Virginia Apgar Professor of Anesthesiology, Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians & Surgeons, New York, USA.
Int J Obstet Anesth. 2019 Aug;39:105-116. doi: 10.1016/j.ijoa.2019.01.011. Epub 2019 Feb 10.
The opioid crisis has reached an unprecedented magnitude in the United States and worldwide, and data on opioid use and misuse in the obstetric population are extremely concerning. Despite an abundant number of studies evaluating strategies to prevent neonatal opioid withdrawal syndrome in babies born to mothers who are chronic opioid users, in babies born to mothers using chronic opioids, numerous questions remain unanswered, including (1) how to optimally manage postpartum pain in opioid-dependent patients (2) how to reconcile buprenorphine and methadone use with intrapartum and post-partum analgesia, so as to avoid opioid withdrawal during and after delivery (3) how to safely and effectively provide a stepwise multimodal approach that incorporates systemic opioid-sparing approaches, such as neuraxial opioids, clonidine, ketamine, gabapentin, and regional anesthetic blocks, to ensure adequate pain relief while avoiding opioid withdrawal (4) how to optimally manage post-partum recovery and (5) how to avoid excessive opioid prescription and possibly leftover opioids that may promote persistent use, misuse and diversion. With the recognition that an increasing number of pregnant women are taking chronic opioids, the goals of this review article are to summarize the existing literature on post-cesarean pain management in the obstetric patient with an opioid-use disorder; and to provide clinicians with a stepwise approach for management before, as well as during and after, cesarean delivery of women who have been chronically using opioids during their pregnancy.
阿片类药物危机在美国和全球达到了前所未有的规模，关于产科人群中阿片类药物使用和滥用的数据令人深感担忧。尽管有大量研究评估了预防母亲慢性使用阿片类药物所生婴儿出现新生儿阿片类戒断综合征的策略，但在母亲使用慢性阿片类药物所生婴儿中，仍有许多问题尚未得到解答，包括：（1）如何优化阿片类药物依赖产妇的产后疼痛管理；（2）如何协调丁丙诺啡和美沙酮的使用与分娩中和产后的镇痛，以避免分娩期间和分娩后出现阿片类药物戒断；（3）如何安全有效地提供逐步的多模式方法，包括鞘内和椎管内阿片类药物、可乐定、氯胺酮、加巴喷丁和区域麻醉阻滞，以确保在避免阿片类药物戒断的情况下获得充分的疼痛缓解；（4）如何优化产后恢复；（5）如何避免过度开具阿片类药物处方，并可能留下阿片类药物，这可能会导致持续使用、滥用和转移。随着越来越多的孕妇开始长期使用阿片类药物，本文的目的是总结现有文献中关于患有阿片类药物使用障碍的产科患者剖宫产术后疼痛管理的内容；并为临床医生提供一个在慢性使用阿片类药物的女性接受剖宫产术前、术中和术后的管理分步方法。
