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Effect of a Change in Analgesic Protocol on Postoperative Outcomes in Women Undergoing Cesarean Delivery
Abstract Number: T1A-2
Abstract Type: Original Research
Adequate pain control following cesarean delivery is important, especially in the setting of enhanced recovery after surgery protocols. At our institution patients receive a standardized multimodal analgesic regimen consisting of neuraxial morphine with scheduled non-steroidal anti-inflammatory drugs and acetaminophen. Our initial protocol involved starting the oral analgesics in the recovery room. There was variability in whether these medications were given in a timely manner or withheld in the setting of postoperative nausea and vomiting. We modified this protocol and performed a study to assess the impact of this change on postoperative analgesic consumption in women undergoing cesarean delivery under neuraxial anesthesia.
We performed a retrospective analysis of patients having cesarean deliveries from 07/01/2014 to 08/22/2017. With the initial analgesic protocol, patients received neuraxial morphine as well as 500 mg of naproxen q12h and 650-975 mg of PO acetaminophen q6h initiated in the recovery room. The protocol was revised in January 2016 using the same neuraxial morphine doses. Patients are now given 975 mg of PR acetaminophen at the start of the case, and 15-30 mg of IV ketorolac at the end of the case. Postoperatively, patients receive PO acetaminophen (975mg q6h), IV ketorolac (15 mg q6h) for 3 doses and are then transitioned to PO ibuprofen (600 mg q6h). Oxycodone PO, IV fentanyl or hydromorphone are given for breakthrough pain with both protocols. Primary outcome is need for rescue opioid analgesia. Secondary outcomes are total opioid used and need for rescue antiemetics. Univariate and multivariate analyses were performed controlling for variables significantly different between the two cohorts.
A total of 3250 patients were included. There was no difference in patient demographics or intraoperative characteristics between the two cohorts except for more primaparous women (26% vs. 17%) and more Pfannenstiel incision (98% vs. 96%) in the new protocol cohort. Need for rescue opioids was reduced with the new protocol at 2, 24 and 48 h (Table). Among those who received opioids, median opioid consumption was reduced (median (IQR) 55 (30,95) vs. 40 (20,70) mg oxycodone equivalents after protocol revision (GMR 0.75,95% CI 0.7,0.81;p<0.0001). Need for rescue antiemetics was also significantly reduced.
There was a significant decrease in need and dose of rescue analgesia with the new protocol.