Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control

The evaluation of the efficacy of etofenamate spray in postoperative cesarean pain: Randomized, double-blind, placebo-controlled trial

OBJECTIVE

It was aimed to investigate the effect of etofenamate spray to be applied around the postoperative incision on pain control in cesarean section in this trial.

MATERIAL AND METHODS

This was a prospective, randomized, double-blind, and placebo-controlled trial. 187 patients (93 cases and 94 controls) were recruited for the study. In the trial group, we applied the etofenamate spray (Doline® 50 ml) after closing the cesarean skin incision and go on four times a day on the skin incision for 24 h. In the control group, we applied a placebo. All patients received paracetamol IV (Paracerol®) as standard analgesic doses. If analgesia was insufficient, tramadol (Contramal®) 50 mg IV doses were added and recorded. A visually analog pain scale (VAS) was performed on both groups at 6-12-18-24th hours. Independent t-tests were performed for data showing normal distributions.

RESULTS

There were no significant differences in the mean of differences VAS scores between the two groups at 6-12, and 6-18 h. However, a significant difference was obtained in the mean of differences VAS score at the 6-24th hour (p < 0.05). When the groups were compared in terms of additional paracetamol need, a significant difference was found again (p < 0.05). There was no significant difference between the groups in terms of tramadol need.

CONCLUSION

Postoperative administration of etofenamate spray provided an analgesic effect at 24 h and additional analgesic usage decreased. Postoperative analgesia can also be used by administering NSAIDs around the cesarean section incision. In this way, the side effects of other systemic analgesics are avoided.

CLINICAL TRIAL ID

PACTR201811864509898. CLINICAL TRIAL WEB LINK: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5745.

Effect of combined paracetamol and dexamethasone vs. paracetamol on postoperative nausea vomiting after cesarean section

OBJECTIVES

Postoperative nausea and vomiting (PONV) are common symptoms after cesarean delivery (CD) that affect patients outcomes and satisfaction. The treatment of choice is still evolving, therefore, we aimed to evaluate PONV of combined paracetamol-dexamethasone vs. paracetamol alone.

METHODS

This study is a double-blind randomized controlled trial on 100 patients undergoing cesarean delivery. Participants were randomly assigned into two groups of paracetamol or combined paracetamol-dexamethasone. Nausea and vomiting score, VAS score of pain, and chill were compared between the two groups.

RESULTS

The result of this study found that mild nausea 2nd h after surgery in the combined group was lesser than paracetamol group (0.03). However, there was no statistically significant difference in nausea and vomiting score in other periods of time between the two groups. VAS score of pain decreased 12th and 6th h after the surgery in the combined and paracetamol group, respectively. Chilling occurred in two patients of combined group and four patients of paracetamol group (p=0.432).

CONCLUSIONS

Dexamethasone added to paracetamol might not improve pain and vomiting after cesarean delivery comparison with just paracetamol. But it can be effective for reducing the score of nausea after the surgery.

A comparison of acute pain management strategies after cesarean delivery

BACKGROUND

There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited.

OBJECTIVE

To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain.

STUDY DESIGN

This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant.

RESULTS

During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001).

CONCLUSION

Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

Postoperative Respiratory Compromise following Cesarean Birth: The Impact of Obesity and Systemic Opioids

Objective  The aim of this study was to measure the effect of obesity and systemic opioids on respiratory events within the first 24 hours following cesarean. Methods  Opioid-naive women undergoing cesarean between January 2016 and December 2017 were included in this retrospective cohort study. The primary outcome was the proportion of women experiencing at least one composite respiratory outcome (oxygen saturation less than 95% lasting 30+ seconds or need for respiratory support) within 24 hours of cesarean. The impact of obesity and total systemic opioid dose in 24 hours (measured in morphine milligram equivalents [MMEs]) on the composite respiratory compromise outcome were evaluated. Results  Of 2,230 cesarean births, 790 women had at least one composite respiratory event. Predictors of the composite respiratory outcome included body mass index (BMI) as a continuous variable (odds ratio = 1.063 for every one unit increase in BMI [95% confidence interval (CI): 1.021-1.108], p  = 0.003), and MME (odds ratio = 1.005 [95% CI: 1.002-1.008], p  = 0.003), adjusting for magnesium sulfate use. The interaction between obesity and opioid dose demonstrated an odds ratio of 1.000 (95% CI: 0.999-1.000, p  = 0.030). Conclusion  The proportion of women experiencing respiratory events following cesarean birth increases with the degree of obesity and opioid dose. Key Points Respiratory events increase with obesity.Respiratory events increase with systemic opioid use.Odds ratio of respiratory events is 1.063/unit BMI increase.

Systematic Review of Systemic and Neuraxial Effects of Acetaminophen in Preclinical Models of Nociceptive Processing

Acetaminophen (APAP) in humans has robust effects with a high therapeutic index in altering postoperative and inflammatory pain states in clinical and experimental pain paradigms with no known abuse potential. This review considers the literature reflecting the preclinical actions of acetaminophen in a variety of pain models. Significant observations arising from this review are as follows: 1) acetaminophen has little effect upon acute nociceptive thresholds; 2) acetaminophen robustly reduces facilitated states as generated by mechanical and thermal hyperalgesic end points in mouse and rat models of carrageenan and complete Freund’s adjuvant evoked inflammation; 3) an antihyperalgesic effect is observed in models of facilitated processing with minimal inflammation (eg, phase II intraplantar formalin); and 4) potent anti-hyperpathic effects on the thermal hyperalgesia, mechanical and cold allodynia, allodynic thresholds in rat and mouse models of polyneuropathy and mononeuropathies and bone cancer pain. These results reflect a surprisingly robust drug effect upon a variety of facilitated states that clearly translate into a wide range of efficacy in preclinical models and to important end points in human therapy. The specific systems upon which acetaminophen may act based on targeted delivery suggest both a spinal and a supraspinal action. Review of current targets for this molecule excludes a role of cyclooxygenase inhibitor but includes effects that may be mediated through metabolites acting on the TRPV1 channel, or by effect upon cannabinoid and serotonin signaling. These findings suggest that the mode of action of acetaminophen, a drug with a long therapeutic history of utilization, has surprisingly robust effects on a variety of pain states in clinical patients and in preclinical models with a good therapeutic index, but in spite of its extensive use, its mechanisms of action are yet poorly understood.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Fifty Years of the Rise in Cesarean Birth in the United States and Opportunities for Improvement

Factors that shaped and promoted cultural norms in the 1900s continue to influence current obstetric practice today. The incidence of cesarean birth too often has little to do with the health needs of the woman or the fetus and more to do with multiple factors over which the woman has no control. Nurses and midwives can reduce unnecessary cesarean births and have the necessary knowledge, competence, and skills to help women give birth without medical intervention.

Efficacy of Intravenous Paracetamol and Ibuprofen on Postoperative Pain and Morphine Consumption in Lumbar Disc Surgery: Prospective, Randomized, Double-Blind, Placebo-Controlled Clinical Trial

OBJECTIVES

Effective postoperative pain management after lumbar disc surgery reduces complications and improves postoperative care. The purpose of this prospective, randomized, double-blind, placebo-controlled clinical study is to evaluate the effects of IV paracetamol and ibuprofen on postoperative pain, morphine consumption and side effects of morphine in patients who underwent lumbar disc surgery.

MATERIALS AND METHODS

Seventy-five patients aged 18-85 years scheduled for lumbar disk surgery with a single level laminectomy included in this study. All patients received morphine with an IV patient-controlled analgesia device during the first postoperative 24hour. The patients were divided randomly and double-blinded into three groups (control, paracetamol and ibuprofen). The demographic characteristics and procedure data, VAS score, cumulative morphine consumption, opioid-related side effects were recorded.

RESULTS

There was no significant difference regarding to demographic characteristics, comorbidities, and durations of anesthesia and surgery. There was a significant difference between all groups regarding to total morphine consumption (P<0.001). IV ibuprofen significantly reduced the total morphine consumption in comparison with control and paracetamol (P<0.001). Repeated measures ANOVA showed in all periods of the study that VAS score was significantly lower in ibuprofen (P<0.001), but not in paracetamol (P=0.394) in comparison with control. There was no difference between groups regarding postoperative heart rate, mean arterial pressure, nausea-vomiting, pruritus and urinary retention.

CONCLUSIONS

This study showed that pain scores and morphine consumption, but not the side effects of patient-controlled analgesia during 24hours after the lumbar disk surgery, were significantly reduced by IV ibuprofen as a supplemental analgesic when compared with controls and paracetamols.

Opioid use after cesarean: a cohort study comparing combined versus separate oxycodone and acetaminophen regimens

OBJECTIVE

To determine whether an inpatient post-cesarean analgesic regimen which separated oxycodone and acetaminophen resulted in less inpatient opioid use, when compared to a regimen using combination medications containing both acetaminophen and oxycodone in a cohort including patients of all gestational ages, acuity levels, and modes of operative anesthesia.

METHODS

This is a retrospective cohort study which was conducted at a single tertiary care center Labor and Delivery unit. Data were collected via retrospective chart review, and a total of 170 records were examined with a final N = 150. Inclusion criteria were all patients over the age of 18, and >23.0 weeks gestational age, who had a singleton or twin cesarean delivery regardless of their mode of operative anesthesia and whether or not they received intrathecal opioid at time of delivery. Exclusion criteria were pregnancies of higher-level multiples (triplets or greater), prolonged intensive care unit (ICU) stay, and patients who received both combination oxycodone-acetaminophen and separately administered oxycodone. For analysis patients were classified into two groups: the "Combined Medication" group representing patients who received combination oxycodone-acetaminophen medication only (n = 83) and the "Separate Medication" group representing patients who received oxycodone and acetaminophen separately (n = 67). Differences between the groups with respect to opioid use and acetaminophen use were assessed.

RESULTS

The primary outcome was inpatient opioid medication use per 12-h period in intravenous morphine mg equivalents (MME). Patients received an average of 4.6 ± 3.5 MME IV morphine per 12 h in the Separate Medication group and 5.7 ± 3.7 MME IV morphine per 12 h in the Combined Medication group. When controlled for several covariates, the Separate Medication group took significantly fewer MME per 12-h period (mean difference = -1.2, 95% CI: (-2.3, -0.1), p = .04). There was no appreciable difference in acetaminophen utilization between groups.

CONCLUSIONS

An analgesic regimen where oxycodone is ordered separately from acetaminophen is associated with reduced inpatient opioid medication use in patients of all gestational ages, acuity levels, and modes of operative anesthesia.

Perioperative intravenous acetaminophen and postcesarean pain control: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to determine the efficacy of perioperative (pre- or intraoperative) intravenous acetaminophen in improving postcesarean pain control in healthy women receiving regional anesthesia.

DATA SOURCES

MEDLINE, Ovid, ClinicalTrials.gov, and Scopus were searched from their inception to September 2019.

STUDY ELIGIBILITY CRITERIA

A systematic review of the literature was performed to identify all randomized placebo-controlled trials examining the effect of perioperative intravenous acetaminophen on postcesarean pain control and other postoperative outcomes. Included trials examined women who were healthy and received regional anesthesia before cesarean delivery at term.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome was 24-hour postoperative pain scores with movement as measured by the individual studies. Secondary outcomes included intravenous morphine milligram equivalents used postoperatively. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference with 95% confidence interval.

RESULTS

Notably, 4 randomized placebo-controlled trials were identified that met the inclusion criteria with a total of 190 in the intervention arm vs 174 women in the control group. Patients in the intervention group received 1000 mg intravenous acetaminophen in 3 of the studies and 2000 mg intravenous acetaminophen in 1 study. All patients received regional anesthesia before surgery. The medication was given anywhere from 1 hour before surgery to intraoperatively immediately after delivery of the fetus. Pain scores 24 hours after surgery were only available in 1 study. The use of opioids as measured by morphine milligram equivalents after surgery was similar for patients receiving perioperative intravenous acetaminophen and those receiving placebo (38.7 vs 42.55; mean difference, -2.54; 95% confidence interval, -9.24 to 4.16). Only 1 study showed decreased postoperative pain scores when using perioperative intravenous acetaminophen, and this was limited to the first 4 hours after surgery. Importantly, these patients did not receive long-acting neuraxial opioids, which may account for the finding of improved pain control in the early postoperative period.

CONCLUSION

There are limited data available on the use of perioperative intravenous acetaminophen for cesarean delivery performed at term with regional anesthesia. The use of long-acting neuraxial opioids may make perioperative (pre- or intracesarean) intravenous acetaminophen unnecessary, whereas intravenous (or oral) acetaminophen may become more effective as neuraxial opioid analgesia wears off. More level-1 data are needed.

Review of Intravenous Acetaminophen for Analgesia in the Postoperative Setting

BACKGROUND

Acetaminophen is a non-opioid analgesic commonly utilized for pain control after several types of surgical procedures.

METHODS

This scoping primary literature review provides recommendations for intravenous (IV) acetaminophen use based on type of surgery.

RESULTS

Intravenous acetaminophen has been widely studied for postoperative pain control and has been compared to other agents such as NSAIDs, opioids, oral/rectal acetaminophen, and placebo. Some of the procedures studied include abdominal, gynecologic, orthopedic, neurosurgical, cardiac, renal, and genitourinary surgeries. Results of these studies have been conflicting and largely have not shown consistent clinical benefit.

CONCLUSION

Overall, findings from this review did not support the notion that IV acetaminophen has significant efficacy for postoperative analgesia. Given the limited clinical benefit of IV acetaminophen, especially when compared to the oral or rectal formulations, use is generally not justifiable.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Evidence for the Efficacy of an Opioid-Sparing Effect of Intravenous Acetaminophen in the Surgery Patient: A Systematic Review

BACKGROUND

Intravenous (IV) acetaminophen is used in multimodal analgesia to reduce the amount and duration of opioid use in the postoperative setting.

METHODS

A systematic review of published randomized controlled trials was conducted to define the opioid-sparing effect of IV acetaminophen in different types of surgeries. Eligible studies included prospective, randomized, double-blind trials of IV acetaminophen compared with either a placebo- or active-treatment group in adult (age ≥18 years) patients undergoing surgery. Trials had to be published in English in a peer-reviewed journal.

RESULTS

A total of 44 treatment cohorts included in 37 studies were included in the systematic analysis. Compared with active- or placebo-control treatments, IV acetaminophen produced a statistically significant opioid-sparing effect in 14 of 44 cohorts (32%). An opioid-sparing effect was more common in placebo-controlled comparisons. Of the 28 placebo treatment comparisons, IV acetaminophen produced an opioid-sparing effect in 13 (46%). IV acetaminophen produced an opioid-sparing effect in only 6% (one out of 16) of the active-control groups. Among the 16 active-control groups, opioid consumption was significantly greater with IV acetaminophen than the active comparator in seven cohorts and not significantly different than the active comparator in eight cohorts.

CONCLUSIONS

The results of this systematic analysis demonstrate that IV acetaminophen is not effective in reducing opioid consumption compared with other adjuvant analgesic agents in the postoperative patient. In patients where other adjuvant analgesic agents are contraindicated, IV acetaminophen may be an option.

Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery

AIM

To evaluate an opioid-free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre-MAP).

METHODS

The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5-6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3.

RESULTS

Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P-value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD.

CONCLUSION

MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre-MAP results while maintaining high patients' satisfaction with pain control.

Pain management strategies in penile implantation

The opioid epidemic continues to be a serious public health concern. Many have pointed to prescription drug misuse as a nidus for patients to become addicted to opioids and as such, urologists and other surgical subspecialists must critically define optimal pain management for the various procedures performed within their respective disciplines. Controlling pain following penile prosthesis implantation remains a unique challenge for urologists, given the increased pain patients commonly experience in the postoperative setting. Although most of the existing urological literature focuses on interventions performed in the operating room, there are many studies that examine the role of preoperative adjunctive pain medicine in diminishing postoperative narcotic requirements. There are relatively few studies looking at postoperative strategies for managing pain in prosthetic surgery with follow-up past the immediate hospitalization. This review assess the various strategies employed for managing pain following penile implantation through the lens of the current state of the opioid crisis, thus examining how urologists can responsibly treat pain without contributing to the growing threat of opioid addiction.

Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial

OBJECTIVE

Examination of postoperative analgesia with intravenous and oral acetaminophen.

DESIGN

Prospective, three-arm, nonblinded, randomized clinical trial.

SETTING

A single academic medical center.

SUBJECTS

Parturients scheduled for elective cesarean delivery.

METHODS

This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects.

RESULTS

Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group.

CONCLUSIONS

Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.

Enhancing patient mobility following cesarean-delivery - the efficacy of an improved postpartum protocol assessed with pedometers

Background

The incidence of thromboembolic complications is highest in the immediate postpartum period, especially following caesarean delivery (CD). Ambulation following CD is important in their prevention. We examined the effect of an educational protocol on patients’ mobility following CD, with the use of digital step counters (pedometers).

Methods

Starting February 2018, we implemented an educational protocol at the maternity ward, which included nurses’ tutoring and subsequent patients’ education, regarding the importance of early ambulation. Following CD, ambulation was initiated 4 h following surgery (as compared to 6 h prior). Scheduled IV acetaminophen was administered at six-hour intervals for 48 h (as compared to only 24 h prior), while additional analgesics were given upon patient request. We compared maternal demographics, delivery and postpartum course between the pre-protocol group (n = 101) and the post-protocol group (n = 100). All patients were asked to wear pedometers for 48 h following the delivery to assess ambulation.

Results

Patients’ demographics, surgical and post-partum course were non-significant between the groups, except for surgical length (48.5 ± 14.6 vs. 53.5 ± 15.3 min in the pre and post protocol groups, respectively, p = 0.02). The pre-protocol group was treated with more additional analgesics (p = 0.02). A higher number of steps was taken in the post-protocol group as compared to the pre-protocol group (4394 ± 2985 vs.3551 ± 2931, respectively p = 0.04). In a linear regression analysis in which the number of steps served as the dependent variable, this educational protocol was independently associated with a higher number of steps [coefficient 988 steps, 95% CI 137–1838, p = 0.02], as was smoking, after adjustment for surgical length, emergent surgery, maternal age and body mass index.

Conclusion

An educational protocol which included earlier ambulation and regular interval pain control was associated with improved ambulation following CD.

The Advantage of Implementation of Enhanced Recovery After Surgery (ERAS) in Acute Pain Management During Elective Cesarean Delivery: A Prospective Randomized Controlled Trial

OBJECTIVE

The aim of this study was to test whether the implementation of an enhanced recovery after surgery (ERAS) protocol for patients undergoing elective cesarean delivery has a positive impact on the postoperative status of the patients in terms of pain management, hospital stay, hospitalization costs, and adverse reactions.

METHODS

Patients who underwent elective cesarean delivery were randomized into two groups - ERAS group and control group - and the groups were managed with the ERAS protocol and traditional protocol, respectively.

RESULTS

Compared to the control group, the ERAS group had significantly fewer patients with intraoperative nausea, pain of visual analog scale (VAS) scores, and VAS grade >3 during rest in the first 24 h and during motion in the first 24 and 48 h after surgery. There were no intergroup differences in the requirement of extra analgesics, the incidence of vomiting, shivering, hypotension, postoperative nausea, and pruritus. None of the patients in either group had postoperative vomiting. Patient satisfaction rated as per the VAS was significantly higher in the ERAS group than in the control group. The total length of stay, postoperative length of stay, and the cost of anesthesia in both groups were comparable. Further, the average daily hospitalization cost was significantly lower in the ERAS group than in the control group.

CONCLUSION

The ERAS protocol shows promise and appears to be worthwhile for widespread implementation among patients undergoing elective cesarean delivery; it was found to be beneficial in reducing the postoperative pain, incidence of intraoperative nausea, and average cost of hospitalization and also improved patient satisfaction.

The analgesic efficacy of IV acetaminophen for acute postoperative pain in C-section patients: a randomized, double-blind, placebo-controlled study

Background: The rate of cesarean delivery is on the rise in the USA. Satisfactory postoperative analgesia remains a top priority for cesarean delivery. Multimodal analgesia with a reduction in opioid consumption and improvement in patient satisfaction is a goal for anesthesiologists caring for this patient population. Our study sought to assess whether IV acetaminophen in four divided doses over 24 h decreased pain scores and opioid requirements in patients undergoing cesarean delivery with neuraxial anesthesia.Methods: 66 patients undergoing elective cesarean delivery under spinal anesthesia with hyperbaric bupivacaine 12 mg, fentanyl 10 µg, and preservative-free morphine 150 µg were randomized to receive either IV acetaminophen or IV placebo for four consecutive doses in the first 24 h postoperatively. The need for rescue medication using morphine equivalence, pain scores, patient satisfaction, and side effects were assessed by a blinded researcher in the first 24 and 48 h postoperatively.Results: There was no difference in opioid requirements in the acetaminophen versus placebo group, 44.32 ± 23 mg versus 47.59 ± 28 mg (p = .607), respectively at 24 h. There was also no difference at 48 h, 57.95 ± 20 mg versus 56.59 ± 22 mg (p = .795). Postoperative pain scores, patient satisfaction, and adverse events were similar in both groups as well.Conclusions: The results of this study failed to demonstrate any additional benefits of administering multiple doses of IV acetaminophen for treating postoperative pain in patients who have undergone CS surgery and receiving intra-thecal morphine as part of their anesthesia and analgesia.Trial Registry number: NCT02069184.

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

The Effect of Intravenous Acetaminophen on Patient Outcomes within a Large Integrated Delivery Network

OBJECTIVE

To evaluate the impact of intravenous acetaminophen on patient outcomes.

METHODS

In this retrospective observational analysis, 54,742 patients were identified from 19 Catholic Health Initiatives hospitals during a 12-month period. Charges were used to identify patients who received intravenous acetaminophen during their encounter. The control group included patients who did not receive intravenous acetaminophen. Five outcomes were measured: total length of stay, intensive care unit (ICU) length of stay, total narcotic use (in morphine milligram equivalents [MME]), likelihood of receiving a narcotic prescription at discharge, and 30-day readmission rate. Patients undergoing five procedures were evaluated: total knee replacements, total hip replacements, cesarean section, coronary artery bypass graft (CABG), and gallbladder resection. These patients were also evaluated in a combined group.

RESULTS

After matching, population imbalances for patient characteristics were addressed. Combined with the five outcomes, 25 populations had a sufficient number of matched pairs for analysis. Six of the 25 tests showed a significant difference favoring the control group. Total length of stay was shorter for the control group in the combined population (-0.18 days [4 hours], 95% confidence interval (CI) -0.26 to -0.11). Total narcotic use was lower for the control group in the caesarean section (-10 MME, 95% CI -16 to -5), CABG (-26 MME, 95% CI -41 to -12), and combined (-13 MME, 95% CI -16 to -11) populations. The control group was less likely to be discharged with a narcotic prescription for the caesarean section (odds ratio (OR) -1.39, 95% CI -1.00 to -1.92) and combined (OR -1.14, 95% CI -1.04 to -1.24) populations.

CONCLUSIONS

Intravenous acetaminophen was not associated with improvement in the following patient outcomes: total length of stay, ICU length of stay, total narcotic use, likelihood of receiving a discharge narcotic prescription, and 30-day readmission rate. Based on these findings, clinicians may reconsider the routine use of intravenous acetaminophen.

Safety of Postoperative Opioid Alternatives in Plastic Surgery: A Systematic Review

With the growing opioid epidemic, plastic surgeons are being encouraged to transition away from reliance on postoperative opioids. However, many plastic surgeons hesitate to use nonopioid analgesics such as nonsteroidal antiinflammatory drugs and local anesthetic blocks because of concerns about their safety, particularly bleeding. The goal of this systematic review is to assess the validity of risks associated with nonopioid analgesic alternatives. A comprehensive literature search of the PubMed and MEDLINE databases was conducted regarding the safety of opioid alternatives in plastic surgery. Inclusion and exclusion criteria yielded 34 relevant articles. A systematic review was performed because of the variation between study indications, interventions, and complications. Thirty-four articles were reviewed that analyzed the safety of ibuprofen, ketorolac, celecoxib, intravenous acetaminophen, ketamine, gabapentin, liposomal bupivacaine, and local and continuous nerve blocks after plastic surgery procedures. There were no articles that showed statistically significant bleeding associated with ibuprofen, celecoxib, or ketorolac. Similarly, acetaminophen administered intravenously, ketamine, gabapentin, and liposomal bupivacaine did not have any significant increased risk of adverse events. Nerve and infusion blocks have a low risk of pneumothorax. Limitations of this study include small sample sizes, different dosing and control groups, and more than one medication being studied. Larger studies of nonopioid analgesics would therefore be valuable and may strengthen the conclusions of this review. As a preliminary investigation, this review showed that several opioid alternatives have a potential role in postoperative analgesia. Plastic surgeons have the responsibility to lead the reduction of postoperative opioid use by further developing multimodal analgesia.

A Meta-Analysis of the Utility of Preoperative Intravenous Paracetamol for Post-Caesarean Analgesia

Background and objectives: Worldwide, the number of caesarean sections performed has increased exponentially. Some studies have reported better pain control and lower postoperative requirements for opioids when intravenous (IV) paracetamol was administered preoperatively. This meta-analysis thus aimed to investigate the utility of preoperative IV paracetamol for post-caesarean analgesia. Materials and Methods: By using the keywords (paracetamol OR acetaminophen) AND [cesarea* OR caesarea* OR cesaria* OR caesaria*], a systematic literature search was conducted using PubMed, Medline, Embase, Google Scholar and ClinicalTrials.gov databases for papers published in English between January 1, 1960 and March 1, 2019. Grey literature was searched as well. Results: Seven clinical trials were reviewed, while five randomized, placebo-controlled, double-blind studies were included in the final meta-analysis. Applying per-protocol analysis and a random-effects model, there was a significant reduction in postoperative opioid consumption and pain score in the group that received preoperative IV paracetamol, compared to placebo, as the standardized mean difference (SMD) were −0.460 (95% CI −0.828 to −0.092, p = 0.014) and −0.719 (95% CI: −1.31 to −0.13, p = 0.018), respectively. However, there was significant heterogeneity amongst the different studies included in the meta-analysis (I² = 70.66%), perhaps owing to their diverse protocols. Some studies administered IV paracetamol 15 min before induction while others gave it before surgical incision. Conclusion: This is the first review on the topic. Overall, preoperative IV paracetamol has convincingly demonstrated useful opioid-sparing effects and it also appears safe for use at the time of delivery. It should be considered as a component of an effective multimodal analgesic regimen. Future studies could be conducted on other patient groups, e.g., those with multiple comorbidities or chronic pain disorders, and further delineate the optimal timing to administer the drug preoperatively.

Systemic adjunct analgesics for cesarean delivery: a narrative review

It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.

Intravenous Acetaminophen Before Pelvic Organ Prolapse Repair: A Randomized Controlled Trial

OBJECTIVE

To compare the effect of preoperative intravenous (IV) acetaminophen compared with placebo on pain scores after pelvic organ prolapse surgery.

METHODS

This double-blind placebo-controlled multicenter trial randomized women undergoing prolapse surgery to IV acetaminophen (1,000 mg) or preoperative saline stratified by surgical route (laparoscopic or vaginal). The primary outcome was the change from baseline in patient-reported visual analog scale pain scores at 24 hours after surgery. Secondary outcomes included narcotic use measured in morphine milligram equivalents, satisfaction and quality of life (QOL) using validated questionnaires on postoperative days 1 and 7, and overall side effects.

RESULTS

Between 2014 and 2017, 204 women were enrolled and primary-outcome data from 162 were analyzed. Women had a mean (±SD) age of 66±10 years, were predominantly Caucasian (96%) and postmenopausal (96%). Acetaminophen was administered to 52 of the 101 women undergoing vaginal surgery, and 50 of the 101 women undergoing laparoscopy. There were no overall or route of surgery differences in mean change from baseline pain scores at 24 hours between acetaminophen and placebo (overall 25±26 vs 21±24 mm; vaginal 29±28 vs 21±23 mm; laparoscopic 20±26 vs 21±25 mm). There were no differences in 24-hour morphine milligram equivalent narcotic use (overall 38±25 vs 40±25 mg; vaginal 32±24 vs 33±25 mg; laparoscopic 45±24 vs 47±24 mg). No differences were seen in patient satisfaction, QOL, or side effects, except for urinary retention.

CONCLUSION

In women undergoing prolapse repair, preoperative IV acetaminophen did not reduce pain scores or opioid use and had no effect on patient satisfaction or QOL. Routine use of preemptive IV acetaminophen alone is not supported by this study.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02155738.

Effect of ibuprofen vs acetaminophen on postpartum hypertension in preeclampsia with severe features: a double-masked, randomized controlled trial

BACKGROUND

Nonsteroidal antiinflammatory drug use has been shown to increase blood pressure in nonpregnant adults. Because of this, the American College of Obstetricians and Gynecologists suggests avoiding their use in women with postpartum hypertension; however, evidence to support this recommendation is lacking.

OBJECTIVE

Our goal was to test the hypothesis that nonsteroidal antiinflammatory drugs, such as ibuprofen, adversely affect postpartum blood pressure control in women with preeclampsia with severe features.

STUDY DESIGN

At delivery, we randomized women with preeclampsia with severe features to receive around-the-clock oral dosing with either 600 mg of ibuprofen or 650 mg of acetaminophen every 6 hours. Dosing began within 6 hours after delivery and continued until discharge, with opioid analgesics available as needed for breakthrough pain. Study drugs were encapsulated in identical capsules such that patients, nurses, and physicians were masked to study allocation. Exclusion criteria were serum aspartate aminotransferase or alanine aminotransferase >200 mg/dL, serum creatinine >1.0 mg/dL, infectious hepatitis, gastroesophageal reflux disease, age <18 years, or current incarceration. Our primary outcome was the duration of severe-range hypertension, defined as the time (in hours) from delivery to the last blood pressure ≥160/110 mm Hg. Secondary outcomes were time from delivery to last blood pressure ≥150/100 mm Hg, mean arterial pressure, need for antihypertensive medication at discharge, prolongation of hospital stay for blood pressure control, postpartum use of short-acting antihypertensives for acute blood pressure control, and opioid use for breakthrough pain. We analyzed all outcome data according to intention-to-treat principles.

RESULTS

We assessed 154 women for eligibility, of whom 100 met entry criteria, agreed to participate, and were randomized to receive postpartum ibuprofen or acetaminophen for first-line pain control. Seven patients crossed over or did not receive their allocated study drug, and 93 completed the study protocol in their assigned groups. We found no differences in baseline characteristics between groups, including mode of delivery, body mass index, parity, race, chronic hypertension, and maximum blood pressure prior to delivery. We did not find a difference in the duration of severe-range hypertension in the ibuprofen vs acetaminophen groups (35.3 vs 38.0 hours, P = .30). There were no differences between groups in the secondary outcome measures of time from delivery to last blood pressure ≥150/100 mm Hg, postpartum mean arterial pressure, maximum postpartum systolic or diastolic blood pressures, any postpartum blood pressure ≥160/110 mm Hg, short-acting antihypertensive use for acute blood pressure control, length of postpartum stay, need to extend postpartum stay for blood pressure control, antihypertensive use at discharge, or opioid use for inadequate pain control. In a subgroup analysis of patients who experienced severe-range hypertension, the mean time to blood pressure control in the acetaminophen group was 68.4 hours and ibuprofen group was 56.7 hours (P = .26). At 6 weeks postpartum, there were no differences between groups in the rates of obstetric triage visits, hospital readmissions, continued opioid use, or continued antihypertensive use.

CONCLUSION

The first-line use of ibuprofen rather than acetaminophen for postpartum pain did not lengthen the duration of severe-range hypertension in women with preeclampsia with severe features.

Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized double-blinded placebo control trial

BACKGROUND

The United States currently has an opioid use disorder epidemic and research evaluating ways to minimize the use of opioids postsurgery are needed. One of these options is intravenous acetaminophen. If the use of preoperative intravenous acetaminophen was found to be effective for cesarean delivery, this would be beneficial for both the mother and breast-feeding neonate.

OBJECTIVE

The primary study objective was to see if maternal opioid use was significantly less in the postoperative period for the study group that received 1 g of intravenous acetaminophen preoperatively compared with a control group that received placebo. The secondary objectives were to evaluate maternal length of stay and pain scores postoperatively, and assess the acetaminophen level in cord blood at delivery.

STUDY DESIGN

This study was a prospective double-blinded randomized placebo-controlled trial. All pregnant patients who entered labor and delivery for a scheduled cesarean from November 2015 through April 2017 were eligible. Once consented, the medication was supplied by the pharmacy department, which performed the blinded randomization. Both the study drug of 1000 mg (1 g) of acetaminophen and placebo of normal saline were distributed as unmarked 100-mL bags administered over 15 minutes just prior to incision. No study personnel from the obstetric or anesthesia departments had any access to the randomization. Based on a power analysis using the published surgical data results, the goal was to obtain a minimum of 100 patients (50 patients in each arm). Primary data collection included demographics, number of opioid doses and morphine milligram equivalents administered to the patient postoperatively, length of stay postdelivery, pain scores, and newborn cord blood acetaminophen levels. Exclusions were maternal acetaminophen allergy, receipt of acetaminophen in the prior 24 hours, opioid use disorder, and hepatitis/liver impairment. Statistics involved χ², Fisher exact, and the Student t test where appropriate and a P value <.05 was considered significant with all tests considered against a 2-sided alternative hypothesis.

RESULTS

A total of 105 patients were evaluated with 51 who received intravenous acetaminophen and 54 who received placebo. The number of postoperative opioid medication doses administered to the study group was 11.1 (±8.9) compared with the number received by the control group of 10.5 (±8.5), P = .72. The morphine milligram equivalents in the study group was 94.2 (±40.4) compared with the control group of 90.7 (±42.1), P = .67. The length of stay and pain scores were not different between the groups. All of the umbilical cord blood values for acetaminophen were subtherapeutic.

CONCLUSION

These data demonstrate that for cesarean delivery, the use of a preoperative 1-g intravenous dose of acetaminophen does not decrease the number of opioid medication doses or the morphine milligram equivalents administered postoperatively, nor does it decrease length of stay postcesarean. The administration of 1-g intravenous acetaminophen preoperatively does not result in elevated newborn cord blood levels (ClinicalTrials.govNCT02694653).