Page 252 Guide to Pain Management in Low-Resource Settings

240 Author(s)

controlled epidural analgesia (PCEA) using fentanyl of 0.25% bupivacaine or 0.5% ropivacaine on each side.
(2 μg bolus, 15 minute lockout time) or pethidine/me- Th e injection is made just above the pelvic brim in the
peridine (20 mg bolus, 15 minute lockout time). Th ese posterior section of the triangle of Petit, in the gap be-
epidural methods are associated with lower rates of tween latissimus dorsi and the external oblique muscle.
opioid consumption (by 20–50%) than intravenous A “two-pop” (or in some countries ultrasound-guided)
opioid and although short-term epidural opioid ad- technique (as the blunt-tip needle passes through the
ministration after cesarean delivery has not been well external oblique fascial extension, then internal oblique
investigated, clinical experience suggests the breast- fascia) allows local anesthetic to be deposited between
fed neonate is not aff ected. the internal oblique and transverse abdominis muscles.
Immediate-release oxycodone (e.g., 5–10 mg Combined with oral analgesics, an eff ective TAP block
regularly 4 hourly for 48 hours, with additional doses on covers the incision for cesarean delivery well (T10 to L1
request) is a more eff ective oral opioid than codeine and dermatomes) and lasts up to 36 hours.
also tastes less unpleasant than oral morphine. Trama-
dol (50–100 mg intravenous or oral, repeated 2 hourly Case report 3 (analgesics
to a maximum of 600 mg per day) is also an excellent in later pregnancy)
choice for postoperative pain relief. Agnes can also be
reassured that short-term use for a couple of days im- Th e nurse comes to tell you that Martine, a healthy
mediately postpartum is associated with low transfer of woman in her fourth pregnancy at 33 weeks gestation
drug into breast milk (less than 3%) and that there are who is attending the antenatal clinic, has been com-
no apparent eff ects on the baby. In some countries the plaining of severe stabbing pain both at the back of her
new generation of NSAIDs, the cyclooxygenase-2-spe- pelvis and low down at the front. Th e pain has been get-
cifi c inhibitors (COX-2 inhibitors) such as intravenous ting progressively worse for several weeks, and Martine
parecoxib (40 mg daily) and oral celecoxib (400 mg then can no longer care properly for her children. She fi nds it
200 mg 12 hourly) may be available, and because they very painful to rise from a sitting position and is more
have no eff ect on platelet function they are the best comfortable crawling around the house on all four limbs
choice for women who are bleeding or at high risk of than walking. When you see Martine, she explains that
bleeding. However, they have not yet been adequately it took her 2 hours to walk from her house to the clinic,
evaluated during human lactation, and although the risk a journey that usually takes her 20 minutes. She is very
of aff ecting the breastfeeding baby appears low, safety tender to palpation over both the suprapubic region and
cannot be guaranteed. Some countries may also have in- upper buttocks. Th e pain is increased by “springing” the
travenous paracetamol/acetaminophen, which provides pelvis. “Please, is there anything that you can do to help
higher and more rapid peak plasma concentrations than me?”asks Martine. You explain that she appears to have
an equivalent oral dose. symphysial diastasis with signifi cant separation and sec-
ondary disruption and infl ammation at the sacroiliac
Might any other local anesthetic blocks be joints. You explain the problem and discuss an initial
useful in reducing Agnes’s risk of having poorly plan of management with her. You tell her that she can
controlled pain?
start on some strong medications if she has not improved
Wound infusion of local anesthetic (or perhaps even di- within a week.
clofenac) is eff ective in reducing the dose of opioid need-
ed, but it requires expensive pumps and wound cath- What sort of painful conditions occur
eters, so it is not likely to be available. If there is a doctor during pregnancy?
with suitable training, bilateral ilioinguinal and iliohypo- Diastasis of the pubic symphysis is an example of a very
gastric blocks into the abdominal wall near the anterior painful and disabling condition that frequently occurs
iliac crest, or a rectus sheath block, can achieve similar during and after pregnancy. However, the principles of
opioid dose-sparing in the fi rst 12–24 hours. Th e best drug treatment for pain present after the fi rst trimes-
peripheral nerve block, if someone has the knowledge ter of pregnancy can be applied to most painful condi-
and expertise, would be for Agnes to receive bilateral tions or diseases, including musculoskeletal pain (other
transverse abdominis plane (TAP) blocks. Th is regional examples are lumbar vertebral facet pain, disk protru-
analgesic block is performed using, for example, 20 mL sion or rupture); visceral pain (cholecystitis, renal