CC#1: Pharmacologic Stepwise Multimodal Approach For Postpartum Pain Management Flashcards
Demographics that receive less narcotic pain meds despite reporting higher pain scores
Black pts, Hispanic pts
Class of meds considered first-line tx in management of PP pain
NSAIDs
Correlation between NSAIDs and severity of PP HTN?
No
Most common sources of pain in early days after NSVD (3)
Perineal lacs, uterine ctxs, breast engorgement
Initial pain management s/p NSVD (2)
NSAIDs, Tylenol
Are scheduled NSAIDs/Tylenol or PRN NSAIDs/Tylenol preferable for PP pain control s/p NSVD?
Scheduled
Step-up tx if NSAIDs/Tylenol are inadequate s/p NSVD
Low-dose, low-potency, short-acting PO opioid (for lowest, briefest exposure)
Common PO opioids w/ low-dosing/low-potency/short-action time (5)
Codeine, hydrocodone, oxycodone, tramadol, morphine
Common opioid-induced side effects
Nausea, constipation, drowsiness
Reasons why opioids are preferred over Tylenol-opioid/NSAID-opioid combo meds (3)
Inelegant dosing, potential excess opioid exposure, risk of unintended med toxicity
Step-up if low-dose/low-potency/short-acting PO opioids are also inadequate s/p NSVD (2)
Stronger opioids (IV hydromorphone, IV fentanyl)
Consideration if pt is requiring strong opioids s/p NSVD
Further evaluation/workup for causes of severe pain (strong opioids rarely indicated s/p NSVD for opioid-naive pts)
Most important component of postop pain control s/p C/S
Neuraxial opioids (ie spinal and/or epidural)
Duration of effects of neuraxial opioids s/p C/S
<1 day postop
Consideration for pts w/ breakthrough pain in immediate postop period s/p C/S
PCA
Preop med shown to provide postop analgesia and reduce postop opioid requirements
IV Tylenol
Adjuvant pain control method at time of C/S that can be considered
Local anesthetic (TAP block)
Technique for TAP block
Blunt-tip needle to inject local anesthetic in plane between internal oblique and transversus abdominis
Nerves targeted at time of TAP block
Thoracolumbar peripheral nerves innervating lower abdomen
Pts who are good candidates for TAP block at time of C/S
Pts for whom neuraxial anesthesia not used (ie C/S under general anesthesia)
General stepwise approach for postop pain control s/p C/S
NSAIDs/Tylenol > PO opioids > IV opioids (same as s/p NSVD)
Describe split-dose strategy for postop oxy administration s/p C/S
Dose is halved and then pt is reassessed for continued pain requirement before receiving remainder of dose
Equipment shown to be associated w/ improved postop pain control s/p C/S
Abdominal binder
Pts who may require more individualized pain control regimens and/or assistance of OB anesthesiology/pain specialist (3)
Pts w/ preop pain, pts w/ chronic pain conditions, pts w/ opioid use disorders
Factors that affect drug transfer to breastmilk (7)
Lipophilic nature of drug, degree to which drug binds to protein, drug’s bioavailability, drug pKa and milk pH, drug’s molecular weight, amount of breastmilk consumed, timing of med administration relative to breastfeeding schedule
Define RID; RID value that is considered concerning
Weight-adjusted max percentage of maternal dose (measures drug safety during lactation); >10%
Resource where you can find RIDs
LactMed database
Peak RID of Tylenol; peak RID of NSAIDs
~2%; ~0.6% (both very safe w/ breastfeeding)
Is PO/IV toradol compatible w/ breastfeeding in immediate postop period?
Yes
Characteristics that facilitate transfer of opioids into breastmilk (3)
Lipophilic nature, low molecular weight, weak base
Enzyme w/ significant variability across population that affects drug metabolism
CYP450
Percentage of pts that are “ultra-rapid metabolizers”, thereby generating higher levels of active analgesic meds in serum
4-5%
Infant risks associated w/ high levels of opioids in breastmilk (3)
Sedation, decreased respiration, (very rarely) death
Risks to infant to review w/ pts if breastfeeding while taking opioids (2)
Infant sedation, CNS depression
Mainstays of outpatient pain control in PP/postop period (3)
Tylenol, NSAIDs, PRN opioids
How to determine number of opioids to prescribe after discharge
Shared decision-making process
