PCEA or duramorph-- help me decide

[michigangirl]

Hi all! Wanted to get some expert opinions on post-op pain control for C/S-- particularly from you private practice types working in the real world-- It's been a year since I've done OB anesthesia and now that I'm a peds fellow I'm a little out of touch.

I'm scheduled for my repeat C/S in a week or so and asked my OB what type of pain control their anesthesia group usually uses-- they said they are a CSE followed by duramorph kind of group, and that the patients seem more pain free post op than PCEA. My first section was an urgent for decels with a spinal so a little different situation. What do you guys think? Is the duramorph really that great? or should I request PCEA?

thanks!

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[drccw]

Hi all! Wanted to get some expert opinions on post-op pain control for C/S-- particularly from you private practice types working in the real world-- It's been a year since I've done OB anesthesia and now that I'm a peds fellow I'm a little out of touch.

I'm scheduled for my repeat C/S in a week or so and asked my OB what type of pain control their anesthesia group usually uses-- they said they are a CSE followed by duramorph kind of group, and that the patients seem more pain free post op than PCEA. My first section was an urgent for decels with a spinal so a little different situation. What do you guys think? Is the duramorph really that great? or should I request PCEA?

thanks!

CSE for c-section??? Wow that's a bit much...
I do spinal for all c-sections... I can't think of the last time I did a CSE for a c-section... I would recommend the duramorph spinal because if you have a pcea it's just one more thing that you are hooked up to....

 

[Noyac]

Duramorph spinal.

 

[cchoukal]

we do cse for c-section occasionaly if the patient is huge (and the frequently are here) because it's sometimes easier to find the space with the touhy than a 24g, and because procedure times can be variable (read: long) in this group.

 

[snowman8]

CSE for c-section??? Wow that's a bit much...
I do spinal for all c-sections... I can't think of the last time I did a CSE for a c-section... I would recommend the duramorph spinal because if you have a pcea it's just one more thing that you are hooked up to....

CSE not to much for csection if you believe PCEA superior.

Both good post-op analgesia. Subjectively PCEA better than Duramorph for pain control. As we all know, the big disadvantage of duramorph is the pruitis. MY opinion, the only reason why most private prctice groups don't do PCEA for post-section b/c of man power. WHo wants to round on these pts with an epidural when you can get almost as good postop analgesia with the duramorph.

Now if you have an epidural placed for labor analgesia and then converted to csection epidural, PCEA definatley better than Epidural morphine!

My wife will get PCEA

 

[militarymd]

duramorph only....unless in want to lie around in bed unnecessarily.

 

[coprolalia]

Yeah, just chuck 250mcg of pres free morphine in the spinal mix. Don't hassle with a PCEA. It's a pain in the ass for everyone, including the patient.

-copro

 

[rsgillmd]

CSE not to much for csection if you believe PCEA superior.

Both good post-op analgesia. Subjectively PCEA better than Duramorph for pain control. As we all know, the big disadvantage of duramorph is the pruitis. MY opinion, the only reason why most private prctice groups don't do PCEA for post-section b/c of man power. WHo wants to round on these pts with an epidural when you can get almost as good postop analgesia with the duramorph.

Now if you have an epidural placed for labor analgesia and then converted to csection epidural, PCEA definatley better than Epidural morphine!

My wife will get PCEA

Explain. We give Duramorph to all our C/S patients done under neuraxial block. Pain relief is good for 16-24 hrs, by which time they have started using PO Percocet/Motrin/Tylenol usually. Some get IM Toradol (floor nurses won't give it IV for some reason). The pruritis is tolerable for most patients -- it's a rare patient that says it is very bad. I find no problems with giving Epidural Duramorph.

 

[TheSandMan]

I agree with others above. Though I'm not out in private practice yet, I've had good results with duramorph and tylenol or toradol supplementation for the synergistic effect if needed, so might as well keep it simple. I also put in for prn nubaine 10mg sq for itching to prevent phone calls- don't think most patients need it though.

 

[cchoukal]

I agree with others above. Though I'm not out in private practice yet, I've had good results with duramorph and tylenol or toradol supplementation for the synergistic effect if needed, so might as well keep it simple. I also put in for prn nubaine 10mg sq for itching to prevent phone calls- don't think most patients need it though.

agreed. most of our non-obese patients get fentanyl and duramorph in the IT dose, and then PO naproxen for 24 hours and we get VERY few phone calls for pain.

 

[SleepIsGood]

We will occasionally do CSE for c/s for the same reasons CC stated (variable time for section and/or resident practice).

If we do a CSE, typically the hyperbaric bupi is given with fentanyl 20mcg. Then pull out the whitacre and thread the cath in. Baby comes out. 3-3.5mg of duramorph goes in. end of surgery the epidural cath comes out.

OR

If it's just a spinal. We'll give hyperbaric bupi + 25 mcg of fent + .2mg of astromorph.

 

[cchoukal]

I should've mentioned, when we do a CSE for obesity, we don't use long-acting opiates with the thought that they may be at increased risk of apnea. As sleep mentioned, the catheter comes out at the end of the case. I don't recall ever using a catheter for post-c/s pain mgmt...

 

[isoman2000]

here is a nice overview by the international journal of obstetric anesthesia

http://www.ptolemy.ca/members/archives/2007/c-section/pan2006.pdf

I ,like most posting ,use 150 to 200 mcg duramorph with tordol q6 for post op C/S pain and rarley have any problems or call backs for pain.

 

[jwk]

We use epidurals for virtually all our C-Sections, and they all get PCEA post-op for 24-36 hrs. The few GA sections we do get IV PCA's. We never do CSE's.

 

[michigangirl]

thanks for all the advice-- its my understanding they do CSE with hyperbaric spinal and then give duramorph at the end of the case and pull it out. i think that's the route i'm going to go-- like op mentioned, the pruritis seems a minor issue and is treatable, and it might be a pain in the arse to wake up in the middle of the night POD 0 to push a PCEA button.

 

[Planktonmd]

thanks for all the advice-- its my understanding they do CSE with hyperbaric spinal and then give duramorph at the end of the case and pull it out. i think that's the route i'm going to go-- like op mentioned, the pruritis seems a minor issue and is treatable, and it might be a pain in the arse to wake up in the middle of the night POD 0 to push a PCEA button.

I am not sure why anyone would want to give the the morphine in the epidural instead of giving it intrathecally, and on top of that goes the extra step of putting an epidural catheter in just to give less effective post-op analgesia!
Very strange.

 

[Noyac]

I am not sure why anyone would want to give the the morphine in the epidural instead of giving it intrathecally, and on top of that goes the extra step of putting an epidural catheter in just to give less effective post-op analgesia!
Very strange.

Ditto.

It seems like they are trying to avoid giving narcs until the baby is out. It makes no sense b/c you could just give 200 mcg intrathecal. That's nothing in the big picture and will not have any effects on the baby.

Plus much better pain control as Plank mentioned.

It seems some people try to over analyze the situation.

 

[CanGas]

I'm on board with this too. Why do a 2nd procedure with potential complications (ie. PDPH) when you can just do a spinal. That said we do have this one OBGYN who re-attaches every cellular layer they seperated on the way in so CSE's are routine for that surgeon as a repeat C/S can last 3+hrs

CanGas (only 222 days of this crap left!)

Ditto.

It seems like they are trying to avoid giving narcs until the baby is out. It makes no sense b/c you could just give 200 mcg intrathecal. That's nothing in the big picture and will not have any effects on the baby.

Plus much better pain control as Plank mentioned.

It seems some people try to over analyze the situation.

 

[drgopoos]

The current level of evidence suggest that for C-sections , the best way to beat post op pain is to use 100 mcg of epimorph.

Anything more than 100mcg does not cause any benefit but rather add to the side effect.

In our practice ( rated as on of the best university hospitals for OB anesthesia) we use 1.8 ml of 0.75% bupivacaine heavy + 10 mcg of fentanyl + 100mcg of epimorph.
( for pts < 5 ft we use 1.6 ml)

( i am an ob fellow)

One thing i forgot to add was that post op all our pts do get acetaminophen 4g( 24hrs) and diclofenac q8h. this is given for the first 24hrs.
With this regimen only 30 % of our pts do need additional narcotic ( usually given iv)

 

[Planktonmd]

In our practice ( rated as one of the best university hospitals for OB anesthesia) we use 1.8 ml of 0.75% bupivacaine heavy + 10 mcg of fentanyl + 100mcg of epimorph.
( for pts < 5 ft we use 1.6 ml)

( i am an ob fellow)

This statement strangely reminds me of : "Man's Best Hospital" from The House of God.
Did you go to BMS? (Best Medical School) as well??

 

[Noyac]

The current level of evidence suggest that for C-sections , the best way to beat post op pain is to use 100 mcg of epimorph.

Anything more than 100mcg does not cause any benefit but rather add to the side effect.

I'm interested in the study. Can you provide it?

 

[badasshairday]

This statement strangely reminds me of : "Man's Best Hospital" from The House of God.
Did you go to BMS? (Best Medical School) as well??

BMS kicks butt, unfortunately I didn't get in... too competitive. However, I'm hoping to do my anesthesiology residency at Man's Best Hospital.

 

[coprolalia]

I also put in for prn nubaine 10mg sq for itching to prevent phone calls- don't think most patients need it though.

Here's a tip: you can give nalbuphine IV just fine. It's a heck of a lot nicer than giving it SQ. It may not have quite the duration of effect as it does SQ, but usually the itching isn't so bad that it causes them to be excoriating themsevles. I usually do 10mg IV q4. Never had a problem when doing my follow-ups with it not working. Not sure what the studies say, but studies don't always have all the answers.

-copro

 

[drccw]

The current level of evidence suggest that for C-sections , the best way to beat post op pain is to use 100 mcg of epimorph.

Anything more than 100mcg does not cause any benefit but rather add to the side effect.

In our practice ( rated as on of the best university hospitals for OB anesthesia) we use 1.8 ml of 0.75% bupivacaine heavy + 10 mcg of fentanyl + 100mcg of epimorph.
( for pts < 5 ft we use 1.6 ml)

( i am an ob fellow)

One thing i forgot to add was that post op all our pts do get acetaminophen 4g( 24hrs) and diclofenac q8h. this is given for the first 24hrs.
With this regimen only 30 % of our pts do need additional narcotic ( usually given iv)

In our OB anesthesia practice; definitely not at one of the best OB anesthesia hospitals in the country nor are there any OB anesthesia fellowship trained practitioners; most practicitioners use 300 mcg of preservative free morphine intrathecally... With this regimen only about 10% of patients need additional intervention, usually 30 mg of IV ketorolac... of those patients, an additional 20% of patients need additional narcotics in the first 24 hours.. usually 2 mg of IV morphine sorts things out....

nalbuphine and diphenhydramine IV prn for pruritius...

but I don't have a study to back it up unfortunately... but our patients seems happy... our hospital did just get voted one of the best hospitals to have a baby in our city... course, that's not cause of the anesthesiologists...

 

[drgopoos]

This statement strangely reminds me of : "Man's Best Hospital" from The House of God.
Did you go to BMS? (Best Medical School) as well??

Sorry, i was just trying to say about the practice in a leading university hospital in north America. I have done my basic training from outside the american continent and i consider myself lucky to do the training in my current hospital.

 

[drgopoos]

I'm interested in the study. Can you provide it?

This is the link to the pubmed abt the latest article 2008).
http://www.ncbi.nlm.nih.gov/pubmed/18502360

In addition if we look at the previous studies that looked at the dosing they too point in the same direction.