OB pain management

[neutro]

Greetings:


Wanted to ask you guys what is the protocol for "around the clock" oral pain management regimen on your OB floor for patients REFUSING/ Not candidates for epidural analgesia.

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[partydoc]

Willow bark

 

[Noyac]

Greetings:


Wanted to ask you guys what is the protocol for "around the clock" oral pain management regimen on your OB floor for patients REFUSING/ Not candidates for epidural analgesia.

We don't get involved with pt like you describe. That's for the OB's to handle.

 

[sevoflurane]

We don't get involved with pt like you describe. That's for the OB's to handle.

Yup. The question is a bit odd. We don't deal with patients w/o neuraxial anesthetics.

 

[teeva]

Nothing. Defer to OB.

 

[neutro]

Yup. The question is a bit odd. We don't deal with patients w/o neuraxial anesthetics.

I do not think that this is an odd question at all.
we routinely used tylenol 1g po q8 hour, tramadol 50 mg po q8h standing and then a low dose opioid for breakthrough at my previous institution.

I wanted to see if there are other med. regimens that exist for patients either not candidates for epidurals or refusing it.

 

[neutro]

Nothing. Defer to OB.

ok.

cant always run though.

 

[AdmiralChz]

We sat down with the OBs about this very thing a couple months ago at my institution, we now do Nubain (nalbuphine) 10 mg q3hr PRN. Have to watch for oversedation, but works pretty well as an alternative agent.

 

[Libertas]

.....oral? Why oral?

 

[anesthesiadoc]

Have been to talks about this issue. Our group hasn't adopted either of these, but we have heard presentations on bedside nitrous oxide as well as remifentanil PCA's for contractions in laboring parturients without epidurals. While I agree that we don't need to get involved with every patient, and it's easy to view rejection of the epidural as a rejection of us, I think it makes sense for us to be aware of alternatives, particularly in the case of women in whom epidurals are contraindicated (very low platelet count, etc). At the very least, we should be a consultant that the OB's can run these questions by, physician to physician, as the acute pain experts on L&D.


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[facted]

There is some good evidence for remifentanil pca, but of course you need good monitoring. I've done fentanyl pca a few times but it's not super effective in my experience. We don't have the ability to do self adminstered nitrous, though there are many centers that are starting to do this.

 

[neutro]

.....oral? Why oral?

cost effective.
for breakthrough we did use low dose opioids, like 25-50 mcg fentanyl IV on top of other oral analgesics - after clear discussion of risks.

 

[neutro]

There is some good evidence for remifentanil pca, but of course you need good monitoring. I've done fentanyl pca a few times but it's not super effective in my experience. We don't have the ability to do self adminstered nitrous, though there are many centers that are starting to do this.

great, thanks.
have you tried mulimodal analgesic approach or plain short acting opioid PCA?

 

[neutro]

We sat down with the OBs about this very thing a couple months ago at my institution, we now do Nubain (nalbuphine) 10 mg q3hr PRN. Have to watch for oversedation, but works pretty well as an alternative agent.

thank you.

will you do nalbuphine on top of tramadol and tylenol standing for breakthrough? or just by itself?

 

[neutro]

Have been to talks about this issue. Our group hasn't adopted either of these, but we have heard presentations on bedside nitrous oxide as well as remifentanil PCA's for contractions in laboring parturients without epidurals. While I agree that we don't need to get involved with every patient, and it's easy to view rejection of the epidural as a rejection of us, I think it makes sense for us to be aware of alternatives, particularly in the case of women in whom epidurals are contraindicated (very low platelet count, etc). At the very least, we should be a consultant that the OB's can run these questions by, physician to physician, as the acute pain experts on L&D.


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yes.
running away and deferring to OB doesnt solve anything and makes you look lazy.
The OB probably knows even less on this matter.

 

[facted]

great, thanks.
have you tried mulimodal analgesic approach or plain short acting opioid PCA?

The OB's usually give some stadol and we would start a fentanyl PCA. It's not super effective to be honest. Haven't done multimodal really. Seems oral Tylenol, etc... would be a drop in the bucket for labor, but I could be wrong.

 

[pgg]

PRN fentanyl IV.
Remifentanil PCA.
Nitrous.

Oral meds for labor are just silly.

 

[Noyac]

I don't think that by not getting involved we are running away from the situation. OB docs are surgeons as well, and they know how to treat pain. They also have dealt with these pts much more than I have. I would only be making suggestions and they could choose to use them or not. I don't mind a call from time to time but I'm not getting involved and making a policy on this.

N2O is an interesting option. It seems to be coming into the arena more and more. I have a couple thoughts on this:
1) it must be ordered by the OB. I am not getting involved just to initiate N2O. If I get called they will get an epidural ( exceptions apply of course). Some places noticed after initiating the program that many pts were given N2O to bridge the labor and then calling us much later in the process. Think midwives using it like water. If the OB wants to turn it on just to get the pt to the morning and then call for epidural, that would be great but they will also be turning it on at 5 pm and then calling for epidural at 2am when the pt needed the epidural at 5 anyway. Plus epidurals are amazing at kicking in the dilation when the pt seems to be putting along.
2) there are environmental and health issues. These systems are pretty good at turning on and off when the pt initiates it. But they still breath out and there is N2O in the air. I'm not an environmental whacko but I don't want to ignore it either. Plus the nursing staff are usually child bearing age as well. We know that N2O can cause miscarriages and other birth issues. All of this is probably a small risk but still a risk. Nobody suffers from epidural exposure beyond the mom.

 

[deleted162650]

Nobody suffers from epidural exposure beyond the mom.

This.

For the life of me I can't figure out why the midwife crowd who is all about drug free/natural child birth, etc. is in love with nitrous. Instead of an epidural which provides amazing analgesia and exposes the baby to literally almost 0 medications, let's let mom huff on this gas which provides marginal analgesia at best (I've had nitrous alone for a small procedure - still hurt like an MF'er), crosses the placenta, reduces FiO2, and has actually been proven to be teratogenic (yes, yes I know the baby is fully developed but still - you get my point). You just can't fix stupid.

 

[jwk]

Patients that don't get epidurals are not our patients - they belong to the OB only. Correct me if I'm wrong but you can't charge for PO analgesia and pain management anywhere. If you can't charge for it, why would you want to be professionally responsible for it?

 

[teeva]

Seriously. You asked specifically about oral meds. Doesn't make sense when we are experts in OB analgesia using better means even if just IV.

We used remi PCA in residency.

 

[neutro]

Patients that don't get epidurals are not our patients - they belong to the OB only. Correct me if I'm wrong but you can't charge for PO analgesia and pain management anywhere. If you can't charge for it, why would you want to be professionally responsible for it?

you can. if you are consulted for pain management reasons. you can bill for a consult (not that I am concerned about billing per se).

 

[neutro]

Seriously. You asked specifically about oral meds. Doesn't make sense when we are experts in OB analgesia using better means even if just IV.

We used remi PCA in residency.

No one is debating the value of epidural analgesia.
IV opioids are certainly an option, but it creates a problem POD # 1 and 2. Hence they are used for breakthrough.
I would not do IV tylenol however - not sure if that has any literature in this population for efficacy vs. PO tylenol which is far cheaper.

I am looking at this from a systems based perspective also.

 

[caligas]

You can bill for anything, the question is one of collection.

 

[neutro]

PRN fentanyl IV.
Remifentanil PCA.
Nitrous.

Oral meds for labor are just silly.

Technically, you dont need ANY analgesia for LaD. Epidurals are elective procedures also...far more invasive than oral meds...playing devil's advocate here.
Again, I really do not argue with the patient on why they should get epidural analgesia if they decline after reasonable attempts are made and sufficient education is provided.
Often the patients will not want epidurals. I do not want to do epidurals in patients for these patients anyways. They will have some BS traumatic experience from this, like headache, persistent back pain and "I have had back pain since i had an epidural 20 years ago" etc etc. The point isnt to argue, rather work with given constraints.
The case for oral meds is not so much in the efficacy of the medications vs. IV opioids. Obviously IV meds will work far better.
The rationale behind oral opioids [standing PO meds - tylenol and tramadol] is to help with mild to moderate pain, and use IV meds for breakthrough, i.e. judicious use of opioids.

Thank you for all your suggestions.

Will incorporate Remi, nalbuphine and may be N2O

 

[fakin' the funk]

Wanted to ask you guys what is the protocol for "around the clock" oral pain management regimen on your OB floor for patients REFUSING/ Not candidates for epidural analgesia.

Patient who desires an epidural but not a candidate = kind of your problem. Remi PCA, nitrous. Fentanyl PCA would be fine too if peds present at delivery.
Patient who does not desire an epidural = 100% not your problem.
Oral pain rx around the clock is ridiculous, inadequate, and fraught with undesired side effects.

 

[vector2]

Remi pca, 50mcg q3-4 min. Seems like a short interval but the dose is rapidly self-limiting based on comfort.

N20 is garbage. 80% of parturients give up after 15 min and ask for the epidural. Also have noticed significant tachyphylaxis after they've been using it for 45min-1h.

 

[pgg]

Technically, you dont need ANY analgesia for LaD. Epidurals are elective procedures also...far more invasive than oral meds...playing devil's advocate here.

The point I was making wasn't as complex as all that - just that oral meds for labor are silly. Full stop.

It has nothing to do with whether it's our problem or the OB's problem, billable or not billable. It's just backwards thinking.


I'm not sure how we got off on the tangent of the electiveness of epidurals. Of course not every woman wants, needs, or is a candidate for an epidural. But since you brought up the electiveness of ALL labor analgesia, I'll point out that the ASA and ACOG agree that labor analgesia is a fundamental human right of all parturients. To read their statements, it's somewhere in the space between the 10 Commandments and the Bill of Rights. A woman who wants pain relief for labor gets it, barring contraindications that we're all familiar with.

I didn't get the impression that was the point of your thread, though.

The rationale behind oral opioids [standing PO meds - tylenol and tramadol] is to help with mild to moderate pain, and use IV meds for breakthrough, i.e. judicious use of opioids.

It's a rationale, but it's a poor one.

There's no upside to using a less titratable, less predictable, slow onset (GI effects of labor?), slow offset, oral drug when the patient has an IV, nursing care is 1:1 or 1:2, and everyone knows pain is going to get worse.