On today’s episode, Nick is flying solo to interview Nathan Riley, MD. Nathan is a practicing OB/GYN, but also a hospice and palliative care medicine fellow at the University of California San Diego. Nathan also is a podcaster in the #FOAMOb movement — check out his podcast, the OB GYNO WINO, where he pairs a reading alongside a bottle of wine. He also posts comprehensive show notes for each episode!
Nathan starts and shares with us his path to hospice/palliative care medicine, and what every OB/GYN should know about the specialty. The WHO definition of palliative care encompasses a lot of the essentials: “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”
Nathan shares with us some pearls on end-of-life and goals of care discussions, code status discussion, and pain management, where we spend the majority of the podcast. We start with the WHO analgesic ladder as a good starting point for a framework.
We then go into some pharmacology:
Cmax: the amount of time it takes a medication to go from administration to peak effect. This often is tied to route of administration: IV meds in 6-10 mins, SC/IM in 20-40 mins, and orally can be as long as 45-60 mins for max effect time!
Half life: the amount of time it takes for a drug to reach half of its original concentration in serum . For many opioids, this is in the 2-4 hour range. It takes 4-5 half lives to reach steady state, or when there’s equilibrium between intake and excretion.
Potency: describes a relationship between the amount of a medication and the effect produced. Higher or lower potency do not necessarily imply more/less side effects; just the dose to produce the response is different. As an example, fentanyl is much higher potency than morphine in its analgesic effect.
Finally, we review multimodal pain control for different common procedures in OB-GYN, including vaginal birth, cesarean section, and hysterectomy.
For vaginal birth and cesarean delivery, ACOG CO 742 is an excellent resource.
For all patients with vaginal birth, ibuprofen and acetaminophen should be enough, in addition to supportive measures and local topical anesthetics. Preparation prior to delivery regarding expected pain/discomfort is also important. If pain after vaginal birth is so severe that these patients require an opioid, Nathan’s pearl is to examine that patient! Many providers are still prescribing opioids, which may contribute to the opioid use epidemic in the USA currently.
After cesarean birth or after hysterectomy or abdominal surgery, preparation and expectation-setting are also key preoperative steps. For cesarean in particular, intrathecal morphine can reduce pain postoperatively.
Enhanced Recovery After Surgery (ERAS) pathways (check out ACOG CO 750), involve scheduled NSAIDs and tylenol, in addition to other steps that get patients eating and moving immediately post-operatively, can reduce opioid use. Opioids are usually necessary in the immediate post-op period; hydrocodone or oxycodone are preferable to hydromorphone (Dilaudid) in terms of opioid choices, due to their relatively lower potency. Local blocks and wound infusions or injections with local anesthetic may also be helpful. To manage constipaton, senna is preferred; docusate sodium may even increase ileus in the post period!
Check out the OBGProject for further reading:
- Cesarean Section Best Practices & Guidelines – The ERAS Committee Recommendations
- Managing Pain in the Postpartum Period: Recommendations Using the Multimodal Approach
- Preemptive Analgesia to Control Postop Hysterectomy Pain: The SGS Clinical Guidelines
- Can Pain Following Gyn Oncology Surgery Be Managed with a Very Restrictive Opioid Protocol?
- How Well Does IV Acetaminophen Control Post-Op Cesarean Pain?
- Fixed-Interval or On-Demand Treatment Better for C-Section Pain?
- Does Preop IV Acetaminophen Reduce Pain following Pelvic Organ Prolapse Surgery?