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TAP'ing into alternative resources for post-Cesarean analgesia
Abstract Number: T-60
Abstract Type: Case Report/Case Series
Post-partum (PP) pain management is critical to maternal-infant bonding and maternal recovery. Parturients with intracranial lesions present a unique challenge for pain management after cesarean section (CS) as neuraxial anesthesia(NA) is often contraindicated in this population. In addition, intravenous narcotic use may be limited, due the potential to cloud sensorium and confound subsequent neurological exams, and to cause nausea/vomiting and hypoventilation, which can increase intracranial pressure(ICP). We report a case of a parturient with a large intracranial mass, where multimodal analgesia(MMA), including a transversus abdominis plane (TAP) block and early maternal bonding, was used to achieve excellent PP pain control and patient satisfaction.
A 33 year-old G1P0 with Neurofibromatosis type 2 (NF2) presented for multidisciplinary discussion on options for delivery. In the setting of pregnancy and a pause in active suppressive Avastin chemotherapy, a left vestibular schwannoma had progressively enlarged, leading to significant compressive mass effect on the left anterior brainstem and cerebral aqueduct(Fig. 1). The result was depletion of the intracranial cerebrospinal fluid, with subsequent downward movement of the brainstem, increase in ICP and new onset deafness. NA was contraindicated because of the risk of further herniation in the setting of an intentional or inadvertent dural puncture. Patient underwent a scheduled CS under general anesthesia (GA) with provisions to avoid increases in ICP and minimize risk of aspiration. Options for PP analgesia were further limited by an allergy to NSAIDs. TAP block was considered a good alternative, and was performed after full recovery from GA , so as to avoid confounding findings of neurological changes that could have resulted from either worsening brainstem compression during the surgery or from local anesthetic toxicity from the TAP block. The MMA achieved excellent pain relief in the PP period.
Early maternal bonding and skin-to-skin contact may improve patient perception of pain and overall satisfaction . In cases where NA is contraindicated and opioid use is limited, MMA including TAP block is a valuable tool for PP pain relief after CS. TAP blocks have been shown to provide adequate analgesia for up to 48 hours and to reduce narcotic use. Considerations such as patient selection, timing of the TAP procedure and priorities of care are reviewed in this repor.