Anaesth Crit Care Pain Med 35 (2016) 373–375

Editorial
Enhanced recovery after caesarean delivery: Potent analgesia and
adequate practice patterns are at the heart of successful management

Enhanced recovery after surgery is a concept that applies well offers a better result [8] but opioids are not potent enough to clear
to caesarean delivery. Although there are still no randomised pain on movement. It seems likely that the most potent drugs in
studies showing that this model improves patients’ outcomes, it this regard are non-steroidal anti-inflammatory drugs (NSAIDS)
does improve patient-centred outcomes and satisfaction [1,2]. Al- and their use should be promoted. Their use is not contra-indicated
though rapid discharge after surgery might be a limitation because and their side effects easy to control in most patients, with
the neonate might require additional care that is outside the scope adequate prescription rules. Unwillingness to use NSAIDs due to
of ERAS (i.e. ERAS is centred on the patient who has undergone transfer in breast milk is a misconception with most NSAID
surgery), studies have shown that it is feasible. One study has even clinically available [9]. Additionally, regular drug administration of
suggested that a one-day postoperative hospital stay is not harmful the basic components of multimodal analgesia should be
and well accepted [3]. promoted. Nurses’ reluctance to administer analgesic drugs when
In this context, the tenets of enhanced recovery should be the patient does not appear in pain is a practice pattern that should
examined in detail and optimised to facilitate home return and be modified since in most cases, the painless situation is observed
sufficient autonomy to allow for neonatal care (with often at rest and does not anticipate what will occur when the patient
additional needs for other children which increase the mother’s will move. Oral administration is feasible, well tolerated and a
workload). It is thus not illogical that studies focus their analyses logical way to do [10] in patients who are allowed to eat and drink
on postoperative analgesia. In this issue of ACCPM, two studies very early after surgery [1].
have brought additional information on postoperative analgesia Regarding the two studies comparing a TAP block to another
after caesarean delivery [4,5], one of them performed in the analgesic method, one [4] showed an already well accepted
context of ERAS [4] while the third one describes a continuous finding, i.e. a TAP block provides almost similar or better analgesia
quality evaluation [6]. Before making any comment on the in the first hours after surgery but the duration of the analgesic
analgesic strategies that were examined in these studies, it is effect is shorter than with intrathecal morphine. By contrast, side
necessary to emphasize (again) the role of pain evaluation and effects occurred significantly more often after intrathecal mor-
particularly the need of regular evaluation of pain on movement. phine. These results have been shown many times before and have
This part of pain evaluation is often missed in clinical practice but even been grouped in several meta-analyses during the last five
also in many clinical studies which only report on pain at rest (or years [11,12]. Most units in France and elsewhere use a 100 mg
sometimes do not state precisely which type of pain is measured). intrathecal dose [13], based on studies and meta-analyses showing
A typical example is the study describing the comparison of TAP that higher doses produce longer lasting analgesia at the expense
blocks and intrathecal morphine in the present issue. Pain on of increased side effects [14]. However, when using multimodal
movement is much more severe that at rest and requires much analgesia, differences in potency are attenuated and a dose as small
powerful analgesia that what is required to overcome pain at rest. as 50 mg is effective [15]. In other words, using a smaller dose of
This is extremely important because analgesic methods that are intrathecal morphine may reduce the negative effects of this
used should be powerful enough to lower pain intensity on analgesic technique while maintaining its efficacy and duration.
movement and should not be prescribed only to cover pain rest. In Additional studies including such small doses are thus necessary.
this context, at least two strategies can be used or even combined. The alternative comparator technique assessed in the second
First, regional techniques which include a local anaesthetic are study of this issue [5] was a continuous infusion of a local
clearly the most powerful. For example, Dahl et al. [7] showed that anaesthetic into the wound and it produced analgesia as potent as
epidural analgesia with a local anaesthetic reduced pain to low a TAP block. Importantly, the efficacy was tested in a model of
levels during mobilisation after abdominal surgery while epidural postoperative care which did not include an enhanced recovery
analgesia with morphine only could not. strategy. Pain scores were similar during the first two days after
Another way is the use of ‘truly’ multimodal analgesia. This surgery but we are not told how much and when patients moved
does not mean combining only an opioid and a non-opioid drug, as out from their bed. In addition, the use of a continuous infusion
seen in many studies. This means combining several drugs that act requires the use of a catheter inserted into the wound connected to
through various mechanisms to minimize the hits of pain that a line linked to the reservoir containing the local anaesthetic.
occur when the patient mobilises. It is true that there are yet Although it is obviously possible to move and walk while being
limited data really demonstrating that multiplying analgesics attached to the device, it does impair patient’s mobilisation, an

[Link]
2352-5568/ß 2016 Published by Elsevier Masson SAS on behalf of Société française d’anesthésie et de réanimation (Sfar).
374 Editorial / Anaesth Crit Care Pain Med 35 (2016) 373–375

effect that is not in line with the principle of enhanced recovery. useful. These comments are aimed to alert our colleagues that a
Additionally, the efficacy of continuous infusion is not always major progress is still needed. Kissin and colleagues have recently
found in reports [16] and it has been suggested that the position published a review entitled ‘‘No evidence of real progress in
of the catheter in the wound may be one reason for success or treatment of acute pain, 1993-2012. . .’’ [25] while Geisler et al. [26]
failure [17]. named their recent editorial ‘‘Low degree of satisfactory individual
In the third study, the authors describe how their continuous pain relief in post-operative pain trials’’. We do share these concerns
improvement programme led to progressive implementation of an and although we recognize that much has been done in the right
enhanced recovery programme. Interestingly, a score describing direction, it remains that ‘‘resources necessary for appropriate use of
the degree of implementation was used based on a previous report new techniques in routine pain management are not adequate’’
[18]. Although the score may be discussed (especially the criterion [25]. This becomes even more obvious in the era of enhanced
based on carbetocin use), it provides an objective way to analyse recovery after surgery with the increased need of powerful analgesia
the team practice pattern. Results were highly expected, i.e. efforts to facilitate mobilisation and discharge.
to implement a change are associated with such change.
Intravenous fluids were no more used and oral analgesia Disclosure of interest
implemented at 24 hours while the urinary catheter was also
removed before the 24th hour in more than 90% of cases at 8 Conferences on the theme of the rehabilitation and employ-
months after the start of the programme. All these three indicators ment of the carbetocin for FERRING laboratories
progressed significantly from the 4-month to the 8-month audit,
suggesting a slow but positive uptake of the programme. One References
should however consider several concerns about the audit design
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[Epub ahead of print]..
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