What is the best approach for post-operative pain management in an asthmatic patient after a Cesarean section?

Post-Operative Pain Management for Asthmatic Patient After Cesarean Section

Your patient should receive scheduled paracetamol and NSAIDs as the foundation of post-operative analgesia, with systemic opioids reserved only for breakthrough pain, since the intrathecal morphine 0.1mg (100 μg) already administered provides excellent baseline analgesia for 12-24 hours. 1

Immediate Post-Operative Regimen (First 24-48 Hours)

Core multimodal analgesia:

• Paracetamol 1000mg every 6 hours (scheduled, not PRN) 1, 2
• NSAIDs: Ibuprofen 400-600mg every 6-8 hours OR Naproxen 500mg every 12 hours (scheduled, not PRN) 1, 2
• Single dose IV dexamethasone 4-8mg (if not already given intraoperatively after delivery) 1, 2
• Systemic opioids (oral morphine, oxycodone, or tramadol) ONLY for breakthrough pain despite scheduled non-opioids 1, 2

Critical Considerations for Asthmatic Patients

NSAIDs can be safely used in most asthmatics, but require specific precautions:

• Approximately 10-20% of asthmatics have aspirin-exacerbated respiratory disease (AERD), which contraindicates all NSAIDs 3
• If your patient has a history of asthma exacerbation triggered by aspirin or NSAIDs, avoid all NSAIDs entirely and rely on paracetamol plus opioids for breakthrough pain 3
• If no prior NSAID sensitivity and last asthma attack was 3 months ago (suggesting reasonable control), NSAIDs are generally safe 3
• COX-2 selective inhibitors (celecoxib) may be safer alternatives if there is concern about NSAID-induced bronchospasm, though cross-reactivity can still occur 3

Advantages of the Intrathecal Morphine Already Given

The 0.1mg (100 μg) intrathecal morphine dose is optimal and provides:

• 12-24 hours of excellent baseline analgesia 1, 2
• Significantly reduced need for systemic opioids 1
• This makes additional regional blocks (TAP blocks, wound infiltration) unnecessary and not recommended, as their benefit is minimal when intrathecal morphine is used 2, 4

Extended Post-Operative Period (Days 2-5)

Continue scheduled non-opioid regimen:

• Paracetamol 1000mg every 6 hours 1, 2
• NSAIDs (if tolerated and no contraindications) for 3-5 days total 1, 2
• Minimize and individualize opioid prescriptions at discharge—prescribe only 5-10 tablets of short-acting opioid (e.g., oxycodone 5mg) rather than standard 30-tablet prescriptions 1, 2

Adjunctive Non-Pharmacological Measures

Additional interventions to enhance analgesia:

• Abdominal binder application (reduces incisional pain with movement) 1, 2
• Transcutaneous electrical nerve stimulation (TENS) as adjunct if available 1, 2

Common Pitfalls to Avoid

Critical errors in post-cesarean analgesia:

• Do NOT prescribe paracetamol and NSAIDs "as needed" (PRN)—they must be scheduled around-the-clock for optimal efficacy 1, 2, 5
• Do NOT add regional blocks (TAP, QL blocks, or wound infiltration) when intrathecal morphine was used—the evidence shows minimal additional benefit and adds unnecessary intervention 2, 4
• Do NOT withhold NSAIDs in all asthmatics reflexively—only avoid if specific history of NSAID/aspirin-induced bronchospasm 3
• Do NOT prescribe large quantities of opioids at discharge—most patients need fewer than 10 tablets, and overprescribing contributes to opioid diversion 1, 2
• Do NOT use heat sources (heating pads, hot baths) if any transdermal opioid patches are considered, as this increases systemic absorption 6

Monitoring for Respiratory Depression

Given asthma history and intrathecal morphine:

• Monitor respiratory rate, oxygen saturation, and sedation level every 2 hours for first 12 hours 1
• Peak risk for respiratory depression from intrathecal morphine is 6-12 hours post-administration 1
• Have naloxone readily available 1