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Effect of Patient Choice of Analgesic Protocol After Cesarean Delivery: A Randomized Prospective Clinical Trial
Abstract Number: O1-8
Abstract Type: Original Research
Background: The study aimed to determine if providing women with a choice for their analgesic protocol after cesarean delivery (CD) would impact opioid requirement, pain report, opioid-related side effects and/or maternal satisfaction.
Methods: Patients undergoing CD with spinal anesthesia were randomly assigned to be offered a choice of postoperative analgesic protocol or to have no choice and receive routine care. Women randomized to receive a choice were asked to choose between a low, medium, or high dose analgesic protocol. The low dose group received 50 mcg intrathecal morphine (ITM), medium dose received 150 mcg ITM, and high dose received 300 mcg ITM and a single dose of oral gabapentin after delivery. The patients randomized to no choice received routine care with a protocol identical to that of the medium dose group. All patients received scheduled acetaminophen and ibuprofen. The primary outcome was rescue oxycodone requirements during first 48 h after CD.
Results: 160 women were enrolled; 120 were offered a choice and 40 were not. In the choice group, 18% chose low, 68% chose medium, and 14% chose high dose analgesic protocol. Rescue oxycodone requirement differed according to choice (Figure 1). Patients who chose the high dose protocol took 5 (0-15) and 15 (10-25) mg more oxycodone than the other groups at 24 and 48 h respectively (p=0.05 and p=0.001), and patients who chose the low dose required 5 (-15-0) mg less rescue oxycodone at 48 h (p=0.03). There was no difference in pain scores according to group choice. Patients who chose the low dose had less pruritus (p=0.001); while those who chose the high dose had more nausea or vomiting (p=0.01). There was no difference in rescue oxycodone dose or pain scores between those offered and not offered a choice; however, those offered a choice were slightly more satisfied with their anesthesia care (5/100 (0-10/100) % difference, p=0.005).
Conclusion: Findings suggest that women have insight into their analgesic needs and appreciate being given a choice for their CD analgesia. Despite receiving six times greater ITM dose plus gabapentin, women who chose the high dose protocol still required more rescue oxycodone. Choice of lower and higher doses was appropriately driven by anticipated side effects and pain aversion, respectively. The study demonstrated the utility of patient engagement and shared decision-making approach for CD pain management.
Reference: Br J Anaesth 2017; 118: 762-771