Pain Management in the Peripartum Period:
This issue of Clinics in Perinatology will carry the reader through the perinatal period and examine pain management throughout that continuum. Beginning with the genetics of obstetrical pain and opioid use in pregnancy, the discussion moves to the provision of anesthesia to the mother and fetus dur...
Gespeichert in:
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| Format: | Buch |
| Sprache: | English |
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Philadelphia
Elsevier
2013
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| Schriftenreihe: | Clinics in perinatology
40,3 |
| Online-Zugang: | Inhaltsverzeichnis |
| Zusammenfassung: | This issue of Clinics in Perinatology will carry the reader through the perinatal period and examine pain management throughout that continuum. Beginning with the genetics of obstetrical pain and opioid use in pregnancy, the discussion moves to the provision of anesthesia to the mother and fetus during fetal surgery - an area of intense concern and interest in many centers. There is an extensive discussion of both pharmacologic and non-pharmacologic management of pain during delivery. A discussion of regional anesthetic techniques is increasingly relevant in light of increasing evidence of adv |
| Beschreibung: | XVII, S. 338-599 Ill., graph. Darst. |
| ISBN: | 9780323188661 |
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| 490 | 1 | |a Clinics in perinatology |v 40,3 | |
| 520 | 1 | |a This issue of Clinics in Perinatology will carry the reader through the perinatal period and examine pain management throughout that continuum. Beginning with the genetics of obstetrical pain and opioid use in pregnancy, the discussion moves to the provision of anesthesia to the mother and fetus during fetal surgery - an area of intense concern and interest in many centers. There is an extensive discussion of both pharmacologic and non-pharmacologic management of pain during delivery. A discussion of regional anesthetic techniques is increasingly relevant in light of increasing evidence of adv | |
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| adam_text | Titel: Pain management in the peripartum period
Autor: Flick, Randall P
Jahr: 2013
Pain Management in the Peripartum Period
Contents
Foreword: Painful Truths About Newborn Pain Management xv
Lucky Jain
Preface: Pain Management in the Perinatal Period xvii
Randall P. Flick and James R. Hebl
Chronic Opioid Use During Pregnancy: Maternal and Fetal Implications 337
Todd J. Stanhope, Lisa A. Gill, and Carl Rose
Current trends in the United States suggest that chronic narcotic use has
increased in reproductive aged women over the past 10 years. Regular
exposure to such substances during pregnancy has maternal and fetal im-
plications. Appropriate prenatal care is critical to optimizing outcomes.
Management options for narcotic dependence should be patient-specific
and may include discontinuation of narcotics with careful observation, lim-
itation of prescription dispensing, or substitution therapy with methadone
or buprenorphine. A multidisciplinary, collaborative approach is highly
recommended. This review discusses usage of narcotic medications,
associated maternal and fetal risks, and management strategies for the
antepartum, intrapartum, and postpartum periods.
Nonpharmacologic Labor Analgesia 351
Katherine W. Arendt and Jennifer A. Tessmer-Tuck
A supportive medical team should be well informed on the various phar-
macologic and nonpharmacologic modalities of coping with or mitigating
labor pain to appropriately support and respectfully care for parturients.
Using the methodical rigor of previously published Cochrane systematic
reviews, this summary evaluates and discusses the efficacy of nonphar-
macologic labor analgesic interventions.
Combined Spinal-Epidural Versus Epidural Analgesia for Labor and Delivery 373
Adam D. Niesen and Adam K. Jacob
The rapid onset of analgesia and improved mobility with combined spinal-
epidural (CSE) techniques has been associated with a higher degree of
maternal satisfaction compared with conventional epidural analgesia.
However, controversy exists in that initiation of labor analgesia with
a CSE may be associated with an increased risk for nonreassuring fetal
status (ie, fetal bradycardia) and a subsequent need for emergent cesar-
ean delivery. Overall, both epidural and CSE techniques possess unique
risk/benefit profiles, and the decision to use one technique rather than
the other should be determined based on individual patient and clinical
circumstances.
viii
Contents
The Association Between Epidural Labor Analgesia and Maternal Fever 385
Katherine W. Arendt and B. Scott Segal
The association between epidural labor analgesia and maternal fever is
complex and controversial. Observational, retrospective, before-and-
after, and randomized controlled trials all support the association, with
the most current evidence supporting the mechanistic involvement of non-
infectious inflammation. Considering the clinically significant neonatal con-
sequences that have been previously demonstrated, and the possibility of
more common subclinical fetal brain injury that animal models imply, the
avoidance of maternal fever during labor is imperative. With the current
popularity of epidural analgesia in labor, it is important that clinicians
delineate how epidurals cause maternal fever and how to block the nonin-
fectious inflammatory response that seems to warm a subset of women
laboring with epidurals.
Anesthetic Management of External Cephalic Version 399
Laurie A. Chalifoux and John T. Sullivan
Breech presentation is common at term and its reduction through external
cephalic version represents a noninvasive opportunity to avoid cesarean
delivery and the associated maternal morbidity. In addition to uterine relax-
ants, neuraxial anesthesia is associated with increased success of version
procedures when surgical anesthetic dosing is used. The intervention is
likely cost effective given the effect size and the avoided high costs of
cesarean delivery.
Maternal Anesthesia for Fetal Surgery 413
Hans P. Sviggum and Bhavani Shankar Kodali
This article describes the anesthetic management of pregnant women
undergoing fetal surgery. Discussion includes general principles common
to all fetal surgeries as well as specifics pertaining to open fetal surgery,
minimally invasive fetal surgery, and ex utero intrapartum therapy (EXIT)
procedures.
Fetal Anesthesia and Pain Management for Intrauterine Therapy 429
Roland Brusseau and Arielle Mizrahi-Arnaud
Anesthesia provision for fetal intervention differs from most other anes-
thetic situations insofar as anesthesiologists must care for 2 or more
patients—each with potentially conflicting requirements. The first is the
mother who can readily indicate discomforts, can be monitored directly,
and to whom drugs may be administered directly and easily. For the fetus
(or fetuses), nociception must be assumed or inferred indirectly, monitor-
ing is limited at best, and drug administration is complicated and often
indirect. Fetal and maternal hemodynamic stability must be assured; and
a plan to resuscitate the fetus, should problems occur during the proce-
dure, must be developed.
Multimodal Postcesarean Delivery Analgesia 443
Anne Lavoie and Paloma Toledo
Cesarean deliveries can be associated with moderate to severe postoper-
ative pain. Appropriate management of pain is important because it results
Contents ix
in better patient satisfaction, earlier mobilization, and improved maternal-
infant bonding. There are many individual options for treatment of pain;
however, multimodal analgesic therapy has become the mainstay of treat-
ment. In this article, the epidemiology of postcesarean delivery pain, pain
mechanisms, and the multiple options available to providers for treatment
of postoperative pain are discussed.
Assessment of Pain in the Neonate 457
Lynne G. Maxwell, Carrie P. Malavolta, and Maria V. Fraga
Accurate pain assessment in preterm and term neonates in the neonatal
intensive care unit (NICU) is of vital importance because of the high
prevalence of painful experiences in this population, including both daily
procedural pain and postoperative pain. Over 40 tools have been devel-
oped to assess pain in neonates, and each NICU should choose a limited
number of pain assessment tools for different populations and contexts.
Only two pain assessment tools have a metric adjustment to account for
differences of pain assessment in prematurity. Preterm neonates do not
display behavior and physiologic indicators of pain as reliably and specif-
ically as full term infants, and preterm infants are vulnerable to long term
sequelae of painful experiences. Brain-oriented approaches for more
objective measurement of pain in neonates may become available in the
future. In the meantime, neonatal pain assessment tools need to be taught,
implemented, and their ongoing use optimized to form a consistent, repro-
ducible basis for the safe and effective treatment of neonatal pain.
Biological and Neurodevelopmental Implications of Neonatal Pain 471
Suellen M. Walker
Nociceptive pathways are functional following birth. In addition to physio-
logical and behavioral responses, neurophysiological measures and
neuroimaging evaluate nociceptive pathway function and quantify
responses to noxious stimuli in preterm and term neonates. Intensive
care and surgery can expose neonates to painful stimuli when the devel-
oping nervous system is sensitive to changing input, resulting in persistent
impacts into later childhood. Early pain experience has been correlated
with increased sensitivity to subsequent painful stimuli, impaired neurode-
velopmental outcomes, and structural changes in brain development. Par-
allel preclinical studies have elucidated underlying mechanisms and
evaluate preventive strategies to inform future clinical trials.
Nonpharmacological Management of Pain During Common Needle Puncture
Procedures in Infants: Current Research Evidence and Practical Considerations 493
Carol McNair, Marsha Campbell Yeo, Celeste Johnston, and Anna Taddio
All infants undergo painful procedures involving skin puncture as part of
routine medical care. Pain from needle puncture procedures is subopti-
mally managed. Numerous nonpharmacologic interventions are available
for these painful procedures, including swaddling, holding, skin-to-skin
care, pacifier, sweet-tasting solutions, and breast-feeding. Adoption of
nonpharmacologic pain-relieving interventions into routine clinical practice
is feasible and should be a standard of care in the delivery of quality health
X
Contents
care for infants. This review summarizes current knowledge about the
epidemiology of pain from common needle puncture procedures in infants,
the effectiveness of nonpharmacologic interventions, implementation con-
siderations, and unanswered questions for future research.
Management of Neonatal Abstinence Syndrome from Opioids 509
Kendra Grim, Tracy E. Harrison, and Robert T. Wilder
Most infants at risk for neonatal abstinence syndrome have opioid plus
another drug exposure; polypharmacy is the rule rather than the exception.
Scales for evaluation of neonatal abstinence syndrome are primarily based
for opioid withdrawal. A standard protocol to treat neonatal abstinence
syndrome has not been developed. Institute nonpharmacologic strategies
for all neonates at risk. The American Academy of Pediatrics recommends
mechanism-directed therapy (treat opioid withdrawal with an opioid) as
the first-line therapy. Second-line medications are currently under
evaluation.
Regional Anesthesia in Neonates and Infants 525
Adrian Bosenberg and Randall P. Flick
Optimal pain management can significantly impact the surgical outcome
and length of stay in the neonatal intensive care unit (NICU). Regional
anesthesia is an effective alternative that can be used in both term and pre-
term neonates. A variety of neuraxial and peripheral nerve blocks have
been used for specific surgical and NICU procedures. Ultrasound guid-
ance has increased the feasibility of using these techniques in neonates.
Education and training staff in the use of continuous epidural infusions
are important prerequisites for successful implementation of regional
anesthesia in NICU management protocols.
Sedation and Analgesia to Facilitate Mechanical Ventilation 539
Michael E. Nemergut, Myron Yaster, and Christopher E. Colby
Regardless of age, health care professionals have a professional and eth-
ical obligation to provide safe and effective analgesia to patients undergo-
ing painful procedures. Historically, newborns, particularly premature and
sick infants, have been undertreated for pain. Intubation of the trachea and
mechanical ventilation are ubiquitous painful procedures in the neonatal
intensive care unit that are poorly assessed and treated. The authors
review the use of sedation and analgesia to facilitate endotracheal tube
placement and mechanical ventilation. Controversies regarding possible
adverse neurodevelopmental outcomes after sedative and anesthetic
exposure and in the failure to treat pain is also discussed.
Neurodevelopmental Implications of the Use of Sedation and Analgesia in
Neonates 559
Andrew Davidson and Randall P. Flick
Laboratory studies have shown that general anesthetics may cause accel-
erated apoptosis and other adverse morphologic changes in neurons of
the developing brain. The mechanism may be related to the neuronal qui-
escence or inactivity associated with anesthetic exposure. Few data exist
Contents xi
on how brief anesthetic exposure may affect neurodevelopment in the
newborn. Good evidence however shows that untreated pain and stress
have an adverse effect on neurodevelopment, and therefore, at this stage,
providing effective analgesia, sedation, and anesthesia would seem to be
more important than concern over neurotoxicity.
Genetic Contributions to Labor Pain and Progress 575
Ruth Landau
Studies on genetic contributions to labor analgesia have essentially eval-
uated the ^-opioid receptor gene (OPRM1), with some evidence that
p.118A/G of OPRM1 influences the response to neuraxial opioids. As for
labor progress, the ß2-adrenergic receptor gene (ADRB2) is associated
with preterm labor and delivery, and impacts the course of labor. Taken
together though, there is no evidence that pharmacogenetic testing is
needed or beneficial in the context of obstetric anesthesia; however, real-
izing the influence of genetic variants on specific phenotypes provides the
rationale for a more cautious interpretation of clinical studies that attempt
to find a dose-regimen that fits all.
Index
589
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