.178) (p=0.062)
at rest 12 h on movement 12 h
group M: 1 (0–2; 0–7) 3 (2–5; 0–8)
group O: 2 (1–3; 0–7) 4 (3–6; 0–8)
(p=0.03) (p=0.10)
at rest 18 h on movement 18 h
group M: 1 (0–2; 0–6) 3 (2–6; 0–8)
group O: 1 (0–2, 0–5) 3 (2–5; 0–8)
(p=0.589) (p=0.852)
at rest 24 h on movement 24 h
group M: 1 (0–2; 0–8) 3 (2–5; 0–9)
group O: 1 (0–2; 0–8) 3 (2–5; 0–9)
(p=0.688) (p=0.792)
AUC to 24 h: at rest on movement
group M: 21 (6–35; 0–117) 63 (37–96; 3–132)
group O: 24 (12–39; 0–84) 71 (42–99; 18–135)
(p=0.306) (p=0.319)
satisfaction with analgesia (0–10): median (IQR; range)
24h 48h
group M: 10 (8–10; 3–10) 9 (8–10; 2–10)
group O: 8 (7–10; 2–10) 9 (8–9; 0–10)
(p=0.01) (p=0.887)
group M: 48 (87)
group O: 31 (56)
(p=0.001)
nausea
further adverse effect/ events
no case of respiratory depression and only one urinary retention in group O
“… multimodal analgesic regimen based on oral oxycodone confers generally comparable and satisfactory clinical analgesic efficacy and a favourable side-effect profile compared with a multimodal regimen based on intrathecal morphine. An intrathecal morphine-based multimodal regimen appeared with reduced need for rescue analgesia and higher maternal satisfaction scores. We consider that a multimodal oral analgesic regimen including oxycodone, paracetamol, parecoxib and diclofenac is an acceptable approach to post-caesarean analgesia. Further refinements to this technique may improve efficacy and maternal satisfaction. Cost-effectiveness evaluation appears warranted.
“…the use of regular oral diclofenac 75 mg twice daily may not provide comparable pain relief on the first postoperative day, but it provided superior patient satisfaction as compared to the traditional method of subcutaneous pethidine 1 mg/kg. Although offering less than perfect analgesia, oral diclofenac provided comfort to the patients with few side effects and can be monitored on the ward. The use of oral diclofenac 150 mg daily did not seem to have any significant side effects in this group of healthy parturient. Therefore, it is still acceptable to use diclofenac alone as an alternative pain relief following caesarean section, in view of the other benefits of non-opioid analgesics and especially in places where newer techniques are neither possible nor practical. However this is only a pilot study, a bigger sample size would be needed to confirm the findings.”
previous C-section: yes [n (%)]/ no [n (%)]
Transnasal butorphanol: A new method for pain relief in post-cesarean section pain.
Acta Anaesthesiologica Scandinavica, 1991. 35(1): p. 14-18.
maternal age [yr.]: mean (range)
group 1: 26.9 (18–41)
group 2: 26.1 (16–40)
group 3: 26.1 (18–37)
group 4: 27.6 (18–43)
group 5: 26.2 (18–36)
baseline pain: moderate [%] / severe [%]
group 1: 41/ 59
group 2: 32/ 68
group 3: 42/ 58
group 4: 37/ 63
group 5: 41/ 59
186
group 1: 37
group 2: 38
group 3: 36
group 4: 38
group 5: 37
general anaesthesia (n=30)
– sodium thiamylat 4 mg/kg and succinylcholine
– 0.5% enflurane with 50% N2O and O2
spinal anaesthesia (n=98)
– usual manner with 1% tetracaine
epidural anaesthesia (n=58)
-2% lidocaine with 1:200 000 epinephrine
no spinal narcotics in regional anaesthesia group
group 1
2 mg intravenous butorphanol (IVB)
group 2
2 mg transnasal butorphanol (TNB)
group 3
1 mg TNB followed by a repeat dose of 1 mg TNB at 60 min
group 4
0.5 mg TNB followed by a repeat dose of 0.5 mg at 60 min
group 5
limited to a maximum of 12 doses/ day with maximum of 1 dose/ hour
morphine sulphate IM
group 1: 3.05 ± 0.28a
group 2: 4.19 ± 0.28
group 3: 4.31 ± 0.29
group 4: 3.65 ± 0.27
group 5: 2.07 ± 0.28b
a p<0.05 vs. the other groups
b p<0.05 vs. group 2 or group 3
patient global assessment (pain intensity and pain relief): mean ± SEM
group 1: 3.19 ± 0.18
group 2: 3.20 ± 0.16
group 3: 3.00 ± 0.17
group 4: 2.65 ± 0.17
group 5: 2.04 ± 0.20b
– sensation of heat
– abnormal dreams
somnolence
significantly lower in group 5 (placebo) compared to group 1, 2 and 3
dizziness and sweating
significantly lower in group 5 (placebo) compared to group 1
“Transnasal butorphanol represents a safe and effective alternative to injectable butorphanol for post-cesarean section pain and offers a better and longer duration of analgesia compared to IV butorphanol. The optimum dose seems to be 2 mg TN nutorphanol and it is tolerated better when divided into 1 mg increments, given 1 h apart.”
Oral analgesia compared with intravenous patient-controlled analgesia for pain after cesarean delivery: A randomized controlled trial.
American Journal of Obstetrics and Gynecology, 2006. 194(4): p. 967-971.
– aged >/=18 yr.
– unplanned caesarean delivery
– known allergy/ hypersensitivity to morphine, oxycodone, or paracetamol
– treatment with magnesium sulphate
– chronic use of narcotics or substance abuse
– use of general anaesthesia
– history of a pain syndrome
group O: 31.9 ± 4.5
group M: 31.5 ± 4.7
BMI [kg/m2]: mean ± SD
group O: 31.6 ± 5.1
group M: 32.6 ± 7.0
primiparous: n (%)
group O: 4 (9)
group M: 6 (13)
indication: group O: n (%)/ group M: n (%)
elective repeat: 34 (74)/ 34 (72)
malpresentation: 7 (15)/ 10 (21)
other: 5 (11)/ 3 (6)
93
group O: 46
group M: 47
SpA: bupivacaine and fentanyl (not specified)
Pfannenstiel incision (not specified)
ketorolac 30 mg IV after surgery followed by 15 mg IV every 6 h for 24 h,
promethazine 25 mg IM every 4 h as needed for nausea
immediately after surgery:
2 tablets of oxycodone-paracetamol
for 12 h:
2 tablets of oxycodone-paracetamol at fixed intervals every 3 h
after 12 h:
1–2 tablets every 4 h as needed,
</=12 tablets in 24 h
morphine via iPCA with continuous infusion of 1 mg/h, additional 1 mg dose was administered on demand (lockout 6 min)
after 12 h
iPCA discontinued, continued with oxycodone-paracetamol (5/325 mg) with 1–2 tablets every 4 h as needed
all patients after 24 h
oral oxycodone-paracetamol and ibuprofen (not specified)
meperidine 50 mg IM, as frequently as every 4 hours
after 6 h
group O: 3.2 ± 1.8
group M: 4.1 ± 2.5
(p=0.04)
group O: 2.9 ± 1.7
group M: 4.1 ± 2.1
(0.004)
group O: 1
(p=0.71)
nausea: mean ± SD
group O: 0.2 ± 0.9
group M: 2.0 ± 3.4
group O: 1.0 ± 2.0
group M: 0.3 ± 0.8
drowsiness: mean ± SD
group O: 2.9 ± 2.9
group M: 5.3 ± 3.3
group O: 2.4 ± 2.6
group M: 2.5 ± 2.6
(p=0.95)
pruritus: mean ± SD
group O: 0.9 ± 1.9
group M: 1.7 ± 2.5
group O: 1.0 ± 2.3
group M: 1.1 ± 1.8
(p=0.84)
emesis: n (%)
group O: 5 (11)
group M: 12 (26)
group O: 7 (15)
group M: 7 (15)
(p=1.00)
ambulation: n (%)
(p=0.76)
group O: 1 (2)
group M: 2 (4)
oral intake: n (%)
group O: 2 (4)
group M: 1 (2)
(p=0.62)
group M: 0 (0)
“… oral analgesia with oxycodone-paracetamol for the treatment of post-caesarean pain appears to be a less expensive and more convenient option for providers and hospitals. It also offers superior pain relief with fewer undesirable side effects such as nausea and drowsiness for patients. Given this favourable profile, consideration should be given to expanding its use after planned caesarean delivery.“
Pain management after cesarean: a randomized controlled trial of oxycodone versus intravenous piritramide.
Archives of gynecology and obstetrics, 2012. 286(4): p. 859-865.
– aged >18 years
– delivery of elective or secondary CS
– gestational age >36 weeks
– no history of opioid or metamizol treatment
– ability to use PCA device
– CS in intubation anaesthesia
– use of epidural catheter for pre-, peri- or post-CS analgesia
– additional post-CS use of metamizol
– allergy/ hypersensitivity to morphine, oxycodone, paracetamol or ibuprofen
– chronic use of opioids or history of chronic pain syndrome
group O: 28.5 ± 5.9
group P: 29.8 ± 5.1
group O: 39.2 ± 3.1
group P: 39.2 ± 2.7
indication: group O: n (%)/ group P: n (%)
maternal request: 12 (10.6)/ 11 (8.7)
medical indication: 47 (41.6)/ 61 (48.4)
secondary CS: 22 (19.5)/ 24(19.0)
previous CS: 28 (24.8)/ 30 (23.8)
previous other laparotomies: 4 (3.5)/ 0
closure vesical peritoneum: no closure n (%)/ closure n (%)
group O: 31 (27.4)/ 82 (72.6)
group P: 29 (23)/ 97 (77)
239
group O: 113
group P: 126
SpA: bupivacaine 10 mg and sufentanil 5 µg
Pfannenstiel incision (standard fashion)
-great importance not to exteriorize the uterus, as it might influence the visceral pain
treatment started 2 h after surgery
oral oxycodone 20 mg at 2 and 12 h after surgery
single use of piritramide 2 mg/mL IV in 0.9% saline via iPCA (bolus of 1 mg pritramide, lockout 5 min, </=30 mg piritramide) for 24 h
all patients for first day
oral ibuprofen 500 mg every 8 h
from first day ibuprofen 500 mg and paracetamol 1 g as needed
group O: 5.88 ± 2.01
group P: 4.85 ± 2.23
(p=0.34)
after 48 h
group O: 3.83 ± 1.34
group P: 3.85 ± 1.69
(p=0.72)
after 72 h
group O: 3.00 ± 1.84
group P: 2.65 ± 1.42
need for rescue analgesia: %
group O: 45
(p=0.57)
group O: 21
(p=0.057)
group O: 7
(p=0.30)
mobilisation [h]: mean ± SD
group O: 4.9 ± 1.3
group P: 5.2 ± 1.6
patient satisfaction on rating scale from 1 to 10:
group O: 8.75 ± 1.5
group P: 8.4 ± 2.1
clinical assessment of the newborn: no difference in general health and activity of the offspring
“were minor and equally distributed between both groups and restricted to nausea, vomiting and headache” (not specified)
“…general satisfaction with both treatment regimes was a high. The results support the potential use of oral pain regimes and emphasis the importance of a multimodal approach to treat post-caesarean pain. Oral oxycodone is a not expensive, convenient and comparable analgesic to PCA devices with opioids after caesarean“
Postoperative analgesia after caesarean section: Intermittent intramuscular versus subcutaneous morphine boluses.
Acute Pain, 2007. 9(4): p. 215-219.
– aged 16–45 yr.
– Mini Mental Status score <26
– emergency caesarean section
– contraindications to morphine use
group SC: 24.2 ± 4.2
group IM: 25.9 ± 4.4
group SC: 161.7 ± 6.1
group IM: 161.2 ± 4.1
group SC: 67.4 ± 9.4
group IM: 67.8 ± 11.3
ASA physical status I/ II
group SC: 26/ 4
group IM: 25/ 5
group SC: 30
group IM: 30
GA: induction with: thiopental 4 mg/kg followed by succinylcholine 1.5 mg/kg,
50% nitrous oxide in oxygen and 1.25% isoflurane,
after delivery: morphine 0.1 mg/kg,
muscle paralysis: atracurium
boluses of morphine 0.15 mg/kg SC or IM every 10 min until VAS<30
group SC:
– butterfly needle was primed with morphine 10 mg/mL to fill needle dead space with 0.2 mL
– injection of 5 mg in 0.5 mL morphine
-subcutaneous injections of morphine (0.15 mg/kg) started 4h after the study or earlier if VAS >30, could be repeated every 4 h
group IM:
intramuscular injections of morphine (0.15 mg/kg), could be repeated every 4 h
on movement
significant lower pain scores in group SC at 12, 16 and 20 h, but not from 0 to 8 h and from 24 to 48 h
hospital stay
adverse effects/ events: n (%)
no significant differences in
-no sample size calculation
“…the subcutaneous route of morphine administration is a satisfactory alternative to IM morphine in management of postoperative pain after caesarean section surgery and warrants further investigation.”
Intravenous paracetamol (perfalgan) for analgesia after cesarean section: A double-blind randomized controlled study.
Rawal Medical Journal, 2011. 36(4).
– known contraindication to paracetamol or meperidine
– history of severe allergic, hepatic, renal cardiovascular, pulmonary disease
– preeclampsia or eclampsia
– intraoperative complications, history of chronic abdominal pain or treated with analgesics
– conversion to general anaesthesia during surgery
group P: 30.8 ± 4.79
group S: 29.6 ± 5.20
gestational age [days]: mean ±SD
group P: 269.86 ± 5.89
group S: 271.97 ± 6.59
group P: 32 (80)
group S: 29 (72.5)
nulliparity: n (%)/ multiparity: n (%)
group P: 8 (20)/ 32 (80)
group S: 11 (27.5)/ 29 (72.5)
group S: 40
– SpA: hyperbaric bupivacaine 8–10 mg mixed with morphine 0.2 mg
paracetamol IV (1 g/ 100 mL) at the end of surgery and every 6 h for 24 h
group S:
normal 100 mL saline at the stated time points
– meperidine (not specified)
group P: 1 (0–6)
group S: 4 (0–6)
group P: 2 (0–5)
group S: 3 (0–7)
group P: 1.5 (0–4)
group S: 3 (1–8)
rescue meperidine: n (%)
group P: 0 (0)
group S: 8 (20)
group S: 4.33 ± 0.52
group P: 4.00 ± 0.50
group S: 4.25 ± 0.54
“… intravenous paracetamol is an effective treatment option and can be used to reduce the requirement of rescue opioid drugs for pain control after caesarean section.”
– =37 gestational weeks
request for rescue analgesia:2
due to excessive vomiting:1
PD < P, differences were significant between all time periods except 8–11.9 h and 12–15.9 h.
Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief.
Cochrane Database Syst Rev, 2009(3): p. Cd006954.
– Cochrane Pregnancy and Childbirth Group’s Trials Register
– Central
– Pubmed/ Medline
– hand searches of 30 journals
search period
through 04.2009
inclusion criteria
– randomised controlled trials
– comparing pre-emptive local analgesia:
1) local anaesthetic agent wound infiltration versus placebo/ no infiltration
2) ilioinguinal/ iliohypogastric nerve block versus placebo/ no treatment
3) local anaesthetic agent vs other methods of pain relief
4) comparison of different local anaesthetic agent techniques
included studies (n participants)
[1] Bamigboye 2008 (100)
[2] Bell 2002 (59)
[3] Caulry 2003 (10)
[4] Chen 1990 (36)
[5] Ganta 1994 (62)
[6] Givens 2002 (36)
[7] Kumar 1999 (50)
[8] Kuppuvelamini 1992 (60)
[9] Lacrosse 2004 (55)
[10] Lavand’homme 2007 (90)
[11] Marbaix 2004 (55)
[12] McDonnell 2008 (50)
[13] Mecklem 1995 (79)
[14] Pavy 1994 (40)
[15] Pirbudak 2004 (60)
[16] Rosaeg 1997 (40)
[17] Solak 1999 (30)
[18] Trotter 1991 (28)
[19] Zohar 2002 (50)
[20] Zohar 2006 (90)
IG: 225 mg ropivacaine if >/=64 kg and 3 mg/kg if less,
CG: equivalent volume of saline,
all layers of the anterior abdominal incision infiltrated including the peritoneum,
postoperatively: pethidine, diclofenac injection and oral paracetamol/tramadol
[2] Bell 2002
IG: ilioinguinal-iliohypogastric nerve block with 0.5% bupivacaine with adrenaline,
CG: saline placebo
[3] Caulry 2003
IG1: ropivacaine
IG2: diclofenac
CG: saline
wound irrigation in each group
[4] Chen 1990
IG1: plain marcaine
IG2: marcaine with adrenaline
CG: no treatment
ilioinguinal nerve block after caesarean section
[5] Ganta 1994
IG: bilateral ilioinguinal nerve block with 0.5% bupivacaine
CG1: wound infiltration with 0.5% bupivacaine,
CG2: no local anaesthetic
[6] Givens 2002
IG: wound irrigation with 0.25% bupivacaine,
CG: normal saline solution irrigation
[7] Kumar 1999
IG: pre-incisional 40 mL of 0.5% bupivacaine,
CG: 40 mL of bupivacaine and 2 mg morphine mixture
[8] Kuppuvelamini 1992
IG: mixture of 0.5% bupivacaine with adrenaline with 1% xylocaine injected to block the ilioinguinal/iliohypogastric,
CG: no abdominal nerve block
IG1: wound irrigation with 300 mg of diclofenac for 48 h,
IG2: ropivacaine 0.2%,
CG: saline control
[10] Lavand’homme 2007
continuous wound infiltration of:
IG1: diclofenac,
IG2: 0.2% ropivacaine
[11] Marbaix 2004
IG: wound irrigation with 300 mg of diclofenac for 48 h,
CG1: ropivacaine 0.2%,
CG2: saline
[12] McDonnell 2008
IG: 1.5 mg/kg ropivacaine, per side injection into the transversus abdominis plane
CG: saline TAP block
[13] Mecklem 1995
IG: 0.25% bupivacaine
[14] Pavy 1994
IG: 0.5% bupivacaine,
[15] Pirbudak 2004
IG: 40 mL of 0.25% bupivacaine + 100 mg tramadol + 20 mg tenoxicam,
CG: normal saline
[16] Rosaeg 1997
both groups received 0.75% bupivacaine spinal analgesia:
IG: IT morphine, incisional bupivacaine and ibuprofen and acetaminophen,
CG: IV morphine weaned to acetaminophen and codeine
[17] Solak 1999
IG: 20 mL of 0.5% bupivacaine,
[18] Trotter 1991
[19] Zohar 2002
multi-holed device placed in wound and connected to a PCA:
IG: bupivacaine,
CG: combined with ketamine
[20] Zohar 2006
IG1: wound instillation via a patient-controlled analgesic infusion pump of 0.25% bupivacaine and 75 mg intravenous diclofenac.
CG1: only bupivacaine instillation,
CG2: only diclofenac infusion
wound infiltration associated with:
reduced morphine consumption at 24 h: SMD (95% CI)
-1.70 mg (-2.75;-0.94) [3,6,13]
no difference in pain scores at 24 h: MD (95% CI)
-0.39 (-1.72;0.94) [3,6]
wound infiltration with local anaesthetic and peritoneal spraying versus placebo
local anaesthetic and peritoneal spraying associated with:
reduced need for pethidine rescue within 1 h: risk ratio (95%)
0.51 (0.38;0.69) [1]
reduced pain scores at 1 h: MD (95% CI)
-1.46 (-2.60;-0.32) [1]
similar pain scores at 8 h: MD (95% CI)
-0.58 (-3.29;2.13) [1]
similar pain scores at 24 h: MD (95% CI)
0.19 (-0.67;1.05) [1]
similar consumption of total pethidine at 24 h: MD (95% CI)
-44.0 (-108.31;20.31) [1]
reduced consumption of oral paracetamol/tramadol: MD (95% CI)
-2.35 (-3.62;-1.08) [1]
wound infiltration with local anaesthetic + nonsteroidal anti-inflammatory drugs versus control
associated with:
similar no of attempts to activate PCA: MD (95% CI)
-15.0 (-30.22;0.22) [20]
reduced total morphine [mg] used in the first 18 h: MD (95% CI)
-7.4 (-9.58;-5.22) [20]
similar occurrence of nausea: risk ratio (95% CI)
1.40 (0.9;2.16) [16]
increased occurrence of pruritus: risk ratio (95% CI)
1.81 (1.01;3.23) [16]
abdominal nerve blocks with local anaesthetic versus placebo block or no block
lower pain scores [VAS] at 24 h: MD (95% CI)
-1.82 (-2.74;-0.9) [2,4]
reduced postoperative opioid use [mg]: MD (95% CI)
-25.80 (-50.39;-1.21) [2,4,5,12]
wound infiltration with local anaesthetic versus local anaesthetic + narcotics
similar pain scores at 2 h: MD (95% CI)
0.69 (-0.08;1.46) [7]
similar pain scores at 12 h: MD (95% CI)
0.18 (-0.59;0.95) [7]
-0.15 (-0.92;2.94) [7]
wound infiltration with local anaesthetic versus local anaesthetic + ketamine
similar total morphine consumption </=6 h: MD (95% CI)
0.10 (-2.74;2.94) [19]
– publication bias not assessed
“Local analgesia infiltration and abdominal nerve blocks as adjuncts to regional analgesia and general anesthesia are of benefit in caesarean section by reducing opioid consumption. Nonsteroidal anti-inflammatory drugs as an adjuvant may confer additional pain relief.”
Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia.
Journal of Clinical Anesthesia, 2012. 24(4): p. 298-303.
– preeclampsia
– eclampsia
– renal disease
– progressive neurologic disease
– allergies to local anaesthetics, NSAIDs, or opioids
– infection at the site of block
group IG: 28 ± 6
group CG: 25 ± 7
group IG: 165 ± 9
group CG: 163 ± 5
group IG: 88 ± 24
group CG: 91 ± 12
group IG: 32 ± 7
group CG: 34.3 ± 5
group IG: 39 ± 1
group CG: 39 ± 1
group IG: 25
group CG: 25
excluded: 16
8 in each group due to receiving epidural block instead of SpA
analysed: 34
group IG: 17
group CG: 17
SpA: 0.75% bupivacaine 12 mg with fentanyl 10 µg and preservative-free morphine 200 µg
low transverse caesarean section via Pfannenstiel incision
iliohypogastric-ilioinguinal (IHII) peripheral nerve block
needle was inserted at a point 2 cm medial and 2 cm superior to the anterior superior iliac spine
IG:
– 0.5% bupivacaine 2 mL injected between external and internal oblique muscle layers,
– another 2 mL of anaesthetic solution were injected between the internal oblique and transversus abdominus muscles,
– laterally at 15°-angles two injections
– same six injection procedure was repeated on the contralateral side,
– in total, 24 mL of anaesthetic solution were deposited (6 injections per side).
CG:
placebo (saline)
ketorolac 30 mg IV at first request for pain relief
paracetamol 500 mg/ oxycodone 5 mg tablets every 6 h on request
intravenous morphine via PCA (2 mg, lockout 10 min)
group IG group CG
in PACU 0 (0–0) 0 (0–0)
at 6 h 0 (0–10) 30 (10–60)*
at 12 h 10 (0–15) 20 (15–45)*
at 18 h 10 (10–20) 30 (10–40)*
at 24 h 15 (10–30) 40 (10–50)*
*p<0.05
time to first request for analgesia [h]: mean ± SD
group IG: 14.3 ± 1.8
group CG: 5.6 ± 1.1
request for supplemental analgesia (acetaminophen and oxycodone): n (%)
group IG: 1 (6)
group CG: 12 (71%)
need for rescue analgesia (PCA morphine)
no patients in either group
maternal satisfaction with pain relief regimen: median (IQR)
a significant greater degree at 6, 12 and 18 h, but not in PACU and 24 h
in PACU 5 (5–5) 5 (5–5)
at 6 h 5 (5–5) 4 (4–5)*
at 12 h 5 (5–5) 4 (4–5)*
at 18 h 5 (5–5) 5 (4–5)*
at 24 h 5 (5–5) 5 (4–5)
no significant differences in PONV and pruritus
nausea (n) group IG group CG
in PACU 2 5
at 6 h 3 3
at 12 h 2 0
at 18 h 0 1
at 24 h 0 0
vomiting (n) group IG group CG
in PACU 1 2
at 6 h 1 0
at 12 h 0 0
at 18 h 0 0
pruritus (n) group IG group CG
in PACU 2 7
at 6 h 6 10
at 12 h 6 6
at 18 h 3 4
at 24 h 2 2
no methodological shortcomings according to the evaluation sheet
“… the use of bilateral IHII multi-injection nerve blocks, given in conjunction with neuraxial morphine, is an effective way to optimise analgesia for the first 24 hours after caesarean delivery”
– term parturients scheduled for caesarean section under GA
– renal, hepatic or cardiac disorders
– history of allergy to the study drugs
– history of chronic pain and chronic analgesia use
– any infection on the nerve block area
group II-IH: 26.27 ± 2.72
group P: 27.13 ± 4.20
group II-IH: 72.93 ± 8.12
group P: 77.30 ± 10.20
group II-IH: 163.80 ± 4.96
group P: 164.03 ± 4.56
64
group II-IH: 32
group P: 32
group II-IH:
– because of blood aspiration with a negative aspiration test at the nerve block area while performing the II-IH block (n=2)
group II-IH: 30
follow-up: 24 hours
– 150 mg ranitidine or 20 mg famotidine PO the night before surgery
– 30 mL sodium citrate 0.3 mol/L PO 30 min before induction of anaesthesia
general anaesthesia:
– 5 min preoxygenation
– induction was performed with thiopental 4 mg/kg and 1 mg/kg rocuronium IV – ventilation with desflurane 3% and nitrous oxide 50% in oxygen
intraoperative analgesia
– 1 µg/kg fentanyl IV after cord clamping
after antagonization of the neuromuscular block with neostigmine 0.04 mg/kg IV and 0.02 mg/kg atropine (before extubation) blocks were performed:
Group II-IH:
nerve block: 0.5% ropivacaine 10 mL on each side (total volume 20 mL)
Group P: – sham block with saline
all patients received IV tramadol (50 mg loading dose, bolus 25 mg and lock out time 15 min, 4 h >/= 300 mg) via PCA
rescue analgesia IV meperidine 0.5 mg/kg
– generation of sequence generation not reported
“… II-IH nerve block, performed after CS operations under general anesthesia, increased the quality of pain control in the postoperative period and apparently decreased the consumption of tramadol. Therefore it is advocated that II-IH nerve block, performed after the operation, is a preferable technique for the pain control after CS.“
– wish to have GA
(data not shown)
26
group B: 13
– 150 mg ranitidine PO 2 doses in 12 h before surgery
– 30 mL sodium citrate 0.3 mol/L PO before induction of anaesthesia
– preoxygenation for 4 min
– induction with thiopentone 4 mg/kg and suxamethonium 1.5 mg/kg
– neuromuscular blockade maintained with vecuronium 0.1 mg/kg – anaesthesia maintained using nitrous oxide and enflurane in oxygen
at delivery
all received oxytocin 10 unit followed by fentanyl 100 µg at the end of surgery: group B:
block was performed (technique not described) with 0.5% bupivacaine (10 mL)
group P: no nerve block
postoperative pain management:
– papaveretum 10 mg/m² body surface area
significantly lower pain scores in group B than in group P at 0, 4, 8 and 24 h, but not at 12 h p<0.01
consumption of papaveretum at 24 h [mg/m2]: mean (range) group B: 16.57 mg/m² (0–47.05) group P: 51.5 mg/m² (27–76.9)
adverse events/ effects
– generation of sequence unclear
– blinding of patients unclear
“… when general anaesthesia is indicated for lower segment Caesarean section using a Pfannenstiel incision, bilateral ilioinguinal nerve blocks improve the quality of postoperative analgesia.“
Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative caesarean delivery analgesia
The scientific world journal 2012, p: 1-6
– singleton fetus >37 weeks
– SpA
exclusion criteria – emergent caesarean delivery for maternal or fetal distress
– progressive neurological disease
– infection at insertion site
– allergy to local anaesthetics and narcotics
group A: 31.35 ± 4.74
group B: 30.88 ± 5.34
group C: 31.76 ± 5.52
group A: 85.73 ± 20.02
group B: 87.53 ± 17.92
group C: 89.65 ± 25.37
group A: 163.36 ± 8.51
group B: 160.97 ± 7.20
group C: 162.40 ± 8.10
gravity median (range) group A: 2 (1–6)
group B: 2 (1–5)
group C: 3 (1–5)
parity median (range) group A: 1 (0–3)
group B: 1 (0–3)
group C: 1 (0–4)
51
(1 excluded to logistical problems)
group A: 17
group B: 16
group C: 17
follow-up: 48 hours
“… the IIIH block under ultrasound guidance does not improve postoperative analgesia or decrease opioid side effects such as nausea, vomiting, and pruritus in patients receiving spinal anesthesia with ITM for Caesarean delivery.”
Transversus abdominis plane block for analgesia after Cesarean Delivery. A systematic review.
Minerva Anestesiologica 2014 Apr 16 [EPUB ahead of print]
– Medline
– Cochrane Database of Systematic Reviews
– Cochrane Controlled Clinical Trial Register
– Embase
– Scopus
– ISI Web of Knowledge
through 31.12.2013
– studies comparing TAP block with placebo in patients undergoing SpA
– all publication years and all languages
– studies not reporting data
– pathological obesity
– taking medications known to result in tolerance to opioids
– chronic pain
– duplicate or ancillary studies
– primary outcome of interest not analysed
[1] McDonnell 2008 (50)
[2] Belavy 2009 (47)
[3] Costello 2009 (96)
[4] Kanazi 2010 (57)
[5] Baaj 2010 (40)
[6] McMorrow 2011 (80)
[7] Loane 2012 (66)
[8] Bollag 2012 (90)
[9] Canovas 2013 (90)
[10] Singh 2013 (60)
[11] Lee 2013 (51)
[1] landmark technique:
ropivacaine 0.75% (1.5 mg/kg) to </=150 mg per side
[2] US-guided:
ropivacaine 0.5% 100 mg per side
[3] US-guided:
ropivacaine 0.375% 75 mg per side
[4] US-guided:
bupivacaine 0.375% + epinephrine 5 mg/mL 75 mg per side
[5] US-guided:
bupivacaine 0.25% 50 mg per side
[6] Landmark technique:
bupivacaine 0.375% 1 mg/kg per side
[7] US-guided:
[8] US-guided:
bupivacaine 0.375% and bupivacaine 0.375% + 75 µg clonidine per side
[9] US-guided:
levobupivacaine 0.5% per side
[10] US-guided:
ropivacaine 0.5% 3 mg/kg to </=300 mg in TAP high and ropivacaine 0.25% 1.5 mg/kg to </=150 mg TAP low
[11] US-guided: ropivacaine 0.5% 100 mg per side
opioids in surgical analgesia
[1] 25 µg IT fentanyl
[2] 15 µg IT fentanyl
[3] 10 µg IT fentanyl;
100 µg IT morphine
[4] 200 µg IT morphine
[5] 20 µg IT fentanyl
[6] 10 µg IT fentanyl;
[7] 10 µg IT fentanyl;
[8] 25 µg IT fentanyl and 100 µg IT morphine
[9] 100 µg IT morphine 10 µg IT fentanyl
[10] 10 µg IT fentanyl and 150 µg IT morphine
[11] 250 µg IT morphine and 15 µg IT fentanyl
[1] 1 g/6 h of paracetamol, rectal diclofenac 100 mg/18 h and PCA with morphine
[2] 1 g/6 h of paracetamol, ibuprofen 400 mg/8 h and PCA with morphine
[3] 1 g/6 h of paracetamol, oral diclofenac 50 mg/8 h and morphine
[4] rectal diclofenac 100 mg/12 h paracetamol 1 g/6 h, tramadol 100 mg/8 h
[5] PCA with morphine
[6] oral paracetamol 1g/h; rectal diclofenac 100 mg/18 h and morphine with PCA
[7] oral paracetamol 1 g/6 h, oral or rectal naproxen 500 mg/12 h and oral hydromorphone 2–4 mg/4 h; morphine with PCA if pain control is inadequate
[8] paracetamol 1 g/6 h, diclofenac 75 mg/8 h and oral tramadol 50 mg/8 h
[9] morphine with PCA
[10] ketorolac 30 mg oral, paracetamol 650 mg/6 h, codeine 30 mg or oxycodone 5–10 mg/4 h
[11] paracetamol 1g/6 h, ketorolac 30 mg or ibuprofen 800 mg/6 h, IV morphine 2 mg/10 min as needed, paracetamol 300 mg/codeine 30 mg 2 times/6 h or oxycodone 5 mg/paracetamol 325 mg 2 times/6 h
analysed in seven trials [1,2,4,8-11]
– shorter in placebo group vs TAP block group in women who received IT opioids [1,2,8,9,11]
– longer with IT morphine group only than in TAP block group only [4]
– no difference between IT morphine group and TAP block group at 24 h in patients who received IT opioids [10]
postoperative analgesic consumption
opioid consumption analysed in four trials [1,2,6,7]
– significant reduction of opioids at 48 h [1]
– reduction of opioids at 24 h in TAP block group vs placebo group in patients who received IT opioids [2,5]
– greater supplemental morphine requirements compared with IT morphine alone [7]
postoperative pain
analysed in all trials
– TAP block vs IT opioids did not improve pain relief [4,6,7]
– TAP block added to IT opioids did not improve pain relief [3,8,9]
– TAP block added to IT opioids, comparison with placebo, reduced pain intensity [1,2,5,11]
analysed in 10 trials [1,2,4-11]
PONV and sedation
TAP block reduced PONV but without significant difference for sedation [1,2,4-11]
– reduced in four trials [4,6,7,9]
– no difference in three trials [2,8,10]
all opioid-related side effects
analysed in 3 trials [8,10,11]
no difference in patients in occurrence or severity of PONV, sedation and pruritus
analysed in 7 trials [2,3,5,6,9-11]
– high satisfaction with TAP block added to intrathecal opioids compared with placebo group [2,5,9]
– similar between the groups [3,6,10,11]
– can`t answer if a priori design was provided
– excluded/ included list is not provided
– no conflicts of interests stated
“If correctly executed, US-guided TAP block as a part of multimodal analgesic regimen including intrathecal opioids might reduce postoperative opioids consumption and opioid-related side effects, improving postoperative pain control and patient satisfaction, but further studies are necessary to explore this field of research…“
A randomised trial of the analgesic efficacy of ultrasound-guided transversus abdominis plane block after caesarean delivery under general anaesthesia.
Eur J Anaesthesiol, 2012. 29(2): p. 88-94.
– elective or grade 3 emergency caesarean delivery
– chronic pain states
– history of postoperative nausea and vomiting
– known allergies or contraindication to any of drugs used in study
group TAP: 31.9 ± 2.0
group noTAP: 29.2 ± 1.7
maternal BMI [kg/m2]: mean ± SD
group TAP: 27.7 ± 0.7
group noTAP: 29.6 ± 1.5
group ED: 20
group SM: 20
GA: induced with thiopentone 5 mg/kg,
maintained with sevoflurane at end-tidal concentration of 2.5%
IV morphine 0.15 mg/kg
after delivery and cord clamping: slow administration of oxytocin 5 lU
additional drugs
dexamethasone 4 mg and ondansetron 4 mg
neostigmine 2.5 mg and atropine 0.9 mg to antagonise residual neuromuscular blockade
group TAP:
US-guided bilateral TAP block:
20 mL of levobupivacaine 2.5 mg/mL with aspiration after every 5 mL
group noTAP:
no TAP Block or skin punctured
surgical bandage/ dressing to maintain blinding
IV morphine via PCA
(bolus dose 1 mg lockout 5 min, </=40 mg/4 h)
group TAP: 10.7 ± 0.4
group noTAP: 10.6 ± 0.4
postoperative morphine consumption at 24 h [mg]: mean ± SD
group TAP: 12.3 ± 2.6
group noTAP: 31.4 ± 3.1
postoperative pain at rest and on activity [VAS]
no differences between the two groups
patient satisfaction: n (%)
very satisfied
group TAP: 16 (80)
group noTAP: 5 (25)
“… US-guided TAP blocks in the manner we have described resulted in reduced systemic morphine consumption and positive impact on maternal satisfaction in women undergoing caesarean section under general anaesthesia. We propose that the TAP block is another arsenal in the obstetric anaesthesiogist’s armamentarium in managing pain after caesarean section and is a valuable resource in patients undergoing general anaesthesia, or in those with contraindications to long-acting neuraxial opioids.”
Transversus abdominis plane block reduces postoperative pain intensity and analgesic consumption in elective cesarean delivery under general anesthesia.
J Anesth, 2012. 26(3): p. 334-8.
– primiparous singleton pregnant women
– aged 20–40 yr.
– elective caesarean delivery
– history of addiction (including opioids and benzodiazepines)
– sensitivity to prescribed analgesics
– psychological disorders
– any patients with surgical complications during surgery
group TAP: 27.88 ± 3.9
group noTAP: 25.54 ± 3.8
group TAP: 68.8 ± 3.0
group noTAP: 69.9 ± 4.2
group TAP: 162.1 ± 3.37
group noTAP: 162.8 ± 3.34
ASA physical status I/II
group TAP: 14/10
group noTAP: 15/9
group TAP: 25
group noTAP: 25
excluded: 2
one in each group due to surgical complications
GA: induced with sufentanil 5 µg and thiopental sodium 5 mg/kg,
maintained with isoflurane 0.8%, N20 50% and 0.4 mg/kg artracurium
morphine 0.1 mg/kg and
sufentanil 15 µg
US-guided bilateral TAP block
(0.25% bupivacaine 15 mL in each side)
no TAP Block
diclofenac suppository 100 mg daily
IV tramadol 50 mg/4 h
at rest [VAS]: median (range)
group TAP group noTAP
0h 0 (0–2) 4 (0–8)
6h 1 (0–4) 6 (3–9)
12h 1 (0–3) 3 (1–5)
24h 0 (0–1) 0 (0–3)
during coughing [VAS]: median (range)
time to first analgesic request [min]
group TAP: 210 (0–300)
group noTAP: 30 (10–180)
postoperative tramadol consumption [mg]
group TAP: 75 (0–150)
group noTAP: 250 (0–400)
“Two-sided TAP block with 0.25% bupivacaine in parturients who undergo cesarean section with a Pfannenstiel incision under general anesthesia can decrease postoperative pain and analgesic consumption. The time to the first analgesic rescue was longer in the parturients who received the TAP block.”
Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.
Br J Anaesth, 2011. 106(5): p. 706-12.
– ASA physical status I/II/III
– history of relevant drug allergy
– tolerance to opiates
– BMI >35 kg/m2
– contraindication to neuraxial anaesthesia
SMTS: 33 ± 4
SMTLA: 34 ± 6
SSTLA: 33 ± 5
SSTS: 34 ± 5
SMTS: 70 ± 13
SMTLA: 74 ± 14
SSTLA: 72 ± 14
SSTS: 66 ± 15
SMTS: 162 ± 7
SMTLA: 161 ± 5
SSTLA: 166 ± 6
SSTS: 162 ± 6
ASA physical status: median (IQR)
SMTS: 1 (1–1)
SMTLA: 1 (1–1)
SSTLA: 1 (1–1)
SSTS: 1 (1–1)
gestation (wk): mean ± SD
SMTS: 39 ± 1
SMTLA: 39 ± 1
SSTLA: 38 ± 2
SSTS: 39 ± 2
parity: median (IQR)
SMTS: 1 (1–2)
SMTLA: 1 (1–2)
SSTS: 1 (0–1)
SMTS: 20
SMTLA: 20
SSTLA: 20
SSTS: 20
SpA: hyperbaric bupivacaine 11–12.5 mg with fentanyl 10 µg
SMTS:
spinal morphine 100 µg and
bilateral TAP block containing saline
SMTLA:
bilateral TAP block containing bupivacaine 2 mg/kg
SSTLA:
spinal saline and
SSTS:
spinal saline 100 µg and
rectal paracetamol 1 g and diclofenac 100 mg
afterwards
oral paracetamol 1 g 6 hourly,
rectal diclofenac 100 mg 18 hourly
IV morphine via (PCA):
1 mg bolus, 5 min lockout
SMTS: 16
SMTLA: 8.5*
SSTLA: 31**
SSTS: 29
* (p<0.05) versus SSTS
** (p<0.05) versus SMTLA
SMTS: 10*
SMTLA: 12
SSTLA: 26.5
* (p<0.05) versus SSTLA
postoperative pain on movement [mm]: median
SMTS: 27.5*
SMTLA: 20*
SSTLA: 52
SSTS: 51.5
morphine consumption [mg]: median
SMTS: 4.0*
SMTLA: 5.0*
SSTLA: 8.0
SSTS: 12.0
SMTS: 2.0*
SMTLA: 5.0
SSTLA: 10.5
SSTS: 6.0
SMTS: 6.0
SSTLA: 15.0*
SSTS: 9.5
* (p<0.05) versus SMTLA
at 36 h
sedation scores
mild pruritus
significantly more frequent in SMTLA at 6 h
“…spinal morphine reduces early pain after Caesarean section. TAP block does not provide comparable analgesia and does not provide additional benefit to spinal morphine. Therefore, TAP block as described in the study is of no therapeutic value for patients administered alone or in combination with spinal morphine. Additional studies using ultrasound and different drug combinations and doses of local anaesthetic for TAP block are warranted.”
Hi-TENS combined with PCA-morphine as post caesarean pain relief.
Midwifery, 2011. 27(4): p. 547-552.
– no serious medical complications
– no tolerance to opiates
– gestational weeks 37–39
– singleton birth
– Apgar score >7 at one minute
– no complications immediately after childbirth
maternal age [yr.]: median (IQR)
group TENS: 33 (27–37)
group CG: 33 (29–35)
group TENS: 38
group CG: 38
previous c-section: n
group TENS: 11
group CG: 11
group TENS: 25
group TENS:
– maternal complications: 1
– infant with complication: 1
– mother felt discomfort with TENS: 1
– maternal complications: 2
– undisclosed reasons: 2
group TENS: 22
group CG: 20
1 g paracetamol
SpA: with median 12.5 mg high density bupivacaine
group TENS
for > 24 h:
Hi-TENS sensory level, by 2+2 electrode pads with two pads on each side along the wound, 2–3 cm distance from the wound
Two other electrode pads were placed on the upper part of the wound immediately after closure
Stimulator was set to high-frequency stimulation at 70 Hz, mother was instructed to adjust amplitude.
group CG
no Hi-TENS
1 g paracetamol every 6 h for at least 24 h
iPCA: morphine 5 mL (10 mg/mL) and 45 mL NaCl (set to 1 mg for each request, lock-out time 6 min, max. dosage per four hours was set to 35 mg)
bolus dose of 2–5 mg morphine
group TENS: 16.2 ± 12.6 (0.0–45.5)
group CG: 33.1 ± 20.9 (2.0–91.0)
(p=0.008)
mean pain scores at rest [VAS]
(p>0.136)
no additional morphine was required
sedation level over 24 h
significantly lower in group TENS
(p=0.045)
– patients and outcome assessors not blinded
“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 postoperative pain relief before surgery.”
The effects of transcutaneous electrical nerve stimulation on post-cesarean pain.
Pain, 1986. 27(2): p. 181-193.
– multiparous
– aged >/=21 yr.
– English speaking
– regular narcotic use within 6 months prior to study
– mentally ill
– using cardiac pacemaker
– previous TENS exposure
TENS: 30.5
noTENS: 28.0
18
TENS: 9
noTENS: 9
EA or GA
TENS
first 48h: spike waveform impulses of 80 µ sec duration, delivered at a frequency of 85 Hz,
amplitude adjustable, ranging from 0 to 75 mA,
impulses were delivered to the skin, by a pair of 2.5 cm x 14 cm pre-gelled sterile electrodes
noTENS
first 48h: placebo stimulator identical to the real one, but the current activated only the indicator light and not the electrode leads
first 24–48 h
meperidine 50–75 mg and promethazine 25 mg
thereafter
codeine 30–60 mg and acetaminophen 300–600 mg
steady cutaneous incisional pain (pain rating index)
day of surgery: –
POD 1: <0.05
POD 2: NS
POD 3: NS
steady cutaneous incisional pain (present pain intensity scale)
day of surgery: NS
POD 2: <0.05
movement-associated cutaneous incisional pain (pain rating index)
POD 1: <0.01
POD 2: <0.001
movement-associated cutaneous incisional pain (present pain intensity scale)
day of surgery: <0.05
POD 2: <0.01
steady deep incisional pain (pain rating index)
POD 1: NS
steady deep incisional pain (present pain intensity scale)
movement-associated deep incisional pain (pain rating index)
movement-associated deep incisional pain (present pain intensity scale)
uterine contraction-associated pain (pain rating index)
uterine contraction-associated pain (present pain intensity scale)
gas pain (present pain intensity scale)
need for additional analgesics [total number of doses/day]:
“…TENS was significantly more effective than placebo TENS in reducing cutaneous, movement associated incisional pain. However, pain resulting from internal structures, i.e., deep pain, afterbirth pain (due to uterine contractions), and the somatic pain associated with decreased peristalsis (gas pains) were not amenable to TENS. No significant differences in analgesic intake were observed.”
J Matern Fetal Neonatal Med, 2014.
– healthy women who gave birth to healthy newborns
– patients with cardiac pacemakers
– epilepsy
– preeclampsia/ eclampsia
– who used TENS previously
TENS: 27.7 ± 4.1
noTENS: 26.9 ± 6.6
TENS: 26.8 ± 2.0
noTENS: 27.3 ± 2.0
gestational age [wk]: mean ± SD
TENS: 37.8 ± 2.2
noTENS: 37.8 ± 2.2
TENS: 2.32 ± 1.2
noTENS: 2.39 ± 1.6
TENS: 1.2 ± 0.9
noTENS: 1.2 ± 1.1
randomised in
TENS: 50
noTENS: 50
8 hours
GA: not specified
once for 30 min after childbirth
applied at 100 Hz frequency starting from 0 mA, stabilised at current value for which the patient felt
optimal relief without any discomfort
noTENS (placebo)
placebo: no electrical current was transmitted
IM diclofenac 75 mg 30 min after delivery
not specified
VAS before TENS after TENS
TENS 82.8 ± 25.9 17.7 ± 12.7
placebo 87.5 ± 14.1 37.4 ± 20.6
p-value (p=0.12) (p<0.001)
VNS before TENS after TENS
TENS 7.6 ± 1.8 2.0 ± 1.8
placebo 8.4 ± 1.4 4.6 ± 1.4
p-value (p=0.16) (p<0.001)
need for supplemental analgesia at 8 h
TENS: 37 (74%)
placebo: 47 (94%)
“TENS is an effective, reliable, practical, easily available and relatively cheap modality of treatment for postpartum pain. Further research is needed to achieve standardisation about the accomplishment of TENS after vaginal delivery or cesarean section.”
2) Ilioinguinal/ iliohypogastric nerve block versus placebo/ no treatment
postoperatively: pethidine, diclofenac injection and paracetamol/tramadol
IG2:ropivacaine 0.2%,
reduced need for pethidine rescue within 1 h: Risk ratio (95%)
reduced consumption of tramacet: MD (95% CI)
Continuous subcutaneous instillation of bupivacaine compared to saline reduces interleukin 10 and increases substance P in surgical wounds after cesarean delivery.
Anesth Analg, 2010. 111(6): p. 1452-9.
– gestational age>37 weeks
– singleton pregnancies
– twin pregnancy
– BMI >40 kg/m2
– emergency caesarean delivery
– postpartum tubal ligation
– any contraindication to neuraxial anaesthesia
-previous reaction to opioid medications
– history of chronic opioid use
– intolerance to (NSAIDs)
group Bupi: 35 ± 4
group P: 35 ± 5
group Bupi: 165 ± 8
group P: 164 ± 6
group Bupi: 79 ± 18
group P: 77 ± 15
nulliparous: [%]
group Bupi: 26
group P: 21
previous caesarean delivery [%]
group Bupi: 74
group P: 74
gestational age [wk]: median (range)
group Bupi: 39 (38–39)
group P: 38 (38–39)
38
group Bupi: 19
group P: 19
SpA: IT hyperbaric bupivacaine 12 mg, IT fentanyl 10 µg, and IT morphine 200 µg
before wound closure
On-Q Pain-Buster Post-Op Pain Relief System inserted subcutaneously to deliver:
group Bupi:
bupivacaine 5 mg/mL for 24 h
normal saline at 2 mL/h for 24 h
oral ibuprofen 600 mg every 6 h for 48 h
oral oxycodone 5 mg (</=60 mg/24 h) with acetaminophen 325 mg tablets (</=4 g/24 h),
(1 to 2 tablets every 4 h)
for severe pain:
IV morphine
AUC NVPS at rest 0–48 h:
group Bupi: 47 (31–92)
group P: 45 (9–78)
AUC NVPS activity 0–48 h:
group Bupi: 173 (135–195)
group P: 140 (105–212)
need for supplemental analgesia [mg]: median (IQR)
group Bupi: 7.5 (5–10)
group P: 5 (0–15)
group Bupi: 15 (8–24)
group P: 10 (4–18)
need for rescue analgesia
oral opiod analgesia: n (%)
group Bupi: 19 (100)
group P: 16 (84)
IV morphine analgesia: n (%)
group Bupi: 1 (5)
group P: 1 (5)
“Subcutaneous surgical wound infiltration with bupivacaine 5 mg/mL compared with saline at 2 mL/h for 24 h resulted in similar postoperative pain scores and need for supplemental and rescue analgesia”
Pre-incisional, post-incisional and combined pre- and post-incisional local wound infiltrations with lidocaine in elective caesarean section delivery: a randomised clinical trial.
J Obstet Gynaecol, 2013. 33(1): p. 54-9.
– >/=37 weeks’ gestation
– age between 23 and 36 years
– uncomplicated singleton pregancy
– history of maternal medical or obstetric illness
– prior surgery in the operative site
– allergy to medications
maternal age [yr.]: mean ± SD (range)
pre: 27.00 ± 3.45 (24–35)
post: 28.79 ± 3.11 (23–36)
mixed: 29.09 ± 4.22 (23–36)
weight [kg]: mean ± SD (range)
pre: 70.61 ± 7.60 (58–84)
post: 72.07 ± 5.23 (53–87)
mixed: 73.19 ± 4.29 (51–92)
height [cm]: mean ± SD (range)
pre: 163.24 ± 5.28 (151–175)
post: 164.55 ± 4.29 (152–177)
mixed: 165.21 ± 5.32 (151–181)
gravidity: mean ± SD (range)
pre: 1.98 ± 0.66 (1–4)
post: 2.02 ± 0.55 (1–4)
mixed: 1.89 ± 0.43 (1–3)
operating time: mean ± SD (range)
pre: 46.61 ± 5.65 (39–55)
post: 47.29 ± 4.31 (38–57)
mixed: 46.76 ± 5.09 (39–61)
300
pre: 100
post: 100
mixed: 100
excluded: 19
pre: 6
post: 8
mixed: 5
analysed: 281
pre: 94
post: 92
mixed: 95
SpA: 60–70 mg of 5% lidocaine (1.2–1.5 mL)
pre:
infiltrated with anaesthetic mixture containing 1% lidocaine with 1:100,000 adrenaline 5 min before incision,
surrounding subcutaneous tissues infiltrated with the anaesthetic solution (20 mL)
post:
fascia and subcutaneous tissues around incision wound, and abdominal rectus muscle infiltrated
with the same anaesthetic solution (20 mL).
mixed:
both the pre-incisional and post-incisional infiltrations performed together in the same ways mentioned before but with one half volume of the local anaesthetic mixture (total volume = 20 mL).
in recovery room
IV morphine 5 mg at request
diclofenac sodium 100 mg (50 mg rectal suppository) rectally every 8 h.
IM morphine 5 mg
VAS pre versus post
significantly reduced in pre in recovery room, at 12 and 24 h, but not at 30 min, 1, 2, 3, and 6 h
VAS pre versus mixed
significantly reduced in mixed in all time points
VAS post versus mixed
significantly reduced in mixed in all time point except for recovery room
pre: 2.89 ± 2.01
post: 3.27 ± 2.02
mixed: 4.49 ± 3.09*
* (p<0.05) mixed compared with pre and post
need for rescue analgesia [demands]: mean ± SD
pre: 1.61 ± 0.72
post: 1.62 ± 0.51
mixed: 1.40 ± 0.52*
* (p<0.05) mixed compared with post
time to ambulation [h]: mean ± SD
pre: 9.26 ± 2.43
post: 9.10 ± 1.98
mixed: 8.79 ± 2.09
pre: 8.86 ± 0.41
post: 8.90 ± 0.33
mixed: 8.83 ± 0.51
pre: 9.67 ± 0.47
post: 9.73 ± 0.45
mixed: 9.66 ± 0.48
“combined pre- and post-incisional local wound infiltrations with lidocaine was superior to each one alone in reducing pain and postoperative analgesic requirements in pregnant women undergoing elective caesarean section”
Comparison of postoperative analgesic effect of tramadol and bupivacaine subcutaneous infiltration in patients undergoing cesarean section.
Acta Clin Croat, 2013. 52(1): p. 93-7.
– known allergy/ hypersensitivity to tramadol
– systemic diseases (cardiopulmonary disease, diabetes, hypertension)
– neurologic disorder
– preeclampsia and chronic use of narcotics or substance abuse
group tramadol: 26.7 ± 5.1
group Bupi: 28.1 ± 7.9
parity: primiparous [n (%)]/ multiparous [n (%)]:
group tramadol: 12 (40)/ 18 (60)
group Bupi: 10 (33.3)/ 20 (66.7)
group tramadol: 38.6 ± 1.3
group Bupi: 38.4 ± 1.6
indication [n (%)]: repeated/ cephal. disprop/ other
group tramadol: 19 (63.3)/ 5 (16.7)/ 6 (20)
group Bupi: 16 (53.4)/ 7 (23.3)/ 7 (23.3)
operating time [min]: mean ± SD
group tramadol: 60.4 ± 15.3
group Bupi: 61.8 ± 16.8
group tramadol: 30
group Bupi: 30
all randomised women analysed
induced with
thiopental 5 mg/kg and succinylcholine 1–1.5 mg/kg;
maintained with
0.5 MAC isoflurane, 50% O2, 50% N2O
Pfannenstiel and Kerr incision
before skin closure
group tramadol:
subcutaneous wound infiltration with 50 mg of tramadol in 10 mL normal saline
subcutaneous wound infiltration with 10 mL of 0.5% bupivacaine
after delivery:
fentanyl 2 µg/kg
VAS: mean ± SD
group tramadol group Bupi p-value
at 1 h 5.13 ± 0.93 5.53 ± 1.52 0.12
at 2 h 5 ± 1.17 5.57 ± 1.22 0.11
at 6 h 3.83 ± 1.08 4.73 ± 1.25 0.004
group tramadol: 6.6 ± 3.98
group Bupi: 4.66 ± 3.66
women requiring more analgesia </=24 h [n (%)]
group tramadol: 11 (36.67)
group Bupi: 20 (66.67)
total pentazocine consumption </=24 h [mg]: mean ± SD
group tramadol: 42.9 ± 24.3
group Bupi: 37.8 ± 17.4
(p=0.03)
hospital stay [h]: mean ± SD
group tramadol: 60.1 ± 8.2
group Bupi: 62.3 ± 9.1
nausea 6 (20) 8 (26.7) 0.37
vomiting 4 (13.3) 7 (23.3) 0.23
hypotens. 0 0 –
cardiov. 0 0 –
“… subcutaneous infiltration of tramadol provided analgesic effect equal to bupivacaine but with longer pain relief after cesarean section. We conclude that tramadol may be a good choice
for local anesthesia after surgery”
The analgesic efficacy of patient-controlled ropivacaine instillation after cesarean delivery
Obstetric Anesthesia, 2000. 91: p. 1436-1440
– history of clinically significant cardiovascular, pulmonary, hepatic, renal, neurologic, psychiatric, or metabolic disease
group R: 32 ± 5
group P: 30 ± 4
group R: 162 ± 8
group P: 165 ± 5
group R: 81 ± 15
group P: 72 ± 25
gravity: mean ± SD
group R: 3 ± 1
group P: 3 ± 1
parity: mean ± SD
group R: 1 ± 1
group P: 2 ± 1
group R: 25
all patients analysed
– PO effervescent cimetidine
before anaesthesia: 10-15 mL/ kg lactated Ringer’s solution
SpA: hyperbaric bupivacaine 8–10 mg
elastometric pump:
multi-hole 20-gauge epidural catheter inserted above the fascia with the catheter tip sited at the point that demarcated 50% of the length of the surgical wound,
using an aseptic technique, the catheter connected to the elastometric pump
group R:
wound instillation with 0.2% ropivacaine 100 mL
wound instillation with sterile water
all patients in PACU
PO dipyrone 1 g
IV morphine 2 mg at 10 min until VAS</=30 mm for first 6 h,
afterwards oral dipyrone 1 g
group R group P
total* 7 ± 2 4 ± 1
0–6 h 4 ± 1 3 ± 1
6–24 h* 3 ± 2 1 ± 1
* (p<0.01)
total volume infused via pump (24 h): mean ± SD
group R: 67 ± 22
group P: 42 ± 14
rescue morphine administration:
number of patients* 12 (48%) 23 (92%)
number of 2 mg doses/ pat.* 1 ± 2 4 ± 3
total morphine [mg/6 h]* 2 ± 3 10 ± 5
rescue dipyrone [1 g] 1 ± 1 1 ± 1
*(p<0.01)
pain at rest
no differences between the two groups between first 6 h and at removal of catheter
pain during coughing
significantly reduced in group R between 3 and 6 h, but not before, and at removal of catheter
pain during leg raising
hospitalization time [days]: mean ± SD
group R: 5 ± 1
group P: 5 ± 1
patient satisfaction with analgesia
group R* group P
excellent 6 0
good 15 12
satisfactory 4 10
poor 0 3
*(p=0.0008), comparing two groups
“All patients stated that the elastometric pump was easy to use. Ropivacaine wound instillation via an elastometric pump is a simple technique that provides safe and effective analgesia after cesarean delivery.”
Ropivacaine continuous wound infusion versus epidural morphine for postoperative analgesia after cesarean delivery: A randomized controlled trial.
Anesthesia and Analgesia, 2012. 114(1): p. 179-185.
– aged between 18 and 50 yr.
– gestational age: 37–42 weeks
– BMI: 18–30
– Pfannenstiel incision
– >1 prior caesarean delivery
– physical separation of patients from the neonate during the postoperative period
group W: 33 ± 5
group E: 33 ± 5
group W: 29.3 ± 0.6
group E: 27.4 ± 0.9
nulliparous: n (%)
group W: 21 (72)
group E: 22 (76)
primary caesarean delivery: %
group W: 25 (86)
group E: 24 (83)
intraoperative bupivacaine [mg]: mean ± SD
group W: 8.7 ± 0.5
group E: 9.1 ± 0.3
intraoperative sufentanil [µg]: mean ± SD
group W: 2.1 ± 0.2
group E: 2.3 ± 0.1
67
group W: 35
group E: 32
group W: 6
– did not receive allocated intervention: 3
– accidental removal of catheter: 3
group E: 3
– refusal of epidural analgesia due to vomiting: 3
analysed: after 48 h (after 3 months)
group W: 29 (26)
group E: 29 (24)
48 hours and 3 months
group W:
SpA: single shot of hyperbaric bupivacaine and sufentanil (not specified)
group E:
CSEA: hyperbaric bupivacaine and sufentanil (not specified)
Pfannenstiel incision and peritoneal closure (not specified)
wound catheter placed below the fascia:
initial dose of 10 mL ropivacaine 10 mg/mL. followed by continuous infusion of ropivacaine 2 mg/mL at 5 mL/h for 48 h
2 mg/10 mL bolus of epidural morphine every 12 h (4 times)
both groups:
paracetamol 1 g IV every 6 h for 48 h
diclofenac 75 mg (</=4 daily) IM
significantly reduced in group W at 2, 6, 24 and 48 h
significantly reduced in group W at 2 and 6 h, but not at 24 and 48 h
consumption of rescue analgesia: median (IQR)
group W: 0 (0, 1)
group E: 0 (0, 1)
3 month postoperative patient satisfaction: median (IQR)
group W: 8 (8; 10)
group E: 9 (6, 9)
fullfillment of discharge criteria
at 24 h: n
group W: 25
group E: 0
PONV: n
group W: 0
group E: 11
group E: 17
(p=0.007)
urinary retention: n
group E: 13
gastrointestinal function reestablishment at 48 h: n
group E: 14
(p=0.005)
“… continuous wound infusion with ropivacaine through a catheter placed below the fascia, after an initial loading dose, provided better analgesia with fewer side effects then intermittent epidural morphine analgesia.”
Tramadol and levobupivacaine wound infiltration at Cesarean delivery for postoperative analgesia.
Journal of Anesthesia, 2013. 27(2): p. 175-179.
– history of previous local anaesthetic events
– hypertension in pregnancy with proteinuria
– cardiac diseases
– any other major medical disorder associated with pregnancy
group P: 27.8 ± 5.2
group L: 26.5 ± 4.4
group T: 25.6 ± 4.7
group P: 79.5 ± 10.0
group L: 77.7 ± 9.3
group T: 80.6 ± 10.2
group P: 160.9 ± 4.0
group L: 161.0 ± 5.1
group T: 162.0 ± 3.8
primary caesarean delivery: n (%)
group P: 23 (76)
group L: 24 (80)
group T: 22 (73)
group P: 18 (60)
group L: 17 (56)
group T: 20 (66)
group L: 30
group T: 30
GA: induced with thiopental 4–6 mg/kg and atracurium 0.5 mg/kg, maintained with 1.5–2% sevoflurane and 50% N2O-50% O2 mixture at 5 L/min
at the end of surgery: local wound infiltration subcutaneously of 20 mL solution along the skin wound edges and the skin approximated with a subcutaneous absorbable 3-0 polyglecaprone suture
20 mL with 0.9% saline solution
group L:
20 mL with 0.25% levobupivacaine solution
group T:
20 mL with tramadol 1.5 mg/kg within 0.9% saline solution
tramadol via PCA: loading dose: total of repeated 20 mg bolus doses every 3 min until VAS </=3, basal infusion rate: 5 mg/h, bolus dose: 20 mg, lockout 15 min; bolus dose increased to 25 mg in patients with VAS>3
diclofenac 75 mg IV
at rest group P group L group T
15 min 7.7 ± 1.8 4.6 ± 1.3 4.5 ± 1.3*
2h 2.7 ± 1.3 2.2 ± 1.2 2.6 ± 1.7
*p=0.001
movement group P group L group T
4 h 1.7 ± 1.0 2.0 ± 1.4 1.8 ± 1.2
8 h 1.5 ± 1.3 1.6 ± 1.3 1.5 ± 1.1
12 h 1.5 ± 1.3 1.7 ± 1.5 1.4 ± 0.9
16 h 0.9 ± 0.5 1.4 ± 1.2 1.0 ± 0.6
20 h 1.0 ± 1.1 1.2 ± 1.2 0.7 ± 0.6
24 h 0.4 ± 0.5 0.7 ± 0.7 0.4 ± 0.5
tramadol consumption [mg] 24 h: mean ± SD
group P: 557.5 ± 76.9
group L: 401.6 ± 105.3*,**
group T: 483.3 ± 120.0*
* among all groups p=0.001
** between groups T and L p=0.007
rescue diclofenac consumption [mg]: mean ± SD
group P: 17.5 ± 32.2
group L: 10.0 ± 25.9
group T: 17.5 ±32.2
group P group L group T
pruritus 2 3 2
vomiting 4 5 5
temp. >38°C 0 1 2
wound infection 1 0 0
“…wound infiltration with tramadol and levobupivacaine in patients having caesarean section under general anaesthesia may be a good choice for postoperative analgesia.”
Continuous wound infusion with ropivacaine fails to provide adequate analgesia after caesarean section.
International Journal of Obstetric Anesthesia, 2012. 21(2): p. 119-124.
– Pfannenstiel incision under combined spinal-epidural anaesthesia
– ASA physical status III/IV
– significant co-existing disease
– intrahepatic cholestasis of pregnancy
– allergy to study drugs
– major haemorrhage (>1500 mL)
– BMI >35
– refusal to participate
– if >8 mL of lidocaine during surgery
group M: 33 (23–42)
group R: 33 (25–41)
group P: 32 (23–40)
height [cm]: mean (range)
group M: 167 (156–187)
group R: 167 (157–178)
group P: 166 (156–178)
weight [kg]: mean (range)
group M: 80 (59–102)
group R: 78 (63–99)
group P: 77 (63–113)
nullipara n/ multipara n
group M: 10/ 14
group R: 10/ 12
group P: 9/ 11
gestational age (wk.): mean (range)
group M: 39 (38–42)
group R: 39 (38–41)
group P:39 (36–41)
66
group M: 24
group R: 22
excluded: two from each group
– significant leakage of fluid from the wound catheter: 2
– wound haematoma: 1
– bleeding from the uterus: 1
– catheter accidentally removed: 1
– left study due to infant with heart anomaly: 1
unclear: data collected before interruption used in the analysis
CSEA: isobaric bupivacaine 10 mg (2.0 mL) combined with fentanyl 15 µg (0.3 mL) and either saline (0.4 mL) or morphine (160 µg) according to randomisation, additional lidocaine (20 mg/mL) as needed,
1000 mL of acetated Ringer’s solution,
ephedrine and/or phenylephrine as needed
Pfannenstiel incision and transverse lower uterine segment incision,
depending on haemostasis, the uterus was closed with one or two layers of continuous absorbable suture,
the peritoneum and muscles were left open and the fascia was closed with a running continuous suture of absorbable material,
skin was closed with non-absorbable individual stitches (removed on day five or six)
IT morphine 160 µg (0.4 mL) and saline wound infiltration at 5 mL/h
IT saline 0.4 mL and wound infiltration with 0.375% ropivacaine at 5 mL/h
saline was administered both intrathecally and by wound infiltration
oral ketoprofen 100 mg three times a day and oxycodone via iPCA for 24 h (bolus of 2 mL, lockout 8 min, max. 32 mg/4 h),
after 24 h: oral oxycodone (5 or 10 mg) on demand
for 24 h
group M: 26 ± 21
group R: 48 ± 23**
group P: 45 ± 23*
*p=0.021 between group M and group P
**p=0.007 between group M and group R
(p=NS) between group R and group P
group M: 15 (n. r.)
group R: 12 (n. r.)
group P: 15 (n. r.)
postoperative pain at rest [VAS]: mean ± SD
during first 24 h
group M: 1.3 ± 1.2*
group R: 1.7 ± 0.8
group P: 2.2 ± 1.3
* significant lower in group M compared to group P (p=0.021), but no significant differences between group M and group R or group R and group P
significant differences at 6, 9 and 12 h but not at 2, 3, 15, 18, 21, 24 h
from 24 h to 48 h
group M: 2.1 ± 1.2
group R: 2.4 ± 1.0
significantly more common in group M compared to group R and group P at 2, 3 and 6–12 h (p=0.04, p=0.04 and p=0.009, respectively), but not during surgery, 12–24 and 24–48 h
no significant differences between the groups on POD 1 and POD 2
spontaneous voiding [h]: mean ± SD
group M: 2.4 ± 1.1*
group R: 3.5 ± 1.5
group P: 3.7 ± 1.2
* (p=0.004)
no significant differences concerning:
– flatus
– defecation within 48 h
– first successful lactation
– satisfaction with sleep first, second night and pain management
– discharge
– mean satisfaction scores
“…in the current study continuous wound infusion with ropivacaine failed to reduce PCA opioid consumption or pain scores when compared to both saline control with and without the addition of intrathecal morphine. However, intrathecal morphine resulted in a significant reduction in opioid consumption and, when compared to saline wound infusion, reduced pain scores. Pruritus was a common side effect in parturients receiving intrathecal morphine.”
Postoperative analgesia after cesarean section by continued administration of levobupivacaine with the On-Q Painbuster system over the fascia vs ketorolac + morphine IV
Clinical and experimental obstetrics & gynecology, 2006. 33(4): p. 223-225
– preterm gestation (< 36 weeks),
– intrauterine fetal death,
– multiple pregnancy,
– known or suspected fetal abnonnalities,
– breech presentation,
– ASA physical status III/IV,
– relative and absolute contraindications to regional anaesthesia
20
group B: 10
SpA: isobaric 0.5% bupivacaine 10 mg with
sufentanyl 2.5 µg and
morphine 50 µg
IV morphine 10 mg + ketorolac 120 mg + normal saline up to 96 mL with an elastomeric pump
(infusion speed of 2 mL/h for 48 h)
local infusion of 0.2% levobupivacaine with On-Q PAINBUSTER system with catheter placed in subcutaneous layer
bolus of IV ketorolac 30 mg as needed
group A: 455 ± 22
group B: 380 ± 30
postoperative pain scores
significantly less in group A compared with group B
need for supplemental analgesics: n
significantly lower in group A than group B
nausea and itching
more cases in group A
no signs of
– local or general infection
– inflammatory infiltration
time to first mobilisation
“The IV system with morphine and ketorolac is more effective than levobupivacaine subcutaneous infusion in reducing postoperative pain associated with caesarean section”
Improving continuous wound infusion effectiveness for postoperative analgesia after cesarean delivery
Obstretrics and Gynecology; 2012. 116(4): p. 893-900.
– <37 wk. of gestation
– known allergy to NSAID
– ASA physical status III or higher
group above: 33 ± 4
group below: 32 ± 6
group above: 163 ± 6
group below: 164 ± 5
group above: 74 ± 13
group below : 76 ± 17
gravidity: mean ± SD
group above: 3 ± 1
group below: 3 ± 2
group above: 2.0 ± 1
group below: 2.5 ± 2
group above: 64
group below: 52
group above: 29
group below: 27
group above
disconnection/ dysfunction of device: 2
wound leakage: 2
group below
group above: 25
group below: 25
SpA: 2 mL of 0.5% hyperbaric bupivacaine (10 mg) with
sufentanil 5 µg,
morphine 100 µg
Joel Cohen approach without peritoneal closure
multihole 20-gauge catheter below the fascia or above the fascia (according to randomization):
catheter positioned below the fascia between the unclosed parietal peritoneum and the underside of the transversalis fascia before its closure, along the full length of the wound.
catheter set above the superficial abdominal fascia,
the surgeon closed the skin and secured the infusion catheter on the skin using a sterile tape without any difference regarding group allocation.
when wound was closed, a 10 mL bolus of sterile saline administered through the catheter,
catheter then connected to an elastomeric pump set to deliver 5 mL/h for 48 hours containing ropivacaine 450 mg and ketoprofene 200 mg in 240 mL isotonic saline.
morphine 1.5 mg per demand,
lockout: 7 min, </=20 mg/4 h
significantly reduced in group below at 12, 24, 36 and 48 h, but not at 3 and 6 h
significantly reduced in group below at 3, 6, 12, 24, and 36 h, but not at 48 h
during movement
residual pain or discomfort at 1 month
no difference between the two groups
(p=0.55)
residual pain or discomfort at 6 month
(p=1)
group above group below p-value
nausea/ vomiting
7 (28%) 6 (24%) 0.74
itching
11 (44%) 12 (48%) 0.77
satisfaction [0–10 scale]
group above: 8.6 ± 1.1
group below: 8.9 ± 1.3
(p=0.81)
hospital stay [days]: mean ±SD
group above: 6.1 ±1.2
group below: 6.3 ± 1.3
“We show here that local anesthetic combined with NSAID are more effective for postoperative pain control after cesarean delivery when administered below the fascia rather than above. The mechanism of action requires further investigation, but the next studies comparing different analgesic modalities will have to integrate this current result.”
Incisional and epidural analgesia after caesarean delivery: a prospective, placebo-controlled, randomised clinical study
International Journal of Obstetric Anesthesia; 2006. 15: p. 189-194.
– no contraindication to perispinal anaesthesia
– no allergy to any of the study medications
– no history of alcohol/drug abuse or major medical disease such as clinically significant cardiovascular, pulmonary, metabolic, renal, neurologic or psychiatric disease.
group epi: 28 ± 5
group subfas: 29 ± 6
body mass index: mean ± SD
group epi: 30 ± 3
group subfas: 29 ± 5
gestation [weeks]: mean ± SD
group epi: 40 ± 1
group subfas: 39 ± 1
primipara/ multipara: [n]
group epi: 8/12
group subfas: 8/12
group epi: 20
group subfas: 20
excluded: 7 after 24 h
group epi:
insufficient analgesia: 3
group subfas:
insufficient analgesia: 4
analysed: 33
group epi: 17
group subfas: 16
epidural catheters inserted 5 cm into epidural space
SpA: hyperbaric bupivacaine (5 mg/mL)
IV alfentanil on request
intermittent 10 mL boluses of 0.125% levobupivacaine via an epidural catheter,
ten 10 mL syringes of epidural
levobupivacaine available,
at the same time 10 mL of physiologic saline administered into the wound as a placebo via a subfascial catheter by pressing the button of the balloon pump
10 mL boluses of 0.25% levobupivacaine via the subfascial wound catheter connected to the balloon pump,
10 mL boluses of physiologic saline as placebo were administered via
the epidural catheter
oral paracetamol 1 g/6 h
recue analgesia
IV oxycodone 0.05 mg/kg at 10 min interval (until VAS </=3)
alfentanil [n]
group epi: 12/20
group subfas: 16/20
alfentanil [mg]: mean ± SD
group epi: 0.38 ± 0.39
group subfas: 0.50 ± 0.11
time to first request for analgesia [min]: mean ± SD
group epi: 32 ± 32
group subfas: 34 ± 26
postoperative pain:
significantly lower in group epi during first 4 hours (p=0.006), but not afterwards
at walking
similar during 72 h
volume of local anaesthetic [mL]: mean ±SD
group epi group subfas p-value
4 h 29 ± 10 38 ± 12 0.01
24 h 57 ± 15 (n=19) 41 ± 20 (n=16) 0.007
48 h 10 ± 7 (n=10) 8 ± 13 (n=8) NS
72 h 10 (n=1) 20 (n=1) NS
total vol. 86 ± 22 83 ± 20 NS
total dose 107 ± 28 206 ± 51 <0.001
dose of opioid [mg]: mean ± SD
4 h 11 ± 9 (n=14) 17 ± 11 (n=19) NS
24 h 11 ± 12 (n=13) 17 ± 9 (n=14) NS
48 h 13 ± 22 (n=12) 8 ± 3 (n=9) NS
72 h n=0 16 (6,16,24) (N=3) NS
total 32 ± 27 37 ± 23 NS
hospital stay [days]: median (min–max)
group epi: 5 (4–5)
group subfas: 5 (5–5)
no differences between the groups
mild nausea [n]
group epi: 1
group subfas: 2
motor weakness
group subfas: 0
“… incisional local analgesia administered via a subfascial catheter after caesarean delivery provided satisfactory analgesia without clinically significant side effects. The technique was easy to use, and patient satisfaction scores were comparable to that attained with epidural analgesia. Thus, incisional local analgesia as a component of multimodal pain management may be a good alternative to the more invasive epidural technique. It can also be a good choice for patients undergoing caesarean section under general anaesthesia. Further studies are needed to evaluate the costs of the two techniques and the appropriate concentrations and volumes of LA for subfascial administration.”
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