Comparison of postoperative pain between patients who underwent primary and repeated cesarean section: a prospective cohort study

Comparison of postoperative pain severity between primary and repeated cesarean section: a prospective cohort study

BACKGROUND

The cesarean section was associated with moderate to severe postoperative pain. Uncertain differences exist between parturient who undergo a primary cesarean section and a repeat cesarean section in terms of post-operative pain.

OBJECTIVE

To compare the degree of postoperative pain in patients who had primary and repeat cesarean sections.

METHOD

An institutional-based prospective cohort study was conducted on 336 patients who fulfilled eligibility criteria and underwent caesarian section under spinal anesthesia. Study participants were selected by a systematic random sampling technique. An independent sample t test and a Mann-Whitney U test were used to compare symmetric and asymmetric data, respectively. Time to first analgesic request was analyzed using log rank Kaplan-Meier survival curves and cox-regression for covariates. Comparisons of categorical variables between groups were done using the chi-square test. The significance was determined at a P value of < 0.05.

RESULTS

There was a high Risk of moderate to severe postoperative pain in repeated caesarean section compared to primary caesarean section in both incisional pain (RR, 1.364[95% CI, 1.12-1.66], p = 0.002) and visceral pain (RR, 1.66[95% CI, 1.40-1.66], p = 0.001). In comparison to the primiparas, parturient with repeated cesarean sections had highest post-operative pain severity in NRS with median NRS of 5(IQR, 3-5) at the 4th hour (p < 0.001) for the incisional pain and 6(IQR, 5-7) at the 8th hour for visceral pain, respectively, for the repeated group. The primiparas group had a longer median time to first rescue analgesic administration (median [minute], 875.7[95% CI, 750.3-1001]; P < 0.001)) than the repeated group (median [minute], 534.8 [95% CI, 426.8-642.8]; P < 0.001.

CONCLUSIONS

Compared to primary CS, repeated cesarean had a high incidence of moderate to severe postoperative pain, both visceral and incisional; within 48-h. In future endeavors of crafting postoperative analgesic plans, it is imperative to take into account individual variations and distinctions.

Prevalence and Associated Factors of Postoperative Acute Pain for Mothers Who Gave Birth With Cesarean Section: A Systematic Review and Meta-Analysis

BACKGROUND

Cesarean section frequently is associated with different undesirable postoperative outcomes. Acute postoperative pain is one of the most frequently experienced adverse outcomes that occurs as the result of actual tissue damage. Previous studies have shown inconsistent results regarding the prevalence and predictors of acute postoperative pain. Therefore, this study aimed to assess the pooled prevalence and associated factors of postoperative pain after cesarean section.

METHODS

This is a systematic review and meta-analysis study that was performed on the basis of studies published within the last 10 years on the prevalence and associated factors of postoperative pain after cesarean section. After PubMed, Google Scholar, HINAR, Scopus, Web of Sciences, Cochrane, EMBASE, and gray literature extensive search for primary studies, their quality was assessed and data was extracted. STATAMP, version 17.0, was used for all possible analyses of the study.

RESULTS

Twenty-eight studies were included in this systematic review and meta-analysis. The pooled prevalence of postoperative pain was 58% (95% confidence interval [CI] 48%, 67%) with heterogeneity (I2 99.33%). Incision length >10 centimeters (odds ratio [OR] 2.34 [95% CI 1.71, 2.97]); spinal anesthesia without adjuvant (OR 3.45 [95% CI 1.56, 5.33]); general type of anesthesia (OR 3.54 [95% CI 2.61, 4.48]); presence of preoperative anxiety (OR-1.73, 95% CI 1.12-2.35); and no peripheral nerve block (OR 3.23 [95% CI, 2.27-4.18]) were associated with the prevalence of postoperative pain significantly.

CONCLUSIONS

The pooled prevalence of acute postoperative pain after cesarean section was high (58%), which needs more strategies for pain management. Incision length >10 centimeters, spinal anesthesia without adjuvants, general type of anesthesia, preoperative anxiety, and no peripheral nerve block were significantly associated with this prevalence.

Association between duration of urinary catheterization and post-operative mobilization following elective cesarean section: A retrospective case-control study in Espoo, Finland

INTRODUCTION

Cesarean section is the most common surgery performed on women. The enhanced recovery recommendations are early urinary catheter removal and early mobilization, as essential elements of post-operative care. This study aimed to analyze the association between these elements and whether limiting the catheter treatment duration affects the timing of post-operative mobilization.

METHODS

This retrospective case-control study compared the mobilization of healthy elective cesarean patients under different instructions on urinary catheter removal: cases with a preset catheter removal time (8-12 hours) and controls with catheter removal based on midwife considerations. Apart from the preset time of catheter removal, the routine post-operative care was given by the same personnel without any advice on patient mobilization. Data on patient demographics, surgery details, post-operative medication, first upright mobilization, the length of hospital stay, and patient satisfaction were analyzed.

RESULTS

The study comprised 52 cases and one control for each case (N=104). The mean duration of urinary catheterization was 20.15 ± 6.59 and 11.30 ± 4.20 hours in the control and intervention groups, respectively (p<0.001). A linear regression analysis showed a significant association between the catheter removal time and patient mobilization, when adjusted for maternal background parameters (age, BMI, fear of childbirth diagnosis, prior uterine scar), duration and timing of the surgery, bleeding and post-operative analgesic use (R2=0.444, p<0.001). No difference was detected in the length of hospital stay, or patient satisfaction.

CONCLUSIONS

Limiting the duration of urinary catheter therapy is associated with shorter time to post-operative mobilization. A prospective randomized trial would provide more detailed information.

Postoperative analgesic consumption for primary versus first repeat Cesarean delivery: a historical cohort study

PURPOSE

It is unclear if postoperative pain experience and opioid consumption differ in patients undergoing primary vs repeat Cesarean delivery (CD) as prior studies have yielded conflicting results and none used the same patients as their own controls. We sought to compare opioid consumption and pain scores in patients undergoing both a primary and a first repeat CD, using the same patients as their own controls.

METHODS

We conducted a single-centre historical cohort study of patients who underwent both a primary and a first repeat CD under neuraxial anesthesia between 1 January 2016 and 30 November 2022. The same standardized multimodal analgesic regimen was used for all patients. The primary outcome was opioid consumption in oral morphine equivalents (OME) at 48 hr after surgery. Secondary outcomes included area under the curve for pain scores at 24 and 48 hr, and opioid consumption at 24 hr.

RESULTS

We included 409 patients. In unadjusted analysis, there were no significant differences between primary and repeat CD in median [interquartile range] opioid consumption at 48 hr (45 [15-89] mg vs 45 [15-83] mg OME) or in any of the secondary outcomes. In the multivariable model adjusting for age, body mass index, anxiety, depression, priority, surgery duration, gestational age, receipt of postoperative ketorolac, and neuraxial type, repeat CD was still not associated with increased opioid consumption compared with primary CD (adjusted rate ratio, 1.20; 95% confidence interval, 0.95 to 1.51).

CONCLUSION

In this retrospective study, we found no differences in postoperative opioid consumption or reported pain scores in patients who underwent both a primary and a first repeat CD.

Effects of hydromorphone-based patient-controlled intravenous analgesia on postoperative hypoxaemia: a randomised controlled non-inferiority clinical trial

OBJECTIVE

This study aimed to compare the effects of patient-controlled intravenous analgesia (PCIA) with and without low-basal infusion on postoperative hypoxaemia.

DESIGN

A randomised parallel-group non-inferiority trial.

SETTING

The trial was conducted at a grade-A tertiary hospital from December 2021 to August 2022.

PARTICIPANTS

160 adults undergoing gastrointestinal tumour surgery and receiving postoperative PCIA.

INTERVENTIONS

Participants randomly received a low-basal (0.1 mg/hour of hydromorphone) or no-basal infusion PCIA for postoperative 48 hours.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was area under curve (AUC) per hour for hypoxaemia, defined as pulse oxygen saturation (SpO2) <95%. Secondary outcomes included: AUC per hour at SpO2<90% and <85%, hydromorphone consumption, ambulation time and analgesic outcomes up to 48 hours after surgery.

RESULTS

Among 160 randomised patients, 159 completed the trial. An intention-to-treat analysis showed that AUC per hour (SpO2<95%) was greater in the low-basal infusion group compared with the no-basal infusion group, with a median difference of 0.097 (95% CI 0.001 to 0.245). Non-inferiority (margin: ratio of means (ROM) of 1.25) was not confirmed since the ROM between the two groups was 2.146 (95% CI 2.138 to 2.155). Hydromorphone consumption was higher in the low-basal group than in the no-basal group (median: 5.2 mg versus 1.6 mg, p<0.001). Meanwhile, there were no differences in the AUC values at the other two hypoxaemia thresholds, in ambulation time, or pain scores between the groups.

CONCLUSIONS

Among the patients receiving hydromorphone PCIA after gastrointestinal tumour resection, low-basal infusion was inferior to no-basal infusion PCIA for postoperative hypoxaemia at SpO2<95% up to 48 hours after surgery.

TRIAL REGISTRATION NUMBER

ChiCTR2100054317.

Comparison of analgesic effects between programmed intermittent epidural boluses and continuous epidural infusion after cesarean section: a randomized controlled study

BACKGROUND

This study aimed to compare the analgesic effects of programmed intermittent epidural boluses (PIEB) and continuous epidural infusion (CEI) for postoperative analgesia after elective cesarean section (CS).

METHODS

Seventy-four women who underwent elective CS were randomized to receive either PIEB or CEI. The PIEB group received 4 ml-intermittent boluses of 0.11% ropivacaine every hour at a rate of 120 ml/h. The CEI group received a constant rate of 4 ml/h of 0.11% ropivacaine. The primary outcome was the pain score at rest at 36 h after CS. Secondary outcomes included the pain scores during mobilization, time-weighted pain scores, the incidence of motor blockade, and complications-related epidural analgesia during 36 h after CS.

RESULTS

The pain score at rest at 36 h after CS was significantly lower in the PIEB group compared with that in the CEI group (3.0 vs. 0.0; median difference: 2, 95% CI [1, 2], P < 0.001). The mean time-weighted pain scores at rest and during mobilizations were also significantly lower in the PIEB group than in the CEI group (pain at rest; mean difference [MD]: 37.5, 95% CI [24.6, 50.4], P < 0.001/pain during mobilization; MD: 56.6, 95% CI [39.8, 73.5], P < 0.001). The incidence of motor blockade was significantly reduced in the PIEB group compared with that in the CEI group (P < 0.001).

CONCLUSIONS

PIEB provides superior analgesia with less motor blockade than CEI in postpartum women after CS, without any apparent adverse events.

Effect of Personality and Pain Catastrophizing on Postoperative Analgesia Following Cesarean Section: A Prospective Cohort Study

Purpose

This study aimed to investigate the effects of different psychological personalities and pain catastrophizing levels on postoperative analgesia in patients undergoing cesarean section.

Patients and Methods

Puerperas who underwent cesarean section at our hospital between January and August 2023 were recruited into the study and assessed using the Eysenck Personality Questionnaire-Revised Short Scale (EPQRSC) and Pain Catastrophizing Scale (PCS). Data on the numerical pain intensity at rest and during activity 24 h after surgery, number and dosage of analgesia pumps, and satisfaction with analgesia were recorded. According to the numerical pain score during activity 24 h post-operation, the patients were divided into the analgesia incomplete group (≥4) and control group (<4). Univariate analysis, Spearman correlation analysis, and binary logistic regression analysis were used to evaluate the influence of personality characteristics and PCS on postoperative analgesia.

Results

A total of 778 women were included in the study. The incidence of inadequate analgesia was 89.8%. The satisfaction rate of analgesia was 66.8%. Univariate analysis showed that extraversion; neuroticism; PCS; numbers of previous cesarean delivery; ASA; analgesic satisfaction; and 24-h analgesia pump compressions and dosage were associated with postoperative analgesia after cesarean section (P<0.05). Using binary logistic regression analysis, the first cesarean section (odds ratio [OR]=0.056, 95% confidence interval [CI]=1.913-19.174), the number of 24-h analgesic pump compressions (OR=8.464, 95% CI=0.356-0.604), extraversion (OR=0.667, 95% CI=0.513-0.866), neuroticism (OR=1.427, 95% CI=1.104-1.844), and PCS (OR=7.718, 95% CI=0.657-0.783) were factors affecting postoperative analgesia.

Conclusion

The incidence of inadequate analgesia after a cesarean section was high (89.8% on the first day after surgery). Formulating accurate analgesia programs for women undergoing cesarean section with extraversion, neuroticism personality characteristics, and pain catastrophizing behaviors is necessary for improving their postoperative analgesia effects and satisfaction and promoting postpartum comfort.

Incidence and predictors of postoperative severe acute pain within 24 hours after cesarean section performed under spinal anesthesia at public hospitals in West Shoa, Ethiopia, 2022 prospective cohort study

Background

Acute postoperative pain is common after a caesarean section; the mother suffers severe pain in the first 24 h after the caesarean section compared to spontaneous birth. Failure to discover predictors of pain leads to maternal dissatisfaction, increased expenses, and restricted movement; it increases the risk of deep vein thrombosis, lengthens hospital stays, and decreases social intimacy.

Methods and materials

An institution-based prospective cohort study was conducted among 422 women who went to undergo caesarean sections under spinal anaesthesia at public hospitals in West Shoa from 30 July to 30 October. Participants were selected by systematic random sampling. Data were collected by a structured questionnaire, and the collected data were entered into SPSS version 20 and exported into STATA 64 for analysis. The results were presented in tables and figures. Risk factors were assessed by Poisson regression with a robust standard error.

Results

The overall incidence of severe postoperative pain after a caesarean section performed under spinal anaesthesia within 24 h of follow-up was 50.4% [95% confidence interval (CI): 40.7, 60.1]. Preoperative anxiety risk ratio 1.7 (95% CI: 1.4-2.0), preoperative pain risk ratio 1.3 (95% CI: 1.0-1.48), type of incision risk ratio 11.3 (95% CI: 1.1-1.6), spinal anaesthesia without adjuvants risk ratio 4.1 (95% CI: 1.5-10.9), and duration of surgery risk ratio 1.5 (95% CI: 1.3-1.8) were found to be predictors for postoperative severe acute pain after caesarean section performed under spinal anaesthesia.

Conclusion

In this study, the overall incidence of severe acute pain after a caesarean section under spinal anaesthesia was high. Preoperative fear, duration of the operation, preparatory pain, spinal anaesthesia without the use of adjuvants, and the type of incision were risk factors for severe acute postoperative pain after a caesarean section under spinal anaesthesia.

Efficacy of electroacupuncture combined with intravenous patient-controlled analgesia after cesarean delivery: a randomized clinical trial

BACKGROUND

Electroacupuncture is a nonpharmacologic intervention for analgesia that is widely recognized as therapy for pain. However, the clinical efficacy of electroacupuncture combined with patient-controlled intravenous analgesia for postoperative analgesia after cesarean delivery remains unclear.

OBJECTIVE

This study aimed to assess the efficacy of electroacupuncture + patient-controlled intravenous analgesia for postoperative analgesia after cesarean delivery, determine the optimal frequency for the best analgesic effect, and explore the underlying mechanism of action.

STUDY DESIGN

This single-center, randomized, single-blinded, sham acupuncture controlled clinical trial was conducted at a tertiary university hospital in China. Female patients who underwent cesarean delivery and received fentanyl as patient-controlled intravenous analgesia for postoperative analgesia were enrolled. Patients were after surgery randomized to receive 2 Hz electroacupuncture treatment (n=53), 20/100 Hz electroacupuncture treatment (n=53), or sham electroacupuncture treatment (n=52) (controls). The 2 electroacupuncture groups received electroacupuncture treatment at 2 or 20/100 Hz at the ST36 and SP6 points, whereas, in the sham electroacupuncture group, sham electroacupuncture was performed at nonmeridian points with nonenergized electroacupuncture instruments. Of note, 4 electroacupuncture treatments were performed in all groups at 6, 12, 24, and 48 hours after surgery. The primary outcome was the number of analgesic pump compressions at 48 hours after surgery. The secondary outcomes included number of analgesic pump compressions at 6, 12, and 24 hours after surgery; pain scores at 6, 12, 24, and 48 hours after surgery; fentanyl consumption at 48 hours after surgery; interleukin 6 and procalcitonin levels at 12 and 48 hours after surgery; and time to first exhaust.

RESULTS

Overall, 174 primigravida women were included in the intention-to-treat analysis. The number of analgesic pump compressions and pain scores at all 4 time points and fentanyl consumption at 48 hours after surgery were significantly lower in the electroacupuncture treatment groups than in the sham electroacupuncture group (P<.001).

CONCLUSION

Electroacupuncture + patient-controlled intravenous analgesia had a significantly better analgesic effect than sham electroacupuncture + patient-controlled intravenous analgesia within 48 hours after surgery. Thus, electroacupuncture can be considered safe and effective and may improve the efficacy of patient-controlled intravenous analgesia for pain management after cesarean delivery. Electroacupuncture can be recommended as a routine complementary therapy for pain control after cesarean delivery.

Glucose-insulin-potassium alleviates uterine cramping pain following cesarean delivery: A randomized, controlled trial

Objectives

To explore the effect of glucose-insulin-potassium (GIK) therapy on uterine cramping pain (UCP) following cesarean delivery (CD).

Design

Single-center, randomized controlled study.

Setting

Second Affiliated Hospital of Army Medical University, Chongqing, China.

Participants

A total of 140 women, aged 20-40 years, who underwent CD with a transverse incision were randomly assigned to the GIK (P) or control (C) groups in a 1:1 ratio.

Interventions

GIK was intravenously administered to patients in Group P. Patients in Group C received normal saline (NS). After umbilical cord clamping, oxytocin was administered intravenously. The same GIK and NS regimens were administered on postoperative days 1 and 2, followed by oxytocin 10 min later.

Primary and secondary outcome measures

Following oxytocin administration, UCP was assessed using the visual analog scale (VAS), and the maximum VAS score (primary outcome) was recorded.

Results

Patients in Group P had significantly lower maximum VAS scores than those in Group C on postoperative days 1 (38.4 ± 21.1 vs. 52.3 ± 20.8, p < 0.001) and 2 (10 [0,30] vs. 30.5 [8.75,50], p < 0.001). Group P patients also had shorter pain duration on postoperative day 1 (39.6 ± 19.5 min vs. 50.6 ± 18.2 min, p = 0.001). Group P patients had a lower incidence of inadequate analgesia of UCP than Group C on days 1 (45.5% vs. 74.2%, p < 0.001) and 2 (10.6% vs. 47.0%, p < 0.001); the RRs for experiencing inadequate analgesia for UCP postpartum in Group P patients was 0.612 (95% CI: 0.454-0.826, p < 0.001) on day 1 and 0.226 (95% CI: 0.107-0.476, p < 0.001) on day 2. The absolute risk reduction (ARR) was 28.7%; thus number needed to treat (NNT) was 3 after rounding up. A subgroup analysis demonstrated that Group P patients undergoing repeat CD had lower maximum VAS scores for UCP on both postoperative days 1 and 2.

Conclusion

Our findings suggest that GIK can relieve UCP and shorten its duration. Our results provide information to facilitate the development of novel approaches for managing UCP.Clinical Trial Registration: This study was approved by the Medical Ethics Committee of Second Affiliated Hospital of Army Medical University (2020-109-01, 19/11/2020) and registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn, ChiCTR2100041607,01/01/2021).

Nalbuphine May Be Superior to Sufentanil in Relieving Postcesarean Uterine Contraction Pain in Multiparas: A Retrospective Cohort Study

Purpose

Postcesarean pain remains a major complaint from puerperium women who have undergone cesarean section, especially uterine contraction induced visceral pain. The optimal opioid for pain relief after cesarean section (CS) is still unclear. The goal of this study was to compare the analgesic effect of Nalbuphine to Sufentanil in patients who underwent CS.

Patients and Methods

In this single-center retrospective cohort study, we included patients who received Nalbuphine or Sufentanil Patient-Controlled Intravenous Analgesia (PCIA) after CS between 1 January 2018 and 30 November 2020. Data on a Visual Analog Scale (VAS) at uterine contraction, at rest, and at movement, analgesic consumption, and side effects were collected. We performed logistic regression to identify predictors of severe uterine contraction pain.

Results

A total of 674 patients were identified in the unmatched cohort, and 612 patients in the matched one. Compared to the Sufentanil group, lower VAS-contraction was recorded in the Nalbuphine group in both the unmatched and matched cohorts, the mean difference (MD) on POD1 was 0.35 (95% CI: 0.17 to 0.54, p<0.001) and 0.28 (95% CI: 0.08 to 0.47, p<0.001), respectively, and the MD of POD2 was 0.12 (95% CI: 0.03 to 0.40, P=0.019) and 0.12 (95% CI: 0.03 to 0.41, P=0.026), respectively. On POD1 but not POD2, VAS-movement was lower in the Nalbuphine group as compared to the Sufentanil group. No difference was found between VAS-rest on POD1 and POD2 in both unmatched and matched cohorts. Less analgesic consumption, and side effects were recorded in the Nalbuphine group. Logistic regression indicated that multipara and analgesic consumption were risk factors for severe uterine contraction pain. In subgroup analysis, VAS-contraction was meaningfully reduced in the Nalbuphine group compared with the Sufentanil group in multipara patients, but not primiparas.

Conclusion

Compared to Sufentanil, Nalbuphine may provide better analgesia on uterine contraction pain. The superior analgesia may only exhibit in multiparas.

Effects of hydromorphone-based intravenous patient-controlled analgesia with and without a low basal infusion on postoperative hypoxaemia: study protocol for a randomised controlled clinical trial

INTRODUCTION

When patients receive patient-controlled intravenous analgesia (PCIA), no basal infusion is always recommended, as the addition of a basal infusion increases the occurrence of postoperative opioid-induced respiratory depression. However, few studies have investigated whether low basal infusions increase the incidence of postoperative hypoxaemia relative to no basal infusion. We intend to conduct a clinical trial to test the hypothesis that PCIA with a low basal infusion does not increase the occurrence of postoperative hypoxaemia relative to PCIA with no basal infusion.

METHODS AND ANALYSIS

This single-centre parallel randomised controlled clinical trial will be conducted with 160 patients undergoing gastrointestinal tumour surgery. The assigned nurse will set analgesic pumps (low or no basal infusion PCIA) according to block-based randomisation sequence. Other investigators and all participants will be blinded to intervention allocation. All patients will be monitored continuously with the ep pod, a wireless wearable device, recording of oxygen saturation (SpO₂) and daily ambulation duration for 48 hours postoperatively. Three follow-up evaluations will be conducted to assess the analgesic effect (Numeric Rating Scale (NRS) pain score) and opioid-related side effects (Overall Benefit of Analgesic Score (OBAS)). The primary outcome will be the area under the curve for hypoxaemia (defined as SpO₂<95%) per hour. The secondary outcomes will be the areas under the curve for hypoxaemia defined as SpO₂<90% and <85% per hour, hydromorphone consumption, OBASs at 24 and 48 hours postoperatively, NRS scores at 4, 24 and 48 hours postoperatively, and the ambulation time per hour over 48 hours.

ETHICS AND DISSEMINATION

The study has been approved by the Xijing Hospital Ethics Committee (KY20212163-F-1). Written informed consent will be obtained from all patients or their authorised surrogates. All data will be managed with confidentiality. Findings will be disseminated at international conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100054317.

Incidence and Effect of Intrathecal Fentanyl Use in Spinal Anesthesia for Cesarean Deliveries in the Community Setting: A Single-Center Observational Retrospective Study

Background: The addition of intrathecal fentanyl to spinal anesthesia for cesarean delivery has been shown to be beneficial, but its rate of utilization in the community setting is unknown. The primary aim of our study was to determine the rate of intrathecal fentanyl use for cesarean deliveries with spinal anesthesia in a community hospital, and our secondary aim was to determine its effect on anesthetic outcomes.

Methods: Patients who underwent cesarean delivery from June 1, 2017 to November 30, 2019 with spinal anesthesia as the initial anesthetic technique were included.

Results: Seven hundred sixty-one cesarean deliveries met inclusion criteria, and 161 (21.2%) patients received intrathecal fentanyl in their spinal anesthetic for cesarean delivery. A multivariate model that controlled for patient weight and time from spinal placement to procedure end showed that patients who received intrathecal fentanyl were less likely to have conversion to general anesthesia or administration of systemic anesthetic adjuncts compared to patients who did not receive intrathecal fentanyl (odds ratio 2.889, 95% CI 1.552-5.903; P=0.0017).

Conclusion: Only 1 in 5 patients received intrathecal fentanyl for cesarean deliveries performed under spinal anesthesia in a community hospital despite known benefits. Patients who did not receive intrathecal fentanyl had increased odds of conversion to general anesthesia or administration of systemic anesthetic adjunct administration, a finding consistent with previous studies. The addition of intrathecal fentanyl to spinal anesthesia for cesarean delivery should be strongly considered in the community setting.

Labor prior to cesarean delivery associated with higher post-discharge opioid consumption

Background

Severe acute post-cesarean delivery (CD) pain has been associated with an increased risk for persistent pain and postpartum depression. Identification of women at increased risk for pain can be used to optimize post-cesarean analgesia. The impact of labor prior to CD (intrapartum CD) on acute post-operative pain and opioid use is unclear. We hypothesized that intrapartum CD, which has been associated with both increased inflammation and affective distress related to an unexpected surgical procedure, would result in higher postoperative pain scores and increased opioid intake.

Methods

This is a secondary analysis of a prospective cohort study examining opioid use up to 2 weeks following CD. Women undergoing CD at six academic medical centers in the United States 9/2014-3/2016 were contacted by phone two weeks following discharge. Participants completed a structured interview that included questions about postoperative pain scores and opioid utilization. They were asked to retrospectively estimate their maximal pain score on an 11-point numeric rating scale at multiple time points, including day of surgery, during hospitalization, immediately after discharge, 1^st week, and 2^nd week following discharge.

Pain scores over time were assessed utilizing a generalized linear mixed-effects model with the patient identifier being a random effect, adjusting for an a priori defined set of confounders. A multivariate negative binomial model was utilized to assess the association between intrapartum CD and opioid utilization after discharge, also adjusting for the same confounders. In the context of non-random prescription distribution, this model was constructed with an offset for the number of tablets dispensed.

Results

A total of 720 women were enrolled, 392 with and 328 without labor prior to CD. Patients with intrapartum CD were younger, less likely to undergo repeat CD or additional surgical procedures, and more likely to experience a complication of CD.

Women with intrapartum CD consumed more opioid tablets following discharge than women without labor (median 20, IQR 10–30 versus 17, IQR 6–30; p = 0.005). This association persisted after adjustment for confounders (incidence rate ratio 1.16, 95% CI 1.05–1.29; p = 0.004). Pain scores on the day of surgery were higher in women with intrapartum CD (difference 0.91, 95% CI 0.52–1.30; adj. p = <0.001) even after adjustment for confounders. Pain scores at other time points were not meaningfully different between the two groups.

Conclusion

Intrapartum CD is associated with worse pain on the day of surgery but not other time points. Opioid requirements following discharge were modestly increased following intrapartum CD.

Risk factors of uterine contraction after ureteroscopy in pregnant women with renal colic

Background

Ureteroscopy is widely applied in pregnant women with renal colic, but such patients are easy to experience uterine contraction after surgery. There are many factors which may affect uterine contraction, this study aims to explore the risk factors of uterine contraction triggered by ureteroscopy in pregnant women with renal colic.

Methods

One hundred and one pregnant women were retrospectively analyzed, the patients were hospitalized because of severe renal colic. All patients received ureteroscopy during which double J catheters were inserted into ureters for drainage. Patients received other medical treatments individually according to their condition and uterine contractions were detected by EHG within 12 h after operation. Patients were classified as group A (uterine contraction) and group B (no uterine contraction) according to the presence or absence of continuously regular uterine contraction. Clinical characteristics were collected for further analysis, including history of childbirth, anesthesia method, application of phloroglucinol or not, operation time, Oxygen inhalation or not, pain relief or not after surgery, systemic inflammatory response syndrome (SIRS) occurred or not. A binary logistic regression analysis model was established to explore whether such clinical characteristics were relevant to uterine contraction after ureteroscopy.

Results

Continuously regular uterine contraction presented in 46 pregnant women within 12 h after ureteroscopy, making the incidence of uterine contraction as high as 45.54%. The presence of uterine contraction was related to the following factors(P < 0.05): history of childbirth (primipara versus multipara)(OR 6.593, 95% CI 2.231–19.490), operation time (each quarter additional) (OR 2.385, 95% CI 1.342–4.238), application of phloroglucinol (yes versus not) (OR 6.959, 95% CI 1.416–34.194), pain relief after surgery(yes versus not)(OR 6.707, 95% CI 1.978–22.738), SIRS occurred after surgery (yes versus not) (OR 0.099, 95% CI 0.014–0.713).

Conclusion

Continuously regular uterine contraction is easy to occur within 12 h after ureteroscopy in pregnant women. SIRS occurred after surgery is a risk factor for uterine contraction; on the contrary, no history of childbirth, shorter operation time, application of phloroglucinol, pain relief after surgery are protective factors.

Pre-Emptive Incision-Site Infiltration with Ropivacaine Plus Dexamethasone for Postoperative Pain After Supratentorial Craniotomy: A Prospective Randomized Controlled Trial

Background

Incision-site infiltration with local anesthetics prevents pain on incision site, but pain relief is limited to the first few postoperative hours. Dexamethasone as an adjuvant to local infiltration successfully achieves better postoperative pain relief; however, this has not been studied in craniotomy patients yet.

Study Design and Methods

This is a prospective, single-center, blinded, randomized, controlled trial included patients aged between 18 and 64 years, ASA physical status of I–II, scheduled for elective supratentorial tumor craniotomy under general anesthesia. We screened patients for enrollment from April 4, 2019 through August 15, 2019. The final study visit of the last patient was conducted on February 13, 2020. We randomly assigned eligible participants (1:1) to either the dexamethasone group who received incision-site infiltration of 0.5% ropivacaine plus 0.033% dexamethasone (N=70) or the control group who received 0.5% ropivacaine alone (N=70). Primary outcome was the cumulative sufentanil consumption (μg) within 48 hours postoperatively. Primary analysis was performed based on the modified intention-to-treat (MITT) principle.

Results

Baseline characteristics were similar between the groups (p>0.05). Sufentanil consumption during the first 48 hours postoperatively was 29.0 (10.7) μg in the dexamethasone group and 38.3 (13.7) μg in the control group (mean difference −9.3, 95% CI −13.4 to −5.1; p<0.001). There was no serious adverse effect directly associated with incision-site infiltration or local dexamethasone use.

Conclusion

The addition of dexamethasone to pre-emptive incision-site infiltration with the local anesthetic can reduce about 27% of opioids consumption and the postoperative pain scores within 72 hours after craniotomy.

Trial Registration

ClinicalTrials.Gov (NCT03618264).