Any recommendation regarding post c-section pain relief

[artlp]

I am going to be scheduled for a c-section soon and heard great things about duramorph but also heard about the itching problem. Would anyone share what their preference would be for pain relief.

Also, why choose a spinal instead of an epidural for a scheduled c-section?

Thanks.

[Fgr8Out]

Having just left my shift on postpartum....

We give Ibuprofen Q6 hours and Percocet (2) Q4 hours PRN, generally with very good relief. Our orders state the two may be given simultaneously, depending on the patient preference. Most notably, a new mom s/p Ceasarean with spinal anesthesia who I cared for yesterday had very good results and was up and walking as soon as the spinal wore off.

Toradol is another great drug for the inflammation of incisional pain.

[kmchugh]

I have started doing OB anesthesia again, after a two year post-school hiatus. One of the reasons I started looking for a new job was simply that I enjoyed OB anesthesia, and wanted to do it again.

It seems Artlp asked a couple of questions that weren't well answered, so I will take a shot. First, to the issue of spinal duramorph and itching. For many of my patients getting an epidural for pain relief, I do a combined spinal-epidural. The spinal injection gives nearly immediate relief, while the epidural gives long lasting pain control. It works great. One problem I have encountered is itching. I use low dose sufenta (usually 10 mcg) with nothing else for the spinal injection, and usually by the very next contraction, patients report significant relief from pain. However, patients universally report that they suffer itching after the injection as well. While every patient has expressed that they would rather have the itching than the pain, I am on the lookout for a slightly different medication that will cause less discomfort.

I recently attended a conference on regional anesthesia, and it was suggested that a spinal injection with very low dose marcaine (2.5 mg) with 25 mcg of fentanyl will give very good pain relief with a great deal less itching. I have not had the opportunity to try it yet, but have hopes it will help.

I think the issue of itching and spinal (or epidural) narcotics is related to the patient and the narcotic chosen. Some patients seem to be more prone to this itching, and some narcotics seem to be more likely than others to cause it.

As to why spinal rather than epidural for c-section, generally the reason is related to the time factor. Spinal anesthesia is a one shot injection, with a finite duration. Epidural anesthesia is a longer term proposition, with a catheter left in the back. There are cases where the anatomy of the epidural space, or the final position of the catheter in the epidural space can cause a "spotty block." It doesn't happen often, but it does happen. I have never seen a spotty block from a properly administered spinal. Since a (non-emergent) c-section is done with a scheduled start time, and (with some physician variability) is of known duration, spinal anesthesia is an excellent choice for this type of procedure. I also give toredol near the end of the procedure, and this seem to help enormously with pain control after the block has worn off.

On the topic of CRNA's and what we do and don't do, I am in a hospital where ALL anesthetics are provided by CRNA's. We don't have an MDA, and we do just fine. I do all anesthetic procedures, including general anesthesia, regional anesthesia, spinal and epidural anesthesia. I also do anesthetics for c-sections, scheduled and emergent. In fact, about two weeks ago I did a general anesthetic for an emergent c-section for placenta previa. That will increase your pucker factor by a magnitude of 10.

I'll say it again. I think the "fight" between the ASA and the AANA is overblown, and it harmful to both organizations. I am grateful for physicians, like Tenesma, and for experienced CRNA's, like Lois, who post to this and other boards, recognizing that we are all health care professionals with a job to do. I'll take good help where ever I can find it.

Kevin McHugh

[Tenesma]

kevin,

i find it interesting that your favorite OB anesth. is a combined spinal/epidural... it is my favorite as well, however I tend to use it less and less (it is a good trick to keep up my sleeve) - as i see the potential complications as very aggravating:

1) CSE vs. plain old epidural

- increased incidence of post-dural puncture headache

- risk of intra-thecal catheter advancement (you can have an intrathecal catheter and not always know it for sure despite attempts at aspiration first - and then you can be stuck with one hell of a spinal dose when you push your drugs intended for epidural dosing)

- in the setting of an unexpected/possibly expected emergency c-section the spinal may wear off and your epidural catheter is non-functional (misplacement - yet you could never verify a level)

the list goes on and on...

so i find myself doing CSEs for pts w/ low pain-tolerance and very low likelihood of emergent c-sections (like a lady partsl multip) where i know i can always put in a new epidural catheter if the need arises....

don't get me wrong, i still think it is a wonderful technique... now if you want fast pain relief without a spinal you can always give a fast acting dose (chloroprocaine) initially and obtain a quasi surgical level within a few minutes - high risk of hypotension though...

my 2 cents

[WntrMute2]

I'm doing my OB rotation now and w/ CSE we use 2.5mg Marcaine plus 25mcg fentanyl. Low itching incidence.

[KimQCRNA]

Jolie,

It is interesting to note that you have only worked OB in hospitals where anesthesiologists provide all of the OB coverage. I have worked in two different hospitals since I graduated from anesthesia school, and in both institutions, only CRNAs provide OB coverage. Different places do things differently, it is based on what the docs want to do, how much call they want to take, how much they want to hold on to areas of "turf" or "territory", etc. And how financially solvent their group is, if they have all the money they want/need, and are secure professionally, and don't mind giving away tasks, and actually value CRNAs as professionals, they will "let" us do OB........in many places, there are no MDAs.......so we are the one and only option.......just my 2 cents.....Kim CRNA