CC#1: Pharmacologic Stepwise Multimodal Approach For Postpartum Pain Management

Question 1

Demographics that receive less narcotic pain meds despite reporting higher pain scores

Answer 1

Black pts, Hispanic pts

Question 2

Class of meds considered first-line tx in management of PP pain

Answer 2

NSAIDs

Question 2

Correlation between NSAIDs and severity of PP HTN?

Answer 2

No

Question 3

Most common sources of pain in early days after NSVD (3)

Answer 3

Perineal lacs, uterine ctxs, breast engorgement

Question 4

Initial pain management s/p NSVD (2)

Answer 4

NSAIDs, Tylenol

Question 5

Are scheduled NSAIDs/Tylenol or PRN NSAIDs/Tylenol preferable for PP pain control s/p NSVD?

Answer 5

Scheduled

Question 6

Step-up tx if NSAIDs/Tylenol are inadequate s/p NSVD

Answer 6

Low-dose, low-potency, short-acting PO opioid (for lowest, briefest exposure)

Question 7

Common PO opioids w/ low-dosing/low-potency/short-action time (5)

Answer 7

Codeine, hydrocodone, oxycodone, tramadol, morphine

Question 8

Common opioid-induced side effects

Answer 8

Nausea, constipation, drowsiness

Question 9

Reasons why opioids are preferred over Tylenol-opioid/NSAID-opioid combo meds (3)

Answer 9

Inelegant dosing, potential excess opioid exposure, risk of unintended med toxicity

Question 10

Step-up if low-dose/low-potency/short-acting PO opioids are also inadequate s/p NSVD (2)

Answer 10

Stronger opioids (IV hydromorphone, IV fentanyl)

Question 11

Consideration if pt is requiring strong opioids s/p NSVD

Answer 11

Further evaluation/workup for causes of severe pain (strong opioids rarely indicated s/p NSVD for opioid-naive pts)

Question 12

Most important component of postop pain control s/p C/S

Answer 12

Neuraxial opioids (ie spinal and/or epidural)

Question 13

Duration of effects of neuraxial opioids s/p C/S

Answer 13

<1 day postop

Question 14

Consideration for pts w/ breakthrough pain in immediate postop period s/p C/S

Answer 14

PCA

Question 15

Preop med shown to provide postop analgesia and reduce postop opioid requirements

Answer 15

IV Tylenol

Question 16

Adjuvant pain control method at time of C/S that can be considered

Answer 16

Local anesthetic (TAP block)

Question 17

Technique for TAP block

Answer 17

Blunt-tip needle to inject local anesthetic in plane between internal oblique and transversus abdominis

Question 18

Nerves targeted at time of TAP block

Answer 18

Thoracolumbar peripheral nerves innervating lower abdomen

Question 19

Pts who are good candidates for TAP block at time of C/S

Answer 19

Pts for whom neuraxial anesthesia not used (ie C/S under general anesthesia)

Question 20

General stepwise approach for postop pain control s/p C/S

Answer 20

NSAIDs/Tylenol > PO opioids > IV opioids (same as s/p NSVD)

Question 21

Describe split-dose strategy for postop oxy administration s/p C/S

Answer 21

Dose is halved and then pt is reassessed for continued pain requirement before receiving remainder of dose

Question 22

Equipment shown to be associated w/ improved postop pain control s/p C/S

Answer 22

Abdominal binder

Question 23

Pts who may require more individualized pain control regimens and/or assistance of OB anesthesiology/pain specialist (3)

Answer 23

Pts w/ preop pain, pts w/ chronic pain conditions, pts w/ opioid use disorders

Question 24

Factors that affect drug transfer to breastmilk (7)

Answer 24

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

Question 25

Define RID; RID value that is considered concerning

Answer 25

Weight-adjusted max percentage of maternal dose (measures drug safety during lactation); >10%

Question 26

Resource where you can find RIDs

Answer 26

LactMed database

Question 27

Peak RID of Tylenol; peak RID of NSAIDs

Answer 27

~2%; ~0.6% (both very safe w/ breastfeeding)

Question 28

Is PO/IV toradol compatible w/ breastfeeding in immediate postop period?

Answer 28

Yes

Question 29

Characteristics that facilitate transfer of opioids into breastmilk (3)

Answer 29

Lipophilic nature, low molecular weight, weak base

Question 30

Enzyme w/ significant variability across population that affects drug metabolism

Answer 30

CYP450

Question 31

Percentage of pts that are “ultra-rapid metabolizers”, thereby generating higher levels of active analgesic meds in serum

Answer 31

4-5%

Question 32

Infant risks associated w/ high levels of opioids in breastmilk (3)

Answer 32

Sedation, decreased respiration, (very rarely) death

Question 33

Risks to infant to review w/ pts if breastfeeding while taking opioids (2)

Answer 33

Infant sedation, CNS depression

Question 34

Mainstays of outpatient pain control in PP/postop period (3)

Answer 34

Tylenol, NSAIDs, PRN opioids

Question 35

How to determine number of opioids to prescribe after discharge

Answer 35

Shared decision-making process