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Analgesia Post Emergency CaesareanSection and Educational Intervention in
The Developing World
Dr Michelle GerstmanAnaesthesia Registrar
Alfred Hospital Melbourne
Hospital Nacional Guido Valdares (HNGV)
Introduction
• Caesarean sections amongst the most common surgical procedures performed in the world
• Pain relief is a basic human right• Acute pain often poorly managed in developing
world• High morbidity associated with pain• Small improvements can potentially have a large
positive impact• Simple easy to follow education regarding obstetric
postoperative analgesia has wide application
WHO: Mother Baby Package: implementing safe motherhood in countries (practical guide).
Bosenber, A, Paediatric anaesthesia in developing countries, Current opinion in Anaesthesiology, 2007, 20:204-120
Current Evidence
• Minimal in the developing world
• Extensive evidence regarding multimodal analgesia in the developed world
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3rd Edition 2010
Hypothesis
• Simple education regarding postoperative multimodal analgesia can result in significantly improved pain scores after Emergency Surgery for Caesarean Section in a Developing World setting with limited resources.
Study
• Prospective audit
• Analgesia prescribing patterns and pain intensity after Emergency Cesarean Section for a 48 hour period in two groups.
• BEFORE and AFTER simple education regarding multimodal analgesia for prescribers.
Analgesic Prescribing
• Obstetricians prescribe post op analgesia in Timor
• Midwives transcribe and administer• Analgesics available• Any combination• Opioid analgesia is not prescribed
Methods• Emergency CS
– Pre education - 16 October - 1 December 2009– Education – Post education - 10 May 2010 - 21 June 2010
• Anaesthesia Registrar/Consultant
• Nurse anaesthetists acted as an interpreters
Methods: Education
• Obstetricians and midwives
• Presentation and discussion of pre-education audit data
• Agreement that analgesia provision was inadequate
• A multimodal analgesia protocol of regular tramadol, paracetamol and ibuprofen was agreed upon
Audit data: Primary Measures
• Analgesia prescribed by the surgical team in surgical notes
• Actual analgesia transcribed by midwives to drug chart and given on day 1 and day 2 post operatively
• Pain scores at rest and with movement on day 1 and day 2 post surgery
• verbal description of pain (5 categories) from no pain to severe pain then converted to numerical value 1-5
Results• 54 patients were
included in the pre-education audit– 54/54 on day 1– 52/54 on day 2
• 63 in the post-education audit– 63/63 on day 1– 55/63 on day 2
Post op analgesia
AnalgesiaPre Education Post Education
Day 1 Day 2 Day 1 Day 2
Tramadol alone 62% 12% 32% 11%
Paracetamol alone 9% 35% 0% 0%
Ibuprofen alone 2% 31% 5% 0%
Tramadol/Paracetamol 19% 6% 0% 0%
Tramadol/ Ibuprofen 4% 0% 0% 0%
Ibuprofen /Paracetamol 0% 4% 3% 74%
Tramadol/ Ibuprofen /Paracetamol
0% 0% 57% 11%
Nil 4% 12% 0% 2%
Mean Pain scores
Pre Education Post Education P value
Day 1 Rest 2.7 ± 0.9 2.0 ± 0.8 0.0003
Day 1 Movement 3.7 ± 0.8 3.3 ± 0.8 0.0036
Day 2 Rest 2.1 ± 0.8 1.8 ± 0.9 0.0908
Day 2 Movement 3.0 ± 0.8 3.0 ± 0.7 0.8858
Conclusion
• Large increase in the use of multimodal analgesia after educational intervention
• Significant improvement of early postoperative pain relief
• Successful education and implementation of knowledge after one education session
Discussion
• Less marked improvement with late pain relief – Impact of tramadol? – Rapid mobilization of patients with less use of
pre-emptive analgesia?– Loss to follow up?
• Language/cultural issues• Challenges with staff changeover• Stoic patients vs. developed world
Discussion
• Different Anaesthesia Registrar
• Audit, not RCT
• Small number of patients had midline incision rather than Pfannenstiel incision
Future
• Further education sessions
• Retention of information - repeat audit 1 year after post education audit
• Written pain protocol displayed in Obstetric ward and OR
• Potential application to other surgical specialties
• Potential for opioid?
Acknowledgements
• Dr Eric Vreede – Head Department of Anaesthesia HNGV, Team Leader RACS
• Dr Alex Konstantatos – Analysis
• Dr Jane Chia – Audit 1
• HNGV Nurse Anaesthetists - Translation services