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* From the Department of Anaesthesia Surgical Intensive Care Changi General Hospital, and the
Department Of Anaesthesia Kandang Kerbau Women's Children's Hospital Singapore.
Address correspondence to: Dr. Noelle Louise Siew Hua Lim, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore. Phone: (65)8503831; Fax: (65)2601693; E-mail:nllsh{at}singnet.com.sg
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Abstract |
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Methods: Forty-eight ASA physical status I or II term parturients scheduled for elective LSCS under regional anesthesia were enrolled into this randomised double-blind study. The patient-controlled epidural analgesia device was programmed to deliver a bolus of 4 ml of local anesthetic mixture with a lockout period of ten minutes and an hourly limit of 12 ml. There was no baseline infusion. The study commenced upon the patient's first demand for analgesia post-operatively and the patients were assessed at one, six, 12 and 24 hr post-operatively for pain scores on movement, dermatomal level of sensory blockade, degree of motor blockade and volume of local anesthetic used. At conclusion of the study, patients' satisfaction scores were recorded.
Results: The two groups of patients were similar demographically. Patients who received a diclofenac suppository used 52.8 ± 17.8 ml of local anesthetic mixture while those who did not, used 74 ± 25 ml (P <0.005). Pain scores and satisfaction scores did not differ significantly between the groups.
Conclusion: A single administration of 100 mg diclofenac suppository is effective in reducing post-Cesarean epidural local anesthetic/opioid requirements by 33% for the first 24 hr post-operatively.
EPIDURAL bupivacaine, with or without fentanyl, has been used for post-operative analgesia for patients who have undergone lower segment Cesarean section (LSCS).1–3 Limitations to its usefulness include motor blockade and cardiovascular toxicity, especially in parturients. As a result, ropivacaine was developed as an alternative to bupivacaine. Being the S-isomer of bupivacaine, it has less cardiotoxicity and may be more selective for sensory fibres.
Patient-controlled analgesia is not a new concept. In existence for more than 20 years,4 it has been used for post- operative pain relief, labour analgesia and even for alleviation of chronic pain. The epidural route utilising a combination of local anesthetic and opioid provides better pain relief, improved mental status and bowel activity after major abdominal surgery.5 The addition of a single dose of diclofenac suppository post-operatively may enhance the quality of post-operative pain relief and may reduce the epidural local anesthetic/opioid requirements.
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The patients were premedicated with 30 ml 0.3 molar concentration of sodium citrate when called to the operating theatre (OT). In OT, they received 500 ml Hartmann's solution intravenously while baseline non-invasive blood pressure, electrocardiogram and pulse oximetry were recorded. After positioning the patient in the right lateral position, after lidocaine 1% infiltration, combined spinal-epidural anesthesia was instituted in the L2-3 or L3-4 interspace, using a 19G Weiss® epidural needle and a 27G Whitacre® spinal needle; 1.5 ml of hyperbaric bupivacaine 0.5% (7.5 mg) was administered intrathecally after which the epidural catheter was inserted 4 cm into the space. The patients were then turned supine and a wedge placed under the right hip to effect left uterine displacement. Sensory level to cold using an ice pack was recorded and surgery allowed to commence when a dermatomal level of T4 - T6 was achieved. None of the patients required additional epidural local anesthetics for surgery.
Post-operatively, in randomly selected patients, 100 mg diclofenac suppository was administered after digital removal of blood clots from the vagina was done by the surgeon. Patient grouping was decided by the drawing of shuffled coded envelopes. The patients were then monitored in the post-anesthesia care unit (PACU) for a variable period of time, depending on the moment of first demand for post-operative analgesia. No bolus dose of local anesthetic mixture was administered prior to starting the PCEA. The PCEA device was programmed to allow a bolus dose of 4 ml of ropivacaine 0.2% with fentanyl 2 µg•ml–1, lockout period of ten minutes with an hourly dose limit of 12 ml and no basal infusion. Subsequently, the patients were seen by an independent observer one, six, 12 and 24 hr from the time of first PCEA demand. Parameters recorded were the sensory level, degree of motor blockade using a modified Bromage score (0=no motor blockade, 1=able to flex hip and knee but unable to straight leg raise, 2=able to move ankle only and 3=unable to move lower limb), number of PCEA demands, volume of local anesthetic solution infused, pain score on movement using a visual analogue scale of 0 to 100 mm and the presence or absence of side effects such as nausea, vomiting or excessive drowsiness. Blood pressure, heart rate and pulse oximetry were monitored hourly for eight hours, four hourly subsequently if stable. Pain score and sedation score were monitored hourly. No additional analgesics were prescribed and the study was terminated 24 hr after the first PCEA demand, after which the patients were prescribed oral analgesics. Satisfaction score (0–100%) and the desire to have a PCEA should they present for surgery again were recorded at the end of the 24-hr study period.
Patients, nursing and medical staff were unaware of patient grouping. A computer package (SPSS) was used for statistical analysis. Results were compared using Student's t test for demographic data and Mann-Whitney test for non-parametric data. A P value of <0.05 was considered significant.
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Results |
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Data from these patients were included up to the assessment time before premature exclusion from the study.
The two groups of patients were similar demographically (Table I
). Group D used 52.8 ± 17.8 ml of local anesthetic mixture while group N used 74 ± 25 ml (P <0.005). There was no significant difference in the volumes of local anesthetic mixture used in the first and last six hours from the time of first PCEA demand. However, between six to 18 hr, PCEA use differed significantly between the two groups (P <0.005) (Table II). Pain scores did not differ significantly between the two groups (Figure). Overall satisfaction was high and did not differ significantly between the groups.
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All the patients were keen to have a PCEA should they have another operation except for the patient who had moderately severe motor blockade in group D and three in group N, one of whom detested the back discomfort due to the dressing over the epidural insertion site, the second preferred im opioid injection and the third was unsure.
One patient in each group required oxytocin infusion for post-partum hemorrhage. None of the patients experienced nausea or vomiting. There was no pruritus or excessive sedation.
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Discussion |
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Our data show a significant difference in the volume of local anesthetic solution used between six to 18 hr post-operatively. Residual operative analgesia may account for the similar volumes of local anesthetic solution used in the first six hours post-operatively. Subsequently, the analgesic effect of the administered suppository came into play, enhancing the quality of analgesia for the ensuing 12 hr.
Diclofenac, being an NSAID, is thought to act via inhibiting prostaglandin synthesis, hence its efficacy in post-Cesarean analgesia by the reduction of pain from uterine contractions. A central anti-nociceptive effect has also been postulated.9,10
Rectal diclofenac has a rapid onset of absorption, although slower than that from enteric coated tablets administered orally. Peak plasma concentrations are attained on average within an hour with a 50-mg suppository.
There is a theoretical risk of post-partum hemorrhage with the use of diclofenac as it prolongs the bleeding time and reduces platelet aggregation.11,12 However, diclofenac-induced post-operative hemorrhage is infrequent in clinical practice.11,12 NSAIDS, being weak acids, are not readily distributed to breast milk as they are readily ionised in the range of pH of breast milk. Therefore, they are not a concern for breastfeeding mothers.
Pain scores on movement did not differ significantly between the two groups. This is hardly surprising as all patients had the PCEA pump at their disposal.
Epidural ropivacaine 0.2% has been found to have a high incidence of motor block during labour analgesia, possibly because higher volumes of epidural ropivacaine 0.2% are used. We did not find a high incidence of motor block in our study although we did not make any attempt to assess the ability of the patients to ambulate. In fact, sensory loss in the lower extremities may have an adverse effect on ambulation.3 However, we acknowledge that post-Cesarean patients should be encouraged to ambulate as early as possible in order to minimize post-operative complications and also to allow for care of the newborn.
We conclude that the use of a single post-operative dose of diclofenac (100 mg suppository) in conjunction with PCEA with ropivacaine 0.2% and fentanyl 2 µg•ml–1 provides effective post-Cesarean analgesia and reduces epidural local anesthetic/opioid requirements by 33% for the first 24 hr post-operatively.
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Footnotes |
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Accepted for publication November 27, 2000.
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2 Cohen S, Amar D, Pantuck CB, et al. Epidural patient-controlled analgesia after cesarean section: buprenorphine-0.015% bupivacaine with epinephrine versus fentanyl-0.015% bupivacaine with and without epinephrine. Anesth Analg 1992; 74: 226–30.[Medline]
3
Cohen S, Amar D, Pantuck CB, Pantuck EJ, Weissman AB. Adverse effects of epidural 0.03% bupivacaine during analgesia after cesarean section. Anesth Analg 1992; 75: 753–6.
4 Evans JM, Rosen M, McCarthy J, Hogg MI. Apparatus for patient-controlled administration of intravenous narcotics in labour. Lancet 1976; 1: 17–8.[Medline]
5 Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology 2000; 92: 433–41.[Medline]
6
Roseag OP, Lui ACP, Cicutti NJ, Bragg PR, Crossan ML, Krepski B. Peri-operative multi-modal pain therapy for Caesarean section: analgesia and fitness for discharge. Can J Anaesth 1997; 44: 803–9.
7 Sia ATH, Thomas E, Chong JL, Loo CC. Combination of suppository diclofenac and intravenous morphine infusion in post-caesarean section pain relief – a step towards balanced analgesia? Singapore Med J 1997; 38: 68–70.[Medline]
8 Olofsson CI, Legeby MH, Nygårds E-B, Östman KM. Diclofenac in the treatment of pain after caesarean delivery. An opioid-saving strategy. Eur J Obstet Gynecol Reprod Biol 2000; 88: 143–6.[Medline]
9 Ferreira SH, Lorenzetti BB, Corrêa FMA. Central and peripheral antialgesic action of aspirin-like drugs. Eur J Pharmacol 1978; 53: 39–48.[Medline]
10 Jurna I, Brune K. Central effect of the non-steroid anti-inflammatory agents, indometacin, ibuprofen and diclofenac, determined in C fibre-evoked activity in single neurons of the rat thalamus. Pain 1990; 41: 71–80.[Medline]
11 Rosarius M, Miralles J, Baer GA, Palomäki E. Diclofenac versus indomethacin given as intravenous infusions: their effect on haemodynamics and bleeding time, and side-effects in healthy subjects. Ann Clin Res 1985; 17: 306–9.[Medline]
12 Power I, Chambers WA, Greer IA, Ramage D, Simon E. Platelet function after intramuscular diclofenac. Anaesthesia 1990; 45: 916–9.[Medline]
13
Sia ATH, Ruban P, Chong JL, Wong K. Motor blockade is reduced with ropivacaine 0.125% for parturient-controlled epidural analgesia during labour. Can J Anesth 1999; 46: 1019–23.
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