analgesia post emergency caesarean section and educational intervention in the developing world dr...

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