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 Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 3-6

Effective pain relief after caesarean section; Are we on the right path or still on the crossroad


1 Anesthesia and Pain Relief Service, Tata Motors Hospital, Jamshedpur, Jharkhand, India
2 Obstetrics and Gynaecology, Tata Motors Hospital, Jamshedpur, Jharkhand, India

Date of Web Publication11-Apr-2019

Correspondence Address:
Dr. Ashok Jadon
Duplex-63, Vijaya Heritage Phase-6, Near Marine Drive, Kadma, Jamshedpur - 831 005, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_7_19

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How to cite this article:
Jadon A, Bagai R. Effective pain relief after caesarean section; Are we on the right path or still on the crossroad. J Obstet Anaesth Crit Care 2019;9:3-6

How to cite this URL:
Jadon A, Bagai R. Effective pain relief after caesarean section; Are we on the right path or still on the crossroad. J Obstet Anaesth Crit Care [serial online] 2019 [cited 2019 May 21];9:3-6. Available from: http://www.joacc.com/text.asp?2019/9/1/3/255898



Pain relief is an integral and essential component of any surgical procedure, and caesarean section (CS) is no exception. Pain is ranked highest among undesirable clinical outcomes associated with CS.[1] Patients after CS often suffer moderate to severe pain in postoperative period.[2] If this pain is not treated adequately, it may interfere in the care of new born, breastfeeding, and also increase the risk of depression in the mother and devolvement of chronic pain syndrome.[3],[4],[5]

Severity of pain after CS is multifactorial,[6] and the blanket approach that is currently applied is not suitable for all women, given individual differences in pain perception and other factors that influence CS-related pain.[4] Although many tools have been developed to help in prediction of pain severity,[7] effective pain control remains a challenge in patients after CS.[8] Parenteral opioids, although have been used extensively, often result in inadequate pain relief, and opioids-related side effects may expose the mothers to become persistent opioids' user.[9] Neuraxial opioids provide effective analgesia after CS however; duration of pain relief is short and patients often require additional analgesia.[10] Inherent limitation of previously used technique and individual variability of postoperative pain makes it difficult to achieve the standard goals of effective analgesia in CS patients (visual analog scale score of >3 in 90% of patients).[11]

To overcome the limitation of an individual technique in providing effective pain relief in CS, current recommendation is to use multimodal analgesia (MMA) for pain relief.[12] In MMA, simultaneous use of more than two drugs or technique with different mechanism of action is used to provide effective analgesia after caesarean.[13] The goal of MMA is to obtain synergistic or additive analgesia with fewer side effects by combining lesser amounts of each drug with different mechanisms of action. MMA constitutes the use of nonsteroidal anti-inflammatory (NSAIDs) drugs, local wound infiltration, neuraxial opioids/adjuvants, and use of truncal blocks.[10] The parenteral opioids are only reserved for resistant cases.

When NSAIDs are used along with neuraxial opioids for analgesia in CS, they potentiate opioid effect, decrease opioid consumption, and reduce side effects.[14],[15] In this synergistic effect, NSAIDs reduce visceral pain and may compliment the somatic wound pain relief from the opioid. However, NSAIDs must be used with caution because of the potential problems with bleeding, platelet dysfunction, and renal insufficiency.

The NICE guidelines for CSs suggest that wound infiltration could be an alternative to systemic analgesia.[16] However, there are conflicting findings in the literature on the analgesic efficacy of wound infiltration.[17] A meta-analysis of 512 patients from nine randomized controlled trials (RCTs) for CS pain relief has shown that local anaesthetic (LA) wound infiltration can reduce morphine requirements and nausea but not pain scores after CS.[18] Almost similar findings were observed by other meta-analysis which has shown that LA wound infiltration reduces postoperative opioid consumption but had minimal effect on pain scores and did not reduce opioid-related side effects in women who had undergone delivery by CS.[19] Recent studies have shown that wound infiltration with LA and dexmedetomidine is more effective than LA alone to control the pain and without risk of side effects.[20] However, further studies are required to accept the efficacy and safety of dexmedetomidine as adjuvant to LA infiltration for mother and for new born.

Adjuvants like neostigmine and clonidine in neuraxial route have shown some analgesic advantages when used for analgesia in CS, but due to adverse effects they have limited scope for routine clinical use.[21],[22]

Over the past few years, truncal blocks have gained popularity as an important component of MMA. One of the oldest in this category is the transversus abdominis plane (TAP) block. Use of TAP block in CS was first described by Kuppuvelumani et al. in 1993 as abdominal field block[23] and showed that it provided effective pain relief and has opioid-sparing effect. With the availability of ultrasound and better understanding of abdominal wall anatomy, TAP block became popular for analgesia in CS.[24] Many studies have suggested that TAP block in CS provides effective pain relief and could be a viable alternative to reducing opioid consumption and opioid-related side effects.[25],[26],[27] Although the above-mentioned studies have suggested the efficacy and advantages of TAP block in CS, high-level evidence is lacking.

RCTs have reported controversial outcomes with the traditional TAP technique and showed no difference in total morphine consumption at 48 h when compared with wound infiltration of LA for postcaesarean pain.[28],[29] Many recent meta-analyses have also concluded that results of large pooled data are inconclusive and there is a further need for high-quality studies.[30],[31] We do not know the exact reason why there is so much variability of results with TAP blocks. It could be due to the use of different approaches as the choice of technique influences the involved area and block duration. However, this also suggests that blocking somatic fibers alone is insufficient, and including blockade of the visceral fibers may be more likely to provide adequate analgesia.[32]

With pretext to provide better pain relief by blocking, somatic and visceral pain quadratus lumborum blocks (QLB) have been evaluated to manage pain after CS.[33],[34] The analgesic efficacy of QLB after CS has also been evaluated by an RCT and the results demonstrated statistically better morphine consumption and morphine demands in the QLB group compared with the control group.[35] A recent RCT has also showed effective analgesia in CS compared with the control group.[36] Although the evidence in favor of QLB is high as shown by various RCTs, due to a small number of studies it is too early to conclude. There are four different approaches of QLB and all have different profiles of LA spread, and it is still not clear which one is going to be better for CS.[37] The exact mechanism of how QLB works and provides analgesia is also not fully understood. However, it is attributed to paravertebral spread[38] of LA and also effect of LA on sympathetic fibres present in lumbar fascia.[39],[40] The safety is another concern in QLB as this is a deep block and endpoints of injection are close to kidney and other intraperitoneal visceral organs. Particularly, in patients receiving anticoagulant therapy, QLB should be carefully considered due to the vascularity of area, retroperitoneal spread of hematoma, and proximity to paravertebral area and lumbar plexus.[41] Recently, erector spinae block has shown effective analgesia after CS; however, only few case reports have been published and definitive proof of efficacy is yet to come.[42]

Other truncal blocks like iliohypogastric–ilioinguinal nerve block have been evaluated for post-CS pain relief.[43],[44] However, studies are limited and evidence is not enough. Drugs like ketamine[44],[45] and gabapentin[46] have been tried but not recommended yet due to limited studies and inherent risk to fetus and side effects.

With regard to effective pain relief in CS, few more questions have to be answered before we say that we are on the right path or still at the crossroad. First, is the modern technique or drugs sufficient to provide effective pain relief? The answer is no, because resources may be available but the staff fails to routinely assess the pain and provide pain relief.[47] Second, only the objective of pain relief is not enough in patients with CS. In addition to pain relief, optimal management of patients after CS should address the goals of unrestricted maternal mobility, minimal maternal and neonatal side effects, rapid recovery to baseline functionality, and early discharge to home. The present techniques although trying to address these issues are not able to provide the necessary component all together. Moreover, as the drug availability, maternal health conditions, patient preferences, and availability of medical expertise and trained support staff play a role in choice of analgesic method and the quality of pain relief, it will remain a hurdle at least in the present Indian scenario.

Multimodal analgesic regimen (MMA) is the current standard recommendation for analgesia in CS. However, multimodal regimen which is currently recommended is still in infancy. As yet, we do not know what combination will be the most effective in relieving pain and the safest for the mother and her baby. Therefore, we feel that there is still a long way to go to achieve effective analgesia for CS. However, we should always try to achieve it, and the first step is to adopt protocol-based practices where benchmarking, auditing, and plan for continuous improvement have to be in place.[48],[49],[50]



 
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