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///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

Transversus Abdominis Plane (TAP) Block and Epidural Analgesia for Postoperative Pain Management following Emergency Cesarean Delivery in a Patient on Buprenorphine

Abstract Number: 231
Abstract Type: Case Report/Case Series

Mary Amelia Luckett M.D.1 ; Jill Mhyre M.D.2

Introduction: Buprenorphine is a partial μ-opioid receptor agonist and κ-opioid receptor antagonist used for opioid replacement therapy in the setting of opioid dependence and/or addiction. Because of its mechanism of action, prenorphine impedes the effectiveness of additional opioids. Withdrawl from buprenorphine requires 8-10 days, so peripartum analgesia for patients maintained on buprenorphine requires high-dose opiate PCA with sedation orregional analgesia.

Case Report: A 37-year-old woman, G9P4, at 32 weeks gestational age arrived to labor and delivery triage with abdominal pain after smoking cocaine "all afternoon." Additional medical history was significant for hepatitis C, sleep apnea, depression, post-traumatic stress syndrome, and polysubstance abuse including cocaine, tobacco, marijuana, and heroin. Opiate replacement therapy with buprenorphine 8mg TID was discontinued by the patient approximately 48 hours prior to presentation. The triage staff noted fetal heart tones in the 80s by Doppler and confirmed by ultrasound, and the birth center pager was activated for emergent cesarean delivery. Rapid sequence induction of general anesthesia occurred with propofol and succinylcholine, the patients airway was secured with an ETT, and anesthesia was maintained with isoflurane, nitrous oxide and oxygen. A 1930 gram girl was delivered with Apgars 2, 4, 6 and umbilical artery pH 6.9, base excess -14. Placental pathology was consistent with abruption, meconium staining, and severe chorioamnionitis.

Upon completion of the surgery, general anesthesia was maintained while a transabdominal plane (TAP) block was performed under ultrasound guidance with 20ml 0.5% ropivacaine injected on each side of the abdomen. The patient was awoken, extubated, and transported to the postanesthesia care unit (PACU). In the PACU, the patient complained of visceral cramping and abdominal pain. Ninety minutes postoperatively, an epidural catheter was inserted. She was given ketorolac 15mg every 6 hours around-the-clock and oxycodone 30mg every 4 hours as needed.

On postoperative day 1, the patient complained of pain involving her neck, both shoulders, lower back, and abdomen-all symptoms attributed to withdrawal-and managed with scheduled oxycodone. Her incisional pain was minimal. The epidural catheter was discontinued on postoperative day 4, when oral analgesics provided sufficient relief. She was discharged on postoperative day 6.

Discussion: This case illustrates how regional techniques may be used to provide postoperative analgesia for cesarean delivery patients maintained on buprenorphine. For emergency cesarean delivery under general anesthesia, the TAP block may facilitate a smooth emergence and awake positioning for postoperative epidural block placement.

Barash, P., ed. (2006) Clinical Anesthesia. Philadelphia; Lippincott, Williams, and Wilkins

Johnson RE, et al. (2005) Journal of Pain Symptom Management 29(3): 297-326

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