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Multimodal Pain Management for Cesarean Delivery: A Doubled Blinded, Placebo Controlled, Randomized Clinical Trial
Abstract Number: O1-5
Abstract Type: Original Research
Objective: Opioid misuse/addiction may develop after medically-indicated use, such as postoperative pain management. Multimodal pain management strategies have been shown to reduce opioid use after abdominal surgery, but little is known about its benefits in cesarean delivery (CD). Our objective was to evaluate the efficacy of multimodal pain management in reducing opioid use after scheduled CD.
Study Design: Single center double-blind placebo-controlled randomized trial of women undergoing scheduled CD. Those with contradictions to study medications were excluded. Participants were allocated 1:1 to receive study medications (pre-operative IV Tylenol, SC bupivacaine pre-incision and IM ketorolac at fascia closure) or matching placebos. Postoperative pain management was per standard of care. The primary outcome was amount of opioid intake at 48 hours postoperatively. Secondary outcomes were postoperative pain score at 6-12, 24, and 48 hours and time to first opioid intake. Data was analyzed using parametric and non-parametric tests as appropriate. Quantile regression was used to investigate potential determinants of inpatient opioid use and the time to 1st opioid administration postoperatively. We estimated 120 women would be needed for 90% power to show a 25% reduction in our primary outcome.
Results: Baseline characteristics and indication for CD were not different between the multimodal and control groups. There was no significant difference in amount of opioid use at 48 hours between the groups (mean difference (Δ)-5.2, 95%CI -13.8-3.4, p=0.2) and no difference in the time to first opioid administration (Δ0.2, 95%CI -3.3-3.6, p=0.9) or pain scores at 6-12, 24, or 48 hours. Univariate quantile regression showed the median inpatient morphine-equivalents used was higher among Caucasians (5.19 mg 95%CI 0.16-10.2, p=0.04). Smokers and patients with a history of illicit drug use, not only had higher median postoperative opiate use (11.43 mg, 95%CI 5.07-17.79; 11.43 mg, 95%CI 5.07-17.79 respectively), but also had earlier administration (6.47 hours, 95%CI 3.2 - 9.74, and 6.24 hours, 95%CI 3.4 - 9.08 respectively).
Conclusion: We were unable to show that our multimodal pain regimen reduced opioid use in the 48 hours after scheduled CD. We did find that patients who are Caucasian, smokers, or with history of drug use require opioids earlier and in larger amounts in the immediate post-operative