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Managing Post-Cesarean Analgesia in Opioid-Dependant Parturients: A Case Report of a Woman on Chronic Buprenorphine Therapy
Abstract Number: S 62
Abstract Type: Case Report/Case Series
Pre-existing opioid dependence in pregnant women increases the complexity involved with management of peripartum analgesia. Buprenorphine, a mixed partial µ-opioid receptor agonist and κ-opioid receptor antagonist, is increasingly being prescribed over methadone in opioid dependent parturients (3,4,5). Use of this drug, which may produce a “ceiling effect” in achievable pain relief via additional µ-opioid receptor agonists, is of concern (2,4). We report our experience with managing a buprenorphine-dependent parturient presenting for urgent Cesarean section.
A 36 y.o. G1P0 female at term gestation with a history of opioid dependence presented for urgent Cesarean section due to low biophysical profile score and breech presentation. She was taking buprenorphine 2mg sl twice daily, and had her most recent dose the morning of her arrival.
Combined spinal-epidural anesthesia with 1.5 cc of 0.75% hyperbaric bupivicaine and 10 mcg fentanyl was administered intrathecally. Immediately post-surgery, ultrasound-guided transversus abdominis plane (TAP) block was performed bilaterally with 20 mL of 0.5% ropivicaine, in addition to commencing patient-controlled epidural analgesia (PCEA: infusion of 0.08% bupivicaine with 2 mcg/ml fentanyl, rate 10 cc/hr, bolus 6cc, lockout 10 mins). Diclofenac sodium, 100 mg pr, was given once, followed by regular doses of acetaminophen (1 g po q6h) and diclofenac (50 mg po q8h). Buprenorphine was continued on her regular schedule. Oxycodone (10 mg po q4h prn) for breakthrough was seldom used as she found her pain to be generally well managed, with verbal pain score 2/10. She required one epidural bolus on post-operative day (POD) 1 with 6cc 0.25% bupivicaine, 4cc 2% lidocaine and 50 mcg fentanyl. PCEA was discontinued POD 2 and the patient was discharged home POD 4 on her usual dose of buprenorphine, diclofenac and acetaminophen. There was no evidence of opioid withdrawal during her admission. The patient provided consent for publication of this case.
Our choice of PCEA as primary modality of analgesia allowed unaltered maternal buprenorphine therapy. It obviated the risk of therapeutic failure of administered opioid agonists, due to functional antagonism by buprenorphine. Omitting epidural morphine, the TAP block was utilized as part of multimodal therapy and provided 8 hours of analgesia. Our multimodal approach, with regional and neuraxial anesthesia techniques and oral adjuncts, appeared to reduce opioid requirements, as our patient required less oxycodone than amounts published in literature. We expect the prevalence of patients maintained on buprenorphine to increase, given that buprenorphine has shown promising results compared to methadone in terms of neonatal outcomes (1).
1. Am J Obstet Gynecol. 2011;205(4):302-8.
2. Am Surg. 2010;76(4):397-9.
3. Drug Alcohol Depend. 2003;70(2 Suppl):S59-77
4. Drug Alcohol Depend. 2003;70(2 Suppl):S87-101.
5. N Engl J Med. 2010;363(24).