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Impact of an enhanced recovery pathway for cesarean delivery on postoperative opioid use
Abstract Number: F3A-146
Abstract Type: Original Research
Background: Enhanced recovery after surgery pathways have been implemented in a number of surgical specialties with positive outcomes. Cesarean delivery is one of the most common surgeries performed worldwide, and the adoption of enhanced recovery pathways for cesarean delivery is gaining popularity. We tested the hypothesis that implementation of an enhanced recovery pathway for cesarean delivery would be associated with a decrease in postoperative opioid consumption without negative impact on post-operative pain control, patient satisfaction, length of stay, or 30-day postoperative complications.
Methods: A single center observational cohort study that compared a retrospective cohort of women delivered by elective, scheduled cesarean section (January 1, 2017 to June 30, 2018) to a prospective cohort exposed to the enhanced recovery pathway (July 1, 2018 to December 31, 2018). The primary clinical outcome was maternal opioid use, measured as total oral morphine equivalents, during the inpatient postoperative stay. Secondary outcomes included post-operative pain scores, patient satisfaction, length of stay, and 30-day postoperative complications including unscheduled clinic visits and hospital readmission. We also evaluated process measures reflective of protocol adherence which included time to post-operative ambulation, oral intake, and urinary catheter removal.
Results: 547 patients were included, 112 in the enhanced recovery cohort (ERC) and 435 in the pre-enhanced recovery cohort (Pre-ERC). The ERC used significantly less oral morphine equivalents (OMEs) postoperatively compared with the pre-ERC (average total postoperative OME for the ERC was 60.34mg, vs 105.87mg in the pre-ERC, p <0.001). 58.93% of patients in the ERC did not consume opioids within the 24hrs prior to discharge, compared with 25.75% in the Pre-ERC (p <0.001). Post-operative pain scores were slightly lower in the ERC compared with the pre-ERC (average pain score 1.61/10 in EHC vs 1.90/10 in pre-EHC, p = 0.033, average daily maximum pain score 4.40/10 in EHC vs 4.93/10 in pre-EHC, p = 0.047). There was no significant difference in post-operative length of stay (81.37 hours in ERC vs 90.70 hours in pre-ERC, p = 0.076) or 30-day postoperative complication rate (12.50% in ERC vs 14.94% in pre-ERC, p = 0.512) between cohorts.
Conclusions: The implementation of an enhanced recovery pathway for cesarean deliveries was associated with a 43% reduction in post-operative opioid consumption. There was also a significant reduction in the percentage of patients who consumed opioids within 24hrs prior to discharge. Post-operative pain scores were slightly lower after implementation of the enhanced recovery pathway, without significant difference in length of stay or 30-day postoperative complications.