///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Perioperative Pain Management Plan for Cesarean Hysterectomy in a Patient with Placenta previa/accreta on Extremely High Dose Medication Assisted Therapy (MAT) for Substance Use Disorder

Abstract Number: RF3AC-310
Abstract Type: Case Report Case Series

Jennifer L Harris M.D.1 ; H. Jane Huffnagle D.O.2; Suzanne L. Huffnagle D.O.3; John T. Wenzel M.D.4

Introduction:

Medication assisted therapy (MAT) is an established treatment option for opioid dependence; methadone has been used since the 1950s for this purpose. With the exponential increase in opioid-related deaths and addiction rates, MAT has become more prevalent in the perioperative population. Unfortunately, there is little data and few published reviews addressing acute pain management strategies. Moreover, methadone dosage escalates during pregnancy (1). We present the anesthetic management and challenging perioperative pain control of a parturient on an extremely high dose of methadone with placenta previa/accreta undergoing urgent cesarean hysterectomy.

Case:

A 40 y/o G5P2022 at 35 2/7 wks gestation presented for cesarean hysterectomy for placenta accreta with complete previa. PMH included HIV, Hepatitis C liver disease, non-sustained V-tach, prolonged QT, MSSA endocarditis, seizure disorder, asthma, depression/anxiety, polysubstance abuse (benzodiazepine abuse this pregnancy) and cigarette smoking. Surgical history consisted of C/S x 2 and multiple I&Ds for skin infections. Home medications included methadone 460 mg daily (split dosing), gabapentin, ipratropium-albuterol, levetiracetam, mirtazapine, dolutegravir, and emtricitabine/tenofovir. Preoperatively, a lumbar epidural was placed and a T6 anesthetic level obtained. A ketamine infusion was started and she received her regular doses of methadone and gabapentin. The procedure began promptly as she was bleeding; a baby girl was delivered 8 minutes later. Our patient remained hemodynamically stable but experienced progressive discomfort requiring supplemental IV fentanyl and increasing doses of ketamine as the procedure lasted 2.5 hours. Postoperatively, her pain was moderately controlled continuing the epidural and ketamine infusions, regular dosing of methadone and gabapentin, and adding hydromorphone, acetaminophen, ibuprofen, and transdermal clonidine. After careful consideration, enoxaparin was started with the epidural still in place (2). Hydromorphone was discontinued POD#2, the epidural removed POD#3 and she was discharged POD#4 with methadone, gabapentin, acetaminophen, and ibuprofen.

Discussion:

A successful outcome in this complicated patient was achieved using 4 crucial aspects of care: early preoperative evaluation, patient involvement in and agreement to the anesthetic plan, multimodal analgesia, and multidisciplinary teamwork. Patients on methadone should be referred for early pre-anesthetic evaluation to discuss expectations, limitations of pain management, and to formulate a plan together. A multimodal analgesic strategy incorporating various classes of medications is essential for reasonable postoperative pain control (3). Lastly, teamwork and communication across disciplines is fundamental and may improve patient outcomes/satisfaction.

References: 1. Can J Hosp Pharm 2012;65:380-386. 2. Anesth Analg 2018;126:928-944. 3. Curr Opin Anes 2006;19:244-248.

SOAP 2019