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A case-series describing analgesic approaches in women receiving general anesthesia for cesarean delivery
Abstract Number: T2A-237
Abstract Type: Case Report Case Series
Neuraxial anesthesia for cesarean delivery (CD) is performed in more than 95% of cases in academic centers in the US, which allows neuraxial opioids for post-CD analgesia to be provided. Circumstances leading to women receiving general anesthesia (GA) for CD are numerous and varied and for that reason, such cases are most often excluded from clinical studies evaluating pain outcomes and analgesic consumption. We believe that these women actually represent the outliers that may require enhanced analgesic modalities, and therefore decided to evaluate the circumstances for GA and subsequent analgesia management, in an attempt to find patterns that may guide protocols.
Using electronic anesthesia records, 1713 CD cases were identified during a 9-month study period in 2018, of which 77 (4.5%) received a GA. Circumstances leading to the GA were assessed (STAT, contraindication to neuraxial, patient refusal, failure of intrapartum epidural, failed spinal, spinal wearing off). Analgesia modalities (neuraxial morphine, TAP block, IV PCA hydromorphone, PO oxycodone use) were recorded for each case.
The 2 most common circumstances for GA were failure of intrapartum epidural catheter to achieve surgical anesthesia (33/77; 42.9%) followed by emergent CD with no time for spinal (31//77; 40.2%) (Figure). Overall, 33 women (42.9%) received neuraxial morphine (26 epidural and 7 spinal). Most women with failed epidural anesthesia received epidural morphine (26/33; 79%), among those not receiving epidural morphine (N=6/33; 18.2%), 3 received no TAP, PCA or PCEA, and average in-hospital oxycodone use was 31mg. Overall, 42 women (29.5%) received IV PCA hydromorphone, and 9 women (11.7%) received a TAP block (of which 5 received both TAP and PCA). Among the 60 women (77.9%) taking oxycodone, the average dose was 25.4mg (± 34.6 SD). Only 4 women received no systemic opioids (no PCA or oxycodone), however all had received neuraxial morphine (3 epidural & 1 spinal).
This descriptive analysis of all cases receiving GA in our institution in 2018 allowed us to identify that while opioid-sparing approaches for cases receiving neuraxial anesthesia are now robustly promoted, this is not yet the case when GA is provided. Only a handful of women received a TAP block, and 30% received IV PCA hydromorphone. Next steps will be to increase the use of TAP blocks or quadratus lumborum blocks.