A standardized post-cesarean analgesia regimen reduces postpartum opioid use.

Abstract

BACKGROUND\nOptimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen.\n\n\nOBJECTIVE\nTo determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth.\n\n\nSTUDY DESIGN\nA standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975\u2009mg every 6\u2009h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15\u2009mg IV every 6\u2009h for 5 doses followed by ibuprofen 600\u2009mg oral every 6\u2009h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72\u2009h postoperatively. Total dose at 12, 24, and 48\u2009h were also compared.\n\n\nRESULTS\nOf 2340 women who underwent cesarean birth during the study period (1 July 2017\u2009-\u200930 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72\u2009h postoperatively was 216.3\u2009±\u200984.3 MME prior to implementation compared to 171.5\u2009±\u200991.5 MME following implementation (p\u2009<\u2009.001). The average cumulative MME use was higher in the pre-protocol period compared to post-protocol at all time periods: 12\u2009h (57.3\u2009±\u200923.8 vs 48.6\u2009±\u200926.2 MME, p\u2009<\u2009.001), 24\u2009h (98.1\u2009±\u200934.1 vs 82.1\u2009±\u200938.8 MME, p\u2009<\u2009.001), and 48\u2009h (165.8\u2009±\u200958.3 vs 134.9\u2009±\u200966.2 MME, p\u2009<\u2009.001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p\u2009<\u2009.001).\n\n\nCONCLUSION\nScheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72\u2009h postoperatively.