How targeted pain relief can improve outcomes for new mothers: 3 Qs with MemorialCare Saddleback Medical Center’s Dr. Stephen Garber

Enhanced recovery after surgery protocols have been linked to improve outcomes for mothers and newborns, but MemorialCare Saddleback Medical Center in Laguna Hills, Calif., is going a step further.

The hospital, a Society for Obstetric Anesthesia and Perinatology-designated center of excellence, is implementing early recovery after cesarean section protocols, or ERAC, which can help reduce postoperative pain and improve maternal outcomes, Stephen Garber, MD, the hospital’s medical director for obstetric anesthesiology, said.

ERAC includes the use of multimodal pain relief protocols, such as the use of liposomal bupivacaine delivered via a transversus abdominis plane block or TAP block. It offers long-lasting and localized pain relief for mothers undergoing C-sections.

Here, Dr. Garber discusses ERAC and how it can help hospitals improve care for women undergoing C-sections.

Note: Responses have been edited for length and clarity.

Question: What is the current status of ERAS and multimodal protocols in the world of obstetrics? Where are we in the continuum of evolution?

Dr. Stephen Garber: Our hospital system is implementing ERAC, early recovery after C-section, which has some particular elements that are different than ERAS.

Our particular campus is a center of excellence for obstetric anesthesia. We’ve had that designation for two years now, and in order to keep the designation and move forward, it’s important to embrace ERAC and ideas like this to keep us on top of things. C-sections are the most common surgery performed in the world and the United States. In the U.S., there are approximately between 1.2 and 1.3 million cesarean sections a year. So, it’s important to focus our care.

We are just at the beginning of implementing this [ERAC] process nationwide. There are some institutions that have already introduced it, there are some, like ours, that are just starting to, and there are some lagging behind. Hopefully it’s going to take off and become the standard of care across the nation for C-section patients.

Q: Why did MemorialCare Saddleback Medical Center adopt enhanced recovery after C-sections? What has been the most recent addition/improvements and why?

SG: So, if you look at the ERAC protocol overall, it has several different elements to it. We use multimodal protocols for pain and that includes giving acetaminophen and the equivalent of Motrin around the clock, every six hours, for the entire stay of 72 hours. This has helped reduce postoperative pain and narcotic use. Narcotic misuse is a very large problem here in Orange County. So anytime that we can reduce the narcotic use, there is a potential of reducing the possibility of someone misusing the narcotics themselves.

In addition, we recently added on the use of a TAP block with liposomal bupivacaine, which is an unbelievable addition to our armory to reduce postoperative pain and narcotic use. After the C-section has been completed, under ultrasound guidance, you deposit the liposomal bupivacaine, also known as EXPAREL (bupivacaine liposome injectable suspension), admixed with regular bupivacaine, and that has been shown to even further reduce the use of narcotics.

The way that ties into ERAC is that the patients that have those TAP blocks, they are using little to no narcotics which means they are not getting constipated, they are able to eat earlier, they feel better.

If you are taking narcotics, the nurse has to be a little more attentive to you and you can’t really be left alone with your baby because of the risk of you falling asleep, but not with this protocol. I had a patient last week. I came in in the morning and said, ‘how was your night?’ She had had a TAP block and she said, ‘it was great because I got to keep the baby with me all night and my husband got to go home to be with my son.’

So, we are talking about patient comfort, we’re talking about patient satisfaction.

Q: Why are enhanced recovery protocols in obstetrics relevant now more than ever?

SG: Like I said, we can improve patient comfort and as a result satisfaction. We can potentially get the patients out of the hospital sooner, we can reduce nausea and vomiting, we can reduce the use of narcotics, and also, we see when we use a multimodal program for medications in conjunction with the TAP Block, they go home with very few to no narcotics. That’s what we are looking for. Also, when patients are doing better, when they’re able to get up faster, it reduces the workload on the nurses.

And, it’s a very empowering experience for the patients, knowing that if they have to have a C-section that they can expect this level of care. 

Indication
EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.
Important Safety Information
  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia
  • Adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation
  • If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine
  • EXPAREL is not recommended to be used in the following patient population: patients <18 years old and/or pregnant patients
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease
Warnings and Precautions Specific to EXPAREL
  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials
Warnings and Precautions for Bupivacaine-Containing Products
  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability which may lead to dysrhythmias, sometimes leading to death
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use
Please refer to full Prescribing Information.

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