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Summary

University of North Carolina (UNC) initiative: to control opioid prescribing practices, the obstetric anesthesia division at UNC took over the prescription of post-cesarean analgesic regimen in 2019; multimodal analgesia (MMA) consists of neuraxial morphine (Duramorph) in the operating room (OR), followed by scheduled acetaminophen (eg, Acephen, Dapacin, Tylenol) and ibuprofen for the remainder of the hospitalization; oxycodone was provided as needed

Drugs to be avoided in the postpartum MMA after cesarean delivery: neuraxial morphine is the only prophylactic opioid that should be given in the OR for patients undergoing cesarean delivery; intramuscular morphine can cause respiratory depression and opioid-related side effects; omit scheduled opioids and combination medications, eg, acetaminophen-oxycodone (eg, Percocet) and acetaminophen-hydrocodone (eg, Norco), as well as provider-dependent, non-standardized regimens; setting expectations for patients helps with pain control

Impact of change in the regimen: at UNC, the switch to ibuprofen and acetaminophen scheduled every 6 hr was easy, cheap, and beneficial, and it enabled better education of patients; prior to the change to scheduled ibuprofen and acetaminophen, 3% of patients were not using any opioids; after the change, ≈20% of patients are not receiving systemic opioids; the high-user group (those using ≥60 mg oxycodone in 48 hr or ≥30 mg in 24 hr) decreased by ≈50%; at UNC, receipt of ≥30 mg oxycodone in 24 hr among breastfeeding patients triggers a visit from the obstetric anesthesiologist and the pediatrician to explore other options, eg, truncal blocks

Benefits of MMA: reduces pain, improves mobilization in patients prone to venous thromboembolism, decreases opioid dependence and opioid-related side effects, and limits opioids at discharge

Enhanced recovery after cesarean delivery guidelines: the gold standard for opioid reducing medication is long-acting neuraxial morphine; in the era of drug shortages, hydromorphone (eg, Dilaudid) may be the only other option; it does not last long because it is not hydrophilic, and little data are available on its safety profile; intrathecal or epidural morphine can cause delayed respiratory depression 6 to 18 hr after administration, usually at ≈8 hr; some institutions cite this as the reason for not using neuraxial morphine; the American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia (ASRA) have guidelines on rigorous respiratory monitoring in patients receiving neuraxial morphine

Consensus statement from the Society of Obstetric Anesthesia and Perinatology (SOAP) on respiratory monitoring: no additional respiratory monitoring is needed with use of an ultra-low dose of intrathecal morphine (≤0.05 mg) or epidural morphine (≤1 mg); with low-dose intrathecal (>0.05 mg and ≤0.15 mg) or epidural (>1 mg and ≤3 mg) morphine, monitor with measurement of respiratory rate and sedation every 2 hr for 12 hr postoperatively; with high doses of intrathecal morphine (>0.15 mg) or epidural morphine (>3 mg), follow the ASA and ASRA guidelines for rigorous respiratory monitoring (every 1 hr for first 12 hr, followed by every 2 hr for the next 12 hr); patient with risk factors, eg, morbid obesity, chronic opioid use, or sleep apnea, are also in the high-risk category and should be monitored with rigorous respiratory monitoring independent of dose

Drugs to be started in the OR: at UNC, 1 g oral acetaminophen is given before going back to the OR; this can also be given as an IV dose, although it is very expensive and does not have an analgesic benefit over the oral form; can be given rectally as well; NSAIDs should be started in the OR; ketorolac is typically given in the OR, followed by an oral NSAID every 6 hr after surgery

Truncal blocks: not needed if neuraxial morphine is available; neuraxial morphine is the gold standard for pain control and is better than truncal blocks alone; addition of truncal blocks to neuraxial morphine does not provide analgesic benefit; they are encouraged in patients under general anesthesia; they can be administered at quadratus lumborum, at transverse abdominal plane, via wound infiltration, or at erector spinae; chronic opioid users and patients with chronic pain may benefit from truncal blocks with neuraxial morphine

Drug safety: meperidine should be avoided in breastfeeding women because doses of 25 to 50 mg can cause clinically significant respiratory depression in breastfeeding neonates; it is often used in doses of 6.25 to 12 mg for the intense shivering caused by neuraxial morphine; however, the recommendations are to avoid meperidine at any dose; recent study found that 10 μg of dexmedetomidine (eg, Precedex) can be given after delivery and reduces shivering caused by neuraxial anesthesia without causing hypotension, bradycardia, or sedation; 30-μg doses caused some side effects

Contraindications: codeine and tramadol are metabolized through the cytochrome P450 2D6; an unpredictable amount of women are ultrarapid metabolizers; codeine and tramadol are converted into their active metabolite (morphine and M1, respectively) that acts on the μ receptor; these active metabolites transfer to the neonate and cause respiratory depression or death; they can be given to women who are not ultrarapid metabolizers, but it is difficult to identify these women; therefore, they are contraindicated

Discharge medications: despite decreasing the opioid use by 50% in the hospital, patients at UNC were being discharged with 20 tablets of oxycodone (5 mg), even if they did not use any opioids in the hospital; the obstetricians were advised to multiply the number of 5-mg oxycodone tablets given to the patient in last 24 hr by 5 and give that to the patient at discharge; text message surveys showed that patient satisfaction was adequate, and they had an adequate, but not excessive, number of opioid tablets; education was added to their discharge about safe disposal of the opioids; they can be taken to most medical stores or brought back to UNC for disposal at the clinic