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