Department of Anesthesiology, GZA Sint-Augustinus Hospital, Antwerp, Belgium.
Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven, Belgium.
Anaesthesia. 2021 May;76(5):665-680. doi: 10.1111/anae.15339. Epub 2020 Dec 28.
Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50-100 µg or diamorphine 300 µg administered pre-operatively; paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single-injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel-Cohen incision; non-closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.
剖宫产术与中重度术后疼痛相关，这会影响术后恢复和患者满意度，以及母乳喂养的成功和母婴关系。本系统评价的目的是更新现有文献，并为椎管内麻醉下择期剖宫产术后的最佳疼痛管理提供建议。采用特定手术术后疼痛管理（PROSPECT）方法进行系统评价。检索了 MEDLINE、Embase 和 Cochrane 数据库中 2014 年 5 月 1 日至 2020 年 10 月 22 日发表的评估镇痛、麻醉和手术干预效果的英文随机对照试验。排除了评估紧急或计划外手术分娩或全身麻醉下进行的剖宫产术疼痛管理的研究。共有 145 项研究符合纳入标准。对于接受椎管内麻醉下择期剖宫产术的患者，建议包括术前给予鞘内吗啡 50-100μg 或二氢吗啡酮 300μg；给予对乙酰氨基酚；非甾体抗炎药；以及分娩后给予静脉注射地塞米松。如果未给予鞘内阿片类药物，则建议行单次注射局部麻醉剂切口浸润；连续切口局部麻醉剂输注；和/或筋膜平面阻滞，如腹横肌平面或腰方肌阻滞。术后方案应包括定期给予对乙酰氨基酚和非甾体抗炎药，并按需给予阿片类药物进行解救。手术技术应包括 Joel-Cohen 切口；不缝合腹膜；和使用腹部束带。经皮电神经刺激可作为辅助镇痛。一些干预措施虽然有效，但存在风险，因此未被列入建议。一些干预措施由于证据不足、不一致或缺乏证据而未被推荐。需要注意的是，这些建议可能不适用于计划外分娩或全身麻醉下进行的剖宫产术。
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