The results of a before-and-after study reveal that combined administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen in fixed intervals optimized postoperative pain management after scheduled cesarean delivery. These findings were published in the Journal of Clinical Anesthesia.
The investigators assessed enhanced recovery after cesarean delivery (ERAC) protocols at the University of Virginia Health System. Patients scheduled to undergo cesarean delivery were coadministered NSAID and acetaminophen every 6 hours (ERAC2; n=162) or alternating the 2 medications every 3 hours (ERAC1; n=179) and evaluated for postoperative pain management and opioid consumption. Data were collected prospectively for ERAC1 between May 2016 and September 2017 and for ERAC2 between November 2017 and June 2018. Historical data from September 2014 to October 2015 were used as the control group (pre-ERAC; n=179).
The pre-ERAC, ERAC1, and ERAC2 cohorts comprised women aged mean 30.9, 31.1, and 31.4 years; 50%, 60%, and 64% were White; mean BMI was 34.0, 34.4, and 35.8 kg/m2; and 10%, 12%, and 9% had gestational diabetes.
On postoperative days 0 to 3, the pre-ERAC cohort consumed the highest amount of total morphine milligram equivalents (MME) (MMEs; mean, 128.7; 95% CI, 47.0-174.5 MME), followed by the ERAC1 (mean, 72.6; 95% CI, 15.0-108.0 MME) and the ERAC2 (mean, 47.4; 95% CI, 7.5-60.0 MME) groups. The ERAC2 group was associated with decreased use of opioids on days 0 (odds ratio [OR], 0.15; P <.0001), 1 (OR, 0.21; P <.0001), 2 (OR, 0.37; P <.0001), and 3 (OR, 0.47; P =.008).
Maximum pain scores were significantly decreased among the ERAC2 cohort compared with the control group (mean difference [MD], -0.57; P =.018). No significant differences were reported between the ERAC1 and Pre-ERAC groups (MD, -0.47; P =.060) or between the ERAC2 and ERAC1 groups (MD, -0.10; P =.999).
Compared with the pre-ERAC group, the median length of hospital stay significantly decreased from 3 days to 2 days in both the ERAC1 (P <.0001) and ERAC2 (P =.002) groups.
Stratified by ethnicity, in the pre-ERAC cohort Hispanic women (MD, -1.11 MMD; P =.0003) and women described as “non-Hispanic other” (MD, -1.56 MMD; P =.004) used fewer opioids than Black women. No differences between racial/ethnic groups in postoperative opioid use were observed among women in the ERAC1 and ERAC2 groups.
The major limitation of this study was the before-and-after design, in which clinicians and patients may have gained more understanding of the potential harms of opioids as the opioid epidemic progressed over time.
The researchers concluded, “This combined administration schedule for multimodal analgesia medications was associated with a decrease in postoperative opioid utilization and an increase in the number of women who did not take opioids postoperatively.” Teams developing or modifying their center’s ERAC protocols should consider this analgesic strategy.
Forkin KT, Mitchell RD, Chiao SS, et al. Impact of timing of multimodal analgesia in enhanced recovery after cesarean delivery protocols on postoperative opioids: a single center before-and-after study. J Clin Anesth. Published online April 22, 2022. doi:10.1016/j.jclinane.2022.110847