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Koltenyuk V, Mrad I, Choe I, Ayoub MI, Kumaraswami S, Xu JL. Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review. J Pain Res 2024; 17:797-813. [PMID: 38476879 PMCID: PMC10928917 DOI: 10.2147/jpr.s434010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/08/2024] [Indexed: 03/14/2024] Open
Abstract
The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.
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Affiliation(s)
| | - Ismat Mrad
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, NY, USA
| | - Ian Choe
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Mohamad Ibrahim Ayoub
- Department of Anesthesiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sangeeta Kumaraswami
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jeff L Xu
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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Gurmu M, Mulugeta H, Zemedkun A, Girma T, Destaw B, Tadessa M, Adamu Y, Hailu S. Postoperative analgesic effects of intravenous dexamethasone for patients undergoing cesarean delivery under spinal anesthesia at Dilla University Referral Hospital, Ethiopia, 2023: a double-blind randomized controlled trial. Ann Med Surg (Lond) 2024; 86:232-239. [PMID: 38222682 PMCID: PMC10783290 DOI: 10.1097/ms9.0000000000001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/20/2023] [Indexed: 01/16/2024] Open
Abstract
Background The use of cesarean section (CS) worldwide has increased to unprecedented levels. In Ethiopia, the CS delivery rate is above the rate recommended by the WHO. The postoperative pain experience is moderate to severe in most patients during their postoperative period. The administration of intravenous dexamethasone is thought to have an analgesic effect after surgery even though the analgesic profile of preoperatively administered dexamethasone is less addressed. Objective This study aimed to assess the postoperative analgesic effect of preoperative intravenous dexamethasone for patients undergoing cesarean delivery under spinal anesthesia at Dilla University Referral Hospital, Southern Ethiopia. Methodology A double-blinded randomized controlled trial (RCT) was done on 112 patients undergoing elective CS under spinal anesthesia who were allocated randomly into normal saline and dexamethasone groups. Total analgesic consumption, time to first analgesic request, and postoperative pain score with the numerical rating scale (NRS) were followed for 24 h in both groups. Shapiro-Wilk tests were used to check normality. Independent samples t-test was used for the comparison of means between groups, Mann-Whitney U test for non-normally distributed data, and χ 2 test for categorical variables, and P-value <0.05 was considered statistically significant with a power of 80%. Result The finding of this study showed that the postoperative pain score of the dexamethasone group was significantly lower than the normal saline group at 2, 4, 6, 12, 18, and 24 h with a statistically significant P-value <0.05. There was also a significant difference in the time to the first rescue analgesic request between the two groups, with the dexamethasone group (median=347.5 min) and the normal saline group (median=230 min) with P=0.001. Conclusion and recommendation The authors conclude that preoperative administration of 8 mg of dexamethasone prolongs the first analgesic request time, decreases postoperative tramadol and diclofenac consumption, and decreases the postoperative pain score. The authors recommend that researchers conduct further RCTs with a different dose of dexamethasone and on a multicenter basis.
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Affiliation(s)
| | | | | | | | | | | | | | - Seyoum Hailu
- Department of Anesthesiology, Dilla University, Dilla, Ethiopia
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Zaslansky R, Baumbach P, Edry R, Chetty S, Min LS, Schaub I, Cruz JJ, Meissner W, Stamer UM. Following Evidence-Based Recommendations for Perioperative Pain Management after Cesarean Section Is Associated with Better Pain-Related Outcomes: Analysis of Registry Data. J Clin Med 2023; 12:jcm12020676. [PMID: 36675605 PMCID: PMC9864952 DOI: 10.3390/jcm12020676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Women who have had a Cesarean Section (CS) frequently report severe pain and pain-related interference. One reason for insufficient pain treatment might be inconsistent implementation of evidence-based guidelines. We assessed the association between implementing three elements of care recommended by guidelines for postoperative pain management and pain-related patient-reported outcomes (PROs) in women after CS. The analysis relied on an anonymized dataset of women undergoing CS, retrieved from PAIN OUT. PAIN OUT, an international perioperative pain registry, provides clinicians with treatment assessment methodology and tools for patients to assess multi-dimensional pain-related PROs on the first postoperative day. We examined whether the care included [i] regional anesthesia with a neuraxial opioid OR general anesthesia with wound infiltration or a Transvesus Abdominis Plane block; [ii] at least one non-opioid analgesic at the full daily dose; and [iii] pain assessment and recording. Credit for care was given only if all three elements were administered (= “full”); otherwise, it was “incomplete”. A “Pain Composite Score-total” (PCStotal), evaluating outcomes of pain intensity, pain-related interference with function, and side-effects, was the primary endpoint in the total cohort (women receiving GA and/or RA) or a sub-group of women with RA only. Data from 5182 women was analyzed. “Full” care was administered to 20% of women in the total cohort and to 21% in the RA sub-group. In both groups, the PCStotal was significantly lower compared to “incomplete” care (p < 0.001); this was a small-to-moderate effect size. Administering all three elements of care was associated with better pain-related outcomes after CS. These should be straightforward and inexpensive for integration into routine care after CS. However, even in this group, a high proportion of women reported poor outcomes, indicating that additional work needs to be carried out to close the evidence-practice gap so that women who have undergone CS can be comfortable when caring for themselves and their newborn.
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Affiliation(s)
- Ruth Zaslansky
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
- Correspondence: (R.Z.); (U.M.S.)
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ruth Edry
- Acute Pain Service, Department of Anesthesiology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Sean Chetty
- Department of Anaesthesiology& Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7500, South Africa
| | - Lim Siu Min
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Isabelle Schaub
- Department of Anesthesiology and Pain Clinic, Clinique St Jean, 1000 Brussels, Belgium
| | - Jorge Jimenez Cruz
- Department of Obstetrics and Gynecology, Bonn University Hospital, 53127 Bonn, Germany
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ulrike M. Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence: (R.Z.); (U.M.S.)
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The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review. Anesthesiol Res Pract 2021; 2021:2156918. [PMID: 34589125 PMCID: PMC8476264 DOI: 10.1155/2021/2156918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
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.
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Sacha CR, Mortimer R, Hariton E, James K, Hosseini A, Gray M, Xuan C, Hammer K, Lange A, Mahalingaiah S, Wang J, Petrozza JC. Assessing efficacy of intravenous acetaminophen for perioperative pain control for oocyte retrieval: a randomized, double-blind, placebo-controlled trial. Fertil Steril 2021; 117:133-141. [PMID: 34548165 DOI: 10.1016/j.fertnstert.2021.08.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/29/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effect of preoperative intravenous (IV) acetaminophen versus oral (PO) acetaminophen or placebo on postoperative pain scores and the time to discharge in women undergoing oocyte retrieval. DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Single academic fertility center. PATIENT(S) Women aged 18-43 years undergoing oocyte retrieval. INTERVENTION(S) Randomization to preoperative 1,000 mg IV acetaminophen and PO placebo (group A), IV placebo and 1,000 mg PO acetaminophen (group B), or IV and PO placebo (group C) MAIN OUTCOME MEASURE(S): Difference in patient-reported postoperative visual analog scale pain scores from baseline and the time to discharge. RESULT(S) Of the 159 women who completed the study, there were no differences in the mean postoperative pain score differences or the time to discharge. Although not statistically significant, the mean postoperative opioid dose requirement in group A was lower than that in groups B and C (0.24 vs. 0.59 vs. 0.58 mg IV morphine equivalents, respectively) due to fewer women in group A requiring rescue pain medication (8% vs. 19% vs. 15%, respectively). Group A also reported less constipation when compared with groups B and C (19% vs. 33% vs. 40%, respectively). The rates of postoperative nausea were similar, and there were no differences in embryology or early pregnancy outcomes between the study groups. CONCLUSION(S) Preoperative IV acetaminophen for women undergoing oocyte retrieval did not reduce postoperative pain scores or shorten the time to discharge when compared with PO acetaminophen or placebo and, thus, cannot currently be recommended routinely in this patient population. CLINICAL TRIAL REGISTRATION NUMBER NCT03073980.
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Affiliation(s)
- Caitlin R Sacha
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Roisin Mortimer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of OB/GYN, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts
| | - Eduardo Hariton
- University of California San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California
| | - Kaitlyn James
- Center for Outcomes Research, Department of OB/GYN, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Afrooz Hosseini
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Morgan Gray
- Boston University School of Medicine, Boston, Massachusetts
| | - Chengluan Xuan
- Department of Anesthesia, The First Hospital of Jilin University, Jilin, China; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Karissa Hammer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Shruthi Mahalingaiah
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jingping Wang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John C Petrozza
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Tepper JL, Harris OM, Triebwasser JE, Ewing SH, Mehta AD, Delaney EJ, Sehdev HM. Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery. Am J Perinatol 2021. [PMID: 34311489 DOI: 10.1055/s-0041-1732450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. STUDY DESIGN An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. RESULTS A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10-181.6) MME to 15.8 (IQR: 0-75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18-3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48-1.02). CONCLUSION Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. KEY POINTS · ERAS after cesarean reduces inpatient opioid consumption.. · ERAS after cesarean increases the proportion of women not consuming any opioids.. · This pathway can be feasibly adopted elsewhere..
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Affiliation(s)
- Jared L Tepper
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Malvern, Pennsylvania
| | - Olivia M Harris
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Malvern, Pennsylvania
| | - Jourdan E Triebwasser
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Malvern, Pennsylvania
| | - Stephanie H Ewing
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Malvern, Pennsylvania
| | - Aasta D Mehta
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Malvern, Pennsylvania
| | - Erica J Delaney
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Malvern, Pennsylvania
| | - Harish M Sehdev
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Malvern, Pennsylvania
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Mirteimouri M, Pourali L, Soltani M, Salehi M, Vatanchi A, Abolkheir AZ. Comparison of Pain Score and Complications Following Acetaminophen and Pethidine Injection During Vaginal Delivery: A Double-blind
Clinical Trial. Oman Med J 2021; 36:e250. [PMID: 33936778 PMCID: PMC8072821 DOI: 10.5001/omj.2021.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 08/30/2020] [Indexed: 11/30/2022] Open
Abstract
Objectives Recently, intravenous acetaminophen has been introduced as an intervention with analgesic potential similar to that of opioid analgesics in labor pain management. This study aimed to compare the pain score and maternal and neonatal complications following acetaminophen and pethidine injections during vaginal delivery. Methods This randomized, double-blind clinical trial was conducted on pregnant women during the first stage of delivery referred to Ghaem and Omolbanin Hospitals in Mashhad, Iran, from March to December 2017. The subjects were assigned randomly to one of two groups: acetaminophen and pethidine. The pain intensity was measured before and 15, 60, 120, 180, and 240 minutes after injection. Results The pain score and pain score changes showed no significant difference between the two groups at different times. The incidence of maternal complications during delivery and the first hour after delivery was not statistically significant between the two groups, but 15 minutes after injection, vomiting (p = 0.001), nausea (p = 0.001), and dizziness (p = 0.001) were significantly higher in the pethidine group. The mean one and five minutes Apgar scores were significantly higher in the acetaminophen group. Conclusions Intravenous acetaminophen led to fewer maternal complications than pethidine, especially during the first 15 minutes after injection and fewer neonatal complications, especially in the Apgar score.
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Affiliation(s)
- Masoumeh Mirteimouri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Pourali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mozhgan Soltani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Salehi
- Department of Socio-medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atiyeh Vatanchi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Birchall CL, Maines JL, Kunselman AR, Stetter CM, Pauli JM. Opioid use after cesarean: a cohort study comparing combined versus separate oxycodone and acetaminophen regimens. J Matern Fetal Neonatal Med 2021; 35:5730-5735. [PMID: 33645397 DOI: 10.1080/14767058.2021.1892065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Courtney L Birchall
- Department of Obstetrics and Gynecology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jaimie L Maines
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Allen R Kunselman
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christy M Stetter
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jaimey M Pauli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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Felder L, Riegel M, Quist-Nelson J, Berghella V. Perioperative intravenous acetaminophen and postcesarean pain control: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol MFM 2021; 3:100338. [PMID: 33618034 DOI: 10.1016/j.ajogmf.2021.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 01/10/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Laura Felder
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (Drs Felder, Quist-Nelson, and Berghella); Sidney Kimmel Medical College of Thomas Jefferson University (Ms Riegel), Philadelphia, PA.
| | - Melissa Riegel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (Drs Felder, Quist-Nelson, and Berghella); Sidney Kimmel Medical College of Thomas Jefferson University (Ms Riegel), Philadelphia, PA
| | - Johanna Quist-Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (Drs Felder, Quist-Nelson, and Berghella); Sidney Kimmel Medical College of Thomas Jefferson University (Ms Riegel), Philadelphia, PA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (Drs Felder, Quist-Nelson, and Berghella); Sidney Kimmel Medical College of Thomas Jefferson University (Ms Riegel), Philadelphia, PA
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10
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Tompkins DM, DiPasquale A, Segovia M, Cohn SM. Review of Intravenous Acetaminophen for Analgesia in the Postoperative Setting. Am Surg 2021; 87:1809-1822. [PMID: 33522265 DOI: 10.1177/0003134821989056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Danielle M Tompkins
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA.,Department of Pharmacy, 3673Hackensack University Medical Center, Hackensack, NJ, USA
| | - Arielle DiPasquale
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Michelle Segovia
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Stephen M Cohn
- Department of Surgery, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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Roofthooft E, Joshi GP, Rawal N, Van de Velde M. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 76:665-680. [PMID: 33370462 PMCID: PMC8048441 DOI: 10.1111/anae.15339] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- E Roofthooft
- Department of Anesthesiology, GZA Sint-Augustinus Hospital, Antwerp, Belgium.,Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven, Belgium
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - N Rawal
- Department of Anesthesiology, Orebro University, Orebro, Sweden
| | - M Van de Velde
- Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven, Belgium
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Wilson SH, Wolf BJ, Robinson SM, Nelson C, Hebbar L. Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial. PAIN MEDICINE 2020; 20:1584-1591. [PMID: 30561704 DOI: 10.1093/pm/pny253] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
| | | | - Stefanie M Robinson
- Departments of Anesthesia and Perioperative Medicine.,East Carolina Anesthesia Associates, Greenville, North Carolina, USA
| | - Cecil Nelson
- Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA.,Regional Obstetrical Consultants, Chattanooga, Tennessee, USA
| | - Latha Hebbar
- Departments of Anesthesia and Perioperative Medicine
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13
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Turan A, Essber H, Saasouh W, Hovsepyan K, Makarova N, Ayad S, Cohen B, Ruetzler K, Soliman LM, Maheshwari K, Yang D, Mascha EJ, Ali Sakr Esa W, Kessler H, Delaney CP, Sessler DI. Effect of Intravenous Acetaminophen on Postoperative Hypoxemia After Abdominal Surgery: The FACTOR Randomized Clinical Trial. JAMA 2020; 324:350-358. [PMID: 32721009 PMCID: PMC7388016 DOI: 10.1001/jama.2020.10009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. OBJECTIVE To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. DESIGN, SETTING, AND PARTICIPANTS Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. INTERVENTIONS Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. MAIN OUTCOMES AND MEASURES The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. RESULTS Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). CONCLUSIONS AND RELEVANCE Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02156154.
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Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Hani Essber
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Wael Saasouh
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Karen Hovsepyan
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Natalya Makarova
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of Regional Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Division of Anesthesiology, Intensive Care, and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | | | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Dongsheng Yang
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward J. Mascha
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Wael Ali Sakr Esa
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Herman Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Conor P. Delaney
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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14
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Pan J, Hei Z, Li L, Zhu D, Hou H, Wu H, Gong C, Zhou S. The Advantage of Implementation of Enhanced Recovery After Surgery (ERAS) in Acute Pain Management During Elective Cesarean Delivery: A Prospective Randomized Controlled Trial. Ther Clin Risk Manag 2020; 16:369-378. [PMID: 32440135 PMCID: PMC7210449 DOI: 10.2147/tcrm.s244039] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 04/02/2020] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Jingru Pan
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Ziqing Hei
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Liping Li
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Dan Zhu
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Hongying Hou
- Department of Obstetrics, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Huizhen Wu
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Chulian Gong
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Shaoli Zhou
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
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15
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Ng QX, Loke W, Yeo WS, Chng KYY, Tan CH. A Meta-Analysis of the Utility of Preoperative Intravenous Paracetamol for Post-Caesarean Analgesia. ACTA ACUST UNITED AC 2019; 55:medicina55080424. [PMID: 31370298 PMCID: PMC6723542 DOI: 10.3390/medicina55080424] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/02/2019] [Accepted: 07/29/2019] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Qin Xiang Ng
- MOH Holdings Pte Ltd., 1 Maritime Square, Singapore 099253, Singapore.
- KK Women's and Children's Hospital, Department of Women's Anaesthesia, 100 Bukit Timah Rd, Singapore 229899, Singapore.
| | - Wayren Loke
- MOH Holdings Pte Ltd., 1 Maritime Square, Singapore 099253, Singapore
- Singapore General Hospital, Department of Anaesthesiology, Outram Rd, Singapore 169608, Singapore
| | - Wee Song Yeo
- National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Kelvin Yong Yan Chng
- MOH Holdings Pte Ltd., 1 Maritime Square, Singapore 099253, Singapore
- KK Women's and Children's Hospital, Department of Women's Anaesthesia, 100 Bukit Timah Rd, Singapore 229899, Singapore
| | - Chin How Tan
- KK Women's and Children's Hospital, Department of Women's Anaesthesia, 100 Bukit Timah Rd, Singapore 229899, Singapore
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16
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Hamburger J, Beilin Y. Systemic adjunct analgesics for cesarean delivery: a narrative review. Int J Obstet Anesth 2019; 40:101-118. [PMID: 31350096 DOI: 10.1016/j.ijoa.2019.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 05/24/2019] [Accepted: 06/28/2019] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- J Hamburger
- Department of Anesthesiology, Pain and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, USA.
| | - Y Beilin
- Department of Anesthesiology, Pain and Perioperative Medicine, Department of Obstetrics, Genecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, USA
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17
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Fullin D. Unaccounted factors for opioid use after vaginal delivery. Am J Obstet Gynecol 2019; 220:604. [PMID: 30771343 DOI: 10.1016/j.ajog.2019.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/07/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Daniel Fullin
- Department of Anesthesiology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI.
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18
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Dafna L, Herman HG, Ben-Zvi M, Bustan M, Sasson L, Bar J, Kovo M. Comparison of 3 protocols for analgesia control after cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol MFM 2019; 1:112-118. [DOI: 10.1016/j.ajogmf.2019.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/21/2022]
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Effect of ibuprofen vs acetaminophen on postpartum hypertension in preeclampsia with severe features: a double-masked, randomized controlled trial. Am J Obstet Gynecol 2018; 218:616.e1-616.e8. [PMID: 29505772 DOI: 10.1016/j.ajog.2018.02.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/13/2018] [Accepted: 02/26/2018] [Indexed: 11/23/2022]
Abstract
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.
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