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Now That Duramorph Is Gone, What Are We To Do About Post-Cesarean Pain Management? In light of continuing drug shortages in the United States, most notably preservative-free morphine, we thought we would summarize our experience using epidural meperidine
Abstract Number: T-37
Abstract Type: Original Research
Introduction: In light of continuing drug shortages in the United States, most notably preservative-free morphine, the search for alternative therapies becomes more important. Meperidine is a mu opioid receptor agonist with intermediate lipid solubility. It is used extensively in Australia and New Zealand for post-cesarean pain management. Meperidine has been removed from many hospital formularies due to the risk of seizures when administered intravenously (IV) or intramuscularly. However, the analgesic properties and low incidence of side effects when administered via epidural make meperidine an excellent alternative to other narcotics in the management of post-cesarean section (CS) pain. This report is a review of 35 years of experience using continuous epidural infusion of meperidine to provide post- (CS) analgesia in a high volume community hospital.
Methods: Mercy Hospital St. Louis is a community teaching hospital that has a delivery rate of 7000-8000 per year with a (CS) rate of approximately 40%. The primary approach to post-cesarean delivery pain management is epidural meperidine infusion in a concentration of 2 mg/ml. The infusion is administered for 36-48 hours post-operatively at 8-12 ml/hr (16-22 mg/hr). Patients also receive ketorolac 30 mg IV every 6 hours. Inadequate analgesia is managed with boluses of 10-20 mg of meperidine and rate increases if necessary. Unacceptable side effects are managed by medications or decreasing the rate and or turning it off for 30-60 minutes. Patients with impaired renal function, a history of seizures, or fever are not managed with meperidine. The obstetrical anesthesia team follows patients for 2-3 days and the epidural catheter is removed on post-operative day 2. Removal may happen earlier due to loss of dressing integrity, catheter disconnection, unacceptable side effects, inadequate analgesia, loss of IV access or patient desire.
Results: Since 2005 we have treated over 19,000 patients in such a manner. In an interim analysis of 411 patients, VPS scores (0-10 scale) at rest were an average of 1.53 and with activity were an average of 2.76. Fifty-six patients (13.63%) required nalbuphine and 16 (3.98%) required diphenhydramine for itching. Thirty patients (7.30%) required ondansetron and 9 (2.19%) required metoclopramide for nausea. Seventy patients (17.03%) required a rate increase, 23 (5.6%) required a rate decrease, and 126 (30.66%) required a bolus. Twenty-nine patients (7.06%) got supplemental analgesia (acetaminophen, percocet, or morphine) during the infusion and the majority of these patients did not receive toradol for various reasons. One-hundred-thirty five patients (32.85%) had their epidural pulled early for a variety of reasons. No patients experienced adverse events such as seizures or respiratory depression. In 35 years there have been no reported cases of seizure or respiratory depression with this infusion.
Conclusion: While this observational retrospective data has its limitations, our experience shows that epidural meperidine infusion is well tolerated with excellent pain relief and minimal side effects.
Anaesth Intensive Care 1998; 26: 247-255
Australian and New Zealand College of Anaesthetists Annual Scientific Meeting Proceedings 1997