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Senn L, Anand S. Integrative Review of Opioid Use and Protocol Adherence in Hospitals After Implementing Enhanced Recovery After Surgery Protocols for Cesarean Birth. Nurs Womens Health 2024:S1751-4851(24)00199-5. [PMID: 39370120 DOI: 10.1016/j.nwh.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 05/15/2024] [Accepted: 09/09/2024] [Indexed: 10/08/2024]
Abstract
OBJECTIVE To evaluate the enhanced recovery after surgery (ERAS) protocols used and amount of opioids administered during hospitalization for cesarean birth after the ERAS protocols were implemented. DATA SOURCES A search was conducted in CINAHL Complete, Scopus, and PubMed for sources published in English between January 2018 and December 2023. Search terms were cesarean AND opioid∗ AND eras OR erac OR enhanced recovery. STUDY SELECTION Eligible studies were conducted in the United States, used key pain management components from the ERAS guidelines, and reported results for in-patient postsurgical opioid use. DATA EXTRACTION Data obtained were for post-ERAS implementation only and included authors, date, sample size, study location, participant inclusion and exclusion criteria, methods, interventions used (ERAS guideline components), and morphine milligram equivalents used during the hospital stay. DATA SYNTHESIS Weighted averages were calculated for results reported as means and percentages. Descriptive summaries were used for the remainder of the results. RESULTS Twenty-six studies were found, accounting for 19,961 individuals' experiences after ERAS implementation. Although 30% of participants experienced only scheduled cesarean births, 70% experienced all types of cesarean births, including scheduled, urgent, or emergent. There was substantial heterogeneity of the data reported, especially for opioid use and time frames. In 11 studies that reported means, the weighted average for opioid use was 54 morphine milligram equivalents per stay. In 17 studies, researchers reported the number of women who experienced an opioid-free recovery, which averaged 40% of the women. CONCLUSION Implementation of standardized orders built on the ERAS guidelines in U.S. hospitals is associated with reduced opioid exposure for women experiencing scheduled and nonscheduled cesarean births while maintaining adequate pain relief. This review offers evidence that can support perinatal teams who are considering ERAS for cesarean birth or those looking for further improvements.
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Silva F, Costa G, Veiga F, Cardoso C, Paiva-Santos AC. Parenteral Ready-to-Use Fixed-Dose Combinations Including NSAIDs with Paracetamol or Metamizole for Multimodal Analgesia-Approved Products and Challenges. Pharmaceuticals (Basel) 2023; 16:1084. [PMID: 37630999 PMCID: PMC10459253 DOI: 10.3390/ph16081084] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
The combination of non-steroidal anti-inflammatory drugs (NSAIDs) with non-opioid analgesics is common in clinical practice for the treatment of acute painful conditions like post-operative and post-traumatic pain. Despite the satisfactory results achieved by oral analgesics, parenteral analgesia remains a key tool in the treatment of painful conditions when the enteral routes of administration are inconvenient. Parenteral ready-to-use fixed-dose combinations of non-opioid analgesics combinations, including NSAIDs and paracetamol or metamizole, could play a central role in the treatment of painful conditions by combining the advantages of multimodal and parenteral analgesia in a single formulation. Surprisingly, only in 2020, a parenteral ready-to-use fixed-dose combination of ibuprofen/paracetamol was launched to the market. This review aims to investigate the current availability of combinations of NSAIDs with paracetamol or metamizole in both European and American markets, and how the combination of such drugs could play a central role in a multimodal analgesia strategy. Also, we explored how the parenteral formulations of NSAIDs, paracetamol, and metamizole could serve as starting elements for the development of new parenteral ready-to-use fixed-dose combinations. We concluded that, despite the well-recognized utility of combining NSAIDs with paracetamol or metamizole, several randomized clinical trial studies demonstrate no clear advantages concerning their efficacy and safety. Future clinical trials specifically designed to assess the efficacy and safety of pre-formulated fixed-dose combinations are required to generate solid evidence about their clinical advantages.
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Affiliation(s)
- Fernando Silva
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Gustavo Costa
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Laboratory of Pharmacognosy, Faculty of Pharmacy, University of Coimbra, Azinhaga de Santa Comba, Pólo das Ciências da Saúde, 3000-548 Coimbra, Portugal
| | - Francisco Veiga
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Catarina Cardoso
- Laboratórios Basi, Parque Industrial Manuel Lourenço Ferreira, Lote 15, 3450-232 Mortágua, Portugal
| | - Ana Cláudia Paiva-Santos
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
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Hostage J, Kolettis D, Sverdlov D, Ludgin J, Drzymalski D, Sweigart B, Mhatre M, House M. Increased Scheduled Intravenous Ketorolac After Cesarean Delivery and Its Effect on Opioid Use: A Randomized Controlled Trial. Obstet Gynecol 2023; 141:783-790. [PMID: 36897140 DOI: 10.1097/aog.0000000000005120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/01/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate the efficacy of scheduled ketorolac in reducing opioid use after cesarean delivery. METHODS This was a single-center, randomized, double-blind, parallel-group trial to assess pain management after cesarean delivery with scheduled ketorolac compared with placebo. All patients undergoing cesarean delivery with neuraxial anesthesia received two doses of 30 mg intravenous ketorolac postoperatively and then were randomized to receive four doses of 30 mg of intravenous ketorolac or placebo every 6 hours. Additional nonsteroidal anti-inflammatory drugs were held until 6 hours after the last study dose. The primary outcome was total morphine milligram equivalents (MME) used in the first 72 postoperative hours. Secondary outcomes included the number of patients who used no opioid postoperatively, postoperative pain scores, postoperative change in hematocrit and serum creatinine, and postoperative satisfaction with inpatient care and pain management. A sample size of 74 per group (n=148) provided 80% power to detect a population mean difference in MME of 32.4, with an SD for both groups of 68.7 after accounting for protocol noncompliance. RESULTS From May 2019 to January 2022, 245 patients were screened and 148 patients were randomized (74 per group). Patient characteristics were similar between groups. The median (quartile 1-3) MME from arrival in the recovery room until postoperative hour 72 was 30.0 (0.0-67.5) for the ketorolac group and 60.0 (30.0-112.5) for the placebo group (Hodges-Lehmann median difference -30.0, 95% CI -45.0 to -15.0, P <.001). In addition, participants who received placebo were more likely to have numeric rating scale pain scores higher than 3 out of 10 ( P= .005). The mean±SD decrease from baseline hematocrit to postoperative day 1 was 5.5±2.6% for the ketorolac group and 5.4±3.5% for the placebo group ( P =.94). The mean±SD postoperative day 2 creatinine was 0.61±0.06 mg/dL in the ketorolac group and 0.62±0.08 mg/dL in the placebo group ( P =.26). Participant satisfaction with inpatient pain control and postoperative care was similar between groups. CONCLUSION Compared with placebo, scheduled intravenous ketorolac significantly decreased opioid use after cesarean delivery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT03678675.
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Affiliation(s)
- Jean Hostage
- Department of Obstetrics and Gynecology, the Department of Anesthesiology and Perioperative Medicine, and the Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
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Badreldin N, Ditosto JD, Holder K, Beestrum M, Yee LM. Interventions to Reduce Inpatient and Discharge Opioid Prescribing for Postpartum Patients: A Systematic Review. J Midwifery Womens Health 2023; 68:187-204. [PMID: 36811227 PMCID: PMC10089962 DOI: 10.1111/jmwh.13475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 12/12/2022] [Accepted: 12/27/2022] [Indexed: 02/24/2023]
Abstract
INTRODUCTION As deaths related to opioids continue to rise, reducing opioid use for postpartum pain management is an important priority. Thus, we conducted a systematic review of postpartum interventions aimed at reducing opioid use following birth. METHODS From database inception through September 1, 2021, we conducted a systematic search in Embase, MEDLINE, Cochrane Library, and Scopus including the following Medical Subject Heading (MeSH) terms: postpartum, pain management, opioid prescribing. Studies published in English, restricted to the United States, and evaluating interventions initiated following birth with outcomes including an assessment of change in opioid prescribing or use during the postpartum period (<8 weeks postpartum) were included. Authors independently screened abstracts and full articles for inclusion, extracted data, and assessed study quality using the Grading of Recommendations, Assessment, Development, and Evaluation tool and risk of bias using the Institutes of Health Quality Assessment Tools. RESULTS A total of 24 studies met inclusion criteria. Sixteen studies evaluated interventions aimed at reducing postpartum opioid use during the inpatient hospitalization, and 10 studies evaluated interventions aimed at reducing opioid prescribing at postpartum discharge. Inpatient interventions included changes to standard order sets and protocols for the management of pain after cesarean birth. Such interventions resulted in significant decreases in inpatient postpartum opioid use in all but one study. Additional inpatient interventions, including use of lidocaine patches, postoperative abdominal binder, valdecoxib, and acupuncture were not found to be effective in reducing postpartum opioid use during inpatient hospitalization. Interventions targeting the postpartum period included individualized prescribing and state legislative changes limiting the duration of opioid prescribing for acute pain both resulted in decreased opioid prescribing or opioid use. DISCUSSION A variety of interventions aimed at reducing opioid use following birth have shown efficacy. Although it is not known if any single intervention is most effective, these data suggest that implementation of any number of interventions may be advantageous in reducing postpartum opioid use.
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Affiliation(s)
- Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia D Ditosto
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kai Holder
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Molly Beestrum
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Lima CMS, Segatto CZ, Zanelli GR, Nicácio GM, Cassu RN. Effects of Lidocaine Injection at Acupuncture Points on Perioperative Analgesia in Cats Undergoing Ovariohysterectomy. J Acupunct Meridian Stud 2022; 15:255-263. [DOI: 10.51507/j.jams.2022.15.4.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/21/2022] [Accepted: 06/01/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
- Camila Menossi Sueza Lima
- Department of Veterinary Surgery and Anestesiology, Faculty of Veterinary Medicine, Universidade do Oeste Paulista, Presidente Prudente, SP, Brazil
| | - Camila Zanetti Segatto
- Department of Veterinary Surgery and Anestesiology, Faculty of Veterinary Medicine, Universidade do Oeste Paulista, Presidente Prudente, SP, Brazil
| | - Gustavo Ricci Zanelli
- Department of Veterinary Surgery and Anestesiology, Faculty of Veterinary Medicine, Universidade do Oeste Paulista, Presidente Prudente, SP, Brazil
| | - Gabriel Montoro Nicácio
- Department of Veterinary Surgery and Anestesiology, Faculty of Veterinary Medicine, Universidade do Oeste Paulista, Presidente Prudente, SP, Brazil
| | - Renata Navarro Cassu
- Department of Veterinary Surgery and Anestesiology, Faculty of Veterinary Medicine, Universidade do Oeste Paulista, Presidente Prudente, SP, Brazil
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Llarena NC, Krivanek K, Yao M, Kim DD, Devarajan J, Ayad S, Chiang E. A multimodal approach to reducing post-caesarean opioid use: a quality improvement initiative. BJOG 2022; 129:1583-1590. [PMID: 35014757 DOI: 10.1111/1471-0528.17094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/15/2021] [Accepted: 09/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the impact of a QI initiative to reduce post-caesarean opioid use. DESIGN Retrospective cohort study. SETTING Academic hospital in the USA. POPULATION Women over 18 years undergoing caesarean section. METHODS A quality improvement (QI) initiative titled Reduced Option for Opioid Therapy (ROOT) was implemented in women undergoing caesarean section. The intervention included implementation of a postpartum order set maximising the use of scheduled NSAIDs and acetaminophen. Additionally, nursing education promoted non-opioid therapy as first-line, with opioids reserved for breakthrough pain. Performance feedback was provided to nursing staff on a bimonthly basis. Post-caesarean opioid use was reviewed in the 6 months before and after implementation of ROOT. MAIN OUTCOME MEASURES The primary outcome was the total morphine milligram equivalents (MME) consumed during the postpartum admission. Secondary outcomes included opioid use per postoperative day, the proportion of opioid-free admissions, the percentage of patients discharged with a prescription for opioids, prescription size, and pain scores. RESULTS Following implementation of ROOT, median inpatient opioid use decreased by more than 60%, from 75 to 30 MME per admission (P < 0.001). The proportion of opioid-free admissions increased from 12.6% pre-intervention to 30.7% post-intervention (P < 0.001). Additionally, the median opioid dose prescribed at discharge decreased in the post-intervention cohort, and the proportion of patients discharged without an opioid prescription increased. The reduction in opioids was associated with a slight decrease in patient-reported pain scores. CONCLUSIONS Implementation of ROOT significantly reduced opioid use while achieving comparable pain control.
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Affiliation(s)
- Natalia C Llarena
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin Krivanek
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, Ohio, USA
| | - Meng Yao
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Outcomes Research, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel D Kim
- Anesthesiology and Pain Management Institute, Cleveland Clinic, Fairview Hospital, Cleveland, Ohio, USA
| | - Jagan Devarajan
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
| | - Sabry Ayad
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Outcomes Research, Anesthesiology and Pain Management Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Anesthesiology and Pain Management Institute, Cleveland Clinic, Fairview Hospital, Cleveland, Ohio, USA.,Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
| | - Eric Chiang
- Anesthesiology and Pain Management Institute, Cleveland Clinic, Fairview Hospital, Cleveland, Ohio, USA
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Laksono I, Matelski J, Flamer D, Gold S, Selk A. Evaluation of a quality improvement bundle aimed to reduce opioid prescriptions after Cesarean delivery: an interrupted time series study. Can J Anaesth 2021; 69:1007-1016. [PMID: 34750746 PMCID: PMC9343303 DOI: 10.1007/s12630-021-02143-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/29/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To evaluate whether opioid prescriptions at discharge after Cesarean delivery decreased following implementation of a quality improvement bundle. Methods A quality improvement bundle was instituted at Mount Sinai Hospital in Toronto. Interventions included opioid prescribing instructions in resident orientation, nursing and patient education, and standard electronic prescriptions. We used an interrupted time series study design and included patients who had a Cesarean delivery six months pre intervention and six months post intervention. Primary outcome data (opioids prescribed at discharge in morphine milliequivalents [MME]), were aggregated (averaged) by calendar week and analyzed using interrupted time series. Secondary outcomes were assessed using bivariate methods and included opioid use for breakthrough pain in hospital, and amount of opioids prescribed by prescriber specialty and training level. Results We included 2,578 women in our analysis. Based on the segmented regression analysis, prescribed opioids decreased from 97.6 MME in 2018 to 35.8 MME in 2019 (difference in means, − 61.7; 95% confidence interval [CI], − 72.2 to − 51.3; P < 0.001), and this decrease was sustained over the study period. Post intervention, there were no visits to our postnatal assessment clinic for inadequate pain control. Conclusion A quality improvement bundle was associated with a marked and sustained decrease in discharge prescriptions of opioids post Cesarean delivery at a large Canadian tertiary academic hospital. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-021-02143-7.
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Affiliation(s)
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - David Flamer
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Shira Gold
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Amanda Selk
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, 700 University Ave, 3rd Floor, Toronto, ON, M5G1Z5, Canada.
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