2020 FSA Posters

P092: PAIN MANAGEMENT IN A PARTURIENT WITH MAST CELL ACTIVATION SYNDROME AFTER CAESARIAN SECTION
Katarina Nikolic, MD; Daniel Perez, MD; Igor Kislinger, MD; Pamela Sharaf, MD; Maria Suarez, MD; University of Miami

Introduction: Mast cell activation syndrome (MCAS) is a disorder characterized by dysfunctional mast cells with abnormal release of mediators such as histamine, tryptase, leukotrienes, and prostaglandins. Activation typically occurs in response to triggers, although none may be identified. Mast cell activation causes symptoms associated with multiple organ systems, displays different signs such as hives, rash, anaphylaxis, hot flushing of skin, tachycardia, nausea, and fatigue.Pain is the most common trigger for mast cell activation, its prevention is crucial for the management of patient’s MCAS.

We report a case of postoperative pain management in a parturient with MCAS after cesarean section.

Case Presentation: A 33- year -old female G1P0 at 34.3 weeks reporting mast cell activation disorder, history of L4-S1 instrumentation for disk herniation and spondylolisthesis was admitted for induction of labor. She has history of symptoms including flushing, nausea, vomiting, abdominal pain, diarrhea, dizziness and vasovagal syncope (positive tilt test).

Due to concern for MCAS acute pain service has been consulted for postoperative pain management following the procedure.

TAP block was performed after caesarian section while patient still was sedated under general anesthesia. Ultrasound guided TAP was located on the both sides and 20 ml mixture of 10 ml Exparel (133g) and 10 ml Normal Saline was administrated on each side. Patient controlled analgesia (PCA) with Hydromorphone at basal rate 0.3 ml/hour with allowed 0.2 mg bolus 3 times per hour was planned for postoperative pain control. Acetaminophen 1000mg IV every six hours was prescribed as needed. In the first 24h after surgery patient required 2 boluses of Hydromorphone 0.2 mg IV (0.4mg in total). On postoperative day (POD) 2 patient reported mild pain, remined on PCA but did not need additional Hydromorphone bolus or Acetaminophen. Pain was well controlled on POD 3, PCA was stopped and patient was switched to perioral acetaminophen 1000 mg every six hours which she needed 3 times.  Patient was discharged from the hospital on POD4, comfortable with no requirement for pain medications. Hospital course was uneventful with no signs of MCAS symptoms.

Discussion: Pain control after delivery is imperative in order to facilitate early mother mobility, care of baby, and breastfeeding. Conservative pain treatment includes systemic opioids which provide significant relief but possess possible adverse effects such as nausea, vomiting, pruritus, constipation, and respiratory depression.

It’s well known that morphine can trigger release of histamine and NSAIDs cause overproduction of leukotrienes, therefore peripheral nerve block techniques like transversus abdominis plane (TAP) block were introduced as an effective component of multimodal analgesia after caesarean delivery.  Exparel is liposomal bupivacaine a newly approved formulation by the US Food and Drug Administration (FDA) which liposomal nature causes prolong release of bupivacaine into the injected area and consequently may provide analgesia up to 72h.

TAP blocks with Exparel were an effective adjunct in the pain management of our patient with history MCAS after CS. She had uneventful recovery period with adequate analgesia throughout and minimal opioid consumption. Most importantly, there were no signs of MCAS