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400 J. Shah et al.
ropivacaine. Commonly used opioids include lipophilic agents, such as fentanyl and
sufentanil, or hydrophilic medications such as morphine. Additionally, epinephrine
is often added to a local anesthetic to prolong the duration or increase the density
of the block. Table 1 lists a series of combinations that could be used for epidural
infusions as well as dosing for related adjunct medications.
Other neuraxial options aside from epidural anesthesia include single-injection
spinal anesthesia, continuous spinal analgesia, and combined spinal-epidural anes-
thesia. A single injection spinal anesthesia is often used for patients when delivery
is predicted to occur within an hour or for cesarean delivery. Continuous spinal anal-
gesia allows for rapid onset analgesia to be incrementally extended and confirmed to
surgical anesthesia. Similar local anesthetic/opioid solutions are utilized, but the rate
of infusion is decreased significantly and slowly titrated. This technique is not often
intentionally used because of the high incidence of post dural puncture headaches as
well as risk for spinal infection secondary to the indwelling catheter. Third, combined
spinal-epidural analgesia consists of Tuohy needle placement in the epidural space
followed by spinal needle placement through the Tuohy to pierce the dura and access
the intrathecal space. A single intrathecal injection provides rapid onset of anal-
gesia and then, after removal of the spinal needle, an epidural catheter is placed and
continuous infusions or bolus dosing can be performed to provide sustained labor
analgesia. Alternatively, for a dural puncture epidural, the intrathecal space can be
accessed to verify midline placement, as noted by the return of cerebrospinal fluid,
and then an epidural catheter is placed. This technique is thought to have an increased
rate of analgesic onset as compared to a traditional labor epidural.
Table 1 Labor analgesia doses [10]
Standard dilution instructions • 0.0625% bupivacaine = 35 mL 0.5%
bupivacaine + 250 mL normal saline
• 0.1% bupivacaine = 60 mL 0.5% bupivacaine
+ 250 mL normal saline
• 0.1255% bupivacaine = 83 mL 0.5%
bupivacaine + 250 mL normal saline
Maximum anesthetic doses (with epinephrine) • Bupivacaine: 3 mg/kg (3 mg/kg)
• Lidocaine 5 mg/kg (7 mg/kg
• Ropivacaine 2 mg/kg (2 mg/kg)
• 2-chloroprocaine 11 mg/kg (14 mg/kg)
Adjuncts • Epinephrine 2 mcg/mL
• Fentanyl 2 mcg/mL
• Clonidine 50–100 mcg bolus, then 1–2 mcg/
mL
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Peripartum Pain Management 401
3 Postpartum Pain Management
Multimodal analgesia is critical for postpartum pain management. Common pain
sources following vaginal delivery include uterine cramping, perineal pain from
lacerations, and discomfort from hemorrhoids. It is important to address all the
sources of pain to treat a postpartum patient effectively. Acetaminophen and non-
steroidal anti-inflammatory medications such as ibuprofen should ideally be sched-
uled as first line agents. If they are ineffective, then opioids can be added on an
as-needed basis. Ice packs, ice gels, and local perineal lidocaine spray can be admin-
istered for perineal pain. Bowel regimen and topical agents including astringent,
steroid, or anesthetic creams can be used for hemorrhoid pain relief [8, 11].
4 ERAS Protocol for Cesarean Section
Enhanced recovery after cesarean delivery (ERAC) was adopted from the enhanced
recovery after surgery (ERAS) protocols with the aim of optimizing patient outcomes
using evidence-based methods (Table 2 provides an outline of ERAC components).
Per the Society of Obstetric Anesthesia and Perinatology (SOAP) guidelines, preop-
erative goals of an ERAC protocol include patient education, limiting fasting inter-
vals, nonparticulate carbohydrate loading, lactation and breastfeeding education, and
hemoglobin optimization.
Active patient participation in the recovery process is paramount to realizing
improved outcomes after surgery; this has been demonstrated in studies on ERAS
implementation in various surgical specialties [12]. Patients should be instructed on
the details of the procedure, postoperative pain management plan, early feeding and
mobilization goals, length of stay, and criteria for discharge. Education should also
focus on breastfeeding and lactation support services.
The current practice guidelines for obstetric anesthesia from the American Society
of Anesthesiologists ( ASA) recommend six to eight hour fasting for solids and clear
Table 2 Perioperative components of ERAC [15]
Preoperative Intraoperative Postoperative
• Patient education
• Limited fasting
interval
• Carbohydrate loading
• Prevent and treat spinal
induced hypotension
• Maintain normothermia
• Intraoperative and
postoperative nausea and
vomiting prophylaxis
• Optimal uterotonic
administration
• Multimodal analgesia
• Promote breastfeeding
• Early oral intake
• Early mobilization
• Promote resting periods
• Early urinary catheter removal
• Venous thromboembolism
prophylaxis
• Continue multimodal analgesia
• Breastfeeding support
• Promote return of bowel
function
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402 J. Shah et al.
oral fluid intake up to two hours before the initiation of any anesthetic technique [9].
The intake of a high-caloric carbohydrate drink up to two hours before surgery has
been shown to reduce preoperative thirst, hunger, and anxiety in patients undergoing
abdominal surgery [13]. It has also been associated with a reduction in insulin resis-
tance and a higher anabolic state postoperatively; both of which are likely to promote
positive surgical outcomes.
In terms of intraoperative pain management, neuraxial anesthesia (specifically
spinal anesthesia) is preferred for elective cesarean deliveries because it facilitates
the presence of a support person, skin-to-skin contact with the newborn, and decreases
surgical stress responses. Opioids are usually added to regional anesthetic mixtures
because they improve intraoperative anesthesia, prolong its duration, decrease local
anesthetic requirements, and provide postoperative analgesia. Short-acting opioids
such as fentanyl or sufentanil are often considered better for intraoperative pain
management, while long-acting intrathecal and epidural opioids such as morphine
are effective for postoperative pain control.
For postoperative pain management, adequate analgesia is integral to implemen-
tation of ERAC protocols. Suboptimal analgesia after cesarean delivery is associated
with delayed functional recovery, delayed mobilization which could increase the risk
of thromboembolic complications, poor maternal bonding with the newborn, breast-
feeding difficulties, and an increase in the risk of persistent pain and postpartum
depression. Using analgesics with different mechanisms of action is emphasized in
ERAS protocols to minimize opioid use and improve pain control while minimizing
side effects [12]. The combination includes regional anesthesia, neuraxial opioid
analgesics, and oral analgesics. Neuraxial morphine is considered the gold standard
for pain management after cesarean delivery. Acetaminophen and non-steroidal anti-
inflammatory agents such as ibuprofen have additive effects and they should ideally
be scheduled; opioids should be administered on an as-needed basis to optimize
analgesia.
Other adjuvants for analgesia after cesarean delivery include fascial plane blocks,
local anesthetic wound infiltration, and anesthetic/analgesic infusions such as lido-
caine, ketamine, dexmedetomidine, and magnesium. Recently, quadratus lumborum
(QL) blocks have come into discussion and these may be considered in patients who
are not good candidates for neuraxial analgesia [14].
Components of enhanced recovery after cesarean are detailed in Fig. 1 [14].
ERAS, enhanced recovery after surgery; NPO, nil per os (nothing by mouth);
PONV, postoperative nausea and vomiting.
5 Pregnant Patients with Opioid Use Disorder
Rates of opioid use disorder (OUD) among pregnant women have increased since
1999 [16]. From 1999–2014, the national prevalence of opioid use disorder increased
333%, from 1.5 cases per 1,000 delivery hospitalizations to 6.5 [16]. For pregnant
patients who use opioids for pain, it is important to recognize and differentiate
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Peripartum Pain Management 403
Fig. 1 Enhanced Recovery After Cesarean Delivery
between therapeutic medical opioid use, occasional aberrant behaviors, and untreated
opioid use disorder. Pregnant patients with substance use disorders such as OUD face
public and political stigma in seeking care, often discouraging them from seeking
comprehensive medical care [17].
Treating pain in patients with opioid use disorder requires the consideration of
the OUD journey for each individual patient. Patients with long-term sobriety will
respond much differently to various anesthetic/analgesic options than those with
untreated OUD. In addition, current treatment modalities must be accounted for.
Patients with largely untreated OUD may have underlying infections, significant
opioid tolerance, and potentially opioid-induced hyperalgesia. These must be consid-
ered as they often mandate risk/benefit analysis of catheter placement as well as
consideration of non-opioid therapies for pain management.
For vaginal delivery, epidural analgesia should be offered to patients if they have
no contraindications. For patients with untreated OUD, long-acting neuraxial opioids
such as morphine can be considered in complicated vaginal deliveries or for post-
operative pain relief after cesarean sections [18]. Although, evidence does show that
patients may need as much as four times the dose required in non-opioid dependent
patients [18]. Additionally, withdrawal must be considered in this population of
patients, as it can precipitate preterm labor. Neuraxial opioids have not been shown to
be as effective in managing opioid withdrawal compared to parenteral or intravenous
opioids, although buprenorphine and methadone may be better long-term options for
treatment than short-acting, intravenous full opioid agonists [18]. If a pregnant patient
is managed with medications for opioid use disorder (MOUD), such as buprenorphine
or methadone prior to delivery, those agents should be continued in the intra and
postpartum settings.
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404 J. Shah et al.
For planned cesarean delivery in the OUD patient, any neuraxial technique is
reasonable, but a combined spinal-epidural may be most optimal for several reasons;
the spinal component will quickly provide surgical anesthesia and the epidural
catheter placement will allow for treatment of postoperative pain with local anes-
thetic infusion for a patient whose opioid use may have resulted in substantial receptor
upregulation and tolerance to opioids.
The importance of proper pain management for pregnant patients in the periop-
erative period must be acknowledged. There are limited medications deemed safe
for use during pregnancy currently available on the market. Individualized care is
necessary to manage pain in this patient population. Individual institutional policies
should be evidence based and preferably written with guidance from knowledge
experts in the field [19]. In the future, consensus guidelines for management of these
patients, in addition to consolidated resources and decreased barriers to access, will
be beneficial to the patient and to the care team.
6 Breastfeeding Considerations
Neuraxial opioids for intrapartum pain management have minimal excretion into
breast milk and hence are preferred due to minimal effects on the newborn. Parenteral
and oral opioids such as morphine, hydromorphone, and fentanyl are excreted into
breast milk and thus frequent monitoring of the mother and infant for sedation and
respiratory depression is always encouraged. Opioids such as tramadol and codeine
are metabolized in the liver by the CYP450 system into morphine to be pharmaco-
logically active. Some patients may be ultrarapid metabolizers, which could lead to
supratherapeutic morphine levels. This could lead to sedating levels of morphine in
the breast milk and, in extreme cases, respiratory depression and death in t he infant.
Hence, in 2017, the Food and Drug Administration released a statement recom-
mending against the use of tramadol and codeine in breastfeeding patients [20, 21].
See Table 3 for a non-exhaustive list of agents used in pregnant and postpartum
patients and their safety regarding breastfeeding.
Key Takeaways
•
Neuraxial anesthesia remains the gold standard for pain management in the
laboring patient.
•
Multimodal analgesia is critical for postpartum pain management. Most common
pain sources after vaginal delivery are uterine cramping, perineal pain from
lacerations, and discomfort from hemorrhoids. It is important to address all the
sources of pain to effectively treat a postpartum patient. Enhanced Recovery
After Cesarean (ERAC) protocols aim to optimize patient outcomes using
evidence-based methods.
•
Proper pain management for the pregnant person with OUD requires adequate
planning, collaboration with all involved parties, and should involve continuation
of the patient’s prior MOUD.
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Peripartum Pain Management 405
Table 3 Anesthetic and Analgesic medication safety for breastfeeding mothers [22–25]
Medication Safe to administer for
anesthesia
Safe to breastfeed
when awake/alert
Consider pause in
breastfeeding
Midazolam Yes Ye s Not needed
Propofol Yes Ye s Not needed
Etomidate Yes Ye s Not needed
Ketamine Unknown Unknown Unknown (so yes)
Volatile anesthetics Ye s Ye s Not needed
Fentanyl Yes Ye s Not needed
Remifentanil Likely yes Likely yes Not needed
Morphine (IV) Ye s Probably, but need
dose discretion
Likely not needed if
potency controlled
Hydromorphone (IV) Yes Probably, but need
dose discretion
Likely not needed if
potency controlled
Morphine (epidural) Ye s Yes Likely not needed
Meperidine No No Ye s
Codeine N/A No (due to potential
for ultrarapid
metabolism)
Yes
Tramadol N/A No (due to potential
for ultrarapid
metabolism)
Yes
NMBAs (depolarizing
and non-depolarizing)
Yes Ye s Not needed
NMBA Reversal
Agents
Yes Ye s Not needed
Lidocaine Ye s Ye s Not needed
Bupivacaine Ye s Ye s Not needed
Ondansetron Ye s Ye s Not needed
Dexamethasone Yes Ye s Not needed
•
Some pain medications during breastfeeding are minimally excreted into the
breastmilk and are therefore safe to use during the postpartum period. Caution
should be maintained in attending to the newborn’s level of sedation and respira-
tory depression. Codeine and Tramadol are contraindicated during breastfeeding.
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406 J. Shah et al.
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Perioperative Pain Management
for Chest Wall Procedures
Christopher R. Cowart, Benjamin Hull, Dennis J. Warfield, Shane Barre,
and Sanjib Adhikary
Abstract Fascial plane blocks involve injecting local anesthetic between myofas-
cial tissue layers to target multiple nerves or nerve branches. Initially, these blocks
were primarily utilized in breast surgery. Recently, they have demonstrated efficacy
in both thoracic and cardiac surgery, thus are now being accepted into periopera-
tive analgesic plans. Effective fascial plane blocks for surgeries involving the chest
wall include the Pectoralis I and II (PECS I and II), Serratus Anterior Plane (SAP),
Erector Spinae Plane (ESP), Transversus Thoracis Plane (TTP), Pectointercostal
Fascial Plane (PIF), Retrolaminar Block (RLB), Midpoint Transverse Process to
Pleura (MTP), Rhomboid Intercostal Block (RIB), and Rhomboid Intercostal Sub-
Serratus (RISS) blocks. Of note, in order to help standardize nomenclature in regional
anesthesia, several of these blocks have undergone name changes during the ASRA-
ESRA Delphi consensus in 2021 (El-Boghdadly et al. in Reg Anesth Pain Med
46:571–580, 2021 [1]). PECS I blocks are now referred to as Interpectoral Plane
blocks and PECS II blocks are now referred to as Pectoserratus Plane blocks. PIF
and TTP blocks are now referred to as Superficial and Deep Parasternal Intercostal
C. R. Cowart
Department of Anesthesiology and Perioperative Medicine, Division of Cardiovascular
Anesthesiology, Milton S. Hershey Medical Center, Pennsylvania State University College of
Medicine, Hershey, PA, USA
e-mail: ccowart@pennstatehealth.psu.edu
B. Hull
Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey,
PA, U S A
e-mail: bhull@pennstatehealth.psu.edu
D. J. Warfield · S. Barre · S. Adhikary (
B
)
Department of Anesthesiology and Perioperative Medicine, Division of Regional Anesthesia and
Acute Pain Medicine, Milton S. Hershey Medical Center, Pennsylvania State University College
of Medicine, 500 University Drive, Hershey, PA 17033, USA
e-mail: sadhikary1@pennstatehealth.psu.edu
D. J. Warfield
e-mail: dwarfield@pennstatehealth.psu.edu
S. Barre
e-mail: sbarre@pennstatehealth.psu.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_26
409
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410 C. R. Cowart et al.
Plane blocks, respectively. The RIP and RISS blocks have since been lumped together
as the RIP block while the MTP block has been renamed as one of the Intertransverse
Process blocks. The old nomenclature will mostly be referred to in this chapter, as
most of the research articles mentioned took place prior to the nomenclature change.
These blocks have been shown to reduce postoperative pain scores, intraoperative
and postoperative opioid requirements, need for rescue analgesia, and postoperative
nausea and vomiting. In some situations, these blocks have not only been shown
to improve postoperative lung function and decrease time to extubation, but also
improve patient satisfaction. Due to their utility as a component of multimodal anal-
gesia, fascial plane blocks have the potential to be included in enhanced recovery
pathways for surgeries involving the chest wall.
Keywords Pectoralis
· Serratus anterior · Erector spinae · Transversus thoracis ·
Retrolaminar · Rhomboid intercostal sub-serratus
1 Introduction
Fascial plane blocks are regional anesthetic techniques that involve the injection of
local anesthesia between two myofascial tissue layers. This technique targets nerves
found lying within the desired fascial plane, in contrast to locating and targeting
a specific nerve or plexus as performed in other regional anesthesia techniques.
Originally, these blocks were performed using surface anatomy landmarks and the
tactile feeling of the needle tip penetrating through fascial layers, but they are now
performed under ultrasound guidance [2]. Chest wall fascial plane blocks were orig-
inally employed in breast surgery, but have recently been adopted in both thoracic
and cardiac surgery [3, 4].
Classically, neuraxial and paraneuraxial anesthesia, including thoracic epidurals
and paravertebral nerve blocks (PVB), have been used in combination with systemic
opioids and adjuncts for multimodal analgesia in thoracic surgery. Thoracic epidu-
rals are efficacious; however, they can be contraindicated in some patients and are
subject to complications including hypotension, hematoma, infection, and neuro-
logic injury. PVBs have displayed similar analgesic benefits but can share the same
major complications and contraindications as thoracic epidurals. As a result, chest
wall fascial plane blocks are frequently utilization in thoracic surgery [3]. In cardiac
surgery, postoperative analgesia traditionally has been achieved with large doses of
intravenous (IV) opioids. However, this convention has changed as practice patterns
shifted towards favoring extubating patients either in the operating room or shortly
after admission to the intensive care unit (ICU). Neuraxial anesthesia is not widely
accepted as an appropriate analgesia option for patients undergoing cardiac surgery
due to increased risk associated with intraoperative systemic heparinization and
hemodynamic instability [4]. Ultrasound-guided fascial plane blocks have subse-
quently been adopted as components of multimodal anesthesia in cardiac surgery
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